facility_name: ftmyersyouthacademy prea report

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Fort Myers Youth Academy
Physical Address: 2515 Ortiz Avenue, Fort Myers, FL 33905
Date report submitted: February 25, 2016
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: February 1, 2016
Facility Information
Facility Mailing Address: 2515 Ortiz Avenue, Fort Myers, FL 33905
Telephone Number: 239-210-0940
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention Corrections X Other: Residential
Name of PREA Compliance Manager: Joseph Nixon, Acting Facility Administrator Title: Dir. Program Support
Email Address: joseph.nixon@us.g4s.com Telephone Number:
239-210-0940
Agency Information
Name of Agency: G4S Youth Services
Governing Authority or
Parent Agency: NA
Physical Address: 6302 Benjamin Road, Suite 400, Tampa, FL 33634
Mailing Address: Same as Physical Address
Telephone Number: 813-514-6275
Agency Chief Executive Officer
Name: James Hill Title: President
Email Address: jim.hill@us.g4s.com Telephone Number: 8 1 3 - 5 1 4 - 6 2 7 5
Agency Wide PREA Coordinator
Name: Bobbi Pohlman Title: Senior Director of JJDPA/PREA
954-818-5131
Email Address: bobbi.pohlman@us.g4s.com Telephone Number:
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AUDIT FINDINGS
NARRATIVE:
Fort Myers Youth Academy is a 28-bed residential facility for male juvenile offenders who have
been committed to the Florida Department of Juvenile Justice (FDJJ) and are in need of substance
abuse treatment. It is located in Fort Myers, Florida and is operated by G4S Youth Services through
a contract with FDJJ. The facility serves residents ranging from 14 to 18 years of age who have been
classified as low to moderate risk for placement in a residential environment. The length of stay is
from three to nine months for low risk residents and six to nine months for those classified as
moderate risk. The facility is accredited by the Commission on Accreditation of Rehabilitative
Facilities (CARF).
Residents receive medical and mental health screenings during the intake process and on-going
services throughout their stay in the facility. Medical services are provided by the Health Services
Administrator, two other Registered Nurses, and there is a contract physician who visits the facility
weekly. Mental health services are provided by the Director of Clinical Services and three therapists;
a consulting psychiatrist visits the facility weekly. Additional contract positions are psychologist,
Certified Behavior Analyst, and a certified addictions professional. Education services, which
include academic and career education, are provided through school personnel from the Lee County
School District. Residents receive case management services; individual, group and family therapy;
substance abuse counseling; recreation therapy; social/life skills training; and academic/career
education services.
A Performance Plan of goals and expectations is developed for each resident. Residents are assisted
by staff in completing any court sanctions and they are incorporated in the Performance Plan. The
sanctions may include but are not limited to community service hours, apology letters, or written
essays. Residents are involved in restorative justice education sessions and activities using specific
curricula that help residents understand the impact that unlawful behavior has on individuals,
families and the community. Information about the Fort Myers Youth Academy is provided to
parents/guardians through direct contact, Parent Handbook, program handbook, and a follow-up letter
after the arrival of the resident to the facility. A behavior management system, Positive Performance
System, exists where a resident may earn advancing levels through earning points for demonstrating
positive behavior. Each level has identified privileges that increase with the earning of each
advanced level; more responsibility is placed on the resident at each level.
DESCRIPTION OF FACILITY CHARACTERISTICS:
There are three main buildings on the grounds; however, there is one primary building that houses the
program. The front of the building contains a reception area, administrative offices and a conference
room. Beyond this section of the building is a large area that is divided into the dayroom and the
dining room; the kitchen is adjacent to the dining room. There is also a hallway in this area and one
end of the hall include the education office and two classrooms; the other end of the hall contains the
residents’ housing area; medical clinic; bathroom for residents; laundry room; and offices. There are
11 rooms on the housing unit that contain 2-3 residents in each room. The Case Manager and two
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mental health therapists are located on the housing unit. Residents are provided a reasonable amount
of privacy during showers, while using the toilet, and when changing clothes. PREA related
information is posted in various areas of the facility.
There is a large patio/porch on the back of the building and grounds that provide a basketball court
and space for recreation and other activities. Behind the primary building is a portable structure
which is used as a multi-purpose room for resident and staff activities. There is a third building that
has two sides; an office on one side and maintenance on the other side. The office houses the
Recreation Therapist’s office and the canteen. The canteen is associated with the behavior
management system and it is managed by the Recreation Therapist.
Cameras are located in various areas inside and outside of the facility and are primarily monitored by
the Assistant Facility Administrator from his desktop system. The number of residents admitted to
the facility during the past 12 months whose length of stay was more than 30 days is 47. In the past
12 months there have been four contracts for services with contractors who might have contact with
residents. The number of staff employed at the facility in the past 12 months who may have contact
with residents is 73 and there are nine volunteers who may have contact with residents.
SUMMARY OF AUDIT FINDINGS:
An introductory conference call was held prior to the site visit and the audit process was discussed
with facility staff and the DJJ statewide PREA Coordinator. The notifications of the on-site audit
were posted in the facility prior to the site visit and pictures of the postings were forwarded to this
Auditor. The Pre-Audit Questionnaire was uploaded to a flash drive with policies and supporting
documentation and was received prior to the site visit. There were follow-up communication with
facility management staff and additional documentation was requested and provided and
information was clarified as needed. The position of Facility Administrator serves as the PREA
Compliance Manager. This position is currently vacant; however, the Director of Program Support
is serving as the Acting Facility Administrator and the PREA Compliance Manager.
The on-site audit was conducted February 1, 2016. Introductions were conducted with the Acting
Facility Administrator and a comprehensive tour of the facility was provided by him and the
Assistant Facility Administrator. During the tour, staff members were observed to be providing
direct supervision to the residents and interacting with them. Randomly selected residents and staff
members who provide direct care to residents were interviewed. Direct care staff members were
interviewed from all shifts. Specialized interviews were conducted which included a contractor and
a volunteer. During the on-site visit, additional documentation was provided as requested. At the
conclusion of the site visit, a close-out meeting was held with the Acting Facility Administrator.
Number of standards exceeded: 0
Number of standards met: 38
Number of standards not met: 0
Number of standards not applicable: 3
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Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
The facility adheres to Policy 10-25, Prison Rape Elimination Act (PREA) and Policy 1919 of
the Florida Department of Juvenile Justice (FDJJ 1919). The policies are aligned and provide
guidelines for implementing the strategies for complying with the requirements of the PREA
standards. Both policies state a zero-tolerance of all forms of sexual abuse and sexual
harassment. The Policies contain definitions of prohibited behaviors and sanctions for those
found to have participated in the prohibited behaviors.
Policy 10-25 states that the Facility Administrator or a person designated by the G4S Regional
Director serves as the PREA Compliance Manager. The interview with the Director of
Program Support and a review of the organizational chart revealed that the Facility
Administrator (FA) manages the facility and serves as the PREA Compliance Manager. The
Director of Program Support is serving in the roles of Acting FA and PREA Compliance
Manager until the vacancy is filled. The interview further revealed that the FA would have
sufficient time and authority to implement and coordinate the activities regarding PREA
compliance. The FA in the capacity of the Compliance Manager reports to the G4S PREA
Coordinator regarding PREA initiatives.
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
This standard is not applicable. The facility does not contract with other facilities for the
confinement of its residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 and periodic internal management reviews of the staffing schedule, ensures
adequate levels of staffing for all shifts. The contract with FDJJ requires staffing ratios of 1:7
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during the waking hours and 1:10 during the sleeping hours and the staffing plan reflect the
stated ratios. The interview with the Director of Program Support/Acting FA revealed that the
internal reviews of the staff schedule, staff hold-over process, and the use of a pool of “as
needed” staff ensures no deviations from the staffing plan. The facility reports that the
average number of residents in the facility since August 2012 is 27 and that the average daily
number of residents in which the staffing plan was predicated is 28.
A Staffing Plan Assessment was reviewed which was completed by FDJJ’s statewide PREA
Coordinator and includes a review of the items listed in the standard and other related areas
of facility operations. The Staffing Plan Assessment contains a review of the staffing plan;
staffing patterns; deployment of cameras; unannounced rounds; operating procedures; and
other factors that contribute to maintaining compliance with the staffing plan. Policy 10-25
provides that the Administrative Duty Officer conducts unannounced rounds at least once a
month and that the visits are documented in the logbook or the shift report. A review of
logbook entries and staff interviews confirmed that unannounced rounds occur as required
and are conducted by the FA, Assistant Facility Administrator (AFA) and shift supervisors.
The PREA Policy and the facility practice, confirmed through interviews, prohibit staff from
alerting other staff of the occurrence of the unannounced rounds. The Acting FA has since
adapted a specific form for the facility in order to capture more details of the unannounced
rounds and to make the documentation and review of the rounds more accessible.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
This standard is met through a review of Policy 10-3, observations and the results of staff and
resident interviews. Staff members and residents revealed that cross-gender pat-down searches
and cross-gender strip searches are not conducted at this facility. Policy 10-3 addresses staff
conducting searches of residents and provides the details of each type search and the
documentation of searches. Although the practice of the facility is that cross-gender searches
are not conducted, Policy 10-3 does provide for when a female staff may assist a male by
acting as a second person in the search area, observing the staff, while not viewing the
resident. The Policy requires that in these circumstances, the reason for the opposite gender
assisting in the search must be authorized by the FA and the reason for the search documented.
Staff interviews shared that training regarding the searches of all residents includes the
techniques as well as conducting them in a professional and respectful manner. The search
methods were explained that demonstrates a professional manner for all residents.
Policy 10-25 and resident and staff interviews provide that residents are able to shower, use
the toilet, and change clothes without being viewed by female staff. Staff shared that female
staff members do not supervise the aforementioned activities. All residents and staff
interviewed confirmed that female staff follow the prompting of the observed posted signs and
announce themselves when entering the living unit where residents may be showering,
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changing clothes or performing bodily functions. It was observed that there were no shower
curtains and that the toilets were open with no type closures. The supervision of bathroom
activities is supervised by same gender staff, who are strategically placed during showers and
use of the toilet. However, in order to provide each resident with a reasonable amount of
privacy, the facility implemented a corrective action plan and installed shower curtains at the
entrance of the toilets and the showers in a manner that serves this purpose. Policy 8-14 states
that transgender or intersex residents shall not be searched or physically examined for the sole
purpose of determining their genital status. Staff interviews confirmed their awareness of this
Policy and no such searches occurred during this audit period.
Standard 115.316 Residents with Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 provides disabled residents the equal opportunity to participate in or benefit from
resident education to protect them from sexual abuse and sexual harassment. Residents are not
to be used as interpreters or readers, according to Policy 10-25, unless an extended delay in
obtaining an interpreter could compromise the resident’s safety, the performance of the first
responder duties, or the investigation of the resident’s allegation. The facility may use the
Registry of Certified Court Interpreters as a resource, as well as other G4S staff members who
may serve as interpreters. The facility provides an extensive list of internal interpreters which
identifies the G4S facility the staff member works in and other contact information as well as
the language for which they may provide interpreter services.
The list for the external interpreters, Registry of Certified Court Interpreters, is composed of
several pages that contain the contact information as well as the language specialty. Contact
information for American Sign Language interpreters is also included in the lists of external
interpreters. Interviews with staff confirmed their awareness of staff members who may be
used as interpreters and the existence of the list of external interpreters. Staff report that no
residents have been used as interpreters during this audit period.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 3-16, Employee Recruitment and Selection, and FDJJ Policies 1800 and 1919 address
this standard regarding hiring or promoting anyone who has engaged in sexual abuse in a jail,
lockup or similar facility; has been convicted of engaging or attempting to engage in coerced
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or forced sexual activity; or has been adjudicated for any of the aforementioned activities.
The Policies prohibit hiring, promoting or contracting with anyone who has been convicted of
engaging in any activity prohibited by the standard and it provides directions regarding
background checks and screenings. Any incident of sexual harassment is considered
regarding the hiring or promotion of anyone. This was confirmed through the review of the
hiring packet and the staff interview.
A review of a sample of personnel files revealed that they include background checks; signed
acknowledgement forms regarding PREA related issues and information received; signed
disclosure forms; and interview information. The staff interview also revealed that hiring and
promotion decisions are based on background information obtained and according to the
considerations required by the standards. The policies provide that the omission of
information regarding misconduct is grounds for termination of employment. The Business
Manager reports that all staff hired during this audit period received background checks and
he verbalized his knowledge of the hiring and promotion process.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
In addition to direct supervision, a camera system is used to support the monitoring of
residents. The current program has occupied the facility since 2014 and a camera system was
already installed. However, since that time the agency has installed additional cameras to the
outside recreation area and inside of the Recreation Therapist’s office which is located on the
outside grounds. The AFA conducts the primary monitoring on the desktop system from his
office.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
According to Policies 10-25 and FDJJ 1919 and staff interviews, the elements of the standard
are met and facility staff members are not responsible for conducting administrative or
criminal investigations. FDJJ 1919 and 10-25 support that the Florida Department of Juvenile
Justice Office of the Inspector General (OIG) is responsible for conducting administrative
investigations; the Florida Department of Children and Families (DCF) is responsible for
conducting allegations of child abuse; and local law enforcement is responsible for
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conducting criminal investigations. A review of documentation shows that the facility has
shared with law enforcement personnel the FDJJ written information regarding PREA related
investigations and comprehensive uniform evidence protocols developed after 2011.
Documented correspondence shows that the FDJJ PREA information sheet has been shared
with the Ft. Myers Police Department.
The facility has provided for victim services, at no cost to the victim, through entering a
Memorandum of Agreement (MOA) with a rape crisis center, Abuse Counseling and
Treatment Center. Assistance that will be provided by the agency include Sexual Assault
Nursing Examiner/Sexual Assault Forensic Examiner services; counseling services; a list of
approved victim advocates so that one is available in person when needed; and facility staff
training regarding the role of the rape crisis center. The MOA provides that a victim advocate
may accompany and provide support to the victim through the forensic medical examination
and investigatory processes. An interview with the rape crisis center representative confirmed
the content of the MOA and that advocacy services and the forensic examination will be
provided to a victim when requested. There have been no forensic examinations conducted
during this audit period.
Standard 115.322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 10-25; FDJJ 1919; FDJJ 2020; document review; and staff interviews support that an
administrative or criminal investigation is completed for all allegations of sexual abuse and
sexual harassment. The Policies identify who is responsible for conducting the criminal and
administrative investigations and instructs staff to cooperate with investigations. During the
past 12 months there were two administrative investigations of sexual abuse and sexual
harassment. The administrative investigations resulted in findings of Unsubstantiated and the
other one was closed as Information Only. There is an allegation that involves a criminal
investigation that is ongoing by the Collier County Sherriff’s Office that did not occur in the
facility. According to the incident report and management staff interview, the alleged incident
occurred after the resident left the facility and was reported by the youth’s community
worker. The facility staff member associated with the allegation was placed on suspension by
facility management pending the outcome of the investigation; however, the staff member has
since resigned. A review of policies and other documents and management staff interview
indicate that the allegations were reported, as well as investigated, as required by the
standards.
The Florida Department of Juvenile Justice website contains the policy regarding reporting
allegations of sexual abuse and sexual harassment. The OIG follows unit specific policy in
conducting administrative investigations. Additionally, the facility provides parents/
guardians and visitors with information regarding how they, as well as the residents, may
report allegations of sexual abuse and sexual harassment allegations. Staff interviews support
policy and the practice that all referrals of allegations for investigations are documented.
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Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 5-1 and 5-2 address employee training and staff interviews and a review of the Skill-
Pro training documents confirmed the training as required by the standard and includes the
facility and agency zero-tolerance policies. Documents and staff interviews also support that
PREA refresher training is provided at least annually, and as needed to address specific
PREA topics. The facility reports that the training is tailored to the needs of the population
they serve and that all staff members have received training as required by the standard. A
review of a sample of staff training records and staff interviews support that initial training
and refresher training occurs. There is documentation of the receipt of PREA training and the
comprehensive PREA training curriculum. Florida DJJ provides on-line training through
Skill-Pro and facility in-house training has been conducted regarding specific areas of the
standards.
Standard 115.332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919, a review of the training curriculum for volunteers, and documented training
support that volunteers and contractors receive training on their responsibilities regarding the
zero-tolerance of sexual assault and sexual harassment and how to report any allegations or
incidents. Interviews with a volunteer and a contractor confirmed their participation in PREA
related training. All volunteers receive a Volunteer Handbook.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
According to Policy 10-25, resident and staff interviews, and a review of documentation
acknowledging resident participation in PREA education sessions, all residents are provided
age-appropriate PREA information during the intake process. All residents receive PREA
education regardless if they are transferring from another facility or are a new admission and
9
the facility policy addresses retaliation if a resident should report an allegation from a former
facility or the current one. Staff members may assist with the PREA education for residents
that are limited English proficient, visually impaired, otherwise disabled, or have limited
reading skills. Additional support services may be obtained from the Registry of Certified
Court Interpreters, Florida Registry of Interpreters for the Deaf, and staff members that work
at other G4S facilities. The PREA information is posted within the facility in various
locations and program handbooks remain available to all residents. The interviews with the
residents showed that they were lacking in their awareness of the specific services that they
would be provided by the rape crisis center if they should need them and the confidentiality
practices. A corrective action plan was implemented and this auditor received the education
roster where each resident had written his name showing that the education session had been
conducted by the Acting Facility Administrator, based on the information provided by the
agency.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 addresses the training of the OIG Investigators, including the related policies and
procedures regarding the handling of sexual misconduct incidents and reports. Appropriate
training is provided to investigative staff regarding conducting investigations in the DJJ
settings. The FDJJ information sheet regarding investigations protocols are shared with local
law enforcement by the facility management staff. The facility staff members do not conduct
administrative or criminal investigations. Staff interviews confirmed the practice and they are
aware of the investigative entities.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 and facility Policies 5-1 and 5-2 address staff training. The medical and mental
health staff members have received the training developed for those areas, as well as the
initial PREA training. The specialized training is developed by DJJ and is accessible to
medical and mental health staffs online and is documented through the Skill-Pro training
process. The medical and mental health staff interviewed supported the documented training.
The medical staff does not conduct forensic medical examinations.
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Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 9-1, 8-14 and FDJJ 1919 provide information regarding screening for risk of
victimization and abusiveness. Staff and resident interviews and a review of documentation
also confirmed that residents are screened for risk of victimization and abusiveness within 24
hours of intake, whether a transfer or new admission. The screening is conducted using the
FDJJ objective instrument, Screening for Vulnerability to Victimization and Sexuality
Aggressive Behavior (VSAB). The VSAB is used to obtain the information required by the
standard. The facility reports that 47 residents received the screening during this audit period.
Interviews revealed that reassessment screenings are conducted as needed on a formal basis
and on an informal basis through resident meetings with treatment staff. The residents that
were interviewed were able to indicate some of the questions that are contained in the VSAB.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 9.3, 8-14 and FDJJ 1919 address this standard regarding the information from the
VSAB and other risk screening instruments and outline how the information is to be used to
help determine housing and program assignments with the goal of keeping all residents safe.
No resident has been placed in isolation during this audit period regarding their safety from
sexual assault; isolation is not used at this facility. Policy 8-14 prohibit placing gay, bisexual,
transgender or intersex residents in specific housing or making other assignments solely
based on how they self-identify or their status and also prohibits staff from considering that
identification as an indicator that these residents may be sexually abusive. Facility policy and
staff interviews support that housing and program assignments for transgender or intersex
residents are made on a case-by-case basis.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Policies 8-3, 10-25 and FDJJ 1919 address this standard and provide multiple internal ways a
resident may privately report sexual abuse and sexual harassment, retaliation for reporting,
and staff neglect or violations of responsibilities that may lead to the aforementioned
incidents. Residents may report allegations of sexual abuse or sexual harassment by
telephone, using the abuse hotline 800 number. Staff may also use the abuse hotline to
privately report sexual abuse and sexual harassment of residents. There are also additional
internal ways a resident may report, such as completing a grievance form; talk to any staff
member; complete a Let’s Talk form requesting to speak to a specific staff member; and third
parties may report allegations. Access to writing tools is provided for residents so that they
are able to complete the forms used for reporting or making requests. Resident and staff
interviews support the ways a resident may report allegations and the information is also
provided in the program handbook.
Staff and resident interviews revealed that they are aware of the policies regarding accepting
reports of allegations of sexual abuse and sexual harassment that are made verbally, in
writing, anonymous, and by third parties. Policies and staff interviews support that staff are
required to document verbal reports and to report the information to the Central
Communications Center within two hours of receipt of the verbal report. Staff receives this
related information through policies and procedures, training and the Employee Handbook.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 8-4 provides the details regarding completing and responding to a grievance,
including an emergency grievance that alleges sexual assault or sexual harassment.
Emergency grievances may be completed at any time and may be given to the grievance
officer or placed in the locked grievance box. The resident is not required to handle an
emergency grievance informally by attempting to resolve the situation with staff. The
grievance policy provides for assistance to the resident, by third-parties, in filing the
grievance and that grievances may be received by third parties. It must be documented when
a resident refuses third-party assistance. A resident’s parents or legal guardians may file a
grievance on behalf of the resident whether he agrees or not to the grievance being filed.
When an emergency grievance is received, it is immediately provided to the FA, per Policy
8-4. A response is provided to the resident immediately and the policies and procedures for
reporting allegations of sexual abuse are initiated and a report is made as required by policy.
The facility’s grievance system is not intended to provide for an investigation or to resolve
allegations of sexual abuse. The content of the grievance is reported and an investigation is
conducted by the OIG, DCF or local law enforcement. The purpose of the submission of a
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grievance concerning sexual abuse provides an avenue for ensuring the reporting of the
allegation and provides management staff with the opportunity to intervene and protect the
resident. During the past 12 months, there has not been a grievance filed alleging sexual
abuse.
Policy 10-25 and the Employee Handbook provide staff with the required information for
reporting sexual abuse and sexual harassment of residents. The agency policy provides that a
resident may be disciplined when it has been determined that a grievance alleging sexual
abuse has been filed in bad faith. The residents and staff interviewed were able to articulate
how the grievance system may be used to report allegations of abuse and the residents are
aware of how grievances are handled. This Auditor observed the locked grievance boxes.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 addresses this standard and requires the Facility Administrator to ensure that
residents have access to an outside victim advocacy agency for emotional support services.
The resident is provided with general and contact information during PREA education
sessions and it is made available through posters as observed by this auditor. There is
documentation of a Memorandum of Agreement (MOA) between the facility and a rape
crisis center, Abuse Counseling and Treatment Center. The MOA includes how services will
be provided to victims in as confidential a manner as possible. Services to be provided that
are contained in the MOA were confirmed through a telephone interview with a
representative of the rape crisis center. Among other services, the agency will provide
residents with an advocate to be present during the forensic examination and investigative
processes and will provide emotional support services. According to policy and residents’
interviews, the facility provides residents with reasonable and confidential access to
attorneys or other legal representation and court workers and reasonable access to their
parents or legal guardians. Family Fun Day is held at the facility every quarter and provides
planned pleasurable activities for residents and their family members, in addition to
visitation.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Policies 8-3 and 10-25 address third party reporting and interviews revealed that residents are
familiar with the concept of third-party reporting of sexual abuse and sexual harassment. All
residents interviewed stated that they had someone who did not work at the facility that they
could report to regarding sexual abuse. Staff interviews revealed their knowledge of third-
party reporting. Information regarding reporting is provided through posters that are located in
areas of the facility that are accessible to the public, residents and staff members. The FDJJ
website contains information regarding third party reporting.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 8-3, 10-25 and FDJJ 1919 provide that all staff immediately report any knowledge,
suspicion, or information regarding an incident of sexual abuse, sexual harassment or incidents
of retaliation. The direct report of an incident should be reported to the Central
Communications Center no later than two hours after receipt of the information. Policy 10-25
prohibits staff from revealing any related information to anyone other than to the extent
necessary to make treatment, investigation and other security and management decisions. A
review of incident reports and interviews revealed that staff members are aware of the
requirement regarding their reporting duties and understand that they are mandated reporters.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 instructs staff to take immediate action to keep residents safe when they learn
that there is substantial risk of imminent threat of sexual abuse. Interviews with staff
confirmed their knowledge of this policy and they were able to verbalize measures they would
take to protect residents who are at substantial risk of imminent sexual abuse. Some of the
protective measures stated that could be implemented immediately were one-on-one staff
supervision, room re-assignments and alerting other staff to the situation. Safety tips for self-
protection while in the facility are listed in the resident’s program handbook. It was
determined that during the past year, no resident was at substantial risk of sexual abuse.
Residents indicated that during the intake process, their feelings about their safety are explored
and they also report that staff will inquire about whether they feel safe in the program during
treatment meetings.
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Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 19-25 and FDJJ 1919 address this standard and requires the Facility Administrator,
upon receiving an allegation that a resident was sexually abused while confined at another
facility, must notify the head of that facility where the alleged abuse occurred. Notification
must be made as soon as possible but no later than 72 hours after receipt of the allegation. The
Facility Administrator must also notify the Central Communications Center to report the
incident for an investigation. The facility reports that during this audit period, there have not
been any reports from a resident about an incident of abuse occurring while they were
confined in another facility. The Acting Facility Administrator indicated his awareness of the
policy regarding reporting to other confinement facilities and the requirement that allegations
received from other facilities must be investigated.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 details the first responder duties which are generally to separate the victim from
the abuser; preserve and protect the scene; and request that the alleged victim does not take
any action that would destroy physical evidence. Initial training and a refresher was
conducted with staff through a combination of online statewide training and in-house
training. Staff interviews revealed that they are aware of the steps to take if they are the first
responder. FDJJ 1919 directs that if the employee first responder is not direct care staff, they
should request that physical evidence is preserved and direct care staff should be notified.
During the past 12 months, a non-direct care staff has not acted as a first responder.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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The facility has a written institutional plan, Sexual Abuse Incident Coordinated Response
Plan, which outlines the coordinated actions of the various identified staff such as the first
responder, supervisors, medical, mental health, and management staff. This coordinated
response to an incident of sexual abuse is also aligned with FDJJ 1919. Staff interviewed were
familiar with their role regarding the response to an incident of sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents From Contact With Abusers.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
This standard is not applicable. The facility does not maintain collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 10-25 and FDJJ 1919 provide protection to residents and staff from retaliation. The
retaliation monitor has been identified as the Assistant Facility Administrator (AFA). He
understands that he is charged with observing for whether or not retaliation occurs after a
resident or staff reports allegations of sexual abuse or cooperates with an investigation. Policy
10-25 identifies items to be monitored to determine whether retaliation is occurring. The
interview with the retaliation monitor supported the Policy and identified some of the things he
would consider in detecting retaliation such as a review of any grievance, review cameras,
review the Let’s Talk forms, and observe interactions. The AFA reports that there has not been
an incident of retaliation during the past 12 months and there was no indication of such.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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This standard is not applicable. Segregated housing is not used at this facility to house
residents who allege sexual abuse.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 10-25 and FDJJ 1919, staff interviews, and a review of reports provide that
administrative investigations are conducted by the OIG and criminal investigations are
conducted by the Fort Myers Police Department. The Florida Department of Children and
Families are also called when there is an allegation of sexual abuse. The Policies direct
facility staff to cooperate with investigations and FDJJ 1919 further provides that an
investigation is not terminated because the source recants the information. This practice is
evidenced through an interview with management staff and through the review of an
investigation report. The OIG follows protocols in conducting administrative investigations in
FDJJ settings. Facility management staff provided local law enforcement with the FDJJ form
regarding the expected protocols related to PREA investigations that are criminal in nature.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 provides that the OIG, responsible for administrative investigations, impose a
standard of a preponderance of the evidence for determining whether allegations are
substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 allows for the victim to be informed that the investigation has been concluded and
Policy 10-25 provides that the Facility Administrator notifies the victim or victim’s parents or
legal guardians. This information is provided to the resident on the Investigation Notification
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(PREA) form. A review of the form for a notification made to a resident who reported an
allegation, stated the purpose of the notice and the results of the investigation which were
Unsubstantiated. The form contains the resident’s signature and signature of a staff witness.
The form is designed to contain the information required in the standard such as the results of
the investigation, whether or not the alleged abuser has remained at the facility, and whether
the alleged abuser has been charged or convicted of the crime. The form will also let a
resident know if the findings of an investigation were Unfounded.
During the past 12 months there were two administrative investigations; the findings for one
allegation was unsubstantiated and the other was closed as Information Only. Regarding the
unsubstantiated findings, the written notification of the findings was provided to the resident
prior to his release from the facility. The allegation involving a facility staff member
regarding an alleged incident occurring after the resident’s release to a community placement
was made by the youth’s community worker. The investigation is ongoing by the Collier
County Sherriff’s Office and the staff is no longer employed at the facility.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 3-3 provides that disciplinary sanctions, up to and including termination for those staff
that violate the facility’s sexual abuse and sexual harassment zero-tolerance policy. The
facility reports that during this audit period, it is alleged that one facility direct care staff
member has violated FDJJ agency policy regarding sexual abuse or sexual harassment after
the youth was released and was in another placement. According to facility policy,
management staff placed the staff on suspension pending the outcome of the investigation; the
employee subsequently resigned. The investigation is ongoing by the Collier County Sherriff’s
Office.
Disciplinary sanctions for violations of facility/agency policies relating to sexual abuse, other
than actually engaging in the act, and sexual harassment are appropriate to the circumstances
of the incident, staff’s disciplinary history, and the sanctions for similar cases of other staff.
During the past 12 months, no staff member has been disciplined for violation of agency
sexual abuse or sexual harassment policies or reported to law enforcement by the facility for
violating such policies. Agency policy provide that terminations or resignations by staff who
would have been terminated if not for the resignation, are reported to local law enforcement if
the situation appeared to be criminal in nature and to relevant licensing bodies. The staff
interviews revealed knowledge of the personnel policies and practices.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 addresses this standard, including requiring that any contractor or volunteer who
engages in sexual abuse be prohibited from contact with residents. It also provides for
contractors and volunteers who engage in sexual abuse to be reported to law enforcement
agencies and to relevant licensing bodies. Policy 10-25 prohibits sexual activity between
residents and volunteers and contracted personnel. The facility ensures that volunteers and
contractors have a clear understanding that a sexual relationship with a resident is strictly
prohibited and is a serious breach of conduct. Interviews with a volunteer and a contractor
and a review of the training document confirmed the related orientation and training for
volunteers and contractors. A handbook is also provided to volunteers that includes the PREA
related information. During this audit period, there have been no allegations of sexual assault
or sexual harassment regarding a contractor or volunteer.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 8-1 and FDJJ 1919 address the formal administrative process and the measures to be
taken regarding major rule violations. This information is also addressed in the program
handbook and isolation is not used as a sanction in response to any rule violation. A resident
may also be referred to law enforcement for charges and possible removal from the facility
regarding resident-on-resident abuse. Sexual activity between residents is prohibited and
administrative or court processes and sanctions occur when it has been determined that the
sexual activity was coerced. Residents are disciplined for sexual contact with staff only when
it has been determined that the staff member did not consent to the sexual contact.
Policy 10-25 states that anyone reporting in good faith shall be immune from any civil or
criminal liability. During the past 12 months there have been no administrative findings or
criminal findings of guilt regarding resident-on-resident sexual abuse that occurred at the
facility. Policies 10-25 and FDJJ 1919 and interviews with mental health and medical staffs
support that counseling or other interventions will be offered to address and correct the
underlying reasons or motivations for abuse when the resident remains in or returns to the
facility after an incident. The staff members interviewed stated that any type interventions or
treatment services provided would not be dependent on the resident’s participation in the
behavior management system, education or other programs.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 and FDJJ 1919 address all sections of this standard, including providing for a
follow-up meeting with a medical or mental health practitioner within 14 days when the
resident discloses any prior incidents of sexual abuse whether victim or perpetrator.
Interviews with medical and mental health staff confirmed the practice of residents being
generally seen by mental health and medical staff on the same day of the disclosure or
discovery. Policy supports that information related to sexual victimization or abusiveness that
occurred in an institutional setting is limited to medical and mental health practitioners and
those staff, based on their need to know. A review of files show that medical and mental health
staff members maintain documentation of the services they provide to the residents. Medical
and mental health staffs discussed their knowledge of informed consent regarding 18 year olds
and how it is used and the consent form was reviewed by this Auditor.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 7-30 and FDJJ 1919 address the elements of this standard. Staff interviews and a
review of documented practices revealed that crisis intervention services will be maintained by
medical and mental health staff as required. Observations of files show that medical and
mental health staff members maintain secondary materials that document services to residents
and in an incident of sexual abuse the requirement of the standards will be met as
demonstrated through interviews and the current records reviewed. It is documented through
policies and understood by staff that treatment services will be provided at no cost to the
victim, whether or not the victim names the abuser, or whether or not the victim cooperates
with the investigation.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 10-25 and 7-30 and interviews with medical and mental health staff confirmed that
on-going medical and mental health care will be provided for sexual abuse victims and
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abusers, as appropriate. Policy 10-25; staff interviews; document review; and observations
revealed that medical and mental health services are consistent with the community level of
care. Policies, interviews and observations also support that medical and mental health
evaluations and treatment will be offered to all residents who have been victimized by sexual
abuse in any prison, jail, lockup, or juvenile facility.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 and FDJJ 1919 provide for an incident review to be conducted within 30 days of
the completion of an investigation in accordance with the tenets of this standard. During the
past 12 months, there were two administrative investigations. One resulted in findings of
Unsubstantiated and the other one resulted in findings being labeled as Information Only. A
document review and staff interviews show that a sexual abuse incident review was
conducted, with documented findings and participants, within 30 days of the completion of the
investigation of the allegations that were unsubstantiated.
The incident review report process allows for the inclusion of recommendations and the report
is provided to the Facility Administrator, who also serves as the PREA Compliance Manager.
The Policies outline the requirements of the standard for discussion and review by the incident
review team. The Policies also identifies the positions that comprise the team. The Policies,
documentation and staff interviews verify the existence and identity of the Incident Review
Team. The identified participants on the team may include the Facility Administrator;
Assistant Facility Administrator; facility treatment staffs; direct care staff; statewide FDJJ
PREA Coordinator; FDJJ Regional Program Administrator; and other participants as needed.
The incident review team member interviewed explained the purpose and the process of the
team.
Standard 115.387 Data Collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 and documentation confirm that FDJJ collects incident-based, uniform data
regarding allegations of sexual abuse at facilities under its direct control, including
contractors, using a standardized instrument and specific guidelines. The format used for
FDJJ facilities and contractors capture the information required to complete the most recent
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version of the Survey of Sexual Violence conducted by the U. S. Department of Justice
(DOJ). The agency maintains and collects various types of identified data and related
documents regarding sexual abuse incidents. FDJJ aggregates the sexual abuse data annually
which culminates into an annual report, which has been reviewed by this Auditor. The agency
provides DOJ with data as requested.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 addresses the sections of this standard. The collected and aggregated data is
reviewed to assess and improve the effectiveness of the PREA related efforts and initiatives
by identifying problem areas; developing and implementing corrective actions as needed; and
preparing an annual report based on the collected data. The Policy also states that an annual
report will be prepared that will provide an assessment of the agency’s progress in addressing
sexual misconduct. The annual report is approved as required. It is obvious from staff
interviews, observations, and document review that the agency has compared the results of
the annual reports and used them to continuously improve policies; procedures; practices; and
training on a statewide basis. The annual reports have been reviewed by this Auditor and the
report is accessible to the public through the agency’s website. There are no personal
identifiers on the annual reports.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 provide that all data collected will be securely maintained and for at least 10 years
after the initial collection date, unless statutes require otherwise. According to the Policy, the
aggregated sexual abuse data from all facilities will be readily available to the public through
the agency’s website; the practice is that the report is posted on the agency’s website. A
review of the annual report verified that there are no personal identifiers, as required.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and
no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under
review.
February 25, 2016
Auditor Signature Date
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program_name_raw: ftmyersyouthacademy prea report