state: FL

summary: PREA - Year 2 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Duval Academy
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 03/14/2024
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:
03/14/
2024
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 02/12/2024
Site Audit:
End Date of On-Site 02/13/2024
Audit:
FACILITY INFORMATION
Facility name: Duval Academy
Facility physical 7500 Ricker Road, Jacksonville, Florida - 32244
address:
Facility mailing
address:
Primary Contact
Name: Chris Anderson
Email Address: canderson@waynehalfway.com
Telephone Number: 9044157614
Superintendent/Director/Administrator
Name: Chris Anderson
Email Address: canderson@waynehalfway.com
Telephone Number: 9044157614
Facility PREA Compliance Manager
Name: Chris Anderson
Email Address: canderson@waynehalfway.com
Telephone Number: O: 904-415-7614
Name: Jason Katz
Email Address: jkatz@waynehalfway.com
Telephone Number: O: 352-474-9016
Facility Health Service Administrator On-Site
Name: Dr. Bargas
Email Address: NA
Telephone Number: 904-777-0100
Facility Characteristics
Designed facility capacity: 28
Current population of facility: 25
Average daily population for the past 12 25
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: 13-19
Facility security levels/resident custody non-secure
levels:
Number of staff currently employed at the 40
facility who may have contact with
residents:
Number of individual contractors who have 2
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 20
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Wayne Halfway House, Inc.
Governing authority
or parent agency (if
applicable):
Physical Address: 942 Andrew Jackson Dr, Waynesboro, Tennessee - 38485
Mailing Address:
Telephone number:
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Kelly Banks Email Address: kbanks@waynehalfway.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 2024-02-12
audit:
2. End date of the onsite portion of the 2024-02-13
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 Women's Center of Jacksonville - Jacksonville,
organization(s) or victim advocates with Florida.
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 28
15. Average daily population for the past 25
12 months:
16. Number of inmate/resident/detainee 2
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/ 28
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
38. Enter the total number of inmates/ 1
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/ 1
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/ 1
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/ 1
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/ 1
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, 40
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 2
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
52. Provide any additional comments No text provided.
regarding the population characteristics
of staff, volunteers, and contractors who
were in the facility as of the first day of
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
53. Enter the total number of RANDOM 9
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 records,
RANDOM INMATE/RESIDENT/DETAINEE reviewed population sheet, and observed
interviewees was geographically population.
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 3
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 1
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
61. Enter the total number of interviews 1
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 and observations.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
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 and observed
to determine if this population exists in interactions.
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 Observed population and conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
65. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
66. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
67. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
68. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who disclosed prior sexual
victimization during risk screening using
the "Inmates who Disclosed Sexual
Victimization during Risk Screening"
protocol:
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 Isolation/segregated housing not used in this
to determine if this population exists in facility.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
70. Provide any additional comments No text provided.
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 12
STAFF who were interviewed:
72. Select which characteristics you Length of tenure in the facility
considered when you selected RANDOM
STAFF interviewees: (select all that Shift assignment
apply)
Work assignment
Rank (or equivalent)
Other (e.g., gender, race, ethnicity,
languages spoken)
None
73. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
74. Provide any additional comments No text provided.
regarding selecting or interviewing
random staff (e.g., any populations you
oversampled, barriers to completing
interviews, barriers to ensuring
representation):
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties.
Therefore, more than one interview protocol may apply to an interview with a single staff
member and that information would satisfy multiple specialized staff interview requirements.
75. Enter the total number of staff in a 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- 1 0 1 0
on-
inmate
sexual
abuse
Total 2 0 2 0
93. Total number of SEXUAL HARASSMENT allegations and investigations overview
during the 12 months preceding the audit, by incident type:
# of allegations
# of sexual # of that had both
# of criminal
harassment administrative criminal and
investigations
allegations investigations administrative
investigations
Inmate-on- 0 0 0 0
inmate
sexual
harassment
Staff-on- 0 0 0 0
inmate
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal
investigation was referred for prosecution and resulted in a conviction, that investigation
outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for
question brevity, we use the term “inmate” in the following questions. Auditors should provide
information on inmate, resident, and detainee sexual abuse investigation files, as applicable to
the facility type being audited.
94. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding
the audit:
Referred Indicted/
Convicted/
Ongoing for Court Case Acquitted
Adjudicated
Prosecution Filed
Inmate-on- 0 0 0 0 0
inmate sexual
abuse
Staff-on- 0 0 0 0 0
inmate sexual
abuse
Total 0 0 0 0 0
95. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 1 0
sexual abuse
Staff-on-inmate 1 0 0 0
sexual abuse
Total 1 0 1 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
96. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months
preceding the audit:
Indicted/
Referred
Court Convicted/
Ongoing for Acquitted
Case Adjudicated
Prosecution
Filed
Inmate-on- 0 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
97. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual
harassment
Staff-on-inmate 0 0 0 0
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
98. Enter the total number of SEXUAL 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 0
HARASSMENT investigation files
reviewed/sampled:
a. Explain why you were unable to There were no allegations of sexual
review any sexual harassment harassment during this audit period.
investigation files:
107. Did your selection of SEXUAL Yes
HARASSMENT investigation files include
a cross-section of criminal and/or
No
administrative investigations by
findings/outcomes?
NA (NA if you were unable to review any
sexual harassment investigation files)
Inmate-on-inmate sexual harassment investigation files
108. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
109. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT files
include criminal investigations? No
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
110. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative
No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
Staff-on-inmate sexual harassment investigation files
111. Enter the total number of STAFF- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
112. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include criminal No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
113. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
114. Provide any additional comments 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 1.03, Provisions of an Abuse Free Environment
Facility Policy 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Employee Handbook
Monthly Reporting Flow Chart
Interviews:
Superintendent
Random Staff
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 PREA policies are aligned and provide guidance to staff regarding the facility’s
approach to preventing, detecting, and responding to allegations of sexual abuse
and sexual harassment. The 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 Florida Department of Juvenile Justice (DJJ) agency Policy,
FDJJ 1919, serves as the overarching PREA Policy for the state-run and contract
facilities. The facility has additional policies and procedures which outline and
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 of the
zero-tolerance and other related policies regarding sexual abuse and sexual
harassment.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator
with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
The agencies’ policies provide for the designation of PREA Coordinators. The DJJ
PREA Coordinator manages the PREA implementation efforts statewide. The
facility’s parent agency’s Executive Director of Policy, Quality Assurance, and
Improvement provides support to the facility and directly supervises the agency's
PREA Coordinator, who is relatively new in the position. Collaboration exists with the
statewide PREA Coordinator and facility staff. The interview with the DJJ statewide
PREA Coordinator, observations and other interviews revealed his authority to
oversee the PREA initiatives and efforts in contract residential facilities as well as
State-run detention facilities. He lends support and direction to all of the contract
facilities and there is continual communication with the Auditor
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 Superintendent has been designated as the PREA Compliance Manager and
reports directly to the State Director, a corporate position. The interview indicated
he has the time to fulfill the PREA duties with the support of facility and corporate
staff and it was determined he has the authority required to fulfill those duties.
Interviews conducted with staff revealed their awareness of the role of the PREA
Compliance Manager. Observations and interviews confirmed the Superintendent
has the support of the facility and corporate staff, and the DJJ statewide PREA
Coordinator.
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:
Agency Policy FDJJ 1919
Contract Language
Provider Contract
Contractors Log
Interviews:
Superintendent
Department of Juvenile Justice (DJJ) Statewide PREA Coordinator
Provisions (a) and (b):
Provision (a): A public agency that contracts for the confinement of its residents
with private agencies or other entities, including other government agencies, shall
include in any new contract or contract renewal the entity’s obligation to adopt and
comply with the PREA standards. Provision (b): Any new contract or contract
renewal shall provide for agency contract monitoring to ensure that the contractor is
complying with the PREA standards.
The public agency, DJJ, contracts for residential services with private providers.
Wayne's Halfway House, Incorporated/Duval Academy is one of the private vendors.
Contracts exist that inform all providers of the requirements by the DJJ to comply
with the PREA Standards and be subject to PREA audits by third-party certified PREA
Auditors. The practice was also confirmed by the interviews and previously
completed and posted PREA audit reports. The facility, Duval Academy, is not
involved in a contract with other facilities for the confinement if its assigned youth
from DJJ.
Conclusion:
Based upon the review and analysis of the available evidence and communication
with the DJJ PREA Coordinator, the Auditor determined compliance with this
standard.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5.01, Youth Supervision
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Staffing Plan
Annual Staffing Plan Assessment
Unannounced Rounds
Interviews:
Superintendent
Intermediate or Higher Level Staff
DJJ Statewide PREA Coordinator
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 policies and staffing plan provide details for maintaining the staffing ratios and
the written plan outlines the staffing requirements. The facility’s staffing plan,
internal controls and management ensures that the PREA staffing ratios are
maintained during the waking hours and during the sleeping hours. 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
and interviews indicated the PREA staffing ratios are maintained. The facility
maintains a mandatory hold-over system and staff that are called in as needed to
ensure adherence to the staffing ratio and staffing plan, according to the interview
with the Superintendent.
The camera system is located in the control room and monitors are also located in
the offices of the Superintendent and Assistant Superintendent. Provisions of the
standard are taken into consideration regarding adequate staffing levels as
confirmed through the interview with the Superintendent and facility policy which
outline staffing requirements. The work schedules are based on the facility’s staffing
plan and population. There is collaboration and review of the work schedules and
logbooks 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.
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.
There are no reported deviations from the staffing ratios in the past 12 months. A
coordinated effort was described in maintaining the staffing ratios which includes
mandatory hold-over and use of staff as needed. The operations of the facility
provide for staff to be held-over to ensure the ratios are met and staff called in as
needed. The facility is prepared to document any deviations from the staffing
requirements. The Superintendent and the Assistant Superintendent monitor 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 can provide for additional staff for days and times
when increased staffing is required.
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 ratios of 1:8 during the waking hours and 1:12
during the sleeping hours are met. The facility’s contract requires less residents to a
staff member during the sleeping hours which ensures the PREA ratio will be met.
The ratios were discussed and observed for and met during the site review. Direct
care staff members provide direct observation of residents. During the last 12
months the average daily number of residents is 25. Since the last 12 months, the
average daily number of residents on which the staffing plan was predicated is 28.
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 Coordinator required by
§115.311, the agency shall assess, determine, and document whether adjustments
are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other monitoring
technologies; and
(4) The resources the facility has available to commit to ensure adherence to the
staffing plan.
The staffing plan assessment was facilitated and completed by the DJJ statewide
PREA Coordinator on March 14, 2023. The document reviews but is not limited to
the following areas: prevailing staffing patterns and review of staffing plan;
electronic monitoring system; and review of other areas related to adequate
supervision. The review considers any adjustments that need to be made by the
construction and implementation of a corrective action plan that would be indicated
through findings or recommendations. The annual assessment documents the
summarization of the review including staffing, physical plant and the electronic
monitoring system. The Staffing Plan Assessment did not contain any
recommendations for corrective actions.
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.
Unannounced rounds are conducted by management staff and covers all shifts.
Rounds had previously been documented in the logbook and on a dedicated form
however the documentation was not consistent. The Auditor was able to observe a
documented unannounced round, completed by the Superintendent, on the camera
system through recorded video. The rounds are made at various times and an
additional round on the overnight shift was conducted by the Superintendent and
documented on the dedicated form which includes the areas visited, considerations
and observations made, and any follow-up.
The interview with the Assistant Superintendent, review of documentation and
policy, and review of camera footage, confirm the unannounced rounds occur. The
staff is not informed of when the rounds will occur and the visits are not conducted
at scheduled times. The unannounced rounds are conducted throughout the facility
to identify and deter sexual abuse and sexual harassment. Staff members are
prohibited from alerting other staff when the rounds are occurring.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the Auditor determined the facility is adhering to this standard.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 6.13, PREA
Facility Policy 5.09, Searches and Full Body Visual Searches
Agency Policy FDJJ 1919, PREA
Training Curriculum
Pre-service Orientation Plan
In-service Training Plan
Interviews:
Random Staff
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual
body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
Cross-gender strip, visual body cavity and pat-down searches are prohibited and the
regular searches must be documented. Policy and training provide guidance to staff
on how the searches are to be conducted. There is no evidence of cross-gender
searches of any type occurring at the facility in the last 12 months. Based on the
review of documentation and according to the interviews, no type of cross-gender
search has been conducted at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy and practice do not support staff conducting cross-gender pat-down searches.
All searches must be documented. Responses from staff included that there is
always a male staff present to conduct searched of the residents. The training
materials and interviews provide that staff receives training on how to conduct
searches, including cross gender searches if there are exigent circumstances. Staff
interviews confirmed awareness of how to conduct searches. No residents or staff
interviewed reported the occurrence of any cross-gender searches. The evidence
shows cross-gender pat-down searches have not occurred at the facility during the
last 12 months.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-gender
visual body cavity searches, and cross-gender pat-down searches.
Cross-gender strip and cross-gender visual body cavity searches are prohibited.
Policy provides for documenting the occurrence of searches. All interviews
confirmed that no cross-gender searches have occurred at the facility during this
audit period. Staff members are aware of the requirement to document all searches.
There was no evidence documenting or justifying any type cross-gender 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. 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 site
review a direct care staff member 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.
Observations and interviews provide that residents shower, perform bodily
functions, and change clothing without non-medical staff of the opposite gender
viewing their buttocks or genitalia. The staff interviews and observations support
that viewing of the camera monitors does not show residents when they are
showering, using the toilet or changing clothes. The bathroom area does not allow
staff to get a view of the resident while performing bodily functions. Hygiene
practices are performed with the expectations of reasonable privacy for each
resident. Shower and toilet stalls are covered.
The Auditor observed the staff announcing the presence of the opposite gender in
the mod during an informal walkthrough of the mod however it was observed that
there were no signs posted informing staff of the opposite gender to announce there
presence upon entering. Collectively, 25% of the total residents and random staff
interviewed revealed that female staff do not announce or do not routinely
announce their presence upon entering the mod. The Superintendent and corporate
staff present during the onsite audit phase implemented corrective actions of
posting a sign on the doors to the mods reminding the opposite gender staff to
announce their presence upon entering the mod. A written directive to all staff was
distributed and it informed staff that the directive would also be discussed in the
staff meetings on February 20, 2024. The review of the process was added to the
agenda for the staff meeting on February 20, 2024. The Auditor was provided a copy
of the directive and the announcement/agenda for the staff meetings; two meetings
were timed to cover both shifts.
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 staff training prohibit the search of transgender or intersex residents
solely for the purpose of determining the residents’ genital status. Staff interviews
verified no such searches have occurred or would occur at the facility. The facility
reports that staff received the training on conducting searches and searches of
transgender and intersex youth. Staff interviews confirmed they are aware that
policy prohibits staff from conducting a physical examination of a 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 would be
part of a broader medical examination conducted by a medical practitioner in
private. The agency has a form that may be used, Statement of Preference Form,
when indicated by a youth regarding 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 training curriculum for staff provides information on conducting cross-gender
pat-down searches and searches of transgender and intersex youth. Training
materials and interviews indicate the provision of search techniques consistent with
the security needs. A Department of Juvenile Justice dedicated form, Statement of
Preference, may be used for a youth to identify the sexual preference of the staff
preferred to conduct the searches.
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 2.02, Youth Orientation
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Targeted Residents
Random Staff
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities
(including, for example, residents who are deaf or hard of hearing, those who are
blind or have low vision, or those who have intellectual, psychiatric, or speech
disabilities), have an equal opportunity to participate in or benefit from all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. Such steps shall include, when necessary to ensure effective
communication with residents who are deaf or hard of hearing, providing access to
interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary. In
addition, the agency shall ensure that written materials are provided in formats or
through methods that ensure effective communication with residents with
disabilities, including residents who have intellectual disabilities, limited reading
skills, or who are blind or have low vision. An agency is not required to take actions
that it can demonstrate would result in a fundamental alteration in the nature of a
service, program, or activity, or in undue financial and administrative burdens, as
those terms are used in regulations promulgated under title II of the Americans With
Disabilities Act, 28 CFR 35.164.
Policies address 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 in compliance with agency policy.
Policy supports interpreter and translation services, including the services for the
Deaf by requiring PREA education to be in formats accessible to all residents. The
education staff provides support services through a certified teacher with the
educational background to modify/adapt information for all residents to understand.
Assistance may also be provided by the treatment staff to ensure all residents’
understanding of the PREA information. Posted and other PREA information is in
English, French Creole and Spanish. The facility also has access to LanguageLine
Solutions for interpreting and translating services, including services for the Deaf.
Provision (b):
The agency shall take reasonable steps to ensure meaningful access to all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment to residents who are limited English proficient, including steps to
provide interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary.
A contract exists between the parent agency and LanguageLine Solutions for
professional interpreting services as needed to ensure the residents’ understanding
of PREA and other information. 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, French Creole, and Spanish; 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
professional interpreters who can interpret effectively, accurately, and impartially.
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.
The use of resident readers and interpreters is prohibited 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 education unit and 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 English, French Creole, and Spanish; the facility also has bilingual
staff. 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 1.01, Background Screening of Employees and Volunteers
Facility Policy 1.02, Five-Year Screening
Facility Policy 6.13, PREA
Agency Policy FDJJ 1800, Background Screening and Hiring Practice
Agency Policy FDJJ 1919, PREA
Personnel Records
Interview:
Human Resources Staff
Provision (a) & (f):
Provision (a): The agency shall not hire or promote anyone who may have contact
with residents, and shall not enlist the services of any contractor who may have
contact with residents, who—
(1) Has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997);
(2) Has been convicted of engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or coercion, or if
the victim did not consent or was unable to consent or refuse; or
(3) Has been civilly or administratively adjudicated to have engaged in the activity
described in paragraph (a)(2) of this section.
Provision (f): The agency shall also ask all applicants and employees who may
have contact with residents directly about previous misconduct described in
paragraph (a) of this section in written applications or interviews for hiring or
promotions and in any interviews or written self-evaluations conducted as part of
reviews of current employees. The agency shall also impose upon employees a
continuing affirmative duty to disclose any such misconduct.
Policies address hiring and other personnel matters, including and 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 agency Policy. 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.
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;
· Have been civilly or administratively adjudicated to have engaged in the
activity described above.
The interview and a review of policies provide 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, interview and policies 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 background checks.
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.
Provisions (c) & (d):
Provision (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.
Provision (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 and review of documentation. 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.
Provision (e):
The agency shall either conduct criminal background records checks at least every
five years of current employees and contractors who may have contact with
residents or have in place a system for otherwise capturing such information for
current employees.
The facility has been in operation since 2021 and there were no five-year
background checks to review. The human resources staff is familiar with the policy
and practice that background checks are to be conducted every five years.
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. Staff members have a continuing duty to report related
misconduct; employees are informed during new employee orientation that they
have a continuing affirmative duty to disclose any such misconduct. Additionally,
the facility is notified electronically 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, information will be provided
regarding substantiated allegations of sexual abuse or sexual harassment involving
the former employee.
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
Documents:
Agency Policy FDJJ 1919, PREA
Annual Staffing Plan Assessment
Interview:
Superintendent
Provision (a):
If the agency designed or acquired any new facility or planned any substantial
expansion or modification of existing facilities, the agency considered the effect of
the design, acquisition, expansion, or modification upon the agency’s ability to
protect residents from sexual abuse.
The facility has been under the management of Wayne's Halfway House
Incorporated since December 2021 and there have not been any major renovations
during this time period.
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.
Since December 2021 when the facility came under new management, additional
cameras were added to the system making a total of 65. Additional cameras have
been installed to address blind spots and to ensure residents are on camera as
much as possible. The system was demonstrated and explained to the Auditor's
Associate by the control room operator during the comprehensive site review and to
the Auditor by the Assistant Superintendent in his office. Monitors are also located
in the Superintendent's office.
Conclusion:
The triangulation of the data reveals the facility is compliant with this standard.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Correspondence
PREA Compliance Form
Interviews:
Random Staff
Medical Staff
Mental Health Staff
Superintendent/PREA Compliance Manager
Targeted Interviewee
Victim Advocate
Provisions (a) & (b):
Provision (a): To the extent the agency is responsible for investigating allegations
of sexual abuse, the agency shall follow a uniform evidence protocol that maximizes
the potential for obtaining usable physical evidence for administrative proceedings
and criminal prosecutions. Provision (b): The protocol shall be developmentally
appropriate for youth and, as appropriate, shall be adapted from or otherwise based
on the most recent edition of the U.S. Department of Justice’s Office on Violence
Against Women publication, “A National Protocol for Sexual Assault Medical Forensic
Examinations, Adults/Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011.
Administrative investigations are conducted by the Florida Department of Juvenile
Justice (DJJ), Office of Inspector General (OIG), agency investigators. Allegations of
sexual abuse are also reported to the Department of Children and Families and local
law enforcement. The policy will be followed regarding investigations of sexual
abuse in accordance with the standard. The PREA Compliance Form is intended to
be provided to law enforcement to ensure the PREA Standards are followed. The
previous interview with DJJ investigative staff and random staff 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 DJJ investigators are also aware of the PREA Compliance
Form and investigation protocols. The facility staff is not responsible for conducting
investigations.
Provision (c):
The agency shall offer all residents who experience sexual abuse access to forensic
medical examinations whether on-site or at an outside facility, without financial
cost, where evidentiarily or medically appropriate. Such examinations shall be
performed by Sexual Assault Forensic Examiners (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.
Correspondence regarding the planning and development of a Memorandum of
Understanding exists between the the contract agency's Executive Director of
Policy, Quality Assurance and Empowerment and the Director/Rape Recovery Team,
Women's Center of Jacksonville. Forensic medical examinations will be conducted by
a qualified medical practitioner at the hospital or the Women's Center of
Jacksonville. Continuity of care will be provided at the facility to include medical and
mental health follow-up services. Forensic medical examinations will be provided at
no cost to the victim, per policy. No forensic medical examinations were conducted
during this audit period. Information regarding the advocacy agency is posted in
the facility for residents, staff and visitors to see. The two allegations of sexual
abuse for the past year did not involve actions that required a forensic medical
examination.
Provisions (d) & (e):
Provision (d): The agency shall attempt to make available to the victim a victim
advocate from a rape crisis center. If a rape crisis center is not available to provide
victim advocate services, the agency shall make available to provide these services
a qualified staff member from a community-based organization or a qualified
agency staff member. Agencies shall document efforts to secure services from rape
crisis centers. For the purpose of this standard, a rape crisis center refers to an
entity that provides intervention and related assistance, such as the services
specified in 42 U.S.C. 14043g(b)(2)(C), to victims of sexual assault of all ages. The
agency may utilize a rape crisis center that is part of a governmental unit as long as
the center is not part of the criminal justice system (such as a law enforcement
agency) and offers a comparable level of confidentiality as a nongovernmental
entity that provides similar victim services. Provision (e): As requested by the
victim, the victim advocate, qualified agency staff member, or qualified community-
based organization staff member shall accompany and support the victim through
the forensic medical examination process and investigatory interviews and shall
provide emotional support, crisis intervention, information, and referrals.
Victim advocacy services will be provided by the Women's Center of Jacksonville
which provides a range of services, including to incarcerated persons.
Correspondence shows both agencies, facility and advocacy agency, working
together to develop a written agreement. The advocacy agency follows all
applicable laws and regulations with respect to confidentiality. The victim advocacy
services to the residents include but are not limited to the following: 24-hour
hotline services; emotional Support; accompaniment; and referrals.
Information regarding victim advocacy services is provided to the residents during
the intake process and is provided through the accessibility of posted information.
The interviews with the residents did not convey specific knowledge regarding the
services provided by the advocacy agency. A corrective action was implemented
and a refresher education session was conducted with all residents. During PREA
education sessions, auxiliary aids, interpreter/language services and
accommodations due to a disability are accessible by the facility as needed and also
at no cost to the victim.
Provisions (f) & (g):
Provision (f): To the extent the agency itself is not responsible for investigating
allegations of sexual abuse, the agency shall request that the investigating agency
follow the requirements of paragraphs (a) through (f) of this section.
Provision (g): The requirements of paragraphs (a) through (f) of this section shall
also apply to:
(1) Any State entity outside of the agency that is responsible for investigating
allegations of sexual abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for investigating
allegations of sexual abuse in juvenile facilities.
Florida Department of Juvenile Justice/Office of Inspector General investigators
conduct administrative investigations in accordance with agency policy, and the
protocols as outlined on the PREA Compliance Form, aligned with the Standard.
Investigations of allegations of sexual abuse or sexual harassment that are criminal
in nature is investigated by local law enforcement.
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.
Although there is no formal Memorandum of Understanding (MOU), victim advocacy
services will be provided to the residents upon request by the resident, facility staff
or law enforcement as confirmed through an interview with a Victim Advocate with
the Women's Center of Jacksonville. Written correspondence provides that
arrangements are underway for the development of a formal MOU.
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 6.13. PREA
Agency Policy FDJJ 1919, PREA
Investigation Report
Incident Report
Agency Website
Interviews:
Random Staff
Contract 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.
Policies provide that staff report all allegations of sexual abuse and sexual
harassment and to document reports; staff members are aware of the requirements.
Sexual abuse and sexual harassment allegations are referred to the Florida
Department of Juvenile Justice/Office of Inspector General (DJJ/OIG), Florida
Department of Children and Families, and law enforcement where the allegation is
criminal in nature. Policies and interviews provide for investigations of all allegations
of sexual abuse and sexual harassment. The facility reports two allegations; one of
resident-on-resident sexual abuse and one of staff-on-resident sexual abuse. The
second allegation occurred after submitting the PREA Pre-Audit Questionnaire. The
investigation for the allegation of resident-on-resident sexual abuse was closed as
Information Only; the other investigation is ongoing.
Provisions (b) and (c):
Provision (b): The agency shall have in place a policy to ensure that allegations of
sexual abuse or sexual harassment are referred for investigation to an agency with
the legal authority to conduct criminal investigations, unless the allegation does not
involve potentially criminal behavior. The agency shall publish such policy on its
website or, if it does not have one, make the policy available through other means.
The agency shall document all such referrals. Provision (c): If a separate entity is
responsible for conducting criminal investigations, such publication shall describe
the responsibilities of both the agency and the investigating entity.
Policy and reporting information are located on the DJJ website and posted within
the facility, accessible to the public as well as staff and residents. PREA information
was added in the lobby to make reporting information more accessible for third-
parting reporting. Policies, documents and interviews confirmed allegations of
sexual abuse and sexual harassment are investigated. Administrative investigations
are conducted by trained DJJ/OIG investigators. Allegations of sexual abuse and
sexual harassment that are criminal in nature are referred to local law enforcement.
Allegations are also reported to the Florida Department of Children and Families.
Provision (d):
Any State entity responsible for conducting administrative or criminal investigations
of sexual abuse or sexual harassment in juvenile facilities shall have in place a
policy governing the conduct of such investigations.
The DJJ/OIG has policies governing administrative investigations. The agency utilizes
trained investigators. The previous interview with the investigative staff and agency
investigation reports confirm that administrative investigations are conducted by a
trained investigator and allegations that are criminal in nature are referred to local
law enforcement.
Provision (e):
Any Department of Justice component responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in juvenile facilities
shall have in place a policy governing the conduct of such investigations.
The Department of Justice is not responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in this facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Training Curricula
Electronic Training Records
In-service Training Plan
Written Directive
Staff Meeting Agenda
Interviews:
Random Staff
Provisions (a) and (c):
Provision (a): The agency shall train all employees who may have contact with
residents on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency sexual abuse and sexual
harassment prevention, detection, reporting, and response policies and procedures;
(3) Residents’ right to be free from sexual abuse and sexual harassment;
(4) The right of residents and employees to be free from retaliation for reporting
sexual abuse and sexual harassment;
(5) The dynamics of sexual abuse and sexual harassment in juvenile facilities;
(6) The common reactions of juvenile victims of sexual abuse and sexual
harassment;
(7) How to detect and respond to signs of threatened and actual sexual abuse and
how to distinguish between consensual sexual contact and sexual abuse between
residents;
(8) How to avoid inappropriate relationships with residents;
(9) How to communicate effectively and professionally with residents, including
lesbian, gay, bisexual, transgender, intersex, or gender nonconforming residents;
and
(10) How to comply with relevant laws related to mandatory reporting of sexual
abuse to outside authorities;
(11) Relevant laws regarding the applicable age of consent.
Provision (c): All current employees who have not received such training shall be
trained within one year of the effective date of the PREA standards, and the agency
shall provide each employee with refresher training every two years to ensure that
all employees know the agency’s current sexual abuse and sexual harassment
policies and procedures. In years in which an employee does not receive refresher
training, the agency shall provide refresher information on current sexual abuse and
sexual harassment policies.
Policies address PREA related training for staff which is provided initially upon
employment and annually. Interviewed staff members were generally familiar with
the PREA information. Policy and the In-service Training Plan provide for refresher
training to occur annually. PREA training is provided to staff, as indicated by a
review of facility and agency policies, electronic records, PowerPoint presentations,
training documents, and interviews. The facility reports all staff members that may
have contact with residents have been trained or re-trained on the PREA Standards
requirements.
Staff meetings were conducted as a refresher in PREA related issues and
requirements as a result of the PREA onsite audit phase and the comprehensive site
review. The meeting highlighted and reminded female staff to announce their
presence upon entering the mods. Although the requirement is in policy and was
practiced during the onsite review, interviews relayed that the announcements were
not consistent. The leadership staff ensured that posted signs were placed on the
outside of each mod door. The meetings also included informing staff to leave the
lights on at all times in the exterior kitchen area and the laundry room to ensure
visibility in those areas at all times. Additionally, during the mandatory meeting,
staff was informed to be mindful of blind spots in residents' rooms when doing room
checks due to a cubby which may block the view; staff was instructed on how to
conduct the room check. A directive was issued to all staff containing the
aforementioned, prior to the meetings. The facility has two shifts; a meeting was
conducted on each shift and included all staff.
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 does consider the needs of the
population served as indicated by the interviews. The policies and interviews
support training being tailored to the needs and attributes of the population served.
The program provides services that are tailored to the special needs of the
population served and contribute to peer support. Interaction with the residents,
observations, staff and resident interactions indicate the positive interactive culture
within the facility. 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 verified through
staff interviews, policy review, and the agency’s training curricula.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the standard.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Acknowledgement Statements
Training Curriculum
Interviews:
Volunteers (2)
Contractors (2)
Provision (a):
The agency shall ensure that all volunteers and contractors who have contact with
residents have been trained on their responsibilities under the agency’s sexual
abuse and sexual harassment prevention, detection, and response policies and
procedures.
Policy require volunteers and contractors who have contact with residents to be
trained on PREA and their responsibilities regarding sexual abuse prevention,
detection, and response to allegations of sexual abuse and sexual harassment. The
training curriculum includes but is not limited to reporting allegations of sexual
abuse and sexual harassment, related definitions and maintaining professional
relationships with residents. The interviews revealed knowledge of the agency’s
zero-tolerance policy, how to report allegations of sexual abuse and other PREA
related components. The interviewees stated they received initial PREA training a
few years ago.
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, including how to report. The training is based on the services
provided by the contractors and volunteers. The interviews confirmed that the
review of the zero-tolerance policy is included in the PREA training. PREA education
is available within the facility and through the Department of Juvenile Justice online
course or through downloading the booklet for review. The contractors interviewed
provide education services to the residents and the volunteers conduct religious
services.
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 the contractors and volunteers. The interviews and
acknowledgement statements indicate the participants understand the training
received.
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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Acknowledgement Statements
Orientation Checklist
Brochures
Posted Information
Resident Handbook
PREA Video
Interviews:
Residents
Intake Staff
Provisions (a) and (b):
Provision (a): During the intake process, residents shall receive information
explaining, in an age- appropriate fashion, the agency’s zero tolerance policy
regarding sexual abuse and sexual harassment and how to report incidents or
suspicions of sexual abuse or sexual harassment. Provision (b): Within 10 days of
intake, the agency shall provide comprehensive age-appropriate education to
residents either in person or through video regarding their rights to be free from
sexual abuse and sexual harassment and to be free from retaliation for reporting
such incidents, and regarding agency policies and procedures for responding to
such incidents.
All residents receive directions on how to report allegations of sexual abuse and
sexual harassment; and information about the right to be free from retaliation for
reporting, in accordance with policy. This premise was supported through the review
of secondary documentation and the interviews. A review of the education materials
indicated the information provided to the residents is age-appropriate. The intake
staff reviewed the subject matter with the Auditor during the interview that is used
to provide PREA education to residents.
The residents initially sign acknowledgement statements which represent receipt of
the PREA information provided. The interviews with the residents revealed their
understanding of the methods to report allegations of sexual abuse and sexual
harassment. The intake staff, review of documents, and the residents revealed the
initial PREA education is conducted on the first day of admission to the facility
during the intake process. Although advocacy information is available and reviewed,
interviews revealed residents were not familiar with the victim advocacy agency
and/or the related services available.
A corrective action was implemented which included a general overview of PREA
information for residents and included information regarding the advocacy agency,
Women's Center of Jacksonville or as it is referred to, "WCJ." The documentation
provided to the Auditor regarding the refresher PREA education session outlines the
agenda covered with the residents, including specific information and confidentiality
regarding WCJ. PREA refresher education sessions may be conducted as needed and
during mod and/or treatment meetings.
Provision (c):
Current residents who have not received such education shall be educated within
one year of the effective date of the PREA standards, and shall receive education
upon transfer to a different facility to the extent that the policies and procedures of
the resident’s new facility differ from those of the previous facility.
Based on the evidence shown documenting the PREA education sessions in
Provisions (a) and (b), residents received PREA education. The facility reports that
61 youth were admitted to the facility during the past 12 months prior to the onsite
audit phase and all participated in PREA education sessions. Twenty-eight residents
were in the facility and all had been involved in PREA education sessions.
Acknowledgement statements, observed posted information, brochures, and the
interviews indicate that general PREA education is provided to residents.
Provision (d):
The agency shall provide resident education in formats accessible to all residents,
including those who are limited English proficient, deaf, visually impaired, or
otherwise disabled, as well as to residents who have limited reading skills.
The facility has the capability to provide the PREA education in formats accessible to
all residents including those who may be hearing impaired; Deaf; have intellectual,
psychiatric and speech disabilities; low vision; blind; limited reading, limited English
proficient, and based on the individual need of the resident. The education unit is a
resource for accessibility and accommodations. The education staff provide support
services through certified teachers with the educational background to modify/adapt
information for residents to understand.
Policy address the provision of support services for limited English proficient and
disabled residents by the requirement of providing residents 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. Assistance may also be
provided by the treatment staff and bilingual staff to ensure all residents’
understanding of the PREA information.
PREA information is accessible in English, French, Creole and Spanish and may be
obtained in other languages as needed. Consistent reporting information is posted
within the facility, accessible to residents, staff and visitors at varying levels. The
staff revealed a practice of residents not used as translators or readers for other
residents. 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 leadership staff.
Residents are asked about feelings of safety during informal encounters with staff
and during formal treatment team meetings. PREA information is also included in
the Resident Handbook and brochures. The PREA brochure and Handbook are
accessible in languages other than English, as needed. The contract agency also
has an arrangement with LanguageLine Solutions for professional interpreting and
translating services, including services for the Deaf. There was not a need for
specialized services for assistance with the interviews during the onsite audit phase.
Provision (e):
The agency shall maintain documentation of resident participation in these
education sessions.
Signed acknowledgement statements support the residents’ involvement in PREA
education sessions. The interviews with the residents and intake staff confirm PREA
education sessions occur. 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 residents are aware of their PREA related rights and are
currently aware of the availability of specific advocacy services.
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 interviews with the residents and observations confirmed PREA information is
continuously and readily available and visible to residents during their stay in the
facility. 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; definitions of related terms; safety
tips; and reporting information. Each resident is provided a Handbook which also
contains PREA and reporting information.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, the Auditor determined the facility is compliant with this standard.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Training Curriculum
Interviews:
Superintendent
Provisions (a) & (b):
Provision (a): In addition to the general training provided to all employees
pursuant to §115.331, the agency shall ensure that, to the extent the agency itself
conducts sexual abuse investigations, its investigators have received training in
conducting such investigations in confinement settings. Provision (b): Specialized
training shall include techniques for interviewing juvenile sexual abuse victims,
proper use of Miranda and Garrity warnings, sexual abuse evidence collection in
confinement settings, and the criteria and evidence required to substantiate a case
for administrative action or prosecution referral.
Administrative investigations are conducted by the Department of Juvenile Justice
(DJJ), Office of Inspector General (OIG). PREA training is required in addition to the
specialized training regarding conducting administrative investigations. Allegations
of sexual abuse are referred for investigation to be conducted by law enforcement.
The previous interview with investigative staff and review of agency 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; 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.
Training records of the administrative investigators are maintained by the agency
that conducts administrative investigations, DJJ. Allegations of sexual abuse are
referred to law enforcement and the Florida Department of Children and Families, in
accordance with policy. All allegations of sexual abuse and sexual harassment are
reported to the Office of Inspector General.
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 contract facilities which was confirmed by interviews. Local law
enforcement is responsible for training their investigators who conduct sexual abuse
investigations and allegations that are criminal in nature. Trained investigators also
conduct investigations with the Department of Children and Families.
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 Reviewed:
Agency Policy FDJJ 1919, PREA
Training Curricula
Training Logs
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.
The Department of Juvenile Justice requires medical and mental health staff
members to receive the regular PREA training as well as the specialized training
provided through the agency. 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 by facility staff.
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 Department of Juvenile Justice.
Regular and refresher PREA trainings are also provided at the facility through
sessions incorporated in staff meetings and training sessions.
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 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 2.04, Classification Factors, Procedures, and Reassessments for
Activities
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
Superintendent/PREA Compliance Manager
PREA Coordinators
Residents
Provision (a):
Within 72 hours of the resident’s arrival at the facility and periodically throughout a
resident’s confinement, the agency shall obtain and use information about each
resident’s personal history and behavior to reduce the risk of sexual abuse by or
upon a resident.
Policies collectively provide for each resident 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 documentation indicate the risk
assessment is completed on the day of admission. The staff responsible for risk
screening revealed the questions on the screening instrument are straightforward
and may be asked verbatim. The youth is interviewed to obtain information about
personal history and behavior. The court packet for the youth is also reviewed to
gather pertinent information.
The primary PREA intake screening instrument, Screening for Vulnerability,
Victimization and Sexually Aggressive Behavior (VSAB), is used to assess and
document risk. The interviews revealed the practice of the risk screening being
conducted is in accordance with the policies and Standard. Screening instruments
and interview with the staff responsible the risk screening 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. The interview with the staff responsible for risk screening supports
reassessments are conducted if there is an incident or allegation. The average
length of stay in the facility is six months. It is reported that the number of youths
admitted to the facility within the past 12 months who were screened during the
admission process for risk of sexual victimization and the risk of sexually abusing
other residents prior to the onsite audit phase is 61. The risk assessments are
accessible to treatment staff. The current resident files were observed to be
maintained in a confidential manner within lockable cabinets in a lockable area.
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 objective
primary instrument containing items that collectively provide a presumptive
determination of risk for victimization or abusiveness. Additional assessment tools
are used in the facility in measuring various risks, including sexual safety.
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 staff responsible for risk screening confirmed awareness of the elements of
the risk screening instrument and the use of the instrument was explained. 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, review of the commitment packet through
the court, and other assessments conducted prior to and after arrival to the facility.
Additional information may be obtained from interviews with parents/guardians
where indicated. The facility is aware of the youth’s pending arrival to the facility
and treatment staff has the opportunity to review the youth’s record in an effort to
prepare for the needs of the youth prior to arrival. Additional assessments and
screenings 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.
Staff takes appropriate controls to ensure that sensitive information is protected and
not exploited by maintaining the files in a locked and secure manner, behind locked
door. The online information on computers is password protected and is only
accessible to identified staff. The screening instrument is available to case
management staff, Clinical Director, Therapists, and medical staff. Pertinent
information is provided to other staff based on the need to know. Staff training
includes information regarding confidentiality of information concerning residents.
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 2.04, Classification Factors, Procedures, and Reassessments for
Activities
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Residents
Random Staff
Provision (a):
The agency shall use all information obtained pursuant to §115.341 and
subsequently to make housing, bed, program, education, and work assignments for
residents with the goal of keeping all residents safe and free from sexual abuse.
Policies provide guidance to staff regarding the use of the information obtained from
the screening instrument, VSAB. The interviews indicate the screening and
assessment information and observations are used to inform staff of information
regarding housing and program assignments, and assist in identifying treatment
and any special services.
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.
Protective custody is not used regarding a potential or victim of sexual abuse. The
facility does not use isolation as determined through the interviews and observation
during the site review. The interviews support the practice of isolation is not used in
this facility. The staff interviews and policy collectively indicate that protective
measures will be taken immediately when needed and includes separating
residents; notifying other staff, including supervisors and administrators; closer
supervision; and documenting the situation. There were not any residents identified
as at risk of sexual victimization placed in isolation in the 12 months preceding the
audit.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in
particular housing, bed, or other assignments solely on the basis of such
identification or status, nor shall agencies consider lesbian, gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being
sexually abusive.
Gay, bisexual, transgender, or intersex residents are not placed in specific housing
solely based on how the residents identify or their status, in accordance with the
policy. 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 policies, 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 staff responsible for the risk
screening supports that staff considers on a case-by-case basis whether a
placement would ensure a resident’s health and safety, and whether the placement
would present management or security problems. The interviews indicate staffs’
awareness and the importance of their efforts in keeping transgender and intersex
youth safe.
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.
Agency 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 staff
responsible for risk screening confirmed awareness of policy. There were no
transgender or intersex residents identified in the facility during this audit.
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 instruments, treatment team
meetings and individual sessions and informal interactions with treatment and other
staff. The interviews did not reveal or identify any issues in this area.
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 supported by the interview with the staff responsible
for the risk screening and policy. No problems or issues were identified.
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 would 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 would 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 and were placed in isolation in the
12 months preceding the audit. The interviews and observations during the
comprehensive site review confirm that isolation is not used in this facility
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. No residents at risk of sexual victimization were
placed in isolation in the 12 months preceding the audit.
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 1.03, Provision of an Abuse Free Environment
Facility Policy 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Florida Statute, Child abuse reporting, et al.
Student Handbook
Help Request Forms
Posted Information
Incident Report Summary
Interviews:
Random Staff
Residents
Targeted Interviewee
Superintendent/PREA Compliance Manager
Provision (a):
The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation by other residents or staff for
reporting sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents.
Policies provide 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. The targeted
interviewee confirmed the accessibility of the telephone to make a report through
the hotline if he desired
Policy, posters, brochures, and the Student 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, or call the abuse reporting hotline. A resident may put
an allegation in writing utilizing a help request form such as Sick Call Request,
Speak Out, Grievance, or write a note and drop the written allegations in the locked
grievance box or give the document directly to the Assistant Facility Administrator
or put it under his office door. The residents interviewed identified someone who did
not work at the facility that they could report to about sexual abuse or sexual
harassment. The random staff and resident interviews collectively revealed
residents may use the 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 in the Student Handbook, brochures, and
through posted information.
On the first day of the site visit, the opening of the locked grievance box was bent
rendering it inoperable to receive written complaints and residents were directed to
put all complaints under the door of the Assistant Facility Administrator. The locked
box for Sick Call Requests was operable. The grievance box was repaired by the end
of the day and the signs were removed. The choice of putting the document under
the door or in the locked box was restored back to the resident. If a grievance form
is used to make a written allegation of sexual abuse, the reporting procedures will
be implemented in accordance with policy. Grievances alleging sexual abuse will be
handled directly by the facility administrators/designee and reported as required
and investigated by law enforcement, Florida Department of Children and Families,
and/or Department of Juvenile Justice/Office of Inspector General.
The Speak Out Form allows the resident to request the specific staff member he
would like to speak with and includes the following staff: Facility Administrator;
Assistant Facility Administrator; Operations Administrator; Therapist; Transition
Specialist; Case Management; Clinical Director; Education Staff; Shift Supervisor;
Youth Care Worker; and Kitchen Staff. The form is also used for staff to record the
results of the meeting The Speak Out Form may be placed in one of the locked
boxes or given directly to staff. The Sick Call Request form provides for the resident
to make a written request for medical, dental or mental health care and provides for
the staff seen to document the disposition of the encounter. The Grievance and
Speak Out forms and written notes may all be placed in the grievance box and the
Sick Call Requests are to be placed in the Sick Call box.
PREA information is posted and each resident is provided a Student Handbook which
contains reporting and other PREA related information. Writing materials are
accessible to residents. Acknowledgement statements are signed by residents
confirming receipt of PREA information, along with the intake staff. Staff members
receive information on how to report allegations of sexual abuse or sexual
harassment through policies and procedures, training, statutes, 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 policies and posted and other printed information on how to report
allegations of sexual abuse and sexual harassment. Telephones are accessible to all
staff and are made accessible to residents by staff. The reports of sexual abuse or
sexual harassment are accepted and referred for an investigation. The hotline
number was tested during the comprehensive site review; while the telephone was
working, there was a lengthy wait to speak with a live person. The facility does not
detain residents solely for civil immigration purposes according to written
communication between the DJJ statewide PREA Coordinator and the DJJ legal
department.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third-
parties and shall promptly document any verbal reports.
Staff interviews confirmed 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. Interviewed staff members are aware
of their duty to receive and document the receipt of verbal reports and that the
documentation must be done as soon as possible. Documentation confirms the
allegation of sexual abuse was received verbally, documented and referred to the
three investigative entities, in accordance with policy.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written
report.
Writing materials are available for residents to complete Grievance, Sick Call
Request, Speak Out forms, and write notes. Each resident is provided a Student
Handbook which contains information regarding reporting allegations and the
residents are informed about reporting methods during PREA education sessions.
The interviews, review of documents and facility practices revealed that residents
are provided the tools to make written allegations of sexual abuse and sexual
harassment.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The staff interviews collectively revealed staff can privately report allegations of
sexual abuse and sexual harassment through a call to the Florida abuse reporting
hotline or talk to a supervisor/Facility Administrator/Assistant Facility.
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
When a grievance form is received that contains an allegation of sexual abuse or
sexual harassment, the policy and procedures for reporting allegations of sexual
abuse and sexual harassment are implemented and a report is made to the
investigative entities. 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 will be
conducted by the Department of Juvenile Justice/Office of Inspector General, Florida
Department of Children and Families, and/or law enforcement.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Correspondence
Student Handbook
PREA Compliance Form
US Citizenship and Investigation Service Information
Posted Information
Interviews:
Residents
Targeted Interviewee
Superintendent/PREA Compliance Manager
Victim Advocacy Agency Representative
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.
Although advocacy information is in the Student Handbook and posted, interviews
revealed residents were not familiar with the victim advocacy agency and/or the
related services available. There is not a written agreement at this time however
memoranda document the plans underway to construct an agreement with the
Women's Center of Jacksonville that outlines the specific services in accordance with
the PREA Standard. The written agreement will be a formality and the lack of one
does not impede services to a resident when requested by the resident, facility staff
or law enforcement personnel. The advocacy agency provides services to
confinement facilities according to a representative of the agency which include
accompaniment, emotional support, and hotline services.
A corrective action was implemented which included a general overview of PREA
information for residents and included information regarding the advocacy agency,
Women's Center of Jacksonville or as it may be referred to, "WCJ." The
documentation provided to the Auditor regarding the refresher PREA education
session outlines the agenda covered with the residents, including how to report and
specific information regarding the advocacy agency.
Provision (b):
The facility shall inform residents, prior to giving them access, of the extent to
which such communications will be monitored and the extent to which reports of
abuse will be forwarded to authorities in accordance with mandatory reporting laws.
The overarching agency PREA policy, staff interviews, Student Handbook, and the
PREA education sessions provide that there will be adherence to confidentiality
measures. Advocacy services were not requested by the targeted interviewee,
facility staff or an investigative agency.
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 interviews document the provision of advocacy services including but not
limited to emotional support; accompaniment through the forensic medical
examination and investigation interview; access to counseling services; and
referrals. Memoranda between facility staff and leadership staff at the advocacy
agency confirm communication in process for the development of a formal service
agreement confirming the availability and accessibility of advocacy services for
residents. The interview with the advocacy agency representative also confirmed
the availability of advocacy services to the residents upon request. Agency policy
and the Student Handbook support confidentiality regarding victims of sexual
abuse.
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 Student Handbook. The visitation areas was visited
during the comprehensive site review. Offices will be made available if an attorney
or Probation Officer may visit.
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 1.03, Provisions of an Abuse Free Environment
Facility Policy 1.05, Incident Reporting
Agency Policy FDJJ 1919, PREA
Employee Handbook
Posted and other Printed Materials
Website Information
Interviews:
Random Staff
Residents
Provision:
The agency shall establish a method to receive third-party reports of sexual abuse
and sexual harassment and shall distribute publicly information on how to report
sexual abuse and sexual harassment on behalf of a resident.
Staff members are to receive, document and report allegations of sexual abuse and
sexual harassment made by a third-party. The staff members are aware third-party
reporting of sexual abuse or sexual harassment can be done and indicated the
information will be accepted and reported. Staff members are to document all
verbal reports received as verified by the random staff interviews. The interviews
collectively revealed staff may report allegations privately through the use of the
abuse reporting hotline, complete a report, call law enforcement, and tell a
supervisor. The Department of Juvenile Justice agency website contains the
information needed for third-parties to report allegations of sexual abuse and sexual
harassment.
Information regarding reporting is posted within the facility and accessible to
residents, staff and visitors. General information flyers containing reporting
information have been placed in the lobby of the facility. All residents interviewed
indicated knowing someone who did not work at the facility they have contact with
and could report allegations of sexual abuse and sexual harassment to. 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. No
third-party reports were received during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is in compliance with this standard.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 1.03, Provisions of an Abuse Free Environment
Facility Policy 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Florida Statute Chapter 39, Section 201, Mandatory reports of child abuse, et al.
Employee Handbook
Occurrence Flow Chart
Investigation Reports
Interviews:
Random Staff
Superintendent/PREA Compliance Manager
Medical Staff
Mental Health Staff
Targeted Interviewee
Provisions (a) & (b):
Provision (a): The agency shall require all staff to report immediately and
according to agency policy any knowledge, suspicion, or information they receive
regarding an incident of sexual abuse or sexual harassment that occurred in a
facility, whether or not it is part of the agency; retaliation against residents or staff
who reported such an incident; and any staff neglect or violation of responsibilities
that may have contributed to an incident or retaliation. Provision (b): The agency
shall also require all staff to comply with any applicable mandatory child abuse
reporting laws.
The State Statute and policies support 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. Trained Department of Juvenile Justice (DJJ)
agency investigators conduct administrative investigations and allegations that are
criminal in nature are investigated by trained law enforcement investigators.
Allegations are also reported to the Department of Children and Families (DCF); also
with trained investigators. The facility and agency policies provides 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 and staff training address confidentiality of information and the conditions for
providing information. Once allegations have been appropriately reported, staff will
keep the information confidential regarding what was reported except when
necessary for the investigation and treatment and management decisions.
Provision (d):
(1) Medical and mental health practitioners shall be required to report sexual abuse
to designated supervisors and officials pursuant to paragraph (a) of this section, as
well as to the designated State or local services agency where required by
mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation of
services of their duty to report and the limitations of confidentiality.
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 received regarding 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 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 would be notified where indicated by the resident being under
the guardianship of the Florida Department of Children and Families.
The resident’s attorney will be notified of an allegation of sexual abuse within 14
days, where applicable. Policies also provide the appropriate timelines and
directions to staff for reporting allegations. There was one allegation of staff-on-
resident sexual abuse and one allegation of youth-on-youth sexual abuse during this
audit period. The youth-on-youth allegation was closed as Information Only; the
other investigation is ongoing. The allegations were reported to the three
investigative entities.
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 DJJ
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 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, DCF and to law enforcement, where the allegation is
criminal in nature.
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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Occurrence Flow Chart
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Crisis Assessment Screening Instrument
Interviews:
Superintendent
Contract Agency Head Designee
Random Staff
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, one-
on-one or closer supervision, and contacting administrators and supervisors.
The expectation is that any action to protect a resident would be taken immediately
as deemed from interviews. During the intake process, residents are asked about
how they feel about their safety as part of the inquiries by staff completing the
primary sexual safety instrument, 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:
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Contract Agency Head Designee
Provisions (a)-(d):
Provision (a): Upon receiving an allegation that a resident was sexually abused
while confined at another facility, the head of the facility that received the
allegation shall notify the head of the facility or appropriate office of the agency
where the alleged abuse occurred and shall also notify the appropriate investigative
agency. Provision (b): Such notification shall be provided as soon as possible, but
no later than 72 hours after receiving the allegation. Provision (c): The agency
shall document that it has provided such notification. Provision (d): The facility
head or agency office that receives such notification shall ensure that the allegation
is investigated in accordance with these standards.
If an allegation of sexual abuse is received that a resident was sexually abused
while confined at another facility, the Superintendent understands he will notify the
head of the facility where the alleged abuse occurred. The notification will be made
as soon as possible and within 72 hours in accordance with policy. The
Superintendent is also required to make a report to the Department of Juvenile
Justice Central Communications Center. The policy and interviews support
allegations of sexual abuse or sexual harassment from a resident regarding their
stay in another facility will be reported and investigated as required. The
Superintendent is also required to notify identified staff in the corporate office of the
parent agency. In the past 12 months, there were no allegations reported of sexual
abuse occurring at another facility.
Conclusion:
Based upon the information reviewed 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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Facility Coordinated Response Plan for Reports of Sexual Abuse
Interviews:
Random Staff
Targeted Interviewee
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 two allegations of sexual abuse; no allegations or
incidents where staff had to act as a first responder in the last 12 months. The
completed and ongoing investigative incidents did not involve the intervention of a
first responder. 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.
Non-security staff who may act as a first responder will request that physical
evidence be preserved and contact direct care staff for assistance. There were no
allegations or incidents where any 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 1.03, Provisions of an Abuse Free environment
Facility Policy 1.04, Management Response to Allegations
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Employees Handbook
Interviews:
Superintendent
Random Staff
Provision:
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.
A institutional plan is outlined in a section of the facility's PREA policy. The policy
outlines the actions of the staff in general. A separate written coordinated response
plan to be implemented in the event of an allegation or incident of sexual abuse has
be developed to ensure all staff members actions identified in the Standard are
documented. Staff members' interviews in general and the coordinated response
plan identify each step and roles such as the first responder; supervisors; medical;
mental health; and leadership staff; and when to contact such. The plan provides
guidance to staff regarding the actions to take when there is an alleged incident of
sexual abuse.
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:
Contract Agency Head Designee
Provision (a) & (b):
Provision(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.
Provision (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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Retaliation Monitoring Forms
Interviews:
Retaliation Monitor
Superintendent
Contract 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, procedures and practice support protecting residents and staff who report
sexual abuse or sexual harassment, or cooperate with sexual abuse or sexual
harassment investigations from retaliation by other residents, or staff. The
retaliation monitoring activities are documented. The staff member interviewed for
retaliation monitoring is familiar with the role of retaliation monitor and its purpose.
Responsibility of retaliation monitoring is conducted by and/or shared with the
Facility Administrator, Assistant Facility Administrator and Clinical Director. The
documents reviewed provide for recording whether the reporter of the allegation
received any of the following: verbal or non-verbal threats; treated unfairly;
disciplinary reports; and/or reassignment of housing unit or shift. The document also
provides for the explanation of any action taken by the retaliation monitor.
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.
General protective measures were generally identified during the interviews with
random staff and the retaliation monitor and in policy. Implementation measures to
protect residents from retaliation include but are not limited to housing changes for
resident victims or abusers; removing alleged staff or resident; closer monitoring;
change in shift assignments; and transferring youth, if needed, and in accordance
with policy. The retaliation monitoring will be documented and follow-up checks with
the parties involved ensure safe feelings and identifies whether retaliation is
occurring. The interviews confirmed that measures to detect and protect staff and
residents from retaliation will be implemented immediately.
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, documentation and the interview with the retaliation monitor provide that
the monitoring occurs for at least 90 days to see if there are any changes that may
suggest possible retaliation is occurring. The monitoring period could last longer, 20
days based on need, according to the retaliation monitor. The interview identified
items that are monitored to assess retaliation and include but not limited to
program and housing changes; youth point sheets; and observed staff and resident/
resident and resident interactions.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
Policy and the interview with the retaliation monitor indicate that status checks will
occur as a part of retaliation monitoring. The interview revealed that initial contact
is made, follow-up checks occur weekly and are 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 application is extended to those who cooperate with an investigation if there
is a concern regarding retaliation. Policy indicates the appropriate measures would
be taken to protect any related individuals against retaliation.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the
allegation is unfounded.
The obligation to monitor for retaliation terminates, if it is determined that the
allegation is unfounded. The interviews determined familiarity with the
requirements 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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Mental Health Staff
Medical Staff
Provision:
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. No segregated area was observed or
identified during the comprehensive site review.
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 6.13, PREA
Agency Policy FDJJ 1919, PREA
PREA Compliance Form
Incident Information Summary
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 policy and other documentation 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 and all allegations are reported through the DJJ Central
Communications Center. Investigations are conducted thoroughly and objectively
and the agencies’ policy provides for the training of investigators. The facility staff
does not conduct any investigations.
Provision (b) & (c):
Provision (b): Where sexual abuse is alleged, the agency shall use investigators
who have received special training in sexual abuse investigations involving juvenile
victims pursuant to §115.334. Provision (c): Investigators shall gather and
preserve direct and circumstantial evidence, including any available physical and
DNA evidence and any available electronic monitoring data; shall interview alleged
victims, suspected perpetrators, and witnesses; and shall review prior complaints
and reports of sexual abuse involving the suspected perpetrator.
Based on the previous interview with investigative staff, the DJJ investigative staff is
trained through the OIG. The DJJ Investigator will turn over any evidence found to
law enforcement investigators since they generally do not handle direct evidence.
The DJJ investigators will assist law enforcement and among other activities, may
review video; gather witness statements; and review logs during the administrative
investigation of the allegation.
The law enforcement investigator and/or qualified medical practitioner are
responsible for collecting direct physical and DNA evidence. The facility staff and DJJ
investigators are trained on how to assist in preserving evidence. The agency, DJJ,
provides each facility with the PREA Form which is provided to law enforcement
investigators referencing the PREA standards regarding conducting investigations in
accordance with the standards. The DJJ investigators follow the OIG guidelines
governing PREA related investigations, in accordance with agency policy.
Provision (d):
The agency shall not terminate an investigation solely because the source of the
allegation recants the allegation.
The interviews and policy confirm the provision that an investigation is not
terminated if the source recants an allegation of sexual abuse or sexual
harassment.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the agency
shall conduct compelled interviews only after consulting with prosecutors as to
whether compelled interviews may be an obstacle for subsequent criminal
prosecution.
The DJJ agency investigators do not conduct compelled interviews.
Provision (f):
The credibility of an alleged victim, suspect, or witness shall be assessed on an
individual basis and shall not be determined by the person’s status as resident or
staff. No agency shall require a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition for proceeding
with the investigation of such an allegation.
The credibility of an alleged victim, suspect, or witness is assessed on an individual
basis and is not determined by the person’s status as a resident or staff as
supported by the previous interview with investigative staff, training, and in
accordance with policy. The previous interview with investigative staff revealed that
credibility may be influenced by past history; what can be verified; what other
evidence can corroborate the information; body language; and/or whether or not the
person is answering questions or being dismissive. No resident who alleges sexual
abuse will be subjected to a polygraph examination or other truth telling device as a
condition for proceeding with the investigation.
Provisions (g) & (h):
Provision (g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse.
(2) Shall be documented in written reports that include a description of the physical
and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings.
Provision (h): Criminal investigations shall be documented in a written report that
contains a thorough description of physical, testimonial, and documentary evidence
and attaches copies of all documentary evidence where feasible.
The administrative investigations include an effort to determine whether staff
actions or failures to act contributed to the abuse. Investigations in all facilities are
completed with written reports that include a description of the evidence and
investigative facts and findings as gleaned from the previous interview with
investigative staff. The report also contains information regarding the initial call or
allegation; list of interviews; list of exhibits; logbook information; critique of any
video; and a host of other information.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for
prosecution.
The DJJ agency investigators do not conduct criminal investigations. It is the
responsibility of law enforcement personnel to refer cases for prosecution.
Provision (j):
The agency shall retain all written reports referenced in paragraphs (g) and (h) of
this section for as long as the alleged abuser is incarcerated or employed by the
agency, plus five years, unless the abuse was committed by a juvenile resident and
applicable law requires a shorter period of retention.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years as stated in agency policy.
Provision (k):
The departure of the alleged abuser or victim from the employment or control of the
facility or agency shall not provide a basis for terminating an investigation.
Upon the start of an investigation, it will not end until the investigation has been
completed. The departure of the alleged abuser or victim from the employment or
control of the facility will not terminate the investigation, as the interviews and
incident summary document.
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.
Agency policy and interviews indicate that staff cooperate with investigators and
that the agency/facility is kept informed of the progress of an investigation. The
Superintendent maintains contact with the investigator from the applicable
investigative entity. The Superintendent may also be kept informed through the DJJ
statewide PREA Coordinator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Agency Policy FDJJ 1919
Investigative Report
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. A previous
interview with investigative staff, review of documentation, and practice confirm
this premise.
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 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Notification to Residents
Interviews:
Superintendent
Contract Agency PREA Coordinator
Targeted Interviewee
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 interviews
and documentation revealed knowledge of the requirement. There was evidence of
a resident being notified of the results of the investigation and notice to a resident
regarding staff no longer working at the facility. There were two allegations of sexual
abuse; one occurred after completion of the PREA Pre-Audit Questionnaire.
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, Department of Children and Families or the Department of Juvenile
Justice investigator and is provided information regarding the findings, in
accordance with the interviews of the Superintendent and contract agency PREA
Coordinator. The results of one of the investigations and notification regarding
accused staff no longer working at the facility were provided to the residents by the
Clinical Director.
Provision (c):
Following a resident’s allegation that a staff member has committed sexual abuse
against the resident, the agency shall subsequently inform the resident (unless the
agency has determined that the allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge related
to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a charge related
to sexual abuse within the facility.
Policy requires that following a resident’s allegation that a staff member committed
sexual abuse against the resident, the resident will be informed of the following,
unless it has been determined that the allegation is unfounded, whenever:
a. The staff member is no longer posted within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse in the
facility; and/or
d. The staff member has been convicted on a charge related to sexual abuse in the
facility.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused by another
resident, the agency shall subsequently inform the alleged victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related
to sexual abuse within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a charge
related to sexual abuse within the facility.
Policy provides that following a resident’s allegation of being sexually abused by
another resident the alleged victim shall be informed whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the
facility.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides for the notification to the resident be documented and be made by
the administrator. There is knowledge with the requirement by the Superintendent.
Notifications and results of investigations have been provided by the Clinical
Director and are documented.
Provision (f):
An agency’s obligation to report under this standard shall terminate if the resident is
released from the agency’s custody.
The agency’s obligation to report under this standard terminates if the resident is
released from the agency’s custody. All notifications or attempted notifications will
be documented.
Conclusion:
The interviews and review of policy and other documentation confirmed the facility
is compliant with this standard.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
The policies and interview support that staff be subject to disciplinary sanctions up
to and including termination for violating facility sexual abuse or sexual harassment
policies.
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 any 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 of engaging in sexual activities are subject to termination,
and other measures appropriate to the circumstance of the incident and in
accordance with agency 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 supports that terminations for violations of the agency’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.
There have been no violations by staff of the agency'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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Contractors (2)
Volunteers (2)
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.
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. Policies
and interviews with contractors 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.
The facility will take the appropriate remedial measures and prohibit further contact
with residents in the case of any other violation of the sexual abuse and sexual
harassment policies by a contractor or volunteer. In the past 12 months, no
contractors or volunteers were 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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Student 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 and practice 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 administrative process. The consequences
will be administered through the administrative system, encompassing the behavior
management system. Allegations of sexual abuse are referred for an investigation
to the appropriate investigative entities and may result in the resident being
removed from the facility. Policy prohibits sexual activity between residents.
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.
The 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 youth transported to a
detention center 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 disciplinary process involves sanctions and the behavior
management system.
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.
Participation in such interventions will not be a condition for participation in or
access to general programming or education however it will be a condition to access
the behavior management system as determined from the interview. Mental health
staff members will develop treatment planning and interventions to address
underlying reasons or motivations for the abuse with alleged victims and offending
residents.
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.
A resident may be disciplined for sexual contact with staff only upon a finding that
the staff member did not consent to such contact. The alleged incident will be
reported to the Central Communications Center and law enforcement regarding lack
of consent by staff.
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.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between residents and
may discipline residents for such activity. An agency may not, however, deem such
activity to constitute sexual abuse if it determines that the activity is not coerced.
Policy prohibits 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 2.03, Written Consent of Youth 18 Years or Older
Facility Policy 2.04, Classification Factors, Procedures, and Reassessment for
Activities
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Crisis Assessment
Interviews:
Medical Staff
Mental Health Staff
Staff Responsible for Risk Screening
Residents
Provisions (a) & (b):
Provision (a): If the screening pursuant to §115.341 indicates that a resident has
experienced prior sexual victimization, whether it occurred in an institutional setting
or in the community, staff shall ensure that the resident is offered a follow-up
meeting with a medical or mental health practitioner within 14 days of the intake
screening. Provision (b): If the screening pursuant to §115.341 indicates that a
resident has previously perpetrated sexual abuse, whether it occurred in an
institutional setting or in the community, staff shall ensure that the resident is
offered a follow-up meeting with a mental health practitioner within 14 days of the
intake screening.
Agency 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 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 initial
follow-up is provided the same day.
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.
Information related to sexual victimization or abusiveness that occurred in an
institutional setting is limited to clinical and treatment staff and to other staff, based
on their need to know, to make effective management decisions. During the onsite
review, the clinical files were observed to be maintained in locked cabinets in the
lockable area. Resident files are maintained separated in three separate folders:
general information, medical, and mental health. Information maintained
electronically is password protected with limited staff access.
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 supports that 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.
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 3.16, Emergency Mental Health and Substance Abuse Services
Facility Policy 4.12, Episodic/First Aid/Emergency Care and Drills
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Mental Health Staff
Medical Staff
Targeted Interviewee
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.
According to clinical staff, the nature and scope of their services are determined
according to their professional judgment and there is no interference by other staff.
Residents are informed of clinical services and meet with those practitioners during
the intake process and are provided services throughout their stay in the facility as
needed. The allegation did not require medical or mental health intervention.
An alleged victim will get services within the facility as well as timely services in the
community. An alleged victim of sexual abuse will be transported to the Women's
Center of Jacksonville or the hospital emergency room, depending on the age of the
resident, for a forensic medical examination that will be conducted by a Sexual
Assault Nurse Examiner (SANE), Sexual Assault Forensic Examiner (SAFE) or other
qualified medical practitioner. The examination will be performed at no cost to the
victim, in accordance with policy, in response to an allegation of sexual abuse.
Medical and mental health staff members will continue to maintain secondary
materials and documentation of encounters with residents related to such.
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. Policies 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. Policy also provides guidance in dispensing emergency and
first aid care. A review of the documentation and observations of the interactions
among residents and staff during the onsite audit phase; and the interviews
indicated unimpeded medical and crisis intervention services are available to an
alleged victim of sexual abuse.
Staff training also prepare staff members to properly report sexual abuse, protect
the alleged victim and notify the appropriate staff and investigative entities.
According to the targeted interview, once he made the allegation to staff, it was
immediately reported and an investigator from the Jacksonville Sheriff's Office
arrived at the facility on the same day the report was made.
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 and services
not available within the facility will be contracted. The standard of care within the
facility ensures the appropriate medical and mental health follow-up as needed.
Medical services were not required for either of the two allegations.
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 treatment services will be provided to the victim
without financial cost to the victim. Treatment services will also be provided at no
cost to the victim regardless of whether the victim names the abuser, or cooperate
with any investigation arising out of the incident.
Conclusion:
Based on the evidence reviewed, observations 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 3.05, Mental Health and Substance Abuse Assessment/Evaluation
Facility Policy 3.06, Mental Health and Substance Abuse Treatment
Facility Policy 4.10, Sexually Transmitted Infection Screening/HIV Screening
Facility Policy 6.13, PREA
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 evaluation and
treatment will be offered to resident victims of sexual abuse. Crisis assessments and
nursing assessments are conducted by clinical staff. The clinical staff interviews
revealed that follow-up services will be provided that include but are not limited to
increased individual counseling; placement on indicated precaution; medical doctor
follow-up; treatment of STIs as indicated; and wound treatment. The allegation of
sexual abuse did not require medical or mental health services however mental
health staff conducted retaliation monitoring.
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, clinical follow-up and referrals as needed.
Specialized treatment may also be provided by clinicians on site and through
contract and referral services. Additionally, directions contained any discharge
summary 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, 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.
This is a facility for male juvenile offenders.
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.
This is a facility for male juvenile offenders.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
Victims of sexual abuse will be provided tests for sexually transmitted infections as
medically appropriate as confirmed by the medical staff. Tests will be provided at
the medical care facility. Tests and treatment may also be done at the facility based
on policy and the interview with medical staff.
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 and interviews.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history and
offer treatment when deemed appropriate by mental health practitioners.
The mental health staff confirmed the resident will get a mental health evaluation
within 24 hours upon learning of a resident-on-resident abuser and history and be
offered appropriate treatment. Medical and mental health evaluations and
treatment will be offered to resident victims of sexual abuse.
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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Incident Review Team Meeting Minutes
Investigative Report
Interviews:
Superintendent/PREA Compliance Manager
Incident Review Team Member
Statewide PREA Coordinator
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every
sexual abuse investigation, including where the allegation has not been
substantiated, unless the allegation has been determined to be unfounded.
The facility 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 the policies,
documentation and interviews confirmed incident reviews are conducted regarding
the investigation of an allegation of sexual abuse, unless unfounded and in
accordance with the policy. The interviews confirm this premise and the DJJ
statewide PREA Coordinator serves as the facilitator of the PREA incident review
teams for State-run and contract facilities.
The meeting minutes summarizes that the allegation of youth-on-youth sexual
abuse was investigated administratively by a DJJ investigator. The investigative
report and interviews confirm the allegation was reported to DJJ, Department of
Children and Families (DCF), and law enforcement. The administrative investigation
determined the case is closed as Information Only and no further action is required.
Due to the findings not being determined as Unfounded, an incident review team
meeting was conducted and facilitated by the statewide PREA Coordinator. The case
was closed by DCF with no recommendations and closed by the Jacksonville Sheriff's
Office as Information Only.
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. An incident review team meeting was conducted regarding the case
that was closed as Information Only which was conducted beyond the 30 days. The
statewide PREA Coordinator facilitated the meeting and copies were provided to the
Superintendent and regional staff. There was no delay in the initiation of the
investigation by the investigative entities in fulfilling their roles. The interviews
revealed knowledge of the purpose of the incident review process.
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
DJJ statewide PREA Coordinator facilitates the incident review team meeting.
Members of the team are identified in policy and includes upper-level management
staff such as the Superintendent, Assistant Superintendent, treatment staff, with
input from line supervisors including mental health and medical staff. The
investigator of the investigative entity may also participate in the incident review
where applicable. The additional staff members will attend the meeting as needed,
related to the incident. The minutes of the incident review for the allegation of
sexual abuse are provided to the Superintendent and DJJ regional staff.
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.
Policy 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 meeting minutes identified that consideration for causation
included group dynamics; make-up of the population; area where allegation
occurred; and deployment of staff. The minutes reflected their were no
recommendations for change in policy, staff training, or otherwise.
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 the policy requirement. 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 include recommendations where indicated as
determined from a review of the documented meeting. It was documented there
were no PREA related recommendations or actions necessary at the time of the
incident review team meeting. However, it is understood that reasons for not
following recommendations of the incident review team must be documented.
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 6.13, PREA
Agency Policy FDJJ 1919, PREA
Agency Policy FDJJ 2020, Incident Operations Center and Incident Reviews
Monthly Reporting Flow Chart
Agency Data Log
Interviews:
Superintendent
PREA Coordinators
Provisions (a) & (c):
Provision (a): The agency shall collect accurate, uniform data for every allegation
of sexual abuse at facilities under its direct control using a standardized instrument
and set of definitions. Provision (c): The incident-based data collected shall
include, at a minimum, the data necessary to answer all questions from the most
recent version of the Survey of Sexual Violence conducted by the Department of
Justice.
The facility and agency policies and both PREA Coordinators collectively provide for
the collection of accurate and uniform data for every allegation of sexual abuse
from incident-based documents. The Department of Juvenile Justice (DJJ) collects the
data and completes an annual report with the compilation of data gleaned from the
State-run and contract facilities through the central reporting system. Agency and
facility policies contain standardized set of definitions and provide support for the
collection of accurate and uniform data. The facility follows the parent agency's
Monthly Reporting Flow Chart in submitting PREA-related data to their parent
agency. DJJ and the parent agency maintain 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 agency 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, including incident reports, investigative
reports and incident revie team minutes. Statistical information is maintained for
various service areas and occurrences, including major or significant 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
agency’s 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, Department of Juvenile Justice, 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. The data is aggregated at the central office level. The
facility does not contract for confinement services for youth assigned to the facility.
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 will submit the data to the Department of Justice in a timely manner based on
the year of the most recent version of the Survey of Sexual Victimization. Currently,
a request has not been made by the Department of Justice.
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:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Annual Reports
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinators
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 and policies support the review of data and that it is used to improve
both agencies’ 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 agencies as well as individual facilities. The data is also primary
to preparing annual and quarterly reports. The interview with the contract agency
head designee revealed that on a quarterly basis, allegations are assessed to
determine threats to the facility and to address any issues presented.
Provisions (b), (c) & (d):
Provision (b): Such report shall include a comparison of the current year’s data
and corrective actions with those from prior years and shall provide an assessment
of the agency’s progress in addressing sexual abuse. Provision (c): The agency’s
report shall be approved by the agency head and made readily available to the
public through its website or, if it does not have one, through other means.
Provision (d): The agency may redact specific material from the reports when
publication would present a clear and specific threat to the safety and security of a
facility, but must indicate the nature of the material redacted.
The agency's annual report is prepared by the statewide PREA Coordinator for the
Department of Juvenile Justice and includes data from all state-run and contract
facilities. The annual reports are approved by the agency head/designee. There are
no personal identifiers in the reports. The annual report contains PREA related data
that represents previous calendar years allowing for the comparison of data. The
overarching annual report, inclusive of all facilities within the agency that meet the
requirement of adhering to the PREA Standards, 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 6.13, PREA
Agency Policy FDJJ 1316, Records and Information Management Procedures
Agency Policy FDJJ 1919, PREA
Annual Reports
Interview:
Statewide PREA Coordinator
Provisions (a)-(d):
Provision (a): The agency shall ensure that data collected pursuant to §115.387
are securely retained. Provision (b): The agency shall make all aggregated sexual
abuse data, from facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through its website or, if it
does not have one, through other means. Provision (c): Before making aggregated
sexual abuse data publicly available, the agency shall remove all personal
identifiers. Provision (d): The agency shall maintain sexual abuse data collected
pursuant to §115.387 for at least 10 years after the date of its initial collection
unless Federal, State, or local law requires otherwise.
Policy provides that the data collected is securely stored and maintained for at least
10 years after the date of collection unless a law requires otherwise. 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 (DJJ) website. The DJJ annual report is the overarching report for the
agency that encompasses the PREA data for all state-run and contract facilities
within the agency. A review of annual reports verified there are no personal
identifiers.
All current facility and agency records maintained by the current contractor are
securely stored in locked cabinets behind locked doors and electronic records are
password protected with limited staff access. The previous contractor left records/
files in the facility which are being maintained in the facility in a locked storage
room with limited key access. The Department of Juvenile Justice (DJJ) is in
communication with the facility to remove the files for proper storage off-site. The
latest communication provided by the DJJ PREA Coordinator asserts that contact has
been made and DJJ is waiting for a vendor to pick the files up and deliver them for
proper storage and handling.
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 Auditor was provided initial documentation in the online audit system,
additional information onsite during the site review, and by email during the post
audit phase. Evidence that the corrective actions were implemented was also
provided during the post audit phase. The Department of Juvenile Justice statewide
PREA Coordinator ensured the completion of PREA audits for each state-run and
contract facility as required, including this facility. The site review was facilitated by
the Superintendent and corporate office staff; all areas of the facility were included.
The Superintendent and Assistant Superintendent and other staff were very
cooperative in providing information and participating in or assisting in coordinating
the resident and staff interviews. All interviews were conducted in private. The PREA
posted notices regarding the occurrence of the audit provided the general
information and included instructions and Auditor contact information regarding how
to provide confidential information to the Auditor. Due to the cancellation of the
initially assigned Auditor and change in audit dates, a revised notice was posted and
remained posted for a six-week period. 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, volunteers, or visitors
during the post audit phase.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Annual Reports
Interviews:
Superintendent
Department of Juvenile Justice 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 of other State-run and contract facilities are posted on the
DJJ website. The agency practice and the interview with the PREA Coordinator
document that this report will be posted on the agency website, accessible to the
public. This report and other posted reports do not contain any personal identifying
information other than names and job titles. The facility and agency policies,
additional documentation, observed practices, and interviews were reviewed
regarding compliance with the standards and have been identified in the reports.
The audit findings for this report 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.
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 na
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, na
electronic surveillance system, or other monitoring technology,
did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit,
whichever is later.)
115.321
Evidence protocol and forensic medical examinations
(a)
If the agency is responsible for investigating allegations of sexual yes
abuse, does the agency follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions? (N/A if the
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
115.321
Evidence protocol and forensic medical examinations
(b)
Is this protocol developmentally appropriate for youth? (N/A if the yes
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based yes
on the most recent edition of the U.S. Department of Justice’s
Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/
Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative
sexual abuse investigations. )
115.321
Evidence protocol and forensic medical examinations
(c)
Does the agency offer all residents who experience sexual abuse yes
access to forensic medical examinations, whether on-site or at an
outside facility, without financial cost, where evidentiarily or
medically appropriate?
Are such examinations performed by Sexual Assault Forensic yes
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs)
where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must
have been specifically trained to conduct sexual assault forensic
exams)?
Has the agency documented its efforts to provide SAFEs or yes
SANEs?
115.321
Evidence protocol and forensic medical examinations
(d)
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate yes
services, does the agency make available to provide these
services a qualified staff member from a community-based
organization, or a qualified agency staff member?
Has the agency documented its efforts to secure services from yes
rape crisis centers?
115.321
Evidence protocol and forensic medical examinations
(e)
As requested by the victim, does the victim advocate, qualified yes
agency staff member, or qualified community-based organization
staff member accompany and support the victim through the
forensic medical examination process and investigatory
interviews?
As requested by the victim, does this person provide emotional yes
support, crisis intervention, information, and referrals?
115.321
Evidence protocol and forensic medical examinations
(f)
If the agency itself is not responsible for investigating allegations yes
of sexual abuse, has the agency requested that the investigating
entity follow the requirements of paragraphs (a) through (e) of this
section? (N/A if the agency is responsible for investigating
allegations of sexual abuse.)
115.321
Evidence protocol and forensic medical examinations
(h)
If the agency uses a qualified agency staff member or a qualified yes
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
Policies to ensure referrals of allegations for investigations
(a)
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual
harassment?
115.322
Policies to ensure referrals of allegations for investigations
(b)
Does the agency have a policy in place to ensure that allegations yes
of sexual abuse or sexual harassment are referred for
investigation to an agency with the legal authority to conduct
criminal investigations, unless the allegation does not involve
potentially criminal behavior?
Has the agency published such policy on its website or, if it does yes
not have one, made the policy available through other means?
Does the agency document all such referrals? yes
115.322
Policies to ensure referrals of allegations for investigations
(c)
If a separate entity is responsible for conducting criminal yes
investigations, does such publication describe the responsibilities
of both the agency and the investigating entity? (N/A if the
agency/facility is responsible for criminal investigations. See
115.321(a))
115.331
Employee training
(a)
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency
sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and
sexual harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual
harassment in juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual
abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with
residents?
Does the agency train all employees who may have contact with yes
residents on: How to communicate effectively and professionally
with residents, including lesbian, gay, bisexual, transgender,
intersex, or gender nonconforming residents?
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
115.331
Employee training
(b)
Is such training tailored to the unique needs and attributes of yes
residents of juvenile facilities?
Is such training tailored to the gender of the residents at the yes
employee’s facility?
Have employees received additional training if reassigned from a yes
facility that houses only male residents to a facility that houses
only female residents, or vice versa?
115.331
Employee training
(c)
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training yes
every two years to ensure that all employees know the agency’s
current sexual abuse and sexual harassment policies and
procedures?
In years in which an employee does not receive refresher training, yes
does the agency provide refresher information on current sexual
abuse and sexual harassment policies?
115.331
Employee training
(d)
Does the agency document, through employee signature or yes
electronic verification, that employees understand the training
they have received?
115.332
Volunteer and contractor training
(a)
Has the agency ensured that all volunteers and contractors who yes
have contact with residents have been trained on their
responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and
procedures?
115.332
Volunteer and contractor training
(b)
Have all volunteers and contractors who have contact with yes
residents been notified of the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment and informed how
to report such incidents (the level and type of training provided to
volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)?
115.332
Volunteer and contractor training
(c)
Does the agency maintain documentation confirming that yes
volunteers and contractors understand the training they have
received?
115.333
Resident education
(a)
During intake, do residents receive information explaining the yes
agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment?
During intake, do residents receive information explaining how to yes
report incidents or suspicions of sexual abuse or sexual
harassment?
Is this information presented in an age-appropriate fashion? yes
115.333
Resident education
(b)
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from sexual abuse and
sexual harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from retaliation for
reporting such incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Agency policies and procedures for responding to
such incidents?
115.333
Resident education
(c)
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility yes
to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility?
115.333
Resident education
(d)
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are deaf?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Have limited reading skills?
115.333
Resident education
(e)
Does the agency maintain documentation of resident participation yes
in these education sessions?
115.333
Resident education
(f)
In addition to providing such education, does the agency ensure yes
that key information is continuously and readily available or visible
to residents through posters, resident handbooks, or other written
formats?
115.334
Specialized training: Investigations
(a)
In addition to the general training provided to all employees yes
pursuant to §115.331, does the agency ensure that, to the extent
the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such
investigations in confinement settings? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.334
Specialized training: Investigations
(b)
Does this specialized training include: Techniques for interviewing yes
juvenile sexual abuse victims? (N/A if the agency does not conduct
any form of administrative or criminal sexual abuse investigations.
See 115.321(a).)
Does this specialized training include: Proper use of Miranda and yes
Garrity warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Sexual abuse evidence yes
collection in confinement settings? (N/A if the agency does not
conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence yes
required to substantiate a case for administrative action or
prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See
115.321(a).)
115.334
Specialized training: Investigations
(c)
Does the agency maintain documentation that agency yes
investigators have completed the required specialized training in
conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.335
Specialized training: Medical and mental health care
(a)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have
any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to preserve physical evidence of sexual
abuse? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-
time medical or mental health care practitioners who work
regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(b)
If medical staff employed by the agency conduct forensic yes
examinations, do such medical staff receive appropriate training
to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not
employ medical staff.)
115.335
Specialized training: Medical and mental health care
(c)
Does the agency maintain documentation that medical and yes
mental health practitioners have received the training referenced
in this standard either from the agency or elsewhere? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(d)
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by
§115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Do medical and mental health care practitioners contracted by yes
and volunteering for the agency also receive training mandated
for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care
practitioners contracted by or volunteering for the agency.)
115.341
Obtaining information from residents
(a)
Within 72 hours of the resident’s arrival at the facility, does the yes
agency obtain and use information about each resident’s personal
history and behavior to reduce risk of sexual abuse by or upon a
resident?
Does the agency also obtain this information periodically yes
throughout a resident’s confinement?
115.341
Obtaining information from residents
(b)
Are all PREA screening assessments conducted using an objective yes
screening instrument?
115.341
Obtaining information from residents
(c)
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Prior sexual
victimization or abusiveness?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any gender
nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident
may therefore be vulnerable to sexual abuse?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Current
charges and offense history?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Level of
emotional and cognitive development?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical size
and stature?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Mental illness
or mental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical
disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: The resident’s
own perception of vulnerability?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any other
specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or
separation from certain other residents?
115.341
Obtaining information from residents
(d)
Is this information ascertained: Through conversations with the yes
resident during the intake process and medical mental health
screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case yes
files, facility behavioral records, and other relevant documentation
from the resident’s files?
115.341
Obtaining information from residents
(e)
Has the agency implemented appropriate controls on the yes
dissemination within the facility of responses to questions asked
pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or
other residents?
115.342
Placement of residents
(a)
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Education
Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Program Assignments?
115.342
Placement of residents
(b)
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other
residents safe, and then only until an alternative means of
keeping all residents safe can be arranged?
During any period of isolation, does the agency always refrain yes
from denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain yes
from denying residents any legally required educational
programming or special education services?
Do residents in isolation receive daily visits from a medical or yes
mental health care clinician?
Do residents also have access to other programs and work yes
opportunities to the extent possible?
115.342
Placement of residents
(c)
Does the agency always refrain from placing: Lesbian, gay, and yes
bisexual residents in particular housing, bed, or other assignments
solely on the basis of such identification or status?
Does the agency always refrain from placing: Transgender yes
residents in particular housing, bed, or other assignments solely
on the basis of such identification or status?
Does the agency always refrain from placing: Intersex residents in yes
particular housing, bed, or other assignments solely on the basis
of such identification or status?
Does the agency always refrain from considering lesbian, gay, yes
bisexual, transgender, or intersex identification or status as an
indicator or likelihood of being sexually abusive?
115.342
Placement of residents
(d)
When deciding whether to assign a transgender or intersex yes
resident to a facility for male or female residents, does the agency
consider on a case-by-case basis whether a placement would
ensure the resident’s health and safety, and whether a placement
would present management or security problems (NOTE: if an
agency by policy or practice assigns residents to a male or female
facility on the basis of anatomy alone, that agency is not in
compliance with this standard)?
When making housing or other program assignments for yes
transgender or intersex residents, does the agency consider on a
case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would
present management or security problems?
115.342
Placement of residents
(e)
Are placement and programming assignments for each yes
transgender or intersex resident reassessed at least twice each
year to review any threats to safety experienced by the resident?
115.342
Placement of residents
(f)
Are each transgender or intersex resident’s own views with yes
respect to his or her own safety given serious consideration when
making facility and housing placement decisions and
programming assignments?
115.342
Placement of residents
(g)
Are transgender and intersex residents given the opportunity to yes
shower separately from other residents?
115.342
Placement of residents
(h)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The basis for the facility’s
concern for the resident’s safety? (N/A for h and i if facility doesn’t
use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The reason why no alternative
means of separation can be arranged? (N/A for h and i if facility
doesn’t use isolation?)
115.342
Placement of residents
(i)
In the case of each resident who is isolated as a last resort when yes
less restrictive measures are inadequate to keep them and other
residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general
population EVERY 30 DAYS?
115.351
Resident reporting
(a)
Does the agency provide multiple internal ways for residents to yes
privately report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: 2. Retaliation by other residents or staff for
reporting sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: Staff neglect or violation of responsibilities that
may have contributed to such incidents?
115.351
Resident reporting
(b)
Does the agency also provide at least one way for residents to yes
report sexual abuse or sexual harassment to a public or private
entity or office that is not part of the agency?
Is that private entity or office able to receive and immediately yes
forward resident reports of sexual abuse and sexual harassment to
agency officials?
Does that private entity or office allow the resident to remain yes
anonymous upon request?
Are residents detained solely for civil immigration purposes yes
provided information on how to contact relevant consular officials
and relevant officials at the Department of Homeland Security to
report sexual abuse or harassment?
115.351
Resident reporting
(c)
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from
third parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351
Resident reporting
(d)
Does the facility provide residents with access to tools necessary yes
to make a written report?
115.351
Resident reporting
(e)
Does the agency provide a method for staff to privately report yes
sexual abuse and sexual harassment of residents?
115.352
Exhaustion of administrative remedies
(a)
Is the agency exempt from this standard? yes
NOTE: The agency is exempt ONLY if it does not have
administrative procedures to address resident grievances
regarding sexual abuse. This does not mean the agency is exempt
simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This
means that as a matter of explicit policy, the agency does not
have an administrative remedies process to address sexual abuse.
115.352
Exhaustion of administrative remedies
(b)
Does the agency permit residents to submit a grievance regarding na
an allegation of sexual abuse without any type of time limits? (The
agency may apply otherwise-applicable time limits to any portion
of a grievance that does not allege an incident of sexual abuse.)
(N/A if agency is exempt from this standard.)
Does the agency always refrain from requiring an resident to use na
any informal grievance process, or to otherwise attempt to resolve
with staff, an alleged incident of sexual abuse? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(c)
Does the agency ensure that: A resident who alleges sexual abuse na
may submit a grievance without submitting it to a staff member
who is the subject of the complaint? (N/A if agency is exempt from
this standard.)
Does the agency ensure that: Such grievance is not referred to a na
staff member who is the subject of the complaint? (N/A if agency
is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(d)
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the
initial filing of the grievance? (Computation of the 90-day time
period does not include time consumed by residents in preparing
any administrative appeal.) (N/A if agency is exempt from this
standard.)
If the agency determines that the 90 day timeframe is insufficient na
to make an appropriate decision and claims an extension of time
(the maximum allowable extension of time to respond is 70 days
per 115.352(d)(3)) , does the agency notify the resident in writing
of any such extension and provide a date by which a decision will
be made? (N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, na
if the resident does not receive a response within the time allotted
for reply, including any properly noticed extension, may a resident
consider the absence of a response to be a denial at that level?
(N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(e)
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on na
behalf of residents? (If a third party, other than a parent or legal
guardian, files such a request on behalf of a resident, the facility
may require as a condition of processing the request that the
alleged victim agree to have the request filed on his or her behalf,
and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.) (N/A if
agency is exempt from this standard.)
If the resident declines to have the request processed on his or na
her behalf, does the agency document the resident’s decision?
(N/A if agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a na
grievance regarding allegations of sexual abuse, including
appeals, on behalf of such juvenile? (N/A if agency is exempt from
this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an na
appeal) on behalf of a juvenile regarding allegations of sexual
abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her
behalf? (N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(f)
Has the agency established procedures for the filing of an na
emergency grievance alleging that a resident is subject to a
substantial risk of imminent sexual abuse? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance alleging a resident is na
subject to a substantial risk of imminent sexual abuse, does the
agency immediately forward the grievance (or any portion thereof
that alleges the substantial risk of imminent sexual abuse) to a
level of review at which immediate corrective action may be
taken? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency provide an initial response within 48 hours? (N/A if
agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency issue a final agency decision within 5 calendar days?
(N/A if agency is exempt from this standard.)
Does the initial response and final agency decision document the na
agency’s determination whether the resident is in substantial risk
of imminent sexual abuse? (N/A if agency is exempt from this
standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt
from this standard.)
Does the agency’s final decision document the agency’s action(s) na
taken in response to the emergency grievance? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(g)
If the agency disciplines a resident for filing a grievance related to na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
115.353 Resident access to outside confidential support services and
(a) legal representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse
by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline
numbers where available, of local, State, or national victim
advocacy or rape crisis organizations?
Does the facility provide persons detained solely for civil yes
immigration purposes mailing addresses and telephone numbers,
including toll-free hotline numbers where available of local, State,
or national immigrant services agencies?
Does the facility enable reasonable communication between yes
residents and these organizations and agencies, in as confidential
a manner as possible?
115.353 Resident access to outside confidential support services and
(b) legal representation
Does the facility inform residents, prior to giving them access, of yes
the extent to which such communications will be monitored and
the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws?
115.353 Resident access to outside confidential support services and
(c) legal representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service
providers that are able to provide residents with confidential
emotional support services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
115.353 Resident access to outside confidential support services and
(d) legal representation
Does the facility provide residents with reasonable and yes
confidential access to their attorneys or other legal
representation?
Does the facility provide residents with reasonable access to yes
parents or legal guardians?
115.354
Third-party reporting
(a)
Has the agency established a method to receive third-party yes
reports of sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report yes
sexual abuse and sexual harassment on behalf of a resident?
115.361
Staff and agency reporting duties
(a)
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding an incident of sexual abuse or
sexual harassment that occurred in a facility, whether or not it is
part of the agency?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding retaliation against residents or
staff who reported an incident of sexual abuse or sexual
harassment?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding any staff neglect or violation of
responsibilities that may have contributed to an incident of sexual
abuse or sexual harassment or retaliation?
115.361
Staff and agency reporting duties
(b)
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361
Staff and agency reporting duties
(c)
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited
from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency
policy, to make treatment, investigation, and other security and
management decisions?
115.361
Staff and agency reporting duties
(d)
Are medical and mental health practitioners required to report yes
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section as well as to the designated State or
local services agency where required by mandatory reporting
laws?
Are medical and mental health practitioners required to inform yes
residents of their duty to report, and the limitations of
confidentiality, at the initiation of services?
115.361
Staff and agency reporting duties
(e)
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
appropriate office?
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
alleged victim’s parents or legal guardians unless the facility has
official documentation showing the parents or legal guardians
should not be notified?
If the alleged victim is under the guardianship of the child welfare na
system, does the facility head or his or her designee promptly
report the allegation to the alleged victim’s caseworker instead of
the parents or legal guardians? (N/A if the alleged victim is not
under the guardianship of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does yes
the facility head or designee also report the allegation to the
juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation?
115.361
Staff and agency reporting duties
(f)
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the
facility’s designated investigators?
115.362
Agency protection duties
(a)
When the agency learns that a resident is subject to a substantial yes
risk of imminent sexual abuse, does it take immediate action to
protect the resident?
115.363
Reporting to other confinement facilities
(a)
Upon receiving an allegation that a resident was sexually abused yes
while confined at another facility, does the head of the facility that
received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse
occurred?
Does the head of the facility that received the allegation also yes
notify the appropriate investigative agency?
115.363
Reporting to other confinement facilities
(b)
Is such notification provided as soon as possible, but no later than yes
72 hours after receiving the allegation?
115.363
Reporting to other confinement facilities
(c)
Does the agency document that it has provided such notification? yes
115.363
Reporting to other confinement facilities
(d)
Does the facility head or agency office that receives such yes
notification ensure that the allegation is investigated in
accordance with these standards?
115.364
Staff first responder duties
(a)
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Request that the alleged victim not take any actions
that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating,
smoking, drinking, or eating, if the abuse occurred within a time
period that still allows for the collection of physical evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical
evidence?
115.364
Staff first responder duties
(b)
If the first staff responder is not a security staff member, is the yes
responder required to request that the alleged victim not take any
actions that could destroy physical evidence, and then notify
security staff?
115.365
Coordinated response
(a)
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in
response to an incident of sexual abuse?
115.366 Preservation of ability to protect residents from contact with
(a) abusers
Are both the agency and any other governmental entities no
responsible for collective bargaining on the agency’s behalf
prohibited from entering into or renewing any collective
bargaining agreement or other agreement that limits the agency’s
ability to remove alleged staff sexual abusers from contact with
any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is
warranted?
115.367
Agency protection against retaliation
(a)
Has the agency established a policy to protect all residents and yes
staff who report sexual abuse or sexual harassment or cooperate
with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff?
Has the agency designated which staff members or departments yes
are charged with monitoring retaliation?
115.367
Agency protection against retaliation
(b)
Does the agency employ multiple protection measures for yes
residents or staff who fear retaliation for reporting sexual abuse or
sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers,
removal of alleged staff or resident abusers from contact with
victims, and emotional support services?
115.367
Agency protection against retaliation
(c)
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents or staff who reported the sexual abuse to
see if there are changes that may suggest possible retaliation by
residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible
retaliation by residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Act promptly to remedy any
such retaliation?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident housing
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident program
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Negative performance
reviews of staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Reassignments of
staff?
Does the agency continue such monitoring beyond 90 days if the yes
initial monitoring indicates a continuing need?
115.367
Agency protection against retaliation
(d)
In the case of residents, does such monitoring also include yes
periodic status checks?
115.367
Agency protection against retaliation
(e)
If any other individual who cooperates with an investigation yes
expresses a fear of retaliation, does the agency take appropriate
measures to protect that individual against retaliation?
115.368
Post-allegation protective custody
(a)
Is any and all use of segregated housing to protect a resident who yes
is alleged to have suffered sexual abuse subject to the
requirements of § 115.342?
115.371
Criminal and administrative agency investigations
(a)
When the agency conducts its own investigations into allegations yes
of sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual
abuse or harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, yes
including third party and anonymous reports? (N/A if the agency
does not conduct any form of administrative or criminal
investigations of sexual abuse or harassment. See 115.321(a).)
115.371
Criminal and administrative agency investigations
(b)
Where sexual abuse is alleged, does the agency use investigators yes
who have received specialized training in sexual abuse
investigations involving juvenile victims as required by 115.334?
115.371
Criminal and administrative agency investigations
(c)
Do investigators gather and preserve direct and circumstantial yes
evidence, including any available physical and DNA evidence and
any available electronic monitoring data?
Do investigators interview alleged victims, suspected yes
perpetrators, and witnesses?
Do investigators review prior reports and complaints of sexual yes
abuse involving the suspected perpetrator?
115.371
Criminal and administrative agency investigations
(d)
Does the agency always refrain from terminating an investigation yes
solely because the source of the allegation recants the allegation?
115.371
Criminal and administrative agency investigations
(e)
When the quality of evidence appears to support criminal yes
prosecution, does the agency conduct compelled interviews only
after consulting with prosecutors as to whether compelled
interviews may be an obstacle for subsequent criminal
prosecution?
115.371 Criminal and administrative agency investigations
(f)
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of
that individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition
for proceeding?
115.371
Criminal and administrative agency investigations
(g)
Do administrative investigations include an effort to determine yes
whether staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports yes
that include a description of the physical evidence and testimonial
evidence, the reasoning behind credibility assessments, and
investigative facts and findings?
115.371
Criminal and administrative agency investigations
(h)
Are criminal investigations documented in a written report that yes
contains a thorough description of the physical, testimonial, and
documentary evidence and attaches copies of all documentary
evidence where feasible?
115.371
Criminal and administrative agency investigations
(i)
Are all substantiated allegations of conduct that appears to be yes
criminal referred for prosecution?
115.371
Criminal and administrative agency investigations
(j)
Does the agency retain all written reports referenced in yes
115.371(g) and (h) for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years unless
the abuse was committed by a juvenile resident and applicable
law requires a shorter period of retention?
115.371
Criminal and administrative agency investigations
(k)
Does the agency ensure that the departure of an alleged abuser yes
or victim from the employment or control of the facility or agency
does not provide a basis for terminating an investigation?
115.371
Criminal and administrative agency investigations
(m)
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain
informed about the progress of the investigation? (N/A if an
outside agency does not conduct administrative or criminal sexual
abuse investigations. See 115.321(a).)
115.372
Evidentiary standard for administrative investigations
(a)
Is it true that the agency does not impose a standard higher than yes
a preponderance of the evidence in determining whether
allegations of sexual abuse or sexual harassment are
substantiated?
115.373
Reporting to residents
(a)
Following an investigation into a resident’s allegation of sexual yes
abuse suffered in the facility, does the agency inform the resident
as to whether the allegation has been determined to be
substantiated, unsubstantiated, or unfounded?
115.373
Reporting to residents
(b)
If the agency did not conduct the investigation into a resident’s yes
allegation of sexual abuse in an agency facility, does the agency
request the relevant information from the investigative agency in
order to inform the resident? (N/A if the agency/facility is
responsible for conducting administrative and criminal
investigations.)
115.373
Reporting to residents
(c)
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer posted within the resident’s unit?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer employed at the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been indicted on a charge related to
sexual abuse in the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been convicted on a charge related to
sexual abuse within the facility?
115.373
Reporting to residents
(d)
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been indicted on a charge related to sexual abuse
within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been convicted on a charge related to sexual abuse
within the facility?
115.373
Reporting to residents
(e)
Does the agency document all such notifications or attempted yes
notifications?
115.376
Disciplinary sanctions for staff
(a)
Are staff subject to disciplinary sanctions up to and including yes
termination for violating agency sexual abuse or sexual
harassment policies?
115.376
Disciplinary sanctions for staff
(b)
Is termination the presumptive disciplinary sanction for staff who yes
have engaged in sexual abuse?
115.376
Disciplinary sanctions for staff
(c)
Are disciplinary sanctions for violations of agency policies relating yes
to sexual abuse or sexual harassment (other than actually
engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable
offenses by other staff with similar histories?
115.376
Disciplinary sanctions for staff
(d)
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to: Law
enforcement agencies, unless the activity was clearly not
criminal?
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to:
Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(a)
Is any contractor or volunteer who engages in sexual abuse yes
prohibited from contact with residents?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Law enforcement agencies (unless the activity was
clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(b)
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility
take appropriate remedial measures, and consider whether to
prohibit further contact with residents?
115.378
Interventions and disciplinary sanctions for residents
(a)
Following an administrative finding that a resident engaged in yes
resident-on-resident sexual abuse, or following a criminal finding
of guilt for resident-on-resident sexual abuse, may residents be
subject to disciplinary sanctions only pursuant to a formal
disciplinary process?
115.378
Interventions and disciplinary sanctions for residents
(b)
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary
history, and the sanctions imposed for comparable offenses by
other residents with similar histories?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied daily
large-muscle exercise?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied access
to any legally required educational programming or special
education services?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident receives daily visits
from a medical or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the resident also have access to other programs
and work opportunities to the extent possible?
115.378
Interventions and disciplinary sanctions for residents
(c)
When determining what types of sanction, if any, should be yes
imposed, does the disciplinary process consider whether a
resident’s mental disabilities or mental illness contributed to his or
her behavior?
115.378
Interventions and disciplinary sanctions for residents
(d)
If the facility offers therapy, counseling, or other interventions yes
designed to address and correct underlying reasons or motivations
for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions?
If the agency requires participation in such interventions as a yes
condition of access to any rewards-based behavior management
system or other behavior-based incentives, does it always refrain
from requiring such participation as a condition to accessing
general programming or education?
115.378
Interventions and disciplinary sanctions for residents
(e)
Does the agency discipline a resident for sexual contact with staff yes
only upon a finding that the staff member did not consent to such
contact?
115.378
Interventions and disciplinary sanctions for residents
(f)
For the purpose of disciplinary action, does a report of sexual yes
abuse made in good faith based upon a reasonable belief that the
alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish
evidence sufficient to substantiate the allegation?
115.378
Interventions and disciplinary sanctions for residents
(g)
Does the agency always refrain from considering non-coercive yes
sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.)
115.381
Medical and mental health screenings; history of sexual abuse
(a)
If the screening pursuant to § 115.341 indicates that a resident yes
has experienced prior sexual victimization, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(b)
If the screening pursuant to § 115.341 indicates that a resident yes
has previously perpetrated sexual abuse, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a mental health
practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(c)
Is any information related to sexual victimization or abusiveness yes
that occurred in an institutional setting strictly limited to medical
and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions,
including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local
law?
115.381
Medical and mental health screenings; history of sexual abuse
(d)
Do medical and mental health practitioners obtain informed yes
consent from residents before reporting information about prior
sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18?
115.382
Access to emergency medical and mental health services
(a)
Do resident victims of sexual abuse receive timely, unimpeded yes
access to emergency medical treatment and crisis intervention
services, the nature and scope of which are determined by
medical and mental health practitioners according to their
professional judgment?
115.382
Access to emergency medical and mental health services
(b)
If no qualified medical or mental health practitioners are on duty yes
at the time a report of recent sexual abuse is made, do staff first
responders take preliminary steps to protect the victim pursuant
to § 115.362?
Do staff first responders immediately notify the appropriate yes
medical and mental health practitioners?
115.382
Access to emergency medical and mental health services
(c)
Are resident victims of sexual abuse offered timely information yes
about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically
appropriate?
115.382
Access to emergency medical and mental health services
(d)
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(a) victims and abusers
Does the facility offer medical and mental health evaluation and, yes
as appropriate, treatment to all residents who have been
victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility?
115.383 Ongoing medical and mental health care for sexual abuse
(b) victims and abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when
necessary, referrals for continued care following their transfer to,
or placement in, other facilities, or their release from custody?
115.383 Ongoing medical and mental health care for sexual abuse
(c) victims and abusers
Does the facility provide such victims with medical and mental yes
health services consistent with the community level of care?
115.383 Ongoing medical and mental health care for sexual abuse
(d) victims and abusers
Are resident victims of sexually abusive vaginal penetration while 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” yes
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 na
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.)

source: DJJ

file_name: Florida_Duval Academy_Year2Cycle4.pdf

program_name_raw: Duval Academy