facility_name: Miami Youth Academy

summary: PREA - Year 3 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Miami Youth Academy
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 08/21/2024
Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review.
I have not included in the final report any personally identifiable information (PII)
about any inmate/resident/detainee or staff member, except where the names of
administrative personnel are specifically requested in the report template.
Auditor Full Name as Signed: Shirley Turner Date of Signature: 08/21/2024
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 07/24/2024
Site Audit:
End Date of On-Site 07/25/2024
Audit:
FACILITY INFORMATION
Facility name: Miami Youth Academy
Facility physical 10855 Southwest 84th Street, Miami, Florida - 33173
address:
Facility mailing
address:
Primary Contact
Name: De'Juan Guillory
Email Address: dejuan.guillory@truecorebehavioral.com
Telephone Number: 5616543989
Superintendent/Director/Administrator
Name: De'Juan Guillory
Email Address: dejuan.guillory@truecorebehavioral.com
Telephone Number: 561-654-3989
Facility PREA Compliance Manager
Name: De'Juan Guillory
Email Address: dejuan.guillory@truecorebehavioral.com
Telephone Number: O: (561) 654-3989
Name: Pamela Webb
Email Address: pamela.webb@truecorebehavioral.com
Telephone Number: O: (786) 305-8550
Facility Health Service Administrator On-Site
Name: Jennifer Delgado
Email Address: jennifer.delgado@truecorebehavioral.com
Telephone Number: 813-861-3275
Facility Characteristics
Designed facility capacity: 28
Current population of facility: 24
Average daily population for the past 12 27
months:
Has the facility been over capacity at any No
point in the past 12 months?
Which population(s) does the facility hold? Males
Age range of population: 12-19
Facility security levels/resident custody Non Secure
levels:
Number of staff currently employed at the 34
facility who may have contact with
residents:
Number of individual contractors who have 3
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 20
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: TrueCore Behavioral Solutions, LLC.
Governing authority
or parent agency (if
applicable):
Physical Address: 1907 US Highway 301, Suite C 150, Tampa, Florida - 33619
Mailing Address:
Telephone number:
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Calvetti Pate Email Address: calvetti.pate@truecorebehavioral.com
Facility AUDIT FINDINGS
Summary of Audit Findings
The OAS automatically populates the number and list of Standards exceeded, the number of
Standards met, and the number and list of Standards not met.
Auditor Note: In general, no standards should be found to be "Not Applicable" or "NA." A
compliance determination must be made for each standard. In rare instances where an auditor
determines that a standard is not applicable, the auditor should select "Meets Standard” and
include a comprehensive discussion as to why the standard is not applicable to the facility being
audited.
Number of standards exceeded:
0
Number of standards met:
43
Number of standards not met:
0
POST-AUDIT REPORTING INFORMATION
GENERAL AUDIT INFORMATION
On-site Audit Dates
1. Start date of the onsite portion of the 2024-07-24
audit:
2. End date of the onsite portion of the 2024-07-25
audit:
Outreach
10. Did you attempt to communicate Yes
with community-based organization(s)
or victim advocates who provide
No
services to this facility and/or who may
have insight into relevant conditions in
the facility?
a. Identify the community-based Roxcy Bolton Rape Treatment Center - Miami,
organization(s) or victim advocates with FL
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 28
15. Average daily population for the past 27
12 months:
16. Number of inmate/resident/detainee 1
housing units:
17. Does the facility ever hold youthful Yes
inmates or youthful/juvenile detainees?
No
Not Applicable for the facility type audited
(i.e., Community Confinement Facility or
Juvenile Facility)
Audited Facility Population Characteristics on Day One of the Onsite
Portion of the Audit
Inmates/Residents/Detainees Population Characteristics on Day One of the Onsite Portion
of the Audit
36. Enter the total number of inmates/ 24
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
38. Enter the total number of inmates/ 0
residents/detainees with a physical
disability in the facility as of the first
day of the onsite portion of the audit:
39. Enter the total number of inmates/ 8
residents/detainees with a cognitive or
functional disability (including
intellectual disability, psychiatric
disability, or speech disability) in the
facility as of the first day of the onsite
portion of the audit:
40. Enter the total number of inmates/ 0
residents/detainees who are Blind or
have low vision (visually impaired) in the
facility as of the first day of the onsite
portion of the audit:
41. Enter the total number of inmates/ 0
residents/detainees who are Deaf or
hard-of-hearing in the facility as of the
first day of the onsite portion of the
audit:
42. Enter the total number of inmates/ 0
residents/detainees who are Limited
English Proficient (LEP) in the facility as
of the first day of the onsite portion of
the audit:
43. Enter the total number of inmates/ 0
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
44. Enter the total number of inmates/ 0
residents/detainees who identify as
transgender or intersex in the facility as
of the first day of the onsite portion of
the audit:
45. Enter the total number of inmates/ 0
residents/detainees who reported sexual
abuse in the facility as of the first day of
the onsite portion of the audit:
46. Enter the total number of inmates/ 0
residents/detainees who disclosed prior
sexual victimization during risk
screening in the facility as of the first
day of the onsite portion of the audit:
47. Enter the total number of inmates/ 0
residents/detainees who were ever
placed in segregated housing/isolation
for risk of sexual victimization in the
facility as of the first day of the onsite
portion of the audit:
48. Provide any additional comments No text provided.
regarding the population characteristics
of inmates/residents/detainees in the
facility as of the first day of the onsite
portion of the audit (e.g., groups not
tracked, issues with identifying certain
populations):
Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite
Portion of the Audit
49. Enter the total number of STAFF, 34
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
50. Enter the total number of 20
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
51. Enter the total number of 3
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
52. Provide any additional comments No text provided.
regarding the population characteristics
of staff, volunteers, and contractors who
were in the facility as of the first day of
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
53. Enter the total number of RANDOM 10
INMATES/RESIDENTS/DETAINEES who
were interviewed:
54. Select which characteristics you Age
considered when you selected RANDOM
INMATE/RESIDENT/DETAINEE Race
interviewees: (select all that apply)
Ethnicity (e.g., Hispanic, Non-Hispanic)
Length of time in the facility
Housing assignment
Gender
Other
None
55. How did you ensure your sample of Conferred with staff, reviewed population
RANDOM INMATE/RESIDENT/DETAINEE roster, reviewed sample of risk assessments.
interviewees was geographically
diverse?
56. Were you able to conduct the Yes
minimum number of random inmate/
resident/detainee interviews?
No
57. Provide any additional comments No text provided.
regarding selecting or interviewing
random inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews,
barriers to ensuring representation):
Targeted Inmate/Resident/Detainee Interviews
58. Enter the total number of TARGETED 5
INMATES/RESIDENTS/DETAINEES who
were interviewed:
As stated in the PREA Auditor Handbook, the breakdown of targeted interviews is intended to
guide auditors in interviewing the appropriate cross-section of inmates/residents/detainees who
are the most vulnerable to sexual abuse and sexual harassment. When completing questions
regarding targeted inmate/resident/detainee interviews below, remember that an interview with
one inmate/resident/detainee may satisfy multiple targeted interview requirements. These
questions are asking about the number of interviews conducted using the targeted inmate/
resident/detainee protocols. For example, if an auditor interviews an inmate who has a physical
disability, is being held in segregated housing due to risk of sexual victimization, and disclosed
prior sexual victimization, that interview would be included in the totals for each of those
questions. Therefore, in most cases, the sum of all the following responses to the targeted
inmate/resident/detainee interview categories will exceed the total number of targeted inmates/
residents/detainees who were interviewed. If a particular targeted population is not applicable in
the audited facility, enter "0".
60. Enter the total number of interviews 0
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed population
to determine if this population exists in roster, reviewed sample of risk assessments;
the audited facility (e.g., based on observed population.
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
61. Enter the total number of interviews 5
conducted with inmates/residents/
detainees with a cognitive or functional
disability (including intellectual
disability, psychiatric disability, or
speech disability) using the "Disabled
and Limited English Proficient Inmates"
protocol:
62. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Blind or have low
vision (i.e., visually impaired) using the
"Disabled and Limited English Proficient
Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed population
to determine if this population exists in roster, observed population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
63. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Deaf or hard-of-
hearing using the "Disabled and Limited
English Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed sample of risk
to determine if this population exists in assessments, observed population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
64. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Limited English
Proficient (LEP) using the "Disabled and
Limited English Proficient Inmates"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed population
to determine if this population exists in roster, observed population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
65. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed population
to determine if this population exists in roster, reviewed sample of risk assessments.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
66. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed sample of risk
to determine if this population exists in assessments.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
67. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, and reviewed sample of
to determine if this population exists in risk assessments.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
68. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who disclosed prior sexual
victimization during risk screening using
the "Inmates who Disclosed Sexual
Victimization during Risk Screening"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff and reviewed sample of
to determine if this population exists in risk assessments.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
69. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are or were ever placed
in segregated housing/isolation for risk
of sexual victimization using the
"Inmates Placed in Segregated Housing
(for Risk of Sexual Victimization/Who
Allege to have Suffered Sexual Abuse)"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies The facility does not have segregated housing
to determine if this population exists in as determined from observations, interviews,
the audited facility (e.g., based on and informal conversations with staff.
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
70. Provide any additional comments Conferred with staff.
regarding selecting or interviewing
targeted inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews):
Staff, Volunteer, and Contractor Interviews
Random Staff Interviews
71. Enter the total number of RANDOM 10
STAFF who were interviewed:
72. Select which characteristics you Length of tenure in the facility
considered when you selected RANDOM
STAFF interviewees: (select all that Shift assignment
apply)
Work assignment
Rank (or equivalent)
Other (e.g., gender, race, ethnicity,
languages spoken)
None
If "None," explain: Interviewed all available random staff.
73. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
a. Select the reason(s) why you were Too many staff declined to participate in
unable to conduct the minimum number interviews.
of RANDOM STAFF interviews: (select all
that apply) Not enough staff employed by the facility
to meet the minimum number of random staff
interviews (Note: select this option if there
were not enough staff employed by the
facility or not enough staff employed by the
facility to interview for both random and
specialized staff roles).
Not enough staff available in the facility
during the onsite portion of the audit to meet
the minimum number of random staff
interviews.
Other
74. Provide any additional comments No text provided.
regarding selecting or interviewing
random staff (e.g., any populations you
oversampled, barriers to completing
interviews, barriers to ensuring
representation):
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties.
Therefore, more than one interview protocol may apply to an interview with a single staff
member and that information would satisfy multiple specialized staff interview requirements.
75. Enter the total number of staff in a 6
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
76. Were you able to interview the Yes
Agency Head?
No
77. Were you able to interview the Yes
Warden/Facility Director/Superintendent
or their designee?
No
78. Were you able to interview the PREA Yes
Coordinator?
No
79. Were you able to interview the PREA Yes
Compliance Manager?
No
NA (NA if the agency is a single facility
agency or is otherwise not required to have a
PREA Compliance Manager per the Standards)
80. Select which SPECIALIZED STAFF Agency contract administrator
roles were interviewed as part of this
audit from the list below: (select all that Intermediate or higher-level facility staff
apply) responsible for conducting and documenting
unannounced rounds to identify and deter
staff sexual abuse and sexual harassment
Line staff who supervise youthful inmates
(if applicable)
Education and program staff who work with
youthful inmates (if applicable)
Medical staff
Mental health staff
Non-medical staff involved in cross-gender
strip or visual searches
Administrative (human resources) staff
Sexual Assault Forensic Examiner (SAFE) or
Sexual Assault Nurse Examiner (SANE) staff
Investigative staff responsible for
conducting administrative investigations
Investigative staff responsible for
conducting criminal investigations
Staff who perform screening for risk of
victimization and abusiveness
Staff who supervise inmates in segregated
housing/residents in isolation
Staff on the sexual abuse incident review
team
Designated staff member charged with
monitoring retaliation
First responders, both security and non-
security staff
Intake staff
Other
81. Did you interview VOLUNTEERS who Yes
may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 2
VOLUNTEERS who were interviewed:
b. Select which specialized VOLUNTEER Education/programming
role(s) were interviewed as part of this
audit from the list below: (select all that Medical/dental
apply)
Mental health/counseling
Religious
Other
82. Did you interview CONTRACTORS Yes
who may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 2
CONTRACTORS who were interviewed:
b. Select which specialized CONTRACTOR Security/detention
role(s) were interviewed as part of this
audit from the list below: (select all that Education/programming
apply)
Medical/dental
Food service
Maintenance/construction
Other
83. Provide any additional comments No text provided.
regarding selecting or interviewing
specialized staff.
SITE REVIEW AND DOCUMENTATION SAMPLING
Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas
of the audited facilities." In order to meet the requirements in this Standard, the site review
portion of the onsite audit must include a thorough examination of the entire facility. The site
review is not a casual tour of the facility. It is an active, inquiring process that includes talking
with staff and inmates to determine whether, and the extent to which, the audited facility's
practices demonstrate compliance with the Standards. Note: As you are conducting the site
review, you must document your tests of critical functions, important information gathered
through observations, and any issues identified with facility practices. The information you
collect through the site review is a crucial part of the evidence you will analyze as part of your
compliance determinations and will be needed to complete your audit report, including the Post-
Audit Reporting Information.
84. Did you have access to all areas of Yes
the facility?
No
Was the site review an active, inquiring process that included the following:
85. Observations of all facility practices Yes
in accordance with the site review
component of the audit instrument (e.g.,
No
signage, supervision practices, cross-
gender viewing and searches)?
86. Tests of all critical functions in the Yes
facility in accordance with the site
review component of the audit
No
instrument (e.g., risk screening process,
access to outside emotional support
services, interpretation services)?
87. Informal conversations with inmates/ Yes
residents/detainees during the site
review (encouraged, not required)?
No
88. Informal conversations with staff Yes
during the site review (encouraged, not
required)?
No
89. Provide any additional comments No text provided.
regarding the site review (e.g., access to
areas in the facility, observations, tests
of critical functions, or informal
conversations).
Documentation Sampling
Where there is a collection of records to review-such as staff, contractor, and volunteer training
records; background check records; supervisory rounds logs; risk screening and intake
processing records; inmate education records; medical files; and investigative files-auditors must
self-select for review a representative sample of each type of record.
90. In addition to the proof Yes
documentation selected by the agency
or facility and provided to you, did you
No
also conduct an auditor-selected
sampling of documentation?
91. Provide any additional comments No text provided.
regarding selecting additional
documentation (e.g., any documentation
you oversampled, barriers to selecting
additional documentation, etc.).
SEXUAL ABUSE AND SEXUAL HARASSMENT ALLEGATIONS AND
INVESTIGATIONS IN THIS FACILITY
Sexual Abuse and Sexual Harassment Allegations and Investigations
Overview
Remember the number of allegations should be based on a review of all sources of allegations
(e.g., hotline, third-party, grievances) and should not be based solely on the number of
investigations conducted. Note: For question brevity, we use the term “inmate” in the following
questions. Auditors should provide information on inmate, resident, or detainee sexual abuse
allegations and investigations, as applicable to the facility type being audited.
92. Total number of SEXUAL ABUSE allegations and investigations overview during
the 12 months preceding the audit, by incident type:
# of allegations
# of
# of that had both
sexual # of criminal
administrative criminal and
abuse investigations
investigations administrative
allegations
investigations
Inmate- 1 0 1 0
on-
inmate
sexual
abuse
Staff- 0 0 0 0
on-
inmate
sexual
abuse
Total 1 0 1 0
93. Total number of SEXUAL HARASSMENT allegations and investigations overview
during the 12 months preceding the audit, by incident type:
# of allegations
# of sexual # of that had both
# of criminal
harassment administrative criminal and
investigations
allegations investigations administrative
investigations
Inmate-on- 0 0 0 0
inmate
sexual
harassment
Staff-on- 1 0 1 0
inmate
sexual
harassment
Total 1 0 1 0
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal
investigation was referred for prosecution and resulted in a conviction, that investigation
outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for
question brevity, we use the term “inmate” in the following questions. Auditors should provide
information on inmate, resident, and detainee sexual abuse investigation files, as applicable to
the facility type being audited.
94. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding
the audit:
Referred Indicted/
Convicted/
Ongoing for Court Case Acquitted
Adjudicated
Prosecution Filed
Inmate-on- 0 0 0 0 0
inmate sexual
abuse
Staff-on- 0 0 0 0 0
inmate sexual
abuse
Total 0 0 0 0 0
95. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 1 0 0
sexual abuse
Staff-on-inmate 0 0 0 0
sexual abuse
Total 0 1 0 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
96. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months
preceding the audit:
Indicted/
Referred
Court Convicted/
Ongoing for Acquitted
Case Adjudicated
Prosecution
Filed
Inmate-on- 0 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
97. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual
harassment
Staff-on-inmate 0 1 0 0
sexual
harassment
Total 0 1 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
98. Enter the total number of SEXUAL 1
ABUSE investigation files reviewed/
sampled:
99. Did your selection of SEXUAL ABUSE Yes
investigation files include a cross-
section of criminal and/or administrative
No
investigations by findings/outcomes?
NA (NA if you were unable to review any
sexual abuse investigation files)
Inmate-on-inmate sexual abuse investigation files
100. Enter the total number of INMATE- 1
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
101. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations?
No
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
102. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative
No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
Staff-on-inmate sexual abuse investigation files
103. Enter the total number of STAFF- 0
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
104. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
105. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
Sexual Harassment Investigation Files Selected for Review
106. Enter the total number of SEXUAL 1
HARASSMENT investigation files
reviewed/sampled:
107. Did your selection of SEXUAL Yes
HARASSMENT investigation files include
a cross-section of criminal and/or
No
administrative investigations by
findings/outcomes?
NA (NA if you were unable to review any
sexual harassment investigation files)
Inmate-on-inmate sexual harassment investigation files
108. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
109. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT files
include criminal investigations?
No
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
110. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative
No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
Staff-on-inmate sexual harassment investigation files
111. Enter the total number of STAFF- 1
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
112. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include criminal
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
113. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
114. Provide any additional comments No text provided.
regarding selecting and reviewing
sexual abuse and sexual harassment
investigation files.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
115. Did you receive assistance from any Yes
DOJ-CERTIFIED PREA AUDITORS at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
Non-certified Support Staff
116. Did you receive assistance from any Yes
NON-CERTIFIED SUPPORT STAFF at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
a. Enter the TOTAL NUMBER OF NON- 1
CERTIFIED SUPPORT who provided
assistance at any point during this audit:
AUDITING ARRANGEMENTS AND COMPENSATION
121. Who paid you to conduct this audit? The audited facility or its parent agency
My state/territory or county government
employer (if you audit as part of a consortium
or circular auditing arrangement, select this
option)
A third-party auditing entity (e.g.,
accreditation body, consulting firm)
Other
Identify the name of the third-party Correctional Management and
auditing entity Communications Group, LLC
Standards
Auditor Overall Determination Definitions
• Exceeds Standard
(Substantially exceeds requirement of standard)
• Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant
review period)
• Does Not Meet Standard
(requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-
compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions.
This discussion must also include corrective action recommendations where the facility does not
meet standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Zero tolerance of sexual abuse and sexual harassment; PREA
115.311
coordinator
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Facility Policy 3-36, Guidelines to Detect, Respond and Prevent Abuse of Youth
Facility Policy 3-5, Professional Relationships with Residents
Facility Policy 1-8, Professional Boundaries
Agency Policy FDJJ 1919, PREA
Organization Chart
Interviews:
Superintendent
Random Staff
Residents
PREA Coordinators
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 Miami Youth Academy, located in Miami, Florida, serves adolescent male
juvenile offenders. Program services include but are not limited to individual, group,
and family therapy and psychiatric services. The facility is managed by TrueCore
Behavioral Solutions, LLC through a contract with the Florida Department of Juvenile
Justice (DJJ). The facility serves a population from 12 to 19 years of age and is staff
secure for youth classified as moderate risk. The Prison Rape Elimination Act (PREA)
Standards are applied to ensure a sexually safe environment.
Facility policies and procedures and DJJ agency policy collectively provide direction
to staff regarding the facility’s approach to preventing, detecting, and responding to
allegations of sexual abuse and sexual harassment. Policies provide and address
conduct that violates the zero-tolerance approach regarding all forms of sexual
abuse and sexual harassment. Definitions of prohibited behaviors of sexual abuse
and sexual harassment are contained in policy and include sanctions for those
found to have participated in the prohibited behaviors. The DJJ agency policy, FDJJ
1919, serves as the overarching PREA Policy for the state-run and contract facilities.
The facility also has additional policies which support adherence to the PREA
standards.
Staff training, resident education, and intake screening assist in detecting sexual
abuse and sexual harassment. The identified and other supporting policies include
but are not limited to responding to sexual abuse and sexual harassment through
prevention; responsive planning; training and education; reporting; investigations;
medical and mental care; assessments; disciplinary sanctions for residents and
staff; and data collection and review. The interviews confirmed knowledge and an
environment of zero-tolerance of sexual abuse and sexual harassment.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator
with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
In accordance with policy, TrueCore Behavioral Solutions has identified a PREA
Coordinator that is a member of the agency's regional management team with
direct access to leadership staff. The DJJ has a statewide PREA Coordinator that also
provides support to the contract facilities regarding PREA related issues. The PREA
Coordinators have knowledge of the standards and the audit processes.
Provision (c):
Where an agency operates more than one facility, each facility shall designate a
PREA Compliance Manager with sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards.
The Facility Administrator/Superintendent has been designated as the PREA
Compliance Manager and indicated he has the time to fulfill the PREA duties and it
was determined that she has the authority required to fulfill those duties. Interviews
conducted with staff revealed their awareness of the role of the PREA Compliance
Manager. Observations confirmed he has the support of the Assistant
Superintendent, other facility staff, and both agency's statewide PREA Coordinator.
The facility and agency policies provide for the designation of the PREA Compliance
Manager within the facility.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, it was determined there is compliance with this standard.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Contract
Contract Log
Previous PREA Audit Reports
Interviews:
Superintendent
PREA Coordinators
Provisions (a) and (b):
(a): A public agency that contracts for the confinement of its residents with private
agencies or other entities, including other government agencies, shall include in any
new contract or contract renewal the entity’s obligation to adopt and comply with
the PREA standards. (b): Any new contract or contract renewal shall provide for
agency contract monitoring to ensure that the contractor is complying with the
PREA standards.
The public agency contracts for the confinement of its residents. Contracts exist
that inform the contractors of the requirements of the Florida Department of
Juvenile Justice to comply with the PREA Standards and participate in PREA audits.
The practice was also confirmed by interviews and completed PREA audit reports for
this facility and other contract sites.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined compliance with this standard.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-8, Staffing Ratios and Coverage
Facility Policy 10-25, PREA
Staffing Plan
Annual Staffing Plan Assessments
PREA Unannounced Rounds
PREA Pre-Audit Questionnaire
Interviews:
Superintendent/PREA Compliance Manager
Intermediate or Higher-Level Staff
Provision (a):
The agency shall ensure that each facility it operates shall develop, implement, and
document a staffing plan that provides for adequate levels of staffing, and, where
applicable, video monitoring, to protect residents against sexual abuse. In
calculating adequate staffing levels and determining the need for video monitoring,
facilities shall take into consideration:
(1) Generally accepted juvenile detention and correctional/secure residential
practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4) Any findings of inadequacy from internal or external oversight bodies;
(5) All components of the facility’s physical plant (including “blind spots” or areas
where staff or residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of sexual
abuse; and
(11) Any other relevant factors.
The agency, Florida Department of Juvenile Justice, requires all State-run and
contract facilities to develop, document, and make its best efforts to comply on a
regular basis with a staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring to protect residents against abuse. The policies
and staffing plan provide details for maintaining the staffing ratios and the staffing
plan outlines the staffing requirements. The facility’s staffing plan, internal controls
and management ensures that the PREA staffing ratios of 1:8 during the waking
hours and 1:16 during the sleeping hours are maintained or exceeded due to the
internal staffing ratios of 1:8 and 1:12. Direct supervision is provided to residents
during the daily activities and program services. The number of staff increases as
needed due to program activities, one-on-one supervision indicated, or other
relevant factors. Observations during the site review, review of schedules, and
interviews indicated the staffing ratios are maintained. The facility maintains a
mandatory hold-over system to ensure adherence to the staffing ratios and staffing
plan.
The camera monitors located in the offices of the Superintendent and Assistant
Superintendent and are periodically monitored. Provisions of the standard are taken
into consideration regarding adequate staffing levels as confirmed through the
interviews which outline staffing requirements. The interview with the
Superintendent revealed collaboration and review of the work schedules on a
regular basis. In addition to program activities and special needs of residents, the
shift schedules are made regarding the considerations that ensure adequate shift
coverage including standard security practices; composition of the resident
population; inclement weather; and emergencies. The average daily population is
24 and the staffing plan is predicated on a population of 24.
Provision (b):
The agency shall comply with the staffing plan except during limited and discrete
exigent circumstances, and shall fully document deviations from the plan during
such circumstances.
The facility reports no deviations from the staffing ratios in the past 12 months. The
staffing plan is incorporated in policy. A coordinated effort was described in
maintaining the staffing ratios which meets the PREA ratio during the awake hours
and exceeds the PREA ratio during the sleeping hours. The operations of the facility
provide for staff to be held-over on identified mandated hold-over days. The facility
is prepared to document any deviations from the staffing requirements. The
Superintendent regularly monitors the effectiveness of the work schedules based on
the staffing plan requirements. The staffing plan shows the required staffing ratios.
The staffing plan provides for the staffing ratios to be met and provides for
additional staff for days and times when increased staffing is required. The staffing
ratios of 1:8 and 1:12 must be maintained in accordance with the executed contract
between the Florida Department of Juvenile Justice (DJJ) and TrueCore Behavioral
Solutions, LLC.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8 during
resident waking hours and 1:16 during resident sleeping hours, except during
limited and discrete exigent circumstances, which shall be fully documented. Only
security staff shall be included in these ratios. Any facility that, as of the date of
publication of this final rule, is not already obligated by law, regulation, or judicial
consent decree to maintain the staffing ratios set forth in this paragraph shall have
until October 1, 2017, to achieve compliance.
Staffing ratios for the facility are provided by the direct care staff. The security
practices and policies ensure the PREA ratios of 1:8 during the waking hours and
1:16 during the sleeping hours. The facility's staffing plan provides for the staffing
ratios to be met and provides for additional staff for days and times when increased
staffing is required. The staffing ratios of 1:8 and 1:12 must be maintained in
accordance with the executed contract between the two agencies. The ratios were
discussed and observed for and met during the site review and review of
documentation. In addition to mandatory holdover days, trained direct care staff
from a larger sister facility may be used to maintain the staffing ratios during a
shortage of staff. Direct care staff members provide direct observation of residents.
Since the last PREA audit the average daily number of residents is 24. Since the last
PREA audit, the average daily number of residents on which the staffing plan was
predicated is 24. The facility is not involved in any lawsuits or consent decrees.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each facility
the agency operates, in consultation with the PREA Compliance Manager required
by §115.311, the agency shall assess, determine, and document whether
adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other monitoring
technologies; and
(4) The resources the facility has available to commit to ensure adherence to the
staffing plan.
At least annually, the PREA Compliance Manager in collaboration with the DJJ
statewide PREA Coordinator, review and assess the staffing plan to see whether
adjustments are needed in the four tenets identified in the Standard. The formally
documented assessment data was completed by the DJJ statewide PREA Coordinator
who also facilitated the process, in collaboration with the PREA Compliance
Manager. The document reviews but is not limited to the following areas: prevailing
staffing patterns and review of staffing plan; electronic monitoring system; and
review of other areas related to adequate supervision. The assessment considers
any adjustments that need to be made by the construction and implementation of a
corrective action plan where indicated through findings of recommendations. The
annual assessment documents the summarization of the review including the
staffing, physical plant and electronic monitoring system. There were no corrective
actions recommended through the completion of the 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 supervisory rounds are occurring, unless such announcement is related to the
legitimate operational functions of the facility.
Policy and practice provide for the occurrence of unannounced rounds that are
conducted by management staff members. The staff conducting the rounds include
the Superintendent, Assistant Superintendent and Clinical Director. The documents
show the rounds are made at various times. A dedicated form is used which records
the areas visited and considerations and observations may be included. The
interview with the Intermediate or Higher-Level Staff and review of documentation
confirmed the unannounced rounds occur.
The staff is not informed of when the rounds will occur and the visits are not
conducted at scheduled times in accordance with policy. The unannounced rounds
are conducted throughout the facility to identify and deter sexual abuse and sexual
harassment. Staff members are prohibited by policy from alerting other staff when
the rounds are occurring. Over time, the formal unannounced rounds cover all shifts.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the Auditor determined the facility is compliant with this standard.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Facility Policy 8-14, LGBTI Youth
Agency Policy FDJJ 1919, PREA
Training Curricula
Statement of Preference Form
Acknowledgement Statements
Electronic Training Records
Interviews:
Random Staff
Superintendent
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual
body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
Cross-gender strip searches and cross-gender visual body cavity searches are
prohibited. Cross-gender pat-sown searches are not permitted, except in exigent
circumstances and they must be documented. Policy and training provide guidance
to staff on how the searches are to be conducted. The practice is that cross-gender
pat searches are not conducted. There is no evidence of cross-gender searches of
any type occurring at the facility in the last 12 months. Based on the review of the
PREA Pre-Audit Questionnaire and according to the interviews, cross-gender
searches have not been conducted at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy does not support staff conducting cross-gender pat-down searches, except in
exigent circumstances. All searches and the reason for the search must be
documented. The interviews revealed that male staff only conduct searches and
there is always a male staff on the floor. There would have to be an extreme
emergency for a cross-gender pat-down search to occur, based on the interviews
with random staff. The training materials and staff interviews support that staff
receives training on how to conduct cross-gender pat-down searches. No residents
or staff interviewed reported the occurrence of any cross-gender searches. The
evidence shows cross-gender pat-down searches have not occurred at the facility
during the last 12 months.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-gender
visual body cavity searches, and cross-gender pat-down searches.
The practice is that cross-gender strip and cross-gender visual body cavity searches
are prohibited. Policy provides for documenting the occurrence of searches and the
reasons for each type of search if the situation occurs. All interviews confirmed that
no cross-gender searches have occurred at the facility during this audit period. Staff
members are instructed to document all searches. There was no evidence
documenting any cross-gender searches. All residents interviewed stated they have
not received a cross-gender pat-down search.
Provision (d):
The facility shall implement policies and procedures that enable residents to
shower, perform bodily functions, and change clothing without nonmedical staff of
the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent
circumstances or when such viewing is incidental to routine cell checks. Such
policies and procedures shall require staff of the opposite gender to announce their
presence when entering a resident housing unit. In facilities (such as group homes)
that do not contain discrete housing units, staff of the opposite gender shall be
required to announce their presence when entering an area where residents are
likely to be showering, performing bodily functions, or changing clothing.
Residents are able to shower, perform bodily functions, and change clothes without
staff of the opposite gender viewing them, supported by policy and interviews. This
practice was confirmed through interviews with residents and staff. No residents
interviewed reported ever having been naked in full view of the opposite gender
staff while showering, changing clothes, and performing bodily functions. During the
comprehensive site review, the Superintendent explained how hygiene practices are
conducted and the bathroom procedures. It was observed that residents have a
reasonable amount of privacy during use of the bathroom.
Staff members of the opposite gender must announce their presence when entering
the residents’ housing area and signs are posted. The residents stated that the
opposite gender staff announce their presence upon entering the living area. The
practice of opposite gender announcement was confirmed by the random staff and
resident interviews. The evidence shows residents shower, perform bodily functions,
and change clothes without nonmedical staff of the opposite gender viewing their
buttocks or genitalia. The staff interviews and observations supported that viewing
of the camera monitors does not show residents when they are showering, using the
toilet or changing clothes. The shower and toilet area do not allow staff to get a
view of the resident’s body. Hygiene practices are performed with the expectations
of reasonable privacy for each resident.
Provision (e):
The facility shall not search or physically examine a transgender or intersex resident
for the sole purpose of determining the resident’s genital status. If the resident’s
genital status is unknown, it may be determined during conversations with the
resident, by reviewing medical records, or, if necessary, by learning that information
as part of a broader medical examination conducted in private by a medical
practitioner.
Policy and the training curriculum prohibit the search of transgender or intersex
residents solely for the purpose of determining the residents’ genital status and
staff interviews verified no such searches have occurred or would occur at the
facility. The facility reports and staff interviews support that staff receive training on
conducting searches and searches of transgender and intersex youth. Staff
interviews confirmed they are aware that policy prohibits staff from conducting a
physical examination of transgender or intersex youth solely for the purpose of
determining the resident’s genital status. When the genital status of a resident is
unknown, learning this information will be part of a broader medical examination
conducted by a medical practitioner in private, according to policy. The facility will
utilize the Statement of Preference Form where indicated when a youth indicates
the gender of the staff preferred to conduct the search.
Provision (f):
The agency shall train security staff in how to conduct cross-gender pat-down
searches, and searches of transgender and intersex residents, in a professional and
respectful manner, and in the least intrusive manner possible, consistent with
security needs.
The facility reports that 100% of the direct care staff have received training on how
to conduct cross-gender pat-down searches and searches of transgender and
intersex youth. The training curricula for staff provides information on conducting
cross-gender pat-down searches and searches of transgender and intersex youth.
Electronic training records, interviews and training materials indicate the provision
of search techniques consistent with the security needs. A dedicated form,
Statement of Preference, may be used for a youth to identify the sexual preference
of the staff to perform the searches. The training materials and interviews indicate
staff receive the training. No such searches have been conducted during the past 12
months.
Conclusion:
Based on the reviewed documentation and interviews, the Auditor determined
compliance with this standard.
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
PREA Brochures (English, Creole, Spanish)
PREA Video (Spanish)
Multilingual Posters
Interviews:
Residents
Random Staff
Facility Administrator
Assistant Facility Administrator
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities
(including, for example, residents who are deaf or hard of hearing, those who are
blind or have low vision, or those who have intellectual, psychiatric, or speech
disabilities), have an equal opportunity to participate in or benefit from all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. Such steps shall include, when necessary to ensure effective
communication with residents who are deaf or hard of hearing, providing access to
interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary. In
addition, the agency shall ensure that written materials are provided in formats or
through methods that ensure effective communication with residents with
disabilities, including residents who have intellectual disabilities, limited reading
skills, or who are blind or have low vision. An agency is not required to take actions
that it can demonstrate would result in a fundamental alteration in the nature of a
service, program, or activity, or in undue financial and administrative burdens, as
those terms are used in regulations promulgated under title II of the Americans With
Disabilities Act, 28 CFR 35.164.
Policy addresses the provision of support services for Limited English Proficient and
disabled residents by providing residents the equal opportunity to participate in or
benefit from all aspects of the facility’s efforts to prevent, detect, and respond to
sexual abuse and sexual harassment. Residents are not used as readers or
interpreters, confirmed by staff interviews and policy. The facility has bilingual staff
that will assist with interpreting. Policy provides for interpreter and translation
services, including the services for the Deaf.
The facility’s parent agency has a contract for services with LanguageLine Solutions.
An additional resource accessible by the parent agency is a Nationally Certified
Interpreter through the Florida Registry of Interpreters for the Deaf. The education
and school district provides support services, especially through certified teachers
with the educational background to modify/adapt information for all residents to
understand. Assistance may also be provided by the mental health staff to ensure
all residents’ understanding of the PREA information. Posted and other PREA
information is in English, Creole, and/or Spanish.
Provision (b):
The agency shall take reasonable steps to ensure meaningful access to all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment to residents who are limited English proficient, including steps to
provide interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary.
Professional interpreting services are available. Each resident has an equal
opportunity to participate in or benefit from all aspects of the facility’s efforts to
prevent, detect and respond to sexual abuse and sexual harassment. PREA
information is accessible to residents in English, Spanish, Creole, and other
languages are obtainable where indicated. The facility is capable of providing
access to support services for preventing, detecting, and responding to sexual
abuse and sexual harassment to residents who are Limited English Proficient,
including taking steps to provide interpreters who can interpret effectively,
accurately, and impartially. There were no targeted interviewees during this site
review.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other types
of resident assistants except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s safety, the
performance of first-response duties under §115.364, or the investigation of the
resident’s allegations.
Policies prohibit the use of resident readers and interpreters except in limited
circumstances where an extended delay in obtaining an interpreter could
compromise a resident’s safety; performance of first responder duties; or
investigation of allegations of sexual abuse or sexual harassment. The facility
documents that there is access to services. The school system and teachers assist
and facility mental health staff members have the capabilities to provide support
services. Information regarding reporting allegations of sexual abuse and sexual
harassment is posted and accessible in both English, Creole, and Spanish. The
facility has the resources available to get the PREA information translated and
printed in additional languages as needed.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 3-16, Employee Recruitment and Selection
Facility Policy 10-25, PREA
Agency Policy FDJJ 1800, Background Screening and Hiring Practice
Agency Policy FDJJ 1919, PREA
Personnel Records
Personal Preference Verification Form
Employee Handbook
Interview:
Superintendent
Provisions (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.
The collective documents address hiring and other personnel matters, including but
not limited to promotion processes and decisions; position descriptions; and
background checks, including child abuse registries. The background checks occur
initially and every five years thereafter, aligned with policy and the Standard. The
personnel files include the completed background checks and hiring documents.
Background checks are obtained through the Florida Department of Juvenile Justice,
Background Screening Unit. Policy FDJJ 1919 prohibits hiring or promoting anyone
who may have contact with residents with residents when they have been involved
in sexual abuse and sexual harassment behavior.
Through the employment application process, prior to hire and promotion,
applicants are asked to verify, in writing, the following information which is a part of
the background screening information packet:
• Have engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42
U.S.C. 1997);
• Have been convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent or refuse;
or,
• Have been civilly or administratively adjudicated to have engaged in the
activity described above.
The aforementioned is also gleaned from current employees during evaluations.
Staff are informed of their continuing duty to report any related misconduct. The
interview and a review of policies provided details about the hiring process,
completion of background checks, and grounds for termination. The forms
completed and included in the personnel files are responsive to the provisions of
this standard. All applicants are asked about any prior misconduct involving any
sexual activity. The documentation and interview support the facility does not hire
anyone who has engaged in sexual abuse or anyone who has used or attempted to
use force in the community to engage in sexual abuse. This documentation is a part
of the background information packet, required for conducting the criminal
background checks. A sample of background checks were reviewed which confirmed
that they are conducted in accordance with policy and the interview.
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.
Policies support that the facility does not hire or promote anyone who has been
civilly or administratively adjudicated or have been convicted of engaging in or
attempted to engage in sexual activity by any means. The interview was aligned
with the standard and the documentation shows the inquiries made during the
application process regarding previous misconduct.
Policy and the interview indicate the facility considers any incidents of sexual
harassment in determining whether to hire or promote anyone, or to enlist the
services of any contractor or volunteer, who may have contact with residents. No
applicant will be considered for employment if a background check reveals any
history of inappropriate sexual behavior or arrest for inappropriate sexual behavior.
A sample of background checks were reviewed confirming the background checks
occur.
Provisions (c) & (d):
(c): Before hiring new employees who may have contact with residents, the agency
shall:
(1) Perform a criminal background records check;
(2) Consult any child abuse registry maintained by the State or locality in which the
employee would work; and
(3) Consistent with Federal, State, and local law, make its best efforts to contact all
prior institutional employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an allegation of sexual
abuse.
(d): The agency shall also perform a criminal background records check, and
consult applicable child abuse registries, before enlisting the services of any
contractor who may have contact with residents.
The background check process includes consulting a child abuse registry as
confirmed during the interview. The prospective employee or contractor also has to
be cleared through the Florida Department of Children and Families. Best efforts are
made to identify information of incidents or allegations of sexual abuse by a
prospective employee. The facility conducts background checks on contractors and
volunteers.
Provision (e):
The agency shall either conduct criminal background records checks at least every
five years of current employees and contractors who may have contact with
residents or have in place a system for otherwise capturing such information for
current employees.
Initial background checks are conducted and are conducted every five years
thereafter, in accordance with policy. The interview, review of documentation and a
review of the policies provide details about the hiring process, completion of
background checks, and the grounds for termination in accordance with the PREA
standard. A sample of Re-Screens (five-year background checks) were reviewed by
the Auditor.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false
information, shall be grounds for termination.
The omission of sexual misconduct information or providing false information is
grounds for termination in accordance with policy. According to the interview, this
information is also covered in the new employee orientation. Staff members have a
continuing duty to report related misconduct as indicated in the Employee
Handbook. Employees are informed during new employee orientation that they
have a continuing affirmative duty to disclose any such misconduct. Additionally,
the facility receives an alert if an employee is arrested.
Provision (h):
Unless prohibited by law, the agency shall provide information on substantiated
allegations of sexual abuse or sexual harassment involving a former employee upon
receiving a request from an institutional employer for whom such employee has
applied to work.
The interview revealed that when a former employee applies for work at another
institution, upon the request from that institution, the employment and hire date
may be verified. Other requests will be forwarded to regional administrative
personnel staff.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has
determined the facility meets the provisions of the standard.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Interview:
Superintendent
Provision (a):
If the agency designed or acquired any new facility or planned any substantial
expansion or modification of existing facilities, did the agency consider the effect of
the design, acquisition, expansion, or modification upon the agency’s ability to
protect residents from sexual abuse?
The facility has not completed substantial expansion or modification since the last
PREA audit.
Provision (b):
If the agency installed or updated a video monitoring system, electronic surveillance
system, or other monitoring technology, the agency considered how such
technology may enhance the agency’s ability to protect residents from sexual
abuse.
The camera system supplements direct supervision provided to residents by staff.
The system has received maintenance since the last PREA audit.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Memorandum of Understanding (MOU)
PREA Compliance Form
Interviews:
Random Staff
Medical Staff
Mental Health Staff
Advocacy Agency Representative
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.
Administrative investigations are investigated by the Florida Department of Juvenile
Justice (DJJ), Office of Inspector General (OIG), agency investigators. All allegations
that are criminal in nature will be referred to law enforcement. Policy will be
followed regarding investigations of sexual abuse in accordance with the standard.
The investigative staff's interview from a previous audit and random staff interviews
confirmed awareness of protocol for obtaining usable physical evidence and
knowledge of the entities responsible for conducting investigations. The protocol for
investigations is appropriate for youth. The PREA Compliance Form is shared with
local law enforcement investigators outlining the PREA standards that must be
adhered to regarding an investigation of an allegation of sexual abuse. The DJJ
investigators are also aware of the PREA standards and investigation protocols.
Provision (c):
The agency shall offer all residents who experience sexual abuse access to forensic
medical examinations whether on-site or at an outside facility, without financial
cost, where evidentiarily or medically appropriate. Such examinations shall be
performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse
Examiners (SANEs) where possible. If SAFEs or SANEs cannot be made available, the
examination can be performed by other qualified medical practitioners. The agency
shall document its efforts to provide SAFEs or SANEs.
Forensic medical examinations will be conducted by a Sexual Assault Nurse
Examiner or other qualified medical practitioner. Continuity of care will be provided
at the facility. Forensic examinations will be provided at no cost to the victim in
accordance with policy, interviews and written agreement with the Roxcy Bolton
Rape Treatment Center. No forensic medical examinations were conducted during
this audit period.
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. (e): As requested by the victim, the victim
advocate, qualified agency staff member, or qualified community-based
organization staff member shall accompany and support the victim through the
forensic medical examination process and investigatory interviews and shall provide
emotional support, crisis intervention, information, and referrals.
Victim advocacy services have been arranged and outlined in a written agreement
between the facility and the Roxcy Bolton Rape Treatment Center. The Center
provides a range of programs and services including forensic examinations,
advocacy and resource assistance for survivors of sexual assault. The advocacy
agency follows all applicable laws and regulations with respect to confidentiality and
privacy. The advocacy services include but are not limited to:
• 24-hour hotline services;
• Emotional Support/Counseling;
• Follow-up support services;
• Provision of a forensic medical examination;
• Accompaniment for forensic medical examination; and
• Accompaniment for investigation interview.
Information regarding victim advocacy services is provided to the residents during
the intake process, according to staff, and is provided through the accessibility of
posted information. Victim advocacy services are provided at no cost to the victim.
The medical staff and representative from Roxcy Bolton Rape Treatment Center
confirmed the advocacy services that will be provided to a victim. The interviews
with the residents revealed five out of 10 did not have a clear understanding of the
services provided by the advocacy agency. The Superintendent implemented a
corrective action and conducted a refresher educations session, focused on
advocacy services, for all residents; the sign-in sheet was provided to the Auditor.
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. (g): The requirements of
paragraphs (a) through (f) of this section shall also apply to:
(1) Any State entity outside of the agency that is responsible for investigating
allegations of sexual abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for investigating
allegations of sexual abuse in juvenile facilities.
Florida DJJ/OIG investigators from its central office will conduct administrative
investigations in accordance with agency policy and the protocols as outlined on the
PREA Compliance Form. Investigations of allegations of sexual abuse or sexual
harassment that are criminal in nature will be referred to law enforcement in
accordance with policies and the provisions of the Standard.
Provision (h):
For the purposes of this standard, a qualified agency staff member or a qualified
community-based staff member shall be an individual who has been screened for
appropriateness to serve in this role and has received education concerning sexual
assault and forensic examination issues in general.
The facility has made arrangements for victim advocacy services with the Roxcy
Bolton Rape Treatment Center (RBRTC) which provides a comprehensive approach
to the care and treatment of sexual assault victims. The interviews and MOU
confirmed the availability of advocacy services. The MOU is currently being
reviewed to update the signatures on the written agreement. The RBRTC services to
a victim will not be impeded pending the update of signatures to the MOU,
according to RBRTC management staff. The background and training of some
treatment staff provide them with familiarity of general sexual assault and forensic
examination issues and they may be of service to a youth as an advocate if needed.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the provisions of this standard.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Investigation Reports
PREA Compliance Form
Websites
Interviews:
Random Staff
Superintendent
Statewide PREA Coordinator/Agency Head Designee
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
The Florida Department of Juvenile Justice (DJJ) ensures an administrative or
criminal investigation is completed for all allegations of sexual abuse and sexual
harassment in State-run and contract facilities such as this facility. Policies provide
that staff report all allegations of sexual abuse and sexual harassment and to
document reports; staff members are aware of the requirements. The facility reports
one allegation of sexual abuse and one allegation of sexual harassment. Sexual
abuse and sexual harassment allegations are referred to the DJJ/Office of Inspector
General (OIG), Florida Department of Children and Families, and law enforcement if
criminal in nature. The allegation of sexual harassment was staff-on-resident; the
allegation of sexual abuse was resident-on-resident. Both allegations were
investigated by a DJJ/OIG investigator. The results of the administrative
investigations determined the allegations were unfounded. There were no
allegations that were criminal in nature. Policies and interviews provide for
investigations of all allegations of sexual abuse and sexual harassment.
Provisions (b) & (c):
(b): The agency shall have in place a policy to ensure that allegations of sexual
abuse or sexual harassment are referred for investigation to an agency with the
legal authority to conduct criminal investigations, unless the allegation does not
involve potentially criminal behavior. The agency shall publish such policy on its
website or, if it does not have one, make the policy available through other means.
The agency shall document all such referrals. (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.
DJJ has an overarching PREA policy that requires allegations of sexual abuse or
sexual harassment be referred for investigation to an agency with the legal
authority to conduct criminal investigations which include the Florida Department of
Children and Families and law enforcement. The DJJ does not conduct criminal
investigations; only administrative investigations. Policy, indicating which
investigative entities investigate what, and reporting information are located on the
DJJ and facility’s parent agency websites and posted within the facility, accessible to
the public. Policies, investigation reports, and interviews confirmed allegations of
sexual abuse and sexual harassment are investigated. Administrative investigations
are conducted by DJJ/OIG trained investigators. Allegations that are criminal in
nature are referred to law enforcement. There were no allegations reported that
were criminal in nature.
Provision (d):
Any State entity responsible for conducting administrative or criminal investigations
of sexual abuse or sexual harassment in juvenile facilities shall have in place a
policy governing the conduct of such investigations.
The DJJ/OIG has policy/directive governing investigations. The agency utilizes
trained investigators. A previous interview with an investigative staff, investigation
reports, and agency previous reports confirm that administrative investigations are
conducted by a trained investigator and allegations that are criminal in nature will
be referred to law enforcement.
Provision (e):
Any Department of Justice component responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in juvenile facilities
shall have in place a policy governing the conduct of such investigations.
The Department of Justice is not responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in this facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Facility Policy 5-1, Staff Development and Training
Facility Policy 5-2, Staff Development and Annual Training
Agency Policy FDJJ 1919, PREA
Training Curricula
Electronic Training Records
Training Sign-In Sheets
Contract Language
Interviews:
Random Staff
Provisions (a) & (c):
(a): The agency shall train all employees who may have contact with residents on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency sexual abuse and sexual
harassment prevention, detection, reporting, and response policies and procedures;
(3) Residents’ right to be free from sexual abuse and sexual harassment;
(4) The right of residents and employees to be free from retaliation for reporting
sexual abuse and sexual harassment;
(5) The dynamics of sexual abuse and sexual harassment in juvenile facilities;
(6) The common reactions of juvenile victims of sexual abuse and sexual
harassment;
(7) How to detect and respond to signs of threatened and actual sexual abuse and
how to distinguish between consensual sexual contact and sexual abuse between
residents;
(8) How to avoid inappropriate relationships with residents;
(9) How to communicate effectively and professionally with residents, including
lesbian, gay, bisexual, transgender, intersex, or gender nonconforming residents;
and
(10) How to comply with relevant laws related to mandatory reporting of sexual
abuse to outside authorities;
(11) Relevant laws regarding the applicable age of consent.
(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 agency and facility provide and/or conduct the required training, according to
the Standard, for all employees who may have conduct with residents. Policies
address PREA related training for staff which is formally provided initially and
annually; refresher sessions are provided throughout employment. Refresher
sessions may be conducted in staff meetings and shift briefings which include any
changes in policy, procedures, and practice; and general PREA related practices that
do not occur at all or very little in order to keep staff alert. Interviewed staff
members were generally familiar with the PREA information. PREA training is
provided to staff, as indicated by a review of facility and agency policies, training
documents, and interviews. All staff have contact with residents and have received
PREA training.
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 staff training considers the needs of the population
served as indicated by the interviews. Policies and interviews support training being
tailored to the needs and attributes of the population served. All staff within the
facility are provided PREA training.
Provision (d):
The agency shall document, through employee signature or electronic verification
that employees understand the training they have received.
The PREA training reviewed was documented electronically and manually through
sign-in sheets and verified through staff interviews.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the standard.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-22, Volunteers
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Training Curriculum
Acknowledgement Statements
Interviews:
Volunteers
Contractors
Superintendent
Provision (a):
The agency shall ensure that all volunteers and contractors who have contact with
residents have been trained on their responsibilities under the agency’s sexual
abuse and sexual harassment prevention, detection, and response policies and
procedures.
Volunteers and contractors who have contact with residents must be trained on
PREA and their responsibilities regarding sexual assault prevention, detection, and
response to allegations of sexual abuse and sexual harassment. A review of
documents, training curriculum, interviews and observation confirmed the training
occurs. The training curriculum includes but is not limited to information in the
following areas: reporting allegations of sexual abuse and sexual harassment;
related definitions; detecting sexual abuse and sexual harassment; and maintaining
professional relationships with residents.
Provision (b):
The level and type of training provided to volunteers and contractors shall be based
on the services they provide and level of contact they have with residents, but all
volunteers and contractors who have contact with residents shall be notified of the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and
informed how to report such incidents.
The interviews and review of documentation revealed the PREA training informs the
participants of their role in reporting allegations of sexual abuse and sexual
harassment. The participants are informed of their responsibilities regarding sexual
abuse prevention, detection, and response to an allegation of sexual abuse or
sexual harassment. The training is based on the services provided by the
contractors and volunteers. Any person performing contract or volunteer services
receive PREA training as a part of the onboarding process and training is
documented. The interviews revealed familiarity with the zero-tolerance policy
regarding sexual abuse and sexual harassment of residents, including how to report.
The interviews confirmed the review of the zero-tolerance policy is included in the
PREA training. The volunteers interviewed provide life skills education services and
the contractors provide academic education services to the residents.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The training documentation and interviews confirmed the receipt and awareness of
PREA training by contractors and volunteers. The interviews and acknowledgement
statements indicated understanding of the training received. The PREA training is
made available to volunteers and contractors prior to them providing services within
the facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the provisions of this standard.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 9-2, Classification and Orientation
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Resident Handbook
Orientation Checklist
Acknowledgement Statements
Training Logs/Sign-in Sheets
Training Materials
Brochures
Posters
Interviews:
Residents/Targeted Interviewees
Intake Staff
Provisions (a) & (b):
(a): During the intake process, residents shall receive information explaining, in an
age- appropriate fashion, the agency’s zero tolerance policy regarding sexual abuse
and sexual harassment and how to report incidents or suspicions of sexual abuse or
sexual harassment. (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.
Youth receive information at the time of intake about PREA including the zero-
tolerance policy of the facility and how to report allegations of sexual abuse and
sexual harassment. Policies provide that all residents admitted receive PREA
education. Residents receive directions on how to report allegations of sexual abuse
and sexual harassment; and the right to be free from retaliation for reporting,
according to the documentation and interview with the intake staff. The residents
have a clear understanding of the aforementioned and the various ways of how to
report allegations of sexual abuse and sexual harassment.
A review of the education materials indicated the information provided to the
residents is age-appropriate. It was revealed that PREA refresher education sessions
are conducted during group sessions as a rotating topic among treatment topics
covered in group activities. The intake staff makes herself available to also address
questions that a resident may have regarding PREA. A review of the education
materials show the information is age-appropriate however it was recommended
that additional emphasis be placed on the identification and purpose of the
advocacy agency and the services provided and that it be rotated in the group
sessions more often. The residents initially sign acknowledgement statements which
represent receipt of the PREA information provided.
The interviews with the residents revealed the need for a refresher education
session focusing on the advocacy agency and the services provided to victims of
sexual abuse to ensure the residents’ clear and un-contradicted understanding of
the information. Five out of 10 residents interviewed did not have a clear
understanding of the information provided regarding advocacy services. The
corrective action of conducting a refresher PREA education session regarding the
victim advocacy services and agency, Roxcy Bolton Rape Treatment Center, was
implemented. The Superintendent confirmed the refresher education session and
provided documentation of training log/sign-in sheet which included the training
topic that supported the occurrence of the refresher PREA education session. The
sign-in sheet was also signed by the instructor indicating the occurrence of the
refresher education session.
Provision (c):
Current residents who have not received such education shall be educated within
one year of the effective date of the PREA standards, and shall receive education
upon transfer to a different facility to the extent that the policies and procedures of
the resident’s new facility differ from those of the previous facility.
Based on the evidence shown documenting the PREA education sessions in
Provisions (a) and (b), including corrective actions and interviews, all residents
received PREA education. The facility reports that 37 youth were admitted to the
facility during the past 12 months and that all participated in PREA education
sessions. Formal interviews and informal conversations with residents and interview
with intake staff and review of documentation support that all youth admitted to the
facility receive PREA education during the intake process. Acknowledgement
statements and the interviews indicate that general PREA education is provided and
the corrective action supplemented the general education by providing customized
information regarding outside advocacy services which will be incorporated and
emphasized in the future PREA education sessions. Policy provides that all youth
admitted to the facility receive PREA education.
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, per policy. The
education unit is also a resource for accessibility, supportive services, and
translation services and other accommodations. Assistance may also be provided by
the mental health staff to ensure all residents’ understanding of the PREA
information. The facility has bilingual staff as well as access to additional agency
bilingual staff in the sister facility within the same city.
Policy provides for interpreter and translation services. There is documentation and
policy that provide information and accessibility for the accommodations for
residents with special needs in this area. The education staff provides services
through certified teachers with the educational background to modify/adapt
information for all residents to understand. Posted and other printed PREA
information is in English and Spanish. The facility’s parent agency has a contract
with LanguageLine Solutions for translation and interpreting services that may be
used by their facilities as needed. A customer care representative confirmed the
available translating services, including services for the Deaf.
The random staff interviews revealed a practice of residents not used as translators
or readers for other residents. There is a collective awareness of the availability of
bilingual staff and professional translating and interpreting services. The facility has
knowledge of the youth’s arrival to the facility prior to the admission date. This time
period provides for the identified staff to make plans to accommodate the special
needs of residents. The special arrangements are coordinated by treatment team
staff in collaboration with the Superintendent. PREA posters, information sheets,
and other printed materials are collectively available in English, Spanish, some
Creole, and there is access to other languages when indicated.
Provision (e):
The agency shall maintain documentation of resident participation in these
education sessions.
Signed acknowledgement statements were reviewed which supported the residents’
involvement in PREA education sessions. The residents’ interviews revealed the
exposure to PREA through the PREA education sessions. The residents were aware
of how to report allegations of sexual abuse and sexual harassment and that they
would not be punished for reporting such. The refresher PREA education session and
receipt of advocacy agency information provides enhanced PREA education
sessions.
Provision (f):
In addition to providing such education, the agency shall ensure that key
information is continuously and readily available or visible to residents through
posters, resident handbooks, or other written formats.
The PREA education materials provide residents information on how to report
allegations of sexual harassment and sexual abuse. PREA information is posted and
provided to residents to assist in eliminating incidents of sexual abuse and sexual
harassment. The printed materials provide information on sexual abuse and sexual
harassment; steps victims may take; and reporting information. Each resident is
provided a handbook and an orientation packet which also contains PREA
information. PREA-related information was observed posted or displayed throughout
the facility.
PREA signage is placed at varying eye levels and are colorful and/or graphic with
consistent messages. The interviews with the residents revealed they know where
to find information on the wall if they need it. The interviews confirmed the PREA
audit notices had been up for awhile and that the PREA information is always on the
walls. PREA information is located in the housing area; common areas for staff,
residents, contractors, volunteers, and visitors; lobby; and offices. One sign was
adjusted during the onsite audit phase to clarify information regarding the advocacy
agency, in an effort to improve the provision of information regarding such
services.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, the Auditor determined the facility is compliant with the provisions of
this standard.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Agency Policy FDJJ 1800
Training Curriculum
Training Roster
Interview:
Statewide PREA Coordinator
Provisions (a) & (b):
(a): In addition to the general training provided to all employees pursuant to
§115.331, the agency shall ensure that, to the extent the agency itself conducts
sexual abuse investigations, its investigators have received training in conducting
such investigations in confinement settings. (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.
Administrative investigations are conducted by the Florida Department of Juvenile
Justice (DJJ)/Office of Inspector General (OIG). PREA training is required in addition to
the specialized training regarding conducting administrative investigations.
Allegations that are criminal in nature are referred for investigation by local law
enforcement. The previously conducted interview with an investigation staff and
review of documents confirmed administrative investigations are conducted by
trained investigators within the DJJ/OIG. The specialized training includes but is not
limited to interviewing techniques; proper use of Garrity and Miranda warnings/
specifically Garrity; preserving evidence; and criteria for supporting a finding of
substantiated, unsubstantiated or unfounded.
Provision (c):
The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse
investigations.
Documentation of training logs and any training certificates of the investigators are
maintained by DJJ. Allegations that are criminal in nature are referred to local law
enforcement, in accordance with policy.
Provision (d):
Any State entity or Department of Justice component that investigates sexual abuse
in juvenile confinement settings shall provide such training to its agents and
investigators who conduct such investigations.
The DJJ provides training to its investigators who will conduct administrative
investigations at the facility which was confirmed by interviews. Local law
enforcement is responsible for training their investigators who conduct sexual abuse
investigations that are criminal in nature.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Training Curricula
Training Records
Interviews:
Mental Health Staff
Medical Staff
Provision (a):
The agency shall ensure that all full- and part-time medical and mental health care
practitioners who work regularly in its facilities have been trained in:
(1) How to detect and assess signs of sexual abuse and sexual harassment;
(2) How to preserve physical evidence of sexual abuse;
(3) How to respond effectively and professionally to juvenile victims of sexual abuse
and sexual harassment; and
(4) How and to whom to report allegations or suspicions of sexual abuse and sexual
harassment.
Medical and mental health staff members receive the regular PREA training as well
as the specialized training provided through the Florida Department of Juvenile
Justice. Electronic training logs and interviews document regular PREA training and
the specialized training for medical and mental health staff members and the
interviews confirmed the training.
Provision (b):
If medical staff employed by the agency conduct forensic examinations, such
medical staff shall receive the appropriate training to conduct such examinations.
Forensic examinations are not conducted at the facility.
Provision (c):
The agency shall maintain documentation that medical and mental health
practitioners have received the training referenced in this standard either from the
agency or elsewhere.
Electronic training logs and interviews with medical and mental health staffs
confirmed receipt of the regular and specialized training. The regular and
specialized PREA training is provided online by the Florida Department of Juvenile
Justice. Regular PREA training is also provided at the facility through refresher
sessions and information incorporated in staff meetings.
Provision (d):
Medical and mental health care practitioners shall also receive the training
mandated for employees under Standard 115.331 or for contractors and volunteers
under Standard 115.332, depending upon the practitioner’s status at the agency.
Medical and mental health staff completed the general training that is provided for
all employees as indicated by training documentation and the interviews. The
standard PREA training is provided to all employees and the specialized training is
provided online by the Florida Department of Juvenile Justice and the records are
maintained electronically.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 9-1, Intake and Screening Process
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Statewide PREA Coordinator
Residents
Provision (a):
The policy provides that upon arrival or within 72 hours of the resident’s arrival at
the facility and periodically throughout a resident’s confinement, the agency shall
obtain and use information about each resident’s personal history and behavior to
reduce the risk of sexual abuse by or upon a resident.
Policy provides for each resident admitted to the facility to be screened for risk of
victimization or abusiveness, prior to room assignment in order to reduce the risk of
sexual abuse by or upon a resident. The interviews and practice indicate the risk
assessment is completed on the day of admission. According to the risk screener,
the youth is asked questions and an explanation of a question is provided as
needed; probing may be required depending on the youth. The youth is interviewed
to obtain information about personal history and behavior. The process described
indicated a rapport is established with the youth prior to asking any questions.
Information may also be obtained from the parent/guardian and through review of
the court packet.
The intake screening instrument, VSAB, is used to document such information and is
administered in a private office. The interviews revealed the practice of the risk
screening being conducted in accordance with the policies. Screening instruments
and interview with the risk screener confirmed the information obtained includes
but is not limited to:
• Prior sexual victimization or abusiveness;
• Resident’s own perception of vulnerability;
• Current charges and offense history;
• Self-identification of resident;
• Intellectual or developmental disabilities;
• Physical disabilities;
• Mental illness or mental disabilities
• Information regarding relationships with other youth
• Confirmation of size and stature
• Confirmation of Age
Policy addresses the occurrence and criteria regarding formal reassessments of
residents. It is reported that the number of youths admitted to the facility within the
past 12 months who were screened during the admission process for risk of sexual
victimization and the risk of sexually abusing other residents is 37. The risk
assessments are accessible to the clinical and case management staff. The resident
files were observed to be maintained in a confidential manner in a locked file
cabinet in a lockable office which is a part of the key control system. Electronic
information is password protected with access only to identified staff.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
An objective screening instrument is used to obtain the information required by the
standard, including but not limited to prior sexual victimization or abusiveness; self-
identification; current charges and offense history; disabilities; and a resident’s
concern regarding his/her own safety. The instrument, VSAB, is tabulated based on
the information received where identified responses can identify any special needs
and safety concerns. Assessments are conducted through the use of the VSAB
containing verifiable items that collectively provide a presumptive determination of
risk for victimization or abusiveness. The VSAB is administered by mental health
staff consistently, the same trained group, which also assists in minimizing
subjective interpretation and bias.
Provision (c):
At a minimum, the agency shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) Any gender nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident may therefore be
vulnerable to sexual abuse;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The residents’ own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or separation from
certain other residents.
The Auditor reviewed the screening instrument and determined the items required
by this provision of the standard are included within the instrument. The interview
with the risk screener confirmed awareness of the elements of the risk screening
instrument. The resident interviews also confirmed the administration of the
screening instrument and the general inquiries made. The interviews revealed the
practice is that the instrument is administered the first day of the youth’s admission
to the facility.
Provision (d):
This information shall be ascertained through conversations with the resident during
the intake process and medical and mental health screenings; during classification
assessments; and by reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files.
The information to complete the risk screening instrument is gleaned from various
sources. Information in determining the risk for victimization or abusiveness is
obtained through interviewing the youth. Additional information to complete the
screening instrument includes review of the court packet and interviews with a
parent/guardian. The facility is aware of the youth’s pending arrival to the facility
and treatment staff has the opportunity to review the residents electronic record in
an effort to preliminarily prepare for the needs prior to their arrival. Additional
assessments are completed after the youth is admitted to the facility to obtain
supportive information for treatment planning and keeping the youth safe.
Provision (e):
The agency shall implement appropriate controls on the dissemination within the
facility of responses to questions asked pursuant to this standard in order to ensure
that sensitive information is not exploited to the resident’s detriment by staff or
other residents.
Appropriate controls are taken to ensure that sensitive information is protected and
not exploited by maintaining the files securely in a locked file cabined in locked
offices when unoccupied. The key to the offices are in the key control system.
Electronic information is password protected with limited and identified staff access.
The risk screener addressed the management of sensitive information and the
expectation of confidentiality by staff. The treatment and case management staffs
have access to the risk screening instruments. Confidentiality is a component of
staff training and addressed by policy.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 9-1, Intake and Screening Process
Facility Policy 9-2, Classification and Orientation
Facility Policy 9-3, Risk Assessment
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
Medical Staff
Mental Health Staff
Residents
PREA Compliance Manager
PREA Coordinators
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.
The facility uses information from the risk screening required to inform housing,
bed, work, education, and program assignments. Policies collectively provide
guidance to staff regarding the use of the information obtained from the screening
instrument. The interview with the staff responsible for the risk screening indicate
the screening information is used to inform staff of information based on the need to
know, housing and program assignments, and assist in identifying treatment and
any special services. Housing and other assignments are not made by the Case
Manager until the VSAB is completed by mental health staff.
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.
The practice is that the facility does not use isolation as identified through the
interviews and observations. The staff interviews indicated that protective measures
will be taken immediately when needed and includes separating residents, closer
supervision, and notifying supervisors and administrators. There were not any
residents identified as at-risk of sexual victimization. Policy does exists if the
situation should ever occur.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in
particular housing, bed, or other assignments solely on the basis of such
identification or status, nor shall agencies consider lesbian, gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being
sexually abusive.
Gay, bisexual, transgender, or intersex residents are not placed in specific housing
solely based on how the residents identify or their status. Staff members are
prohibited from considering the identification as an indicator that these residents
may be more likely to be sexually abusive. During the site review, there were no
rooms or units observed or identified to be reserved for gay, bisexual, transgender,
or intersex youth. Housing assignments are made on a case-by-case basis as
supported by policy, interviews and practice.
Provision (d):
In deciding whether to assign a transgender or intersex resident to a facility for
male or female residents, and in making other housing and programming
assignments, the agency shall consider on a case-by-case basis whether a
placement would ensure residents’ health and safety, and whether the placement
would present management or security problems.
Policy and practice support that housing and program assignments for transgender
or intersex residents are made on a case-by-case basis which was evident from staff
interviews and observations. The interview with the risk screener confirmed that
staff considers on a case-by-case basis whether a placement ensures a resident’s
health and safety, and whether the placement will present management or security
problems. The interviews indicate staffs’ awareness and efforts in keeping residents
safe. There were no residents in the facility in this category in the facility for the
past year.
Provision (e):
Placement and programming assignments for each transgender or intersex resident
shall be reassessed at least twice each year to review any threats to safety
experienced by the resident.
Policy provides placement and programming assignments for each transgender or
intersex resident be reassessed twice per year to determine any threats to safety
experienced by the resident. The interview with the risk screener confirmed
awareness of policy. The practice of reassessments occurring with all residents
provides that the reassessment of transgender and intersex youth will occur at least
twice per year.
Provision (f):
A transgender or intersex resident’s own views with respect to his or her own safety
shall be given serious consideration.
The resident’s concern for their own safety is taken into account through the
administration of the risk vulnerability screening instrument, treatment team
meetings and individual sessions and interactions with Therapists and Case
Managers. The interviews with staff and review of documentation were aligned with
the policy.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender or intersex residents are given the opportunity to shower separately
from other residents which is also supported by the interviews and policy. There
were no identified residents in this area to be interviewed and have not been for the
last 12 months.
Provision (h):
If a resident is isolated pursuant to paragraph (b) of this section, the facility shall
clearly document:
(1) The basis for the facility’s concern for the resident’s safety; and
(2) The reason why no alternative means of separation can be arranged.
Agency policy provides that a resident will only be placed in isolation as a last resort
for protection and it would only be until other arrangements could be made to keep
the resident safe. The provisions of this standard will be provided if such occurs
however the practice is that isolation is not used in this facility. No residents were
determined at-risk of sexual victimization during the 12 months preceding the
audit.
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.
Isolation is not used in this facility as the practice.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 1-5, Incident Reporting
Facility Policy 8-3, Abuse and Neglect Reporting
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Florida Administrative Code, Rule 63F-11
Resident Handbook
Let's Talk Form
Grievance Form
Posted Information
Brochures
Interviews:
Random Staff
Residents
PREA Compliance Manager
Provision (a):
The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation by other residents or staff for
reporting sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents.
Policy provides for internal ways a resident may report allegations of sexual abuse
and sexual harassment, including how to privately report sexual abuse and sexual
harassment; retaliation for reporting; and staff neglect or violations of
responsibilities that may have contributed to such. Residents may report allegations
of sexual abuse or sexual harassment by telephone through the 24-hour Florida
abuse reporting hotline. Telephones are made accessible to residents for reporting
allegations of sexual abuse and sexual harassment. Staff members are required to
make the use of the telephone accessible for residents to report allegations of
sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents.
Policy, posters, brochures, information sheet, and the handbook collectively provide
telephone numbers and instructions for reporting allegations of sexual abuse or
sexual harassment. In addition to accessing a telephone, residents are also
informed in the PREA education sessions, determined from the interviews, that they
may tell staff; submit a complaint in writing utilizing the use of a Let's Talk form (a
Grievance form may also be used to write the complaint); or use the hotline
regarding allegations of sexual abuse or sexual harassment.
The residents interviewed identified someone who did not work at the facility they
could report to about sexual abuse or sexual harassment. The random staff and
resident interviews collectively revealed residents may use a telephone, submit a
complaint in writing, or talk to staff to privately report allegations of sexual abuse
and sexual harassment. The resident is provided the hotline number in writing
throughout the facility, including in the, resident handbook, brochures, and posted
information.
Residents have access to writing utensils; help request forms; and locked boxes for
receipt of the forms which are accessible to all residents for reporting allegations of
sexual abuse and sexual harassment. Written notes or letters and other completed
forms may also be given to staff. If a grievance form is used to make a written
allegation of sexual abuse or sexual harassment, the reporting procedures will be
implemented in accordance with policy. PREA information is posted and each
resident is provided a handbook which contains reporting and other PREA related
information. Staff members receive information on how to report allegations of
sexual abuse or sexual harassment through policies and procedures, training, shift
briefings, and staff meetings.
Provision (b):
The agency shall also provide at least one way for residents to report abuse or
harassment to a public or private entity or office that is not part of the agency and
that is able to receive and immediately forward resident reports of sexual abuse and
sexual harassment to agency officials, allowing the resident to remain anonymous
upon request. Residents detained solely for civil immigration purposes shall be
provided information on how to contact relevant consular officials and relevant
officials at the Department of Homeland Security.
The Florida abuse reporting hotline may be used by residents and staff to report
allegations of sexual abuse and sexual harassment. The interviews revealed
familiarity with policy and posted information on how to report allegations.
Telephones are accessible to all staff and are made accessible to residents by staff.
The telephone hotline was tested; the telephone was in working order and attended
by an operator. An allegation may also be reported in Spanish by following the
prompt. The reports of sexual abuse or sexual harassment are accepted and
referred for an investigation. The facility does not detain residents solely for civil
immigration purposes according to written communication from the Department of
Juvenile Justice legal department.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third-
parties and shall promptly document any verbal reports.
The staff interviews confirmed the methods available to residents for reporting
allegations of sexual abuse and sexual harassment. Staff members are required to
accept reports made anonymously, third-party reports and to document verbal
reports. The resident interviews collectively indicated awareness of reporting either
in person, in writing, by telephone, or through a third-party. Documentation reveals
the investigation of reports received. Interviewed staff members were aware of their
duty to receive and document the receipt of verbal reports.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written
report.
Interviews and observations revealed writing materials are available for residents to
complete Let's Talk, Grievance and other forms or write notes. Each resident is
provided a handbook which contains information regarding reporting by a written
method. The interviews, review of documents and facility practices revealed
alignment with the agency and facility policies. All residents have access to writing
tools as confirmed by interviews and observations by the Auditor.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The staff interviews revealed staff can privately report allegations of sexual abuse
and sexual harassment through a call to the Florida abuse reporting hotline or
Department of Juvenile Justice, Central Communications Center and/or speak
directly to the supervisor or Superintendent.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Grievance Form
Let's Talk Form
Sick Call Form
Resident Handbook
Interviews:
Random Staff
Residents
Statewide PREA Coordinator
Provision (a):
An agency shall be exempt from this standard if it does not have administrative
procedures to address resident grievances regarding sexual abuse.
When an emergency grievance is received that contains an allegation of sexual
abuse or sexual harassment, the policy and procedures for reporting allegations of
sexual abuse or sexual harassment are initiated and a report is made as required by
policy. The grievance system does not include a process for the facility staff to
investigate or resolve allegations of sexual abuse or sexual harassment. The
content of the grievance is reported and an investigation is conducted by the Florida
Department of Juvenile Justice/Office of Inspector General, Florida Department of
Children and Families, and/or local law enforcement when the allegation is criminal
in nature.
Provision (b):
(1) The agency shall not impose a time limit on when a resident may submit a
grievance regarding an allegation of sexual abuse.
(2) The agency may apply otherwise-applicable time limits on any portion of a
grievance that does not allege an incident of sexual abuse.
(3) The agency shall not require a resident to use any informal grievance process, or
to otherwise attempt to resolve with staff, an alleged incident of sexual abuse.
(4) Nothing in this section shall restrict the agency’s ability to defend against a
lawsuit filed by a resident on the ground that the applicable statute of limitations
has expired.
Policy provides that there is no time limit for completing a Grievance Form to report
allegations of sexual abuse. Residents are not required to use an informal process or
give the Grievance or Let's Talk Form to any staff member regarding allegations of
sexual abuse. Locked boxes are located in the common area for residents to deposit
forms or notes if they choose. Policy does not restrict the facility’s ability to defend
against a lawsuit filed by a resident on the ground that the applicable statute of
limitations expired.
Provision (c):
The agency shall ensure that—
(1) A resident who alleges sexual abuse may submit a grievance without submitting
it to a staff member who is the subject of the complaint, and
(2) Such grievance is not referred to a staff member who is the subject of the
complaint.
The grievance system does not include investigating allegations of sexual abuse
and sexual harassment. Residents are not required to use an informal process or
give the grievance form, if used to document an allegation of abuse, to any staff
member. The staff member involved in the grievance will not be involved in
reporting the allegation stated in the grievance. To assist in the prompt and proper
handling of the allegation of sexual abuse or sexual harassment, the youth may put
the grievance in the grievance box or give it to staff if they choose.
The resident handbook informs residents to report allegations of abuse or neglect
through the Florida abuse hotline and the contact information is provided and the
resident is informed that they have unhindered access to a telephone to report an
allegation of abuse. The handbook informs residents that, the resident should not
use the informal process regarding a PREA related allegation. The locked boxes are
located in the common areas for depositing forms and notes. The resident handbook
explains the regular grievance system and contains information regarding reporting
allegations of sexual abuse and sexual harassment.
Provision (d):
(1) The agency shall issue a final agency decision on the merits of any portion of a
grievance alleging sexual abuse within 90 days of the initial filing of the grievance.
(2) Computation of the 90-day time period shall not include time consumed by
residents in preparing any administrative appeal.
(3) The agency may claim an extension of time to respond, of up to 70 days, if the
normal time period for response is insufficient to make an appropriate decision. The
agency shall notify the resident in writing of any such extension and provide a date
by which a decision will be made.
(4) At any level of the administrative process, including the final level, if the resident
does not receive a response within the time allotted for reply, including any properly
noticed extension, the resident may consider the absence of a response to be a
denial at that level.
Initial response is required within 48 hours to inform the resident of receipt of the
grievance containing an allegation of sexual abuse and that it has been referred for
investigation. All grievances alleging sexual abuse or sexual harassment will be
referred for an investigation in accordance with policy. The purpose of the
submission of a PREA related grievance provides residents and staff another avenue
for ensuring the reporting of allegations and provides management staff with the
opportunity to protect the resident.
Provision (e):
(1) Third parties, including fellow residents, staff members, family members,
attorneys, and outside advocates, shall be permitted to assist residents in filing
requests for administrative remedies relating to allegations of sexual abuse, and
shall also be permitted to file such requests on behalf of residents.
(2) If a third party, other than a parent or legal guardian, files such a request on
behalf of a resident, the facility may require as a condition of processing the request
that the alleged victim agree to have the request filed on his or her behalf, and may
also require the alleged victim to personally pursue any subsequent steps in the
administrative remedy process.
(3) If the resident declines to have the request processed on his or her behalf, the
agency shall document the resident’s decision.
(4) A parent or legal guardian of a juvenile shall be allowed to file a grievance
regarding allegations of sexual abuse, including appeals, on behalf of such juvenile.
Such a grievance shall not be conditioned upon the juvenile agreeing to have the
request filed on his or her behalf.
When third-party reports of allegations of sexual abuse or sexual harassment are
received on a grievance form, the policies and procedures for reporting allegations
of sexual abuse or sexual harassment are initiated and a report is made as required
by policy. The grievance system does not include a process for facility staff to
investigate or resolve allegations of sexual abuse or sexual harassment. The
content of the grievance is reported and an investigation will be conducted by the
investigative entity as appropriate.
Provision (f):
(1) The agency shall establish procedures for the filing of an emergency grievance
alleging that a resident is subject to a substantial risk of imminent sexual abuse.
(2) After receiving an emergency grievance alleging a resident is subject to a
substantial risk of imminent sexual abuse, the agency shall immediately forward the
grievance (or any portion thereof that alleges the substantial risk of imminent
sexual abuse) to a level of review at which immediate corrective action may be
taken, shall provide an initial response within 48 hours, and shall issue a final
agency decision within five calendar days. The initial response and final agency
decision shall document the agency’s determination whether the resident is in
substantial risk of imminent sexual abuse and the action taken in response to the
emergency grievance.
Policy provides for emergency grievances to be responded to within 48 hours. The
response is to inform the resident of the receipt of the grievance and the referral for
an investigation when an allegation of sexual abuse or sexual harassment is placed
on a grievance form. If a grievance form alleging sexual abuse is received, it is
reported by staff to the appropriate investigative entity. The response to the
grievance will include measures to ensure safety and also include but not limited to
determining an immediate corrective action that would be implemented within 48
hours where applicable to ensure the safety of the resident.
Provision (g):
The agency may discipline a resident for filing a grievance related to alleged sexual
abuse only where the agency demonstrates that the resident filed the grievance in
bad faith.
A resident may be disciplined when it has been determined that a report alleging
sexual abuse has been made in bad faith. There has not been a grievance
submitted alleging sexual abuse during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Memorandum of Understanding (MOU)
Posted Information
Resident Handbook
Brochure
Interviews:
Residents
Superintendent/PREA Compliance Manager
Advocacy Agency Representatives
Provision (a):
The facility shall provide residents with access to outside victim advocates for
emotional support services related to sexual abuse, by providing, posting, or
otherwise making accessible mailing addresses and telephone numbers, including
toll free hotline numbers where available, of local, State, or national victim
advocacy or rape crisis organizations, and, for persons detained solely for civil
immigration purposes, immigrant services agencies. The facility shall enable
reasonable communication between residents and these organizations and
agencies, in as confidential a manner as possible.
Interviews revealed that residents required a refresher regarding victim advocacy
services due to 50% not verbalizing a clear understanding of advocacy services. The
residents were in need of a refresher education session, focusing on advocacy
services, which was provided by the Superintendent during the post onsite audit
phase. The MOU with the Roxcy Bolton Rape Treatment Center remains in effect and
is being reviewed for the addition of updated signatures, according to the agency
representative and the facility Superintendent. The interviews with the
representatives of the Roxcy Bolton Rape Treatment Center (RBRTC) confirmed the
services to be provided when needed, as stated in the MOU.
The PREA education materials provide residents information on how to report
allegations of sexual harassment and sexual abuse. PREA information is posted and
provided to residents to assist in eliminating incidents of sexual abuse and sexual
harassment. The printed materials provide information on sexual abuse and sexual
harassment; steps victims may take; and reporting information. Each resident is
provided a handbook and an orientation packet which also contains PREA
information. PREA-related information was observed posted or displayed throughout
the facility.
PREA signage is placed at varying eye levels and are colorful and/or graphic with
consistent messages. The interviews with the residents revealed they know where
to find information on the wall if they need it. The interviews confirmed the PREA
audit notices had been up for awhile and that the PREA information is always on the
walls. PREA information is located in the housing area; common areas for staff,
residents, contractors, volunteers, and visitors; lobby; and offices. One sign was
adjusted during the onsite audit phase to clarify information regarding the advocacy
agency, in an effort to improve the provision of information regarding such
services.
Provision (b):
The facility shall inform residents, prior to giving them access, of the extent to
which such communications will be monitored and the extent to which reports of
abuse will be forwarded to authorities in accordance with mandatory reporting laws.
Policy, facility staff interviews and the refresher education session provide there will
be adherence to confidentiality measures and this information is shared with
residents during PREA education sessions and reminders through postings and other
printed material. The information is provided to residents, in accordance with
mandatory reporting laws.
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 provision of advocacy services includes but not limited to emotional support;
forensic medical examination; and accompaniment through the forensic medical
examination and investigative interview. The RBRTC representative confirmed the
information contained in the written agreement. The MOU speaks to confidentiality
and privileged information between RBRTC and the alleged victim of sexual abuse
and also provides that federal and State laws regarding such information will be
adhered to.
Provision (d):
The facility shall also provide residents with reasonable and confidential access to
their attorneys or other legal representation and reasonable access to parents or
legal guardians.
The residents have reasonable and confidential access to attorneys and court
workers and reasonable access to their parents/legal guardians which is supported
by policy, interviews and the resident handbook. All residents interviewed confirmed
communication opportunities occur.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility meets this standard.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Resident Handbook
PREA Posters
Printed Materials
Website Information
Interviews:
Random Staff
Residents
Superintendent
Provision (a):
The agency shall establish a method to receive third-party reports of sexual abuse
and sexual harassment and shall distribute publicly information on how to report
sexual abuse and sexual harassment on behalf of a resident.
Staff members receive, document and report allegations of sexual abuse and sexual
harassment made by a third-party as indicated by an investigation report. Staff
members are aware third-party reporting of sexual abuse or sexual harassment can
be done and indicated the information will be accepted and reported. Staff
members are to document all verbal reports received. The interviews collectively
revealed staff may report allegations privately through the use of the abuse
reporting hotline, complete a report, call the Department of Juvenile Justice Central
Communications Center, and tell supervisors and administrators. The agency
website contains the information needed for third-parties to report allegations of
sexual abuse and sexual harassment.
Information regarding reporting is posted throughout the facility and accessible to
visitors. Information flyers regarding third-party reporting in also maintained in the
lobby of the facility. Reporting information is also contained in the resident
handbook. All residents interviewed indicated knowing someone who did not work
at the facility that they have contact with. It was determined that a person outside
of the facility may report allegations of sexual abuse and may make a report for a
resident without giving the resident’s name. One third-party report was received
during this audit period and was reported as required. The allegation received an
administrative investigation and was determined unfounded.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Florida Statute Chapter 39, Section 201-Mandatory reports of child abuse,
abandonment, or neglect; mandatory reports of death; central abuse hotline
Investigation Report
Interviews:
Random Staff
Superintendent/PREA Compliance Manager
Mental Health Staff
Medical Staff
Provisions (a) & (b):
(a): The agency shall require all staff to report immediately and according to
agency policy any knowledge, suspicion, or information they receive regarding an
incident of sexual abuse or sexual harassment that occurred in a facility, whether or
not it is part of the agency; retaliation against residents or staff who reported such
an incident; and any staff neglect or violation of responsibilities that may have
contributed to an incident or retaliation. (b): The agency shall also require all staff
to comply with any applicable mandatory child abuse reporting laws.
Per the direction of the State statute, policy supports that all staff report any
knowledge, suspicion, information, or receipt of information regarding an incident or
allegation of sexual abuse, sexual harassment or incidents of retaliation. Staff
members are deemed as mandated reporters by the State. The trained Department
of Juvenile Justice (DJJ) agency investigators conduct administrative investigations
and allegations that are criminal in nature are referred to local law enforcement. The
facility and agency policies provide guidance to staff on reporting allegations of
sexual abuse and sexual harassment and the duties of the first responder.
Provision (c):
Apart from reporting to designated supervisors or officials and designated State or
local services agencies, staff shall be prohibited from revealing any information
related to a sexual abuse report to anyone other than to the extent necessary, as
specified in agency policy, to make treatment, investigation, and other security and
management decisions.
Policy addresses confidentiality of information and the conditions for providing
information. Policies collectively indicate that after allegations have been
appropriately reported, staff will keep the information confidential regarding what
was reported except when necessary regarding the investigation and treatment and
management decisions. Training is provided to all staff regarding confidentiality of
information.
Provision (d):
(1) Medical and mental health practitioners shall be required to report sexual abuse
to designated supervisors and officials pursuant to paragraph (a) of this section, as
well as to the designated State or local services agency where required by
mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation of
services of their duty to report and the limitations of confidentiality.
The clinical staff interviewed indicated residents are informed at the initiation of
services of the limitations of confidentiality and the duty of the staff members to
report. The clinical staff members are also mandated reporters and required by the
State to report allegations of sexual abuse and sexual harassment, in accordance
with policy and State requirements.
Provision (e):
(1) Upon receiving any allegation of sexual abuse, the facility head or his or her
designee shall promptly report the allegation to the appropriate agency office and
to the alleged victim’s parents or legal guardians, unless the facility has official
documentation showing the parents or legal guardians should not be notified.
(2) If the alleged victim is under the guardianship of the child welfare system, the
report shall be made to the alleged victim’s caseworker instead of the parents or
legal guardians.
(3) If a juvenile court retains jurisdiction over the alleged victim, the facility head or
designee shall also report the allegation to the juvenile’s attorney or other legal
representative of record within 14 days of receiving the allegation.
Reports of allegations are made as soon as possible to the investigative entities,
including but not limited to the DJJ Central Communications Center, and parents/
legal guardians. Policy and interview with the Superintendent confirmed that a
resident’s caseworker rather than a parent will be notified where indicated by the
resident being under the guardianship of the Florida Department of Children and
Families. The resident’s attorney would be notified within 14 days. There were two
allegation made during this audit period. Both were reported as required by policy
and were deemed unfounded as the result of administrative investigations.
Provision (f):
The facility shall report all allegations of sexual abuse and sexual harassment,
including third-party and anonymous reports, to the facility’s designated
investigators.
Policy and interviews provide for all allegations to be reported and include the Office
of the Inspector General (OIG) through the Central Communications Center.
Administrative investigations are conducted by a DJJ/OIG investigator. Sexual abuse
and sexual harassment allegations that are criminal in nature are referred for
investigation to local law enforcement. Third-party and anonymous reports received
must be reported and documented by staff as confirmed through interviews. The
interviews confirmed that all allegations are reported to the DJJ Central
Communications Center. One allegation was reported anonymously and it was
forwarded for an investigation in accordance with policy.
Conclusion:
The review of evidence and interviews indicate the facility is in compliance with this
standard.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Superintendent
Random Staff
Residents
Agency Head Designee
Provision (a):
When an agency learns that a resident is subject to a substantial risk of imminent
sexual abuse, it shall take immediate action to protect the resident.
The staff is required to protect the residents through implementing protective
measures. Administration of the risk screening instrument provides information that
assists and guide staff in keeping residents safe through housing and program
assignments. Additional assessment instruments provide information which offer
supporting information in determining the risk level of each resident.
The interviews revealed protective measures include but are not limited to
separating youth and contacting management staff and supervisors. The
expectation is that any action to protect a resident will be taken immediately as
deemed from interviews with the Superintendent, agency head designee, and
random staff. During the intake process, residents are asked about how they feel
about their safety as part of the inquiries by staff completing the VSAB. No resident
was identified to be at substantial risk of imminent sexual abuse in the past 12
months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interview:
Superintendent
Provisions (a) - (d):
(a): Upon receiving an allegation that a resident was sexually abused while confined
at another facility, the head of the facility that received the allegation shall notify
the head of the facility or appropriate office of the agency where the alleged abuse
occurred and shall also notify the appropriate investigative agency. (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.
When an allegation of sexual abuse is received that a resident was sexually abused
while confined at another facility, the Superintendent will notify the head of the
facility where the alleged abuse occurred. The notification will be made as soon as
possible and within 72 hours in accordance with policy. The Superintendent is also
required to make a report to the Central Communications Center. The policy and
interview support that allegations of sexual abuse or sexual harassment from a
resident regarding their stay in another facility will be reported and investigated as
required. In the past 12 months, there were no allegations reported of sexual abuse
occurring at another facility.
Conclusion:
Based upon the information received and interviews, the Auditor determined the
facility is compliant with this standard.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews:
Random Staff
Superintendent
Provision (a):
Upon learning of an allegation that a resident was sexually abused, the first staff
member to respond to the report shall be required to:
(1) Separate the alleged victim and abuser;
(2) Preserve and protect any crime scene until appropriate steps can be taken to
collect any evidence;
(3) If the abuse occurred within a time period that still allows for the collection of
physical evidence, request that the alleged victim not take any actions that could
destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating; and
(4) If the abuse occurred within a time period that still allows for the collection of
physical evidence, ensure that the alleged abuser does not take any actions that
could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating.
The interviews and staff training information support the training areas provided in
this standard. There were no allegations or incidents where staff had to intervene as
a first responder in the last 12 months. Policy and training provide that upon
learning of an allegation that a resident was sexually abused the general staff
response would basically include but not be limited to the following:
a. Separate the victim and alleged abuser.
b. Preserve and protect the scene until appropriate steps can be taken to collect any
evidence.
c. Request that the alleged victim not take any actions that could destroy physical
evidence.
d. Take actions to ensure the alleged abuser does not take any actions that could
destroy physical evidence.
e. Ensure the safety of the victim.
f. Make the required notifications.
Provision (b):
If the first staff responder is not a security staff member, the responder shall be
required to request that the alleged victim not take any actions that could destroy
physical evidence, and then notify security staff.
The non-security staff who may act as a first responder will request that physical
evidence be preserved and contact direct care staff for assistance, in accordance
with policy. There were no allegations or incidents where a non-security staff
member had to act as a first responder in the last 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
Interviews:
Random Staff
Superintendent
Provision (a):
The facility shall develop a written institutional plan to coordinate actions taken in
response to an incident of sexual abuse among staff first responders, medical and
mental health practitioners, investigators, and facility leadership.
The facility has a written institutional plan, Sexual Abuse Incident Coordinated
Response Plan, to be implemented in the event of an allegation or incident of sexual
abuse. The plan outlines the actions of the identified staff members such as the first
responder; medical; mental health; supervisors; and management staff, and
identifies the required notifications. Policy provides guidance to staff regarding the
actions to take when there is an alleged incident of sexual abuse and requires a
written facility plan. The coordinated response to an incident of sexual abuse is also
aligned with the policy. The staff interviews indicated familiarity regarding the
response to an allegation of sexual abuse. The Sexual Abuse Incident Coordinated
Response Plan is located in the conference room adjacent to the multi-purpose area,
accessible to all staff.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with the standard.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Interview:
Superintendent
Provisions (a) & (b):
(a): Neither the agency nor any other governmental entity responsible for collective
bargaining on the agency’s behalf shall enter into or renew any collective
bargaining agreement or other agreements that limits the agency’s ability to
remove alleged staff sexual abusers form contact with residents pending the
outcome of an investigation or of a determination of whether and to what extent
discipline is warranted. (b): Nothing is this standard shall restrict the entering into
on renewal of agreements that govern:
(1) The conduct of the disciplinary process, at long as such agreements are not
inconsistent with the provisions of §115.372 and §115.376; or
(2) Whether a no-contact assignment that is imposed pending the outcome of an
investigation shall be expunged from or retained in the staff member’s personnel
file following a determination that the allegation of sexual abuse is not
substantiated.
The facility is not involved in any collective bargaining agreements.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews
Retaliation Monitor/Superintendent
Contract PREA Coordinator/Agency Head Designee
Provision (a):
The agency shall establish a policy to protect all residents and staff who report
sexual abuse or sexual harassment or cooperate with sexual abuse or sexual
harassment investigations from retaliation by other residents or staff and shall
designate which staff members or departments are charged with monitoring
retaliation.
Policy supports protecting residents and staff who report sexual abuse or sexual
harassment, or cooperate with sexual abuse or sexual harassment investigations
from retaliation by other residents, or staff. The Superintendent is responsible for
conducting and ensuring retaliation monitoring occurs. The Retaliation Monitoring
(PREA) form is used to document the monitoring activities. The Superintendent is
familiar with the role of retaliation monitor and its purpose. A sample of Retaliation
Monitoring (PREA) forms were selected for review. The form documents whether the
individual has been threatened or been treated unfairly. It also provides for the
review of schedule changes, call outs, facility transfers; disciplinary reports; and
housing/bed changes in an effort to determine if retaliation is occurring.
Provision (b):
The agency shall employ multiple protection measures, such as housing changes or
transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services for residents or
staff that fear retaliation for reporting sexual abuse or sexual harassment or for
cooperating with investigations.
Protective measures were generally identified during the interviews with random
staff and the Superintendent/Retaliation Monitor and were aligned with policy.
Protective measures include housing changes for resident victims or abusers;
removing alleged staff or resident abusers from contact with victims; change in shift
assignments; and transferring youth or staff, if needed. The retaliation monitoring is
documented and follow-up checks with the parties involved ensure safe feelings and
identifies whether retaliation is occurring. The interviews confirmed the measures to
detect and protect staff and residents from retaliation by others.
Provision (c):
For at least 90 days following a report of sexual abuse, the agency shall monitor the
conduct or treatment of residents or staff who reported the sexual abuse and of
residents who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff, and shall act
promptly to remedy any such retaliation. Items the agency should monitor include
any resident disciplinary reports, housing, or program changes, or negative
performance reviews or reassignments of staff. The agency shall continue such
monitoring beyond 90 days if the initial monitoring indicates a continuing need.
Policy provides that the monitoring will occur for at least 90 days to see if there are
any changes that may suggest possible retaliation is occurring. The monitoring
period may last longer if needed, according to the Superintendent/Retaliation
Monitor. The interview identified items that would be monitored to assess retaliation
and included but were not limited to program and housing changes; shift
assignments; point cards; and staff and resident interactions and resident to
resident interactions.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
Policy and the interview with the Superintendent/Retaliation Monitor indicate that
status checks will occur as a part of retaliation monitoring. The dedicated
monitoring form and the interview revealed that initial contact will be made and
follow-up checks will be documented.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of
retaliation, the agency shall take appropriate measures to protect that individual
against retaliation.
Policy encompasses those who cooperate with an investigation if there is a concern
regarding retaliation. The interview indicated that the appropriate measures would
be taken to protect any related individuals against retaliation.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the
allegation is unfounded.
The obligation to monitor for retaliation terminates, if it is determined that the
allegation is unfounded. The interview determined familiarity with the requirements
regarding retaliation monitoring.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews:
Superintendent
Medical Staff
Mental Health Staff
Provision (a):
The use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse shall be subject to the requirements of §115.342.
Policies guide staff on measures to be taken to protect residents but does not
include segregated housing for alleged victims. Segregated housing is not used in
the facility to protect residents who alleged to have suffered sexual abuse. The
interviews were aligned with this premise. Policies provide for the separation of
residents by housing reassignments and other aforementioned strategies.
Conclusion:
Based upon the review of Policy, interviews, and observations, the Auditor
determined the facility is compliant with this standard.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
Investigation Reports
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinators
Provision (a):
When the agency conducts its own investigations into allegations of sexual abuse
and sexual harassment, it shall do so promptly, thoroughly, and objectively for all
allegations, including third-party and anonymous reports.
The administrative investigations are conducted by the investigators with the
Florida Department of Juvenile Justice (DJJ), Office of the Inspector General (OIG).
Based on the written institutional plan, policies and interviews, trained investigators
conduct administrative investigations as prescribed by policy. Allegations that are
criminal in nature are referred to local law enforcement and the Florida Department
of Children and Families. Investigations are conducted thoroughly and objectively
and the agency policy provides for the training of investigators.
Provisions (b) & (c):
(b): Where sexual abuse is alleged, the agency shall use investigators who have
received special training in sexual abuse investigations involving juvenile victims
pursuant to §115.334. (c): Investigators shall gather and preserve direct and
circumstantial evidence, including any available physical and DNA evidence and any
available electronic monitoring data; shall interview alleged victims, suspected
perpetrators, and witnesses; and shall review prior complaints and reports of sexual
abuse involving the suspected perpetrator.
The DJJ investigators are trained through the OIG as documented on the investigator
training log and a previous interview with investigative staff. The investigator
gathers direct and circumstantial evidence that includes but is not limited to
reviewing video; gathering witness statements; listening to any related telephone
calls; and reviewing logs. The law enforcement investigator and/or qualified medical
practitioner are responsible for collecting direct physical and DNA evidence. The
facility staff and DJJ investigators are trained on how to assist in preserving
evidence. The agency, DJJ, provides each facility with the PREA Form which is
provided to law enforcement investigators referencing the PREA standards
regarding conducting investigations in accordance with the standards. The DJJ
investigators follow the OIG guidelines governing PREA related investigations, in
accordance with policy.
Provision (d):
The agency shall not terminate an investigation solely because the source of the
allegation recants the allegation.
The interviews and policy confirm the provision that an investigation is not
terminated if the source recants an allegation of sexual abuse or sexual
harassment. The investigation regarding the allegation of sexual abuse
demonstrates how an investigation is continued until the end and findings are
determined.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the agency
shall conduct compelled interviews only after consulting with prosecutors as to
whether compelled interviews may be an obstacle for subsequent criminal
prosecution.
The DJJ agency investigators do not conduct compelled interviews.
Provision (f):
The credibility of an alleged victim, suspect, or witness shall be assessed on an
individual basis and shall not be determined by the person’s status as resident or
staff. No agency shall require a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition for proceeding
with the investigation of such an allegation.
The credibility of an alleged victim, suspect, or witness is assessed on an individual
basis and is not determined by the person’s status as a resident or staff as
supported by the interviews of the administrators and a previous interview with an
investigator, training, and in accordance with policy. No resident who alleges sexual
abuse will be subjected to a polygraph examination or other truth telling device as a
condition for proceeding with the investigation of the allegation.
Provisions (g) & (h):
(g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse.
(2) Shall be documented in written reports that include a description of the physical
and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings.
(h): Criminal investigations shall be documented in a written report that contains a
thorough description of physical, testimonial, and documentary evidence and
attaches copies of all documentary evidence where feasible.
The interviews revealed that PREA investigations include an effort to determine
whether staff actions or failures to act contributed to the abuse. All investigations
are completed with written reports that include a description of the evidence and
investigative facts and findings as gleaned from review of investigation reports
completed by agency investigators and a previous interview with and agency
investigator.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for
prosecution.
The DJJ agency investigators do not conduct criminal investigations. It is the
responsibility of local law enforcement personnel to refer cases for prosecution.
Provision (j):
The agency shall retain all written reports referenced in paragraphs (g) and (h) of
this section for as long as the alleged abuser is incarcerated or employed by the
agency, plus five years, unless the abuse was committed by a juvenile resident and
applicable law requires a shorter period of retention.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years as stated in policy.
Provision (k):
The departure of the alleged abuser or victim from the employment or control of the
facility or agency shall not provide a basis for terminating an investigation.
A previous interview with an investigator and the interviews with the administrators
confirmed that upon the start of an investigation, it will not end until the
investigation has been completed. The departure of the alleged abuser or victim
from the employment or control of the facility will not terminate the investigation.
Provision (l):
Any State entity or Department of Justice component that conducts such
investigations shall do so pursuant to the above requirements.
The investigative agencies are aware of the PREA standards requirements through
the initial sharing of PREA information, PREA Compliance Form, and subsequent
interactions.
Provision (m):
When outside agencies investigate sexual abuse, the facility shall cooperate with
outside investigators and shall endeavor to remain informed about the progress of
the investigation.
The policies and interviews indicate that staff cooperate with investigators and that
the agency/facility is kept informed of the progress of an investigation. The
Superintendent maintains contact with the investigator from the appropriate
investigative entity and also remains informed through the statewide PREA
Coordinator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Facility Policy 10-25
Interview:
Superintendent
Provision (a):
The agency shall impose no standard higher than a preponderance of the evidence
in determining whether allegations of sexual abuse or sexual harassment are
substantiated.
The Florida Department of Juvenile Justice/Office of Inspector General, responsible
for administrative investigations, imposes a standard of a preponderance of the
evidence for determining whether allegations are substantiated as confirmed by
investigative staff in a previous interview and by the Superintendent.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Notification Letters
Interview:
Superintendent
Provision (a):
Following an investigation into a resident’s allegation of sexual abuse suffered in an
agency facility, the agency shall inform the resident as to whether the allegation
has been determined to be substantiated, unsubstantiated, or unfounded.
Policy addresses the resident being informed when a sexual abuse investigation is
completed and the outcome of the investigation provided in writing. The results of
such investigations will be documented and provided to the resident. The interview
and notification letters revealed awareness and practice of the requirement. The
Superintendent or designee informs the resident of the outcome of the
investigation.
Provision (b):
If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency in order to inform the resident.
The Superintendent remains abreast of an investigation conducted by law
enforcement or the Department of Juvenile Justice/Office of Inspector General
investigator and will be provided a copy of completed investigations. The
Superintendent also has contact with law enforcement regarding a PREA-related
investigation. The results of the investigation are shared with the resident verbally
by the Superintendent and are documented.
Provision (c):
Following a resident’s allegation that a staff member has committed sexual abuse
against the resident, the agency shall subsequently inform the resident (unless the
agency has determined that the allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge related
to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a charge related
to sexual abuse within the facility.
Policy requires that following a resident’s allegation that a staff member committed
sexual abuse against the resident, the resident will be informed, in writing, of the
following, unless it has been determined that the allegation is unfounded,
whenever:
a. The staff member is no longer posted within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse in the
facility; and/or
d. The staff member has been convicted on a charge related to sexual abuse in the
facility.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused by another
resident, the agency shall subsequently inform the alleged victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related
to sexual abuse within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a charge
related to sexual abuse within the facility.
Policy provides that following a resident’s allegation that she has been sexually
abused by another resident the alleged victim shall be informed, in writing,
whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the
facility.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides that the notifications to the resident be documented and be made
by the Superintendent. There is familiarity and practice with the requirement.
Provision (f):
An agency’s obligation to report under this standard shall terminate if the resident is
released from the agency’s custody.
The agency’s obligation to report under this standard terminates if the resident is
released from the agency’s custody. All notifications or attempted notifications are
documented in accordance with agency policy.
Conclusion:
The interview and review of policy and other documentation confirmed the facility is
compliant with this standard.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 3-3, Employee Standards of Conduct and Performance
Facility 10-25, PREA
Agency Policy FDJJ 1919, PREA
Employee Handbook
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
Policies and the interview support that staff be subject to disciplinary sanctions up
to and including termination for violating facility sexual abuse or sexual harassment
policies. There were no disciplinary sanctions regarding staff during the audit period.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who has
engaged in sexual abuse.
Termination is the presumptive disciplinary sanction for staff who has engaged in
sexual abuse with a resident. The interview was aligned with policies. The facility
reports that no staff member violated policy regarding sexual abuse or sexual
harassment during this audit period.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or
sexual harassment shall be commensurate with the nature and circumstances of the
acts committed, the staff member’s disciplinary history, and the sanctions imposed
for comparable offenses by other staff with similar histories.
Any staff with findings other than actually engaging in sexual abuse will be subject
to termination, and other measures appropriate to the circumstance of the incident
and the other components of the provision and remedial in-service if permitted to
return to work, in accordance with policy. Disciplinary sanctions for violations of
policies relating to sexual abuse or sexual harassment (other than engaging in
sexual abuse) will be commensurate with the act committed, the staff member’s
disciplinary history, and the similar history of other staff.
Provision (d):
All terminations for violations of agency sexual abuse or sexual harassment policies,
or resignations by staff who would have been terminated if not for their resignation,
shall be reported to law enforcement agencies, unless the activity was clearly not
criminal, and to any relevant licensing bodies.
Policy provides that terminations for violations of the facility’s sexual abuse or
sexual harassment policies or resignations by staff that would have been terminated
if not for their resignation, will be reported to law enforcement, unless the activity is
clearly not criminal. In addition, such will be reported to relevant licensing bodies.
No staff member has been terminated for violating the facility’s sexual abuse or
sexual harassment policies during this audit period.
Conclusion:
Based upon the review of documentation and the interview, the Auditor determined
the facility is compliant with this standard.
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Acknowledgement Statements
Interviews:
Volunteers
Superintendent
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall be prohibited from
contact with residents and shall be reported to law enforcement agencies, unless
the activity was clearly not criminal, and to relevant licensing bodies.
The policies provide for contractors and volunteers who engage in sexual abuse with
a resident to be reported to law enforcement and to relevant licensing bodies.
Documentation and interviews with contractors and the volunteer confirm
contractors and volunteers receive a clear understanding that sexual misconduct
with a resident is prohibited. Any contractor or volunteer who violates the agency’s
sexual abuse or sexual harassment policies is prohibited from contact with
residents. During this audit period, there have been no allegations of sexual abuse
or sexual harassment regarding a contractor or volunteer.
Provision (b):
The facility shall take appropriate remedial measures, and shall consider whether to
prohibit further contact with residents, in the case of any other violation of agency
sexual abuse or sexual harassment policies by a contractor or volunteer.
Policies and the interview confirm that the appropriate remedial measures will be
taken and include prohibiting further contact with residents in the case of any
violation of the sexual abuse and sexual harassment policies by a contractor or
volunteer. In the past 12 months, no contractor or volunteer was reported for
allegations of sexual abuse or sexual harassment.
Conclusion:
Based upon the review of the documentation and interviews, the Auditor
determined the facility is compliant with this standard.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Investigation Reports
Resident Handbook
Interviews:
Superintendent
Mental Health Staff
Medical Staff
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a formal
disciplinary process following an administrative finding that the resident engaged in
resident-on-resident sexual abuse or following a criminal finding of guilt for resident-
on-resident sexual abuse.
Policies support that an administrative process exists for dealing with violations and
that residents be held accountable for their actions. Residents may be subject to
disciplinary sanctions only after formal proceedings regarding resident-on-resident
sexual abuse. Residents found in violation of facility rules are subject to sanctions
pursuant to a formal process. The consequences will be administered through the
administrative process, encompassing the behavior management system.
Allegations of sexual abuse are referred for an investigation to the appropriate
investigative entities and may result in charges being filed and the resident being
removed from the facility. Sexual activity between residents is prohibited.
Provision (b):
Any disciplinary sanctions shall be commensurate with the nature and
circumstances of the abuse committed, the resident’s disciplinary history, and the
sanctions imposed for comparable offenses by other residents with similar histories.
In the event a disciplinary sanction results in the isolation of a resident, agencies
shall not deny the resident daily large-muscle exercise or access to any legally
required educational programming or special education services. Residents in
isolation shall receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work opportunities to the
extent possible.
Policies consider that disciplinary sanctions, applicable to the offense, are
commensurate with the nature and circumstances of the offense committed;
considers resident’s disciplinary history; considers similar disciplinary history of
other residents. The interview with the Superintendent supported there is
consideration of mental disabilities or mental illness contributing to the behavior.
PREA related violations may result in charges filed and the resident transported to a
detention facility based on the circumstances of the incident. Allegations of sexual
abuse are referred for an investigation to the appropriate investigative entities.
Isolation is not used as a disciplinary sanction.
Provision (c):
The disciplinary process shall consider whether a resident’s mental disabilities or
mental illness contributed to his or her behavior when determining what type of
sanction, if any, should be imposed.
Disciplinary and other processes consider whether a resident’s mental disabilities or
mental illness contributed to a resident’s behavior regarding the application of
disciplinary measures. The interviews were aligned with this provision and policy.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed to address
and correct underlying reasons or motivations for the abuse, the facility shall
consider whether to offer the offending resident participation in such interventions.
The agency may require participation in such interventions as a condition of access
to any rewards-based behavior management system or other behavior-based
incentives, but not as a condition to access to general programming or education.
The facility will consider whether to offer the offending resident intervention
services designed to address and correct underlying reasons or motivations for the
abuse participation, based on the interview with the mental health staff. The facility
would not require participation in such interventions as a condition for participation
in the behavior management system or to access general programming or
education as determined from the interview. Staff members within the mental
health unit are equipped to develop treatment planning and interventions to
address underlying reasons or motivations for the abuse with alleged victims and
offending residents. A psychiatrist provides services to the residents twice per
month. .
Provision (e):
The agency may discipline a resident for sexual contact with staff only upon a
finding that the staff member did not consent to such contact.
Policy provides that a resident may be disciplined for sexual contact with staff only
upon a finding that the staff member did not consent to such contact.
Provision (f):
For the purpose of disciplinary action, a report of sexual abuse made in good faith
based upon a reasonable belief that the alleged conduct occurred shall not
constitute falsely reporting an incident or lying, even if an investigation does not
establish evidence sufficient to substantiate the allegation.
Any resident reporting in good faith shall be immune from any civil or criminal
liability. A report of sexual abuse made in good faith based on the belief that the
alleged incident occurred does not constitute falsely reporting an incident or lying,
even if an investigation does not establish evidence sufficient to substantiate the
allegation, in accordance with Policy.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between residents and
may discipline residents for such activity. An agency may not, however, deem such
activity to constitute sexual abuse if it determines that the activity is not coerced.
Policies prohibit any sexual conduct between residents. All such conduct is subject
to disciplinary action as a rule violation. Referrals are made to the investigative
entities and court processes occur after determination the sexual activity was
coerced.
Conclusion:
Based on the available evidence and interviews, the Auditor concluded the facility is
compliant with the standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 7-3, Admission Screening and Evaluations
Facility Policy 7-8, Informed Consent
Facility Policy 7-30, Sexual Assault Reporting
Facility Policy 10-25
Agency Policy FDJJ 1919
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior
Interviews:
Medical Staff
Mental Health Staff
Superintendent
Staff Responsible for Risk Screening
Residents
Provision (a) & (b):
(a): If the screening pursuant to §115.341 indicates that a resident has experienced
prior sexual victimization, whether it occurred in an institutional setting or in the
community, staff shall ensure that the resident is offered a follow-up meeting with a
medical or mental health practitioner within 14 days of the intake screening. (b): If
the screening pursuant to §115.341 indicates that a resident has previously
perpetrated sexual abuse, whether it occurred in an institutional setting or in the
community, staff shall ensure that the resident is offered a follow-up meeting with a
mental health practitioner within 14 days of the intake screening.
Policy and practice provide that a resident be referred to mental health or medical
staff within 14 days if identified as having been a victim or perpetrator of sexual
abuse. The interviews with clinical staff and risk screener revealed the issues are
identified and addressed. The practice is residents are generally seen by medical
and mental health staff on the same day of admission as part of the intake process
and follow-up is provided immediately when there is disclosure. Therapists
administer the screening assessment, Screening for Vulnerability, Victimization and
Sexually Aggressive Behavior (VSAB).
Provision (c):
Any information related to sexual victimization or abusiveness that occurred in an
institutional setting shall be strictly limited to medical and mental health
practitioners and other staff, as necessary, to inform treatment plans and security
and management decisions, including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local law.
Policy supports that no information is to be shared with other staff unless it is
required for security and management decisions regarding sexual abuse history.
Policy and interviews collectively revealed that information related to sexual
victimization or abusiveness that occurred in an institutional setting is limited to
clinical staff and Case Managers to make effective management decisions. During
the site review, the files are observed to be maintained in a secure manner in a
desks behind lockable doors and information maintained electronically is password
protected.
Provision (d):
Medical and mental health practitioners shall obtain informed consent from
residents before reporting information about prior sexual victimization that did not
occur in an institutional setting, unless the resident is under the age of 18.
Policy addresses informed consent being obtained for residents 18 years or over
prior to clinical personnel reporting information disclosed about prior sexual
victimization that did not occur in an institutional setting. Clinical staff members
understand the practice of informed consent.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 7-30, Sexual Assault Reporting
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
Memorandum of Understanding (MOU)
Interviews:
Mental Health Staff
Medical Staff
Advocacy Agency Representative
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded access to
emergency medical treatment and crisis intervention services, the nature and scope
of which are determined by medical and mental health practitioners according to
their professional judgment.
The interviews and policies support the alleged victim will receive timely and
unimpeded access to emergency medical treatment and crisis intervention services.
The interviews with medical and mental health staffs were aligned with the policy
including that the nature and scope of their services are determined according to
their professional judgment. Residents are informed of clinical services and meet
with those representatives and experience services during the intake process and
on a routine basis throughout their stay in the facility. Reported allegations during
this audit period were determined unfounded following administrative
investigations.
The alleged victim will get services appropriate to the facility as well as timely
services in the community. An alleged victim will be transported to the Roxcy Bolton
Rape Treatment Center for a forensic medical examination that will be conducted by
a qualified medical practitioner. The examination will be performed at no cost to the
victim, and in accordance with policy, coordinated response plan, and the MOU.
Medical and mental health staff members maintain secondary materials and
documentation of encounters with residents.
Provision (b):
If no qualified medical or mental health practitioners are on duty at the time a
report of recent abuse is made, staff first responders shall take preliminary steps to
protect the victim pursuant to §115.362 and shall immediately notify the
appropriate medical and mental health practitioners.
The interviews with clinical staff revealed residents have access to unimpeded
access to emergency services. The policies and coordinated response plan provide
guidance to staff in protecting residents and for contacting the appropriate staff and
agencies regarding allegations or incidents of sexual abuse, including contacting
treatment staff and investigative entities. A review of the written plan and related
documentation and policies; observations of the interactions among residents and
staff during the comprehensive site review; and staff interviews indicated
unimpeded medical and crisis intervention services are available to an alleged
victim of sexual abuse. Staff training also prepare staff members to appropriately
report sexual abuse, protect the alleged victim, and make the appropriate
notifications.
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.
Policy, review of documentation and interviews confirmed processes and services
are in place for an alleged victim to receive timely access to sexually transmitted
infection prophylaxis, where medically appropriate. If needed after an incident,
follow-up services may be provided by the facility’s medical and mental health staff
members to provide support services coordinated by staff as needed. Services not
available within the facility will be contracted.
Provision (d):
Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident.
The interviews and policies provide that treatment services will be provided to the
victim without financial cost to the victim and regardless of whether the victim
names the abuser, or cooperate with any investigation arising out of the incident.
The written agreement is clear that services will be provided at no cost to the
victim.
Conclusion:
Based on the evidence reviewed and interviews, the Auditor determined the facility
is compliant with this standard.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-5
Agency Policy FDJJ 1919
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
The facility shall offer medical and mental health evaluation and, as appropriate,
treatment to all residents who have been victimized by sexual abuse in any prison,
jail, lockup, or juvenile facility.
The policies and interviews support that medical and mental health evaluations and
treatment will be offered to resident victims of sexual abuse. The interviews
revealed that follow-up services will be provided that include but are not limited to
medication management; additional crisis assessments; increased therapy sessions;
and contract and referral services as needed.
Provision (b):
The evaluation and treatment of such victims shall include, as appropriate, follow-up
services, treatment plans, and, when necessary, referrals for continued care
following their transfer to, or placement in, other facilities, or their release from
custody.
Interviews and documentation of encounters confirm on-going medical and mental
health care will be provided as appropriate and will include but not be limited to
treatment planning; evaluations, and clinical follow-up and referrals as needed.
Specialized treatment may also be provided by clinicians on site and through
contract services. Any directions contained in the discharge information will be
followed.
Provision (c):
The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
Review of policies, staff interviews, and observations during the site review
indicated medical and mental health services are consistent with the community
level of care. Treatment services may be provided by facility staff and contract
services if needed. The interviews and observations during the site review
underscored the treatment services at the facility are consistent with the
community level of care.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall be
offered pregnancy tests.
Male facility
Provision (e):
If pregnancy results from conduct specified in paragraph (d) of this section, such
victims shall receive timely and comprehensive information about and timely access
to all lawful pregnancy-related medical services.
Male facility
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
The interviews and policies ensure that victims of sexual abuse will be provided
tests for sexually transmitted infections as medically appropriate as confirmed by
the medical staff. These services were not needed during this audit period.
Provision (g):
Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident.
All treatment services will be provided at no cost to the victim and whether or not
the victim names the abuser of cooperates with the investigation, according to
policy, interviews, and the MOU between the facility and the Roxcy Bolton Rape
Treatment Center
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history and
offer treatment when deemed appropriate by mental health practitioners.
Medical and mental health evaluations and treatment will be offered to resident
victims of sexual abuse. The mental health staff confirmed the resident will get a
mental health evaluation within 30 days however policy does provide for the mental
health evaluation to be conducted within 60 days.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the facility is compliant with this standard.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews:
Incident Review Team Member
Superintendent/PREA Compliance Manager
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every
sexual abuse investigation, including where the allegation has not been
substantiated, unless the allegation has been determined to be unfounded.
The facility is required to conduct a sexual abuse incident review at the conclusion
of an investigation, unless the allegation was unfounded. The interviews reflected
an understanding of the role of the incident review team. A review of policies,
documentation and interviews confirmed incident reviews will be conducted
regarding the investigation of an allegation of sexual abuse, unless unfounded and
in accordance with the policy and standard. The statewide PREA Coordinator
facilitates the incident review team meetings. There were no incident review team
meetings during this audit period. The two allegations were determined unfounded
as a result of administrative investigations.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
Policy requires that the review occurs within 30 days of the conclusion of the
investigation. The interviews confirmed incident reviews will occur. The interviews
revealed knowledge of the purpose of the incident review process and the timeline.
There were no substantiated or unsubstantiated allegations of sexual abuse during
this audit period.
Provision (c):
The incident review team shall include upper-level management officials, with input
from line supervisors, investigators, and medical or mental health practitioners.
Policy and interviews collectively identify members of the incident review team. The
statewide PREA Coordinator facilitates the incident review team meeting. Members
of the team are identified, in accordance with policy. There will also be input from
line supervisors and other staff as needed. The Department of Juvenile Justice/Office
of Inspector General investigator may also participate in the incident review. The
additional staff members will attend the meeting as needed, related to the incident.
Provision (d):
The review team shall:
(1) Consider whether the allegation or investigation indicates a need to change
policy or practice to better prevent, detect, or respond to sexual abuse;
(2) Consider whether the incident or allegation was motivated by race; ethnicity;
gender identity; lesbian, gay, bisexual, transgender, or intersex identification,
status, or perceived status; or, gang affiliation; or was motivated or otherwise
caused by other group dynamics at the facility;
(3) Examine the area in the facility where the incident allegedly occurred to assess
whether physical barriers in the area may enable abuse.
(4) Assess the adequacy of staffing levels in that area during different shifts;
(5) Assess whether monitoring technology should be deployed or augmented to
supplement supervision by staff; and
(6) Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to paragraphs (d)(1)-(d)(5) of this section, and any
recommendations for improvement and submit such report to the facility head and
PREA compliance manager.
The policies and interviews collectively outline the requirements of the standard for
the areas to be assessed by the incident review team. The interviews and review of
Policy confirmed the incident review team is charged with considering the factors
identified in this standard provision regarding the results of the investigation. The
incident review process is documented and is facilitated by the DJJ statewide PREA
Coordinator. The written report also includes any recommendations for
improvement confirmed by the agency's documented practice.
Provision (e):
The facility shall implement the recommendations for improvement, or shall
document its reasons for not doing so.
Policy indicates the reasons for not following recommendations are documented.
The interviews revealed familiarity with policy requirements. The incident review
process allows for the assessment of the circumstances surrounding the incident. A
format for documenting the incident review process has been developed by the DJJ
statewide PREA Coordinator and includes recommendations where indicated as
determined from a review of documentation of reports from other facilities.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
Auditor determined the facility is compliant with this standard.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1919, PREA
Agency Policy FDJJ 2020, Incident Operations Center and Incident Reviews
PREA Data Log
Interviews:
Superintendent
Statewide PREA Coordinator
Provisions (a) & (c):
(a): The agency shall collect accurate, uniform data for every allegation of sexual
abuse at facilities under its direct control using a standardized instrument and set of
definitions. (c): The incident-based data collected shall include, at a minimum, the
data necessary to answer all questions from the most recent version of the Survey
of Sexual Violence conducted by the Department of Justice.
The policies provide for the collection of accurate and uniform data for every
allegation of sexual abuse from incident-based documents. The agency collects the
data and completes an annual report with the compilation of data gleaned from the
facilities through the central reporting system. Agency Policy FDJJ 2020 contains a
standardized set of definitions and provides support for the collection of accurate
and uniform data. The agency maintains incident-based data complete enough to
complete the most recent version of the instrument formerly identified as the
Survey of Sexual Violence and now identified as the Survey of Sexual Victimization.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least annually.
The agency aggregates the incident-based, uniform data regarding allegations of
sexual abuse and sexual harassment. The aggregated data contributes to the
development of the annual report for the agency which is supported by the
reviewed data and policy.
Provision (d):
The agency shall maintain, review, and collect data as needed from all available
incident-based documents, including reports, investigation files, and sexual abuse
incident reviews.
The data is collected and various types of data are identified and related documents
regarding PREA information as applicable. The policies require that statistical
information is maintained for various service areas and occurrences, including major
incidents and medical and mental health emergencies. The agency collects and
maintains data for State-run and contract facilities and aggregates the data which
culminates into the annual report.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every private
facility with which it contracts for the confinement of its residents.
The agency collects and maintains data for state-run and contract facilities and
aggregates the data which culminates into the annual report. The data is collected
from the contract facilities and is included in the agency’s annual reports.
Provision (f):
Upon request, the agency shall provide all such data from the previous calendar
year to the Department of Justice no later than June 30.
Upon request, the facility completes all such data from the previous calendar year
and submits to the Department of Justice in a timely manner based on the year of
the most recent version of the Survey of Sexual Victimization.
Conclusion:
Based upon the review and analysis of the documentation and the interviews, the
Auditor determined the facility is compliant with this standard.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Annual Reports
Interviews:
PREA Compliance Manager
Statewide PREA Coordinator
Contract Agency Head Designee
Provision (a):
The agency shall review data collected and aggregated pursuant to §115.387 in
order to assess and improve the effectiveness of its sexual abuse prevention,
detection, and response policies, practices, and training, including:
(1) Identifying problem areas;
(2) Taking corrective action on an ongoing basis; and
(3) Preparing an annual report of its findings and corrective actions for each facility,
as well as this agency as a whole.
The interviews support the review of data and that it is used to improve the PREA
efforts. The interviews and review of documentation revealed the collection of
various types of data, including PREA related information. Data is reviewed to
assess and improve the effectiveness of prevention, detection and response within
the agency as well as individual facilities. The data is also primary to preparing
annual reports.
Provisions (b)-(d):
(b): Such report shall include a comparison of the current year’s data and corrective
actions with those from prior years and shall provide an assessment of the agency’s
progress in addressing sexual abuse. (c): The agency’s report shall be approved by
the agency head and made readily available to the public through its website or, if it
does not have one, through other means. (d): The agency may redact specific
material from the reports when publication would present a clear and specific threat
to the safety and security of a facility, but must indicate the nature of the material
redacted.
The annual report is prepared by the statewide PREA Coordinator for the agency
and includes data from all State-run and contract facilities within the agency. The
annual reports are approved by the agency head/designee. There are no personal
identifiers in the report. The annual report contains PREA related data that
represents previous calendar years allowing for the comparison of data. The
overarching annual report for the agency is posted on the agency’s website,
accessible to the public.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the agency is compliant with this standard.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25, PREA
Agency Policy FDJJ 1316, Records and Information Management Procedures
Agency Policy FDJJ 1919, PREA
Annual Report
Interview:
Statewide PREA Coordinator
Provisions (a)-(d):
(a): The agency shall ensure that data collected pursuant to §115.387 are securely
retained. (b): The agency shall make all aggregated sexual abuse data, from
facilities under its direct control and private facilities with which it contracts, readily
available to the public at least annually through its website or, if it does not have
one, through other means. (c): Before making aggregated sexual abuse data
publicly available, the agency shall remove all personal identifiers. (d): The agency
shall maintain sexual abuse data collected pursuant to §115.387 for at least 10
years after the date of its initial collection unless Federal, State, or local law requires
otherwise.
The data collected is securely stored and maintained for at least 10 years after the
date of collection unless a law requires otherwise, in accordance with policy.
Personal identifiers are removed from aggregated data before making the data
publicly available. The annual report is available to the public through the
Department of Juvenile Justice agency website. A review of the annual report
verified there are no personal identifiers. All facility and agency records are
securely stored in locked cabinets behind locked doors and electronic records are
password protected. The interviews support the premise and policies.
Conclusion:
Based upon the review and analysis of the documentation, interviews and
observations, the Auditor determined the facility is compliant with this standard.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
The PREA Pre-Audit Questionnaire and supporting documentation were initially
uploaded in the Online Audit System. The Auditor was provided additional
information onsite as requested and the Auditor selected additional specific
documentation for review. During the post audit phase, the Superintendent provided
the Auditor with evidence the corrective action of refresher education for residents
was completed. The Florida Department of Juvenile Justice ensured the completion
of PREA audits for each State-run and contract facility as required, including this
facility.
The site review was led by the Superintendent; all areas of the building were
included and detailed observations were conducted of the living units and program
areas. The areas containing posted information were observed for consistent
messaging and easy to read signage. The Superintendent, Assistant
Superintendent, other staff, and DJJ statewide PREA Coordinator were cooperative in
providing information and participating in or assisting in coordinating the
interviews. All interviews were conducted in private.
The PREA notices provided the general information and included instructions and
Auditor contact information regarding how to provide confidential information to the
Auditor. The facility has a process in place for confidential correspondence for the
residents however no correspondence was received by the Auditor from residents,
staff, contractors, or volunteers.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Annual Reports
Interview:
Superintendent
DJJ Statewide PREA Coordinator
Provision (f):
The agency shall ensure that the auditor’s final report is published on the agency’s
website if it has one, or is otherwise made readily available to the public.
The posted PREA reports do not contain any personal identifying information other
than names and job titles. The facility and agency policies and additional
documentation, practices and interviews with the Superintendent, Assistant
Superintendent, and other staff were reviewed regarding compliance with the
standards and have been identified in the reports.
The audit findings were based on a review of policies, procedures, supporting
documentation, observations, and interviews. There were no conflicts of interest
regarding the completion of this audit. This report does not contain any personal
identifying information other than names and job titles of facility and agency staff
and the community resource staff member.
Appendix: Provision Findings
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(a) coordinator
Does the agency have a written policy mandating zero tolerance yes
toward all forms of sexual abuse and sexual harassment?
Does the written policy outline the agency’s approach to yes
preventing, detecting, and responding to sexual abuse and sexual
harassment?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(b) coordinator
Has the agency employed or designated an agency-wide PREA yes
Coordinator?
Is the PREA Coordinator position in the upper-level of the agency yes
hierarchy?
Does the PREA Coordinator have sufficient time and authority to yes
develop, implement, and oversee agency efforts to comply with
the PREA standards in all of its facilities?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(c) coordinator
If this agency operates more than one facility, has each facility yes
designated a PREA compliance manager? (N/A if agency operates
only one facility.)
Does the PREA compliance manager have sufficient time and yes
authority to coordinate the facility’s efforts to comply with the
PREA standards? (N/A if agency operates only one facility.)
115.312
Contracting with other entities for the confinement of residents
(a)
If this agency is public and it contracts for the confinement of its yes
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any
new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies
or other entities for the confinement of residents.)
115.312
Contracting with other entities for the confinement of residents
(b)
Does any new contract or contract renewal signed on or after yes
August 20, 2012 provide for agency contract monitoring to ensure
that the contractor is complying with the PREA standards? (N/A if
the agency does not contract with private agencies or other
entities for the confinement of residents OR the response to
115.312(a)-1 is "NO".)
115.313
Supervision and monitoring
(a)
Does the agency ensure that each facility has developed a staffing yes
plan that provides for adequate levels of staffing and, where
applicable, video monitoring, to protect residents against sexual
abuse?
Does the agency ensure that each facility has implemented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility has documented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure
residential practices?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots”
or areas where staff or residents may be isolated)?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
composition of the resident population?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
other relevant factors?
115.313
Supervision and monitoring
(b)
Does the agency comply with the staffing plan except during yes
limited and discrete exigent circumstances?
In circumstances where the staffing plan is not complied with, na
does the facility fully document all deviations from the plan? (N/A
if no deviations from staffing plan.)
115.313
Supervision and monitoring
(c)
Does the facility maintain staff ratios of a minimum of 1:8 during yes
resident waking hours, except during limited and discrete exigent
circumstances? (N/A only until October 1, 2017.)
Does the facility maintain staff ratios of a minimum of 1:16 during yes
resident sleeping hours, except during limited and discrete
exigent circumstances? (N/A only until October 1, 2017.)
Does the facility fully document any limited and discrete exigent yes
circumstances during which the facility did not maintain staff
ratios? (N/A only until October 1, 2017.)
Does the facility ensure only security staff are included when yes
calculating these ratios? (N/A only until October 1, 2017.)
Is the facility obligated by law, regulation, or judicial consent yes
decree to maintain the staffing ratios set forth in this paragraph?
115.313
Supervision and monitoring
(d)
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The staffing plan established
pursuant to paragraph (a) of this section?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: Prevailing staffing patterns?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The facility’s deployment of
video monitoring systems and other monitoring technologies?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The resources the facility has
available to commit to ensure adherence to the staffing plan?
115.313
Supervision and monitoring
(e)
Has the facility implemented a policy and practice of having yes
intermediate-level or higher-level supervisors conduct and
document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities )
Is this policy and practice implemented for night shifts as well as yes
day shifts? (N/A for non-secure facilities )
Does the facility have a policy prohibiting staff from alerting other yes
staff members that these supervisory rounds are occurring, unless
such announcement is related to the legitimate operational
functions of the facility? (N/A for non-secure facilities )
115.315
Limits to cross-gender viewing and searches
(a)
Does the facility always refrain from conducting any cross-gender yes
strip or cross-gender visual body cavity searches, except in
exigent circumstances or by medical practitioners?
115.315
Limits to cross-gender viewing and searches
(b)
Does the facility always refrain from conducting cross-gender pat- yes
down searches in non-exigent circumstances?
115.315
Limits to cross-gender viewing and searches
(c)
Does the facility document and justify all cross-gender strip yes
searches and cross-gender visual body cavity searches?
Does the facility document all cross-gender pat-down searches? yes
115.315
Limits to cross-gender viewing and searches
(d)
Does the facility implement policies and procedures that enable yes
residents to shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their
breasts, buttocks, or genitalia, except in exigent circumstances or
when such viewing is incidental to routine cell checks?
Does the facility require staff of the opposite gender to announce yes
their presence when entering a resident housing unit?
In facilities (such as group homes) that do not contain discrete yes
housing units, does the facility require staff of the opposite gender
to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions,
or changing clothing? (N/A for facilities with discrete housing
units)
115.315
Limits to cross-gender viewing and searches
(e)
Does the facility always refrain from searching or physically yes
examining transgender or intersex residents for the sole purpose
of determining the resident’s genital status?
If a resident’s genital status is unknown, does the facility yes
determine genital status during conversations with the resident,
by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted
in private by a medical practitioner?
115.315
Limits to cross-gender viewing and searches
(f)
Does the facility/agency train security staff in how to conduct yes
cross-gender pat down searches in a professional and respectful
manner, and in the least intrusive manner possible, consistent
with security needs?
Does the facility/agency train security staff in how to conduct yes
searches of transgender and intersex residents in a professional
and respectful manner, and in the least intrusive manner possible,
consistent with security needs?
115.316 Residents with disabilities and residents who are limited
(a) English proficient
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are deaf or hard of hearing?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are blind or have low vision?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have intellectual disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have psychiatric disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have speech disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Other? (if "other," please explain in overall determination notes.)
Do such steps include, when necessary, ensuring effective yes
communication with residents who are deaf or hard of hearing?
Do such steps include, when necessary, providing access to yes
interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any
necessary specialized vocabulary?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
intellectual disabilities?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
limited reading skills?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Who are
blind or have low vision?
115.316 Residents with disabilities and residents who are limited
(b) English proficient
Does the agency take reasonable steps to ensure meaningful yes
access to all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment to residents
who are limited English proficient?
Do these steps include providing interpreters who can interpret yes
effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary?
115.316 Residents with disabilities and residents who are limited
(c) English proficient
Does the agency always refrain from relying on resident yes
interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s
safety, the performance of first-response duties under §115.364,
or the investigation of the resident’s allegations?
115.317
Hiring and promotion decisions
(a)
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has engaged in sexual
abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been convicted of
engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent
or refuse?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been civilly or
administratively adjudicated to have engaged in the activity
described in the bullet immediately above?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has
engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as
defined in 42 U.S.C. 1997)?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of
force, or coercion, or if the victim did not consent or was unable to
consent or refuse?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
civilly or administratively adjudicated to have engaged in the
activity described in the two bullets immediately above?
115.317
Hiring and promotion decisions
(b)
Does the agency consider any incidents of sexual harassment in yes
determining whether to hire or promote anyone, or to enlist the
services of any contractor, who may have contact with residents?
115.317 Hiring and promotion decisions
(c)
Before hiring new employees who may have contact with yes
residents, does the agency: Perform a criminal background records
check?
Before hiring new employees who may have contact with yes
residents, does the agency: Consult any child abuse registry
maintained by the State or locality in which the employee would
work?
Before hiring new employees who may have contact with yes
residents, does the agency: Consistent with Federal, State, and
local law, make its best efforts to contact all prior institutional
employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an
allegation of sexual abuse?
115.317
Hiring and promotion decisions
(d)
Does the agency perform a criminal background records check yes
before enlisting the services of any contractor who may have
contact with residents?
Does the agency consult applicable child abuse registries before yes
enlisting the services of any contractor who may have contact
with residents?
115.317
Hiring and promotion decisions
(e)
Does the agency either conduct criminal background records yes
checks at least every five years of current employees and
contractors who may have contact with residents or have in place
a system for otherwise capturing such information for current
employees?
115.317
Hiring and promotion decisions
(f)
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in written applications or
interviews for hiring or promotions?
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in any interviews or
written self-evaluations conducted as part of reviews of current
employees?
Does the agency impose upon employees a continuing affirmative yes
duty to disclose any such misconduct?
115.317
Hiring and promotion decisions
(g)
Does the agency consider material omissions regarding such yes
misconduct, or the provision of materially false information,
grounds for termination?
115.317
Hiring and promotion decisions
(h)
Unless prohibited by law, does the agency provide information on yes
substantiated allegations of sexual abuse or sexual harassment
involving a former employee upon receiving a request from an
institutional employer for whom such employee has applied to
work? (N/A if providing information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee is
prohibited by law.)
115.318
Upgrades to facilities and technologies
(a)
If the agency designed or acquired any new facility or planned any yes
substantial expansion or modification of existing facilities, did the
agency consider the effect of the design, acquisition, expansion,
or modification upon the agency’s ability to protect residents from
sexual abuse? (N/A if agency/facility has not acquired a new
facility or made a substantial expansion to existing facilities since
August 20, 2012, or since the last PREA audit, whichever is later.)
115.318
Upgrades to facilities and technologies
(b)
If the agency installed or updated a video monitoring system, yes
electronic surveillance system, or other monitoring technology,
did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit,
whichever is later.)
115.321
Evidence protocol and forensic medical examinations
(a)
If the agency is responsible for investigating allegations of sexual yes
abuse, does the agency follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions? (N/A if the
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
115.321
Evidence protocol and forensic medical examinations
(b)
Is this protocol developmentally appropriate for youth? (N/A if the yes
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based yes
on the most recent edition of the U.S. Department of Justice’s
Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/
Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative
sexual abuse investigations. )
115.321
Evidence protocol and forensic medical examinations
(c)
Does the agency offer all residents who experience sexual abuse yes
access to forensic medical examinations, whether on-site or at an
outside facility, without financial cost, where evidentiarily or
medically appropriate?
Are such examinations performed by Sexual Assault Forensic yes
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs)
where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must
have been specifically trained to conduct sexual assault forensic
exams)?
Has the agency documented its efforts to provide SAFEs or yes
SANEs?
115.321
Evidence protocol and forensic medical examinations
(d)
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate yes
services, does the agency make available to provide these
services a qualified staff member from a community-based
organization, or a qualified agency staff member?
Has the agency documented its efforts to secure services from yes
rape crisis centers?
115.321
Evidence protocol and forensic medical examinations
(e)
As requested by the victim, does the victim advocate, qualified yes
agency staff member, or qualified community-based organization
staff member accompany and support the victim through the
forensic medical examination process and investigatory
interviews?
As requested by the victim, does this person provide emotional yes
support, crisis intervention, information, and referrals?
115.321
Evidence protocol and forensic medical examinations
(f)
If the agency itself is not responsible for investigating allegations yes
of sexual abuse, has the agency requested that the investigating
entity follow the requirements of paragraphs (a) through (e) of this
section? (N/A if the agency is responsible for investigating
allegations of sexual abuse.)
115.321
Evidence protocol and forensic medical examinations
(h)
If the agency uses a qualified agency staff member or a qualified na
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
Policies to ensure referrals of allegations for investigations
(a)
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual
harassment?
115.322
Policies to ensure referrals of allegations for investigations
(b)
Does the agency have a policy in place to ensure that allegations yes
of sexual abuse or sexual harassment are referred for
investigation to an agency with the legal authority to conduct
criminal investigations, unless the allegation does not involve
potentially criminal behavior?
Has the agency published such policy on its website or, if it does yes
not have one, made the policy available through other means?
Does the agency document all such referrals? yes
115.322
Policies to ensure referrals of allegations for investigations
(c)
If a separate entity is responsible for conducting criminal yes
investigations, does such publication describe the responsibilities
of both the agency and the investigating entity? (N/A if the
agency/facility is responsible for criminal investigations. See
115.321(a))
115.331
Employee training
(a)
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency
sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and
sexual harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual
harassment in juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual
abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with
residents?
Does the agency train all employees who may have contact with yes
residents on: How to communicate effectively and professionally
with residents, including lesbian, gay, bisexual, transgender,
intersex, or gender nonconforming residents?
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
115.331
Employee training
(b)
Is such training tailored to the unique needs and attributes of yes
residents of juvenile facilities?
Is such training tailored to the gender of the residents at the yes
employee’s facility?
Have employees received additional training if reassigned from a yes
facility that houses only male residents to a facility that houses
only female residents, or vice versa?
115.331
Employee training
(c)
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training yes
every two years to ensure that all employees know the agency’s
current sexual abuse and sexual harassment policies and
procedures?
In years in which an employee does not receive refresher training, yes
does the agency provide refresher information on current sexual
abuse and sexual harassment policies?
115.331
Employee training
(d)
Does the agency document, through employee signature or yes
electronic verification, that employees understand the training
they have received?
115.332
Volunteer and contractor training
(a)
Has the agency ensured that all volunteers and contractors who yes
have contact with residents have been trained on their
responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and
procedures?
115.332
Volunteer and contractor training
(b)
Have all volunteers and contractors who have contact with yes
residents been notified of the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment and informed how
to report such incidents (the level and type of training provided to
volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)?
115.332
Volunteer and contractor training
(c)
Does the agency maintain documentation confirming that yes
volunteers and contractors understand the training they have
received?
115.333
Resident education
(a)
During intake, do residents receive information explaining the yes
agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment?
During intake, do residents receive information explaining how to yes
report incidents or suspicions of sexual abuse or sexual
harassment?
Is this information presented in an age-appropriate fashion? yes
115.333
Resident education
(b)
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from sexual abuse and
sexual harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from retaliation for
reporting such incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Agency policies and procedures for responding to
such incidents?
115.333
Resident education
(c)
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility yes
to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility?
115.333
Resident education
(d)
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are deaf?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Have limited reading skills?
115.333
Resident education
(e)
Does the agency maintain documentation of resident participation yes
in these education sessions?
115.333
Resident education
(f)
In addition to providing such education, does the agency ensure yes
that key information is continuously and readily available or visible
to residents through posters, resident handbooks, or other written
formats?
115.334
Specialized training: Investigations
(a)
In addition to the general training provided to all employees yes
pursuant to §115.331, does the agency ensure that, to the extent
the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such
investigations in confinement settings? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.334
Specialized training: Investigations
(b)
Does this specialized training include: Techniques for interviewing yes
juvenile sexual abuse victims? (N/A if the agency does not conduct
any form of administrative or criminal sexual abuse investigations.
See 115.321(a).)
Does this specialized training include: Proper use of Miranda and yes
Garrity warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Sexual abuse evidence yes
collection in confinement settings? (N/A if the agency does not
conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence yes
required to substantiate a case for administrative action or
prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See
115.321(a).)
115.334
Specialized training: Investigations
(c)
Does the agency maintain documentation that agency yes
investigators have completed the required specialized training in
conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.335
Specialized training: Medical and mental health care
(a)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have
any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to preserve physical evidence of sexual
abuse? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-
time medical or mental health care practitioners who work
regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(b)
If medical staff employed by the agency conduct forensic na
examinations, do such medical staff receive appropriate training
to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not
employ medical staff.)
115.335
Specialized training: Medical and mental health care
(c)
Does the agency maintain documentation that medical and yes
mental health practitioners have received the training referenced
in this standard either from the agency or elsewhere? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(d)
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by
§115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Do medical and mental health care practitioners contracted by yes
and volunteering for the agency also receive training mandated
for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care
practitioners contracted by or volunteering for the agency.)
115.341
Obtaining information from residents
(a)
Within 72 hours of the resident’s arrival at the facility, does the yes
agency obtain and use information about each resident’s personal
history and behavior to reduce risk of sexual abuse by or upon a
resident?
Does the agency also obtain this information periodically yes
throughout a resident’s confinement?
115.341
Obtaining information from residents
(b)
Are all PREA screening assessments conducted using an objective yes
screening instrument?
115.341
Obtaining information from residents
(c)
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Prior sexual
victimization or abusiveness?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any gender
nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident
may therefore be vulnerable to sexual abuse?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Current
charges and offense history?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Level of
emotional and cognitive development?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical size
and stature?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Mental illness
or mental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical
disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: The resident’s
own perception of vulnerability?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any other
specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or
separation from certain other residents?
115.341
Obtaining information from residents
(d)
Is this information ascertained: Through conversations with the yes
resident during the intake process and medical mental health
screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case yes
files, facility behavioral records, and other relevant documentation
from the resident’s files?
115.341
Obtaining information from residents
(e)
Has the agency implemented appropriate controls on the yes
dissemination within the facility of responses to questions asked
pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or
other residents?
115.342
Placement of residents
(a)
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Education
Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Program Assignments?
115.342
Placement of residents
(b)
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other
residents safe, and then only until an alternative means of
keeping all residents safe can be arranged?
During any period of isolation, does the agency always refrain yes
from denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain yes
from denying residents any legally required educational
programming or special education services?
Do residents in isolation receive daily visits from a medical or yes
mental health care clinician?
Do residents also have access to other programs and work yes
opportunities to the extent possible?
115.342
Placement of residents
(c)
Does the agency always refrain from placing: Lesbian, gay, and yes
bisexual residents in particular housing, bed, or other assignments
solely on the basis of such identification or status?
Does the agency always refrain from placing: Transgender yes
residents in particular housing, bed, or other assignments solely
on the basis of such identification or status?
Does the agency always refrain from placing: Intersex residents in yes
particular housing, bed, or other assignments solely on the basis
of such identification or status?
Does the agency always refrain from considering lesbian, gay, yes
bisexual, transgender, or intersex identification or status as an
indicator or likelihood of being sexually abusive?
115.342
Placement of residents
(d)
When deciding whether to assign a transgender or intersex yes
resident to a facility for male or female residents, does the agency
consider on a case-by-case basis whether a placement would
ensure the resident’s health and safety, and whether a placement
would present management or security problems (NOTE: if an
agency by policy or practice assigns residents to a male or female
facility on the basis of anatomy alone, that agency is not in
compliance with this standard)?
When making housing or other program assignments for yes
transgender or intersex residents, does the agency consider on a
case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would
present management or security problems?
115.342
Placement of residents
(e)
Are placement and programming assignments for each yes
transgender or intersex resident reassessed at least twice each
year to review any threats to safety experienced by the resident?
115.342
Placement of residents
(f)
Are each transgender or intersex resident’s own views with yes
respect to his or her own safety given serious consideration when
making facility and housing placement decisions and
programming assignments?
115.342
Placement of residents
(g)
Are transgender and intersex residents given the opportunity to yes
shower separately from other residents?
115.342
Placement of residents
(h)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The basis for the facility’s
concern for the resident’s safety? (N/A for h and i if facility doesn’t
use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The reason why no alternative
means of separation can be arranged? (N/A for h and i if facility
doesn’t use isolation?)
115.342
Placement of residents
(i)
In the case of each resident who is isolated as a last resort when yes
less restrictive measures are inadequate to keep them and other
residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general
population EVERY 30 DAYS?
115.351
Resident reporting
(a)
Does the agency provide multiple internal ways for residents to yes
privately report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: 2. Retaliation by other residents or staff for
reporting sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: Staff neglect or violation of responsibilities that
may have contributed to such incidents?
115.351
Resident reporting
(b)
Does the agency also provide at least one way for residents to yes
report sexual abuse or sexual harassment to a public or private
entity or office that is not part of the agency?
Is that private entity or office able to receive and immediately yes
forward resident reports of sexual abuse and sexual harassment to
agency officials?
Does that private entity or office allow the resident to remain yes
anonymous upon request?
Are residents detained solely for civil immigration purposes no
provided information on how to contact relevant consular officials
and relevant officials at the Department of Homeland Security to
report sexual abuse or harassment?
115.351
Resident reporting
(c)
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from
third parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351
Resident reporting
(d)
Does the facility provide residents with access to tools necessary yes
to make a written report?
115.351
Resident reporting
(e)
Does the agency provide a method for staff to privately report yes
sexual abuse and sexual harassment of residents?
115.352
Exhaustion of administrative remedies
(a)
Is the agency exempt from this standard? yes
NOTE: The agency is exempt ONLY if it does not have
administrative procedures to address resident grievances
regarding sexual abuse. This does not mean the agency is exempt
simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This
means that as a matter of explicit policy, the agency does not
have an administrative remedies process to address sexual abuse.
115.352
Exhaustion of administrative remedies
(b)
Does the agency permit residents to submit a grievance regarding na
an allegation of sexual abuse without any type of time limits? (The
agency may apply otherwise-applicable time limits to any portion
of a grievance that does not allege an incident of sexual abuse.)
(N/A if agency is exempt from this standard.)
Does the agency always refrain from requiring an resident to use na
any informal grievance process, or to otherwise attempt to resolve
with staff, an alleged incident of sexual abuse? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(c)
Does the agency ensure that: A resident who alleges sexual abuse na
may submit a grievance without submitting it to a staff member
who is the subject of the complaint? (N/A if agency is exempt from
this standard.)
Does the agency ensure that: Such grievance is not referred to a na
staff member who is the subject of the complaint? (N/A if agency
is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(d)
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the
initial filing of the grievance? (Computation of the 90-day time
period does not include time consumed by residents in preparing
any administrative appeal.) (N/A if agency is exempt from this
standard.)
If the agency determines that the 90 day timeframe is insufficient na
to make an appropriate decision and claims an extension of time
(the maximum allowable extension of time to respond is 70 days
per 115.352(d)(3)) , does the agency notify the resident in writing
of any such extension and provide a date by which a decision will
be made? (N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, na
if the resident does not receive a response within the time allotted
for reply, including any properly noticed extension, may a resident
consider the absence of a response to be a denial at that level?
(N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(e)
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on na
behalf of residents? (If a third party, other than a parent or legal
guardian, files such a request on behalf of a resident, the facility
may require as a condition of processing the request that the
alleged victim agree to have the request filed on his or her behalf,
and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.) (N/A if
agency is exempt from this standard.)
If the resident declines to have the request processed on his or na
her behalf, does the agency document the resident’s decision?
(N/A if agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a na
grievance regarding allegations of sexual abuse, including
appeals, on behalf of such juvenile? (N/A if agency is exempt from
this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an na
appeal) on behalf of a juvenile regarding allegations of sexual
abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her
behalf? (N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(f)
Has the agency established procedures for the filing of an na
emergency grievance alleging that a resident is subject to a
substantial risk of imminent sexual abuse? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance alleging a resident is na
subject to a substantial risk of imminent sexual abuse, does the
agency immediately forward the grievance (or any portion thereof
that alleges the substantial risk of imminent sexual abuse) to a
level of review at which immediate corrective action may be
taken? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency provide an initial response within 48 hours? (N/A if
agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency issue a final agency decision within 5 calendar days?
(N/A if agency is exempt from this standard.)
Does the initial response and final agency decision document the na
agency’s determination whether the resident is in substantial risk
of imminent sexual abuse? (N/A if agency is exempt from this
standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt
from this standard.)
Does the agency’s final decision document the agency’s action(s) na
taken in response to the emergency grievance? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(g)
If the agency disciplines a resident for filing a grievance related to na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
115.353 Resident access to outside confidential support services and
(a) legal representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse
by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline
numbers where available, of local, State, or national victim
advocacy or rape crisis organizations?
Does the facility provide persons detained solely for civil yes
immigration purposes mailing addresses and telephone numbers,
including toll-free hotline numbers where available of local, State,
or national immigrant services agencies?
Does the facility enable reasonable communication between yes
residents and these organizations and agencies, in as confidential
a manner as possible?
115.353 Resident access to outside confidential support services and
(b) legal representation
Does the facility inform residents, prior to giving them access, of yes
the extent to which such communications will be monitored and
the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws?
115.353 Resident access to outside confidential support services and
(c) legal representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service
providers that are able to provide residents with confidential
emotional support services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
115.353 Resident access to outside confidential support services and
(d) legal representation
Does the facility provide residents with reasonable and yes
confidential access to their attorneys or other legal
representation?
Does the facility provide residents with reasonable access to yes
parents or legal guardians?
115.354
Third-party reporting
(a)
Has the agency established a method to receive third-party yes
reports of sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report yes
sexual abuse and sexual harassment on behalf of a resident?
115.361
Staff and agency reporting duties
(a)
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding an incident of sexual abuse or
sexual harassment that occurred in a facility, whether or not it is
part of the agency?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding retaliation against residents or
staff who reported an incident of sexual abuse or sexual
harassment?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding any staff neglect or violation of
responsibilities that may have contributed to an incident of sexual
abuse or sexual harassment or retaliation?
115.361
Staff and agency reporting duties
(b)
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361
Staff and agency reporting duties
(c)
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited
from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency
policy, to make treatment, investigation, and other security and
management decisions?
115.361
Staff and agency reporting duties
(d)
Are medical and mental health practitioners required to report yes
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section as well as to the designated State or
local services agency where required by mandatory reporting
laws?
Are medical and mental health practitioners required to inform yes
residents of their duty to report, and the limitations of
confidentiality, at the initiation of services?
115.361
Staff and agency reporting duties
(e)
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
appropriate office?
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
alleged victim’s parents or legal guardians unless the facility has
official documentation showing the parents or legal guardians
should not be notified?
If the alleged victim is under the guardianship of the child welfare na
system, does the facility head or his or her designee promptly
report the allegation to the alleged victim’s caseworker instead of
the parents or legal guardians? (N/A if the alleged victim is not
under the guardianship of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does yes
the facility head or designee also report the allegation to the
juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation?
115.361
Staff and agency reporting duties
(f)
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the
facility’s designated investigators?
115.362
Agency protection duties
(a)
When the agency learns that a resident is subject to a substantial yes
risk of imminent sexual abuse, does it take immediate action to
protect the resident?
115.363
Reporting to other confinement facilities
(a)
Upon receiving an allegation that a resident was sexually abused yes
while confined at another facility, does the head of the facility that
received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse
occurred?
Does the head of the facility that received the allegation also yes
notify the appropriate investigative agency?
115.363
Reporting to other confinement facilities
(b)
Is such notification provided as soon as possible, but no later than yes
72 hours after receiving the allegation?
115.363
Reporting to other confinement facilities
(c)
Does the agency document that it has provided such notification? yes
115.363
Reporting to other confinement facilities
(d)
Does the facility head or agency office that receives such yes
notification ensure that the allegation is investigated in
accordance with these standards?
115.364
Staff first responder duties
(a)
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Request that the alleged victim not take any actions
that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating,
smoking, drinking, or eating, if the abuse occurred within a time
period that still allows for the collection of physical evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical
evidence?
115.364
Staff first responder duties
(b)
If the first staff responder is not a security staff member, is the yes
responder required to request that the alleged victim not take any
actions that could destroy physical evidence, and then notify
security staff?
115.365
Coordinated response
(a)
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in
response to an incident of sexual abuse?
115.366 Preservation of ability to protect residents from contact with
(a) abusers
Are both the agency and any other governmental entities no
responsible for collective bargaining on the agency’s behalf
prohibited from entering into or renewing any collective
bargaining agreement or other agreement that limits the agency’s
ability to remove alleged staff sexual abusers from contact with
any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is
warranted?
115.367
Agency protection against retaliation
(a)
Has the agency established a policy to protect all residents and yes
staff who report sexual abuse or sexual harassment or cooperate
with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff?
Has the agency designated which staff members or departments yes
are charged with monitoring retaliation?
115.367
Agency protection against retaliation
(b)
Does the agency employ multiple protection measures for yes
residents or staff who fear retaliation for reporting sexual abuse or
sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers,
removal of alleged staff or resident abusers from contact with
victims, and emotional support services?
115.367
Agency protection against retaliation
(c)
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents or staff who reported the sexual abuse to
see if there are changes that may suggest possible retaliation by
residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible
retaliation by residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Act promptly to remedy any
such retaliation?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident housing
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident program
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Negative performance
reviews of staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Reassignments of
staff?
Does the agency continue such monitoring beyond 90 days if the yes
initial monitoring indicates a continuing need?
115.367
Agency protection against retaliation
(d)
In the case of residents, does such monitoring also include yes
periodic status checks?
115.367
Agency protection against retaliation
(e)
If any other individual who cooperates with an investigation yes
expresses a fear of retaliation, does the agency take appropriate
measures to protect that individual against retaliation?
115.368
Post-allegation protective custody
(a)
Is any and all use of segregated housing to protect a resident who yes
is alleged to have suffered sexual abuse subject to the
requirements of § 115.342?
115.371
Criminal and administrative agency investigations
(a)
When the agency conducts its own investigations into allegations yes
of sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual
abuse or harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, yes
including third party and anonymous reports? (N/A if the agency
does not conduct any form of administrative or criminal
investigations of sexual abuse or harassment. See 115.321(a).)
115.371
Criminal and administrative agency investigations
(b)
Where sexual abuse is alleged, does the agency use investigators yes
who have received specialized training in sexual abuse
investigations involving juvenile victims as required by 115.334?
115.371
Criminal and administrative agency investigations
(c)
Do investigators gather and preserve direct and circumstantial yes
evidence, including any available physical and DNA evidence and
any available electronic monitoring data?
Do investigators interview alleged victims, suspected yes
perpetrators, and witnesses?
Do investigators review prior reports and complaints of sexual yes
abuse involving the suspected perpetrator?
115.371
Criminal and administrative agency investigations
(d)
Does the agency always refrain from terminating an investigation yes
solely because the source of the allegation recants the allegation?
115.371
Criminal and administrative agency investigations
(e)
When the quality of evidence appears to support criminal yes
prosecution, does the agency conduct compelled interviews only
after consulting with prosecutors as to whether compelled
interviews may be an obstacle for subsequent criminal
prosecution?
115.371 Criminal and administrative agency investigations
(f)
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of
that individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition
for proceeding?
115.371
Criminal and administrative agency investigations
(g)
Do administrative investigations include an effort to determine yes
whether staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports yes
that include a description of the physical evidence and testimonial
evidence, the reasoning behind credibility assessments, and
investigative facts and findings?
115.371
Criminal and administrative agency investigations
(h)
Are criminal investigations documented in a written report that yes
contains a thorough description of the physical, testimonial, and
documentary evidence and attaches copies of all documentary
evidence where feasible?
115.371
Criminal and administrative agency investigations
(i)
Are all substantiated allegations of conduct that appears to be yes
criminal referred for prosecution?
115.371
Criminal and administrative agency investigations
(j)
Does the agency retain all written reports referenced in yes
115.371(g) and (h) for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years unless
the abuse was committed by a juvenile resident and applicable
law requires a shorter period of retention?
115.371
Criminal and administrative agency investigations
(k)
Does the agency ensure that the departure of an alleged abuser yes
or victim from the employment or control of the facility or agency
does not provide a basis for terminating an investigation?
115.371
Criminal and administrative agency investigations
(m)
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain
informed about the progress of the investigation? (N/A if an
outside agency does not conduct administrative or criminal sexual
abuse investigations. See 115.321(a).)
115.372
Evidentiary standard for administrative investigations
(a)
Is it true that the agency does not impose a standard higher than yes
a preponderance of the evidence in determining whether
allegations of sexual abuse or sexual harassment are
substantiated?
115.373
Reporting to residents
(a)
Following an investigation into a resident’s allegation of sexual yes
abuse suffered in the facility, does the agency inform the resident
as to whether the allegation has been determined to be
substantiated, unsubstantiated, or unfounded?
115.373
Reporting to residents
(b)
If the agency did not conduct the investigation into a resident’s yes
allegation of sexual abuse in an agency facility, does the agency
request the relevant information from the investigative agency in
order to inform the resident? (N/A if the agency/facility is
responsible for conducting administrative and criminal
investigations.)
115.373
Reporting to residents
(c)
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer posted within the resident’s unit?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer employed at the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been indicted on a charge related to
sexual abuse in the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been convicted on a charge related to
sexual abuse within the facility?
115.373
Reporting to residents
(d)
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been indicted on a charge related to sexual abuse
within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been convicted on a charge related to sexual abuse
within the facility?
115.373
Reporting to residents
(e)
Does the agency document all such notifications or attempted yes
notifications?
115.376
Disciplinary sanctions for staff
(a)
Are staff subject to disciplinary sanctions up to and including yes
termination for violating agency sexual abuse or sexual
harassment policies?
115.376
Disciplinary sanctions for staff
(b)
Is termination the presumptive disciplinary sanction for staff who yes
have engaged in sexual abuse?
115.376
Disciplinary sanctions for staff
(c)
Are disciplinary sanctions for violations of agency policies relating yes
to sexual abuse or sexual harassment (other than actually
engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable
offenses by other staff with similar histories?
115.376
Disciplinary sanctions for staff
(d)
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to: Law
enforcement agencies, unless the activity was clearly not
criminal?
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to:
Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(a)
Is any contractor or volunteer who engages in sexual abuse yes
prohibited from contact with residents?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Law enforcement agencies (unless the activity was
clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(b)
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility
take appropriate remedial measures, and consider whether to
prohibit further contact with residents?
115.378
Interventions and disciplinary sanctions for residents
(a)
Following an administrative finding that a resident engaged in yes
resident-on-resident sexual abuse, or following a criminal finding
of guilt for resident-on-resident sexual abuse, may residents be
subject to disciplinary sanctions only pursuant to a formal
disciplinary process?
115.378
Interventions and disciplinary sanctions for residents
(b)
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary
history, and the sanctions imposed for comparable offenses by
other residents with similar histories?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied daily
large-muscle exercise?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied access
to any legally required educational programming or special
education services?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident receives daily visits
from a medical or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the resident also have access to other programs
and work opportunities to the extent possible?
115.378
Interventions and disciplinary sanctions for residents
(c)
When determining what types of sanction, if any, should be yes
imposed, does the disciplinary process consider whether a
resident’s mental disabilities or mental illness contributed to his or
her behavior?
115.378
Interventions and disciplinary sanctions for residents
(d)
If the facility offers therapy, counseling, or other interventions yes
designed to address and correct underlying reasons or motivations
for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions?
If the agency requires participation in such interventions as a yes
condition of access to any rewards-based behavior management
system or other behavior-based incentives, does it always refrain
from requiring such participation as a condition to accessing
general programming or education?
115.378
Interventions and disciplinary sanctions for residents
(e)
Does the agency discipline a resident for sexual contact with staff yes
only upon a finding that the staff member did not consent to such
contact?
115.378
Interventions and disciplinary sanctions for residents
(f)
For the purpose of disciplinary action, does a report of sexual yes
abuse made in good faith based upon a reasonable belief that the
alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish
evidence sufficient to substantiate the allegation?
115.378
Interventions and disciplinary sanctions for residents
(g)
Does the agency always refrain from considering non-coercive yes
sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.)
115.381
Medical and mental health screenings; history of sexual abuse
(a)
If the screening pursuant to § 115.341 indicates that a resident yes
has experienced prior sexual victimization, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(b)
If the screening pursuant to § 115.341 indicates that a resident yes
has previously perpetrated sexual abuse, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a mental health
practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(c)
Is any information related to sexual victimization or abusiveness yes
that occurred in an institutional setting strictly limited to medical
and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions,
including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local
law?
115.381
Medical and mental health screenings; history of sexual abuse
(d)
Do medical and mental health practitioners obtain informed yes
consent from residents before reporting information about prior
sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18?
115.382
Access to emergency medical and mental health services
(a)
Do resident victims of sexual abuse receive timely, unimpeded yes
access to emergency medical treatment and crisis intervention
services, the nature and scope of which are determined by
medical and mental health practitioners according to their
professional judgment?
115.382
Access to emergency medical and mental health services
(b)
If no qualified medical or mental health practitioners are on duty yes
at the time a report of recent sexual abuse is made, do staff first
responders take preliminary steps to protect the victim pursuant
to § 115.362?
Do staff first responders immediately notify the appropriate yes
medical and mental health practitioners?
115.382
Access to emergency medical and mental health services
(c)
Are resident victims of sexual abuse offered timely information yes
about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically
appropriate?
115.382
Access to emergency medical and mental health services
(d)
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(a) victims and abusers
Does the facility offer medical and mental health evaluation and, yes
as appropriate, treatment to all residents who have been
victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility?
115.383 Ongoing medical and mental health care for sexual abuse
(b) victims and abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when
necessary, referrals for continued care following their transfer to,
or placement in, other facilities, or their release from custody?
115.383 Ongoing medical and mental health care for sexual abuse
(c) victims and abusers
Does the facility provide such victims with medical and mental yes
health services consistent with the community level of care?
115.383 Ongoing medical and mental health care for sexual abuse
(d) victims and abusers
Are resident victims of sexually abusive vaginal penetration while na
incarcerated offered pregnancy tests? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(e) victims and abusers
If pregnancy results from the conduct described in paragraph § na
115.383(d), do such victims receive timely and comprehensive
information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(f) victims and abusers
Are resident victims of sexual abuse while incarcerated offered yes
tests for sexually transmitted infections as medically appropriate?
115.383 Ongoing medical and mental health care for sexual abuse
(g) victims and abusers
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(h) victims and abusers
Does the facility attempt to conduct a mental health evaluation of yes
all known resident-on-resident abusers within 60 days of learning
of such abuse history and offer treatment when deemed
appropriate by mental health practitioners?
115.386
Sexual abuse incident reviews
(a)
Does the facility conduct a sexual abuse incident review at the yes
conclusion of every sexual abuse investigation, including where
the allegation has not been substantiated, unless the allegation
has been determined to be unfounded?
115.386
Sexual abuse incident reviews
(b)
Does such review ordinarily occur within 30 days of the conclusion yes
of the investigation?
115.386
Sexual abuse incident reviews
(c)
Does the review team include upper-level management officials, yes
with input from line supervisors, investigators, and medical or
mental health practitioners?
115.386
Sexual abuse incident reviews
(d)
Does the review team: Consider whether the allegation or yes
investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse?
Does the review team: Consider whether the incident or allegation yes
was motivated by race; ethnicity; gender identity; lesbian, gay,
bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the
facility?
Does the review team: Examine the area in the facility where the yes
incident allegedly occurred to assess whether physical barriers in
the area may enable abuse?
Does the review team: Assess the adequacy of staffing levels in yes
that area during different shifts?
Does the review team: Assess whether monitoring technology yes
should be deployed or augmented to supplement supervision by
staff?
Does the review team: Prepare a report of its findings, including yes
but not necessarily limited to determinations made pursuant to §§
115.386(d)(1)-(d)(5), and any recommendations for improvement
and submit such report to the facility head and PREA compliance
manager?
115.386
Sexual abuse incident reviews
(e)
Does the facility implement the recommendations for yes
improvement, or document its reasons for not doing so?
115.387
Data collection
(a)
Does the agency collect accurate, uniform data for every yes
allegation of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions?
115.387
Data collection
(b)
Does the agency aggregate the incident-based sexual abuse data yes
at least annually?
115.387
Data collection
(c)
Does the incident-based data include, at a minimum, the data yes
necessary to answer all questions from the most recent version of
the Survey of Sexual Violence conducted by the Department of
Justice?
115.387
Data collection
(d)
Does the agency maintain, review, and collect data as needed yes
from all available incident-based documents, including reports,
investigation files, and sexual abuse incident reviews?
115.387
Data collection
(e)
Does the agency also obtain incident-based and aggregated data yes
from every private facility with which it contracts for the
confinement of its residents? (N/A if agency does not contract for
the confinement of its residents.)
115.387
Data collection
(f)
Does the agency, upon request, provide all such data from the na
previous calendar year to the Department of Justice no later than
June 30? (N/A if DOJ has not requested agency data.)
115.388
Data review for corrective action
(a)
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Identifying problem areas?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Taking corrective action on an
ongoing basis?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Preparing an annual report of
its findings and corrective actions for each facility, as well as the
agency as a whole?
115.388
Data review for corrective action
(b)
Does the agency’s annual report include a comparison of the yes
current year’s data and corrective actions with those from prior
years and provide an assessment of the agency’s progress in
addressing sexual abuse?
115.388
Data review for corrective action
(c)
Is the agency’s annual report approved by the agency head and yes
made readily available to the public through its website or, if it
does not have one, through other means?
115.388
Data review for corrective action
(d)
Does the agency indicate the nature of the material redacted yes
where it redacts specific material from the reports when
publication would present a clear and specific threat to the safety
and security of a facility?
115.389
Data storage, publication, and destruction
(a)
Does the agency ensure that data collected pursuant to § 115.387 yes
are securely retained?
115.389
Data storage, publication, and destruction
(b)
Does the agency make all aggregated sexual abuse data, from yes
facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through
its website or, if it does not have one, through other means?
115.389
Data storage, publication, and destruction
(c)
Does the agency remove all personal identifiers before making yes
aggregated sexual abuse data publicly available?
115.389
Data storage, publication, and destruction
(d)
Does the agency maintain sexual abuse data collected pursuant to yes
§ 115.387 for at least 10 years after the date of the initial
collection, unless Federal, State, or local law requires otherwise?
115.401
Frequency and scope of audits
(a)
During the prior three-year audit period, did the agency ensure yes
that each facility operated by the agency, or by a private
organization on behalf of the agency, was audited at least once?
(Note: The response here is purely informational. A "no" response
does not impact overall compliance with this standard.)
115.401
Frequency and scope of audits
(b)
Is this the first year of the current audit cycle? (Note: a “no” no
response does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency na
ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, was
audited during the first year of the current audit cycle? (N/A if this
is not the second year of the current audit cycle.)
If this is the third year of the current audit cycle, did the agency yes
ensure that at least two-thirds of each facility type operated by
the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle?
(N/A if this is not the third year of the current audit cycle.)
115.401
Frequency and scope of audits
(h)
Did the auditor have access to, and the ability to observe, all yes
areas of the audited facility?
115.401
Frequency and scope of audits
(i)
Was the auditor permitted to request and receive copies of any yes
relevant documents (including electronically stored information)?
115.401
Frequency and scope of audits
(m)
Was the auditor permitted to conduct private interviews with yes
inmates, residents, and detainees?
115.401
Frequency and scope of audits
(n)
Were inmates, residents, and detainees permitted to send yes
confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel?
115.403
Audit contents and findings
(f)
The agency has published on its agency website, if it has one, or yes
has otherwise made publicly available, all Final Audit Reports. The
review period is for prior audits completed during the past three
years PRECEDING THIS AUDIT. The pendency of any agency
appeal pursuant to 28 C.F.R. § 115.405 does not excuse
noncompliance with this provision. (N/A if there have been no Final
Audit Reports issued in the past three years, or, in the case of
single facility agencies, there has never been a Final Audit Report
issued.)

report_type: PREA

program_name_raw: Miami Youth Academy

cycle: Year 3 Cycle 4