state: FL

facility_name: Cypress Creek

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Cypress Creek Juvenile Offender Correctional Center
Physical Address: 2285 West Woodland Ridge Drive, Lecanto, FL 33462
Date report submitted: May 6, 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: April 15-16, 2015
Facility Information
Facility Mailing Address: 2285 West Woodland Ridge Drive, Lecanto, FL 33462
Telephone Number: 352-527-3091
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: Calvetti Pate Title: Facility Administrator
Email Address: calvetti.pate@us.g4s.com Telephone Number:
352-527-3091
Agency Information
Name of Agency: G4S Youth Services, LLC
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: Jim Hill Title: President
Email Address: jim.hill@us.g4s.com Telephone Number: 8 1 3 - 5 1 4 - 6 2 7 5 , e x t . 2 0 2
Agency Wide PREA Coordinator
Name: Bobbi Pohlman-Rodgers Title: PREA Coordinator
954-818-5131
Email Address: bobbi.pohlman@us.g4s.com Telephone Number:
1
AUDIT FINDINGS
NARRATIVE:
Cypress Creek Juvenile Offender Correctional Center, a 96-bed juvenile facility, is located in Lecanto,
Florida. It is operated by G4S Youth Services, LLC through a contract with the Florida Department of
Juvenile Justice (FDJJ) and serves male juvenile offenders. The facility has 80 beds for maximum risk
residents, 16 beds for high risk and serves residents that range from 13 to 21 years of age. The average
length of stay is 24 months.
Mental health and substance abuse clinical services include treatment planning and reviews; screenings;
comprehensive assessments, including risk assessments; individual, group and family counseling; and
transition and aftercare planning. Psychiatric services are provided at the facility and include
evaluations, medication monitoring, treatment planning, and emergency consultations. All residents
receive a medical screening within 24 hours of admission. Additional medical services are provided
such as physical assessments; medication administration; sick call; and emergency services either at the
facility or the local emergency room. The education program offers courses that include English,
Mathematics, Science, Social Studies, and Reading. Vocational services are also provided within the
education program.
The residents are involved in groups based on the concept of restorative justice. The Impact of Crime
Services, including the groups are intended to assist residents in understanding that criminal behavior
has harmful consequences. The residents also practice ways they can make amends to their victim(s)
and the community and they may be required to complete community service hours.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The primary building includes administrative offices; control room; intake/medical area; kitchen;
classrooms; chapel/multi-purpose room; medical area; records room; and laundry rooms. There are two
housing areas, Northside and Southside, which contains three units each. Each unit contains 16 rooms, a
dayroom and a laundry room. The outside grounds contain smaller buildings used for storage and a
building used for educational purposes. All units have an outside fenced area used for recreation. The
grounds also contain a basketball court. Additional area provides ample space for recreation and other
activities.
A behavior management system exists that includes incentives for residents to demonstrate positive
behavior and encourages them to fulfill the program’s expectations. Residents may earn level
promotions by demonstrating consistent adaptive behavior. There are five levels of the behavior
management system, including Orientation. As the resident progresses to each level, the incentives
increase along with increased responsibilities for the resident.
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SUMMARY OF AUDIT FINDINGS:
An introductory conference call was held prior to the site visit and the audit process was discussed with
the facility and agency staff and the FDJJ PREA Coordinator. The notifications of the on-site audit were
posted in the facility prior to the site visit and pictures of the postings were forwarded to the Auditor.
The Pre-Audit Questionnaire was uploaded to a flash drive with policies and supporting documentation
and was received by the Auditor prior to the site visit. There were follow-up communication with the
facility staff and additional information was provided and information was clarified as needed.
Corrective actions were implemented and additional information was provided as needed.
The on-site audit was conducted April 15-16, 2015. Introductions were conducted with one of the
Assistant Facility Administrators (AFA), followed by a comprehensive tour of the facility. The tour was
provided by the AFA and the Chief of Security. During the tour, staff members were observed to be
providing engaged supervision to the residents. Randomly selected staff, specialized staff, residents, and
a contractor were interviewed. Direct care staff members were interviewed from all shifts. During the
on-site audit, additional documentation was provided as requested and in a timely manner. At the
conclusion of the site visit, a close-out meeting was held with the Facility Administrator, providing him
with a summary of the findings.
Number of standards exceeded: 0
Number of standards met: 38
Number of standards not met: 0
Number of standards not applicable: 3
3
Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
The Facility Administrator serves as the PREA Compliance Manager. Policy 10-25, Prison
Rape Elimination Act (PREA), provides guidelines for implementing the agency/facility’s
approach to complying with the requirements of the PREA standards and zero-tolerance of all
forms of sexual abuse and sexual harassment. The Policy contains definitions of prohibited
behaviors regarding sexual abuse and sexual harassment. The facility’s PREA Policy is
aligned with the over-arching 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
This standard is not applicable. The facility does not contract with other facilities for the
confinement of their 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)
According to Policy 10-25, periodic internal reviews of the staffing plan are conducted to
ensure adequate levels of staffing. A review of documents included a Staffing Plan
Assessment which had been completed by the agency’s PREA Coordinator based on the
staffing requirements of the contract. The facility reports that there have not been any
deviations from the staffing ratios. The facility uses staff holdovers, when needed, to
maintain compliance with the required ratios. Policy 10-25 also requires supervisory level
staff to conduct unannounced rounds. Interviews and documentation confirm that the
unannounced rounds are conducted by supervisors and administrative staff.
4
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)
Policy 10-3 and staff and resident interviews revealed that cross-gender strip searches and
cross-gender frisk searches are not conducted. Policy 10-3 addresses staff conducting searches
of transgender and intersex residents. Facility policy and resident and staff interviews
supported that residents are able to shower, use the toilet, and change clothes without being
viewed by female staff. Policy 10-25 states and staff interviews support that transgender or
intersex residents shall not be searched or physically examined for the sole purpose of
determining their 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)
Policy 10-25 provides that residents may not be used as interpreters unless an extended delay
in obtaining an interpreter could compromise the resident’s safety, the performance of the first
responder duties, or the investigation of the resident’s allegation. Policy 9-2 addresses
obtaining support for residents who are limited English proficient. The facility may use the
Registry of Certified Court Interpreters as a resource, as well as the agency’s internal list of
staff who may serve as interpreters. The facility practice is to use bilingual staff members as
interpreters, as needed. Interviews with staff and residents confirmed that staff members are
used as interpreters and for other assistance to ensure residents’ understanding of the
information provided. One of the random resident interviews was conducted with the
assistance of an education staff member who served as an interpreter. The PREA pamphlets
are provided in other dominant languages of the facility population.
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)
5
Does Not Meet Standard (requires corrective action)
Policy 3-16, Employee Recruitment and Selection, and FDJJ Policy address this standard.
The Policies prohibit hiring, promoting or contracting with anyone who has been convicted of
engaging in any activity prohibited by the standard and provide directions regarding
background checks and screenings. Interviews with staff and a review of a sample of
documentation revealed that background checks are conducted.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Direct supervision of residents is supported by the use of a camera system. During this audit
period, upgrades to the system have included the addition of new DVRs which increased the
capacity for recording and the storage capacity. The updates also included additional monitors.
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)
Policy 10-25 provides that the facility is not responsible for conducting administrative or
criminal investigations. FDJJ 1919 and Policy 10-25 support that the FDJJ Office of the
Inspector General (OIG) is responsible for conducting administrative investigations; the
Florida Department of Children and Families (DCF) is responsible for conducting allegations
of child abuse; and local law enforcement is responsible for conducting criminal
investigations. The facility has written information regarding PREA related investigations,
provided by FDJJ, to share with local law enforcement investigators. Documented
correspondence shows that discussion occurred and that the written information has been
shared with and received by the Citrus County Sheriff’s Office. Documentation has been
reviewed that shows the on-going collaboration for advocacy services with a victim advocacy
agency. Per policy, forensic exams will be provided at no cost to the victim by a qualified
medical practitioner.
6
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)
Policy 10-25 and FDJJ 1919 identify who is responsible for conducting the criminal and
administrative investigations and instructs staff to cooperate with investigations. Related
policies are published on the DJJ website. During this audit period there was one allegation
that was reported. The investigation was referred to the Citrus County Sheriff’s Office and
was determined to be unfounded. The FDJJ Central Communications Center (CCC)
conducted an administrative review of the situation. The CCC report regarding the allegation,
show the findings of closed as Information Only. The CCC report did show a Violation of
Policy/Rule, regarding the provision of data to the CCC, by the former Facility Administrator
(FA) who was employed at the facility during the time the allegation was reported. The CCC
report stated that the FA has since resigned and that the resignation was independent of the
case. Interviews conducted with the current FA and the FDJJ PREA Coordinator supported
that the former FA’s resignation was independent of and unrelated to the case.
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)
Policy 10-25 refers to G4S FOP Chapter 5 regarding staff training. The facility maintains
documentation of the receipt of PREA training. The initial staff training occurred and staff
has also been provided with refresher training. FDJJ has on-line training and facility in-house
training has been conducted regarding specific areas of the standards.
Standard 115.332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 and the training curriculum support that volunteers and contractors be trained on
their responsibilities regarding the zero-tolerance of sexual assault and sexual harassment.
Documentation has been provided showing that training has been conducted with volunteers
and contractors.
7
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)
Policy 10-25 states that all residents are provided PREA information during the intake
process. Staff and resident interviews and a review of documentation confirmed that residents
are provided PREA education. Staff members may assist with the PREA education for
residents that are limited English proficient, visually impaired, otherwise disabled, or have
limited reading skills. The document review included lists of internal and external interpreters
and information regarding hearing impaired services. The PREA information is posted within
the facility and there are pamphlets that are accessible and available to all residents.
Pamphlets are available in languages of residents that are admitted to the facility.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 state that staff in the OIG will be trained on the related policies and procedures
regarding the handling of sexual misconduct incidents and reports. Appropriate training is
provided to investigative staff regarding conducting investigations in the DJJ settings.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 and facility Policy 5-1address staff training. The medical and mental health staff
members have received the training developed for those areas, as well as the initial PREA
training. The 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)
8
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 9-1, 9-2 and FDJJ 1919 provide information regarding classification, re-classification
and risk screening. It is required that all residents are screened for risk of victimization and
abusiveness within 24 hours of intake. The screening is conducted using the DJJ objective
instrument, Screening for Vulnerability to Victimization and Sexuality Aggressive Behavior
(VSAB). The VSAB is used to obtain the information outlined in the standard. Interviews and
documentation confirm that screening instruments are used to assess risk and that the
resident’s risk is re-assessed periodically.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 8-14 and FDJJ 1919 address this standard regarding the information from the risk
screening instrument and outlines how it is to be used to help determine housing and program
assignments with the goal of keeping all residents safe. The Classification and Orientation
Policy also addresses how the screening information is used. The facility prohibits placing
gay, bisexual, transgender or intersex residents in specific housing or making other
assignments solely based on how they self-identify or their status. There was no indication of
any resident held in isolation or segregated housing because they were at risk for sexual
victimization.
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)
Policies 8-3, 10-25 and FDJJ 1919 address this standard. Residents may report allegations of
sexual abuse or sexual harassment by telephone, using the abuse hotline. There are also
additional internal ways a resident may report allegations of sexual abuse; sexual harassment;
retaliation for reporting; and staff neglect or other violation(s) that lead to abuse. A resident
may complete a grievance form; talk to any staff member; and third parties may report
allegations. Resident and staff interviews support the ways a resident may report allegations
and information is provided in the Youth Handbook.
9
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 8-4 provides the details of how an emergency grievance should be handled. When an
emergency grievance is received alleging sexual abuse, it is reported according to the
procedures for reporting allegations of sexual abuse and sexual harassment. The completed
grievance forms are to be placed in a locked box and are collected by the designated staff.
Policy 8-4 also allows for the receipt of reports from third parties and that third parties may
assist residents in filing grievances. Policy 10-25 and the Employee Handbook provide staff
with the required information for reporting sexual abuse and sexual harassment of residents.
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)
Policies 8-5 and 10-25 address this standard. There is documentation of past collaboration
between the Facility Administrator and a representative from a victim advocacy agency.
There is also evidence of on-going collaboration with an advocacy agency. The facility
provides residents with reasonable and confidential access to their attorneys or other legal
representation and reasonable access to their parents or legal guardians.
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)
Policies 8-3 and 10-25 address third-party reporting. Information is provided through posters
that are located in areas of the facility, accessible to the public. The FDJJ website contains
information regarding third-party reporting.
10
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policies 8-3, 10-25 and FDJJ 1919 provide that all staff report any knowledge, suspicion, or
information regarding an incident of sexual abuse, sexual harassment or incidents of
retaliation. Staff interviews revealed that they are aware of the requirement regarding their
reporting duties and understand that they are mandated reporters. The Employee Handbook
also addresses staff 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)
Policy 10-25 instructs staff to take immediate action to keep residents safe when they learn
that there is substantial risk of imminent threat of sexual abuse. Interviews with staff
confirmed their knowledge of this policy and they were able to verbalize measures they would
take to protect residents who are at substantial risk of imminent sexual abuse. Safety tips for
self-protection are provided to residents during intake and are included in the Youth
Handbook.
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)
Policy 19-25 and FDJJ 1919 address the requirements of this standard. It is reported that
during this audit period, the facility has not received any reports from a resident about an
incident of abuse occurring while they were confined in another facility.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
11
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 contains information on the first responder duties. Initial training and a refresher
was conducted with staff through a combination of online statewide training and in-house
training. During this audit period, there was one allegation reported which was investigated
by the OIG and the Citrus County Sheriff’s Department.
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)
Policies 7-30 and 10-25 address this standard. The facility has an institutional plan, Sexual
Abuse Incident Coordinated Response Plan, which outlines the coordinated actions of the
various identified staff and is aligned with FDJJ 1919.
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)
X Standard Not Applicable
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)
Policy 10-25 and FDJJ 1919 are used as a guide in providing protection to residents and staff
from retaliation. The retaliation monitor has been identified and charged with the duties of
12
observing whether or not retaliation occurs after a resident or staff reports allegations of sexual
abuse or cooperates with an investigation. The Policies and practice direct staff members to
report any neglect or violations of responsibilities by other staff which may have contributed
to an incident of sexual abuse or retaliation.
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
This standard is not applicable. Segregated housing is not used at this facility to house
residents who allege sexual abuse.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
According to Policy 10-25, FDJJ 1919 and facility staff, administrative investigations are
conducted by the OIG and criminal investigations are conducted by local law enforcement.
The Florida Department of Children and Families are also called when there is an allegation
of sexual abuse and they may also conduct an investigation. The Policies direct facility staff
to cooperate with investigations.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 provides that the OIG, responsible for administrative investigations, impose a
standard of a preponderance of the evidence for determining whether allegations are
substantiated.
13
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)
Policy 10-25 and FDJJ 1919 allows for the victim to be informed that the investigation has
been concluded. At the conclusion of an investigation, the victim or the victim’s parents or
legal guardian will be notified when the investigation has been completed. Documentation
shows that the resident was notified of the completion and findings of the investigation that
was conducted during this audit period.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 3-3 provides that disciplinary sanctions, up to and including termination for those staff
that violate the facility’s sexual abuse and sexual harassment zero-tolerance policy. Policy 3-5
and the Employee Handbook also support this standard.
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)
FDJJ 1919 requires that any contractor or volunteer who engages in sexual abuse be
prohibited from contact with residents. It also provides for contractors and volunteers who
engage in sexual abuse to be reported to law enforcement agencies and to relevant licensing
bodies.
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)
14
Does Not Meet Standard (requires corrective action)
Policy 8-1 addresses the administrative process and the measures to be taken regarding major
rule violations. This information is also addressed in the Youth Handbook. A resident may
also be referred to law enforcement for charges and possible removal from the facility.
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)
Policy 9-1 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. 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.
Medical and mental health staff members maintain documentation of the services they provide
to the residents.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 7-30 and FDJJ 1919 address this standard. Staff interviews and review of practices
revealed that documentation regarding crisis intervention services will be maintained by
medical and mental health staff as required.
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)
15
Does Not Meet Standard (requires corrective action)
This standard is addressed in Policy 10-25. Interviews with medical and mental health staff
confirmed their awareness of the Policy and how the policy would be implemented. Staff
interviews and document review revealed that medical and mental health services are
consistent with the community level of care and that appropriate ongoing medical and mental
health services would be provided to the victim and the abuser.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Policy 10-25 and FDJJ 1919 provide for an incident review to be conducted within 30 days of
the completion of an investigation. The Policies outline the requirements of the standard for
discussion and review by the incident review team. There is documentation, PREA Sexual
Incident Review, which shows an assessment of the allegations that were investigated.
Standard 115.387 Data Collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 and documentation confirm that FDJJ collects incident-based, uniform and
aggregated data regarding allegations of sexual abuse at facilities under its direct control
using a standardized instrument. The agency provides DOJ with data as requested.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 addresses this standard on a statewide basis. The collected and aggregated data
will be reviewed to assess and improve the effectiveness of the PREA related efforts and
initiatives. The Policy also states that an annual report will be prepared that will provide an
assessment of the agency’s progress in addressing sexual misconduct.
16
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ 1919 provide that all data collected will be maintained for at least 10 years after the
initial collection date. According to the Policy, the report will be approved and posted on the
agency’s website, accessible to the public, as required by the standard. The practice is that the
report is posted on the agency’s website.
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.
May 6, 2015
Auditor Signature Date
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source: DJJ

report_type: PREA

program_name_raw: cypress creek juvenile offender correctional center