facility_name: oydc oycc

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Okeechobee Youth Development Center/Correctional Center
Physical Address: 7200 Highway 41 North, Okeechobee, FL 34972
Date report submitted: April 20, 2016
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: March 22-23, 2016
Facility Information
Facility Mailing Address: 7200 Highway 41 North, Okeechobee, FL 34972
Telephone Number: 863-763-2174
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention X Corrections Other: Residential
Name of PREA Compliance Manager: Todd Johnson Title: Facility Administrator
Email Address: todd.johnson@us.g4s.com Telephone Number:
863-763-2174
Agency Information
Name of Agency: G4S Youth Services
Governing Authority or
Parent Agency:
Physical Address: 6302 Benjamin Road, Suite 400, Tampa, FL 33634
Mailing Address: Same as Physical Address
Telephone Number: 813-514-6275
Agency Chief Executive Officer
Name: James C. Hill, Jr. Title: President
Email Address: jim.hill@us.g4s.com Telephone Number: 8 1 3 - 5 1 4 - 6 2 7 5
Agency Wide PREA Coordinator
Name: Bobbi Pohlman-Rodgers Title: Senior Director of JJDPA/PREA Compliance
954-818-5131
Email Address: bobbi.pohlman@us.g4s.com Telephone Number:
1
AUDIT FINDINGS
NARRATIVE:
The Okeechobee Youth Development Center (OYDC)/Correctional Center (CC) is a 50-bed
program unit for male juvenile offenders who have been committed to the Florida Department of
Juvenile Justice (FDJJ). The facility is located in Okeechobee, Florida and is operated by G4S
Youth Services through a contract with FDJJ. The program is located on a large campus occupied
by two other program units under the leadership of a Facility Administrator and an Assistant Facility
Administrator. The daily operations of each program unit are managed by a Program Director. This
program unit is comprised of two sections, OYDC and CC (OYDC/CC). The OYDC is a behavioral
and mental health treatment program that serves residents ages 13 to 21 who are classified as high
risk and the length of stay is nine to 12 months. The CC is a highly structured program for residents
classified as maximum risk and serves ages 13 to 21; the length of stay is 18-36 months.
The program unit offers mental health overlay services; substance abuse prevention and counseling;
case management services; life and social skills training; education/vocational services; release and
transition planning; and recreation and leisure time activities. Both program unit components also
provide psychotherapeutic services that include individual, group and family counseling; cognitive
skills training; and relapse prevention training. Medical and mental health screenings are conducted
during the intake process and on-going clinical services are provided throughout the resident’s stay
in the program unit.
Medical services are provided campus wide by the Health Services Administrator and other
Registered Nurses. The physician who is also the Designated Heath Authority visits the campus
weekly. Mental health services are under the leadership of the Director of Treatment Services. A
Therapist is assigned to each resident and provides daily group therapy services as well as individual
and family counseling sessions. A consulting psychiatrist visits the campus weekly and there are
additional contractors that provide support services. Education services are provided through a
contract with the Washington County School District. Each resident is also assigned a case manager
who also serves as the primary contact person to individuals outside of the program that are involved
in the resident’s care.
An individualized treatment plan and goals are developed for each resident based on their identified
needs. A behavior management system exists where a resident may earn advancing levels through
earning points for demonstrating positive behavior. The system is designed to address immediate,
short-term and long-term behavior and supports the treatment plan. Incentives increase as the
resident progresses through each level. The expectations of the resident are increased as he advances
to each level of the system.
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DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is maintained within additional security fencing on the campus where secured care is
provided. One building serves as the housing unit with three halls; two halls contain 17 rooms and
one hall contains 16 rooms. The three living units extend from a control room where there is a view
of all three halls. There are two cells that are used as a temporary measure for controlled observation
that provides residents with the opportunity to gain control of out of control behavior. A Therapist
and a Case Manager are located on each hall. The school building is across from the living unit.
Another building is the administration building where a reception area and offices are located. The
dining hall building is used for meals and it also contains the general store where items may be
purchased with the points earned through the behavior management system.
There is ample space for outside recreation and other activities. The yard includes a half court and
full court area for basketball and a covered pavilion. The procedures and practices provide residents
with a reasonable amount of privacy during showers, while using the toilet, and when changing
clothes. PREA related information is posted in various areas of the program unit and policy and
practice provide the residents with access to telephones for reporting allegations of sexual abuse. The
designed program capacity is 50 and there were 49 residents in the facility during the site visit. The
total number of residents admitted to the program unit during the past 12 months whose length of
stay was for 72 hours or more is 17 for the OYDC and 54 for the CC. The number of staff employed
in the program unit during the past 12 months who may have contact with residents is 52.
SUMMARY OF AUDIT FINDINGS:
An introductory telephone conference call was held prior to the site visit and the audit process was
discussed with facility staff and the FDJJ statewide PREA Coordinator. The notifications of the site
visit were posted in the facility prior to the site visit and pictures of the postings were forwarded to
this Auditor and the locations of the postings were identified. The Pre-Audit Questionnaire was
uploaded to a flash drive with policies and supporting documentation and was received prior to the
site visit. There was follow-up communication with the Program Director for this program unit, who
was also responsible for the data gathering for the other two PREA audits on campus. The Program
Director provided additional documentation as requested and information was clarified as needed.
The Facility Administrator serves as the PREA Compliance Manager; however, due to his absence,
the Assistant Facility Administrator was serving as the Acting Facility Administrator/PREA
Compliance Manager during this time period.
The site visit was conducted March 22-23, 2016 with the introductions and tour of the program unit
occurring on the afternoon of March 22nd. A tour was conducted by the Program Director,
accompanied by the Program Directors from the other two program units located on the campus.
During the tour, staff members were observed to be involved with the residents, providing direct
supervision. Randomly selected residents; randomly selected direct care staff members from all
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shifts; specialized staff members; and a contractor were interviewed. During the site visit,
additional documentation was provided as requested. A close-out meeting was held at the
conclusion of the site visit with the OYDC/CC Program Director and the Assistant Facility
Administrator. The G4S Senior Regional Director was present on campus during the site visit.
Number of standards exceeded: 0
Number of standards met: 37
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:
Facility Policy 10-25, Prison Rape Elimination Act (PREA), and Policy 1919 of the Florida
Department of Juvenile Justice (FDJJ 1919) are aligned and jointly serve as the guidelines and
strategies for staff regarding the application of the PREA standards. The PREA Policy
provides that the program unit is contractually obligated to adopt and comply with the PREA
standards outlined in FDJJ 1919. The policies include the zero-tolerance approach for the
implementation of the PREA standards regarding all forms of sexual abuse and sexual
harassment. The Policies contain definitions of prohibited behaviors and sanctions for those
found to have participated in the prohibited behaviors.
Policy 10-25 states that the Facility Administrator or a person designated by the G4S Regional
Director serves as the PREA Compliance Manager. The interview with the Assistant Facility
Administrator and a review of the organizational chart confirmed that the Facility
Administrator manages the facility and serves as the PREA Compliance Manager. The
Assistant Facility Administrator stated that there is sufficient time and authority to implement
and coordinate the activities related to PREA compliance. The Facility Administrator reports
to the G4S Senior Regional Director.
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)
Auditor Comments:
This standard is not applicable. The facility does not contract with other facilities for the
confinement of its residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 10-25 and 10-8 and management review of the shift schedules ensure adequate levels
of staffing for all shifts. Based on the Shift Briefing Reports, Shift Supervisor Reports, staff
interviews, and observations, the staffing ratio is maintained according to the ratio of 1:8
during the waking hours and 1:12 during the sleeping hours. The campus has a hold-over
process that ensures adherence to the ratios and the program unit reports no deviations from
the staffing plan. The facility reports that the average daily number of residents is 50 and that
the average daily number of residents on which the staffing plan was predicated is also 50.
A Staffing Plan Assessment was reviewed which was completed by the FDJJ statewide
PREA Coordinator and includes a review of the items listed in the standard and other related
areas. The Staffing Plan Assessment contains a review of the shift staffing ratios; staffing
patterns; deployment of cameras; documentation of unannounced rounds; and observations
during the completion of the assessment.
Policy 10-25 provides that the Administrative Duty Officer conducts unannounced rounds at
least once a month and that the visits are documented. Unannounced rounds are completed
and documented by the Assistant Facility Administrator. The documentation provides for the
notation of related concerns and any observations that would be classified as a risk. A review
of documentation and an interview with the Assistant Facility Administrator confirmed that
unannounced rounds occur. The Shift Supervisors conduct unannounced rounds during their
shifts and document such rounds on the Shift Briefing Report. The PREA Policies prohibit
staff from alerting other staff of the occurrence of the unannounced visits and the practices
exercised by the Assistant Facility Administrator support the Policies.
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:
Based on interviews with staff and residents it was determined that cross-gender pat-down
searches and cross-gender strip searches are not conducted in the program unit, in accordance
with Policy 10-3. The Policy addresses staff conducting searches of residents and provides the
details of each type search and requires documentation of the searches. The practice is that
females do not search males; however, Policy 10-3 provides that a female staff may assist
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a male staff by acting as a second person in the search area, observing the staff, while not
viewing the resident. The Policy requires that in these circumstances, the reason for the
opposite gender assistance must be authorized by the Facility Administrator and the reason for
the search documented.
Staff interviews revealed that training and discussions regarding the searches of all residents
include that they are done in a professional and respectful manner as also directed in policy.
The search of a transgender or intersex resident will be referred to medical. Direct care staff
interviews and a Nurse interview indicated that they are aware of the requirement of Policy 8-
14, where transgender or intersex residents are not to be searched or physically examined for
the sole purpose of determining their genital status and that no such searches occurred during
this audit period.
Observations and resident and staff interviews are in accordance with Policy 10-25 in that
residents are able to shower, use the toilet, and change clothes without being directly viewed
by staff and that female staff members do not supervise those activities. All residents and staff
interviewed confirmed that female staff members announce their presence when entering the
living units.
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:
Policy 10-25 ensures that disabled residents are provided equal opportunity to participate in or
benefit from resident education to protect them from sexual abuse and sexual harassment.
Policies 10-25 and FDJJ 1919 require that residents are not to be used as interpreters or
readers, unless in limited circumstances where an extended delay in obtaining an interpreter
could compromise safety, first responder duties, or the investigation. Staff may use the
Registry of Certified Court Interpreters as a resource, as well as other G4S staff members who
may serve as interpreters. The facility provides an extensive list of internal interpreters which
identifies the G4S facility the staff member works in and other contact information as well as
the language for which they may provide interpreter services.
Other staff members may be used as interpreters, according to the staff interviewed, or outside
contacts would be made to obtain assistance. Staff also reported that residents are not used as
interpreters for other residents. The list for the external interpreters, Registry of Certified Court
Interpreters, is composed of several pages that contain the contact information as well as the
language specialty. Contact information for American Sign Language interpreters is also
included in the lists of external interpreters. The lists of interpreters is available to shift
supervisors.
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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:
Policies 3-16 and FDJJ 1919 address hiring or promoting anyone who has engaged in sexual
abuse in a jail, lockup or similar facility; has been convicted of engaging or attempting to
engage in coerced or forced sexual activity; or has been adjudicated for any of the
aforementioned activities. The Policies prohibit hiring, promoting or contracting with anyone
who has been convicted of engaging in any prohibited activities and the Policies provide
directions regarding background checks and screenings. Any incident of sexual harassment is
considered regarding the hiring or promotion of an employee.
The interview with the Regional Human Resource Manager and a review of a sample of
personnel files confirmed the practices that are aligned with the agency personnel policies.
There was confirmation by the Regional Human Resource Manager that it is the employee’s
continuous duty to disclose any related misconduct. The review of the personnel documents
revealed that they include background checks; signed acknowledgement forms regarding
PREA related information and information received. The staff interview also revealed that
hiring and promotion decisions are based on background information obtained and according
to the considerations required by the policies and standards. Documents show that employees
receive a background re-screening every five years as required. The policies and facility
practice provide that the omission of information regarding misconduct is grounds for
termination of employment.
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)
Auditor Comments:
The program unit reports no substantial expansion since August 20, 2012 and the
camera system has not been enhanced.
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:
Policies 10-25 and FDJJ 1919 and staff interviews provide that the facility is not responsible
for conducting administrative or criminal investigations. The Office of the Inspector General
conducts administrative investigations; the Department of Children and Families is
responsible for conducting allegations of child abuse; and the Okeechobee County Sheriff’s
Office is responsible for conducting criminal investigations. The Assistant Facility
Administrator is familiar with and has the FDJJ written document that contains information
regarding PREA related investigations and comprehensive uniform evidence protocols that is
to be shared with investigators regarding allegations that appear to be criminal in nature.
The provision of victim advocacy services has been arranged and the services are no cost to
the victim. The facility has entered into a written agreement, Memorandum of Understanding
(MOU), with the Sexual Assault Assistance Program of the Treasure Coast. Services agreed
to be provided are aligned with the PREA standards and include but are not limited to
forensic examinations conducted by a Sexual Assault Nurse Examiner; access to a 24/7
hotline; confidential emotional support services; referral information; and follow-up
directives for follow-up treatment after the resident’s return to the campus. The MOU
provides that a victim advocate will accompany the victim through the forensic medical
examination, conducted at the Raulerson Hospital emergency room.
A telephone interview with the Victim Services Director for the State Attorney’s Office and
the Sexual Assault Assistance Program of the Treasure Coast confirmed the contents of the
MOU. There was also confirmation that services would include access to a Sexual Assault
Nurse Examiner for a forensic examination when requested. The Sexual Assault Assistance
Program of the Treasure Coast provides the facility with posters and literature which were
observed on campus during the site visit. 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:
Policies 10-25, FDJJ 1919, and FDJJ 2020 and staff interviews confirm that an administrative
or criminal investigation would be completed for all allegations of sexual abuse and sexual
harassment. The Policies identify the agency responsible for conducting the criminal and
administrative investigations and instructs staff to cooperate with investigations. Interviews
with staff confirmed their awareness of the policies, including that all referrals of allegations
for investigations are documented. The Office of Inspector General follows unit specific
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policy in conducting administrative investigations. There was one allegation made in 2014
and the administrative investigation was completed in the last 12 months. There were two
allegations during the past 12 months where one received an administrative and criminal
investigation and the other was an administrative investigation. Investigative reports and a
review provided by the Senior Regional Director indicate staff members’ cooperation with
the administrative and criminal investigations.
Through posted information, the campus provides parents/guardians and visitors with
information on how to report allegations of sexual abuse and sexual harassment allegations.
The Parent Handbook is provided to each parent or guardian and identifies the staff who will
notify them with an update regarding specific situations regarding their child, including
emergency room visits; physical altercations with staff or other residents; and allegations of
staff misconduct. Review of investigative and related reports show the notification of
parent/guardian regarding an allegation of staff misconduct. The Florida Department of
Juvenile Justice‘s website contains the policy regarding reporting allegations of sexual abuse
and sexual harassment.
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)
Auditor Comments:
Policies 5-1 and 5-2 provide guidance regarding employee training. Staff interviews and a
review of the Staff Development and Training-SkillPro electronic records and training
materials confirmed initial and refresher training regarding PREA. The training is tailored to
the needs of the population served. Florida DJJ provides the on-line training through the
SkillPro system and G4S provides supplemental training, including updates regarding
specific areas of the standards. A staff training unit is located on the campus within the
administrative building that serves the entire campus. A training class was in progress during
the site visit. Staff meetings are also used to share and review PREA and other information.
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)
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Auditor Comments:
Policy FDJJ 1919 and the review of training documents and the FDJJ training guide for
training sessions for volunteers and contractors provide for the compliance of this standard.
Documentation in the personnel files show that contractors receive training on their
responsibilities regarding the zero-tolerance of sexual assault and sexual harassment and how
to report any allegations or incidents. Additionally, the training roster for volunteers and the
education contractors confirm that the training occurs. The training guide used for contractors
and volunteers was also reviewed. Interviews with the Regional Human Resource Manager,
Principal and Program Director support that contractors and volunteers receive the
appropriate PREA related training.
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:
Policy 10-25 and a review of documentation acknowledging resident participation in PREA
education sessions document that residents are provided age-appropriate PREA information.
All residents receive PREA education regardless if they are transferring from another facility
or are a new admission.
The Policy addresses retaliation if a resident should report an allegation from a former facility
or this program unit. Interviews with a Case Manager and residents confirmed PREA
education during the intake process and refresher sessions. A checklist is completed for each
new admission and it includes the notation for PREA education to be checked off. The Case
Manager shared that she also ensures that each resident receives the information by
conducting or coordinating reviews twice a month.
During the resident interviews it was noted that the residents were not really familiar with the
services provided by the Sexual Assault Assistance Program of the Treasure Coast and their
confidentiality practice. A corrective action plan was developed during the site visit and has
since been implemented resulting in an update that included the specific information
regarding the services of the rape crisis center. The documented training, including where
residents had written their names was submitted.
Staff members may assist with the PREA education for residents that are limited English
proficient, visually impaired or otherwise disabled, or have limited reading skills. Additional
support services may be obtained from the Registry of Certified Court Interpreters, Florida
Registry of Interpreters for the Deaf, and staff members that work at other G4S facilities. The
PREA information is posted within the program unit and residents are provided a Youth
Handbook that contains information for reporting allegations.
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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)
Auditor Comments:
The facility staff members do not conduct administrative or criminal investigations. Staff
interviews confirmed that they are aware of the investigative agencies responsible for
investigating PREA related allegations. Florida DJJ Policy addresses the training of the Office
of the Inspector General Investigators, including the related policies and procedures regarding
the handling of sexual misconduct incidents and reports. Training is provided to investigative
staff regarding conducting investigations in FDJJ settings. Campus management has been
provided the information sheet, disseminated by FDJJ, regarding appropriate protocols for
PREA investigations for sharing with local law enforcement investigators.
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:
The medical and mental health staff members have received the training developed for their
particular area, as well as the general PREA training. The specialized training is developed
by FDJJ and is accessible to medical and mental health staffs online and is documented
through the Staff Development & Training SkillPro System. Prior to and during the site visit,
some staff had not completed the specialty training modules. A corrective action plan was
agreed upon on site and later implemented resulting in all required staff members completing
the specialized training modules. The training documents have been reviewed to confirm
completion of the training. The medical staff does not conduct forensic 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)
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Auditor Comments:
Policies 9-1, 9-3, 10-25, 8-14, and FDJJ 1919 ensure that all youth admitted to the facility are
properly screened. Staff and resident interviews, Policies 10-25 and FDJJ 1919, and a review
of documentation confirmed that screenings include that residents are also screened for risk
of victimization and abusiveness. This vulnerability screening occurs within 24 hours of
intake, whether the youth is transferred from another facility or is a new admission. The
screening is conducted using the FDJJ objective instrument, Screening for Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB). The information obtained from
the VSAB is aligned with what is required by the standard, including but not limited to prior
sexual victimization or abusiveness; the youth’s self-identification; current charges; offense
history; and intellectual or developmental disabilities. The residents and a Therapist
responsible for administering this screening stated that it is done the same day of admission
and a review of VSABs confirmed the practice.
An interview with a Therapist who administers the VSAB revealed that information is
obtained from the resident, parent/guardian and related paperwork. The Therapist stated that
the administering of the VSAB is treated like a conversation; also, questions are asked and
probing is done where needed. Additional screening and assessment tools are used to obtain
information to aid staff in meeting the individual needs of the residents. According to the
Therapist, the information from the VSAB is accessible to the medical and mental health
staffs and information is communicated on a need to know basis. The files were observed to
be maintained in an orderly and confidential manner. The residents interviewed were able to
identify specific areas that are inquired about through the administration of the VSAB and
they stated that similar questions related to safety are asked periodically by their Therapist,
Case Manager and other staff.
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)
Auditor Comments:
Policies 8-14, 9-3 and FDJJ 1919 provide guidance to staff regarding the information from
the VSAB and other risk screening instruments and outline how the information is to be used.
The information gleaned from the VSAB and other screening instruments is used in the
overall classification of the resident, assisting staff in determining bed, education and other
program assignments with the goal of keeping all residents safe and based on their individual
needs.
There has not been a resident placed in administrative isolation or controlled observation
during this audit period due to concern for their safety from sexual assault. The controlled
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observation rooms will not be used for protective custody regarding the risk of sexual abuse
but may be used for brief periods for a resident to calm down and re-gain control of acting-
out behavior. According to Policy 10-14, control observation may be used in response to a
dangerous crisis situation when staff cannot control highly aggressive and violent behavior
with less restrictive measures, or when less restrictive measures are inappropriate.
Placing lesbian, bisexual, transgender, or intersex residents in specific housing or making
other assignments solely based on how the residents identify or their status is prohibited by
Policy 8-14. It also prohibits staff from considering the identification as an indicator that the
resident may be sexually abusive. The interviews conducted with staff indicated that housing
and program assignments for transgender or intersex residents will be made on a case-by-case
basis in accordance with Policy 8-14.
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:
Policies 8-3, 10-25 and FDJJ 1919 provide multiple internal ways a resident may report,
including how a report may be made privately regarding sexual abuse and sexual harassment;
retaliation for reporting; and staff neglect or violations of responsibilities that may lead to the
aforementioned. Residents may report allegations of sexual abuse or sexual harassment
through access to the FDJJ abuse hotline and the abuse hotline for the victim advocacy
agency. Staff may also use the abuse hotline to privately report sexual abuse and sexual
harassment of residents.
Resident and staff interviews revealed other identified methods a resident may report
allegations of sexual abuse or sexual harassment. The internal methods a resident may report
include completion of a Let’s Talk form requesting to speak to a specific staff member;
completion of a grievance form; talk to any staff member; completion a Sick Call Request
form; and third parties may report allegations. Access to writing tools is provided for
residents so that they are able to complete the forms.
The interviews conducted with staff and residents also revealed that they are aware of the
policies regarding accepting reports of allegations of sexual abuse and sexual harassment that
are made verbally, in writing, anonymously, and by third-parties. All residents interviewed
stated that they have contact with someone who does not work at the facility that they could
report abuse to, if needed. A review of investigative reports indicates that an allegation was
reported anonymously and received an administrative investigation by the Office of Inspector
General.
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Policies and staff interviews provide that staff members are required to document verbal
reports and to report the information immediately to their supervisor which is reported up the
chain and relayed to the Central Communications Center and the appropriate investigating
entity. Staff receives this information on how to report sexual abuse or sexual harassment
through policies and procedures, training, meetings, and posted information.
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:
FDJJ 1919 and facility practice provide that grievances regarding sexual abuse or sexual
harassment may be completed and submitted at any time. The resident is not required to
handle a grievance informally by attempting to resolve the situation with staff. During the
past 12 months, there has not been a grievance submitted alleging sexual abuse. The
residents and staff stated that an allegation may be reported by completing a grievance form.
A grievance alleging sexual abuse would be immediately provided to the Facility
Administrator and the procedures for reporting allegations of sexual abuse would be
initiated. The grievance system does not include a process for facility staff to investigate or
resolve allegations of sexual abuse. The content of the grievance is reported and an
investigation will be conducted by the Office of Inspector General, Florida Department of
Children and Families and/or the Okeechobee County Sheriff’s Office.
Policy 10-25 and FDJJ policy direct staff on reporting sexual abuse and sexual harassment of
residents. A review of investigative reports indicated allegations that were reported by
another staff member as required by Policy. The Policy also provides that a resident may be
disciplined when it has been determined that any report alleging sexual abuse has been made
in bad faith. Residents understand, through the PREA education received, that they will not
be punished if a report is made in good faith.
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)
15
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 10-25 requires that the Facility Administrator ensures accessibility of residents to an
outside victim advocacy agency for emotional support services. A Memorandum of
Understanding (MOU) for the provision of victim support services has been completed and
signed. The details of the services had not yet been thoroughly reviewed with the residents
prior to the site visit. A corrective action was implemented after the site visit and a PREA
education session was conducted with all residents receiving additional information about the
specific services and the confidentiality practices of the victim advocacy agency. A roster of
the residents, where they had printed and signed their names, was submitted to the auditor.
The information for reporting sexual abuse was observed on postings in the facility which
included how to contact the advocacy agency for services. Services to be provided that are
contained in the MOU were confirmed through a telephone interview with the Victim
Services Director for the State Attorney’s Office and the Sexual Assault Assistance Program
of the Treasure Coast. In addition to other support services, the agency will provide residents
with an advocate to be present during the forensic examination and provide a Sexual Assault
Nurse Examiner to conduct the examination at the Raulerson Hospital emergency room.
According to policy and residents’ interviews, the program unit provides residents with
reasonable and confidential access to attorneys or Probation Officers. A review of Policy,
Youth Handbook, and other documentation and according to resident interviews, reasonable
access to parents or legal guardians is provided. The residents interviewed were aware of the
visitation days, weekly phone calls, and Family Day activities.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 8-3 and 10-25 address third-party reporting and interviews revealed that residents are
aware that third-party reporting of sexual abuse and sexual harassment can be done. All
residents interviewed stated that they knew someone who did not work at the facility that they
could report to regarding allegations of sexual abuse and that the third-party could report the
allegations for them to be investigated. Staff interviews revealed their knowledge of third-
party reporting and that they can receive allegations from third-parties. Information regarding
reporting allegations is provided through observed postings that are located in areas of the
campus that are accessible to visitors, residents and staff members. The FDJJ website contains
information regarding third-party reporting.
16
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:
Policies 8-3, 10-25 and FDJJ 1919 provide that all staff immediately report any knowledge,
suspicion, or information regarding an incident of sexual abuse, sexual harassment or incidents
of retaliation. Staff members are instructed to immediately report all allegations of sexual
abuse or sexual harassment to their immediate supervisor and the supervisors and management
are to ensure the report to the Central Communications Center (CCC) and investigative entities
as appropriate.
Policy 10-25 prohibits staff from revealing any related information to anyone other than to the
extent necessary to make treatment, investigation, and other security and management
decisions. The CCC will make appropriate notifications to senior FDJJ management who will
make notification to management overseeing the facility where the alleged abuse occurred.
Policy 10-25 requires the Facility Administrator to notify the alleged victim’s parents or legal
guardians. If the resident is under DCF Custody, the Case Worker will be notified and if
applicable, the attorney of record will be notified of the allegation within 14 days of receipt of
the allegation, according to the Policy. A review of investigative and related reports indicates
notification of the parent/guardian.
Interviews with management, direct care, mental health, and medical staffs revealed that they
are aware of the requirements regarding their reporting duties and understand that they are
mandated reporters. According to interviews with clinical staffs and document review, the
residents are informed at the initiation of services of the limitations of confidentiality and the
clinical staff’s duty to report.
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:
Policies 10-25 and FDJJ 1919 instruct staff to take immediate action to keep residents safe
when they learn there is substantial risk of an imminent threat of sexual abuse. Interviews with
staff confirmed their knowledge of this policy and they were able to identify steps they would
take to protect residents who are at substantial risk of imminent sexual abuse. The steps
17
identified included immediately separating the residents, implementing one-on-one staff
supervision; and alerting shift supervisor for further instruction. Residents indicated that
during the intake process, there was discussion about their feelings concerning their own
safety and that their safety is discussed during treatment meetings.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Upon receiving an allegation that a resident was sexually abused while confined at another
facility, the Facility Administrator must notify the head of that facility where the alleged abuse
occurred, according to FDJJ 1919. Notification must be made as soon as possible but no later
than 72 hours after receipt of the allegation. The Facility Administrator must also notify the
Central Communications Center to report the incident for an investigation. The facility reports
that during this audit period, there has not been a report about an incident of abuse occurring
while the resident was confined in another facility. The Assistant Facility Administrator is
aware of the policy regarding reporting to other confinement facilities and the requirement that
allegations received from other facilities must be investigated.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 10-25 outlines the first responder duties which are generally to separate the victim
from the abuser; preserve and protect the scene; and request that the alleged victim does not
take any action that would destroy physical evidence. Initial training and refresher training
and updates are conducted with staff through a combination of online statewide training and
training conducted on campus. Staff interviews revealed that they are aware of the steps to
take if they are the first responder to an alleged incident. FDJJ 1919 directs that if the
employee first responder is not direct care staff, they should request that physical evidence is
preserved and direct care staff should be notified.
18
During the past 12 months there were three investigations completed for this program unit.
One administrative investigation was substantiated for sexual misconduct. Allegations from
that same incident were also investigated by the Okeechobee Sheriff’s Office and judicial
proceedings are pending. This was not an incident that involved first responder duties or the
collection of physical evidence.
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 has a written institutional plan, Sexual Abuse Incident Coordinated Response
Plan, which outlines the coordinated actions of the various identified staff such as the first
responder, supervisors, medical, mental health, and management staffs. This coordinated
response to an incident of sexual abuse is also aligned with FDJJ 1919. The staff members that
were interviewed are familiar with their role regarding the response to and the reporting of an
alleged incident of sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents From Contact With Abusers.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
This standard is not applicable. The facility does not maintain collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 10-25 and FDJJ 1919 provide protection to residents and staff from retaliation. The
retaliation monitor has been identified as the Assistant Facility Administrator. An interview
19
revealed an understanding of observing for whether or not retaliation occurs after a resident or
staff reports allegations of sexual abuse or cooperates with an investigation. The items
mentioned in the interview that would be monitored were aligned with the standard and Policy
such as observations; reviewing reports, including Let’s Talk and grievance forms; and room
changes. The program unit reports that there has not been an incident of retaliation during the
past 12 months.
Three investigations were completed during the past 12 months. The investigative findings for
one report that was made anonymously resulted in the allegations being unfounded. The other
two reports involved the same staff member. One investigation substantiated findings of
sexual misconduct by the staff as the results of an administrative investigation. The second
report regarding two allegations against that same staff member were made by a different
resident after his placement in another program and those administrative findings were
unfounded and unsubstantiated.
After the first allegation was made against the staff, the staff member was placed on no contact
status regarding residents and was suspended pending the outcome of the investigations by the
Office of Inspector General and the Okeechobee Sheriff’s Office. Subsequently the staff
member was terminated as a result of the administrative investigation. The staff member was
later arrested, as a result of the criminal investigation, and prosecution is pending regarding
allegations of sexual abuse. The incident review report documents that the resident, who has
since been released, received individual therapy by mental health staff and was assisted in
processing the incident.
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)
Auditor Comments:
This standard is not applicable. Segregated housing is not used at this facility for residents who
allege or would have suffered sexual abuse.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
20
Auditor Comments:
Policies 10-25 and FDJJ 1919 and staff interviews provide that administrative investigations
are conducted by the Office of the Inspector General and criminal investigations are
conducted by the Okeechobee County Sheriff’s Office. The Department of Children and
Families (DCF) are also called when there is an allegation of sexual abuse. The Policies direct
facility staff to cooperate with investigations and FDJJ 1919 further provides that an
investigation is not terminated because the source recants the allegation. The Assistant
Facility Administrator is familiar with the Policies. A review of the investigative reports and
related documents show the contacts made as prescribed by policies, such as the Central
Communications Center, parents, DCF, and local law enforcement where the allegations are
criminal in nature.
The Office of Inspector General follows protocols in conducting administrative investigations
in FDJJ settings and the investigators receive training on the related policies. The Assistant
Facility Administrator maintains the information sheet developed by FDJJ that is to be given
to the law enforcement investigator. The information sheet provides law enforcement
investigators with the expected protocols related to PREA investigations that are criminal in
nature. The documentation reviewed shows that allegations that are criminal in nature are
investigated by local law enforcement and that that substantiated allegations are referred for
prosecution. The case that was substantiated for sexual abuse by the Okeechobee Sheriff’s
Office is pending judicial proceedings. The Senior Regional Director remains abreast of the
case through periodic status checks.
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 policy and practice of the Office of Inspector General, responsible for administrative
investigations, impose a standard of a preponderance of the evidence for determining whether
allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
21
Auditor Comments:
FDJJ 1919 provides that the victim is informed when the investigation is completed and
Policy 10-25 provides that the Facility Administrator notifies the victim or victim’s parents or
legal guardians. The Policies also state that the victim must be informed of the findings and
the outcome of the staff or resident perpetrator as outlined in the standard and the Policies
when the investigative findings are substantiated or unsubstantiated. There have not been any
investigations regarding resident-on-resident abuse during the past 12 months.
One report of allegations of sexual abuse was investigated by both the Office of Inspector
General (OIG) and the Okeechobee County Sheriff’s Office. The OIG investigation
determined that the allegations were substantiated as sexual misconduct and the Sheriff’s
Office investigation concluded that there was enough evidence to charge the staff member
regarding the allegation of sexual abuse. The resident was informed of the results of the
investigations and was provided individual therapy as a result of the incident. Judicial
proceedings are still pending for the former employee. The Senior Regional Director
periodically conducts status checks with the Okeechobee Sheriff’s Office for updates
regarding the case. There was another administrative investigation conducted regarding the
same staff member with the findings of unfounded and unsubstantiated. Those allegations
against the staff member were made by a resident who had been released and was in another
placement when the allegations were made. The staff member had been terminated and
arrested when these allegations were made.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 3-3 provides for disciplinary sanctions, up to and including termination for those staff
that violate the facility’s sexual abuse and sexual harassment zero-tolerance policy. Policy
supports that disciplinary sanctions for violations of agency policies relating to sexual abuse,
other than actually engaging in the act, and sexual harassment are appropriate to the
circumstances of the incident, staff’s disciplinary history, and the sanctions for similar cases of
other staff. Policies provide that terminations or resignations by staff that would have been
terminated if not for their resignation are reported to law enforcement if the situation appears
to be criminal in nature and to relevant licensing bodies. Management staff is aware of the
related policies. The facility reports that during this audit period, one staff member violated
policy. The staff member was suspended after the allegation was made and subsequently
terminated after the completion of the administrative investigation. As a result of the criminal
investigation, the former employee was arrested and legal proceedings are pending.
22
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:
FDJJ 1919 addresses this standard, including requiring that any contractor or volunteer who
engages in sexual abuse be prohibited from contact with residents. It also provides that
contractors and volunteers who engage in sexual abuse are reported to law enforcement and to
relevant licensing bodies. Policy 10-25 prohibits sexual activity between residents and
volunteers and contract personnel. There is documentation that supports that PREA training
is provided to contractors and volunteers through acknowledgement forms and training
rosters. During this audit period, there have been no allegations of sexual assault or sexual
harassment regarding a contractor or volunteer.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 8-1 and FDJJ 1919 provide that an administrative process is in place for dealing with
violations, including resident-on-resident sexual abuse. Policy 8-1 and staff interviews support
that the formal process holds the residents accountable for their actions. A resident may also
be referred to law enforcement for charges and possible removal from the facility regarding
resident-on-resident abuse. Sexual activity between residents is prohibited and court or
administrative processes and sanctions occur when it has been determined that the sexual
activity was coerced. There have not been allegations of resident-on-resident abuse reported
in the past 12 months. According to Policy, residents would be disciplined for sexual contact
with staff only when it has been determined that the staff member did not consent to the sexual
contact. Disciplinary isolation is not used in the program unit.
Policy 10-25 states that anyone reporting in good faith shall be immune from any civil or
criminal liability. Policies 10-25 and FDJJ 1919 and interviews with mental health and
medical staffs support that counseling or other interventions will be offered to address and
correct the underlying reasons or motivations where required. Any type interventions or
treatment services provided would not be dependent on the resident’s participation in the
behavior management system, education or other programs. Mental health services were
provided to a resident regarding an allegation against staff while in the facility. The resident
was involved in therapy sessions with his Therapist.
23
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:
Policies 7-30, 10-25, and FDJJ 1919 address this standard, including providing for a follow-up
meeting with a medical or mental health practitioner within 14 days when the resident
discloses any prior incidents of sexual abuse whether victim or perpetrator. The practice is
that all residents are seen by medical and mental health staffs on the same day of admission.
Interviews with medical and mental health staffs and a review of documentation support that
residents are seen on the same day of admission as part of the intake process. Additionally, a
Therapist is assigned to each hall in the housing unit and conduct individual, group and family
sessions with each resident.
Policy supports that information related to sexual victimization or abusiveness that occurred in
an institutional setting is limited to medical and mental health practitioners and those staff,
based on their need to know. A review of files show that medical and mental health staff
members maintain documentation of the services they provide to the residents. Medical and
mental health staffs discussed their knowledge of informed consent, in accordance with policy.
Residents who are 18 years and older sign a different informed consent form.
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:
Policies 7-30, 10.25 and FDJJ 1919; staff interviews; and current practices revealed that
emergency medical care and crisis intervention services will be provided by medical and
mental health staffs as determined by health care staff. Processes and services are in place for
a sexual abuse victim to receive timely access to sexually transmitted infections prophylaxis,
where medically appropriate. Forensic examinations will be conducted at the Raulerson
Hospital emergency room by a Sexual Assault Nurse Examiner provided by the Sexual
Assault Assistance Program of the Treasure Coast.
A review of files indicate that medical and mental health staff members maintain secondary
materials that document services to residents and these staffs are knowledgeable of what must
occur in an incident of sexual abuse. It is documented through policies and understood by the
medical and mental health staffs that treatment services will be provided at no cost to the
24
victim; whether or not the victim names the abuser; or whether or not the victim cooperates
with the investigation. The interviews with the Health Services Administrator and the Director
of Treatment Services revealed that residents would have access to unimpeded access to
emergency services and that medical and mental health services are determined 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:
Policies 10-25 and 7-30 and interviews with medical and mental health staff members
confirmed that on-going medical and mental health care will be provided for sexual abuse
victims and resident abusers, as appropriate. The Health Services Administrator and the
Director of Treatment Services were able to articulate the follow-up care that would be
provided at the facility.
Policy 10-25, staff interviews, document review, and observations revealed that medical and
mental health services are consistent with the community level of care. Policies and interviews
demonstrate that medical and mental health evaluations and treatment will be offered to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or a juvenile
facility. Ongoing clinical services were provided to a resident regarding allegations of sexual
abuse. The Policy also provides for a mental health practitioner to conduct a mental health
evaluation within 60 days on a resident who discloses youth-on-youth abuse. The staff
confirmed that this could be done.
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:
Policy 10-25 and FDJJ 1919 provide for an incident review to be conducted within 30 days of
the completion of an investigation in accordance with the standard. During this audit period,
there were three completed investigations. One was determined as unfounded and two
involved the same staff member. The sexual abuse incident reviews were completed.
25
The Policies identify the positions that comprise the incident review team: Facility
Administrator; Assistant Facility Administrator; facility treatment staffs; direct care staff;
statewide FDJJ PREA Coordinator; FDJJ Regional Program Administrator; and other
participants as needed. The Policies provide that the report from the incident review team is
provided to the Facility Administrator, who also serves as the PREA Compliance Manager.
The interview with the Assistant Facility Administrator as an identified team member revealed
familiarity with the Policies and understanding of the purpose of the review process which is
also demonstrated through the completed sexual abuse incident reviews.
A form/format has been developed by FDJJ to capture the required information for
documentation of an incident review team meeting. The reports identified the attendees and
document the discussions that included motivating factors; physical barriers; review of staffing
levels and review of policy and procedures. The reports also allow for recommendations to the
Facility Administrator. One report contained recommendations which were implemented.
Standard 115.387 Data Collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in a material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 and a review of reports confirm that FDJJ collects incident-based, uniform data
regarding allegations of sexual abuse at facilities under its direct control, including
contractors, using a standardized instrument and specific guidelines. The format used for
FDJJ facilities and contractors capture the information required to complete the most recent
version of the Survey of Sexual Violence conducted by the U. S. Department of Justice
(DOJ).
Florida DJJ maintains and collects various types of identified data and related documents
regarding sexual abuse incidents. The facility collects and maintains data in accordance with
directives by FDJJ and Policy 1-5. Florida DJJ aggregates the sexual abuse data which
culminates into an annual report. The agency provides DOJ with data as requested.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
26
Auditor Comments:
FDJJ 1919 provides guidance regarding this standard. The collected and aggregated data is
reviewed to assess and improve the effectiveness of the PREA related efforts and initiatives
by identifying problem areas; developing and implementing corrective actions as needed; and
preparing an annual report based on the collected data. The Policy also states that an annual
report is prepared that will provide an assessment of the agency’s progress in addressing
sexual misconduct.
The annual report is prepared in accordance with policy and approved as required. A
comparative report has been prepared and it is also obvious from facility and program staff
interviews, discussions with the statewide PREA Coordinator; observations; and document
review that the agency has compared the results of annual reports. The review of the reports
has gleaned information that is used to continuously improve policies; procedures; practices;
and training on a statewide basis. The annual reports are made accessible to the public
through the agency’s website. There are no personal identifiers on the annual reports.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 provides that all data collected will be securely stored and maintained for at least
10 years after the initial collection date, unless statutes require otherwise. According to the
Policy, the aggregated sexual abuse data from all facilities will be readily available to the
public through the agency’s website; the practice is that the report is posted on the agency’s
website. A review of the annual report verified that there are no personal identifiers, as
required.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and
no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under
review.
April 20, 2016
Auditor Signature Date
27

program_name_raw: oydc oycc