facility_name: plam beach ya

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Palm Beach Youth Academy
Physical Address: 9680 Weisman Way, West Palm Beach, FL 33411
Date report submitted: June 23, 2016
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: May 26-27, 2016
Facility Information
Facility Mailing Address: 9680 Weisman Way, West Palm Beach, FL 33411
Telephone Number: 561-333-0664
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Demetreus Jones Title: Assistant Facility Admin.
Email Address: demetreus.jones@sequelyouthservices.com Telephone Number:
561-333-0664
Agency Information
Name of Agency: Sequel Youth and Family Services
Governing Authority or Parent Agency: NA
Physical Address: 1131 Eagletree Lane, Huntsville, AL 35801
Mailing Address: Same as Above
Telephone Number: 256-880-3339
Agency Chief Executive Officer:
Name: John Stupak Title: Chief Executive Officer
Telephone Number: 215-284-5043
Email Address: johnstupak@sequelyouthservices.com
Agency Wide PREA Coordinator
Name: Sonja Schierling Title: Sequel PREA Coordinator
Email Address: sonya.schierling@sequelyouthservices.com
Telephone Number: 941-526-8763
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AUDIT FINDINGS
NARRATIVE:
The Palm Beach Youth Academy is a 70-bed facility which is located in West Palm Beach, Florida
and is operated by Sequel Youth and Family Services through a contract with the Florida Department
of Juvenile Justice (FDJJ). Sequel Youth and Family Services acquired the contract to manage the
Palm Beach Academy on April 1, 2016. The secure residential facility serves male juvenile offenders
from ages 15 to 21 that have been classified as high risk. The program provides mental health
treatment services; substance abuse treatment services; transition and discharge planning; education
services; group, individual and family counseling; medical services; recreation; and case management
services. The program’s emphasis is on the cognitive-behavioral model where the focus is on
changing the thinking patterns which will help change the behavior of the resident. In order to
successfully complete the program, the resident must progress through a series of four levels: 1)
Learning Past Patterns of Delinquent Thinking and Behavior; 2) Learning Victim Impact and
Interpersonal Responsibilities; 3) Learning Alternatives to Past Delinquent Thinking and Behavior;
and 4) Relapse Prevention and Community Transition.
Mental health services are provided under the management of the Clinical Director and other mental
health staff includes an Assistant Clinical Director and seven Therapists. A consulting psychiatrist
and contract Behavior Analysts visit the facility weekly. In addition to the Director of Nursing who
manages the medical clinic, the medical staff includes two Registered Nurses and a contract physician
who visits the facility weekly and is on-call 24 hours, seven days a week. Case management services
are provided by the Director of Case Management and eight Case Managers. A school is onsite and
provides education and vocational services through contract personnel with the Palm Beach County
School District. Education staff and services are managed by the Assistant Principal. All of the core
education subjects are taught and the school offers industry certification in Adobe Photo Shop and/or
Microsoft Office. Vocational services are also provided by an instructor through a contract with the
Home Builders Institute, which provides career training in the building industry. Youth Care Workers
and Shift Supervisors provide direct care and supervision to residents during the day-to-day
operations and during the residents’ movement throughout the facility. Recreational services are
provided by two Recreational Therapists. The recreation program is intended to improve social,
emotional, mental, and physical functional abilities through recreation and to provide opportunities
for fun, enjoyment and self-expression.
An individualized plan of treatment is developed for each resident. Treatment team meetings are held
regularly to discuss each resident’s progress and needs in the program. Residents are held accountable
for positive participation in the program through the application of the components of the behavior
management system. Additionally, youth recognition and awards are provided to motivate and
encourage positive behavior. Based on identified criteria, residents are recognized by the treatment
team, education unit and for their performance of work details. Residents are presented certificates
which are usually awarded to them quarterly, generally during Family Day Activities, and the parent
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or guardian is also given a copy of the resident’s certificate. A dorm recognition party is held
weekly for the best dorm as voted on by various staff members. The criteria for the best dorm
include cleanliness; personalization; ownership; resident culture; and minimal occurrence of
incidents.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is contained in one main building, surrounded by a security fence. The front entrance
has a lobby and reception area where visitors may sign-in/out. Adjacent to the lobby are
administrative offices and a conference room. Beyond the front entrance are six dormitories,
separated by a long hallway. The dormitories are separated as Phase I and Phase II with three dorms
and a control room on each. Both Phase I and Phase II have a Therapist and Case Manager located on
each dorm; a shower, dayroom area, and classrooms. The Phase I area contains a back-up laundry
room and the multipurpose room which also serves as the dining hall. The kitchen is adjacent to the
multipurpose room. Along the hallway between Phase I and Phase II are the medical clinic; intake
area; main laundry room; and storage areas. Two single cells are located in the intake area; however,
isolation is not used in this facility and one of the cells is used as a storage room. Areas where the
residents are not allowed are marked with painted red dots on the locked doors. PREA posters and
other related information are posted in each dorm, visible to all residents, staff and visitors.
Each of the six dormitories has an outside fenced recreation area adjacent to it. A small storage shed
is also located on the outside grounds. There is a large recreation field on the grounds and the dorms
rotate using this area. The recreation field can accommodate an array of recreation and other
activities, including Family Day which is held each quarter. During Family Day activities, the large
recreation area contains picnic tables; a DJ set-up with music; snow cone set-up; bouncy house; and
residents present various performances to entertain the visiting family members. A basketball
tournament may also be held during the Family Day activities. Cameras are located on the outside
grounds in each recreation area.
Residents admitted to the facility stay for a period of nine to twelve months. The population during
the on-site audit was. Some of the rooms contain two beds; however, all the rooms are currently used
for single occupancy since the facility has been under the new contract. The facility provides
comforters for each resident’s room and the residents are allowed to personalize their room. Shower
curtains are a recent addition to the individual showers and were installed by residents through the
Home Builders Institute vocational training. The practice is that female staff members announce their
presence prior to entering a dorm and signs are posted as a reminder of that practice.
.
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various areas of the facility prior to the site
visit. Photographs were taken of the posted notices and the photographs were electronically sent to
this Auditor, noting their locations. An initial telephone introductory conversation was held with
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Sequel Youth and Family Services staff and the FDJJ statewide PREA Coordinator. The Pre-Audit
Questionnaire, facility policies and supporting documentation were uploaded to a flash drive which
was sent to this Auditor prior to the on-site visit. The Pre-Audit Questionnaire was reviewed with
the Assistant Facility Administrator/PREA Compliance Manager for clarity of information and to
request additional information and both were provided as needed. The site visit was conducted on
May 26-27, 2016. The effective date of Sequel Youth and Family Services acquiring the facility is
April 1, 2016.
An entrance meeting was held with the Assistant Facility Administrator of Operations who also
serves as the PREA Compliance Manager and the Assistant Facility Administrator of Programs.
After the meeting, both staff members provided a comprehensive tour of the facility. During the
tour, other staff members were observed to be interacting with the residents and providing direct
supervision. Ten direct care staff members and 11 residents were interviewed. Thirteen specialized
interviews were conducted, including a contractor and a volunteer. The residents and staff
interviewed were aware of how to report sexual assault and sexual harassment and had an
understanding of the meaning of zero-tolerance. A summary of the audit findings was provided to
the Facility Administrator and the two Assistant Facility Administrators.
Number of Standards Exceeded: 0
Number of Standards Met: 38
Number of Standards Not Met: 0
Number of Standards Not Applicable: 3
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Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has a zero-tolerance PREA Policy, 5.29, which details how the facility will
implement its approach to preventing, detecting, and responding to sexual abuse. The
facility’s PREA Policy is used in concurrence with the Florida Department of Juvenile
Justice’s PREA Policy 1919 (FDJJ 1919). Both policies contain definitions of the prohibited
behaviors and sanctions for those who participate in such behaviors. The facility also has a
host of other policies and procedures that support the components of the PREA standards.
The Assistant Facility Administrator of Operations has been identified as the PREA
Compliance Manager who stated in the interview that he has sufficient time to fulfill his duties
regarding PREA and explained his preparation process. A review of the organizational chart
confirms that the Assistant Facility Administrator of Operations reports to the Facility
Administrator who is responsible for the overall facility operations and management.
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The standard is not applicable; the facility does not contract with other agencies for the
confinement of its residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses the facility staffing plan and its requirements. The Policy provides that
documentation is required when deviations from the staffing plan occur. The facility reports
that there have been no deviations from the staffing plan and a review of the staffing plan and
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work schedules show the staff assignments. Interviews with the Facility Administrator and
the Assistant Facility Administrator revealed that staffing is continuously monitored and that
adjustments are made as needed. A staff hold-over system is in place to ensure that the ratios
of 1:8 during the waking hours and 1:12 during the sleeping hours are maintained, per the
contract between FDJJ and Sequel Youth and Family Services. A staffing plan assessment
was conducted and documented by the FDJJ statewide PREA Coordinator. This assessment
reviews staffing; the electronic monitoring system; areas of the physical plant; completion of
unannounced rounds; applicable policies and procedures; and other areas.
Policies 5-01 and 5.29 and practice provide for unannounced rounds that are completed by
intermediate/higher level staff to cover all shifts. The Assistant Facility Administrator of
Operations and Assistant Facility Administrator of Programs explained how the unannounced
rounds are conducted. The Assistant Facility Administrator of Operations stated how
measures are taken so that staff will not alert other staff when unannounced rounds are
occurring. A review of documentation and the staff interviews confirmed that unannounced
rounds occur.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, staff members are prohibited from conducting cross gender
searches. Staff and resident interviews supported that cross-gender strip searches, cross-
gender pat-down searches, and cross-gender visual body searches are prohibited. Staff
training includes the searching of residents. Staff interviews and documentation revealed staff
meetings or reviews regarding the searches of transgender or intersex residents. The facility
has not admitted a transgender or intersex resident; however, the staff members interviewed
are familiar with the applicable procedures including that a transgender or intersex resident
will not be searched for the sole purpose of determining the resident’s genital status.
The viewing of residents by opposite gender staff while they are showering, changing clothes,
and performing bodily functions is not permitted and female staff members announce their
presence when entering a dorm. Signs are posted in each dorm informing female staff to
announce their presence and the practice was observed. Interviews with staff and residents
confirmed that female staff members make the announcement as required.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
Policy 5.29 addresses the facility not relying on resident interpreters or resident readers. All
residents are provided an equal opportunity to participate in or benefit from resident
education to protect them from sexual abuse and sexual harassment. The facility will utilize
support services through Language Line Solutions in partnership with the Florida
Department of Health. Two employees of the facility have been identified who may also
provide assistance as interpreters, as needed. Random staff interviews confirmed that
residents are not used as interpreters. PREA information brochures for residents are available
in languages other than English.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 1.02, 1.12, FDJJ 1800 and FDJJ 1919 provide guidelines for background checks and
hiring and promotion practices. A review of documentation and an interview with the
Assistant Program Director of Administrative Services revealed that applicants, employees
and contractors are asked about previous sexual misconduct and background checks are
completed. Documentation provided and the interview confirmed that prior to the hiring of
an employee or contractor, background checks are conducted. Documentation confirmed that
inquiries are made regarding hiring or promoting anyone who has engaged in sexual abuse in
a jail, lockup or similar facility; anyone who has been convicted of engaging or attempting to
engage in coerced or forced sexual activity; or anyone who has been adjudicated for any of
the aforementioned activities. The Policies and practice prohibit hiring, promoting or
contracting with anyone who has been convicted of engaging in any activity prohibited by
the standard.
The Assistant Program Director of Administrative Services explained the different systems
used to conduct background checks as confirmed through a review of a random sample of
personnel files. The review of the sample of personnel files revealed that they include
background checks and signed acknowledgement forms regarding related information. The
omission of information regarding misconduct is grounds for termination of employment.
The Assistant Program Director of Administrative Services confirmed her knowledge of the
PREA requirements in the area of personnel. She also stated and policy supports that it is the
employee’s continuous duty to disclose any related misconduct within 24 hours.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
Palm Beach Youth Academy is not a new facility and there has not been substantial
expansion or modification since August 20, 2012. Sequel Youth and Family Services
acquired the contract April 1, 2016 and uses the existing camera system to support staff in
monitoring the residents. The camera system has been adjusted to improve the desk top
monitoring, from her office, by the Assistant Facility Administrator of Programs.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses the availability of victim advocacy services to residents and services
and that the services will be provided to the victim at no cost. A review of documentation
shows that the facility staff is involved in finalizing a Memorandum of Understanding with
the local rape crisis center. According to the documentation, the draft document is being
reviewed for the final language to be included in the MOU. The services, as stated in the
brochure provided to the facility, will include but not be limited to advocacy and
accompaniment during medical and investigative procedures; individual therapy; information
about victims’ rights; and access to a 24-hour crisis hotline. There have been no forensic
examinations conducted during the past 12 months.
Policy 5.29 and FDJJ 1919 provide that the facility is not responsible for conducting
administrative or criminal investigations. The DJJ Office of the Inspector General is
responsible for conducting administrative investigations; the Florida Department of Children
and Families is responsible for conducting allegations of child abuse; and local law
enforcement is responsible for conducting criminal investigations. The PREA Compliance
Form which contains the PREA requirements regarding investigations will be provided to law
enforcement investigators as required by FDJJ, prior to an investigation.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 1.02, 1.03, 5.29 and FDJJ 1919 require that allegations of sexual abuse or sexual
harassment are referred for investigation and identify the agencies that will conduct the
investigations. According to FDJJ 1919 facility staff is to cooperate with the OIG
investigations. The facility reports that no allegations have been made. Information regarding
the referral of allegations of sexual abuse or sexual harassment for an investigation and other
PREA related information is posted on the Sequel Youth and Family Services and the FDJJ
websites. PREA related information is also posted in the facility, accessible to the public,
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residents and staff. All Youth Care Workers and Shift Supervisors interviewed stated that
reports of allegations of sexual abuse or sexual harassment will be documented.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 1.05, 1.07 and 5.29 provide information regarding staff training. Employees receive
training and updates and specifics related to the standards as needed onsite and through FDJJ
for additional training. The staff training includes key areas referenced in the standard and is
tailored to the needs of the population served. The FDJJ PREA training is primarily provided
through online courses of the SkillPro training system. Between general scheduled trainings,
the facility provides refresher information as needed. Training records and staff interviews
support that PREA training is provided. During the site visit a staff meeting/training session
was conducted with facility staff and included refresher information regarding PREA,
including working with LGBTI residents.
Standard 115. 332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 5.29, 1.02 and FDJJ 1919 address this standard and require volunteers and
contractors who have contact with residents to be trained on their responsibilities; the
facility’s zero-tolerance policy regarding sexual abuse and sexual harassment; and how to
report such, based on the level of services they provide. The FDJJ has a prepared course
regarding sexual assault prevention, detection, and response that is used for volunteers and
contractors. Receipt of the training was acknowledged through an interview with a contract
staff, the Assistant Principal; an interview with the Assistant Director of Programs who
assists in coordinating some of the contractor training; and a review of documentation. The
facility has a Training Manager who is responsible for staff training and training records.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
Policy 5.29, FDJJ 1919 and practice require that all residents admitted to the facility receive
age-appropriate training about PREA and how to report incidents or suspicions of sexual
abuse and sexual harassment, the facility response, and non-retaliation for reporting. The
facility reports and interviews conducted with 11 residents revealed that residents receive
PREA education upon intake. There are provisions to provide it through accessible formats
for residents who are limited English proficient, deaf, visually impaired, or otherwise
disabled, as needed. Support services will be provided by Language Line Solutions and
facility staff and/or contractors.
Residents sign the PREA education and Youth Rights forms acknowledging that they have
received the relevant information. The Youth Handbook contains PREA information and
materials and brochures are posted in each dorm, accessible to all residents. The Director of
Case Management conducts an education session with each resident. She is notified by e-
mail within 48 hours of the pending arrival of each resident and coordinates the admissions.
Refresher sessions may be handled through the residents’ town hall meetings which are held
monthly.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, the facility staff members do not conduct investigations.
Administrative investigations are conducted by the Office of the Inspector General (OIG) and
criminal investigations are conducted by the Palm Beach County Sheriff’s Office and the
Department of Children and Families. FDJJ 1919 provides that OIG staff be trained on the
related policies and procedures regarding the handling of sexual misconduct incidents and
reports. The investigators have been trained in conducting allegations in the FDJJ settings. The
Assistant Facility Administrator has documented correspondence with the Palm Beach County
Sheriff’s Office regarding expectations for PREA related investigations. The correspondence
indicates the Sheriff’s Office’s capabilities and responsibility in responding to and
investigating allegations of abuse regarding allegations that are criminal in nature.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 address this standard. Medical and mental health staff members
are required to receive the regular PREA training and the specialized training available online
through the SkillPro training system provided by FDJJ. The mental health and medical staffs
competed the general training that is provided for all staff members which is also available
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through the SkillPro training system. Forensic medical examinations will not be conducted
by the facility medical staff.
A review of the training records and staff interviews revealed that all mental health staff had
completed the specialized training but medical staff had not. A corrective action was
implemented and all medical staff members have completed the training since the site visit as
confirmed through the review of the electronic training records and confirmation by the
Assistant Facility Administrator of Operations/PREA Compliance Manager.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses the use of the Screening for Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) instrument. It is administered to determine the
resident’s risk of victimization and abusiveness and other related information. The
instrument is completed on each resident upon intake whether a new admission or transfer.
The VSAB is used to obtain the information required by the standard, including but not
limited to prior sexual victimization or abusiveness; the youth’s self-identification; current
charges and offense history; and intellectual or developmental disabilities. The Risk
Assessment form is used for assessments and reassessments. Staff and resident interviews
and a review of documentation confirmed that screenings occur and that reassessments are
being conducted formally through the Risk Assessment form and informally through
meetings with treatment staff.
Prior to the resident’s arrival to the facility, the Director of Case Management reviews his
commitment paperwork. She states that upon the resident’s arrival to the facility, she
administers the VSAB and the method she uses is to ask open-ended and direct questions.
The information obtained from the commitment paperwork and contact with the parents
assist with the completion of the VSAB. Resident interviews revealed that verbal
reassessments are conducted on an informal basis through resident meetings with treatment
staff.
The information from the risk screening of the resident is accessible to the assigned
Therapist, assigned Case Manager, Clinical Director, Assistant Clinical Director, and
medical staff. The clinical files are maintained in a confidential manner. The residents
interviewed were able to identify specific areas that are inquired about in the administration
of the VSAB and similar questions related to safety that are asked of them by treatment staff
during formal and informal meetings.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
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for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, the information obtained from the VSAB is used to assist in
determining the resident’s housing and the assignment of his Therapist. Staff interviews and
a review of VSABs supported the facility and FDJJ policies, procedures and practices.
Residents confirmed through their interviews that VASBs are being administered. Isolation
is not used at this facility.
Policy 5.29 prohibits placing gay, bisexual, transgender, or intersex residents into separate
housing or any other assignment based solely on such identification or status. The facility
prohibits considering gay, bisexual, transgender, or intersex identification or status as an
indicator of likelihood of being sexually abusive. Staff interviews support that housing and
program assignments for transgender or intersex residents will be made on a case-by-case
basis. The staff members are aware of the policies and practices that would be implemented if
there are transgender or intersex residents within the facility’s population.
Standard 11 5.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, there are internal ways a resident may report allegations of sexual
abuse; sexual harassment; retaliation for reporting; and staff neglect or other violations that
lead to abuse. A resident may talk to any staff member; complete a grievance form and place
it in the grievance box; utilize a phone to report through the DJJ hotline number; and third
parties may report allegations. Residents may also complete a Youth Request to Speak Form
requesting to speak to staff which includes the Facility Administrator; Assistant Facility
Administrator; Clinical Director; Director of Case Management; Program Manager; and the
Assistant Principal. Grievance and sick-call boxes and forms are located in each dorm area
and in the multi-purpose/dining room.
Staff members are required to document verbal reports prior to the end of their shift as stated
in Policy 1.03. Reporting allegations of sexual abuse or sexual harassment is also provided
for in FDJJ 1919. PREA related information is posted within the facility which is accessible
to all residents, staff and visitors. Resident and staff interviews revealed that they are aware
of the reporting methods and how to utilize them. Parents/guardians are provided a handbook
which contains information on how to report allegations of sexual abuse and sexual
harassment.
Staff members are required, through policy and practice, to ensure the resident’s use of a
telephone to report allegations of sexual abuse and sexual harassment. A phone is also
located in the dining/multipurpose room which connects the caller to the Florida abuse
reporting hotline once the receiver is picked up. During the site visit, the posted phone was
not working properly. Since that time the facility implemented a corrective action of getting a
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technician to repair the phone. An invoice has been submitted to this auditor identifying the
repair services.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 5.29 and FDJJ 1919 address residents reporting allegations of sexual harassment or
sexual abuse through the grievance system. If the grievance is PREA related, the resident is
instructed to put their name and date on the form and place it in the grievance box. The
resident has the option to give the grievance to an administrative staff member if he chooses
to; it is not required. The resident is not required to use the informal process for any situation
regarding sexual abuse or sexual harassment allegations. When a grievance is received
regarding sexual abuse or sexual harassment, it will be treated as an allegation and the
reporting procedures will be implemented for an investigation by the Office of Inspector
General, Department of Children and Families, or the Palm Beach County Sheriff’s Office.
The grievance system does not include a process for facility staff to investigate or resolve
allegations of sexual abuse or sexual harassment.
FDJJ 1919 provides that there are no time limits for a resident to complete an emergency
grievance and Policy 5.29 states that a resident may complete one immediately. A resident is
informed of consequences when it has been determined that a report alleging sexual abuse
has been made in bad faith, per Policies 1.02 and FDJJ 1919. Interviews with residents
revealed that they were told and understand that they will not be punished if a report is made
in good faith. The residents and staff interviewed identified the grievance system as one of
the methods that may be used to report allegations of abuse and the residents are aware of
how grievances are handled regarding sexual abuse or sexual harassment. The facility
reports there have not been any grievances alleging sexual abuse.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 provides for residents to have access to outside victim advocacy services and a
draft Memorandum of Understanding between the local rape crisis center and the facility is
being reviewed for the completion of a final document. The facility will ensure that residents
will have access to an outside victim advocate for emotional support and other identified
services related to sexual abuse.
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Staff and resident interviews confirmed that residents have access to their attorney or other
legal representative and may meet with them privately. Interviews also confirmed residents’
access to their parents or legal guardians. All residents interviewed could verbalize the
visitation times and the process for using the telephone and all were aware of Family Day.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility provides methods for third-party reporting of sexual abuse as supported by
Policies 5.29 and FDJJ 1919. Policy 5.29 provides that a resident may have third-party
assistance in filing a grievance/report, including appeals. PREA information, including how
to report is posted in areas of the facility accessible to the public, staff and residents. PREA
information is available on the FDJJ and the Sequel Youth and Family Services websites
regarding the reporting of sexual abuse or sexual harassment and in the Youth Handbook.
Parents/guardians are also provided a Parent Handbook that contains information regarding
reporting allegations of sexual abuse.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 and staff training support that all staff members report any
allegation, knowledge or suspicion of sexual abuse, sexual harassment, retaliation, or neglect
that lead to an incident or retaliation. Allegations must be reported to the Central
Communications Center (CCC), Department of Children and Families and the Palm Beach
County Sheriff’s Office, as required by mandatory reporting laws and facility and FDJJ
policies.
Medical and mental health staffs inform residents at the initiation of services of their duty to
report and the limitations of confidentiality. A review of a sample of residents’ files showed
they contained Orientation/Consent for Treatment forms signed and dated by the resident,
parent/guardian and Therapist. The form contains the following headings and addresses each
Youth’s Rights; Limits of Confidentiality; Youth’s Responsibilities; and Discharge Criteria.
Interviews with the Clinical Director and Director of Nursing and the review of documents,
support that residents are informed at the initiation of services of the limitations of
confidentiality and the duty to report by the clinical staff. All staff interviews revealed that
they are aware of the requirements regarding their reporting duties and understand that they
are mandated reporters.
14
FDJJ 1919 prohibits staff from revealing any related information to anyone other than to the
extent necessary to make treatment, investigation and other security and management
decisions. The CCC will make appropriate notification to senior FDJJ management who will
make notification to management overseeing the facility where the alleged abuse occurred.
Facility staff will notify the alleged victim’s parents or legal guardians. If the resident is under
DCF Custody, the Case Worker will be notified and if applicable, the attorney of record will
be notified of the allegation within 14 days of receipt of the allegation.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide that when staff learns that a resident is subject to
substantial risk of imminent sexual abuse, actions will be taken to protect the resident. There
has not been a case of imminent risk during this audit period. Staff interviews revealed the
protective measures that would be taken when it is determined that a resident is at risk of
imminent sexual abuse and they include placing the resident in another dorm or another
room in the same dorm; closely monitor the resident at risk; call an emergency treatment
team meeting; report information to shift supervisor; and shower separately. During the
interviews with the residents, they indicated that during the intake process, their feelings
about their safety are part of the inquiries by staff and that staff ask them if they feel safe
during treatment team meetings and other interactions.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Facility Administrator will notify the head of that
facility or the appropriate office. The notification will be made as soon as possible but no
later than 72 hours and the contact will be documented. Policies 5.29 and FDJJ 1919 support
notifying the appropriate investigative agency of all allegations of sexual abuse. There has
not been a report in the last 12 months of any allegations of sexual abuse occurring to a
resident while in another facility.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
The staff first responder duties are incorporated in Policy 5.29 and are aligned with the
requirements of FDJJ 1919 and include separating the victim form the abuser; protecting the
scene; preserving any evidence; and making the proper contacts. According to Policy, non-
security staff members are required to take the measures to preserve the evidence, remove
the alleged victim from danger, and alert security staff immediately upon learning of any
sexual abuse or sexual harassment. The facility also has a documented coordinated response
plan. Interviews confirmed that Youth Care Workers and Shift Supervisors are
knowledgeable of their duties as a first responder and that the Kitchen Supervisor is aware of
her duties as a non-security staff that may be the first staff on the scene of an allegation of
abuse. There were two allegations, sexual harassment and sexual misconduct, that were
investigated during the past 12 months while the facility was under contract by another
vendor. Both cases were determined unfounded by the Palm Beach County Sheriff’s Office.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s coordinated response plan is aligned with its PREA Policy, FDJJ 1919 and the
requirements of the standard. Interviews with staff revealed that they are familiar with the
plan. The interactive actions to be taken among facility first responders and other staff in
response to an incident of sexual abuse are documented.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
This standard is not applicable; the facility does not maintain any collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 address this standard and states that victims will be protected
from retaliation and contact with alleged abusers. The Program Manager has been identified
as the staff member that monitors for retaliation. The Policy requires that if retaliation
conduct is identified, the monitoring would be conducted for at least 90 days and longer if
needed, regarding staff. The retaliation monitoring for a resident will be for the duration of
the resident’s stay in the facility.
The interview with the Program Manager revealed that he understands that he is charged with
observing for whether or not retaliation occurs after a resident or staff reports an allegation of
sexual abuse or cooperates with an investigation. He was able to describe the protection
measures that would be taken, including direct monitoring of the interactions of staff and
residents and involving human resources, if needed. The interview with the Program Manager
supported the Policies and the defined role of the retaliation monitor. The facility reports that
there have been no incidents of retaliation in the last 12 months.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
This standard is not applicable; segregated housing or isolation is not used at this facility.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide that administrative investigations are conducted by the
OIG and criminal investigations are conducted by local law enforcement and the Department
of Children and Families. The FDJJ Policy, 1919, directs staff to cooperate with the Office
of the Inspector General’s (OIG) investigations and both Policies provide that an
investigation is not terminated because the source recants the allegation. During the
interviews with random staff, there was the general identification of the agencies responsible
for conducting investigations of sexual abuse and sexual harassment.
The OIG investigators have been trained and follow protocols in conducting administrative
investigations in FDJJ settings. The management staff has been provided a copy of the
information sheet provided by FDJJ regarding the protocols related to PREA related
investigations to be provided to the Sheriff’s Office prior to an investigation. Substantiated
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allegations that are criminal in nature will be referred for prosecution by the Palm Beach
County Sheriff’s Office. There were two investigations, during the tenure of the previous
contractor, conducted by the Palm Beach County Sheriff’s Office in the past year that were
determined to be unfounded.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 5.29 and FDJJ 1919 address this standard and provide that the standard of a
preponderance of the evidence for determining whether allegations are substantiated is
imposed.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide that the victim is informed when an investigation has
been concluded. At the conclusion of an OIG investigation, the victim or the victim’s parents
or legal guardian will be notified. According to Policy 5.29, the facility will also notify the
resident in writing and will have the resident sign the notification acknowledging receipt of
the information. A format has been developed by FDJJ and a form letter by the facility has
been developed for reporting the outcomes of the investigation and placement of the accuser
involved in the allegation, in accordance with the standard.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 provides that staff members found to have violated the policies and statutes will
be subject to immediate termination. The Policy states that a termination or resignation by a
staff member that would have been terminated if not for the resignation is reported to local
law enforcement and FDJJ 1919 provides that relevant licensing bodies also be contacted. It
was determined through interviews that the Facility Administrator, Assistant Facility
Administrator of Operations and the Assistant Program Director of Administrative Services
18
are familiar with this information.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 state that any contractor or volunteer engaging in sexual abuse of
residents will be subject to referral to local law enforcement regarding criminal charges and to
relevant licensing bodies. Both Policies require that the contractor or volunteer be prohibited
from having contact with residents. The document review and interviews with a contractor,
the Assistant Principal, a religious volunteer, and the Assistant Facility Administrator of
Programs revealed participation in PREA training by contractors and volunteers. No
contractor or volunteer has been reported to law enforcement or any investigative agency for
allegations of sexual abuse during the past year.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide that residents found in violation of the facility’s zero-
tolerance policy will receive disciplinary sanctions. The Youth Handbook outlines the formal
administrative and disciplinary processes. The Policies prohibit sexual activity between
residents and state that residents will be disciplined for sexual contact with staff only when it
has been determined that the staff member did not consent to the sexual contact.
Additionally, the Policies allow that anyone reporting in good faith will not receive
disciplinary sanctions when an investigation does not establish evidence sufficient to
substantiate the allegation. Disciplinary isolation is not used at this facility.
Interviews with the Clinical Director and the Director of Nursing support that counseling,
medical, and/or other interventions will be offered to address the underlying reasons or
motivations for abuse when the resident remains in or returns to the facility after an incident.
Staffs confirmed that any type interventions or treatment services provided would not be
dependent on the resident’s participation in the behavior management system, education or
other programs. During the past 12 months, there have been no allegations of resident-on-
resident sexual abuse occurring in this facility.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
19
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses this standard. Residents who disclose prior sexual victimization or
who disclose previously perpetrating sexual abuse during an intake screening will be
provided a follow-up meeting with a medical and mental health practitioner. These meetings
are available from the first day of admission to the facility. Staff interviewed confirmed
awareness of the procedures and verbalized how the intake process incorporates meeting
with nursing and mental health staffs during the intake process which begins upon the
resident’s arrival to the facility. During the formal intake screening, the Director of Case
Management inquires about any prior incidents of sexual victimization or previously
perpetrated sexual abuse through administration of the Screening for Vulnerability to
Victimization and Sexually Aggressive Behavior screening instrument.
A review of documentation and interviews with the Director of Case Management, Clinical
Director and Director of Nursing confirmed the practice of residents being seen by mental
health and medical staffs on the same day of the disclosure when made during the intake
screening process. The observations of current practices and interactions support that residents
who disclose during the intake process would be seen on that same day by mental health and
medical staffs.
A review of the files and staff interviews demonstrate that mental health staff maintain files
that document the services provided to each resident. Information related to sexual
victimization or abusiveness that occurred in an institutional setting is limited to medical and
mental health practitioners and the assigned Case Manager. A review of documentation
revealed that the files are very well maintained and are inclusive of the documentation of the
services provided to the residents. The staffs interviewed shared that they are all mandated
reporters. However, the informed consent process is used for all residents.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 includes and staff interviews support that emergency medical and mental health
services be provided to the victim and that victims will be provided on-going medical and
mental health treatment. The treatment will include testing for Sexually Transmitted
Infections and counseling. Interviews with the Director of Nursing and the Clinical Director
confirmed their knowledge of the procedures and that the scope and nature of the services
will be based on their professional judgment. Documentation regarding medical and crisis
intervention services, including timelines, is maintained by medical and mental health staffs.
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Emergency services are provided at the Wellington Regional Hospital in West Palm Beach.
Sick call is conducted by medical staff and interviews support that there is unimpeded access
to emergency services. It is documented through policies and understood by staff that
treatment services will be provided at no cost to the victim, whether or not the victim names
the abuser, or whether or not the victim cooperates with the investigation.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and mental health and medical staffs’ interviews provide that residents will be
allowed on-going medical and mental health treatment, to include Sexually Transmitted
Infections testing and counseling. The Policy states and practice demonstrates that all
residents have access to mental health evaluations and treatment. The interviews revealed
and Policies 5.29 and FDJJ 1919 support that evaluations and treatment will be provided to
victims and abusers.
Staff interviews, document review, and observations revealed that medical and mental health
services are consistent with the community level of care. Policies, interviews and
observations support that medical and mental health evaluations and treatment will be offered
to all residents who have been victimized by sexual abuse in any prison, jail, lockup, or
juvenile facility.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide information regarding the incident review team and its
role. The Policies detail the facility and agency staff positions that would make-up the sexual
abuse incident review team and they provide the purpose of the team and guidelines for its
function. According to the Policies, the positions that comprise the incident review team
include administrative staff; supervisors; Youth Care Workers (direct care staff); medical;
mental health; and other identified participants and participants as needed. Interviews with
the Facility Administrator and Program Manager, identified members of the incident review
team, confirmed their familiarity with the Policies and the purpose of the review process.
21
Policies 5.29 and FDJJ 1919 provide for an incident review to be conducted within 30 days of
the completion of an investigation in accordance with the standard. A form/format has been
developed by FDJJ to capture the required information for documentation of an incident
review team meeting. FDJJ 1919 states that the report from the incident review team is
provided to the Facility Administrator. During the past 12 months and while the facility was
managed by a different vendor, there were two investigations conducted that were determined
to be unfounded.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 5.29 and FDJJ 1919 and interviews with staff confirmed that FDJJ will continue to
collect incident-based, uniform and aggregated data regarding allegations of sexual abuse
using a standardized instrument and specific guidelines. The Policies require the collection of
accurate, uniform data for every allegation of sexual assault. The facility or FDJJ will provide
the United States Department of Justice (DOJ) with data as requested. The format used for
FDJJ facilities and contractors capture the information required to complete the most recent
version of the Survey of Sexual Violence conducted by DOJ. FDJJ maintains and collects
various types of identified data and related documents regarding sexual abuse incidents in all
of its state and contract facilities. FDJJ aggregates the sexual abuse data annually which
culminates into an annual report.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 includes information regarding annual reports and the facility’s PREA Policy, 5.29,
does also. FDJJ 1919 provides that a review is conducted of the collected and aggregated data
to assess and improve the effectiveness of the PREA related efforts and initiatives managed
within FDJJ. The collected and aggregated data is reviewed to assess and improve the
effectiveness of the PREA related efforts and initiatives by identifying problem areas;
developing and implementing corrective actions as needed; and preparing an annual report
based on the collected data. The FDJJ Annual Report is approved as required and posted on
the agency’s website and a comparison is made regarding the previous year’s data. There are
no personal identifiers on the annual reports.
It remains obvious from staff interviews, including the statewide PREA Coordinator;
observations; and document review that the agency has compared the results of annual reports
and used them to continuously improve policies; procedures; practices; and training on a
22
statewide basis.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 requires that data is collected and securely retained for 10 years. FDJJ 1919
provide that all data collected will be securely stored and maintained for at least 10 years after
the initial collection date, unless statutes require otherwise. The aggregated PREA data is
reviewed and all personal identifiers are removed. According to FDJJ 1919 and practice, the
aggregated sexual abuse data from all facilities is readily available to the public through the
agency’s website. Reviews of the posted annual reports continue to verify the practice.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
June 23, 2016
Auditor Signature Date
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program_name_raw: plam beach ya