facility_name: DOVE Academy

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Dove Vocational Academy
Physical Address: 5270 Ezell Road, Graceville, FL 32440
Date report submitted: May 24, 2015
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: May 10-11, 2015
Facility Information
Facility Mailing Address: 5270 Ezell Road, Graceville, FL 32440
Telephone Number: (850) 263-7550
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Amy Barnes Title: Interim Program Director
(850) 263-7550
Email Address: amybarnes@twinoaksfl.org Telephone Number:
Agency Information
Name of Agency: Twin Oaks Juvenile Development, Inc.
Governing Authority or Parent Agency: NA
Agency Address:2930 Kerry Forest Parkway, #101, Tallahassee, FL
3M2a3i0li9n g A d d r e s s : S a m e a s A b o ve
T e l e phone Number: (850) 643-1090
Agency Chief Executive Officer
Name: Donald B. Read Title: Chief Executive Officer
Telephone (850) 643-1090
Email Address: dread@twinoaksfl.org
Number:
Agency Wide PREA Coordinator
Name: Charles Chervanik Title: Agency PREA Coordinator
Email Address: cchervanik@twinoaksfl.org Telephone Number: ( 8 5 0 ) 6 4 3 - 1 0 9 0
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AUDIT FINDINGS
NARRATIVE:
The Dove Vocational Academy is located in Graceville, Florida and has a capacity of 24. The facility
serves female juvenile offenders in the age range of 15-18. Twin Oaks Juvenile Development, Inc.
operates the facility through a contract with the Florida Department of Juvenile Justice (FDJJ) to
provide residential treatment services. The length of stay is 3-6 months for low risk custody level
residents and 6-9 months for moderate risk custody level. The facility program and services include
education and vocational services; social services; case management, mental health, substance abuse
treatment services; medical; recreation; and transition planning.
Medical care is provided within the facility by a Registered Nurse who serves as the Director of
Nursing, one full-time Licensed Practical Nurse and one part-time Licensed Practical Nurse. The
contract physician visits the facility at least weekly. On-site mental health services are provided by
the Clinical Director and two Clinical Coordinators. The contract psychiatrist visits the facility on a
weekly basis and the contract Behavior Analyst is on-site every other week and attends treatment
team meetings. Education/vocational and case management services are provided by staff at the
facility. The direct care staff provides engaged supervision of the residents in daily activities and
during movement to and from activities and services.
The program has a behavior management system that includes incentives to encourage residents to
display appropriate behavior. Residents earn points on a daily basis for demonstrating the desired
behavior and are allowed to spend those points at the point store. There are different stages within the
behavior management system and privileges earned increase with each stage along with increased
responsibilities. Based on the stage the resident is in, she may participate in off-campus activities that
include educational field trips, community service projects and incentive trips. A safety/risk
assessment is used to help determine whether a resident may participate in an off-campus activity.
Through a partnership between Twin Oaks Juvenile Development, Inc. and the Boys and Girls Club
of America, the facility operates a Boys and Girls Club site at the facility. Staff members administer
services and activities comparable to those found in the community. Additionally, the facility is
accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is contained in eight buildings. The administrative building houses administrative
offices; reception/lobby area; control room; conference room; and the cafeteria. Other buildings
include training; education/vocation; dormitories; medical; and a greenhouse. There are three
dormitories that house the residents; each dormitory contains eight residents and there are two per
room. A full bathroom is located in each dormitory and provides a reasonable amount of privacy for
the residents.
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A pavilion sits in the center of the grounds with the buildings surrounding it. Two basketballs goals
are posted under the pavilion. The outside grounds also contain a garden that is maintained by the
residents as a part of their Boys and Girls Club activities under the supervision of staff. There is
space for volley ball and additional recreation and other activities.
SUMMARY OF AUDIT FINDINGS:
An initial conference call was conducted by the Auditor with the Interim Program Director, an
administrator from the corporate office and the FDJJ PREA Coordinator to discuss the audit process
and data gathering. The notifications of the on-site audit were posted in various parts of the facility
at least six weeks prior to the site visit. Photographs were taken of the postings and were
electronically sent to the Auditor. The Pre-Audit Questionnaire and the supporting documentation
were uploaded to a flash drive, which was received approximately four weeks prior to the on-site
audit. During the review of the information on the flash drive, communication was maintained with
the Interim Program Director and corporate office staff and additional information was provided or
clarified as requested. The Interim Program Director serves as the PREA Compliance Manager and
the Chief Operating Officer (COO) for Twin Oaks Juvenile Development, Inc. serves as the
agency’s PREA Coordinator.
The on-site audit was conducted May 10-11, 2015. On the evening of May 10, a tour of the facility
was conducted by the administrator from the Twin Oaks corporate office and two staff interviews
were conducted. During the tour, staff members were observed to be providing direct supervision
and interacting with the residents. On the morning of May 11, an introductory meeting was
conducted with management and program staff. Afterwards, additional visits were made to areas of
the facility, interviews were conducted and supportive documents were reviewed. The additional
information was provided upon request and in a timely manner. Interviews included random staff
from all three shifts, specialized staff and residents. At the conclusion of the on-site audit, a close-out
meeting was held and a summary of the audit findings was provided to the Interim Program Director,
Twin Oaks corporate staff and other facility staff.
Number of Standards Exceeded: 1
Number of Standards Met: 36
Number of Standards Not Met: 0
Number of Standards Not Applicable: 4
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Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The Twin Oaks Juvenile Development, Inc. Prison Rape Elimination Act (PREA) Policy
provides guidelines to the facility for implementing the agency’s approach to complying with
the requirements of the PREA standards. The Policy provides for a zero-tolerance approach
regarding all forms of sexual abuse and sexual harassment. It contains definitions of the
prohibited behaviors and sanctions for those who participate in such behaviors. The agency’s
PREA Policy and the facility procedures and practices are aligned with and accompany the
Florida Department of Juvenile Justice PREA Policy (FDJJ 1919).
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other facilities for the confinement of residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provide for the implementation of a staffing plan with adequate staffing
levels to protect residents against sexual abuse and provides that the staffing ratios are
maintained. According to the staffing plan and staff interviews the ratios within the facility
are 1:8 during the awake hours and 1:8 during the sleeping hours; documentation supports
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that the Policy is practiced. The ratios for the agency staffing plans include a smaller number
of residents, based on the activity. The assessment of the staffing plan has been conducted by
the agency’s PREA Coordinator. The staffing plan document details the methodology that
ensures adherence to the staffing ratios.
Documentation shows that members of the management team conduct unannounced rounds
for the maintenance of a safe environment. The PREA Policy prohibits staff from alerting
other staff regarding the occurrence of unannounced rounds. Interviews with staff and a
review of video footage confirmed the practices.
Standard 115.315 Limits to Cross-Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy, cross-gender pat-down searches and cross-gender strip or
cross-gender visual body cavity searches of residents are prohibited. The PREA Policy directs
that staff of the opposite gender shall announce themselves when entering an area where
residents may be showering, performing bodily functions or changing clothes. All residents
are able to shower, perform bodily functions, and change clothes without being observed by
staff of the opposite gender. Interviews with staff and residents confirmed that these
procedures are followed.
The practice of the facility is that male staff members announce themselves when entering the
dormitories and signs are posted on each door indicating such. The PREA Policy also
supports that staff shall not search or physically examine a transgender or intersex resident to
determine the resident’s genital status.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for residents with disabilities to have an equal opportunity to
participate in or benefit from all aspects of PREA education. Resources are available for the
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provision of support services for residents with disabilities and residents who are limited
English proficient. The facility provides an approved list of interpreters to be used as needed.
Resident education materials are accessible in dominant languages other than English. A
review of documentation and staff interviews confirmed that resources are available and that,
per Policy, residents are not used as interpreters or readers.
.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 address the components of this standard and provide for
background checks on all employees and contractors through a process that is used
statewide. A review of documentation and interviews with staff confirmed that prior to the
hiring of an employee or contractor, background checks are conducted as required.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable. A camera system is used; however, there have not been any
upgrades or additional installation since the referenced time frame.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
The PREA Policy and FDJJ 1919 state that staff members are expected to cooperate in
investigations conducted by the FDJJ Office of the Inspector General (OIG). Administrative
investigations are conducted by OIG and criminal investigations are conducted by local law
enforcement and Florida Department of Children and Families. Law enforcement
investigators are provided a copy of the FDJJ PREA Compliance Form which contains the
PREA standards requirements regarding investigations.
The PREA Policy provides for forensic medical examinations to be completed at no
financial cost to the victim. The facility has a written Agreement with Panhandle Forensic
Nurse Specialist, Inc. for the provision of forensic medical examinations. There is a
Memorandum of Understanding between the facility and the Gulf Coast Children’s
Advocacy Center for advocacy services for victims of sexual abuse and sexual harassment.
There have been no forensic examinations conducted during this audit period.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s PREA Policy and FDJJ 1919 provide that staff report all allegations of sexual
abuse and sexual harassment and that the appropriate investigative entity be contacted when
allegations of sexual abuse are made. The Twin Oaks Juvenile Development, Inc. website
contains information regarding the referral of allegations for investigations of sexual abuse
and it has related information posted, which is accessible to the public. The website is very
informative and educational to the public and staff.
There were two allegations that resulted in administrative investigations during this audit
period. One case was closed out as Unfounded and the other one was closed out as
Information Only, regarding the allegations. One of the reports did show that reprimands
were given to identified staff members due to the allegation not being reported in the time
frame provided in Policy.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
The PREA Policy and FDJJ 1919 address employee training. Staff interviews and a review of
training documents show employees’ participation. Staff receive initial PREA training,
refresher training and additional training as needed.
Standard 115.332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 contain information regarding the training of volunteers
and contractors who have contact with residents. Receipt of the training is documented and it
contains a review of the agency’s zero-tolerance policy.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Documentation shows and staff and resident interviews support the practice of residents
receiving PREA education, including how to report incidents of sexual abuse or sexual
harassment. According to the PREA Policy and other documentation, the facility will
provide support services in accessible formats for residents who are limited English
proficient, deaf, visually impaired, or otherwise disabled. PREA information is posted and
available to the residents.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
FDJJ 1919 and the PREA Policy state that staff in the OIG will be trained on the related
policies and procedures regarding the handling of sexual misconduct incidents and reports.
Training is provided to FDJJ investigative staff regarding conducting investigations in the
FDJJ settings.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Documentation shows that regular and specialized training occurs for medical and mental
health staffs. Specific FDJJ training modules are accessible online for mental health and
medical staffs. The facility medical staff does not conduct forensic medical examinations.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 provide that screening for the risk of sexual abuse
victimization or sexual abusiveness toward other residents be conducted on each resident.
The initial screening is done during the intake process and the PREA Policy states that the
treatment team should continually review the resident’s adjustment. Interviews support and
documentation show that risk screenings occur.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
The PREA Policy prohibits placing gay, bisexual, transgender, or intersex residents in
particular housing based solely on such identification or status. The Policy supports that
housing and program assignments will be made for transgender or intersex residents on a
case by case basis and the resident’s view regarding her safety will be seriously considered.
Additionally, the PREA Policy prohibits considering gay, bisexual, transgender, or intersex
identification or status as an indicator of the likelihood of being sexually abusive.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
There are internal ways a resident may report allegations of sexual abuse; sexual harassment;
retaliation for reporting; and staff neglect or other violations that lead to abuse. A resident
may complete a grievance form and place it in the grievance box located in the cafeteria;
complete a Request to Speak form requesting to talk to a specific staff member; have a
conversation with any staff member; and third parties may report allegations to staff or
through the Florida abuse hotline.
PREA related information is posted and is accessible to residents. The abuse reporting hotline
number is provided and is contained in the Student Handbook. Residents are provided access
to a telephone to report allegations of sexual abuse and sexual harassment. Interviews
revealed that staff members are aware of their responsibility to report sexual abuse and sexual
harassment. They are also aware that they may accept reports of sexual abuse and sexual
harassment made verbally, in writing, anonymously, and from third parties. Interviews with
staff and residents and a review of documents support that there are internal ways residents
can report allegations.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy prohibits the use of an informal grievance process regarding allegations of
sexual abuse and sexual harassment. The facility considers resident grievances regarding
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sexual abuse to be an allegation and when such a complaint is received, the procedures
regarding reporting allegations is initiated. Residents may place written allegations of sexual
abuse or sexual harassment in the grievance box. The PREA Policy provides for emergency
grievances to be immediately forwarded to the Program Director.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has a Memorandum of Understanding with Gulf Coast Children’s Advocacy
Center, in accordance with the PREA Policy and FDJJ 1919. The services to be provided
include supportive counseling; court accompaniment; referrals; and access to 24-hour hotline
services. Interviews with facility staff and the Executive Director of the advocacy agency
confirmed the support of the recently signed MOU.
Residents are allowed to see their parents at visitation on Sundays and may talk to them at
least once a week by telephone. Attorneys or other legal representation may visit residents in a
confidential manner. Resident and staff interviews and other documentation supported the
occurrence of visitation and related information is contained in the Student Handbook.
Standard 115.354 Third-Party Reporting
X Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
A process for receiving third-party reports exist. Staff members may receive and respond to
third-party reports as stated in the PREA Policy and as confirmed in interviews. Staff
members, family members, attorneys, other residents, and outside advocates may assist
residents with filing requests for administrative remedies.
The agency has completed the construction of a well-assembled PREA page on its website
that provides comprehensive information, including third-party reporting. The web-page,
accessible to the public, contains hotline numbers for the Abuse Registry and the DJJ Central
Communications Center. The viewer is instructed to report sexual abuse or sexual
harassment to either number or to local law enforcement. On the page, a brief history of
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PREA is given, a link to the National PREA Resource Center is provided, and there is
acknowledgement that the PREA Standards can be accessed through the link. Additionally,
there is a statement regarding Twin Oaks’ zero-tolerance for any acts of sexual abuse; access
to the agency’s PREA Policy; and access to the agency’s PREA related Annual Report. The
FDJJ website also provides the public with information regarding the reporting of abuse
allegations.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides that staff immediately report any knowledge, suspicion or
information they receive regarding sexual abuse or sexual harassment. Also, staff should
immediately report any retaliation against residents or staff who reports any incidents; or any
staff neglect or violation of responsibilities that may have contributed to an incident. Each
staff interviewed was aware of their reporting duties.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides that when it is learned that a resident is subject to substantial risk
of imminent sexual abuse, immediate action is taken to protect the resident. The facility
reports that there have been no incidents in the last 12 months where the facility was
required to take action in regards to a resident being at substantial risk of imminent sexual
abuse.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 address this standard. Upon receipt of an allegation that a
resident was sexually abused while confined in another facility, the Program Director will
notify the Central Communications Center (CCC) and the Department of Children and
Families of the allegation. Additionally, the head of the other facility will be notified; the
notifications will be made within 72 hours of receipt of the allegation.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 guide the staff response in meeting the requirements of
this standard. The Policies provide direction to staff in responding to allegations of sexual
abuse. Staff interviews reflect that they have received training regarding their duties.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s coordinated response is addressed in the PREA Policy and is detailed in a
separate document that doubles as a checklist in responding to an alleged incident of sexual
abuse. Through the PREA Policy and the response plan checklist, guidance is provided to
staff regarding steps to take in the event of an incident or allegation of sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
13
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable; the facility does not maintain any collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. The Program Director has been designated
as the staff member responsible for monitoring for the occurrence of retaliation. The Policy
identifies areas to monitor regarding possible retaliation of residents and staff.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The standard in not applicable; the facility does not use segregated housing;
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 address this standard and state that administrative
investigations are conducted by the FDJJ OIG and criminal investigations are conducted by
the Department of Children and Families and local law enforcement. Both Policies direct
staff to cooperate with investigations. According to FDJJ 1919, an investigation is not
terminated solely because the source of the investigation recants the allegation. Substantiated
allegations of conduct that appear to be criminal are referred for prosecution.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The OIG, responsible for administrative investigations, imposes a standard of a preponderance
of the evidence for determining whether allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 provides the process for notifying residents following an
investigation of whether an allegation has been determined to be substantiated,
unsubstantiated, or unfounded. The appropriate notification was made by facility staff
regarding the investigation relative to this standard.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
15
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for disciplinary sanctions for staff to be up to and including
termination for violation of the sexual abuse and sexual harassment policies. The PREA
Policy requires that the violation be reported to local law enforcement and provides for
contacting relevant licensing bodies. In the past 12 months, no staff has been terminated or
has resigned for violating PREA related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 provide guidance to staff regarding reporting incidents of
sexual abuse by a contractor or volunteer, including to relevant licensing bodies. The facility
prohibits future contact with residents in the case of any violation of the facility’s PREA
related policies. During the past 12 months, no contractor or volunteer has been reported to
law enforcement or any investigative entity due to allegations of sexual abuse.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides that any resident found in violation of the Policy may be subject
to disciplinary action, following administrative findings or adjudication. The resident may
receive disciplinary actions or consequences for sexual abuse. During the past 12 months, an
investigation did not determine that there had been an incident of resident-on-resident sexual
abuse.
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Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy, residents who disclose a history of sexual abuse or who
disclose previously perpetrating sexual abuse will be offered a follow-up meeting with a
medical or mental health practitioner within 14 days of the intake screening. Staff
interviewed confirmed the practice that supports compliance with the standard.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy addresses timely and unimpeded access to emergency medical treatment
and crisis intervention services for victims of sexual abuse. Interviews supported that the
nature and scope of the services are determined by medical and mental health practitioners
according to their professional judgment.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for ongoing medical and mental health care for sexual abuse
victims. It also provides for medical and mental health evaluations and appropriate treatment
in accordance with the standard. Staff interviews and a review of documentation confirmed
that the standard of health care is consistent with the community level of care.
17
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides information regarding staff conducting incident reviews. The
Policy details the requirements of the standard and states that the incident review will occur
within 30 days of the conclusion of the investigation. The incident review team has been
identified. Staff interviews indicated familiarity with the role of the incident review team
regarding incidents of sexual abuse. Documentation shows that the practice is in accordance
with the PREA Policy regarding incident reviews following investigations and that the time
frame has been adhered to.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 require the collection of accurate, uniform data for every
allegation of sexual abuse. The facility’s agency uses a system called TRENDSTAT for their
facilities to collect, analyze and submit monthly data to the corporate leadership team. The
agency and FDJJ have developed a data collection instrument that includes pertinent data.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 provide for analyzing the data to identify trends and/or
problem areas and to develop corrective actions where indicated. The Policies require the
review of data with the goal of improving the effectiveness of the agencies’ PREA initiatives
in the areas of prevention; protection and response policies; practices; and training.
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Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 require that data is collected and securely retained for 10
years, unless otherwise required by law. The aggregated PREA data is reviewed and all
personal identifiers are removed. Related reports are posted on the agencies’ websites.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
May 24, 2015
Auditor Signature Date
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report_type: PREA