state: FL

facility_name: Wimauma Academy

summary: PREA - Year 3 Cycle 4

raw_content:
Prison Rape Elimination Act (PREA) Audit Report
Juvenile Facilities
☐ ☒
Interim Final
☒
Date of Interim Audit Report: N/A
If no Interim Audit Report, select N/A
Date of Final Audit Report: May 2, 2025
Auditor Information
Name: Shirley Turner Email: shirley.turner@thecmcg.com
Company Name: Correctional Management and Communications Group, LLC
Mailing Address: PO Box 104 City, State, Zip: Conley, GA 30288-9998
Telephone: 678-895-2829 Date of Facility Visit: March 24-25, 2025
Agency Information
Name of Agency: Wayne Halfway House, Inc.
Governing Authority or Parent Agency (If Applicable): Click or tap here to enter text.
Physical Address: 942 Andrew Jackson Dr. City, State, Zip: Waynesboro, TN 38485
Mailing Address: Same as Above City, State, Zip: Click or tap here to enter text.
The Agency Is:
☐
Military
☒
Private for Profit
☐
Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Agency Website with PREA Information: www.fldjj.gov
Agency Chief Executive Officer
Name: Jason Crews
Email: jcrews@waynehalfway.com Telephone: 931-722-3272
Agency-Wide PREA Coordinator
Name: Kelly Banks
Email: kbanks@waynehalfway.com Telephone: 941-773-3519
PREA Coordinator Reports to: Number of Compliance Managers who report to the PREA
Coordinator:
Helen Rodgers, Special Advisor CEO 11
PREA Audit Report – V7. Page 1 of 156 Facility Name – double click to change
Facility Information
Name of Facility: Wimauma Academy
Physical Address: 4337 Saffold Road City, State, Zip: Wimauma, FL 33598
Mailing Address (if different from above):
City, State, Zip: Click or tap here to enter text.
Same as Above
The Facility Is: ☐ Military ☒ Private for Profit ☐ Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Facility Type: ☐ Prison ☐ Jail
Facility Website with PREA Information: www.fldjj.gov
☐ ☐
Has the facility been accredited within the past 3 years? Yes No
If the facility has been accredited within the past 3 years, select the accrediting organization(s) – select all that apply (N/A if
the facility has not been accredited within the past 3 years):
☐
ACA
☐
NCCHC
☐
CALEA
☐
Other (please name or describe: Click or tap here to enter text.
☒
N/A
If the facility has completed any internal or external audits other than those that resulted in accreditation, please describe:
Department of Juvenile Justice quality assurance audit.
Superintendent/Director/Administrator
Name: Joshua Warren
Email: jwarren@waynehalfway.com Telephone: 813-434-1549
Facility PREA Compliance Manager
Name: Joshua Warren
Email: jwarren@waynehalfway.com Telephone: 813-434-1549
☐
Facility Health Service Administrator N/A
Name: Celian Pogson, Director of Nursing
Email: cpogson@waynehalfway.com Telephone: 931-722-3272
Facility Characteristics
Designated Facility Capacity: 32
Current Population of Facility: 29
PREA Audit Report – V7. Page 2 of 156 Facility Name – double click to change
Average daily population for the past 12 months: 32
Has the facility been over capacity at any point in the past 12 ☐ ☒
Yes No
months?
Which population(s) does the facility hold? ☐ Females ☒ Males ☐ Both Females and Males
Age range of population: 14-18
Average length of stay or time under supervision: Six Months
Facility security levels/resident custody levels: Moderate
Number of residents admitted to facility during the past 12 months: 75
Number of residents admitted to facility during the past 12 months whose length of
75
stay in the facility was for 72 hours or more:
Number of residents admitted to facility during the past 12 months whose length of
75
stay in the facility was for 30 days or more:
Does the audited facility hold residents for one or more other agencies (e.g. a State
correctional agency, U.S. Marshals Service, Bureau of Prisons, U.S. Immigration and
☐
Yes
☒
No
Customs Enforcement)?
☐
Federal Bureau of Prisons
☐
U.S. Marshals Service
☐
U.S. Immigration and Customs Enforcement
☐
Bureau of Indian Affairs
☐
U.S. Military branch
Select all other agencies for which the audited ☐
State or Territorial correctional agency
facility holds residents: Select all that apply (N/A if
☐
the audited facility does not hold residents for any County correctional or detention agency
other agency or agencies):
☐
Judicial district correctional or detention facility
☐
City or municipal correctional or detention facility (e.g. police lockup or
city jail)
☐
Private corrections or detention provider
☐
Other - please name or describe: Click or tap here to enter text.
☒
N/A
Number of staff currently employed by the facility who may have contact with
35
residents:
Number of staff hired by the facility during the past 12 months who may have contact
8
with residents:
Number of contracts in the past 12 months for services with contractors who may
3
have contact with residents:
Number of individual contractors who have contact with residents, currently
5
authorized to enter the facility:
Number of volunteers who have contact with residents, currently authorized to enter
0
the facility:
PREA Audit Report – V7. Page 3 of 156 Facility Name – double click to change
Physical Plant
Number of buildings:
Auditors should count all buildings that are part of the facility, whether residents are
formally allowed to enter them or not. In situations where temporary structures have
been erected (e.g., tents) the auditor should use their discretion to determine whether
8
to include the structure in the overall count of buildings. As a general rule, if a
temporary structure is regularly or routinely used to hold or house residents, or if the
temporary structure is used to house or support operational functions for more than a
short period of time (e.g., an emergency situation), it should be included in the overall
count of buildings.
Number of resident housing units:
Enter 0 if the facility does not have discrete housing units. DOJ PREA Working Group
FAQ on the definition of a housing unit: How is a "housing unit" defined for the
purposes of the PREA Standards? The question has been raised in particular as it
relates to facilities that have adjacent or interconnected units. The most common
concept of a housing unit is architectural. The generally agreed-upon definition is a
space that is enclosed by physical barriers accessed through one or more doors of
various types, including commercial-grade swing doors, steel sliding doors,
interlocking sally port doors, etc. In addition to the primary entrance and exit,
additional doors are often included to meet life safety codes. The unit contains
2
sleeping space, sanitary facilities (including toilets, lavatories, and showers), and a
dayroom or leisure space in differing configurations. Many facilities are designed with
modules or pods clustered around a control room. This multiple-pod design provides
the facility with certain staff efficiencies and economies of scale. At the same time, the
design affords the flexibility to separately house residents of differing security levels,
or who are grouped by some other operational or service scheme. Generally, the
control room is enclosed by security glass, and in some cases, this allows residents
to see into neighboring pods. However, observation from one unit to another is
usually limited by angled site lines. In some cases, the facility has prevented this
entirely by installing one-way glass. Both the architectural design and functional use
of these multiple pods indicate that they are managed as distinct housing units.
Number of single cell housing units: 0
Number of multiple occupancy cell housing units: 0
Number of open bay/dorm housing units: 2
Number of segregation cells (for example, administrative, disciplinary, protective
0
custody, etc.):
In housing units, does the facility maintain sight and sound separation between
youthful residents and adult residents? (N/A if the facility never holds youthful
☐
Yes
☐
No
☒
N/A
residents)
Does the facility have a video monitoring system, electronic surveillance system, or ☒ ☐
Yes No
other monitoring technology (e.g. cameras, etc.)?
Has the facility installed or updated a video monitoring system, electronic surveillance ☒ ☐
Yes No
system, or other monitoring technology in the past 12 months?
Medical and Mental Health Services and Forensic Medical Exams
Are medical services provided on-site?
☒
Yes
☐
No
Are mental health services provided on-site?
☒
Yes
☐
No
PREA Audit Report – V7. Page 4 of 156 Facility Name – double click to change
☐
On-site
☐
Local hospital/clinic
Where are sexual assault forensic medical exams provided?
☒
Select all that apply. Rape Crisis Center
☐
Other (please name or describe: Click or tap here to enter
text.)
Investigations
Criminal Investigations
Number of investigators employed by the agency and/or facility who are responsible
for conducting CRIMINAL investigations into allegations of sexual abuse or sexual 11
harassment:
☐
Facility investigators
When the facility received allegations of sexual abuse or sexual harassment (whether
staff-on-resident or resident-on-resident), CRIMINAL INVESTIGATIONS are conducted ☐ Agency investigators
by: Select all that apply.
☒
An external investigative entity
☐
Local police department
☒
Local sheriff’s department
☐
Select all external entities responsible for CRIMINAL State police
INVESTIGATIONS: Select all that apply (N/A if no
☐
external entities are responsible for criminal A U.S. Department of Justice component
investigations) ☒ Other (please name or describe: FL Dept. of Children &
Families)
☐
N/A
Administrative Investigations
Number of investigators employed by the agency and/or facility who are responsible
for conducting ADMINISTRATIVE investigations into allegations of sexual abuse or 11
sexual harassment?
☐
Facility investigators
When the facility receives allegations of sexual abuse or sexual harassment (whether
☒
staff-on-resident or resident-on-resident), ADMINISTRATIVE INVESTIGATIONS are Agency investigators
conducted by: Select all that apply
☐
An external investigative entity
☐
Local police department
Select all external entities responsible for
☐
ADMINISTRATIVE INVESTIGATIONS: Select all that Local sheriff’s department
apply (N/A if no external entities are responsible for
☐
administrative investigations) State police
☐
A U.S. Department of Justice component
☐ Other (please name or describe: Click or tap here to enter text.)
☒
N/A
PREA Audit Report – V7. Page 5 of 156 Facility Name – double click to change
Summary of Audit Findings
The summary should include the number and list of standards exceeded, number of standards met, and
number and list of standards not met.
Auditor Note: No standard should be found to be “Not Applicable” or “NA”. A compliance determination
must be made for each standard.
Standards Exceeded
Number of Standards Exceeded: 0
List of Standards Exceeded: Click or tap here to enter text.
Standards Met
Number of Standards Met: 41
Standards Not Met
Number of Standards Not Met: 0
List of Standards Not Met: Click or tap here to enter text.
PREA Audit Report – V7. Page 6 of 156 Facility Name – double click to change
Post-Audit Reporting Information
General Audit Information
Onsite Audit Dates
1. Start date of the onsite portion of the audit: March 24, 2025
2. End date of the onsite portion of the audit: March 25, 2025
Outreach
3. Did you attempt to communicate with community-based
organization(s) or victim advocates who provide services ☒ ☐
Yes No
to this facility and/or who may have insight into relevant
conditions in the facility?
a. If yes, identify the community-based organizations
Crisis Center of Tampa Bay
or victim advocates with whom you corresponded:
Audited Facility Information
4. Designated Facility Capacity: 32
5. Average daily population for the past 12 months: 30
6. Number of resident housing units:
DOJ PREA Working Group FAQ on the definition of a housing
unit: How is a "housing unit" defined for the purposes of the
PREA Standards? The question has been raised in particular as
it relates to facilities that have adjacent or interconnected units.
The most common concept of a housing unit is architectural. The
generally agreed-upon definition is a space that is enclosed by
physical barriers accessed through one or more doors of various
types, including commercial-grade swing doors, steel sliding
doors, interlocking sally port doors, etc. In addition to the primary
entrance and exit, additional doors are often included to meet life
safety codes. The unit contains sleeping space, sanitary facilities
(including toilets, lavatories, and showers), and a dayroom or
leisure space in differing configurations. Many facilities are 2
designed with modules or pods clustered around a control room.
This multiple-pod design provides the facility with certain staff
efficiencies and economies of scale. At the same time, the
design affords the flexibility to separately house residents of
differing security levels, or who are grouped by some other
operational or service scheme. Generally, the control room is
enclosed by security glass, and in some cases, this allows
residents to see into neighboring pods. However, observation
from one unit to another is usually limited by angled site lines. In
some cases, the facility has prevented this entirely by installing
one-way glass. Both the architectural design and functional use
of these multiple pods indicate that they are managed as distinct
housing units.
Audited Facility Population on Day One of the Onsite Portion of the Audit
Residents/Residents/Detainees
PREA Audit Report – V7. Page 7 of 156 Facility Name – double click to change
8. Enter the total number of residents housed at the facility
29
as of the first day of the onsite portion of the audit:
10. Enter the total number of residents with a physical
disability housed at the facility as of the first day of the 0
onsite portion of the audit:
11. Enter the total number of residents with a cognitive or
functional disability (including intellectual disability,
psychiatric disability, or speech disability) housed at the 5
facility as of the first day of the onsite portion of the
audit:
12. Enter the total number of residents who are Blind or have
low vision (visually impaired) housed at the facility on the 0
first day of the onsite portion of the audit:
13. Enter the total number of residents who are Deaf or hard-
of-hearing housed at the facility on the first day of the 0
onsite portion of the audit:
14. Enter the total number of residents who are Limited
English Proficient (LEP) housed at the facility as of the 0
first day of the onsite portion of the audit:
15. Enter the total number of residents who identify as
lesbian, gay, or bisexual housed at the facility as of the 0
first day of the onsite portion of the audit:
16. Enter the total number of residents who identify as
transgender, or intersex housed at the facility as of the 0
first day of the onsite portion of the audit:
17. Enter the total number of residents who reported sexual
abuse in this facility who are housed at the facility as of 0
the first day of the onsite portion of the audit:
18. Enter the total number of residents who reported sexual
harassment in this facility who are housed at the facility 0
as of the first day of the onsite portion of the audit:
19. Enter the total number of residents who disclosed prior
sexual victimization during risk screening housed at the
0
facility as of the first day of the onsite portion of the
audit:
20. Enter the total number of residents who are or were ever
placed in segregated housing/isolation for risk of sexual
0
victimization housed at the facility as of the first day of
the onsite portion of the audit:
21. Enter the total number of residents who are or were ever
placed in segregated housing/isolation for having
0
reported sexual abuse in this facility as of the first day of
the onsite portion of the audit:
22. Enter the total number of residents detained solely for
civil immigration purposes housed at the facility as of the 0
first day of the onsite portion of the audit:
23. Provide any additional comments regarding the
population characteristics of residents in the facility as of
the first day of the onsite portion of the audit (e.g.,
groups not tracked, issues with identifying certain
populations).
Click or tap here to enter text.
Note: as this text will be included in the audit report, please
do not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Staff, Volunteers, and Contractors
Include all full- and part-time staff employed by the facility, regardless of their level of contact with residents/residents/detainees
24. Enter the total number of STAFF, including both full- and
part-time staff employed by the facility as of the first day 35
of the onsite portion of the audit:
PREA Audit Report – V7. Page 8 of 156 Facility Name – double click to change
25. Enter the total number of CONTRACTORS assigned to
the facility as of the first day of the onsite portion of the 5
audit who have contact with residents:
26. Enter the total number of VOLUNTEERS assigned to the
facility as of the first day of the onsite portion of the audit 0
who have contact with residents:
27. Provide any additional comments regarding the
population characteristics of staff, volunteers, and
contractors who were in the facility as of the first day of
the onsite portion of the audit.
Click or tap here to enter text.
Note: as this text will be included in the audit report, please
do not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Interviews
Resident/Resident/Detainee Interviews
Random Resident Interviews
28. Enter the total number of RANDOM RESIDENTS who
5
were interviewed:
☒
Age
☒
Race
☒
Ethnicity (e.g., Hispanic, Non-Hispanic)
☒
29. Select which characteristics you considered when you Length of time in the facility
selected random resident interviewees: ☒
Housing assignment
☐
Gender
☐
Other (describe) Click or tap here to enter text.
☐
None (explain) Click or tap here to enter text.
Reviewed the population sheet; observed
30. How did you ensure your sample of random resident
population; reviewed resident files; conferred with
interviewees was geographically diverse?
staff.
31. Were you able to conduct the minimum number of ☒ ☐
random resident interviews? Yes No
a. If no, explain why it was not possible to interview the
Click or tap here to enter text.
minimum number of random resident interviews:
32. Provide any additional comments regarding selecting or
interviewing random residents (e.g., any populations you
oversampled, barriers to completing interviews, barriers
to ensuring representation, etc.).
Click or tap here to enter text.
Note: as this text will be included in the audit report, please do
not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Targeted Resident/Resident/Detainee Interviews
33. Enter the total number of TARGETED RESIDENTS who
5
were interviewed:
PREA Audit Report – V7. Page 9 of 156 Facility Name – double click to change
As stated in the PREA Auditor Handbook, the breakdown of
targeted interviews is intended to guide auditors in
interviewing the appropriate cross-section of
residents/residents/detainees who are the most vulnerable to
sexual abuse and sexual harassment. When completing
questions regarding targeted resident/resident/detainee
interviews below, remember that an interview with one
resident/resident/detainee may satisfy multiple targeted
interview requirements. These questions are asking about the
number of interviews conducted using the targeted
resident/resident/detainee protocols.
For example, if an auditor interviews an resident who has a
physical disability, is being held in segregated housing due to
risk of sexual victimization, and disclosed prior sexual
victimization, that interview would be included in the totals for
each of those questions. Therefore, in most cases, the sum of
all the following responses to the targeted
resident/resident/detainee interview categories will exceed
the total number of targeted residents/residents/detainees
who were interviewed.
If a particular targeted population is not applicable in the
audited facility, enter "0".
35. Enter the total number of interviews conducted with
residents with a physical disability using the “Disabled
0
and Limited English Proficient Residents” protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
Observed, reviewed files, conferred with staff.
PAQ; documentation reviewed onsite; and
discussions with staff and other residents).
36. Enter the total number of interviews conducted with
residents with a cognitive or functional disability
(including intellectual disability, psychiatric disability, or 5
speech disability) using the “Disabled and Limited
English Proficient Residents” protocol:
☐
Facility said there were “none here” during the onsite portion
of the audit and/or the facility was unable to provide a list of
a. If 0, select why you were unable to conduct at least
these residents.
the minimum required number of targeted residents
☐
in this category: The residents in this targeted category declined to be
interviewed.
PREA Audit Report – V7. Page 10 of 156 Facility Name – double click to change
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
PAQ; documentation reviewed onsite; and Click or tap here to enter text.
discussions with staff and other residents).
37. Enter the total number of interviews conducted with
residents who are Blind or have low vision (visually
impaired) using the “Disabled and Limited English 0
Proficient Residents” protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
PAQ; documentation reviewed onsite; and Observed and conferred with staff.
discussions with staff and other residents).
38. Enter the total number of interviews conducted with
residents who are Deaf or hard-of-hearing using the
0
“Disabled and Limited English Proficient Residents”
protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
PAQ; documentation reviewed onsite; and Observed, reviewed files, conferred with staff.
discussions with staff and other residents).
39. Enter the total number of interviews conducted with
residents who are Limited English Proficient (LEP) using
0
the “Disabled and Limited English Proficient Residents”
protocol:
☒
Facility said there were “none here” during the onsite portion
of the audit and/or the facility was unable to provide a list of
a. If 0, select why you were unable to conduct at least
these residents.
the minimum required number of targeted residents
☐
in this category: The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
PAQ; documentation reviewed onsite; and Conferred with staff, reviewed files.
discussions with staff and other residents).
PREA Audit Report – V7. Page 11 of 156 Facility Name – double click to change
40. Enter the total number of interviews conducted with
residents who identify as lesbian, gay, or bisexual using
the “Transgender and Intersex Residents; Gay, Lesbian, 0
and Bisexual Residents” protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
Reviewed files, conferred with staff.
PAQ; documentation reviewed onsite; and
discussions with staff and other residents).
41. Enter the total number of interviews conducted with
residents who identify as transgender or intersex
“Transgender and Intersex Residents; Gay, Lesbian, and 0
Bisexual Residents” protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the
PAQ; documentation reviewed onsite; and Reviewed files and conferred with staff.
discussions with staff and other residents).
42. Enter the total number of interviews conducted with
residents who reported sexual abuse in this facility using
0
the “Residents who Reported a Sexual Abuse” protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the Reviewed files, reviewed investigation reports,
PAQ; documentation reviewed onsite; and
and conferred with staff,
discussions with staff and other residents).
43. Enter the total number of interviews conducted with
residents who disclosed prior sexual victimization during
risk screening using the “Residents who Disclosed 0
Sexual Victimization during Risk Screening” protocol:
PREA Audit Report – V7. Page 12 of 156 Facility Name – double click to change
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited
facility (e.g., based on information obtained from the Conferred with staff, reviewed investigation
PAQ; documentation reviewed onsite; and reports.
discussions with staff and other residents).
44. Enter the total number of interviews conducted with
residents who are or were ever placed in segregated
housing/isolation for risk of sexual victimization using
0
the “Residents Placed in Segregated Housing (for Risk of
Sexual Victimization/Who Alleged to have Suffered
Sexual Abuse)” protocol:
☒
Facility said there were “none here” during the onsite portion
a. If 0, select why you were unable to conduct at least of the audit and/or the facility was unable to provide a list of
the minimum required number of targeted residents these residents.
in this category: ☐
The residents in this targeted category declined to be
interviewed.
b. If 0, discuss your corroboration strategies to
determine if this population exists in the audited The facility does not use segregated
facility (e.g., based on information obtained from the
housing/isolation.
PAQ; documentation reviewed onsite; and
discussions with staff and other residents).
45. Provide any additional comments regarding selecting or
interviewing random residents (e.g., any populations you
oversampled, barriers to completing interviews, barriers
to ensuring representation, etc.).
Click or tap here to enter text.
Note: as this text will be included in the audit report, please do
not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Staff, Volunteer, and Contractor Interviews
Random Staff Interviews
46. Enter the total number of RANDOM STAFF who were
12
interviewed:
☐
Length of tenure in the facility
☐
Shift assignment
☐
47. Select which characteristics you considered when you Work assignment
selected RANDOM STAFF interviewees (select all that
☐
apply): Rank (or equivalent)
☐
Other (describe) Click or tap here to enter text.
☒ None (explain) There was a total of 12 staff in this
category to interview.
48. Were you able to conduct the minimum number of ☒ ☐
RANDOM STAFF interviews? Yes No
a. If no, select the reasons why you were not able to
conduct the minimum number of RANDOM STAFF ☐ Too many staff declined to participate in interviews
interviews (select all that apply):
PREA Audit Report – V7. Page 13 of 156 Facility Name – double click to change
☐
Not enough staff employed by the facility to meet the
minimum number of random staff interviews (Note: select this
option if there were not enough staff employed by the facility
or not enough staff employed by the facility to interview for
both random and specialized staff roles).
☐
Not enough staff available in the facility during the onsite
portion of the audit to meet the minimum number of random
staff interviews.
☐
Other (describe) Click or tap here to enter text.
b. Describe the steps you took to select additional
RANDOM STAFF interviewees and why you were still
Click or tap here to enter text.
unable to meet the minimum number of random staff
interviews:
49. Provide any additional comments regarding selecting or
interviewing random staff (e.g., any populations you
oversampled, barriers to completing interviews, etc.).
Click or tap here to enter text.
Note: as this text will be included in the audit report, please
do not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties. Therefore, more than one interview
protocol may apply to an interview with a single staff member and that interview would satisfy multiple specialized staff interview
requirements.
50. Enter the total number of staff in a SPECIALIZED STAFF
role who were interviewed (excluding volunteers and 6
contractors):
51. Were you able to interview the Agency Head? ☒ Yes ☐ No
a. If no, explain why it was not possible to interview the
Click or tap here to enter text.
Agency Head:
52. Were you able to interview the Superintendent/Director or
their designee?
☒
Yes
☐
No
a. If no, explain why it was not possible to interview the
Click or tap here to enter text.
Superintendent/Director or their designee:
53. Were you able to interview the PREA Coordinator? ☒ Yes ☐ No
a. If no, explain why it was not possible to interview the
Click or tap here to enter text.
PREA Coordinator:
☒ ☐
Yes No
54. Were you able to interview the PREA Compliance ☐
N/A (N/A if the agency is a single facility agency or is
Manager?
otherwise not required to have a PREA Compliance Manager per
the Standards)
a. If no, explain why it was not possible to interview the
Click or tap here to enter text.
PREA Compliance Manager:
☐
Agency contract administrator
☒
Intermediate or higher-level facility staff responsible for
conducting and documenting unannounced rounds to identify
55. Select which SPECIALIZED STAFF roles were and deter staff sexual abuse and sexual harassment
interviewed as part of this audit (select all that apply): ☐
Line staff who supervise youthful residents (if applicable)
☐
Education and program staff who work with youthful residents
(if applicable)
☒
Medical staff
PREA Audit Report – V7. Page 14 of 156 Facility Name – double click to change
☒
Mental health staff
☐
Non-medical staff involved in cross-gender strip or visual
searches
☒
Administrative (human resources) staff
☐
Sexual Assault Forensic Examiner (SAFE) or Sexual Assault
Nurse Examiner (SANE) staff
☒
Investigative staff responsible for conducting administrative
investigations
☐
Investigative staff responsible for conducting criminal
investigations
☒
Staff who perform screening for risk of victimization and
abusiveness
☐
Staff who supervise residents in segregated
housing/residents in isolation
☒
Staff on the sexual abuse incident review team
☒
Designated staff member charged with monitoring retaliation
☐
First responders, both security and non-security staff
☒
Intake staff
☐
Other (describe) Click or tap here to enter text.
56. Did you interview VOLUNTEERS who may have contact ☐ ☒
Yes No
with residents in this facility?
a. Enter the total number of VOLUNTEERS who were
0
interviewed:
☐
Education/programming
☐
b. Select which specialized VOLUNTEER role(s) were Medical/dental
interviewed as part of this audit (select all that ☐
Mental health/counseling
apply):
☐
Religious
☐
Other
57. Did you interview CONTRACTORS who may have contact ☒ ☐
with residents in this facility?
Yes No
a. Enter the total number of CONTRACTORS who were
2
interviewed:
☐
Security/detention
☒
Education/programming
b. Select which specialized CONTRACTOR role(s) were ☐
Medical/dental
interviewed as part of this audit (select all that
☐
apply): Food service
☐
Maintenance/construction
☐
Other
58. Provide any additional comments regarding selecting or The DJJ agency head designee and PREA
interviewing specialized staff (e.g., any populations you
Coordinator were interviewed during a previous
oversampled, barriers to completing interviews, etc.).
audit within the agency. The contract agency
Note: as this text will be included in the audit report, please PREA Coordinator was also interviewed
do not include any personally identifiable information or other
previously during a previous audit within the
information that could compromise the confidentiality of any
persons in the facility. agency.
PREA Audit Report – V7. Page 15 of 156 Facility Name – double click to change
Site Review and Documentation Sampling
Site Review
PREA Standard 115.401(h) states, “The auditor shall have access to, and shall observe, all areas of the audited facilities.” In order to
meet the requirements in this Standard, the site review portion of the onsite audit must include a thorough examination of the entire
facility. The site review is not a casual tour of the facility. It is an active, inquiring process that includes talking with staff and residents to
determine whether, and the extent to which, the audited facility’s practices demonstrate compliance with the Standards. Note:
discussions related to testing critical functions are expected to be included in the relevant Standard-specific overall determination
narratives.
59. Did you have access to all areas of the facility? ☒ Yes ☐ No
a. If no, explain what areas of the facility you were
Click or tap here to enter text.
unable to access and why.
Was the site review an active, inquiring process that included the following:
60. Reviewing/examining all areas of the facility in
accordance with the site review component of the audit
☒
Yes
☐
No
instrument?
a. If no, explain why the site review did not include
Click or tap here to enter text.
reviewing/examining all areas of the facility.
61. Testing and/or observing all critical functions in the
facility in accordance with the site review component of ☒ ☐
Yes No
the audit instrument (e.g., intake process, risk screening
process, PREA education)?
a. If no, explain why the site review did not include
testing and/or observing all critical functions in the Click or tap here to enter text.
facility.
62. Informal conversations with residents during the site ☒ ☐
Yes No
review (encouraged, not required)?
63. Informal conversations with staff during the site review ☒ ☐
Yes No
(encouraged, not required)?
64. Provide any additional comments regarding the site
review (e.g., access to areas in the facility, observations,
tests of critical functions, or informal conversations).
Click or tap here to enter text.
Note: as this text will be included in the audit report, please
do not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Documentation Sampling
Where there is a collection of records to review—such as staff, contractor, and volunteer training records; background check records;
supervisory rounds logs; risk screening and intake processing records; resident education records; medical files; and investigative
files—auditors must self-select for review a representative sample of each type of record.
65. In addition to the proof documentation selected by the
agency or facility and provided to you, did you also
☒
Yes
☐
No
conduct an auditor-selected sampling of documentation?
PREA Audit Report – V7. Page 16 of 156 Facility Name – double click to change
66. Provide any additional comments regarding selecting
additional documentation (e.g., any documentation you
oversampled, barriers to selecting additional
documentation, etc.).
Click or tap here to enter text.
Note: as this text will be included in the audit report, please do
not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Sexual Abuse and Sexual Harassment Allegations and Investigations in this Facility
Sexual Abuse and Sexual Harassment Allegations and Investigations Overview
Remember the number of allegations should be based on a review of all sources of allegations (e.g., hotline, third-party, grievances)
and should not be based solely on the number of investigations conducted.
Note: For question brevity, we use the term “resident” in the following questions. Auditors should provide information on resident,
resident, or detainee sexual abuse allegations and investigations, as applicable to the facility type being audited.
67. Total number of SEXUAL ABUSE allegations and investigations overview during the 12 months preceding the audit, by
incident type:
Instructions: If you are unable to provide information for one or more of the fields below, enter an “X” in the field(s) where information
cannot be provided.
# of allegations that had
# of sexual abuse # of criminal # of administrative both criminal and
allegations investigations investigations administrative
investigations
Resident-on-resident
1 0 1 0
sexual abuse
Staff-on-resident
1 0 1 0
sexual abuse
Total 2 0 2 0
a. If you were unable to provide any of the information
above, explain why this information could not be Click or tap here to enter text.
provided.
68. Total number of SEXUAL HARASSMENT allegations and investigations overview during the 12 months preceding the
audit, by incident type:
Instructions: If you are unable to provide information for one or more of the fields below, enter an “X” in the field(s) where information
cannot be provided.
# of allegations that had
# of sexual harassment # of criminal # of administrative both criminal and
allegations investigations investigations administrative
investigations
Resident-on-resident
0 0 0 0
sexual harassment
Staff-on-resident
0 0 0 0
sexual harassment
Total 0 0 0 0
a. If you were unable to provide any of the information
above, explain why this information could not be Click or tap here to enter text.
provided.
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal investigation was referred for prosecution and
resulted in a conviction, that investigation outcome should only appear in the count for “convicted.”) Do not double count. Additionally,
for question brevity, we use the term “resident” in the following questions. Auditors should provide information on resident, resident,
and detainee sexual abuse investigation files, as applicable to the facility type being audited.
PREA Audit Report – V7. Page 17 of 156 Facility Name – double click to change
69. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding the audit:
Instructions: If you are unable to provide information for one or more of the fields below, enter an “X” in the field(s) where information
cannot be provided.
Referred for Indicted/Court
Ongoing Convicted/Adjudicated Acquitted
Prosecution Case Filed
Resident-on-
resident sexual 0 0 0 0 0
abuse
Staff-on-resident
0 0 0 0 0
sexual abuse
Total 0 0 0 0 0
a. If you were unable to provide any of the information
above, explain why this information could not be Click or tap here to enter text.
provided.
70. Administrative SEXUAL ABUSE investigation outcomes during the 12 months preceding the audit:
Instructions: If you are unable to provide information for one or more of the fields below, enter an “X” in the field(s) where information
cannot be provided.
Ongoing Unfounded Unsubstantiated Substantiated
Resident-on-resident
0 0 1 0
sexual abuse
Staff-on-resident
0 0 1 0
sexual abuse
Total 0 0 2 0
a. If you were unable to provide any of the information
above, explain why this information could not be Click or tap here to enter text.
provided.
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count. Additionally, for question brevity, we use the
term “resident” in the following questions. Auditors should provide information on resident, resident, and detainee sexual harassment
investigation files, as applicable to the facility type being audited.
71. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months preceding the audit:
Instructions: If you are unable to provide information for one or more of the fields below, enter an “X” in the field(s) where information
cannot be provided.
Referred for Indicted/Court
Ongoing Convicted/Adjudicated Acquitted
Prosecution Case Filed
Resident-on-
resident sexual 0 0 0 0 0
harassment
Staff-on-resident
0 0 0 0 0
sexual harassment
Total 0 0 0 0 0
a. If you were unable to provide any of the information
above, explain why this information could not be Click or tap here to enter text.
provided.
72. Administrative SEXUAL HARASSMENT investigation outcomes during the 12 months preceding the audit:
Instructions: If you are unable to provide information for one or more of the fields below, enter an “X” in the field(s) where information
cannot be provided.
Ongoing Unfounded Unsubstantiated Substantiated
Resident-on-resident
0 0 0 0
sexual harassment
Staff-on-resident
0 0 0 0
sexual harassment
Total 0 0 0 0
PREA Audit Report – V7. Page 18 of 156 Facility Name – double click to change
a. If you were unable to provide any of the information
above, explain why this information could not be Click or tap here to enter text.
provided.
Sexual Abuse and Sexual Harassment Investigation Files Selected for Review
Sexual Abuse Investigation Files Selected for Review
73. Enter the total number of SEXUAL ABUSE investigation
0
files reviewed/sampled:
a. If 0, explain why you were unable to review any
No sexual abuse investigations conducted.
sexual abuse investigation files:
☐ ☐
74. Did your selection of SEXUAL ABUSE investigation files Yes No
include a cross-section of criminal and/or administrative ☒
N/A (N/A if you were unable to review any sexual abuse
investigations by findings/outcomes?
investigation files)
Resident-on-resident sexual abuse investigation files
75. Enter the total number of RESIDENT-ON-RESIDENT
0
SEXUAL ABUSE investigation files reviewed/sampled:
76. Did your sample of RESIDENT-ON-RESIDENT SEXUAL ☐ Yes ☐ No
ABUSE investigation files include criminal
☒
investigations? N/A (N/A if you were unable to review any resident-on-
resident sexual abuse investigation files)
77. Did your sample of RESIDENT-ON-RESIDENT SEXUAL ☐ ☐
Yes No
ABUSE investigation files include administrative
☒
investigations? N/A (N/A if you were unable to review any resident-on-
resident sexual abuse investigation files)
Staff-on-resident sexual abuse investigation files
78. Enter the total number of STAFF-ON-RESIDENT SEXUAL
0
ABUSE investigation files reviewed/sampled:
79. Did your sample of STAFF-ON-RESIDENT SEXUAL ☐ ☐
Yes No
ABUSE investigation files include criminal
☒
investigations? N/A (N/A if you were unable to review any staff-on-resident
sexual abuse investigation files)
80. Did your sample of STAFF-ON-RESIDENT SEXUAL ☐ ☐
Yes No
ABUSE investigation files include administrative
☒
investigations? N/A (N/A if you were unable to review any staff-on-resident
sexual abuse investigation files)
Sexual Harassment Investigation Files Selected for Review
81. Enter the total number of SEXUAL HARASSMENT
2
investigation files reviewed/sampled:
a. If 0, explain why you were unable to review any
Click or tap here to enter text.
sexual harassment investigation files:
82. Did your selection of SEXUAL HARASSMENT ☐ ☒
Yes No
investigation files include a cross-section of criminal
☐
and/or administrative investigations by N/A (N/A if you were unable to review any sexual harassment
findings/outcomes? investigation files)
Resident-on-resident sexual harassment investigation files
83. Enter the total number of RESIDENT-ON-RESIDENT
SEXUAL HARASSMENT investigation files 2
reviewed/sampled:
PREA Audit Report – V7. Page 19 of 156 Facility Name – double click to change
☐ ☐
84. Did your sample of RESIDENT-ON-RESIDENT SEXUAL Yes No
HARASSMENT investigation files include criminal ☒
N/A (N/A if you were unable to review any resident-on-
investigations?
resident sexual harassment investigation files)
☒ ☐
85. Did your sample of RESIDENT-ON-RESIDENT SEXUAL Yes No
HARASSMENT investigation files include administrative ☐
N/A (N/A if you were unable to review any resident-on-
investigations?
resident sexual harassment investigation files)
Staff-on-resident sexual harassment investigation files
86. Enter the total number of STAFF-ON-RESIDENT SEXUAL
0
HARASSMENT investigation files reviewed/sampled:
☐ ☐
87. Did your sample of STAFF-ON-RESIDENT SEXUAL Yes No
HARASSMENT investigation files include criminal ☒
N/A (N/A if you were unable to review any staff-on-resident
investigations?
sexual harassment investigation files)
☐ ☐
88. Did your sample of STAFF-ON-RESIDENT SEXUAL Yes No
HARASSMENT investigation files include administrative ☒
N/A (N/A if you were unable to review any staff-on-resident
investigations?
sexual harassment investigation files)
89. Provide any additional comments regarding selecting
and reviewing sexual abuse and sexual harassment
investigation files.
Click or tap here to enter text.
Note: as this text will be included in the audit report, please
do not include any personally identifiable information or other
information that could compromise the confidentiality of any
persons in the facility.
Support Staff Information
DOJ-certified PREA Auditors Support Staff
90. Did you receive assistance from any DOJ-CERTIFIED
PREA AUDITORS at any point during this audit?
☐
Yes
☒
No
Remember: the audit includes all activities from the pre-onsite
through the post-onsite phases to the submission of the final
report. Make sure you respond accordingly.
a. If yes, enter the TOTAL NUMBER OF DOJ-CERTIFIED
PREA AUDITORS who provided assistance at any Click or tap here to enter text.
point during the audit:
Non-certified Support Staff
91. Did you receive assistance from any NON-CERTIFIED
SUPPORT STAFF at any point during this audit?
☒
Yes
☐
No
Remember: the audit includes all activities from the pre-onsite
through the post-onsite phases to the submission of the final
report. Make sure you respond accordingly.
a. If yes, enter the TOTAL NUMBER OF NON-
CERTIFIED SUPPORT STAFF who provided 1
assistance at any point during the audit:
Auditing Arrangements and Compensation
☐
92. Who paid you to conduct this audit? The audited facility or its parent agency
PREA Audit Report – V7. Page 20 of 156 Facility Name – double click to change
☐
My state/territory or county government (if you audit as part of
a consortium or circular auditing arrangement, select this
option)
☒
A third-party auditing entity (e.g., accreditation body,
consulting firm)
☐
Other
PREA Audit Report – V7. Page 21 of 156 Facility Name – double click to change
PREVENTION PLANNING
Standard 115.311: Zero tolerance of sexual abuse and sexual harassment;
PREA coordinator
All Yes/No Questions Must Be Answered by The Auditor to Complete the Report
115.311 (a)
▪ Does the agency have a written policy mandating zero tolerance toward all forms of sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Does the written policy outline the agency’s approach to preventing, detecting, and responding to
sexual abuse and sexual harassment? ☒ Yes ☐ No
115.311 (b)
▪ Has the agency employed or designated an agency-wide PREA Coordinator? ☒ Yes ☐ No
▪ Is the PREA Coordinator position in the upper-level of the agency hierarchy? ☒ Yes ☐ No
▪ Does the PREA Coordinator have sufficient time and authority to develop, implement, and oversee
agency efforts to comply with the PREA standards in all of its facilities? ☒ Yes ☐
No
115.311 (c)
▪ If this agency operates more than one facility, has each facility designated a PREA compliance
manager? (N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA
▪ Does the PREA compliance manager have sufficient time and authority to coordinate the facility’s
efforts to comply with the PREA standards? (N/A if agency operates only one facility.) ☒ Yes ☐ No
☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for
the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does not
meet the standard. These recommendations must be included in the Final Report, accompanied by information
on specific corrective actions taken by the facility.
PREA Audit Report – V7. Page 22 of 156 Facility Name – double click to change
Documents:
Facility Policy 1.03, Provisions of an Abuse Free Environment Facility
Policy 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Employee Handbook
Interviews:
Superintendent
Random Staff
PREA Coordinators
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all forms of
sexual abuse and sexual harassment and outlining the agency’s approach to
preventing, detecting, and responding to such conduct.
The PREA policies are aligned and provide guidance to staff regarding the facility’s approach to
preventing, detecting, and responding to allegations of sexual abuse and sexual harassment. The
policies provide and address conduct that violates the zero-tolerance approach regarding all
forms of sexual abuse and sexual harassment. Definitions of prohibited behaviors of sexual
abuse and sexual harassment are contained in policy and include sanctions for those found to
have participated in the prohibited behaviors. The Florida Department of Juvenile Justice (DJJ)
agency Policy, FDJJ 1919, serves as the overarching PREA Policy for the State-run and contract
facilities. The facility has additional policies and procedures which outline and support
adherence to the PREA standards.
Staff training, resident education, and intake screening assist in detecting sexual abuse and
sexual harassment. The identified and other supporting policies include but are not limited to
responding to sexual abuse and sexual harassment through prevention; responsive planning;
training and education; reporting; investigations; medical and mental care; assessments;
disciplinary sanctions for residents and staff; and data collection and review. The interviews
confirmed knowledge of the zero-tolerance and other related policies regarding sexual abuse
and sexual harassment.
PREA Audit Report – V7. Page 23 of 156 Facility Name – double click to change
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA
Coordinator with sufficient time and authority to develop, implement, and oversee
agency efforts to comply with the PREA standards in all of its facilities.
The agencies’ policies provide for the designation of PREA Coordinators. The Florida Department
of Juvenile Justice (DJJ) PREA Coordinator manages the PREA implementation efforts statewide.
The facility’s parent agency’s designated PREA Coordinator provides support to the facility and
is a part of the management team in the corporate office. Collaboration exists with the
statewide PREA Coordinator and facility staff. The previous interviews with both PREA
Coordinators, observations and other interviews revealed their authority to provide oversight to
the PREA initiatives.
The DJJ statewide PREA Coordinator provides oversight regarding PREA efforts in contract
residential facilities as well as State-run detention facilities. Support and direction are provided
to all contract facilities and there is continual communication with the Auditor.
Provision (c):
Where an agency operates more than one facility, each facility shall designate a
PREA Compliance Manager with sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards.
The position of superintendent has been designated as the PREA Compliance Manager and
reports directly to the State Compliance Director, regarding PREA related issues. The State
Compliance Director served temporarily as the PREA Compliance Manager designee due to the
short time the new superintendent has been in place. The interview with the designee indicated
there is the time to fulfill the PREA duties with the support of facility and corporate staff and it
was determined there is the authority required to fulfill those duties. The superintendent and
the State Compliance Director work cooperatively in the implementation of the PREA
standards.
Interviews conducted with staff revealed their awareness of the role of the PREA Compliance
Manager. Observations and interviews confirmed the superintendent has the support of the
facility and corporate staff, agency PREA Coordinator and the DJJ statewide PREA
Coordinator.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and observations, it
was determined there is compliance with this standard.
PREA Audit Report – V7. Page 24 of 156 Facility Name – double click to change
Standard 115.312: Contracting with other entities for the confinement of
residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.312 (a)
▪ If this agency is public and it contracts for the confinement of its residents with private agencies
or other entities including other government agencies, has the agency included the entity’s
obligation to comply with the PREA standards in any new contract or contract renewal signed on
or after August 20, 2012? (N/A if the agency does not contract with private agencies or other
entities for the confinement of residents.) ☒ Yes ☐ No ☐ NA
115.312 (b)
▪ Does any new contract or contract renewal signed on or after August 20, 2012 provide for
agency contract monitoring to ensure that the contractor is complying with the PREA standards?
(N/A if the agency does not contract with private agencies or other entities for the confinement
of residents.) ☐ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Agency Policy FDJJ 1919
Contract Language
Interviews:
Superintendent
PREA Audit Report – V7. Page 25 of 156 Facility Name – double click to change
DJJ Statewide PREA Coordinator
Provisions (a) and (b):
(a): A public agency that contracts for the confinement of its residents with
private agencies or other entities, including other government agencies,
shall include in any new contract or contract renewal the entity’s obligation
to adopt and comply with the PREA standards. (b): Any new contract or
contract renewal shall provide for agency contract monitoring to ensure that
the contractor is complying with the PREA standards.
The public agency, DJJ, contracts for residential services with private providers. Wayne's
Halfway House, Incorporated/Wimauma Academy is one of the private vendors.
Contracts exist that inform all providers of the requirements by the DJJ to comply with
the PREA Standards and be subject to PREA audits by third-party certified PREA
Auditors. The practice was also confirmed by the interviews and previously completed
and posted PREA audit reports. The facility is not involved in a contract with other
facilities for the confinement if its assigned youth from DJJ.
Conclusion:
Based upon the review and analysis of the available evidence and communication with
the DJJ PREA Coordinator, the Auditor determined compliance with this standard.
Standard 115.313: Supervision and monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.313 (a)
▪ Does the facility have a documented staffing plan that provides for adequate levels of staffing
and, where applicable, video monitoring, to protect residents against sexual abuse?
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Generally accepted juvenile detention and
correctional/secure residential practices? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any judicial findings of inadequacy? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any findings of inadequacy from Federal investigative
agencies? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any findings of inadequacy from internal or external
oversight bodies? ☒ Yes ☐ No
PREA Audit Report – V7. Page 26 of 156 Facility Name – double click to change
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: All components of the facility’s physical plant (including
“blind-spots” or areas where staff or residents may be isolated)? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The composition of the resident population? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The number and placement of supervisory staff? ☒ Yes
☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The institution programs occurring on a particular shift? ☒
Yes ☐ No ☐ NA
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any applicable State or local laws, regulations, or
standards? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The prevalence of substantiated and unsubstantiated
incidents of sexual abuse? ☒ Yes ☐ No
▪ In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any other relevant factors? ☒ Yes ☐ No
115.313 (b)
▪ In circumstances where the staffing plan is not complied with, does the facility document and
justify all deviations from the plan? (N/A if no deviations from staffing plan.)
☒ Yes ☐ No ☐ NA
115.313 (c)
▪ In the past 12 months, has the facility maintained staff ratios of a minimum of 1:8 during resident
waking hours and 1:16 during resident sleeping hours, except during limited and discrete
exigent circumstances? ☒ Yes ☐ No
▪ In the past 12 months, if the facility has not maintained staff ratios of a minimum of 1:8 during
resident waking hours and 1:16 during resident sleeping hours has the facility, has the facility
fully documented each instance? ☒ Yes ☐ No
115.313 (d)
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The staffing plan
established pursuant to paragraph (a) of this section? ☒ Yes ☐ No
PREA Audit Report – V7. Page 27 of 156 Facility Name – double click to change
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The facility’s
deployment of video monitoring systems and other monitoring technologies? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The resources the
facility has available to commit to ensure adherence to the staffing plan? ☒ Yes ☐ No
115.313 (e)
▪ Has the facility/agency implemented a policy and practice of having intermediate-level or higher-
level supervisors conduct and document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? ☒ Yes ☐ No
▪ Is this policy and practice implemented for night shifts as well as day shifts? ☒ Yes ☐ No
▪ Does the facility/agency have a policy prohibiting staff from alerting other staff members that
these supervisory rounds are occurring, unless such announcement is related to the legitimate
operational functions of the facility? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Staffing Plan
Annual Staffing Plan Assessment
Unannounced Rounds
PREA Audit Report – V7. Page 28 of 156 Facility Name – double click to change
Interviews:
Superintendent
Intermediate or Higher-Level Staff
PREA Coordinator
Provision (a):
The agency shall ensure that each facility it operates shall develop, implement,
and document a staffing plan that provides for adequate levels of staffing, and,
where applicable, video monitoring, to protect residents against sexual abuse. In
calculating adequate staffing levels and determining the need for video
monitoring, facilities shall take into consideration:
(1) Generally accepted juvenile detention and correctional/secure
residential practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4) Any findings of inadequacy from internal or external oversight bodies;
(5) All components of the facility’s physical plant (including “blind spots” or
areas where staff or residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of
sexual abuse; and
(11) Any other relevant factors.
The policies and staffing plan provide details for maintaining the staffing ratios and the
written plan outlines the staffing requirements. The facility’s staffing plan, internal controls
and management ensures that the PREA staffing ratios are maintained during the waking
PREA Audit Report – V7. Page 29 of 156 Facility Name – double click to change
hours and during the sleeping hours. Direct supervision is provided to residents during the
daily activities and program services. The number of staff increases as needed due to
program activities, one-on-one supervision indicated, or other relevant factors.
Observations during the site review and interviews indicated the PREA staffing ratios are
maintained. The facility maintains a mandatory hold-over system and staff that are called in
as needed to ensure adherence to the staffing ratio and staffing plan.
The camera system is located in the control room which is staffed at all times. Provisions of
the standard are taken into consideration regarding adequate staffing levels as confirmed
through the interview with the superintendent and facility policy which outline staffing
requirements. The work schedules are based on the facility’s staffing plan and population.
There is collaboration and review of the work schedules and logbooks on a regular basis. In
addition to program activities and special needs of residents, the shift schedules are made
regarding the considerations that ensure adequate shift coverage including standard security
practices; composition of the resident population; inclement weather; and emergencies.
Provision (b):
The agency shall comply with the staffing plan except during limited and
discrete exigent circumstances, and shall fully document deviations from the
plan during such circumstances.
There are no reported deviations from the staffing ratios in the past 12 months. A
coordinated effort was described in maintaining the staffing ratios which includes
mandatory hold-over and use of specifically trained staff as needed. The operations of the
facility provide for staff to be held-over to ensure the ratios are met and staff called in as
needed. The facility is prepared to document any deviations from the staffing
requirements. The superintendent and the assistant superintendents monitor the
effectiveness of the work schedules based on the staffing plan requirements. The staffing
plan shows the required staffing ratios. The staffing plan provides for the staffing ratios to
be met and can provide for additional staff for days and times when increased staffing is
required.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8
during resident waking hours and 1:16 during resident sleeping hours, except
during limited and discrete exigent circumstances, which shall be fully
documented. Only security staff shall be included in these ratios. Any facility
that, as of the date of publication of this final rule, is not already obligated by
law, regulation, or judicial consent decree to maintain the staffing ratios set
forth in this paragraph shall have until October 1, 2017, to achieve
compliance.
PREA Audit Report – V7. Page 30 of 156 Facility Name – double click to change
According to policy, the agency shall comply with the staffing plan except during limited
and discrete exigent circumstances, and shall fully document deviations from the plan
during such circumstances. Staffing ratios for the facility are provided by the direct care
staff. The security practices and policies ensure the PREA ratios are met.
The ratios were discussed and observed for and met during the comprehensive site review.
Direct care staff members provide direct observation of residents. During the last 12
months the average daily number of residents is 32. The facility is not involved in any
lawsuits or consent decrees.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each
facility the agency operates, in consultation with the PREA Coordinator
required by §115.311, the agency shall assess, determine, and document
whether adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other
monitoring technologies; and
(4) The resources the facility has available to commit to ensure adherence to the
staffing plan.
The staffing plan assessment was facilitated and completed by the DJJ statewide PREA
Coordinator. The document reviews but is not limited to the following areas: prevailing
staffing patterns and review of staffing plan; electronic monitoring system; and review of
other areas related to adequate supervision. The review considers any adjustments that
need to be made by the construction and implementation of a corrective action plan that
would be indicated through findings or recommendations. The annual assessment
documents the summarization of the review including staffing, physical plant and the
electronic monitoring system. The Staffing Plan Assessment did not contain any
recommendations for corrective actions.
Provision (e):
Each secure facility shall implement a policy and practice of having
intermediate- level or higher-level supervisors conduct and document
unannounced rounds to identify and deter staff sexual abuse and sexual
harassment. Such policy and practice shall be implemented for night shifts as
well as day shifts. Each secure facility shall have a policy to prohibit staff from
alerting other staff members that these supervisory rounds are occurring,
PREA Audit Report – V7. Page 31 of 156 Facility Name – double click to change
unless such announcement is related to the legitimate operational functions of
the facility.
Unannounced rounds are conducted by management staff, covers all shifts, and are
documented. The Auditor was able to observe a documented unannounced round, completed
by the superintendent, on the camera system through recorded video. The interview with the
superintendent, review of documentation and policy, and review of camera footage,
confirmed the unannounced rounds occur. The staff is not informed of when the rounds will
occur and the visits are not conducted at scheduled times. The unannounced rounds are
conducted throughout the facility to identify and deter sexual abuse and sexual harassment.
Staff members are prohibited from alerting other staff when the rounds are occurring.
Conclusion:
Based upon the review and analysis of the available evidence, the standard is compliant.
Standard 115.315: Limits to cross-gender viewing and searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.315 (a)
▪ Does the facility always refrain from conducting any cross-gender strip or cross-gender visual
body cavity searches, except in exigent circumstances or by medical practitioners?
☒ Yes ☐ No
115.315 (b)
▪ Does the facility always refrain from conducting cross-gender pat-down searches, except in
exigent circumstances?
☒ Yes ☐ No
115.315 (c)
▪ Does the facility document all cross-gender strip searches and cross-gender visual body cavity
searches? ☒ Yes ☐ No
115.315 (d)
▪ Does the facility have policies that enables residents to shower, perform bodily functions, and
change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks,
or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell
checks? ☒ Yes ☐ No
▪ Does the facility have procedures that enables residents to shower, perform bodily functions,
and change clothing without nonmedical staff of the opposite gender viewing their breasts,
PREA Audit Report – V7. Page 32 of 156 Facility Name – double click to change
buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to
routine cell checks? ☒ Yes ☐ No
▪ Does the facility require staff of the opposite gender to announce their presence when entering
a resident housing unit? ☒ Yes ☐ No
115.315 (e)
▪ Does the facility always refrain from searching or physically examining transgender or intersex
residents for the sole purpose of determining the resident’s genital status? ☐ Yes ☐ No
▪ If an resident’s genital status is unknown, does the facility determine genital status during
conversations with the resident, by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted in private by a medical
practitioner? ☒ Yes ☐ No
115.315 (f)
▪ Does the facility/agency train security staff in how to conduct cross-gender pat down searches
in a professional and respectful manner, and in the least intrusive manner possible, consistent
with security needs? ☒ Yes ☐ No
▪ Does the facility/agency train security staff in how to conduct searches of transgender and
intersex residents in a professional and respectful manner, and in the least intrusive manner
possible, consistent with security needs? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
PREA Audit Report – V7. Page 33 of 156 Facility Name – double click to change
Agency Policy FDJJ 1919, PREA
Training Curriculum
Pre-service Orientation Plan
In-service Training Plan
Interviews:
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual
body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
Cross-gender strip, visual body cavity and pat-down searches are prohibited and the regular
searches must be documented. Policy and training provide guidance to staff on how the
searches are to be conducted. There is no evidence of cross-gender searches of any type
occurring at the facility in the last 12 months, supported by resident interviews. Based on the
review of documentation and according to the interviews, no type of cross-gender search has
been conducted at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy and practice do not support staff conducting cross-gender pat-down searches. All
searches must be documented. Responses from staff included that there is always a male
staff present to conduct searched of the residents. The training materials and interviews
provide that staff receives training on how to conduct searches, including cross gender
searches if there are exigent circumstances. Staff interviews confirmed awareness of how to
conduct searches. No residents or staff interviewed reported the occurrence of any cross-
gender searches. The evidence shows cross-gender pat-down searches have not occurred at
the facility during the last 12 months.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-
gender visual body cavity searches, and cross-gender pat-down searches.
Cross-gender strip and cross-gender visual body cavity searches are prohibited. Policy
provides for documenting the occurrence of searches. All interviews confirmed that no
PREA Audit Report – V7. Page 34 of 156 Facility Name – double click to change
cross-gender searches have occurred at the facility during this audit period. Staff members
are aware of the requirement to document all searches. There was no evidence
documenting or justifying any type cross-gender search.
Cross-gender strip and cross-gender visual body cavity searches are prohibited. Policy
provides for documenting the occurrence of searches. All interviews confirmed that no
cross-gender searches have occurred at the facility during this audit period. Staff members
are aware of the requirement to document all searches. There was no evidence
documenting or justifying any type cross-gender search.
Provision (d):
The facility shall implement policies and procedures that enable residents to
shower, perform bodily functions, and change clothing without nonmedical staff
of the opposite gender viewing their breasts, buttocks, or genitalia, except in
exigent circumstances or when such viewing is incidental to routine cell checks.
Such policies and procedures shall require staff of the opposite gender to
announce their presence when entering a resident housing unit. In facilities
(such as group homes) that do not contain discrete housing units, staff of the
opposite gender shall be required to announce their presence when entering an
area where residents are likely to be showering, performing bodily functions, or
changing clothing.
Residents are able to shower, perform bodily functions, and change clothes without staff of
the opposite gender viewing them, supported by policy. This practice was confirmed
through interviews with residents and staff. No residents interviewed reported ever having
been naked in full view of the opposite gender staff while showering, changing clothes, and
performing bodily functions. During the site review a direct care staff member explained
how hygiene practices are conducted and the bathroom procedures. It was observed that
residents have a reasonable amount of privacy during use of the bathroom.
Observations and interviews provide that residents shower, perform bodily functions, and
change clothing without non-medical staff of the opposite gender viewing their buttocks or
genitalia. The staff interviews and observations support that viewing of the camera monitors
does not show residents when they are showering, using the toilet, or changing clothes. The
bathroom area does not allow staff to get a view of the resident while performing bodily
functions. Hygiene practices are performed with the expectations of reasonable privacy for
each resident. Shower and toilet stalls are covered. The majority residents and all staff
revealed that opposite gender staff announce their presence upon entering the living units.
Provision (e):
The facility shall not search or physically examine a transgender or intersex
resident for the sole purpose of determining the resident’s genital status. If the
PREA Audit Report – V7. Page 35 of 156 Facility Name – double click to change
resident’s genital status is unknown, it may be determined during conversations
with the resident, by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted in private by a
medical practitioner.
Policy and staff training prohibit the search of transgender or intersex residents solely for
the purpose of determining the residents’ genital status. Staff interviews verified no such
searches have occurred or would occur at the facility. The facility reports that staff received
the training on conducting searches and searches of transgender and intersex youth. Staff
interviews confirmed they are aware that policy prohibits staff from conducting a physical
examination of a transgender or intersex youth solely for the purpose of determining the
resident’s genital status. When the genital status of a resident is unknown, learning this
information would be part of a broader medical examination conducted by a medical
practitioner in private. The agency has a form that may be used, Statement of Preference
Form, when indicated by a youth regarding the gender of the staff preferred to conduct the
search.
Provision (f):
The agency shall train security staff in how to conduct cross-gender pat-down
searches, and searches of transgender and intersex residents, in a professional
and respectful manner, and in the least intrusive manner possible, consistent
with security needs.
The training curriculum for staff provides information on conducting cross-gender pat-
down searches and searches of transgender and intersex youth. Training materials and
interviews indicate the provision of search techniques consistent with the security needs. A
Department of Juvenile Justice dedicated form, Statement of Preference, may be used for a
youth to identify the sexual preference of the staff preferred to conduct the searches.
Conclusion:
Based on the reviewed documentation and interviews, the Auditor determined compliance
with this standard.
Standard 115.316: Residents with disabilities and residents who are limited
English proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.316 (a)
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
PREA Audit Report – V7. Page 36 of 156 Facility Name – double click to change
and respond to sexual abuse and sexual harassment, including: residents who are deaf or hard
of hearing? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: residents who are blind or have
low vision? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: residents who have intellectual
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: residents who have psychiatric
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: residents who have speech
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Other (if "other," please explain
in overall determination notes)? ☒ Yes ☐ No
▪ Do such steps include, when necessary, ensuring effective communication with residents who
are deaf or hard of hearing? ☒ Yes ☐ No
▪ Do such steps include, when necessary, providing access to interpreters who can interpret
effectively, accurately, and impartially, both receptively and expressively, using any necessary
specialized vocabulary? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
intellectual disabilities? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
limited reading skills? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Are blind
or have low vision? ☒ Yes ☐ No
115.316 (b)
PREA Audit Report – V7. Page 37 of 156 Facility Name – double click to change
▪ Does the agency take reasonable steps to ensure meaningful access to all aspects of the
agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to
residents who are limited English proficient? ☒ Yes ☐ No
▪ Do these steps include providing interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized vocabulary?
☒ Yes ☐ No
115.316 (c)
▪ Does the agency always refrain from relying on resident interpreters, resident readers, or
other types of resident assistance except in limited circumstances where an extended
delay in obtaining an effective interpreter could compromise the resident’s safety, the
performance of first-response duties under §115.64, or the investigation of the resident’s
allegations? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 2.02, Youth Orientation
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Residents
Random Staff
PREA Audit Report – V7. Page 38 of 156 Facility Name – double click to change
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities
(including, for example, residents who are deaf or hard of hearing, those who are blind or
have low vision, or those who have intellectual, psychiatric, or speech disabilities), have
an equal opportunity to participate in or benefit from all aspects of the agency’s efforts
to prevent, detect, and respond to sexual abuse and sexual harassment. Such steps shall
include, when necessary to ensure effective communication with residents who are deaf
or hard of hearing, providing access to interpreters who can interpret effectively,
accurately, and impartially, both receptively and expressively, using any necessary
specialized vocabulary. In addition, the agency shall ensure that written materials are
provided in formats or through methods that ensure effective communication with
residents with disabilities, including residents who have intellectual disabilities, limited
reading skills, or who are blind or have low vision. An agency is not required to take
actions that it can demonstrate would result in a fundamental alteration in the nature of
a service, program, or activity, or in undue financial and administrative burdens, as those
terms are used in regulations promulgated under title II of the Americans With Disabilities
Act, 28 CFR 35.164.
Policies address the provision of support services for Limited English Proficient and disabled
residents by providing residents the equal opportunity to participate in or benefit from all
aspects of the facility’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. Residents are not used as readers or interpreters, confirmed by staff interviews
in compliance with agency policy.
Policy supports interpreter and translation services, including the services for the Deaf by
requiring PREA education to be in formats accessible to all residents. The education staff
provides support services through a certified teacher with the educational background to
modify/adapt information for all residents to understand. Assistance may also be provided by
the treatment staff to ensure all residents’ understanding of the PREA information. Posted
and other PREA information is in English, French Creole and Spanish. The facility also has
access to LanguageLine Solutions for interpreting and translating services, including services
for the Deaf.
Provision (b):
The agency shall take reasonable steps to ensure meaningful access to all aspects of the
agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment
to residents who are limited English proficient, including steps to provide interpreters
who can interpret effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary.
A contract exists between the parent agency and LanguageLine Solutions for professional
PREA Audit Report – V7. Page 39 of 156 Facility Name – double click to change
interpreting services as needed to ensure the residents’ understanding of PREA and other
information. Each resident has an equal opportunity to participate in or benefit from all
aspects of the facility’s efforts to prevent, detect and respond to sexual abuse and sexual
harassment. PREA information is accessible to residents in English, French Creole, and
Spanish; other languages are obtainable where indicated. The facility is capable of providing
access to support services for preventing, detecting, and responding to sexual abuse and
sexual harassment to residents who are Limited English Proficient, including taking steps to
provide professional interpreters who can interpret effectively, accurately, and impartially.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other
types of resident assistants except in limited circumstances where an
extended delay in obtaining an effective interpreter could compromise the
resident’s safety, the performance of first-response duties under §115.364, or
the investigation of the resident’s allegations.
The use of resident readers and interpreters is prohibited except in limited circumstances
where an extended delay in obtaining an interpreter could compromise a resident’s safety;
performance of first responder duties; or investigation of allegations of sexual abuse or
sexual harassment. The facility documents that there is access to services. The education
unit and mental health staff members have the capabilities to provide support services.
Information regarding reporting allegations of sexual abuse and sexual harassment is posted
and accessible in English, French Creole, and Spanish; the facility also has bilingual staff. The
facility has the resources available to get the PREA information translated and printed in
additional languages as needed. The facility has access to the PREA orientation video in
Spanish through the Department of Juvenile Justice.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the facility is
compliant with this standard.
Standard 115.317: Hiring and promotion decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.317 (a)
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who has engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒
Yes ☐ No
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▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who has been convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of force, or coercion, or if the
victim did not consent or was unable to consent or refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who has been civilly or administratively adjudicated to have engaged in the
activity described in the question immediately above? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have
contact with residents who has engaged in sexual abuse in a prison, jail, lockup,
community confinement facility, juvenile facility, or other institution (as defined in 42
U.S.C. 1997)? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have
contact with residents who has been convicted of engaging or attempting to engage in
sexual activity in the community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent or refuse? ☒ Yes ☐
No
▪ Does the agency prohibit the enlistment of services of any contractor who may have
contact with residents who has been civilly or administratively adjudicated to have
engaged in the activity described in the question immediately above? ☒ Yes ☐ No
115.317 (b)
▪ Does the agency consider any incidents of sexual harassment in determining whether to hire or
promote anyone who may have contact with residents? ☒ Yes ☐ No
▪ Does the agency consider any incidents of sexual harassment in determining whether to enlist
the services of any contractor who may have contact with residents? ☒ Yes ☐ No
115.317 (c)
▪ Before hiring new employees, who may have contact with residents, does the agency perform a
criminal background records check? ☒ Yes ☐ No
▪ Before hiring new employees who may have contact with residents, does the agency, consistent
with Federal, State, and local law, make its best efforts to contact all prior institutional employers
for information on substantiated allegations of sexual abuse or any resignation during a pending
investigation of an allegation of sexual abuse? ☒ Yes ☐ No
115.317 (d)
▪ Does the agency perform a criminal background records check and consult applicable child
abuse registries before enlisting the services of any contractor who may have contact with
residents? ☒ Yes ☐ No
PREA Audit Report – V7. Page 41 of 156 Facility Name – double click to change
115.317 (e)
▪ Does the agency either conduct criminal background records checks at least every five years of
current employees and contractors who may have contact with residents or have in place a
system for otherwise capturing such information for current employees? ☒ Yes ☐ No
115.317 (f)
▪ Does the agency ask all applicants and employees who may have contact with residents directly
about previous misconduct described in paragraph (a) of this section in written applications or
interviews for hiring or promotions? ☒ Yes ☐ No
▪ Does the agency ask all applicants and employees who may have contact with residents directly
about previous misconduct described in paragraph (a) of this section in any interviews or written
self-evaluations conducted as part of reviews of current employees? ☒ Yes ☐ No
▪ Does the agency impose upon employees a continuing affirmative duty to disclose any such
misconduct? ☒ Yes ☐ No
115.317 (g)
▪ Does the agency consider material omissions regarding such misconduct, or the provision of
materially false information, grounds for termination? ☒ Yes ☐ No
115.317 (h)
▪ Does the agency provide information on substantiated allegations of sexual abuse or sexual
harassment involving a former employee upon receiving a request from an institutional
employer for whom such employee has applied to work? (N/A if providing information on
substantiated allegations of sexual abuse or sexual harassment involving a former employee is
prohibited by law.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
PREA Audit Report – V7. Page 42 of 156 Facility Name – double click to change
Documents:
Facility Policy 1.01, Background Screening of Employees and Volunteers
Facility Policy 1.02, Five-Year Screening
Facility Policy 6.13, PREA
Agency Policy FDJJ 1800, Background Screening and Hiring Practice
Agency Policy FDJJ 1919, PREA
Personnel Records
Interview:
Human Resources Staff
Provisions (a) & (f):
(a): The agency shall not hire or promote anyone who may have contact with
residents, and shall not enlist the services of any contractor who may have
contact with residents, who—
(1) Has engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42
U.S.C. 1997);
(2) Has been convicted of engaging or attempting to engage in sexual activity in
the community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent or refuse; or
(3) Has been civilly or administratively adjudicated to have engaged in the
activity described in paragraph (a)(2) of this section.
(f): The agency shall also ask all applicants and employees who may have
contact with residents directly about previous misconduct described in
paragraph (a) of this section in written applications or interviews for hiring or
promotions and in any interviews or written self-evaluations conducted as part
of reviews of current employees. The agency shall also impose upon employees
a continuing affirmative duty to disclose any such misconduct.
Policies address hiring and other personnel matters, including and not limited to promotion
processes and decisions, position descriptions, and background checks, including child abuse
registries. The background checks occur initially and every five years thereafter, aligned with
agency Policy. The personnel files include the completed background checks and hiring
documents. Background checks are obtained through the Florida Department of Juvenile
PREA Audit Report – V7. Page 43 of 156 Facility Name – double click to change
Justice, Background Screening Unit.
Through the employment application process, prior to hire and promotion, applicants are
asked to verify, in writing, the following information which is a part of the background
screening information packet:
· Have engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997);
· Have been convicted of engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or coercion, or if the victim
did not consent or was unable to consent or refuse;
· Have been civilly or administratively adjudicated to have engaged in the activity
described above.
The interview and a review of policies provide details about the hiring process, completion
of background checks, and grounds for termination. The forms completed and included in
the personnel files are responsive to the provisions of this standard. All applicants are asked
about any prior misconduct involving any sexual activity. The documentation, interview and
policies support the facility does not hire anyone who has engaged in sexual abuse or
anyone who has used or attempted to use force in the community to engage in sexual
abuse. This documentation is a part of the background information packet, required for
conducting the background checks.
Provision (b):
The agency shall consider any incidents of sexual harassment in determining
whether to hire or promote anyone, or to enlist the services of any contractor,
who may have contact with residents.
Policies support that the facility does not hire or promote anyone who has been civilly or
administratively adjudicated or have been convicted of engaging in or attempted to engage
in sexual activity by any means. The interview was aligned with the standard and the
documentation shows the inquiries made during the application process regarding previous
misconduct. Policy and the interview indicated the facility considers any incidents of sexual
harassment in determining whether to hire or promote anyone, or to enlist the services of
any contractor or volunteer, who may have contact with residents. No applicant will be
considered for employment if a background check reveals any history of inappropriate
sexual behavior or arrest for inappropriate sexual behavior.
Provisions (c) & (d):
(c): Before hiring new employees, who may have contact with residents, the
agency shall:
PREA Audit Report – V7. Page 44 of 156 Facility Name – double click to change
(1) Perform a criminal background records check;
(2) Consult any child abuse registry maintained by the State or locality in which
the employee would work; and
(3) Consistent with Federal, State, and local law, make its best efforts to
contact all prior institutional employers for information on substantiated
allegations of sexual abuse or any resignation during a pending investigation of
an allegation of sexual abuse.
(d): The agency shall also perform a criminal background records check, and
consult applicable child abuse registries, before enlisting the services of any
contractor who may have contact with residents.
The background check process includes consulting a child abuse registry as confirmed
during the interview and review of documentation. The prospective employee or contractor
also has to be cleared through the Florida Department of Children and Families. Best efforts
are made to identify information of incidents or allegations of sexual abuse by a prospective
employee.
Provision (e):
The agency shall either conduct criminal background records checks at least
every five years of current employees and contractors who may have contact
with residents or have in place a system for otherwise capturing such
information for current employees.
The facility has not been in operation under the current contractor and there was only one
employee requiring a five-year background screening and the screening had been completed.
The human resources staff is familiar with the policy and practice that background screenings
are to be conducted every five years.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false
information, shall be grounds for termination.
The omission of sexual misconduct information or providing false information is grounds
for termination. Staff members have a continuing duty to report related misconduct;
employees are informed during new employee orientation that they have a continuing
affirmative duty to disclose any such misconduct. Additionally, the facility is notified
electronically through the Background Screening Unit if an employee is arrested.
PREA Audit Report – V7. Page 45 of 156 Facility Name – double click to change
Provision (h):
Unless prohibited by law, the agency shall provide information on substantiated
allegations of sexual abuse or sexual harassment involving a former employee
upon receiving a request from an institutional employer for whom such
employee has applied to work.
The interview revealed that when a former employee applies for work at another institution,
upon the request from that institution, the request will be forwarded to regional personnel staff
for resolution.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the
facility meets the provisions of the standard.
Standard 115.318: Upgrades to facilities and technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.318 (a)
▪ If the agency designed or acquired any new facility or planned any substantial expansion or
modification of existing facilities, did the agency consider the effect of the design, acquisition,
expansion, or modification upon the agency’s ability to protect residents from sexual abuse?
(N/A if agency/facility has not acquired a new facility or made a substantial expansion to existing
facilities since August 20, 2012, or since the last PREA audit, whichever is later.) ☐ Yes ☐
No ☒ NA
115.318 (b)
▪ If the agency installed or updated a video monitoring system, electronic surveillance system, or
other monitoring technology, did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if agency/facility has not installed
or updated a video monitoring system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit, whichever is later.) ☐ Yes
☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
PREA Audit Report – V7. Page 46 of 156 Facility Name – double click to change
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Agency Policy FDJJ 1919, PREA
Annual Staffing Plan Assessment
Interview:
Superintendent
Provision (a):
If the agency designed or acquired any new facility or planned any substantial
expansion or modification of existing facilities, the agency considered the effect
of the design, acquisition, expansion, or modification upon the agency’s ability
to protect residents from sexual abuse.
There have not been any major renovations to the physical structure since the last PREA
audit.
Provision (b):
If the agency installed or updated a video monitoring system, electronic
surveillance system, or other monitoring technology, the agency considered
how such technology may enhance the agency’s ability to protect residents
from sexual abuse.
The camera system supplements direct supervision provided to residents by staff. The system
was demonstrated and explained to the Auditor by the control room operator and
superintendent during the comprehensive site review. There are monitors in the Superintendent
and Assistant Superintendent’s offices. A new system has been installed since the last PREA audit.
It was taken into consideration how the addition of enhanced technology may protect residents
and staff such as zoom capabilities; enhanced pictures; and storage of footage for up to 30 days.
Conclusion:
The facility is compliant with this standard.
PREA Audit Report – V7. Page 47 of 156 Facility Name – double click to change
RESPONSIVE PLANNING
Standard 115.321: Evidence protocol and forensic medical examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.321 (a)
▪ If the agency is responsible for investigating allegations of sexual abuse, does the agency follow
a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence
for administrative proceedings and criminal prosecutions? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.)
☒ Yes ☐ No ☐ NA
115.321 (b)
▪ Is this protocol developmentally appropriate for youth where applicable? (N/A if the
agency/facility is not responsible for conducting any form of criminal OR administrative sexual
abuse investigations.) ☒ Yes ☐ No ☐ NA
▪ Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of
the U.S. Department of Justice’s Office on Violence Against Women publication, “A National
Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is
not responsible for conducting any form of criminal OR administrative sexual abuse
investigations.) ☒ Yes ☐ No ☐ NA
115.321 (c)
▪ Does the agency offer all victims of sexual abuse access to forensic medical examinations,
whether on-site or at an outside facility, without financial cost, where evidentiarily or medically
appropriate? ☒ Yes ☐ No
▪ Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual
Assault Nurse Examiners (SANEs) where possible? ☒ Yes ☐ No
▪ If SAFEs or SANEs cannot be made available, is the examination performed by other qualified
medical practitioners (they must have been specifically trained to conduct sexual assault
forensic exams)? ☒ Yes ☐ No
▪ Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
115.321 (d)
▪ Does the agency attempt to make available to the victim a victim advocate from a rape crisis
center? ☒ Yes ☐ No
PREA Audit Report – V7. Page 48 of 156 Facility Name – double click to change
▪ If a rape crisis center is not available to provide victim advocate services, does the agency
make available to provide these services a qualified staff member from a community-based
organization, or a qualified agency staff member? (N/A if the agency always makes a victim
advocate from a rape crisis center available to victims.) ☒ Yes ☐ No ☐ NA
▪ Has the agency documented its efforts to secure services from rape crisis centers?
☒ Yes ☐ No
115.321 (e)
▪ As requested by the victim, does the victim advocate, qualified agency staff member, or
qualified community-based organization staff member accompany and support the victim
through the forensic medical examination process and investigatory interviews? ☒ Yes ☐ No
▪ As requested by the victim, does this person provide emotional support, crisis intervention,
information, and referrals? ☒ Yes ☐ No
115.321 (f)
▪ If the agency itself is not responsible for investigating allegations of sexual abuse, has the
agency requested that the investigating agency follow the requirements of paragraphs (a)
through (e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND
administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
115.321 (g)
▪ Auditor is not required to audit this provision.
115.321 (h)
▪ If the agency uses a qualified agency staff member or a qualified community-based staff
member for the purposes of this section, has the individual been screened for appropriateness
to serve in this role and received education concerning sexual assault and forensic examination
issues in general? (N/A if agency always makes a victim advocate from a rape crisis center
available to victims.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
PREA Audit Report – V7. Page 49 of 156 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Correspondence
PREA Compliance Form
Interviews:
Random Staff
Medical Staff
Mental Health Staff
Superintendent
PREA Compliance Manager
Advocacy Agency Representative
Provisions (a) & (b):
(a): To the extent the agency is responsible for investigating allegations of
sexual abuse, the agency shall follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions. (b): The protocol shall be
developmentally appropriate for youth and, as appropriate, shall be adapted
from or otherwise based on the most recent edition of the U.S. Department of
Justice’s Office on Violence Against Women publication, “A National Protocol for
Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols developed after 2011.
Administrative investigations are conducted by the Florida Department of Juvenile Justice
(DJJ), Office of Inspector General (OIG), agency investigators. Allegations of sexual abuse
are also reported to the Department of Children and Families and local law enforcement.
The policy will be followed regarding investigations of sexual abuse in accordance with the
standard. The PREA Compliance Form is intended to be provided to law enforcement to
ensure the PREA Standards are followed. The previous interview with DJJ investigative staff
and random staff confirmed awareness of protocol for obtaining usable physical evidence
PREA Audit Report – V7. Page 50 of 156 Facility Name – double click to change
and knowledge of the entities responsible for conducting investigations. The protocol for
investigations is appropriate for youth. The DJJ investigators are also aware of the PREA
Compliance Form and investigation protocols. The facility staff is not responsible for
conducting investigations.
Provision (c):
The agency shall offer all residents who experience sexual abuse access to
forensic medical examinations whether on-site or at an outside facility, without
financial cost, where evidentiarily or medically appropriate. Such examinations
shall be performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual
Assault Nurse Examiners (SANEs) where possible. If SAFEs or SANEs cannot be
made available, the examination can be performed by other qualified medical
practitioners. The agency shall document its efforts to provide SAFEs or SANEs.
A Memorandum of Understanding (MOU) exists between the facility and the Crisis Center
of Tampa Bay. Forensic medical examinations will be conducted at the Crisis Center of Tampa Bay
by a qualified medical practitioner trained to meet the needs of victims of sexual assault.
Continuity of care will be provided at the facility to include medical and mental health
follow-up services such as follow-up testing and treatment services; intensive counseling;
and follow-up with facility’s contract medical doctor and psychiatrist. Forensic medical
examinations will be provided at no cost to the victim, per policy and printed information of
the Crisis Center of Tampa Bay. No forensic medical examinations were conducted or
required during this audit period. Information regarding the advocacy agency is posted in
the facility for residents, staff, and visitors to see.
Provisions (d) & (e):
(d): The agency shall attempt to make available to the victim a victim advocate
from a rape crisis center. If a rape crisis center is not available to provide victim
advocate services, the agency shall make available to provide these services a
qualified staff member from a community-based organization or a qualified
agency staff member. Agencies shall document efforts to secure services from
rape crisis centers. For the purpose of this standard, a rape crisis center refers to
an entity that provides intervention and related assistance, such as the services
specified in 42 U.S.C. 14043g(b)(2)(C), to victims of sexual assault of all ages. The
agency may utilize a rape crisis center that is part of a governmental unit as long
as the center is not part of the criminal justice system (such as a law
enforcement agency) and offers a comparable level of confidentiality as a
nongovernmental entity that provides similar victim services. (e): As requested
by the victim, the victim advocate, qualified agency staff member, or qualified
community- based organization staff member shall accompany and support the
PREA Audit Report – V7. Page 51 of 156 Facility Name – double click to change
victim through the forensic medical examination process and investigatory
interviews and shall provide emotional support, crisis intervention, information,
and referrals.
Victim advocacy services will be provided by the Crisis Center of Tampa Bay as which provides a
range of services. The MOU outlines the services to be provided and the responsibilities of
the facility including provision of a private room for advocacy services; distribution of
advocacy materials; and provision of a meeting room for group education or support groups
as needed. The advocacy agency follows all applicable laws and regulations with respect to
confidentiality. The victim advocacy services to the residents include but are not limited to
the following: 24-hour hotline services; emotional support; accompaniment; and referrals;
and prevention programming.
Information regarding victim advocacy services is provided to the residents during the
intake process and is provided through the accessibility of posted information. During PREA
education sessions, auxiliary aids, interpreter/language services and accommodations due to
a disability are accessible by the facility as needed and at no cost to the victim.
The interviews with the six out of 10 residents did not convey specific knowledge regarding
the services provided by the advocacy agency. A corrective action was implemented and a
refresher education session was conducted with all residents. The sign-in sheets and outline
of the refresher education sessions were provided along with the confirmation of the training
by the State Compliance Director. The sign-in sheets were signed by the instructor.
Provisions (f) & (g):
(f): To the extent the agency itself is not responsible for investigating allegations
of sexual abuse, the agency shall request that the investigating agency follow the
requirements of paragraphs (a) through (f) of this section.
(g): The requirements of paragraphs (a) through (f) of this section shall also apply
to:
(1) Any State entity outside of the agency that is responsible for
investigating allegations of sexual abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for
investigating allegations of sexual abuse in juvenile facilities.
Florida Department of Juvenile Justice/Office of Inspector General investigators conduct
administrative investigations in accordance with agency policy, and the protocols as
outlined on the PREA Compliance Form, aligned with the Standard. Investigations of
allegations of sexual abuse or sexual harassment that are criminal in nature are investigated
by local law enforcement.
PREA Audit Report – V7. Page 52 of 156 Facility Name – double click to change
Provision (h):
For the purposes of this standard, a qualified agency staff member or a
qualified community-based staff member shall be an individual who has been
screened for appropriateness to serve in this role and has received education
concerning sexual assault and forensic examination issues in general.
The facility has a MOU with the Crisis Center of Tampa Bay for victim advocacy services. It
is in the process of being signed. Services will be provided to the residents upon request
by the resident, facility staff or law enforcement as confirmed through an interview with a
representative of the victim advocacy agency and the Superintendent.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with the provisions of this standard.
Standard 115.322: Policies to ensure referrals of allegations for
investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.322 (a)
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual harassment? ☒ Yes ☐ No
115.322 (b)
▪ Does the agency have a policy and practice in place to ensure that allegations of sexual abuse
or sexual harassment are referred for investigation to an agency with the legal authority to
conduct criminal investigations, unless the allegation does not involve potentially criminal
behavior? ☒ Yes ☐ No
▪ Has the agency published such policy on its website or, if it does not have one, made the policy
available through other means? ☒ Yes ☐ No
▪ Does the agency document all such referrals? ☒ Yes ☐ No
115.322 (c)
▪ If a separate entity is responsible for conducting criminal investigations, does the policy describe
the responsibilities of both the agency and the investigating entity? (N/A if the agency/facility is
responsible for criminal investigations. See 115.21(a).) ☒ Yes ☐ No ☐ NA
PREA Audit Report – V7. Page 53 of 156 Facility Name – double click to change
115.322 (d)
▪ Auditor is not required to audit this provision.
115.322 (e)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13. PREA
Agency Policy FDJJ 1919, PREA
Investigation Reports
DJJ Agency Website
Interviews:
Random Staff
Investigative Staff
Agency Head Designee
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
PREA Audit Report – V7. Page 54 of 156 Facility Name – double click to change
Provisions (b) and (c):
(b): The agency shall have in place a policy to ensure that allegations of sexual
abuse or sexual harassment are referred for investigation to an agency with the
legal authority to conduct criminal investigations, unless the allegation does not
involve potentially criminal behavior. The agency shall publish such policy on its
website or, if it does not have one, make the policy available through other
means. The agency shall document all such referrals. (c): If a separate entity is
responsible for conducting criminal investigations, such publication shall
describe the responsibilities of both the agency and the investigating entity.
Policy and reporting information are located on the DJJ website and posted within the
facility, accessible to the public as well as staff and residents. PREA information was located
in the lobby to make reporting information more accessible for third-parting reporting.
Policies, investigation reports, and interviews confirmed allegations of sexual abuse and
sexual harassment are investigated. Administrative investigations are conducted by trained
DJJ/OIG investigators. Allegations of sexual abuse and sexual harassment that are criminal in
nature are referred to local law enforcement. Allegations are also reported to the Florida
Department of Children and Families.
Provision (d):
Any State entity responsible for conducting administrative or criminal
investigations of sexual abuse or sexual harassment in juvenile facilities shall
have in place a policy governing the conduct of such investigations.
The DJJ/OIG has policies governing administrative investigations. The agency utilizes trained
investigators. The previous interview with the investigative staff and agency investigation
reports confirm that administrative investigations are conducted by a trained investigator and
allegations that are criminal in nature are referred to local law enforcement.
Provision (e):
Any Department of Justice component responsible for conducting
administrative or criminal investigations of sexual abuse or sexual harassment
in juvenile facilities shall have in place a policy governing the conduct of such
investigations.
The Department of Justice is not responsible for conducting administrative or criminal
investigations of sexual abuse or sexual harassment in this facility.
PREA Audit Report – V7. Page 55 of 156 Facility Name – double click to change
TRAINING AND EDUCATION
Standard 115.331: Employee training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.331 (a)
▪ Does the agency train all employees who may have contact with residents on its zero-tolerance
policy for sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on how to fulfill their
responsibilities under agency sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on residents’ right to
be free from sexual abuse and sexual harassment ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on the right of
residents and employees to be free from retaliation for reporting sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on the dynamics of
sexual abuse and sexual harassment in confinement? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on the common
reactions of sexual abuse and sexual harassment victims? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on how to detect and
respond to signs of threatened and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on how to avoid
inappropriate relationships with residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on how to
communicate effectively and professionally with residents, including lesbian, gay, bisexual,
transgender, intersex, or gender nonconforming residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on how to comply
with relevant laws related to mandatory reporting of sexual abuse to outside authorities?
☒ Yes ☐ No
▪ Does the agency train all employees on all relevant laws regarding the applicable age of
consent? ☒ Yes ☐ No
115.331 (b)
PREA Audit Report – V7. Page 56 of 156 Facility Name – double click to change
▪ Is such training tailored to the gender of the residents at the employee’s facility? ☒ Yes ☐ No
▪ Have employees received additional training if reassigned from a facility that houses only male
residents to a facility that houses only female residents, or vice versa? ☒ Yes ☐ No
115.331 (c)
▪ Have all current employees who may have contact with residents received such training?
☒ Yes ☐ No
▪ Does the agency provide each employee with refresher training every two years to ensure that
all employees know the agency’s current sexual abuse and sexual harassment policies and
procedures? ☒ Yes ☐ No
▪ In years in which an employee does not receive refresher training, does the agency provide
refresher information on current sexual abuse and sexual harassment policies? ☒ Yes ☐ No
115.331 (d)
▪ Does the agency document, through employee signature or electronic verification, that
employees understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA Training
Curricula
Training Records
PREA Audit Report – V7. Page 57 of 156 Facility Name – double click to change
In-service Training Plan
Interviews:
Random Staff
Provisions (a) and (c):
(a): The agency shall train all employees who may have contact with residents on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency sexual abuse and sexual
harassment prevention, detection, reporting, and response policies and
procedures;
(3) Residents’ right to be free from sexual abuse and sexual harassment;
(4) The right of residents and employees to be free from retaliation for
reporting sexual abuse and sexual harassment;
(5) The dynamics of sexual abuse and sexual harassment in juvenile facilities;
(6) The common reactions of juvenile victims of sexual abuse and
sexual harassment;
(7) How to detect and respond to signs of threatened and actual sexual abuse
and how to distinguish between consensual sexual contact and sexual abuse
between residents;
(8) How to avoid inappropriate relationships with residents;
(9) How to communicate effectively and professionally with residents,
including lesbian, gay, bisexual, transgender, intersex, or gender
nonconforming residents; and
(10) How to comply with relevant laws related to mandatory reporting of sexual
abuse to outside authorities;
(11) Relevant laws regarding the applicable age of consent.
(c): All current employees who have not received such training shall be trained
within one year of the effective date of the PREA standards, and the agency
shall provide each employee with refresher training every two years to ensure
that all employees know the agency’s current sexual abuse and sexual
harassment policies and procedures. In years in which an employee does not
PREA Audit Report – V7. Page 58 of 156 Facility Name – double click to change
receive refresher training, the agency shall provide refresher information on
current sexual abuse and sexual harassment policies.
Policies address PREA related training for staff which is provided initially upon employment
and annually. Interviewed staff members were generally familiar with the PREA information.
Policy and the In-service Training Plan provide for refresher training to occur annually.
PREA training is provided to staff, as indicated by a review of facility and agency policies,
electronic records, PowerPoint presentations, training documents, and interviews. The
facility reports all staff members that may have contact with residents have been trained or
re-trained on the PREA Standards requirements.
Provision (b):
Such training shall be tailored to the unique needs and attributes of residents
of juvenile facilities and to the gender of the residents at the employee’s
facility. The employee shall receive additional training if the employee is
reassigned from a facility that houses only male residents to a facility that
houses only female residents, or vice versa.
The facility houses males and staff training does consider the needs of the population served
as indicated by the interviews. The policies and interviews support training being tailored to
the needs and attributes of the population served. The program provides services that are
tailored to the special needs of the population served and contribute to peer support.
Interaction with the residents, observations, staff and residents’ interactions indicate the
positive interactive culture within the facility. All staff within the facility are provided PREA
training.
Provision (d):
The agency shall document, through employee signature or electronic
verification that employees understand the training they have received.
The PREA training reviewed was documented electronically and verified through staff
interviews, policy review, and the agency’s training curricula.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility compliant with the standard.
Standard 115.332: Volunteer and contractor training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.332 (a)
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▪ Has the agency ensured that all volunteers and contractors who have contact with residents
have been trained on their responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and procedures? ☒ Yes ☐ No
115.332 (b)
▪ Have all volunteers and contractors who have contact with residents been notified of the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and informed
how to report such incidents (the level and type of training provided to volunteers and
contractors shall be based on the services they provide and level of contact they have with
residents)? ☒ Yes ☐ No
115.332 (c)
▪ Does the agency maintain documentation confirming that volunteers and contractors
understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Training Curriculum
Interviews:
Superintendent
Contractors
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Provision (a):
The agency shall ensure that all volunteers and contractors who have contact
with residents have been trained on their responsibilities under the agency’s
sexual abuse and sexual harassment prevention, detection, and response
policies and procedures.
Policy requires volunteers and contractors who have contact with residents to be trained
on PREA and their responsibilities regarding sexual abuse prevention, detection, and
response to allegations of sexual abuse and sexual harassment. The training curriculum
includes but is not limited to reporting allegations of sexual abuse and sexual harassment,
related definitions and maintaining professional relationships with residents. The
interviews revealed knowledge of the agency’s zero-tolerance policy, how to report
allegations of sexual abuse and other PREA related components. The contractors
interviewed provide education services to the residents. The facility does not have any volunteers and
has not had any in the past year; however, policy and a training curriculum exists if the situation should change.
Provision (b):
The level and type of training provided to volunteers and contractors shall be
based on the services they provide and level of contact they have with residents,
but all volunteers and contractors who have contact with residents shall be
notified of the agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment and informed how to report such incidents.
The interviews and review of documentation revealed the PREA training informs the
participants of their role in reporting allegations of sexual abuse and sexual harassment.
The participants are informed of their responsibilities regarding sexual abuse prevention,
detection, and response to an allegation of sexual abuse or sexual harassment, including
how to report. The training is based on the services provided by the contractors and
volunteers. The interviews confirmed that the review of the zero-tolerance policy is
included in the PREA training. PREA education is available within the facility and through the
Department of Juvenile Justice online course or through downloading the booklet for
review.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
Training documentation and interviews confirmed the receipt and awareness of PREA training
by the contractors. The records of the educators are maintained by the educator of their
contract agency. The interviews are reflective of the PREA training.
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Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with the provisions of this standard.
Standard 115.333: Resident education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.333 (a)
▪ During intake, do residents receive information explaining, in an age-appropriate fashion, the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ During intake, do residents receive information explaining how to report incidents or suspicions
of sexual abuse or sexual harassment? ☒ Yes ☐ No
115.333 (b)
▪ Within 10 days of intake, does the agency provide comprehensive education to residents either
in person or through video regarding: Their rights to be free from sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide comprehensive education to residents either
in person or through video regarding: Their rights to be free from retaliation for reporting such
incidents? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide comprehensive education to residents either
in person or through video regarding: Agency policies and procedures for responding to such
incidents? ☒ Yes ☐ No
115.333 (c)
▪ Have all residents received the comprehensive education referenced in 115.333(b)? ☒ Yes ☐
No
▪ Do residents receive education upon transfer to a different facility to the extent that the policies
and procedures of the resident’s new facility differ from those of the previous facility?
☒ Yes ☐ No
115.333 (d)
▪ Does the agency provide resident education in formats accessible to all residents including
those who are limited English proficient? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who are deaf? ☒ Yes ☐ No
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▪ Does the agency provide resident education in formats accessible to all residents including
those who are visually impaired? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who are otherwise disabled? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who have limited reading skills? ☒ Yes ☐ No
115.333 (e)
▪ Does the agency maintain documentation of resident participation in these education sessions?
☒ Yes ☐ No
115.333 (f)
▪ In addition to providing such education, does the agency ensure that key information is
continuously and readily available or visible to residents through posters, resident handbooks,
or other written formats? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Acknowledgement Statements
Orientation Checklist
Brochures
PREA Audit Report – V7. Page 63 of 156 Facility Name – double click to change
Posted Information
Student Handbook
PREA Video
Interviews:
Residents
Targeted Interviewees
Intake Staff
Provisions (a) & (b):
(a): During the intake process, residents shall receive information explaining, in an age-
appropriate fashion, the agency’s zero tolerance policy regarding sexual abuse and sexual
harassment and how to report incidents or suspicions of sexual abuse or sexual harassment. (b):
Within 10 days of intake, the agency shall provide comprehensive age-appropriate education to
residents either in person or through video regarding their rights to be free from sexual abuse
and sexual harassment and to be free from retaliation for reporting such incidents, and regarding
agency policies and procedures for responding to such incidents.
Youth receive information at the time of intake about PREA including the zero-tolerance policy of the facility
and how to report allegations of sexual abuse and sexual harassment. Policies provide that all residents admitted
receive PREA education. Residents receive directions on how to report allegations of sexual abuse and sexual
harassment; and the right to be free from retaliation for reporting, according to the documentation and
interview with the intake staff. The residents have a clear understanding of the aforementioned and the various
ways of how to report allegations of sexual abuse and sexual harassment.
A review of the education materials indicated the information provided to the residents is age-appropriate. It
was revealed that PREA refresher education sessions are conducted during group sessions as a rotating topic
among treatment topics covered in group activities. The intake staff is also available to address questions that a
resident may have about PREA. The residents initially sign acknowledgement statements which represent receipt
of the PREA information provided. The PREA video is shown to residents and an video in Spanish is available if
needed.
The interviews with the residents revealed the need for a refresher education session focusing on the advocacy
agency and the services provided to victims of sexual abuse to ensure the residents’ clear and un-contradicted
understanding of the information. Six out of 10 residents interviewed did not have a clear understanding of the
information provided regarding advocacy services. It was recommended that additional emphasis be placed on
the identification and purpose of the advocacy agency and the services provided and that it be rotated in the
group sessions more often. The corrective action of conducting a refresher PREA education session regarding
the victim advocacy services and agency, Crisis Center of Tampa Bay, was implemented. The superintendent and
the PREA coordinator confirmed the refresher education sessions and provided documentation of training
log/sign-in sheet which included the training topic that supported the occurrence of the refresher PREA
education session.
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Provision (c):
Current residents who have not received such education shall be educated within one year of the
effective date of the PREA standards, and shall receive education upon transfer to a different
facility to the extent that the policies and procedures of the resident’s new facility differ from
those of the previous facility.
Based on the evidence shown documenting the PREA education sessions in Provisions (a) and (b), including
corrective actions and interviews, all residents received PREA education. The facility reports that youth were
admitted to the facility during the past 12 months all participated in PREA education sessions. Formal interviews
and informal conversations with residents and interview with intake staff and review of documentation support
that all youth admitted to the facility receive PREA education during the intake process. Acknowledgement
statements and the interviews indicate that general PREA education is provided and the corrective action
supplemented the general education by providing customized information regarding outside advocacy services
which will be incorporated and emphasized in the future PREA education sessions. Policy provides that all youth
admitted to the facility receive PREA education.
Provision (d):
The agency shall provide resident education in formats accessible to all residents, including those
who are limited English proficient, deaf, visually impaired, or otherwise disabled, as well as to
residents who have limited reading skills.
The facility has the capability to provide the PREA education in formats accessible to all residents including those
who may be hearing impaired; Deaf; have intellectual, psychiatric and speech disabilities; low vision; blind; limited
reading, limited English proficient, and based on the individual need of the resident, per policy. The education
unit is also a resource for accessibility, supportive services, and translation services and other accommodations.
Assistance may also be provided by the mental health staff to ensure all residents’ understanding of the PREA
information.
Policy provides for interpreter and translation services. There is documentation and policy that provide
information and accessibility for the accommodations for residents with special needs in this area. The education
staff provides services through certified teachers with the educational background to modify/adapt information
for all residents to understand. Posted and other printed PREA information is in English and Spanish. The
facility’s parent agency has a contract with LanguageLine Solutions for translation and interpreting services that
may be used by their facilities as needed. A customer care representative confirmed the available translating
services, including services for the Deaf.
The random staff interviews revealed a practice of residents not used as translators or readers for other
residents. There is a collective awareness of the availability of bilingual staff and professional translating and
interpreting services. The facility has knowledge of the youth’s arrival to the facility prior to the admission date.
This time period provides for the identified staff to make plans to accommodate the special needs of residents.
The special arrangements are coordinated by treatment team staff in collaboration with the Superintendent.
PREA posters, information sheets, and other printed materials are collectively available in English, Spanish,
Creole, and there is access to other languages when indicated.
Provision (e):
The agency shall maintain documentation of resident participation in these education sessions.
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Signed acknowledgement statements were reviewed which supported the residents’ involvement in PREA
education sessions. The residents’ interviews revealed the exposure to PREA through the PREA education
sessions. The residents were aware of how to report allegations of sexual abuse and sexual harassment and that
they would not be punished for reporting such. The refresher PREA education session and receipt of advocacy
agency information provided enhanced PREA education.
Provision (f):
In addition to providing such education, the agency shall ensure that key information is continuously and
readily available or visible to residents through posters, resident handbooks, or other written formats.
The PREA education materials provide residents information on how to report allegations of sexual harassment
and sexual abuse. PREA information is posted and provided to residents to assist in eliminating incidents of
sexual abuse and sexual harassment. The printed materials provide information on sexual abuse and sexual
harassment; steps victims may take; and reporting information. Each resident is provided a handbook and an
orientation packet which also contains PREA information. PREA-related information was observed posted or
displayed throughout the facility.
PREA signage is placed at varying eye levels and are colorful or graphic with consistent messages. The interviews
with the residents revealed they know where to find information on the wall if they need it. The interviews and
informal conversations with residents and staff confirmed the PREA audit notices had been up for the required
time period and that the PREA information is always on the walls. PREA information is located in the housing
area and common areas for residents, staff, contractors, and visitors.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and observations, the Auditor
determined the facility is compliant with the provisions of this standard.
Standard 115.334: Specialized training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.334 (a)
▪ In addition to the general training provided to all employees pursuant to §115.31, does the
agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its
investigators receive training in conducting such investigations in confinement settings? (N/A if
the agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.321(a).) ☒ Yes ☐ No ☐ NA
115.334 (b)
▪ Does this specialized training include techniques for interviewing sexual abuse victims? (N/A if
the agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.321(a).) ☒ Yes ☐ No ☐ NA
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▪ Does this specialized training include proper use of Miranda and Garrity warnings? (N/A if the
agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.321(a).) ☒ Yes ☐ No ☐ NA
▪ Does this specialized training include sexual abuse evidence collection in confinement settings?
(N/A if the agency does not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).) ☒ Yes ☐ No ☐ NA
▪ Does this specialized training include the criteria and evidence required to substantiate a case
for administrative action or prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See 115.321(a).)
☒ Yes ☐ No ☐ NA
115.334 (c)
▪ Does the agency maintain documentation that agency investigators have completed the
required specialized training in conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse investigations. See 115.321(a).)
☒ Yes ☐ No ☐ NA
115.334 (d)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Agency Policy FDJJ 1919, PREA
Training Curriculum
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Interviews:
Superintendent
Investigative Staff
Provisions (a) & (b):
(a): In addition to the general training provided to all employees pursuant to
§115.331, the agency shall ensure that, to the extent the agency itself conducts
sexual abuse investigations, its investigators have received training in
conducting such investigations in confinement settings. (b): Specialized training
shall include techniques for interviewing juvenile sexual abuse victims, proper
use of Miranda and Garrity warnings, sexual abuse evidence collection in
confinement settings, and the criteria and evidence required to substantiate a
case for administrative action or prosecution referral.
Administrative investigations are conducted by the Department of Juvenile Justice (DJJ),
Office of Inspector General (OIG). PREA training is required in addition to the specialized
training regarding conducting administrative investigations. Allegations of sexual abuse are
referred for investigation to be conducted by law enforcement. The previous interview with
investigative staff and review of agency documents confirmed administrative investigations
are conducted by trained investigators within the DJJ/OIG. The specialized training includes
but is not limited to interviewing techniques; proper use of Garrity and Miranda warnings;
preserving evidence; and criteria for supporting a finding of substantiated, unsubstantiated
or unfounded.
Provision (c):
The agency shall maintain documentation that agency investigators
have completed the required specialized training in conducting
sexual abuse investigations.
Training records of the administrative investigators are maintained by the agency that
conducts administrative investigations, DJJ. Allegations of sexual abuse are referred to law
enforcement and the Florida Department of Children and Families, in accordance with policy.
All allegations of sexual abuse and sexual harassment are reported to the Office of
Inspector General.
Provision (d):
Any State entity or Department of Justice component that investigates sexual
abuse in juvenile confinement settings shall provide such training to its agents
and investigators who conduct such investigations.
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The DJJ provides training to its investigators who will conduct administrative investigations at
the contract facilities which was confirmed by interviews. Local law enforcement is
responsible for training their investigators who conduct sexual abuse investigations and
allegations that are criminal in nature. Trained investigators also conduct investigations with
the Department of Children and Families.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with this standard.
Standard 115.335: Specialized training: Medical and Mental Health Care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.335 (a)
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in how to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have any full- or part-time medical
or mental health care practitioners who work regularly in its facilities.) ☒ Yes ☐ No ☐ NA
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in how to preserve physical evidence of
sexual abuse? (N/A if the agency does not have any full- or part-time medical or mental health
care practitioners who work regularly in its facilities.) ☒ Yes ☐ No ☐ NA
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in how to respond effectively and
professionally to victims of sexual abuse and sexual harassment? (N/A if the agency does not
have any full- or part-time medical or mental health care practitioners who work regularly in its
facilities.) ☒ Yes ☐ No ☐ NA
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in how and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the agency does not have any full-
or part-time medical or mental health care practitioners who work regularly in its facilities.)
☒ Yes ☐ No ☐ NA
115.335 (b)
▪ If medical staff employed by the agency conduct forensic examinations, do such medical staff
receive appropriate training to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not employ medical staff.)
☒ Yes ☐ No ☐ NA
115.335 (c)
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▪ Does the agency maintain documentation that medical and mental health practitioners have
received the training referenced in this standard either from the agency or elsewhere? (N/A if
the agency does not have any full- or part-time medical or mental health care practitioners who
work regularly in its facilities.) ☒ Yes ☐ No ☐ NA
115.335 (d)
▪ Do medical and mental health care practitioners employed by the agency also receive training
mandated for employees by §115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners employed by the agency.)
☒ Yes ☐ No ☐ NA
▪ Do medical and mental health care practitioners contracted by or volunteering for the agency
also receive training mandated for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care practitioners contracted by or
volunteering for the agency.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Agency Policy FDJJ 1919, PREA Training
Training Curricula
Training Logs
Interviews:
Mental Health Staff
Medical Staff
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Provision (a):
The agency shall ensure that all full- and part-time medical and mental health
care practitioners who work regularly in its facilities have been trained in:
(1) How to detect and assess signs of sexual abuse and sexual harassment;
(2) How to preserve physical evidence of sexual abuse;
(3) How to respond effectively and professionally to juvenile victims of sexual
abuse and sexual harassment; and
(4) How and to whom to report allegations or suspicions of sexual abuse and
sexual harassment.
Agency policy requires medical and mental health staff members to receive the regular
PREA training as well as the specialized training provided through the agency. Electronic
training logs and interviews document regular PREA training and the specialized training
for medical and mental health staff members and the interviews confirmed the training.
Provision (b):
If medical staff employed by the agency conduct forensic examinations, such
medical staff shall receive the appropriate training to conduct such
examinations.
Forensic examinations are not conducted by facility staff.
Provision (c):
The agency shall maintain documentation that medical and mental health
practitioners have received the training referenced in this standard either from
the agency or elsewhere.
Electronic training logs and interviews with medical and mental health staffs confirmed
receipt of the regular and specialized training. The regular and specialized PREA training is
provided online by the Department of Juvenile Justice. Regular and refresher PREA
trainings are also provided at the facility through sessions incorporated in staff meetings
and training sessions.
Provision (d):
Medical and mental health care practitioners shall also receive the training
mandated for employees under Standard 115.331 or for contractors and
volunteers under Standard 115.332, depending upon the practitioner’s status at
the agency.
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Medical and mental health staff completed the general training that is provided for all
employees as indicated by training documentation and the interviews. The standard PREA
training is provided to all employees and the specialized training is provided online by the
Department of Juvenile Justice and the records are maintained electronically.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with this standard.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION
AND ABUSIVENESS
Standard 115.341: Screening for risk of victimization and abusiveness
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.341 (a)
▪ Within 72 hours of the resident’s arrival at the facility and periodically throughout the resident’s
confinement, are all residents assessed during an intake screening for their risk of being
sexually abused by other residents or sexually abusive toward other residents? ☒ Yes ☐ No
▪ Are all residents assessed upon transfer to another facility for their risk of being sexually abused
by other residents or sexually abusive toward other residents? ☒ Yes ☐ No
115.341 (b)
▪ Are all PREA screening assessments conducted using an objective screening instrument?
☒ Yes ☐ No
115.341 (c)
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (1) Whether the resident has a mental, physical, or developmental
disability? ☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (2) The age of the resident? ☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (3) The physical size and stature of the resident? ☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (3) The resident’s level of emotional and cognitive development?
☒ Yes ☐ No
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▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (4) Whether the resident has previously been incarcerated?
☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (5) The resident’s current charges and offense history?
☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (7) Whether the resident is or is perceived to be gay, lesbian,
bisexual, transgender, intersex, or gender nonconforming (the facility affirmatively asks the
resident about his/her sexual orientation and gender identity AND makes a subjective
determination based on the screener’s perception whether the resident is gender non-
conforming or otherwise may be perceived to be LGBTI)? ☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (8) Whether the resident has previously experienced sexual
victimization? ☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (9) The resident’s own perception of vulnerability? ☒ Yes ☐ No
▪ Does the intake screening consider, at a minimum, the following criteria to assess residents for
risk of sexual victimization: (10) Any other specific information about individual residents that
may indicate heightened needs for supervision, additional safety precautions, or separation from
certain other residents? ☒ Yes ☐ No
115.341 (e)
▪ Has the agency implemented appropriate controls on the dissemination within the facility of
responses to questions asked pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or other residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
PREA Audit Report – V7. Page 73 of 156 Facility Name – double click to change
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Reassessments
Interviews:
Staff Responsible for Risk Screening
Superintendent
PREA Compliance Manager
PREA Coordinators
Residents
Provision (a):
Within 72 hours of the resident’s arrival at the facility and periodically throughout
a resident’s confinement, the agency shall obtain and use information about each
resident’s personal history and behavior to reduce the risk of sexual abuse by or
upon a resident.
Policies collectively provide for each resident to be screened for risk of victimization or
abusiveness prior to room assignment in order to reduce the risk of sexual abuse by or upon
a resident. The interviews and documentation indicate the risk assessment is completed on
the day of admission. The staff responsible for risk screening revealed the questions on the
screening instrument are straightforward and may be asked verbatim. The youth is
interviewed to obtain information about personal history and behavior. The court packet for
the youth is also reviewed to gather pertinent information.
The primary PREA intake screening instrument, Screening for Vulnerability, Victimization
and Sexually Aggressive Behavior (VSAB), is used to assess and document risk. The
interviews revealed the practice of the risk screening being conducted is in accordance with
the policies and Standard. Screening instruments and interview with the staff responsible the
risk screening confirmed the information obtained includes but is not limited to:
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· Prior sexual victimization or abusiveness;
· Resident’s own perception of vulnerability;
· Current charges and offense history;
· Self-identification of resident;
· Intellectual or developmental disabilities;
· Physical disabilities;
· Mental illness or mental disabilities
· Information regarding relationships with other youth
· Confirmation of size and stature
· Confirmation of Age
Policy addresses the occurrence and criteria regarding formal reassessments of residents.
The interview with the staff responsible for risk screening supports reassessments are
conducted if there is an incident or allegation. The average length of stay in the facility is
six months. It is reported that the number of youths admitted to the facility within the
past 12 months who were screened during the admission process for risk of sexual
victimization and the risk of sexually abusing other residents prior to the onsite audit
phase is 75. The risk assessments are accessible to treatment staff. The current resident
files were observed to be maintained in a confidential manner within lockable cabinets in a
locked office.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
An objective screening instrument is used to obtain the information required by the standard,
including but not limited to prior sexual victimization or abusiveness; self- identification;
current charges and offense history; disabilities; and a resident’s concern regarding his/her
own safety. The instrument, VSAB, is tabulated based on the information received where
identified responses can identify any special needs and safety concerns. Assessments are
conducted through the use of the objective primary instrument containing items that
collectively provide a presumptive determination of risk for victimization or abusiveness.
Additional assessment tools are used in the facility in measuring various risks, including
sexual safety.
PREA Audit Report – V7. Page 75 of 156 Facility Name – double click to change
Provision (c):
At a minimum, the agency shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) Any gender nonconforming appearance or manner or identification as
lesbian, gay, bisexual, transgender, or intersex, and whether the resident may
therefore be vulnerable to sexual abuse;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The residents’ own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or separation
from certain other residents.
The Auditor reviewed the screening instrument and determined the items required by this
provision of the standard are included within the instrument. The interview with the staff
responsible for risk screening confirmed awareness of the elements of the risk screening
instrument and the use of the instrument was explained. The resident interviews also
confirmed the administration of the screening instrument and the general inquiries made.
The interviews revealed the practice is that the instrument is administered the first day of
the youth’s admission to the facility.
Provision (d):
This information shall be ascertained through conversations with the resident
during the intake process and medical and mental health screenings; during
classification assessments; and by reviewing court records, case files, facility
behavioral records, and other relevant documentation from the resident’s files.
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The information to complete the risk screening instrument is gleaned from various sources.
Information in determining the risk for victimization or abusiveness is obtained through
interviewing the youth, review of the commitment packet, and other assessments conducted
prior to and after arrival to the facility. Additional information may be obtained from
interviews with parents/guardians where indicated.
The risk screener revealed a conversational and friendly style to obtain information. The
facility is aware of the youth’s pending arrival to the facility and treatment staff has the
opportunity to review the youth’s record in an effort to prepare for the needs of the youth
prior to arrival. Additional assessments and screenings are completed after the youth is
admitted to the facility to obtain supportive information for treatment planning and keeping
the youth safe.
Provision (e):
The agency shall implement appropriate controls on the dissemination within the
facility of responses to questions asked pursuant to this standard in order to
ensure that sensitive information is not exploited to the resident’s detriment by
staff or other residents.
Staff takes appropriate controls to ensure that sensitive information is protected and not
exploited by maintaining the files in a locked and secure manner, behind a locked door in
lockable cabinets. The online information on computers is password protected and is only
accessible to identified staff. The screening instrument is available to case management and
treatment staff. Pertinent information is provided to other staff based on the need to
know. Staff training includes information regarding confidentiality of information concerning
residents.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with this standard.
Standard 115.342: Use of screening information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.342 (a)
▪ Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those residents at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Housing Assignments? ☒ Yes ☐ No
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▪ Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those residents at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Bed assignments? ☒ Yes ☐ No
▪ Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those residents at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Work Assignments? ☒ Yes ☐ No
▪ Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those residents at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Education Assignments? ☒ Yes ☐ No
▪ Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those residents at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Program Assignments? ☒ Yes ☐ No
115.342 (b)
▪ Does the agency isolate residents from others only as a last resort when less restrictive
measures are inadequate to keep them and other residents safe, and then only until an
alternative means of keeping all residents safe can be arranged? ☒ Yes ☐ No
▪ During any period of isolation, does the agency refrain from denying residents daily large-
muscle exercise and any legally required educational programming or special education
services? ☒ Yes ☐ No
▪ Does the agency allow residents in isolation to receive daily visits from a medical or mental
health care clinician? ☒ Yes ☐ No
▪ Does the agency allow residents access to other programs and work opportunities to the extent
possible? ☒ Yes ☐ No
115.342 (c)
▪ Does the agency house lesbian, gay bisexual, transgender, or intersex residents solely on the
basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency consider lesbian, gay, bisexual, transgender, or intersex identification or status
as an indicator of likelihood of being sexually abuse? ☒ Yes ☐ No
115.342 (d)
▪ When deciding whether to assign a transgender or intersex resident to a facility for male or
female residents, does the agency consider, on a case-by-case basis whether a placement
would ensure the resident’s health and safety, and whether a placement would present
management or security problems (NOTE: if an agency by policy or practice assigns residents
to a male or female facility on the basis of anatomy alone, that agency is not in compliance with
this standard)? ☒ Yes ☐ No
▪ When making housing or other program assignments for transgender or intersex residents,
does the agency consider on a case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would present management or security
problems? ☒ Yes ☐ No
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115.342 (e)
▪ Are placement and programming assignments for each transgender or intersex resident
reassessed at least twice each year to review any threats to safety experienced by the resident?
☒ Yes ☐ No
115.342 (f)
▪ Are each transgender or intersex resident’s own views with respect to his or her own safety
given serious consideration when making facility and housing placement decisions and
programming assignments? ☒ Yes ☐ No
115.342 (g)
▪ Are transgender and intersex residents given the opportunity to shower separately from other
residents? ☒ Yes ☐ No
115.342 (h)
▪ If residents are isolated pursuant to 115.342(b), does the facility clearly document: (1) The basis
for the facility’s concern for the resident’s safety; and (2) The reason why no alternative means
of separation can be arranged? ☒ Yes ☐ No
115.342 (i)
▪ Every 30 days, does the facility afford each resident described in paragraph (h) of this section a
review to determine whether there is a continuing need for separation from the general
population? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 2.04, Classification Factors, Procedures, and Reassessments for Activities
PREA Audit Report – V7. Page 79 of 156 Facility Name – double click to change
Facility Policy 6.13, PREA Agency
Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Reassessments
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Residents
Random Staff
Provision (a):
The agency shall use all information obtained pursuant to §115.341 and
subsequently to make housing, bed, program, education, and work assignments
for residents with the goal of keeping all residents safe and free from sexual
abuse.
Policies provide guidance to staff regarding the use of the information obtained from the
screening instrument, VSAB. The interviews indicate the screening and assessment
information and observations are used to inform staff of information regarding housing and
program assignments, and assist in identifying treatment and any special services.
Provision (b):
Residents may be isolated from others only as a last resort when less restrictive
measures are inadequate to keep them and other residents safe, and then only
until an alternative means of keeping all residents safe can be arranged. During
any period of isolation, agencies shall not deny residents daily large-muscle
exercise and any legally required educational programming or special education
services. Residents in isolation shall receive daily visits from a medical or mental
health care clinician. Residents shall also have access to other programs and
work opportunities to the extent possible.
Protective custody is not used regarding a potential or victim of sexual abuse. The facility
does not use isolation as determined through the interviews and observation during the
comprehensive site review. The interviews support the practice of isolation is not used in this
facility. The staff interviews and policy collectively indicate that protective measures will be
taken immediately when needed and includes separating residents; notifying other staff,
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including supervisors and administrators; closer supervision; and documenting the situation.
There were not any residents identified as at risk of sexual victimization placed in isolation
in the 12 months preceding the audit.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in
particular housing, bed, or other assignments solely on the basis of such
identification or status, nor shall agencies consider lesbian, gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of
being sexually abusive.
Gay, bisexual, transgender, or intersex residents are not placed in specific housing solely
based on how the residents identify or their status, in accordance with the policy. Staff
members are prohibited from considering the identification as an indicator that these
residents may be more likely to be sexually abusive. During the site review, there were no
rooms or units observed or identified to be reserved for gay, bisexual, transgender, or
intersex youth. Housing assignments are made on a case-by-case basis as supported by
policies, interviews and practice.
Provision (d):
In deciding whether to assign a transgender or intersex resident to a facility
for male or female residents, and in making other housing and programming
assignments, the agency shall consider on a case-by-case basis whether a
placement would ensure residents’ health and safety, and whether the
placement would present management or security problems.
Policy and practice support that housing and program assignments for transgender or
intersex residents are made on a case-by-case basis which was evident from staff interviews
and observations. The interview with the staff responsible for the risk screening supports
that staff considers on a case-by-case basis whether a placement would ensure a resident’s
health and safety, and whether the placement would present management or security
problems. The interviews indicate staffs’ awareness and the importance of their efforts in
keeping transgender and intersex youth safe.
Provision (e):
Placement and programming assignments for each transgender or intersex
resident shall be reassessed at least twice each year to review any threats to
safety experienced by the resident.
Agency policy provides placement and programming assignments for each transgender or
intersex resident be reassessed twice per year to determine any threats to safety experienced
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by the resident. The interview with the staff responsible for risk screening confirmed
awareness of policy. There were no transgender or intersex residents identified in the facility
during this audit.
Provision (f):
A transgender or intersex resident’s own views with respect to his or her own safety
shall be given serious consideration.
The resident’s concern for their own safety is taken into account through the administration
of the risk vulnerability screening instruments, treatment team meetings and individual
sessions and informal interactions with treatment and other staff. The interviews did not
reveal or identify any issues in this area.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender or intersex residents are given the opportunity to shower separately from
other residents which is supported by the interview with the staff responsible for the risk
screening and policy. No problems or issues were identified.
Provision (h):
If a resident is isolated pursuant to paragraph (b) of this section, the facility shall
clearly document:
(1) The basis for the facility’s concern for the resident’s safety; and
(2) The reason why no alternative means of separation can be arranged.
Agency policy provides that a resident would only be placed in isolation as a last resort for
protection and it would only be until other arrangements could be made to keep the resident
safe. The provisions of this standard would be provided if such occurs however the practice
is that isolation is not used in this facility. No residents were determined at risk of sexual
victimization and were placed in isolation in the 12 months preceding the audit. The
interviews and observations during the comprehensive site review confirm that isolation is
not used in this facility.
Provision (i):
Every 30 days, the facility shall afford each resident described in paragraph (h)
of this section a review to determine whether there is a continuing need for
separation from the general population.
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Isolation is not used in this facility. No residents at risk of sexual victimization were placed in
isolation in the 12 months preceding the audit.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with this standard.
REPORTING
Standard 115.351: Resident reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.351 (a)
▪ Does the agency provide multiple internal ways for residents to privately report sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report retaliation by
other residents or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report staff neglect or
violation of responsibilities that may have contributed to such incidents? ☒ Yes ☐ No
115.351 (b)
▪ Does the agency also provide at least one way for residents to report sexual abuse or sexual
harassment to a public or private entity or office that is not part of the agency? ☒ Yes ☐ No
▪ Is that private entity or office able to receive and immediately forward resident reports of sexual
abuse and sexual harassment to agency officials? ☒ Yes ☐ No
▪ Does that private entity or office allow the resident to remain anonymous upon request?
☒ Yes ☐ No
▪ Are residents detained solely for civil immigration purposes provided information on how to
contact relevant consular officials and relevant officials at the Department of Homeland
Security? (N/A if the facility never houses residents detained solely for civil immigration
purposes) ☐ Yes ☐ No ☒ NA
115.351 (c)
▪ Does staff accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties? ☒ Yes ☐ No
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▪ Does staff promptly document any verbal reports of sexual abuse and sexual harassment?
☒ Yes ☐ No
115.351 (d)
▪ Does the agency provide a method for staff to privately report sexual abuse and sexual
harassment of residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Florida Statute, Child abuse reporting, et al.
Memorandum
Student Handbook
411 Request Form
Sick Call Request
Grievance Form
Interviews:
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Random Staff
Residents
Superintendent
PREA Compliance Manager
Provision (a):
The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation by other residents or staff for
reporting sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents.
Policies provide for internal ways a resident may report allegations of sexual abuse and
sexual harassment, including how to privately report sexual abuse and sexual harassment;
retaliation for reporting; and staff neglect or violations of responsibilities that may have
contributed to such. Residents may report allegations of sexual abuse or sexual harassment
by telephone through the 24-hour Florida abuse reporting hotline. Telephones are made
accessible to residents for reporting allegations of sexual abuse and sexual harassment. Staff
members are required to make the use of the telephone accessible for residents to report
allegations of sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents. The interviews confirmed the
accessibility of the telephone to make a report through the hotline if desired.
Policy, posters, brochures, and the resident handbook collectively provide telephone numbers
and instructions for reporting allegations of sexual abuse or sexual harassment. In addition to
accessing a telephone, residents are also informed in the PREA education sessions,
determined from the interviews, that they may tell staff; submit a complaint in writing, or call
the abuse reporting hotline. A resident may put an allegation in writing utilizing a help
request form such as Sick Call Request, Speak Out, Grievance, 411 Request, or write a note
and drop the written allegations in the locked box or give the document directly to staff.
Writing materials are accessible to residents. Acknowledgement statements are signed by
residents confirming receipt of PREA information, along with the intake staff. Staff members
receive information on how to report allegations of sexual abuse or sexual harassment
through policies and procedures, training, statutes, and staff meetings.
If a grievance form is used to make a written allegation of sexual abuse, the reporting
procedures will be implemented in accordance with policy. Grievances alleging sexual abuse
will be handled directly by the facility administrators/designee and reported as required and
investigated by law enforcement, Florida Department of Children and Families, and/or
Department of Juvenile Justice/Office of Inspector General. The 411 Request form provides
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for the resident to request to see specific staff including the Superintendent, Assistant
Superintendent, Case Manager or Therapist. The staff signs and dates the form once they
have met with the resident.
The residents interviewed identified someone who did not work at the facility that they
could report to about sexual abuse or sexual harassment. The random staff and resident
interviews collectively revealed residents may use the telephone, submit a complaint in
writing, or talk to staff to privately report allegations of sexual abuse and sexual harassment.
The resident is provided the hotline number in writing in the resident handbook, brochures,
and through posted information.
Provision (b):
The agency shall also provide at least one way for residents to report abuse or
harassment to a public or private entity or office that is not part of the agency
and that is able to receive and immediately forward resident reports of sexual
abuse and sexual harassment to agency officials, allowing the resident to remain
anonymous upon request. Residents detained solely for civil immigration
purposes shall be provided information on how to contact relevant consular
officials and relevant officials at the Department of Homeland Security.
The Florida abuse reporting hotline may be used by residents and staff to report allegations
of sexual abuse and sexual harassment. The interviews revealed familiarity with policies and
posted and other printed information on how to report allegations of sexual abuse and
sexual harassment. Telephones are accessible to all staff and are made accessible to
residents by staff. The reports of sexual abuse or sexual harassment are accepted and
referred for an investigation. The hotline number was tested during the comprehensive site
review and was in working order answered by an operator responsible for receiving calls.
The facility does not detain residents solely for civil immigration purposes according to
written communication between the DJJ statewide PREA Coordinator and the DJJ legal
department.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third-
parties and shall promptly document any verbal reports.
Staff interviews confirmed methods available to residents for reporting allegations of sexual
abuse and sexual harassment. Staff members are required to accept reports made
anonymously, third-party reports and to document verbal reports. The resident interviews
collectively indicated awareness of reporting either in person, in writing, by telephone, or
through a third-party. Interviewed staff members are aware of their duty to receive and
document the receipt of verbal reports and that the documentation must be done as soon as
possible. Documentation confirms two allegations were received, documented and referred
for an investigation, in accordance with policy.
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Provision (d):
The facility shall provide residents with access to tools necessary to make a
written report.
Writing materials are available for residents to complete Grievance, Sick Call Request,
411 forms, and write notes. Each resident is provided a handbook which contains
information regarding reporting allegations and the residents are informed about reporting
methods during PREA education sessions. The interviews, review of documents and facility
practices revealed that residents are provided the tools to make written allegations of
sexual abuse and sexual harassment.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The staff interviews collectively revealed staff can privately report allegations of sexual abuse
and sexual harassment through a call to the Florida abuse reporting hotline or call and report
to the DJJ Central Communications Center.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility is compliant with this standard.
Standard 115.352: Exhaustion of administrative remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.352 (a)
▪ Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not
have administrative procedures to address resident grievances regarding sexual abuse. This
does not mean the agency is exempt simply because an resident does not have to or is not
ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of
explicit policy, the agency does not have an administrative remedies process to address sexual
abuse. ☒ Yes ☐ No
115.352 (b)
▪ Does the agency permit residents to submit a grievance regarding an allegation of sexual abuse
without any type of time limits? (The agency may apply otherwise-applicable time limits to any
portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
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▪ Does the agency always refrain from requiring an resident to use any informal grievance
process, or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A
if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (c)
▪ Does the agency ensure that: An resident who alleges sexual abuse may submit a grievance
without submitting it to a staff member who is the subject of the complaint? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency ensure that: Such grievance is not referred to a staff member who is the
subject of the complaint? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (d)
▪ Does the agency issue a final agency decision on the merits of any portion of a grievance
alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the
90-day time period does not include time consumed by residents in preparing any administrative
appeal.) (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ If the agency claims the maximum allowable extension of time to respond of up to 70 days per
115.52(d)(3) when the normal time period for response is insufficient to make an appropriate
decision, does the agency notify the resident in writing of any such extension and provide a date
by which a decision will be made? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ At any level of the administrative process, including the final level, if the resident does not
receive a response within the time allotted for reply, including any properly noticed extension,
may an resident consider the absence of a response to be a denial at that level? (N/A if agency
is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (e)
▪ Are third parties, including fellow residents, staff members, family members, attorneys, and
outside advocates, permitted to assist residents in filing requests for administrative remedies
relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Are those third parties also permitted to file such requests on behalf of residents? (If a third-
party files such a request on behalf of an resident, the facility may require as a condition of
processing the request that the alleged victim agree to have the request filed on his or her
behalf, and may also require the alleged victim to personally pursue any subsequent steps in
the administrative remedy process.) (N/A if agency is exempt from this standard.) ☐ Yes ☐ No
☒ NA
▪ If the resident declines to have the request processed on his or her behalf, does the agency
document the resident’s decision? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
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▪ Are parents or legal guardians of a juvenile allowed to file grievances regarding allegations of
sexual abuse, including appeals, on behalf of residents? ☒ Yes ☐ No
▪ Are such grievances conditioned upon the juvenile agreeing to have the request filed on his or
her behalf? ☒ Yes ☐ No
115.352 (f)
▪ Has the agency established procedures for the filing of an emergency grievance alleging that an
resident is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from
this standard.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance alleging an resident is subject to a substantial risk of
imminent sexual abuse, does the agency immediately forward the grievance (or any portion
thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which
immediate corrective action may be taken? (N/A if agency is exempt from this standard.).
☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency provide an initial
response within 48 hours? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency issue a final agency
decision within 5 calendar days? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Does the initial response and final agency decision document the agency’s determination
whether the resident is in substantial risk of imminent sexual abuse? (N/A if agency is exempt
from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the initial response document the agency’s action(s) taken in response to the emergency
grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency’s final decision document the agency’s action(s) taken in response to the
emergency grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (g)
▪ If the agency disciplines an resident for filing a grievance related to alleged sexual abuse, does
it do so ONLY where the agency demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
PREA Audit Report – V7. Page 89 of 156 Facility Name – double click to change
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
When a grievance form is received that contains an allegation of sexual abuse or sexual
harassment, the policy and procedures for reporting allegations of sexual abuse and sexual
harassment are implemented and a report is made to the investigative entities. The grievance
system does not include a process for the facility staff to investigate or resolve allegations of
sexual abuse. The content of the grievance is reported and an investigation will be conducted
by the Department of Juvenile Justice/Office of Inspector General, Florida Department of
Children and Families, and/or law enforcement.
Standard 115.353: Resident access to outside confidential support services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.353 (a)
▪ Does the facility provide residents with access to outside victim advocates for emotional support
services related to sexual abuse by giving residents mailing addresses and telephone numbers,
including toll-free hotline numbers where available, of local, State, or national victim advocacy or
rape crisis organizations? ☒ Yes ☐ No
▪ Does the facility provide persons detained solely for civil immigration purposes mailing
addresses and telephone numbers, including toll-free hotline numbers where available of local,
State, or national immigrant services agencies? (N/A if the facility never has persons detained
solely for civil immigration purposes.) ☒ Yes ☐ No ☐ NA
▪ Does the facility enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible? ☒ Yes ☐ No
115.353 (b)
▪ Does the facility inform residents, prior to giving them access, of the extent to which such
communications will be monitored and the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws? ☒ Yes ☐ No
115.353 (c)
▪ Does the agency maintain or attempt to enter into memoranda of understanding or other
agreements with community service providers that are able to provide residents with confidential
emotional support services related to sexual abuse? ☒ Yes ☐ No
▪ Does the agency maintain copies of agreements or documentation showing attempts to enter
into such agreements? ☒ Yes ☐ No
PREA Audit Report – V7. Page 90 of 156 Facility Name – double click to change
115.353 (d)
▪ Does the facility provide residents with reasonable and confidential access to their attorneys or
other legal representation and reasonable access to parents or legal guardians? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Memorandum of Understanding (MOU)
Student Handbook
PREA Compliance Form
US Citizenship and Investigation Service Information
Posted Information
Interviews:
Residents
PREA Compliance Manager
Victim Advocacy Agency Representative
PREA Audit Report – V7. Page 91 of 156 Facility Name – double click to change
Provision (a):
The facility shall provide residents with access to outside victim advocates for
emotional support services related to sexual abuse, by providing, posting, or
otherwise making accessible mailing addresses and telephone numbers,
including toll free hotline numbers where available, of local, State, or national
victim advocacy or rape crisis organizations, and, for persons detained solely
for civil immigration purposes, immigrant services agencies. The facility shall
enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible.
Although advocacy information is available to the residents, interviews revealed six out of
10 residents were not familiar with the victim advocacy agency and/or the related services
available. The written agreement is in the process of being signed by the advocacy agency.
The MOU outlines the specific services in accordance with the PREA Standard. Services will
be provided to a resident when requested by the resident, facility staff, or law enforcement
personnel. The advocacy agency provides services to confinement facilities according to a
representative of the agency which includes but not limited to accompaniment, emotional
support, hotline services, and referrals.
A corrective action was implemented which included refresher education regarding the
advocacy agency, Crisis Center of Tampa Bay. The documentation provided to the Auditor
regarding the refresher PREA education session informs the agenda, including how to request
services and specific information regarding the advocacy agency and services provided.
Provision (b):
The facility shall inform residents, prior to giving them access, of the extent to
which such communications will be monitored and the extent to which reports
of abuse will be forwarded to authorities in accordance with mandatory reporting
laws.
The overarching agency PREA policy, staff interviews, Student Handbook, advocacy agency
materials, and the PREA education sessions provide that there will be adherence to
confidentiality measures. The MOU is also specific about the confidentiality of the resident
and services provided to the resident.
Provision (c):
The agency shall maintain or attempt to enter into memoranda of understanding
or other agreements with community service providers that are able to provide
residents with confidential emotional support services related to sexual abuse.
PREA Audit Report – V7. Page 92 of 156 Facility Name – double click to change
The agency shall maintain copies of agreements or documentation showing
attempts to enter into such agreements.
The interviews and MOU document the provision of advocacy services including but not
limited to emotional support; accompaniment through the forensic medical examination
and investigation interview; access to counseling services; and referrals. The interview
with the advocacy agency representative also confirmed the availability of advocacy
services to the residents upon request. Agency policy and the Student Handbook support
confidentiality regarding victims of sexual abuse.
Provision (d):
The facility shall also provide residents with reasonable and confidential access
to their attorneys or other legal representation and reasonable access to
parents or legal guardians.
The residents have reasonable and confidential access to attorneys and court workers and
reasonable access to their parents/legal guardians which is supported by policy, interviews,
and Student Handbook. Offices or the conference room will be made available if an attorney
or Probation Officer may visit. Regular visitation is scheduled and the residents conveyed
visitation days and times during the interviews.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility meets this standard.
Standard 115.354: Third-party reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.354 (a)
▪ Has the agency established a method to receive third-party reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Has the agency distributed publicly information on how to report sexual abuse and sexual
harassment on behalf of a resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA Audit Report – V7. Page 93 of 156 Facility Name – double click to change
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 1.05, Incident Reporting
Agency Policy FDJJ 1919, PREA
Employee Handbook
Posted and Printed Materials
Agency Website Information
Interviews:
Random Staff
Residents
Provision:
The agency shall establish a method to receive third-party reports of sexual
abuse and sexual harassment and shall distribute publicly information on how to
report sexual abuse and sexual harassment on behalf of a resident.
Staff members are to receive, document and report allegations of sexual abuse and sexual
harassment made by a third-party. The staff members are aware third-party reporting of
sexual abuse or sexual harassment can be done and indicated the information will be
accepted and reported. Staff members are to document all verbal reports received as
verified by the random staff interviews.
The interviews collectively revealed staff may report allegations privately through the use of
the abuse reporting hotline, complete a report, call law enforcement, and tell a supervisor.
The Department of Juvenile Justice agency website contains the information needed for
third-parties to report allegations of sexual abuse and sexual harassment. Reporting
information is posted in the lobby area and throughout the facility.
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Information regarding reporting is posted within the facility and accessible to residents,
staff and visitors. All residents interviewed indicated knowing someone who did not work
at the facility they have contact with and could report allegations of sexual abuse and sexual
harassment to. It was determined that a person outside of the facility may report
allegations of sexual abuse and may make a report for a resident without giving the
resident’s name. No third-party reports were received during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility is compliant with this standard.
OFFICIAL RESPONSE FOLLOWING AN RESIDENT REPORT
Standard 115.361: Staff and agency reporting duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.361 (a)
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, whether or not it is part of the agency? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding retaliation against residents or staff who
reported an incident of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities
that may have contributed to an incident of sexual abuse or sexual harassment or retaliation?
☒ Yes ☐ No
115.361 (b)
▪ Does the agency require all staff to comply with any applicable mandatory child abuse reporting
laws? ☒ Yes ☐ No
115.361 (c)
▪ Apart from reporting to designated supervisors or officials, does staff always refrain from
revealing any information related to a sexual abuse report to anyone other than to the extent
necessary, as specified in agency policy, to make treatment, investigation, and other security
and management decisions? ☒ Yes ☐ No
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115.361 (d)
▪ Are medical and mental health practitioners required to report sexual abuse to designated
supervisors and officials pursuant to paragraph (a) of this section, as well as to the designated
State or local services agency where required by mandatory reporting laws? ☒ Yes ☐ No
▪ Are such practitioners required to inform residents at the initiation of services of their duty to
report and the limitations of confidentiality? ☒ Yes ☐ No
▪ Are medical and mental health practitioners required to inform residents of the practitioner’s
duty to report, and the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No
115.361 (e)
▪ Upon receiving any allegation of sexual abuse, does the facility promptly report the allegation to
the appropriate agency office and to the alleged victim’s parents or legal guardians, unless the
facility has official documentation showing the parents or legal guardians should not be notified?
☒ Yes ☐ No
▪ If the alleged victim is under the guardianship of the child welfare system, does the facility
submit the report to the alleged victim’s caseworker instead of the parents or legal guardians?
☒ Yes ☐ No
▪ If a juvenile court retains jurisdiction over the alleged victim, does the facility head or designee
report the allegation to the juvenile’s attorney or other legal representative of record within 14
days of receiving the allegation? ☒ Yes ☐ No
115.361 (f)
▪ Does the facility report all allegations of sexual abuse and sexual harassment, including third-
party and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
PREA Audit Report – V7. Page 96 of 156 Facility Name – double click to change
Documents:
Facility Policy 1.03, Provisions of an Abuse Free Environment
Facility Policy 1.04, Management Response to Allegations
Facility Policy 1.05, Incident Reporting
Facility Policy 6.13, PREA Agency
Policy FDJJ 1919, PREA
Florida Statute Chapter 39, Section 201, Mandatory reports of child abuse, et al.
Employee Handbook
Resident Handbook
Interviews:
Random Staff
Superintendent
PREA Compliance Manager
Medical Staff
Mental Health Staff
Provisions (a) & (b):
(a): The agency shall require all staff to report immediately and according to
agency policy any knowledge, suspicion, or information they receive regarding
an incident of sexual abuse or sexual harassment that occurred in a facility,
whether or not it is part of the agency; retaliation against residents or staff who
reported such an incident; and any staff neglect or violation of responsibilities
that may have contributed to an incident or retaliation. (b): The agency shall also
require all staff to comply with any applicable mandatory child abuse reporting
laws.
The State Statute and policies support that all staff report any knowledge, suspicion,
information, or receipt of information regarding an incident or allegation of sexual abuse,
sexual harassment or incidents of retaliation. Staff members are deemed as mandated
reporters by the State. Trained Department of Juvenile Justice (DJJ) agency investigators
conduct administrative investigations and allegations that are criminal in nature are
PREA Audit Report – V7. Page 97 of 156 Facility Name – double click to change
investigated by trained law enforcement investigators. Allegations are also reported to the
Department of Children and Families (DCF), also with trained investigators. The facility and
agency policies provide guidance to staff on reporting allegations of sexual abuse and sexual
harassment and the duties of the first responder.
Provision (c):
Apart from reporting to designated supervisors or officials and designated State
or local services agencies, staff shall be prohibited from revealing any
information related to a sexual abuse report to anyone other than to the extent
necessary, as specified in agency policy, to make treatment, investigation, and
other security and management decisions.
Policy and staff training address confidentiality of information and the conditions for providing
information. Once allegations have been appropriately reported, staff will keep the
information confidential regarding what was reported except when necessary for the
investigation and treatment and management decisions.
Provision (d):
(1) Medical and mental health practitioners shall be required to report sexual
abuse to designated supervisors and officials pursuant to paragraph (a) of this
section, as well as to the designated State or local services agency where
required by mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation
of services of their duty to report and the limitations of confidentiality.
The clinical staff interviewed indicated residents are informed at the initiation of services of
the limitations of confidentiality and the duty of the staff members to report. The clinical
staff members are also mandated reporters and required by the State to report allegations
received regarding sexual abuse and sexual harassment, in accordance with policy and State
requirements.
Provision (e):
(1) Upon receiving any allegation of sexual abuse, the facility head or his or
her designee shall promptly report the allegation to the appropriate agency
office and to the alleged victim’s parents or legal guardians, unless the facility
has official documentation showing the parents or legal guardians should not
be notified.
(2) If the alleged victim is under the guardianship of the child welfare system,
the report shall be made to the alleged victim’s caseworker instead of the
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parents or legal guardians.
(3) If a juvenile court retains jurisdiction over the alleged victim, the facility
head or designee shall also report the allegation to the juvenile’s attorney or
other legal representative of record within 14 days of receiving the allegation.
Reports of allegations are made as soon as possible to the investigative entities, including
the DJJ Central Communications Center, and parents/legal guardians. Policy and interview
with the superintendent confirmed that a resident’s caseworker rather than a parent would
be notified where indicated by the resident being under the guardianship of the Florida
Department of Children and Families.
The resident’s attorney will be notified of an allegation of sexual abuse within 14 days,
where applicable. Policies also provide the appropriate timelines and directions to staff for
reporting allegations. There were two allegations of sexual abuse; resident-on-resident and
staff-on resident during this audit period. The allegation regarding resident-on-resident was
closed as information only; the other investigation was closed as unsubstantiated. Both
allegations received an administrative investigation by the DJJ.
Provision (f):
The facility shall report all allegations of sexual abuse and sexual harassment,
including third-party and anonymous reports, to the facility’s designated
investigators.
Policy and interviews provide for all allegations to be reported and include the DJJ Office of the
Inspector General (OIG) through the Central Communications Center. Administrative
investigations are conducted by a DJJ/OIG investigator. Sexual abuse and sexual harassment
allegations that are criminal in nature are referred for investigation to law enforcement. Third-
party and anonymous reports received must be reported and documented by staff as
confirmed through interviews. The interviews confirmed that all allegations are reported to
the DJJ Central Communications Center, DCF and to law enforcement, where the allegation is
criminal in nature.
Conclusion:
The review of evidence and interviews indicate the facility is compliant with this standard.
Standard 115.362: Agency Protection Duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.362 (a)
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▪ When the agency learns that a resident is subject to a substantial risk of imminent sexual
abuse, does it take immediate action to protect the resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Superintendent
Random Staff
Provision:
When an agency learns that a resident is subject to a substantial risk of imminent
sexual abuse, it shall take immediate action to protect the resident.
The staff is required to protect the residents through implementing protective measures.
Administration of the risk screening instrument provides information that assists and guide
staff in keeping residents safe through housing and program assignments. Additional
assessment instruments provide information which offer supporting information in
determining the risk level of each resident. The interviews revealed protective measures
include but are not limited to separating youth, one- on-one or closer supervision, and
contacting administrators and supervisors.
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The expectation is that any action to protect a resident would be taken immediately as
deemed from interviews. During the intake process, residents are asked about how they
feel about their safety as part of the inquiries by staff completing the primary sexual safety
instrument, VSAB. No resident was identified to be at substantial risk of imminent sexual
abuse in the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility is compliant with this standard.
Standard 115.363: Reporting to other confinement facilities
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.363 (a)
▪ Upon receiving an allegation that an resident was sexually abused while confined at another
facility, does the head of the facility that received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse occurred? ☒ Yes ☐ No
115.363 (b)
▪ Is such notification provided as soon as possible, but no later than 72 hours after receiving the
allegation? ☒ Yes ☐ No
115.363 (c)
▪ Does the agency document that it has provided such notification? ☒ Yes ☐ No
115.363 (d)
▪ Does the facility head or agency office that receives such notification ensure that the allegation
is investigated in accordance with these standards? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
PREA Audit Report – V7. Page 101 of 156 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Document:
Agency Policy FDJJ 1919, PREA
Interview:
Superintendent
Provisions (a)-(d):
(a): Upon receiving an allegation that a resident was sexually abused while
confined at another facility, the head of the facility that received the allegation
shall notify the head of the facility or appropriate office of the agency where the
alleged abuse occurred and shall also notify the appropriate investigative
agency. (b): Such notification shall be provided as soon as possible, but no later
than 72 hours after receiving the allegation. (c): The agency shall document
that it has provided such notification. (d): The facility head or agency office that
receives such notification shall ensure that the allegation is investigated in
accordance with these standards.
If an allegation of sexual abuse is received that a resident was sexually abused while
confined at another facility, the superintendent understands he will notify the head of the
facility where the alleged abuse occurred. The notification will be made as soon as possible
and within 72 hours in accordance with policy. The superintendent is also required to make
a report to the Department of Juvenile Justice Central Communications Center.
The policy and interviews support allegations of sexual abuse or sexual harassment from a
resident regarding their stay in another facility will be reported and investigated as required.
The superintendent is also required to notify identified staff in the corporate office of the
parent agency. In the past 12 months, there were no allegations reported of sexual abuse
occurring at another facility.
Conclusion:
Based upon the information reviewed and interviews, the Auditor determined the facility is
compliant with this standard.
Standard 115.364: Staff first responder duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.364 (a)
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▪ Upon learning of an allegation that an resident was sexually abused, is the first security staff
member to respond to the report required to: Separate the alleged victim and abuser?
☒ Yes ☐ No
▪ Upon learning of an allegation that an resident was sexually abused, is the first security staff
member to respond to the report required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that an resident was sexually abused, is the first security staff
member to respond to the report required to: Request that the alleged victim not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that an resident was sexually abused, is the first security staff
member to respond to the report required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
115.364 (b)
▪ If the first staff responder is not a security staff member, is the responder required to request
that the alleged victim not take any actions that could destroy physical evidence, and then notify
security staff? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
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Facility Coordinated Response Plan
Interviews:
Random Staff
Provision (a):
Upon learning of an allegation that a resident was sexually abused, the first staff
member to respond to the report shall be required to:
(1) Separate the alleged victim and abuser;
(2) Preserve and protect any crime scene until appropriate steps can be taken
to collect any evidence;
(3) If the abuse occurred within a time period that still allows for the collection
of physical evidence, request that the alleged victim not take any actions that
could destroy physical evidence, including, as appropriate, washing, brushing
teeth, changing clothes, urinating, defecating, smoking, drinking, or eating;
and
(4) If the abuse occurred within a time period that still allows for the collection
of physical evidence, ensure that the alleged abuser does not take any actions
that could destroy physical evidence, including, as appropriate, washing,
brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or
eating.
The interviews and staff training information support the training areas provided in this
standard. The investigative incidents did not require the intervention of a first responder.
Policy and training provide that upon learning of an allegation that a resident was sexually
abused the general staff response would basically include but not be limited to the following:
a. Separate the victim and alleged abuser.
b. Preserve and protect the scene until appropriate steps can be taken to collect any
evidence.
c. Request that the alleged victim not take any actions that could destroy physical
evidence.
d. Take actions to ensure the alleged abuser does not take any actions that could destroy
physical evidence.
e. Ensure the safety of the victim.
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f. Make the required notifications.
Provision (b):
If the first staff responder is not a security staff member, the responder shall be
required to request that the alleged victim not take any actions that could destroy
physical evidence, and then notify security staff.
Non-security staff who may act as a first responder will request that physical evidence be
preserved and contact direct care staff for assistance. There were no allegations or
incidents where any staff member had to act as a first responder in the last 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility is compliant with this standard.
Standard 115.365: Coordinated response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.365 (a)
▪ Has the facility developed a written institutional plan to coordinate actions among staff first
responders, medical and mental health practitioners, investigators, and facility leadership taken
in response to an incident of sexual abuse? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
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Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Random Staff
Provision:
The facility shall develop a written institutional plan to coordinate actions taken in response
to an incident of sexual abuse among staff first responders, medical and mental health
practitioners, investigators, and facility leadership.
An institutional plan is outlined in a section of the facility's PREA policy. The policy outlines
the actions of the staff in general. A separate written coordinated response plan to be
implemented in the event of an allegation or incident of sexual abuse has been developed to
ensure all staff members actions identified in the Standard are documented.
Staff members' interviews in general and the coordinated response plan identify each step
and roles such as the first responder; supervisors; medical; mental health; and leadership
staff; and when to contact such. The plan provides guidance to staff regarding the actions to
take when there is an alleged incident of sexual abuse.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility is compliant with the standard.
Standard 115.366: Preservation of ability to protect residents from contact
with abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.366 (a)
▪ Are both the agency and any other governmental entities responsible for collective bargaining
on the agency’s behalf prohibited from entering into or renewing any collective bargaining
agreement or other agreement that limits the agency’s ability to remove alleged staff sexual
abusers from contact with any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted? ☒ Yes ☐ No
115.366 (b)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
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☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Interview:
PREA Coordinators
Provisions (a) & (b):
(a): Neither the agency nor any other governmental entity responsible for
collective bargaining on the agency’s behalf shall enter into or renew any
collective bargaining agreement or other agreements that limits the agency’s
ability to remove alleged staff sexual abusers form contact with residents
pending the outcome of an investigation or of a determination of whether and
to what extent discipline is warranted.
(b): Nothing is this standard shall restrict the entering into on renewal of
agreements that govern:
(1) The conduct of the disciplinary process, at long as such agreements are
not inconsistent with the provisions of §115.372 and §115.376; or
(2) Whether a no-contact assignment that is imposed pending the outcome of
an investigation shall be expunged from or retained in the staff member’s
personnel file following a determination that the allegation of sexual abuse
is not substantiated.
The facility is not involved in any collective bargaining agreements.
Standard 115.367: Agency protection against retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
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115.367 (a)
▪ Has the agency established a policy to protect all residents and staff who report sexual abuse or
sexual harassment or cooperate with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff? ☒ Yes ☐ No
▪ Has the agency designated which staff members or departments are charged with monitoring
retaliation? ☒ Yes ☐ No
115.367 (b)
▪ Does the agency employ multiple protection measures, such as housing changes or transfers
for resident victims or abusers, removal of alleged staff or resident abusers from contact with
victims, and emotional support services, for residents or staff who fear retaliation for reporting
sexual abuse or sexual harassment or for cooperating with investigations? ☒ Yes ☐ No
115.367 (c)
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents or staff who reported the sexual abuse to see if there are changes
that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy
any such retaliation? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor any resident
disciplinary reports? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor resident
housing changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor resident
program changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor negative
performance reviews of staff? ☒ Yes ☐ No
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▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor reassignments
of staff? ☒ Yes ☐ No
▪ Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a
continuing need? ☒ Yes ☐ No
115.367 (d)
▪ In the case of residents, does such monitoring also include periodic status checks?
☒ Yes ☐ No
115.367 (e)
▪ If any other individual who cooperates with an investigation expresses a fear of retaliation, does
the agency take appropriate measures to protect that individual against retaliation?
☒ Yes ☐ No
115.367 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13,
PREA Agency Policy FDJJ 1919,
PREA Retaliation Monitoring Form
Interviews:
Retaliation Monitor
Superintendent
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Random Staff
Agency Head Designee
Provision (a):
The agency shall establish a policy to protect all residents and staff who report sexual abuse or sexual
harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other
residents or staff and shall designate which staff members or departments are charged with monitoring
retaliation.
Policy supports protecting residents and staff who report sexual abuse or sexual harassment, or cooperate with
sexual abuse or sexual harassment investigations from retaliation by other residents, or staff. The superintendent is
responsible for conducting or ensuring retaliation monitoring occurs. The Retaliation Monitoring form, logbook, or
case notes may be used to document the monitoring activities. The form is intended to document whether the
individual has been threatened or been treated unfairly. Any reported maltreatment must be described on the form.
The written policy also provides for the review of housing changes and removal of alleged staff or youth from contact
with victims.
Provision (b):
The agency shall employ multiple protection measures, such as housing changes or transfers for resident
victims or abusers, removal of alleged staff or resident abusers from contact with victims, and emotional
support services for residents or staff that fear retaliation for reporting sexual abuse or sexual harassment or
for cooperating with investigations.
Protective measures were generally identified during the interviews with random staff, PREA Coordinators, and
superintendent/retaliation monitor and were aligned with policy. According to the interviews the collective
protective measures include but not limited to housing changes for resident victims or abusers; removing alleged
staff or alleged resident abusers from contact with victims; changes in shift or other assignments for staff;
assigned bed or dorm; and transferring resident or staff, if needed. The retaliation monitoring form provides for
documentation of retaliation monitoring and follow-up checks with the parties involved.
Provision (c):
For at least 90 days following a report of sexual abuse, the agency shall monitor the conduct or
treatment of residents or staff who reported the sexual abuse and of residents who were reported
to have suffered sexual abuse to see if there are changes that may suggest possible retaliation by
residents or staff, and shall act promptly to remedy any such retaliation. Items the agency should
monitor include any resident disciplinary reports, housing, or program changes, or negative
performance reviews or reassignments of staff. The agency shall continue such monitoring beyond
90 days if the initial monitoring indicates a continuing need.
Policy and the interview with the retaliation monitor provides that monitoring occurs for at least 90 days to see
if there are any changes that may suggest possible retaliation is occurring. The monitoring period may last longer
if needed, according to the retaliation monitor and policy. The interview identified items that are monitored to
assess retaliation occurring included but were not limited to program and housing changes; excessive write-ups;
shift assignments; review of behavior points; staff and resident interactions; and resident to resident interactions.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
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Policy and the interview with the retaliation monitor indicate that status checks will occur as a part of retaliation
monitoring where there is face-to-face contact. The dedicated monitoring form and the interview with the
retaliation monitor revealed that initial contact is made and there are follow-up checks.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of retaliation, the agency shall
take appropriate measures to protect that individual against retaliation.
Policy encompasses those who cooperate with an investigation if there is a concern regarding retaliation. The
interview with the retaliation monitor indicated the appropriate measures are taken to protect any related
individuals against retaliation. No cases of retaliation were determined through documentation and informal
conversations with staff.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the allegation is unfounded.
The obligation to monitor for retaliation terminates, in accordance with policy, if it is determined the allegation
is unfounded. The interview determined familiarity with the requirements regarding retaliation monitoring
policy.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is compliant
with this standard.
Standard 115.368: Post-allegation protective custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.368 (a)
▪ Is any and all use of segregated housing to protect an resident who is alleged to have suffered
sexual abuse subject to the requirements of § 115.43? ☐ Yes ☒ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
PREA Audit Report – V7. Page 111 of 156 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Mental Health Staff
Medical Staff
Provision:
The use of segregated housing to protect a resident who is alleged to have
suffered sexual abuse shall be subject to the requirements of §115.342.
Policies guide staff on measures to be taken to protect residents but does not include
segregated housing for alleged victims. Segregated housing is not used in the facility to
protect residents who alleged to have suffered sexual abuse. The interviews were aligned
with this premise. No segregated area was observed or identified during the
comprehensive site review.
Conclusion:
Based upon the review of policy, interviews, and observations, the Auditor determined the
facility is compliant with this standard.
INVESTIGATIONS
Standard 115.371: Criminal and administrative agency investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.371 (a)
▪ When the agency conducts its own investigations into allegations of sexual abuse and sexual
harassment, does it do so promptly, thoroughly, and objectively? [N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.
See 115.321(a).] ☒ Yes ☐ No ☐ NA
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▪ Does the agency conduct such investigations for all allegations, including third party and
anonymous reports? [N/A if the agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations. See 115.321(a).] ☒ Yes ☐ No ☐
NA
115.371 (b)
▪ Where sexual abuse is alleged, does the agency use investigators who have received
specialized training in sexual abuse investigations as required by 115.334? ☒ Yes ☐ No
115.371 (c)
▪ Do investigators gather and preserve direct and circumstantial evidence, including any available
physical and DNA evidence and any available electronic monitoring data? ☒ Yes ☐ No
▪ Do investigators interview alleged victims, suspected perpetrators, and witnesses?
☒ Yes ☐ No
▪ Do investigators review prior reports and complaints of sexual abuse involving the suspected
perpetrator? ☒ Yes ☐ No
115.371 (d)
▪ Does the agency terminate investigations solely because the source of the allegation recants
the allegation? ☒ Yes ☐ No
115.371 (e)
▪ When the quality of evidence appears to support criminal prosecution, does the agency conduct
compelled interviews only after consulting with prosecutors as to whether compelled interviews
may be an obstacle for subsequent criminal prosecution? ☒ Yes ☐ No
115.371 (f)
▪ Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an
individual basis and not on the basis of that individual’s status as resident or staff? ☒ Yes ☐
No
▪ Does the agency investigate allegations of sexual abuse without requiring an resident who
alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding? ☒ Yes ☐ No
115.371 (g)
▪ Do administrative investigations include an effort to determine whether staff actions or failures to
act contributed to the abuse? ☒ Yes ☐ No
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▪ Are administrative investigations documented in written reports that include a description of the
physical evidence and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings? ☒ Yes ☐ No
115.371 (h)
▪ Are criminal investigations documented in a written report that contains a thorough description
of the physical, testimonial, and documentary evidence and attaches copies of all documentary
evidence where feasible? ☒ Yes ☐ No
115.371 (i)
▪ Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?
☒ Yes ☐ No
115.371 (j)
▪ Does the agency retain all written reports referenced in 115.71(f) and (g) for as long as the
alleged abuser is incarcerated or employed by the agency, plus five years? ☒ Yes ☐ No
115.371 (k)
▪ Does the agency ensure that the departure of an alleged abuser or victim from the employment
or control of the agency does not provide a basis for terminating an investigation?
☒ Yes ☐ No
115.371 (l)
▪ Auditor is not required to audit this provision.
115.371 (m)
▪ When an outside entity investigates sexual abuse, does the facility cooperate with outside
investigators and endeavor to remain informed about the progress of the investigation? (N/A if
an outside agency does not conduct administrative or criminal sexual abuse investigations. See
115.21(a).) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
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The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
PREA Compliance Form
Investigation Reports
Interviews:
Superintendent
PREA Compliance Manager
PREA Coordinators
Investigative Staff
Provision (a):
When the agency conducts its own investigations into allegations of sexual
abuse and sexual harassment, it shall do so promptly, thoroughly, and
objectively for all allegations, including third-party and anonymous reports.
The administrative investigations are conducted by the investigators with the Florida
Department of Juvenile Justice (DJJ), Office of the Inspector General (OIG). Based on policy
and other documentation and interviews, trained investigators conduct administrative
investigations as prescribed by policy. Allegations that are criminal in nature are referred to
local law enforcement and the Florida Department of Children and Families and all
allegations are reported through the DJJ Central Communications Center. Investigations
are conducted thoroughly and objectively and the agencies’ policy provides for the training
of investigators. The facility staff does not conduct any investigations.
Provisions (b) & (c):
(b): Where sexual abuse is alleged, the agency shall use investigators who have
received special training in sexual abuse investigations involving juvenile victims
pursuant to §115.334. (c): Investigators shall gather and preserve direct and
circumstantial evidence, including any available physical and DNA evidence and
PREA Audit Report – V7. Page 115 of 156 Facility Name – double click to change
any available electronic monitoring data; shall interview alleged victims,
suspected perpetrators, and witnesses; and shall review prior complaints and
reports of sexual abuse involving the suspected perpetrator.
Based on the previous interview with investigative staff, the DJJ investigative staff is trained
through the OIG. The DJJ Investigator will turn over any evidence found to law enforcement
investigators since they generally do not handle direct evidence. The DJJ investigators will
assist law enforcement and among other activities, may review video; gather witness
statements; and review logs during the administrative investigation of the allegation.
The law enforcement investigator and/or qualified medical practitioner are responsible for
collecting direct physical and DNA evidence. The facility staff and DJJ investigators are trained
on how to assist in preserving evidence. The agency, DJJ, provides each facility with the PREA
Form which is provided to law enforcement investigators referencing the PREA standards
regarding conducting investigations in accordance with the standards. The DJJ investigators
follow the OIG guidelines governing PREA related investigations, in accordance with agency
policy.
Provision (d):
The agency shall not terminate an investigation solely because the source of the
allegation recants the allegation.
The interviews and policy confirm the provision that an investigation is not terminated if the
source recants an allegation of sexual abuse or sexual harassment.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the agency
shall conduct compelled interviews only after consulting with prosecutors as to
whether compelled interviews may be an obstacle for subsequent criminal
prosecution.
The DJJ agency investigators do not conduct compelled interviews.
Provision (f):
The credibility of an alleged victim, suspect, or witness shall be assessed on an
individual basis and shall not be determined by the person’s status as resident or
staff. No agency shall require a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition for
proceeding with the investigation of such an allegation.
The credibility of an alleged victim, suspect, or witness is assessed on an individual basis and
is not determined by the person’s status as a resident or staff as supported by the previous
PREA Audit Report – V7. Page 116 of 156 Facility Name – double click to change
interview with investigative staff, training, and in accordance with policy. The previous
interview with investigative staff revealed that credibility may be influenced by past history;
what can be verified; what other evidence can corroborate the information; body language;
and/or whether the person is answering questions or being dismissive. No resident who
alleges sexual abuse will be subjected to a polygraph examination or other truth telling
device as a condition for proceeding with the investigation.
Provisions (g) & (h):
(g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse.
(2) Shall be documented in written reports that include a description of the
physical and testimonial evidence, the reasoning behind credibility
assessments, and investigative facts and findings.
(h): Criminal investigations shall be documented in a written report that contains
a thorough description of physical, testimonial, and documentary evidence and
attaches copies of all documentary evidence where feasible.
The administrative investigations include an effort to determine whether staff actions or
failures to act contributed to the abuse. Investigations in all facilities are completed with
written reports that include a description of the evidence and investigative facts and
findings as gleaned from the previous interview with investigative staff. The report also
contains information regarding the initial call or allegation; list of interviews; list of
exhibits; logbook information; critique of any video; and a host of other information.
(i)Substantiated allegations of conduct that appears to be criminal shall be referred for prosecution.
Allegations that are criminal in nature are referred to local law enforcement and the Florida
Department of Children and Families. DJJ/OIG investigators conduct administrative
investigations only. All allegations are reported through the DJJ Central Communications
Center. There were no allegations that were criminal in nature.
Provision (j):
The agency shall retain all written reports referenced in paragraphs (g) and (h)
of this section for as long as the alleged abuser is incarcerated or employed by
the agency, plus five years, unless the abuse was committed by a juvenile
resident and applicable law requires a shorter period of retention.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years as stated in agency policy.
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Provision (k):
The departure of the alleged abuser or victim from the employment or control of
the facility or agency shall not provide a basis for terminating an investigation.
Upon the start of an investigation, it will not end until the investigation has been completed.
The departure of the alleged abuser or victim from the employment or control of the facility
will not terminate the investigation, as the interviews and incident summary document.
Provision (l):
Any State entity or Department of Justice component that conducts such
investigations shall do so pursuant to the above requirements.
The investigative agencies are aware of the PREA standards requirements through the initial
sharing of PREA information, PREA Compliance Form, and subsequent interactions.
Provision (m):
When outside agencies investigate sexual abuse, the facility shall cooperate with
outside investigators and shall endeavor to remain informed about the progress
of the investigation.
Agency policy and interviews indicate that staff cooperate with investigators and that the
agency/facility is kept informed of the progress of an investigation. The Superintendent
maintains contact with the investigator from the applicable investigative entity. The
Superintendent may also be kept informed through the DJJ statewide PREA Coordinator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor
determined the facility is compliant with this standard.
Standard 115.372: Evidentiary standard for administrative investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.372 (a)
▪ Is it true that the agency does not impose a standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual harassment are
substantiated? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report – V7. Page 118 of 156 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Agency Policy FDJJ 1919
Investigation Reports
Provision (a):
The agency shall impose no standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual
harassment are substantiated.
The Florida Department of Juvenile Justice/Office of Inspector General, responsible for
administrative investigations, imposes a standard of a preponderance of the evidence for
determining whether allegations are substantiated. A previous interview with investigative
staff, review of documentation, and agency practice confirmed this premise.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the facility is
compliant with this standard.
Standard 115.373: Reporting to residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.373 (a)
▪ Following an investigation into an resident’s allegation that he or she suffered sexual abuse in
an agency facility, does the agency inform the resident as to whether the allegation has been
determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No
115.373 (b)
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▪ If the agency did not conduct the investigation into an resident’s allegation of sexual abuse in an
agency facility, does the agency request the relevant information from the investigative agency
in order to inform the resident? (N/A if the agency/facility is responsible for conducting
administrative and criminal investigations.) ☒ Yes ☐ No ☐ NA
115.373 (c)
▪ Following an resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer posted within the resident’s unit? ☒ Yes ☐ No
▪ Following an resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer employed at the facility? ☒ Yes ☐ No
▪ Following an resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been indicted on a charge related to
sexual abuse in the facility? ☒ Yes ☐ No
▪ Following an resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been convicted on a charge related to
sexual abuse within the facility? ☒ Yes ☐ No
115.373 (d)
▪ Following an resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been indicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
▪ Following an resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been convicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
115.373 (e)
▪ Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No
115.373 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
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☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Notification Letters
Interviews:
Superintendent
PREA Compliance Manager
Provision (a):
Following an investigation into a resident’s allegation of sexual abuse suffered
in an agency facility, the agency shall inform the resident as to whether the
allegation has been determined to be substantiated, unsubstantiated, or
unfounded.
Policy addresses the resident being informed when a sexual abuse investigation is completed
and the outcome of the investigation provided in writing. The results of such investigations
will be documented and provided to the resident. The interviews and documentation
revealed knowledge of the requirement. Notification Letters were prepared for the two
residents that made allegations.
Provision (b):
If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency in order to inform the resident.
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The superintendent remains abreast of an investigation conducted by law enforcement,
Department of Children and Families or the Department of Juvenile Justice investigator and
is provided information regarding the findings, in accordance with the interviews of the
superintendent and statewide PREA Coordinator.
Provision (c):
Following a resident’s allegation that a staff member has committed sexual
abuse against the resident, the agency shall subsequently inform the resident
(unless the agency has determined that the allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge
related to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a charge
related to sexual abuse within the facility.
Policy requires that following a resident’s allegation that a staff member committed sexual
abuse against the resident, the resident will be informed of the following, unless it has been
determined that the allegation is unfounded, whenever:
a. The staff member is no longer posted within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse in the facility;
and/or
d. The staff member has been convicted on a charge related to sexual abuse in the facility.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused by
another resident, the agency shall subsequently inform the alleged victim
whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related to
sexual abuse within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a charge related
to sexual abuse within the facility.
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Policy provides that following a resident’s allegation of being sexually abused by another
resident the alleged victim shall be informed whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the facility.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides for the notification to the resident be documented and be made by the
administrator. There is knowledge with the requirement by the superintendent. Notifications
and results of investigations have been provided and signed by one resident; the other
resident had left prior to being notified.
Provision (f):
An agency’s obligation to report under this standard shall terminate if the
resident is released from the agency’s custody.
The agency’s obligation to report under this standard terminates if the resident is released
from the agency’s custody. All notifications or attempted notifications will be documented.
Conclusion:
The interviews and review of policy and other documentation confirmed the facility is
compliant with this standard.
DISCIPLINE
Standard 115.376: Disciplinary sanctions for staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.376 (a)
▪ Are staff subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies? ☒ Yes ☐ No
115.376 (b)
▪ Is termination the presumptive disciplinary sanction for staff who have engaged in sexual
abuse? ☒ Yes ☐ No
115.376 (c)
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▪ Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual
harassment (other than actually engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions
imposed for comparable offenses by other staff with similar histories? ☒ Yes ☐ No
115.376 (d)
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Law enforcement agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Relevant licensing bodies? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
The policies and interview support that staff be subject to disciplinary sanctions up to and
including termination for violating facility sexual abuse or sexual harassment policies.
PREA Audit Report – V7. Page 124 of 156 Facility Name – double click to change
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who has
engaged in sexual abuse.
Termination is the presumptive disciplinary sanction for staff who has engaged in sexual
abuse with a resident. The interview was aligned with policies. The facility reports that no
staff member violated any policy regarding sexual abuse or sexual harassment during this
audit period.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or
sexual harassment shall be commensurate with the nature and circumstances of
the acts committed, the staff member’s disciplinary history, and the sanctions
imposed for comparable offenses by other staff with similar histories.
Any staff with findings of engaging in sexual activities are subject to termination, and other
measures appropriate to the circumstance of the incident and in accordance with agency
policy. Disciplinary sanctions for violations of policies relating to sexual abuse or sexual
harassment (other than engaging in sexual abuse) will be commensurate with the act
committed, the staff member’s disciplinary history, and the similar history of other staff.
Provision (d):
All terminations for violations of agency sexual abuse or sexual harassment
policies, or resignations by staff who would have been terminated if not for their
resignation, shall be reported to law enforcement agencies, unless the activity
was clearly not criminal, and to any relevant licensing bodies.
Policy supports that terminations for violations of the agency’s sexual abuse or sexual
harassment policies or resignations by staff that would have been terminated if not for their
resignation, will be reported to law enforcement, unless the activity is clearly not criminal. In
addition, such will be reported to relevant licensing bodies. There have been no violations
by staff of the agency's sexual abuse or sexual harassment policies during this audit period.
Conclusion:
Based upon the review of documentation and the interview, the Auditor determined the
facility is compliant with this standard.
Standard 115.377: Corrective action for contractors and volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.377 (a)
PREA Audit Report – V7. Page 125 of 156 Facility Name – double click to change
▪ Is any contractor or volunteer who engages in sexual abuse prohibited from contact with
residents? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement
agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing
bodies? ☒ Yes ☐ No
115.377 (b)
▪ In the case of any other violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer, does the facility take appropriate remedial measures, and consider
whether to prohibit further contact with residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Contractors (2)
Superintendent
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall be prohibited
from contact with residents and shall be reported to law enforcement
PREA Audit Report – V7. Page 126 of 156 Facility Name – double click to change
agencies, unless the activity was clearly not criminal, and to relevant licensing
bodies.
Policies provide for contractors and volunteers who engage in sexual abuse with a resident
to be reported to law enforcement and to relevant licensing bodies. Policies and interviews
with contractors confirm they receive a clear understanding that sexual misconduct with a
resident is prohibited.
Any contractor or volunteer who violates the agency’s sexual abuse or sexual harassment
policies is prohibited from contact with residents. During this audit period, there have been
no allegations of sexual abuse or sexual harassment regarding a contractor. The facility has
not had any volunteers during the past year; however, policy and practice are inclusive of the
possibility of volunteers.
Provision (b):
The facility shall take appropriate remedial measures, and shall consider whether to prohibit
further contact with residents, in the case of any other violation of agency sexual abuse or
sexual harassment policies by a contractor or volunteer.
The facility will take the appropriate remedial measures and prohibit further contact with
residents in the case of any other violation of the sexual abuse and sexual harassment
policies by a contractor or volunteer. In the past 12 months, no contractors were reported
for allegations of sexual abuse or sexual harassment.
Conclusion:
Based upon the review of the documentation and interviews, the Auditor determined the
facility is compliant with this standard.
Standard 115.378: Disciplinary sanctions for residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.378 (a)
▪ Following an administrative finding that an resident engaged in resident-on-resident sexual
abuse, or following a criminal finding of guilt for resident-on-resident sexual abuse, are residents
subject to disciplinary sanctions pursuant to a formal disciplinary process? ☒ Yes ☐ No
115.378 (b)
▪ Are disciplinary sanctions commensurate with the nature and circumstances of the abuse
committed, the resident’s disciplinary history, and the sanctions imposed for comparable
offenses by other residents with similar histories? ☒ Yes ☐ No
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▪ In the event a disciplinary sanction results in the isolation of a resident, do agencies deny the
resident daily large-muscle exercise or access to any legally required educational programming
or special education services? ☒ Yes ☐ No
▪ Do residents in isolation receive daily visits from a medical or mental health care clinician?
☒ Yes ☐ No
▪ Do residents have access to other programs and work opportunities to the extent possible?
☒ Yes ☐ No
115.378 (c)
▪ When determining what types of sanction, if any, should be imposed, does the disciplinary
process consider whether an resident’s mental disabilities or mental illness contributed to his or
her behavior? ☒ Yes ☐ No
115.378 (d)
▪ If the facility offers therapy, counseling, or other interventions designed to address and correct
underlying reasons or motivations for the abuse, does the facility consider whether to require
the offending resident to participate in such interventions as a condition of access to
programming and other benefits? ☒ Yes ☐ No
▪ Do agencies require participation in such interventions as a condition to access general
programming or education? ☒ Yes ☐ No
115.378 (e)
▪ Does the agency discipline an resident for sexual contact with staff only upon a finding that the
staff member did not consent to such contact? ☒ Yes ☐ No
115.378 (f)
▪ For the purpose of disciplinary action does a report of sexual abuse made in good faith based
upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish evidence sufficient to substantiate
the allegation? ☒ Yes ☐ No
115.378 (g)
▪ If the agency prohibits all sexual activity between residents, does the agency always refrain
from considering non-coercive sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report – V7. Page 128 of 156 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Student Handbook
Interviews:
Superintendent
Mental Health Staff
Medical Staff
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a formal
disciplinary process following an administrative finding that the resident
engaged in resident-on-resident sexual abuse or following a criminal finding of
guilt for resident- on-resident sexual abuse.
Policies and practice support that an administrative process exists for dealing with
violations and that residents be held accountable for their actions. Residents may be
subject to disciplinary sanctions only after formal proceedings regarding resident-on-
resident sexual abuse.
Residents found in violation of facility rules are subject to sanctions pursuant to a formal
administrative process. The consequences will be administered through the administrative
system, encompassing the behavior management system. Allegations of sexual abuse are
referred for an investigation to the appropriate investigative entities and may result in the
PREA Audit Report – V7. Page 129 of 156 Facility Name – double click to change
resident being removed from the facility. Policy prohibits sexual activity between
residents.
Provision (b):
Any disciplinary sanctions shall be commensurate with the nature and
circumstances of the abuse committed, the resident’s disciplinary history, and
the sanctions imposed for comparable offenses by other residents with similar
histories. In the event a disciplinary sanction results in the isolation of a
resident, agencies shall not deny the resident daily large-muscle exercise or
access to any legally required educational programming or special education
services. Residents in isolation shall receive daily visits from a medical or
mental health care clinician. Residents shall also have access to other programs
and work opportunities to the extent possible.
The policies consider that disciplinary sanctions, applicable to the offense, are
commensurate with the nature and circumstances of the offense committed; considers
resident’s disciplinary history; considers similar disciplinary history of other residents. The
interview with the superintendent supported there is consideration of mental disabilities or
mental illness contributing to the behavior. PREA related violations may result in charges
filed and youth transported to a detention center based on the circumstances of the
incident. Allegations of sexual abuse are referred for an investigation to the appropriate
investigative entities. Isolation is not used as a disciplinary sanction.
Provision (c):
The disciplinary process shall consider whether a resident’s mental disabilities or
mental illness contributed to his or her behavior when determining what type of
sanction, if any, should be imposed.
Disciplinary and other processes consider whether a resident’s mental disabilities or mental
illness contributed to a resident’s behavior regarding the application of disciplinary
measures. The disciplinary process involves sanctions through the behavior management
system and administrative process.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed to
address and correct underlying reasons or motivations for the abuse, the facility
shall consider whether to offer the offending resident participation in such
interventions. The agency may require participation in such interventions as a
condition of access to any rewards-based behavior management system or
PREA Audit Report – V7. Page 130 of 156 Facility Name – double click to change
other behavior-based incentives, but not as a condition to access to general
programming or education.
The facility will consider whether to offer the offending resident intervention services
designed to address and correct underlying reasons or motivations for the abuse
participation, based on the interview with the mental health staff. Participation in such
interventions will not be a condition for participation in or access to general programming or
education however it will be a condition to access the behavior management system as
determined from the interview. Mental health staff members will develop treatment
planning and interventions to address underlying reasons or motivations for the abuse with
alleged victims and offending residents.
Provision (e):
The agency may discipline a resident for sexual contact with staff only upon a
finding that the staff member did not consent to such contact.
A resident may be disciplined for sexual contact with staff only upon a finding that the staff
member did not consent to such contact. The alleged incident will be reported to the Central
Communications Center and law enforcement regarding lack of consent by staff.
Provision (f):
For the purpose of disciplinary action, a report of sexual abuse made in good
faith based upon a reasonable belief that the alleged conduct occurred shall not
constitute falsely reporting an incident or lying, even if an investigation does not
establish evidence sufficient to substantiate the allegation.
Any resident reporting in good faith shall be immune from any civil or criminal liability. A
report of sexual abuse made in good faith based on the belief that the alleged incident
occurred does not constitute falsely reporting an incident or lying, even if an investigation
does not establish evidence sufficient to substantiate the allegation.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between residents
and may discipline residents for such activity. An agency may not, however,
deem such activity to constitute sexual abuse if it determines that the activity is
not coerced.
Policy prohibits any sexual conduct between residents. All such conduct is subject to
disciplinary action as a rule violation. Referrals are made to the investigative entities and
court processes occur after determination the sexual activity was coerced.
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Conclusion:
Based on the available evidence and interviews, the Auditor concluded the facility is compliant
with the standard.
MEDICAL AND MENTAL CARE
Standard 115.381: Medical and mental health screenings; history of sexual
abuse
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.381 (a)
▪ If the screening pursuant to § 115.341 indicates that a prison resident has experienced prior
sexual victimization, whether it occurred in an institutional setting or in the community, do staff
ensure that the resident is offered a follow-up meeting with a medical or mental health
practitioner within 14 days of the intake screening? (N/A if the facility is not a prison.)
☒ Yes ☐ No ☐ NA
115.381 (b)
▪ If the screening pursuant to § 115.341 indicates that a prison resident has previously
perpetrated sexual abuse, whether it occurred in an institutional setting or in the community, do
staff ensure that the resident is offered a follow-up meeting with a mental health practitioner
within 14 days of the intake screening? (N/A if the facility is not a prison.) ☒ Yes ☐ No ☐ NA
115.381 (c)
▪ Is any information related to sexual victimization or abusiveness that occurred in an institutional
setting strictly limited to medical and mental health practitioners and other staff, as necessary, to
inform treatment plans and security and management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law?
☒ Yes ☐ No
115.381 (d)
▪ Is any information related to sexual victimization or abusiveness that occurred in an institutional
setting strictly limited to medical and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report – V7. Page 132 of 156 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Medical Staff
Mental Health Staff
Staff Responsible for Risk Screening
Residents
Provisions (a) & (b):
(a): If the screening pursuant to §115.341 indicates that a resident has
experienced prior sexual victimization, whether it occurred in an institutional
setting or in the community, staff shall ensure that the resident is offered a
follow-up meeting with a medical or mental health practitioner within 14 days
of the intake screening. (b): If the screening pursuant to §115.341 indicates that
a resident has previously perpetrated sexual abuse, whether it occurred in an
institutional setting or in the community, staff shall ensure that the resident is
offered a follow-up meeting with a mental health practitioner within 14 days of
the intake screening.
Agency policy and practice provide that a resident be referred to mental health or medical
staff within 14 days if identified as having been a victim or perpetrator of sexual abuse. The
interviews with clinical staff revealed the issues are identified and addressed. The practice is
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residents are generally seen by medical and mental health staff on the same day of
admission as part of the intake process and initial follow-up is provided the same day.
Provision (c):
Any information related to sexual victimization or abusiveness that occurred in
an institutional setting shall be strictly limited to medical and mental health
practitioners and other staff, as necessary, to inform treatment plans and
security and management decisions, including housing, bed, work, education,
and program assignments, or as otherwise required by Federal, State, or local
law.
Policy supports that no information is to be shared with other staff unless it is required for
security and management decisions regarding sexual abuse history. Information related to
sexual victimization or abusiveness that occurred in an institutional setting is limited to
clinical and treatment staff and to other staff, based on their need to know, to make
effective management decisions.
During the comprehensive onsite review, the clinical files were observed to be maintained
in locked cabinets in the lockable area. Resident files are maintained separated in three
separate folders: general information, medical, and mental health. Information maintained
electronically is password protected with limited staff access.
Provision (d):
Medical and mental health practitioners shall obtain informed consent from
residents before reporting information about prior sexual victimization that did
not occur in an institutional setting, unless the resident is under the age of 18.
Policy and interviews support that informed consent being obtained for residents 18 years or
over prior to clinical personnel reporting information disclosed about prior sexual
victimization that did not occur in an institutional setting.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the
facility is compliant with this standard.
Standard 115.382: Access to emergency medical and mental health
services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.382 (a)
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▪ Do resident victims of sexual abuse receive timely, unimpeded access to emergency medical
treatment and crisis intervention services, the nature and scope of which are determined by
medical and mental health practitioners according to their professional judgment?
☒ Yes ☐ No
115.382 (b)
▪ If no qualified medical or mental health practitioners are on duty at the time a report of recent
sexual abuse is made, do security staff first responders take preliminary steps to protect the
victim pursuant to § 115.362? ☒ Yes ☐ No
▪ Do security staff first responders immediately notify the appropriate medical and mental health
practitioners? ☒ Yes ☐ No
115.382 (c)
▪ Are resident victims of sexual abuse offered timely information about and timely access to
emergency contraception and sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate? ☒ Yes ☐ No
115.382 (d)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 3.16, Emergency Mental Health and Substance Abuse Services
Facility Policy 6.13, PREA
PREA Audit Report – V7. Page 135 of 156 Facility Name – double click to change
Agency Policy FDJJ 1919, PREA
Interviews:
Mental Health Staff
Medical Staff
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded access to
emergency medical treatment and crisis intervention services, the nature and
scope of which are determined by medical and mental health practitioners
according to their professional judgment.
The interviews and policies support the alleged victim will receive timely and unimpeded
access to emergency medical treatment and crisis intervention services. According to clinical
staff, the nature and scope of their services are determined according to their professional
judgment and there is no interference by other staff. Residents are informed of clinical
services and meet with those practitioners during the intake process and are provided
services throughout their stay in the facility as needed. The two allegations of sexual
harassment did not require medical or mental health intervention.
An alleged victim will get services within the facility as well as timely services in the
community. An alleged victim of sexual abuse will be transported to the Crisis Center of
Tampa Bay or the hospital emergency room, depending on the age of the resident, for a
forensic medical examination that will be conducted by a qualified medical practitioner. The
examination will be performed at no cost to the victim, in accordance with policy and the
advocacy agency information, in response to an allegation of sexual abuse. Medical and mental
health staff members will continue to maintain secondary materials and documentation of
encounters with residents related to such.
Provision (b):
If no qualified medical or mental health practitioners are on duty at the time a
report of recent abuse is made, staff first responders shall take preliminary
steps to protect the victim pursuant to §115.362 and shall immediately notify
the appropriate medical and mental health practitioners.
The interviews with clinical staff revealed residents have access to unimpeded access to
emergency services. Policies provide guidance to staff in protecting residents and for
contacting the appropriate staff and agencies regarding allegations or incidents of sexual
abuse, including contacting treatment staff and investigative entities. Policy also provides
guidance in dispensing emergency and first aid care.
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A review of the documentation and observations of the interactions among residents and
staff during the onsite audit phase; and the interviews indicated unimpeded medical and
crisis intervention services are available to an alleged victim of sexual abuse. Staff training
also prepare staff members to properly report sexual abuse, protect the alleged victim and
notify the appropriate staff and investigative entities.
Provision (c):
Resident victims of sexual abuse while incarcerated shall be offered timely
information about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with professionally accepted
standards of care, where medically appropriate.
Policy, review of documentation and interviews confirmed processes and services are in
place for an alleged victim to receive timely access to sexually transmitted infection
prophylaxis, where medically appropriate. If needed after an incident, follow-up services
may be provided by the facility’s medical and mental health staff members to provide
support services coordinated by staff as needed and services not available within the facility
will be contracted. The standard of care within the facility ensures the appropriate medical
and mental health follow-up as needed. Medical services were not required for either of the
two allegations.
Provision (d):
Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident.
The interviews and policies provide treatment services will be provided to the victim without
financial cost to the victim. Treatment services will also be provided at no cost to the victim
regardless of whether the victim names the abuser, or cooperate with any investigation
arising out of the incident.
Conclusion:
Based on the evidence reviewed, observations and interviews, the facility was confirmed
compliant with the standard.
Standard 115.383: Ongoing medical and mental health care for sexual
abuse victims and abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.383 (a)
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▪ Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility? ☒ Yes ☐ No
115.383 (b)
▪ Does the evaluation and treatment of such victims include, as appropriate, follow-up services,
treatment plans, and, when necessary, referrals for continued care following their transfer to, or
placement in, other facilities, or their release from custody? ☒ Yes ☐ No
115.383 (c)
▪ Does the facility provide such victims with medical and mental health services consistent with
the community level of care? ☒ Yes ☐ No
115.383 (d)
▪ Are resident victims of sexually abusive vaginal penetration while incarcerated offered
pregnancy tests? (N/A if “all-male” facility. Note: in “all-male” facilities, there may be residents
who identify as transgender men who may have female genitalia. Auditors should be sure to
know whether such individuals may be in the population and whether this provision may apply in
specific circumstances.) ☐ Yes ☐ No ☒ NA
115.383 (e)
▪ If pregnancy results from the conduct described in paragraph § 115.383(d), do such victims
receive timely and comprehensive information about and timely access to all lawful pregnancy-
related medical services? (N/A if “all-male” facility. Note: in “all-male” facilities, there may be
residents who identify as transgender men who may have female genitalia. Auditors should be
sure to know whether such individuals may be in the population and whether this provision may
apply in specific circumstances.) ☐ Yes ☐ No ☒ NA
115.383 (f)
▪ Are resident victims of sexual abuse while incarcerated offered tests for sexually transmitted
infections as medically appropriate? ☒ Yes ☐ No
115.383 (g)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
115.383 (h)
▪ If the facility is a prison, does it attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history and offer
treatment when deemed appropriate by mental health practitioners? (NA if the facility is a jail.)
☒ Yes ☐ No ☐ NA
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Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
The facility shall offer medical and mental health evaluation and, as appropriate,
treatment to all residents who have been victimized by sexual abuse in any
prison, jail, lockup, or juvenile facility.
The policies and interviews support that medical and mental health evaluation and
treatment will be offered to resident victims of sexual abuse. Crisis assessments and nursing
assessments are conducted by clinical staff. The clinical staff interviews revealed that follow-
up services will be provided that include but are not limited to increased individual
counseling; placement on indicated precaution; medical doctor follow-up; treatment of STIs
as indicated; and wound treatment. The allegation of sexual abuse did not require medical
or mental health services however mental health staff conducted retaliation monitoring.
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Provision (b):
The evaluation and treatment of such victims shall include, as appropriate, follow-up
services, treatment plans, and, when necessary, referrals for continued care following their
transfer to, or placement in, other facilities, or their release from custody.
Interviews and documentation of encounters confirm on-going medical and mental health care
will be provided as appropriate and will include but not be limited to treatment planning;
evaluations, clinical follow-up and referrals as needed. Specialized treatment may also be
provided by clinicians on site and through contract and referral services. Additionally,
directions contained any discharge summary will be followed.
Provision (c):
The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
Review of policies, interviews and observations during the site review indicated medical and
mental health services are consistent with the community level of care. Treatment services
may be provided by facility staff and contract services if needed. The interviews and
observations during the site review underscored the treatment services at the facility are
consistent with the community level of care.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall
be offered pregnancy tests.
This is a facility for male juvenile offenders.
Provision (e):
If pregnancy results from conduct specified in paragraph (d) of this section, such
victims shall receive timely and comprehensive information about and timely
access to all lawful pregnancy-related medical services.
This is a facility for male juvenile offenders.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
Victims of sexual abuse will be provided tests for sexually transmitted infections as
medically appropriate as confirmed by the medical staff. Tests will be provided at the
medical care facility. Tests and treatment may also be done at the facility based on policy
and the interview with medical staff.
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Provision (g):
Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident.
All treatment services will be provided at no cost to the victim and whether or not the victim
names the abuser of cooperates with the investigation, according to policy and interviews.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history
and offer treatment when deemed appropriate by mental health
practitioners.
The mental health staff confirmed the resident will get a comprehensive mental health
evaluation within 21days and be offered appropriate treatment. Medical and mental health
evaluations and treatment will be offered to resident victims of sexual abuse.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined the facility
is compliant with this standard.
DATA COLLECTION AND REVIEW
Standard 115.386: Sexual abuse incident reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.386 (a)
▪ Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse
investigation, including where the allegation has not been substantiated, unless the allegation
has been determined to be unfounded? ☒ Yes ☐ No
115.386 (b)
▪ Does such review ordinarily occur within 30 days of the conclusion of the investigation?
☒ Yes ☐ No
115.386 (c)
▪ Does the review team include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No
115.386 (d)
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▪ Does the review team: Consider whether the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual abuse? ☒ Yes ☐ No
▪ Does the review team: Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the facility? ☒ Yes ☐ No
▪ Does the review team: Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse? ☒ Yes ☐ No
▪ Does the review team: Assess the adequacy of staffing levels in that area during different
shifts? ☒ Yes ☐ No
▪ Does the review team: Assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff? ☒ Yes ☐ No
▪ Does the review team: Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to §§ 115.386(d)(1) - (d)(5), and any recommendations for
improvement and submit such report to the facility head and PREA compliance manager?
☒ Yes ☐ No
115.86 (e)
▪ Does the facility implement the recommendations for improvement, or document its reasons for
not doing so? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
PREA Audit Report – V7. Page 142 of 156 Facility Name – double click to change
Investigation Reports
Incident Review Team Meeting Minutes
Interviews:
Superintendent
Incident Review Team Member
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of
every sexual abuse investigation, including where the allegation has not been
substantiated, unless the allegation has been determined to be unfounded.
The facility is required to conduct a sexual abuse incident review at the conclusion of an
investigation, unless the allegation was unfounded. The interviews reflected an
understanding of the role of the incident review team. A review of the policies,
documentation, and interviews confirmed incident reviews were conducted regarding the
investigations of the two allegations of sexual abuse. One case was determined
unsubstantiated and the other was closed as information only. The interviews confirmed the
practice of incident review team meetings occurring. The DJJ statewide PREA Coordinator
serves as the facilitator of the PREA incident review teams for State-run and contract
facilities.
The meeting minutes summarized the allegation, highlighted investigation points, and
informed that the allegations were investigated administratively by a DJJ investigator. The
case that was closed as information only received an incident review because it was not
determined to be unfounded. The information remains and will be considered if additional
information is received. The case was categorized as unsubstantiated in this report.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
Policy requires that the review occurs within 30 days of the conclusion of the investigation.
The statewide PREA Coordinator facilitates the incident review team meetings and meeting
minutes are provided to the superintendent and regional staff. The interviews revealed
knowledge of the purpose of the incident review process and the timeline.
Provision (c):
The incident review team shall include upper-level management officials, with
input from line supervisors, investigators, and medical or mental health
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practitioners.
Policy and interviews collectively identify members of the incident review team. Members of
the team are identified in policy and includes upper-level management staff such as the
superintendent, assistant superintendent, clinical staff, with input from line supervisors. The
investigator of the investigative entity may also participate in the incident review where
applicable. Additional staff members will attend the meeting as needed, related to the
incident.
Provision (d):
The review team shall:
(1) Consider whether the allegation or investigation indicates a need to change
policy or practice to better prevent, detect, or respond to sexual abuse;
(2) Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex
identification, status, or perceived status; or, gang affiliation; or was
motivated or otherwise caused by other group dynamics at the facility;
(3) Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse.
(4) Assess the adequacy of staffing levels in that area during different shifts; and
(5) Assess whether monitoring technology should be deployed or augmented
to supplement supervision by staff; and
(6) Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to paragraphs (d)(1)-(d)(5) of this section,
and any recommendations for improvement and submit such report to the
facility head and PREA compliance manager.
Policy and interviews collectively outline the requirements of the standard for the areas to
be assessed by the incident review team. The interviews and review of policy confirmed the
incident review team is charged with considering the factors identified in this standard
provision regarding the results of the investigation. The incident review process is
documented and is facilitated by the DJJ statewide PREA Coordinator. The meeting minutes
provide for but is not limited to group dynamics; make-up of the population; area where
allegation occurred; and deployment of staff. The meeting minutes may contain
recommendations for change in policy, staff training, or otherwise.
Provision (e):
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The facility shall implement the recommendations for improvement, or shall
document its reasons for not doing so.
Policy provides the reasons for not following recommendations are documented. The
interviews revealed familiarity with the policy requirement. The incident review process
allows for the assessment of the circumstances surrounding the incident. A format for
documenting the incident review process has been developed by the DJJ statewide PREA
Coordinator and include recommendations when indicated. There were no
recommendations made regarding the two incident reviews that occurred.
Conclusion:
Based upon the review of policy and other documentation and interviews, the Auditor
determined the facility is compliant with this standard.
Standard 115.387: Data collection
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.387 (a)
▪ Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities
under its direct control using a standardized instrument and set of definitions? ☒ Yes ☐ No
115.387 (b)
▪ Does the agency aggregate the incident-based sexual abuse data at least annually?
☒ Yes ☐ No
115.387 (c)
▪ Does the incident-based data include, at a minimum, the data necessary to answer all questions
from the most recent version of the Survey of Sexual Violence conducted by the Department of
Justice? ☒ Yes ☐ No
115.387 (d)
▪ Does the agency maintain, review, and collect data as needed from all available incident-based
documents, including reports, investigation files, and sexual abuse incident reviews?
☒ Yes ☐ No
115.387 (e)
▪ Does the agency also obtain incident-based and aggregated data from every private facility with
which it contracts for the confinement of its residents? (N/A if agency does not contract for the
confinement of its residents.) ☒ Yes ☐ No ☐ NA
115.387 (f)
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▪ Does the agency, upon request, provide all such data from the previous calendar year to the
Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA Agency
Policy FDJJ 1919, PREA
Agency Policy FDJJ 2020, Incident Operations Center and Incident Reviews
Agency Data Log
Interviews:
Superintendent
PREA Coordinators
Provisions (a) & (c):
(a): The agency shall collect accurate, uniform data for every allegation of sexual
abuse at facilities under its direct control using a standardized instrument and
set of definitions. (c): The incident-based data collected shall include, at a
minimum, the data necessary to answer all questions from the most recent
version of the Survey of Sexual Violence conducted by the Department of
Justice.
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The facility and agency policies and both PREA Coordinators collectively provide for the
collection of accurate and uniform data for allegations of sexual abuse from incident-based
documents. The Department of Juvenile Justice (DJJ) collects the data and completes an
annual report with the compilation of data gleaned from the State-run and contract facilities
through the central reporting system.
Agency and facility policies contain standardized definitions and provide support for the
collection of accurate and uniform data. The facility follows the parent agency's Monthly
Reporting Flow Chart in submitting PREA-related data to their parent agency. DJJ and the
parent agency maintain incident-based data complete enough to complete the most recent
version of the instrument formerly identified as the Survey of Sexual Violence and now
identified as the Survey of Sexual Victimization.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least
annually.
The agency aggregates the incident-based, uniform data from state-run and contract facilities
regarding allegations of sexual abuse and sexual harassment. The aggregated data contributes
to the development of the annual report for the agency which is supported by the reviewed
data and agency policy.
Provision (d):
The agency shall maintain, review, and collect data as needed from all
available incident-based documents, including reports, investigation files, and
sexual abuse incident reviews.
The data is collected and various types of data are identified and related documents
regarding PREA information as applicable, including incident reports, investigative reports
and incident revie team minutes. Statistical information is maintained for various service
areas and occurrences, including major or significant incidents and medical and mental
health emergencies. The agency collects and maintains data for state-run and contract
facilities and aggregates the data which culminates into the agency’s annual report.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every
private facility with which it contracts for the confinement of its residents.
The agency, Department of Juvenile Justice, collects and maintains data for state-run and
contract facilities and aggregates the data which culminates into the annual report. The data
is collected from the contract facilities and is included in the agency’s annual reports. The
data is aggregated at the central office level. The facility does not contract for confinement
services for youth assigned to the facility.
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Provision (f):
Upon request, the agency shall provide all such data from the previous
calendar year to the Department of Justice no later than June 30.
Upon request, the facility completes all such data from the previous calendar year and will
submit the data to the Department of Justice in a timely manner based on the year of the
most recent version of the Survey of Sexual Victimization. Currently, a request has not been
made by the Department of Justice.
Conclusion:
Based upon the review and analysis of the documentation and the interviews, the Auditor
determined the facility is compliant with this standard.
Standard 115.388: Data review for corrective action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.388 (a)
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Taking corrective action on an ongoing basis?
☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Preparing an annual report of its findings and
corrective actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No
115.388 (b)
▪ Does the agency’s annual report include a comparison of the current year’s data and corrective
actions with those from prior years and provide an assessment of the agency’s progress in
addressing sexual abuse ☒ Yes ☐ No
115.388 (c)
▪ Is the agency’s annual report approved by the agency head and made readily available to the
public through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.388 (d)
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▪ Does the agency indicate the nature of the material redacted where it redacts specific material
from the reports when publication would present a clear and specific threat to the safety and
security of a facility? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1919, PREA
Annual Reports
Interviews:
PREA Compliance Manager
PREA Coordinators
Agency Head Designee
Provision (a):
The agency shall review data collected and aggregated pursuant to §115.387 in
order to assess and improve the effectiveness of its sexual abuse prevention,
detection, and response policies, practices, and training, including:
(1) Identifying problem areas;
(2) Taking corrective action on an ongoing basis; and
(3) Preparing an annual report of its findings and corrective actions for each
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facility, as well as this agency as a whole.
The interviews and policies support the review of data and that it is used to improve both
agencies’ PREA efforts. The interviews and review of documentation revealed the collection
of various types of data, including PREA related information. Data is reviewed to assess and
improve the effectiveness of prevention, detection and response within the agencies as well
as individual facilities. The data is also primary to preparing annual and quarterly reports.
The interview with the contract agency head designee revealed that on a quarterly basis,
allegations are assessed to determine threats to the facility and to address any issues
presented.
Provisions (b), (c) & (d):
(b): Such report shall include a comparison of the current year’s data and
corrective actions with those from prior years and shall provide an assessment
of the agency’s progress in addressing sexual abuse. (c): The agency’s report
shall be approved by the agency head and made readily available to the public
through its website or, if it does not have one, through other means. (d): The
agency may redact specific material from the reports when publication would
present a clear and specific threat to the safety and security of a facility, but
must indicate the nature of the material redacted.
The agency's annual report is prepared by the statewide PREA Coordinator and includes data
from all state-run and contract facilities. The annual reports are approved by the agency
head/designee. There are no personal identifiers in the reports. The annual report contains
PREA related data that represents previous calendar years allowing for the comparison of
data. The overarching annual report, inclusive of all facilities within the agency that meet the
requirement of adhering to the PREA Standards, is posted on the agency’s website, accessible
to the public.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined the agency
is compliant with this standard.
Standard 115.389: Data storage, publication, and destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.389 (a)
▪ Does the agency ensure that data collected pursuant to § 115.387 are securely retained?
☒ Yes ☐ No
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115.389 (b)
▪ Does the agency make all aggregated sexual abuse data, from facilities under its direct control
and private facilities with which it contracts, readily available to the public at least annually
through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.389 (c)
▪ Does the agency remove all personal identifiers before making aggregated sexual abuse data
publicly available? ☒ Yes ☐ No
115.389 (d)
▪ Does the agency maintain sexual abuse data collected pursuant to § 115.387 for at least 10
years after the date of the initial collection, unless Federal, State, or local law requires
otherwise? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents:
Facility Policy 6.13, PREA
Agency Policy FDJJ 1316, Records and Information Management Procedures
Agency Policy FDJJ 1919, PREA
Annual Report
Interview:
PREA Coordinator
PREA Audit Report – V7. Page 151 of 156 Facility Name – double click to change
Provisions (a)-(d):
(a): The agency shall ensure that data collected pursuant to §115.387 are
securely retained. (b): The agency shall make all aggregated sexual abuse data,
from facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through its website or,
if it does not have one, through other means. (c): Before making aggregated
sexual abuse data publicly available, the agency shall remove all personal
identifiers. (d): The agency shall maintain sexual abuse data collected pursuant
to §115.387 for at least 10 years after the date of its initial collection unless
Federal, State, or local law requires otherwise.
Policy provides that the data collected is securely stored and maintained for at least 10 years
after the date of collection unless a law requires otherwise. Personal identifiers are removed
from aggregated data before making the data publicly available. The annual report is available
to the public through the Department of Juvenile Justice (DJJ) website. The DJJ annual report
is the overarching report for the agency that encompasses the PREA data for all state-run and
contract facilities within the agency. A review of annual reports verified there are no personal
identifiers. All current facility and agency records maintained by the current contractor are
securely stored in locked cabinets behind locked doors and electronic records are password
protected with limited staff access.
Conclusion:
Based upon the review and analysis of the documentation, interviews and observations, the
Auditor determined the facility is compliant with this standard.
AUDITING AND CORRECTIVE ACTION
Standard 115.401: Frequency and scope of audits
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.401 (a)
▪ During the prior three-year audit period, did the agency ensure that each facility operated by the
agency, or by a private organization on behalf of the agency, was audited at least once? (Note:
The response here is purely informational. A "no" response does not impact overall compliance
with this standard.) ☒ Yes ☐ No
115.401 (b)
▪ Is this the first year of the current audit cycle? (Note: a “no” response does not impact overall
compliance with this standard.) ☐ Yes ☒ No
▪ If this is the second year of the current audit cycle, did the agency ensure that at least one-third
of each facility type operated by the agency, or by a private organization on behalf of the
PREA Audit Report – V7. Page 152 of 156 Facility Name – double click to change
agency, was audited during the first year of the current audit cycle? (N/A if this is not the
second year of the current audit cycle.) ☐ Yes ☐ No ☒ NA
▪ If this is the third year of the current audit cycle, did the agency ensure that at least two-thirds of
each facility type operated by the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle? (N/A if this is not the third year
of the current audit cycle.) ☒ Yes ☐ No ☐ NA
115.401 (h)
▪ Did the auditor have access to, and the ability to observe, all areas of the audited facility?
☒ Yes ☐ No
115.401 (i)
▪ Was the auditor permitted to request and receive copies of any relevant documents (including
electronically stored information)? ☒ Yes ☐ No
115.401 (m)
▪ Was the auditor permitted to conduct private interviews with residents, residents, and
detainees? ☒ Yes ☐ No
115.401 (n)
▪ Were residents permitted to send confidential information or correspondence to the auditor in
the same manner as if they were communicating with legal counsel? ☐ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The Auditor was provided initial documentation in the online audit system, additional
information onsite, and by email during the post onsite audit phase. Evidence that the
corrective action was implemented was also provided during the post onsite audit phase.
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The Department of Juvenile Justice statewide PREA Coordinator ensured the completion of
PREA audits for each state-run and contract facility as required, including this facility. The
site review assessment was facilitated by the superintendent and corporate office staff; all
areas of the facility were included. The superintendent and assistant superintendent and
other staff were very cooperative in providing information and participating in or assisting in
coordinating the resident and staff interviews. All interviews were conducted in private.
The PREA posted notices regarding the occurrence of the audit provided the general
information and included instructions and Auditor contact information regarding how to
provide confidential information to the Auditor. The facility has policy and a process in place
for confidential correspondence for residents; however, no correspondence was received by
the Auditor from residents, staff, contractors, or visitors during the audit process.
Standard 115.403: Audit contents and findings
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.403 (f)
▪ The agency has published on its agency website, if it has one, or has otherwise made publicly
available, all Final Audit Reports. The review period is for prior audits completed during the past
three years PRECEDING THIS AUDIT. The pendency of any agency appeal pursuant to 28
C.F.R. § 115.405 does not excuse noncompliance with this provision. (N/A if there have been
no Final Audit Reports issued in the past three years, or in the case of single facility agencies
that there has never been a Final Audit Report issued.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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Documents:
Annual Reports
Interviews:
Superintendent
PREA Coordinator
Provision (f):
The agency shall ensure that the auditor’s final report is published on the
agency’s website if it has one, or is otherwise made readily available to the
public.
The posted PREA reports of other state-run and contract facilities are posted on the DJJ
website. The agency practice and the interview with the PREA Coordinator document that
this report will be posted on the agency website, accessible to the public. This report and
other posted reports do not contain any personal identifying information other than names
and job titles of management staff.
The facility and agency policies, additional documentation, observed practices, and interviews
were reviewed regarding compliance with the standards and have been identified in the
reports. The audit findings for this report were based on a review of policies, procedures,
supporting documentation, observations, and interviews. There were no conflicts of interest
regarding the completion of this audit. This report does not contain any personal identifying
information other than names and job titles of facility and agency staff where indicated.
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AUDITOR CERTIFICATION
I certify that:
☒ The contents of this report are accurate to the best of my knowledge.
☒ No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review, and
☒ I have not included in the final report any personally identifiable information (PII)
about any resident or staff member, except where the names of administrative
personnel are specifically requested in the report template.
Auditor Instructions:
Type your full name in the text box below for Auditor Signature. This will function as your official
electronic signature. Auditors must deliver their final report to the PREA Resource Center as a
searchable PDF format to ensure accessibility to people with disabilities. Save this report document
into a PDF format prior to submission.1 Auditors are not permitted to submit audit reports that have
been scanned.2 See the PREA Auditor Handbook for a full discussion of audit report formatting
requirements.
May 5, 2025
Auditor Signature Date
1 See additional instructions here: https://support.office.com/en-us/article/Save-or-convert-to-PDF-d85416c5-7d77-4fd6-
a216-6f4bf7c7c110 .
2 See PREA Auditor Handbook, Version 1.0, August 2017; Pages 68-69.
PREA Audit Report – V7. Page 156 of 156 Facility Name – double click to change

source: DJJ

report_type: PREA

file_name: Florida_Wimauma Academy_Year3Cycle4.pdf

program_name_raw: Wimauma Academy

cycle: Year 3 Cycle 4