Date of report:12/16/16

Transcription

1 PREAAUDITREPORTINTERIMFINAL JUVENILE FACILITIES Date of report:12/16/16 Auditor Information Auditor name: Nate Parker Address:7555 4th Ave Lino Lakes, MN Telephonenumber: Date of facilityvisit: November 7-8, 2016 Facility Information Facility name: Dakota County Juvenile Services Center Facilityphysical address: 1600 Highway 55, Hastings, MN Facility mailingaddress:(ifdifferentfromabove)click here to enter tet. Facility telephonenumber: The facilityis: Federal State County Military Municipal Private for profit Private not for profit Facilitytype: Correctional Detention Other Name of facility s Chief Eecutive Officer: Sarah Reetz Number of staff assigned to the facility in the last 12 months: 47 Designed facility capacity: 40 Current population of facility: 31 Facility security levels/inmate custody levels: secure Age range of the population: Nameof PREAComplianceManager:N/A Title:Click here to enter tet. address:Click here to enter tet. Telephonenumber:Click here to enter tet. AgencyInformation Nameof agency: Dakota County Community Corrections Governingauthority orparentagency:(ifapplicable)click here to enter tet. Physicaladdress: 1 Mendota Road West, West St. Paul, MN Mailingaddress:(ifdifferentfromabove) 1600 Highway 55, Hastings, MN Telephonenumber: AgencyChief Eecutive Officer Name: Sarah Reetz Title: Deputy Director- Juvenile Section address: sarah.reetz@co.dakota.mn.us Telephonenumber: Agency-WidePREACoordinator Name: Meg Grove Title: Supervisor/PREA Coordinator- Juvenile Section address: meg.grove@co.dakota.mn.us Telephonenumber: PREA Audit Report 1

2 AUDITFINDINGS NARRATIVE On November 7, 2016, I began an audit of the Dakota County Juvenile Services Center located at 1600 Highway 55, Hastings, MN. I arrived at 8:00am and was met by the PREA Coordinator, Meg Grove, and Matt Bauer, Facility Superintendent. We met briefly to discuss the audit schedule for the two days and to acquire a current admissions roster and staff schedule for planning random interviews. I was led on a facility tour by the PREA Coordinator and Facility Superintendent. Our tour started in the visiting area which is used by families for visiting as well as professionals such as case managers, attorneys, and clergy. There were multiple rooms available for private visits that are not under audio surveillance. One of these rooms was selected as the area for my interviews. PREA posters and a drop bo was visible in this area. The net area toured was the gymnasium which is under video surveillance. A tour of the nursing office was also conducted. This office space had PREA posters visible for residents as well. The school area was reviewed and multiple classrooms had residents in place receiving school services. PREA posters and a drop bo were visible in the main room. The net portion of the tour focused on the four living units in the facility. Each pod is made up of ten single cell rooms, five on each tier. Each cell has its own bathroom and sink. Each tier has a shower which is for single use only. It should be noted that each living unit has a bell system in place for staff to announce their gender presence upon entering the unit. I observed PREA posters clearly placed in all housing units and auditor information clearly posted for resident or staff contact purposes. The facility superintendent and I reviewed camera angles and possible dead spot locations in a number of units. The agency at this time is in the process of upgrading their complete camera system to include enhancing facility coverage in areas that would be considered vulnerable spots based on current camera coverage. The net area toured was the facility kitchen area. This area is currently without video monitoring. A recommendation was made to the facility superintendent to consider this area in the camera epansion project. The final area of the tour was the sally port/intake area. The intake area has temporary housing/observation rooms for high risk clients. This is the area in the facility where the initial PREA education process and risk screening occurs. The sally port area was reviewed and currently has no camera monitoring. This area will be added for monitoring in the epansion project. The tour clearly showed a clean, organized facility with PREA education posters available to residents and staff. The facility has a majority of its areas covered by camera technology and is adding a new system and multiple cameras to enhance overall facility coverage. The remainder of day one was used to conduct interviews of residents and staff. On November 7, 2016 there were 31 residents in the facility. I was provided a roster of current residents and 12 were selected randomly from the roster. Focus was put on selecting residents with varying lengths of stay, equal representation from each living unit and diverse clients based on ethnicity. After completing resident interviews, I completed nine random staff interviews based on the facility schedule and the shift leader for the evening shift who is also responsible for completing resident intakes and risk screening. The final interview of day one was with the PREA Coordinator who is also the training coordinator for the facility. On November 8, 2017, I returned for the second day of the audit. The focus for the morning was to complete interviews of specialized staff and non-security staff. Matt Bauer, Facility Superintendent was interviewed and many policies were reviewed for process and procedure. The net interview was Sarah Reetz, Deputy Director of Juvenile Services. The final interviews conducted included a facility supervisor who is responsible for risk screening and administrative investigations, facility nurse, teaching staff and resident case manager. By the end of the facility interviews, 12 youth and 17 staff had completed interviews. The remainder of day two focused on staff and resident file review, policy review, training records, and investigative reports. The day concluded with an eit interview that included myself, Meg Grove, Matt Bauer, and Sarah Reetz. I notified all parties at the time of the eit interview that the facility was found to be in compliance with all PREA Standards. I want to thank Dakota County for their cooperation and professionalism in all phases of the audit process. PREA Audit Report 2

3 DESCRIPTIONOF FACILITYCHARACTERISTICS The Dakota County Juvenile Services Center is a 40-bed, secured residential facility. It has four distinct living units which house up to ten residents each. Each living unit has a lower and upper tier with five single cell rooms per tier. Each resident room has its own toilet and sink. Each tier has a single use shower for resident use. A staff is assigned to each unit as the primary staff. There is also a shift leader, supervisor, utility staff, and a control room staff assigned depending on shift. Each living unit has a day room for leisure activities and group programming. The facility has its own kitchen area where the youth are responsible for cleaning after meal time. A dining area is situated right off the kitchen where residents take their meals. A large day room/recreation space is situated off the dining area where residents may participate in passive recreation and programming. A separate school area with classrooms is included in the facility. Residents are escorted to the school area for classroom instruction and supervised by both school and facility staff. The facility has a nursing office where residents are able to get medical attention if needed. This office area has a private room available if necessary. The facility includes a full gymnasium for active recreation and is under video surveillance. A contact visiting room is adjacent to the facility control room. Family visits take place in this area. There are also private visiting rooms available for professional visits from caseworkers, attorneys, or clergy. The final area in the facility is the sally port and intake area. A secure sally port is available for new admits and this is where the intake process begins. The intake area has holding cells available for high risk youth or over flow housing if needed. All intake procedures are completed in this area to include PREA education and risk screening by a qualified, trained staff. The Juvenile Services Center offers both detention and residential services for male and female juveniles who pose the greatest risk to public safety. The facility serves Dakota County, the MN Department of Corrections, and other Minnesota counties. Juveniles placed in the facility receive specific services based on their need to include gender and culturally specific programming, chemical dependency treatment, cognitive skill development, se offender treatment and mental health services to include trauma informed care. The facility was built in and opened in July PREA Audit Report 3

4 SUMMARY OF AUDITFINDINGS On November 7-8, 2016, an on-site audit was completed at the Dakota County Juvenile Services Center in Hastings, MN. The results of the audit indicate: Numberof standardseceeded: 0 Numberof standardsmet: 38 Numberof standards notmet: 0 Number of standards not applicable: 3 PREA Audit Report 4

5 Standard Zero tolerance of seual abuse and seual harassment; PREA Coordinator The agency has developed a Zero Tolerance of seual abuse and seual harassment policy and has trained all staff on this policy. The agency provided policy # in the Pre-audit phase. The policy meets the requirements as outlined in the standard. All staff interviewed during the onsite audit were able to review the main points of the zero tolerance policy. Staff Training curriculum reviewed also contained information on the agency's Zero Tolerance policy. The agency provided an organizational chart that referenced the position of PREA Coordinator. The agency PREA Coordinator was the main contact for the auditor in the pre-audit and on-site audit phases. The PREA Coordinator was interviewed as part of the on-site inspection and was able to articulate her role in the agency as it pertains to developing, implementing and overseeing agency compliance efforts with PREA standards. The PREA Coordinator indicated she has sufficient time to complete her duties. The agency does not employ a facility compliance manager due to operating one facility. Standard Contracting with other entities for the confinement of residents Not Applicable. Standard Supervision and monitoring PREA Audit Report 5

6 The agency provided the auditor with a detailed staffing plan- policy # and PREA Video Surveillance- policy #3410-A5 in the preaudit phase. These policies were reviewed and contained the necessary areas as outlined in the standard. During the Superintendent interview, the staffing plan was reviewed to include current facility staff to resident ratios. The superintendent indicated there have been no eigent circumstances that would cause a deviation from the prescribed staffing plan. At the time of the audit, the facility has a current staff to student ratio of 1:10 during wake hours and 1:16 during sleep hours. They are working towards a 1:8 ratio and have plans for adding staff to their current compliment in The agency has created an auditing form to annually review the staffing plan, prevailing staffing patterns, deployment of video monitoring systems, and resources available to ensure adherence to the staffing plan. The agency provided a policy in regards to unannounced facility rounds- # 3410-E5. The auditor reviewed the policy and it meets the provisions of the standard. The agency developed an Unannounced Rounds form to streamline the process and ensure that all areas were reviewed during the rounds. The agency provided copies of ten such reports for Each report was detailed, thorough and passed along to the Superintendent and PREA Coordinator for review. The auditor interviewed one supervisory staff and the Superintendent to gauge understanding of this standard. Both staff were very knowledgeable and had a great understanding to the purpose and intent of the unannounced rounds. Standard Limits to cross-gender viewing and searches During the pre-audit phase, the agency provided the auditor with a detailed policy on strip searches- # Upon review of the policy, the agency has met all provisions of this standard. In the past twelve months, the facility has no instances of cross-gender pat downs documented. The auditor completed interviews with random residents and staff and questioned each group as to the practice of cross-gender searches. All residents and staff were consistent with facility practice and procedure that cross-gender searches do not occur. It should also be noted that based on the facility staffing plan a staff of each gender is assigned to every shift. The facility has implemented policy and procedure to ensure that residents shower, perform bodily functions and change clothing in a private setting. During the facility tour, all shower and bathroom facilities were viewed to determine that residents have privacy to perform these functions. Resident and staff interviews confirmed that each resident is afforded privacy to complete these tasks as well. The agency has implemented a dual system for announcing opposite staff gender entering the unit. Staff of the opposite gender announce their presence upon entering the unit verbally and also ring a door bell as a means to effectively communicate to all youth on the unit that an opposite gender staff is present. During interviews with residents, all confirmed this practice happens regularly and none could recall a time when it hadn t. Staff were also asked during interviews what the process is to announce gender on the unit. All staff were consistent with the policy and procedure implemented by the agency. During the pre-audit phase, the agency provided the auditor with a pat search policy- # Upon review of the policy, the agency has met all provisions as it related to conducting pat searches of transgender or interse residents. The agency does not allow for searching or eamining transgender or interse residents for the sole purpose of determining a resident s genital status. This policy and procedure was confirmed through staff interviews. All staff were well versed on agency policy and procedure. At the time of the on-site audit, there were no transgender or interse residents at the facility. At the time of the audit, all staff were trained in how to conduct cross-gender pat down searches and searches of transgender and interse PREA Audit Report 6

7 residents. The training curriculum was sent to the auditor in the pre-audit phase and reviewed in its entirety. Also, staff training records were reviewed. All staff had completed the necessary training as described in this standard. Standard Residents with disabilities and residents who are limited English proficient The agency has developed a PREA- Juvenile Education policy- #3420-A6 to ensure all residents have equal access to the agency s efforts to prevent, detect, and respond to seual abuse and seual harassment. The agency provided this policy as part of the pre-audit phase and the policy was reviewed in its entirety. During the interview with the Agency Head designee, this policy was reviewed and sample materials were provided to the auditor. All provided materials met the standard. At the time of the on-site inspection, there were no residents in the facility that met the criteria for disability or limited English proficiency. The agency provided the auditor with policy # which addresses Interpreter Services/Limited English Proficiency. This policy was reviewed during the pre-audit phase. The policy describes in great detail the procedures to access interpreter services for residents or their families. The agency also provided si current contracts that are in place for interpreter services. Agency policy #3420-A6 prohibits the use of resident interpreters. This policy was discussed with staff during the on-site audit. All staff interviewed were able to describe in detail the process of getting an interpreter for a resident. All staff indicated that resident interpreters are never allowed. Standard Hiring and promotion decisions The agency has a thorough policy outlining hiring practices which includes not hiring staff who have engaged in seual abuse in a confinement setting as well as persons convicted of engaging or attempting to engage in seual activity in the community facilitated by force, overt or implied threats of force or coercion. Policy provided for review was #3104. Agency policy also considers incidents of seual harassment when making hiring and promotional decisions. The agency provided policy #3042 which outlines the agencies guidelines for seual and general harassment. The agency takes staff behavior very seriously and strives for an inclusive and healthy workplace. Agency practice for completing background checks was reviewed. All potential new hires have a BCA background check completed, Department of Public Safety driving record review, and a Department of Human Services background check completed to ensure the employee is eligible for employment. In the past 12 months, all new employees have had the required checks completed. As part of the reference check process, current and past employers are asked to provide information on prospective candidates. PREA Audit Report 7

8 Agency policy requires all contracted staff to complete the necessary background checks as well. The agency has developed a policy- # , that requires a criminal background check be completed on current employees at a minimum every five years. At the time of the audit- all employees had a criminal background check completed in A random sample of staff files were reviewed for compliance. Agency policy identifies that material omissions regarding seual misconduct shall be grounds for termination. Agency policy allows for the department to provide information on substantiated allegations of seual abuse or seual harassment involving a former employee upon receiving a request from an institutional employer. Standard Upgrades to facilities and technologies At the time of the audit, the facility superintendent indicated that a camera upgrade project would be taking place in the net si months. During the facility tour, current camera locations and new camera locations were reviewed. The agency has taken blind spots, resident population and building dynamics into consideration while developing their implementation plan. Standard Evidence protocol and forensic medical eaminations The agency has entered into a detailed memorandum of understanding with Regina Medical Center to ensure all residents who eperience seual abuse have access to forensic medical eaminations by a Seual Assault Forensic Eaminer or Seual Assault Nurse Eaminer. The memo of understanding was provided to the auditor for review and meets the standard. The agency also assumes financial responsibility for the cost of the eamination. In the past 12 months, the agency has had no forensic medical eams conducted. The agency has entered into a memorandum of understanding with 360 Communities to provide victim advocacy services for any resident who eperiences seual abuse. The agency provided a copy of the memo of understanding for review. The memo outlines agency and victim advocacy roles clearly. Agency practice as outlined in both MOU s allows for advocacy services to accompany and support the victim through the forensic medical eamination process and investigatory interviews and shall provide support, crisis intervention, information, and referrals. This process was reviewed with the PREA Coordinator. PREA Audit Report 8

9 The agency has entered into a memorandum of understanding with the Dakota County Sheriff s Office to ensure that all paragraphs of standard are complied with during a seual abuse investigation. Standard Policies to ensure referrals of allegations for investigations The agency has a policy in place- # to ensure all allegations of seual abuse and seual harassment are investigated. The agency provided documentation of all allegations received in the past 12 months, to include investigation material. There were a total of 11 allegations of seual harassment in the past 12 months. Of the 11, 9 were unsubstantiated, 1 was substantiated and 1 case was open for administrative investigation. In the past 12 months, there were zero allegations of seual abuse. Policy and practice were reviewed with the Agency Head designee. Agency policy also directs allegations of seual abuse and seual harassment to an agency that has legal authority to conduct investigations. The agency investigation policy is available on the county website. The agency policy describes in detail the responsibilities of both the agency and the investigating authority. Standard Employee training The agency provided the auditor policy # which describes training delivered to staff. Training includes all areas in (a) as specified by this standard. As part of the audit process, the agency provided all staff training curriculum for review. All training curriculum meets the provisions of the standard. During random interviews with staff, all staff were able to articulate the training received and the means of delivery. The PREA Coordinator provided training records for all staff who have direct contact with residents. All staff have completed the necessary training. Staff also receive specialized training based on unit assignment. For eample, staff assigned to the female unit receive gender specific training to enhance the services delivered based on client need. At the time of the audit, all staff have received initial PREA training. In 2017, the agency has a plan in place to complete refresher training for all eisting staff. All staff training records have been verified through staff signature. Standard Volunteer and contractor training PREA Audit Report 9

10 The agency has developed a policy, # , to ensure all volunteers and contractors who have contact with residents have been trained on their responsibilities to prevent, detect and respond to seual abuse and seual harassment. The PREA Coordinator provided training curriculum as part of the pre-audit phase and that curriculum was reviewed. Training records of volunteers and contractors was also reviewed during the in-site audit to verify completion. At the time of the audit, all volunteers and contractors had completed the necessary training. The agency maintains signed documentation confirming that each staff understands the training received. Standard Resident education The agency provided the auditor a comprehensive, detailed policy on resident education, #3420-A6. At the time of intake, all residents are educated on the agency s zero tolerance policy, how to make a report and view a PREA Juvenile Education Video. At the time of the audit, all residents had completed this initial education process. During the on-site audit, a random sample of residents were interviewed and asked questions about their intake process. All interviewed indicated they were given the necessary information at the time of their intake. Two staff who facilitate the intake education with new residents were also interviewed and were able to describe in detail the education process of a new resident. The PREA Coordinator provided signed documentation for a random sample of residents that indicated they were given PREA education at the time of their intake. Agency policy also directs staff to complete a comprehensive re-education with residents focusing the Zero Tolerance Policy, Resident Education video, and ways the resident can make a report. The staff member notes delivery of the re-education in the information management system. Thereafter, all resident s complete weekly education groups focusing on the Zero Tolerance Policy, how to make reports, and view the Resident Education video. The staff member who completes the re-education notes delivery in the information management system for each youth. The PREA Coordinator provided documentation for a random sample of residents to verify delivery of re-education. Each resident viewed had completed the necessary re-education. The agency has developed delivery methods to ensure residents with limited English proficiency, deaf, visually impaired, or with limited reading skills have access to resident education. The agency provides continuous access to key information through educational posters and resident handbooks. Standard Specialized training: Investigations PREA Audit Report 10

11 N/A Standard Specialized training: Medical and mental health care The agency provided documentation during the pre-audit phase outlining training provided to nursing and mental health staff. Training provided meets the provisions as stated in this standard. The agency also provided signed documentation of all nursing staff that have completed the training and the structure of the training. The auditor interviewed one nurse during the on-site audit and she was able to articulate training received and her role in resident seual safety. Standard Screening for risk of victimization and abusiveness The agency provided policy # , which includes PREA Screening, Classification for Housing, Programming, Education and Work Assignments for Residents. At the time of intake, each resident is administered the JSC Screening Supplement which aims to identify residents that are at risk for seual victimization or seual perpetration. Residents identified as high risk are re-assessed ten days after the initial assessment and every thirty days thereafter. The agency provided documentation of residents that were identified as high risk and also provided documentation of ten and thirty day re-assessments. The screening process was reviewed with two staff who regularly complete risk screenings. They were both able to walk the auditor through the process start to finish. During resident interviews, all were able to articulate that they had been asked screening questions at the time of their intake. As part of the pre-audit phase, the agency provided a screening tool that was reviewed by the auditor. The screening tool contains all items as outlined in standard (c). Staff responsible for completing risk screenings use all available information to determine risk level for the resident at time of intake to PREA Audit Report 11

12 include: medical and mental health screenings, assessments, court records, criminal history data, discharge reports, past facility records, and other relevant documentation. This process was confirmed while completing interviews with two staff who conduct risk screening on new admissions. The agency policy and practice allows for timely screening and access to that information by staff working directly with the client. All documents and risk screening alerts are stored electronically in the information management system. Agency policy outlines the importance of keeping risk screening information confidential. During interviews with the PREA Coordinator, Screening Staff and Facility Superintendant all interviewed felt like their policy and procedure in place keeps residents safe but also allows for the needed flow of information to keep staff informed and educated in order to keep all the residents safe. Standard Use of screening information The agency provided policy # that addresses placement of residents in housing, bed, program, education, and work assignments. The agency uses a risk screening form to make all placement decisions. Staff responsible for risk screening were able to identify all steps in the process for placing a youth based on high risk of victimization or high risk to perpetrate seual abuse. Agency policy allows for isolation only as a last resort when less restrictive measures are inadequate to keep residents safe. State licensing standards call for daily large muscle eercise and educational or special education services. Policy also requires daily visits from medical or mental health clinician. Access to other programs and work opportunities will be made available to the etent possible. In the past 12 months, the agency has had no cases of isolation for the protection of residents from seual victimization. The policy and information was confirmed during the interview with the Facility Superintendent. Agency policy does not allow lesbian, gay, biseual, transgender or interse residents to be placed in particular housing or programs solely based on such identification or status. This policy and practice was confirmed in the interview with the PREA Coordinator. All housing and programming assignments for transgender or interse residents are reviewed on a case-by-case basis and whether the placement would present management or security problems. Each transgender or interse resident s status is reviewed every 30 days per agency policy. A transgender or interse resident s own views with respect to his or her own safety will be given serious consideration. All youth in the facility are able to shower separately from other residents. Agency policy requires clear documentation to the basis for the facility safety concern and the reason why less restrictive measures were not used. All documentation occurs in the information management system. As previously noted, all residents deemed high risk are reviewed every 30 days per agency policy. At the time of the audit, there were no residents who identified as being transgender or interse. During facility admission record review, there were no residents admitted in the past 12 months that identify as being transgender or interse. Standard Resident reporting PREA Audit Report 12

13 The agency provided policy #3420-A6 that outlines the various ways a resident can make a seual abuse and seual harassment report. Residents can make a verbal report, a written report than can be turned in to staff or placed in a secure bo which are located throughout the facility, phone the PREA information line or phone 360 Communities victim advocacy hotline. Both phone numbers provided to the auditor were called during the pre-audit phase and confirmed as operable phone lines. Random residents and staff were interviewed and all were able to discuss in great detail all of the reporting mechanisms in place and the processes used to make a report. As previously noted, the agency has a memorandum of understanding with 360 Communities to provide advocacy services and act as an outside resource for residents if needed. Resident interviewed confirmed the practice in place and all residents were able to describe services available and where to access information. The agency provided policy # , PREA First Responder, which details the procedure used by staff if receiving a report made verbally, in writing, anonymously or from a third party. Agency policy requires all staff to document reports on the First Report of Suspected Misconduct form and submit thru the appropriate channels. During resident interviews, all residents provided knowledge of the ability to make verbal or anonymous reports if they so choose. During staff interviews, all staff were well versed on the procedures for taking a report to include verbal, anonymous and third party reports. In order to make a written report, all residents are provided the tools necessary to make a report. The auditor observed these tools available in all resident areas throughout the facility during the tour portion of the audit. Agency policy affords staff the same means of filing a report of seual abuse or seual harassment. During staff interviews, all staff were able to identify the avenues available to them in order to make a report of suspected seual abuse or seual harassment. Standard Ehaustion of administrative remedies N/A Standard Resident access to outside confidential support services PREA Audit Report 13

14 The facility provides residents with phone numbers and mailing addresses to outside victim advocacy services. The agency has entered into a memorandum of understanding with 360 Communities victim advocacy organization to provide those services. Contact phone numbers and mailing address for this organization was posted in living units, common areas and also available through the weekly re-education groups facilitated by staff. As part of the audit process, random residents were asked questions in reference to outside support services and availability to that contact information. All residents interviewed were able to identify the role of the support services, where to get contact info and the etent to which that contact with the outside support agency would be confidential based on mandated reporting requirements which are statutory in Minnesota. During a residents stay at the facility, all residents are afforded confidential and regular access to their legal representatives. Residents also have access to parents or legal guardians through phone calls and on site visiting. The agency provided policy # outlining residents rights for visitation and policy # which provides for confidential interview space with legal representatives and clergy. During the onsite audit, all residents interviewed confirmed regular access to parent or legal guardians and legal representatives. Standard Third-party reporting The agency has placed third party reporting methods on the agency website. Methods include the Dakota County Corrections PREA information line and contact information for 360 Communities, a local victim advocacy hotline. Any report placed on either of these two lines will be routed to the PREA Coordinator and Facility Superintendent for review. Standard Staff and agency reporting duties The agency provided policy # , PREA First Responder, which outlines staff responsibility to report immediately any knowledge or suspicion of seual abuse or seual harassment; retaliation against residents or staff who report such an incident; and any staff neglect or violation of responsibilities that may have contributed to an incident or retaliation. Staff interviewed during the on-site audit were able to eplain their responsibilities and the immediacy of such a report. PREA Audit Report 14

15 All facility staff have been trained on the mandatory child abuse reporting laws in the State of Minnesota. Staff were able to confirm their training during their interviews and all staff training records were reviewed for training documentation. The PREA First Responder policy also details that staff taking the initial report are not to discuss the allegation or associated events unless instructed by supervisors or law enforcement. Staff competency in this area was gauged during the on-site audit during interviews. All staff were able to articulate their role as first responders and the importance for confidentiality. Agency policy directs medical and mental health practitioners to report seual abuse to designated facility staff as well as inform the appropriate county service agency as required by mandatory reporting laws. Such practioners are also required to inform residents at the initiation of services of their duty to report and the limits of confidentiality. At the time of the audit, no such reports had been submitted. The auditor interviewed a nursing staff who confirmed policy and facility practice as noted above. The agency provided policy # , PREA Investigations, that details the responsibility of the Facility Superintendent to promptly report the allegation to the appropriate investigative office and the alleged victim s parents or legal guardians unless the facility has official documentation showing the parents or legal guardians should not be notified. If the alleged victim is under county guardianship, the Facility Superintendent shall report to the assigned caseworker instead of the parent or legal guardian. If the juvenile court retains jurisdiction, the Facility Superintendent shall inform the alleged victim s legal representatives within 14 days of receiving the allegation. This policy and procedure was reviewed and confirmed through interviews with the PREA Coordinator and Facility Superintendent. Policy # also requires that all allegations of seual abuse and seual harassment, including third-party and anonymous reports, be referred for investigation. This procedure was confirmed with the Facility Superintendent during his interview and also during a review of all allegations from the previous 12 months. Standard Agency protection duties The agency provided policy # , PREA First Responder, which outlines staff procedure for dealing with a resident who is at imminent risk of seual abuse. The policy requires staff to act immediately to ensure the safety of the resident making the report. In the past 12 months, the facility has had no cases of imminent risk for seual abuse. Agency Head Designee, Facility Superintendent and Random Staff interviews confirmed the policy and procedure to ensure resident safety. Standard Reporting to other confinement facilities Meets Standard(substantial compliance; complies in all material ways with the standard for the relevant review period) PREA Audit Report 15

16 As part of the pre-audit process, the agency provided policy # , PREA First Responder, for review. Per agency policy, the facility superintendent or designee notifies the head of the appropriate agency where the alleged abuse occurred. The facility superintendent also notifies the appropriate investigative agency where the alleged abuse occurred. All notifications are documented and made within 72 hours after being made aware of the allegation. In the past 12 months, the agency has had no such reports made. The agency head designee and facility superintendent reviewed policy and procedure regarding this standard and clearly have a process in place that meets all provisions of the standard. Standard Staff first responder duties The agency provided policy # , PREA First Responder, as part of the pre-audit phase. This policy was reviewed by the auditor for compliance. The agency policy included all steps as outlined in (a). In the past 12 months, the facility has had no reported allegations of seual abuse. Through interviews of security and non-security staff, all interviewed were very well versed on their first responder duties. All staff interviewed were given a scenario to use and were able to guide the auditor through the scenario from beginning to end of their process. Standard Coordinated response The agency provided policy # , PREA Investigations, in the pre-audit phase. This policy offers a detailed description of the coordinated response that the facility would use in an incident of seual abuse. In the past 12 months, the facility has had no such cases. The facility superintendent was interviewed as to the coordinated response process and the roles of each staff in that process. The policy and procedure reviewed meet this standard. Standard Preservation of ability to protect residents from contact with abusers PREA Audit Report 16

17 The agency provided the current union contract for for AFSCME Local 450. The contract reviewed does not limit the agency's ability to remove alleged staff seual abusers from contact with residents pending the outcome of an investigation or a determination of whether and to what etent discipline is warranted. This contract was reviewed with the agency head designee at the time of the on-site audit. The contract provided meets the standard. Standard Agency protection against retaliation The agency provided two policies for review in the pre-audit phase in regards to agency protection against retaliation. Policy # ; PREA Screening, Classification for Housing, Programming, Education, and Work Assignments; and policy # PREA First Responder. Each of these policies was reviewed as part of the pre-audit process. The agency has identified the PREA Coordinator, facility superintendent and case managers as the responsible parties for monitoring against retaliation. The agency employs multiple protection measures to include 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 seual abuse or seual harassment. The agency has established a 90 monitoring period to protect against retaliation. Case managers meet weekly with clients to ensure resident safety and to monitor changes that may suggest retaliation by residents or staff. Agency policy allows for monitoring beyond 90 days if the initial monitoring indicates a continuing need. Policy and procedure was reviewed with PREA Coordinator, facility superintendent and one case manager during the on-site audit. Each interview detailed a very thorough process to ensure residents and staff are protected against retaliation. At the time of the audit, there was one resident who was under a 90-day monitoring period. The facility provided documentation of regular status checks of that resident. Standard Post-allegation protective custody PREA Audit Report 17

18 The agency provided policy # , Seclusion, as part of the pre-audit phase. All requirements of standard are included in this policy. In the past 12 months, the facility has had no cases of post-allegation protective custody. The policy, procedure and yearly data was reviewed with the facility superintendent. Facility protocol meets the standard. Standard Criminal and administrative agency investigations The agency provided policy , PREA Investigations, and a memorandum of understanding with the Dakota County Sheriff's Office as part of the pre-audit phase. Each document was reviewed by the auditor. The agency conducts its own administrative investigations into seual harassment allegations and refers all allegations of seual abuse to the local sheriff's department for investigation. The auditor interviewed the facility superintendent and one facility supervisor in regards to the administrative investigation process. Each interview included a thorough description of the policy and procedure used. At the time of the on-site audit, the PREA Coordinator reviewed each administrative investigation report with the auditor. Each report was detailed and timely. In the past 12 months, there have been no allegations of seual abuse in the facility. The policy requires all investigations to be completed even if the alleged victim recants the original allegation. This was confirmed with the facility superintendent. Administrative investigations include an effort to determine whether staff actions or failures to act contributed to the incident. All administrative investigations are documented in written reports and secured by the PREA Coordinator. Agency policy requires all written reports to be retained 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. Agency policy also requires all investigations to continue even if the alleged abuser or victim departs the facility or if an alleged abuser is no longer employed by the agency. Agency policy requires the facility to cooperate with outside investigators and to remain informed about the progress of the investigation. This process was reviewed with the facility superintendent at the time of the on-site audit. Standard Evidentiary standard for administrative investigations PREA Audit Report 18

19 The agency provided policy # , PREA Investigations, as part of the pre-audit phase. This policy was reviewed by the auditor. The agency has implemented a standard of a preponderance of the evidence when determining whether allegations of seual abuse or seual harassment occurred. This practice was confirmed in an interview with the facility superintendent. Standard Reporting to residents The agency provided policy # , PREA Investigations, as part of the pre-audit phase. This policy was reviewed by the auditor. Agency policy requires all alleged victims of seual abuse to be informed of the final determination of the agency investigation. In the past 12 months, the agency has had no allegations of seual abuse. The facility also has a procedure in place to receive updated information from the agency responsible for conducting criminal investigations. The agency provided a memorandum of understanding with the Dakota County Sheriff's office detailing that process. This outside agency has conducted no criminal investigations of alleged seual abuse in the past 12 months. Per agency policy, if a staff member is alleged to have committed seual abuse against a resident, the agency will inform the resident that the staff member is no longer posted in the resident's pod, the staff member has been terminated or the staff member as been indicted or convicted. In the past 12 months, there have been no such allegations. Per agency policy, if the perpetrator is another resident, the agency will inform the victim if the perpetrator has been indicted or convicted. In the past 12 months, there have been no such allegations. Per agency policy, all notifications or attempted notifications will be documented in the investigative report. Policy, procedure and data were reviewed with the facility superintendent at the time of the on-site audit. Standard Disciplinary sanctions for staff The agency provided two policies for review in regards to this standard; # , Zero Tolerance of Seual Misconduct and # 3042, Seual and General Harassment. Per policy, staff is subject to disciplinary sanctions up to and including termination for violating agency seual abuse or seual harassment policies. Termination is the presumptive disciplinary sanction for staff who have engaged in seual abuse. In the PREA Audit Report 19

20 past 12 months, the agency has had no cases of staff seual abuse or seual harassment. The policies and facility data were reviewed with the agency head designee. Standard Corrective action for contractors and volunteers The agency provided policy # , Abuse and Neglect Reporting, as part of the pre-audit phase. The policy was reviewed by the auditor. The policy requires that any contractor or volunteer who engages in seual abuse be reported to law enforcement and to relevant licensing bodies. The policy also requires that further contact with residents be prohibited. In the past 12 months, there have been no cases reported of contractors or volunteers engaging in seual abuse of residents. Agency policy and data was reviewed with facility superintendent. Standard Disciplinary sanctions for residents The agency provided multiple policies to address this standard. Each policy was reviewed by the auditor in the pre-audit phase. In the past 12 months, the facility has had no cases of seual abuse reported. Any use of isolation as a consequence for resident-on resident seual abuse requires daily access to large muscle eercise, legally required educational programming, and special education services. Policy also requires that residents placed in isolation receive daily visits from a medical or mental health care clinician. Residents placed in isolation also have access to other programs and work opportunities to the etent possible. Agency policy takes into consideration a resident's mental disabilities or mental illness when determining what type of sanction, if any, should be imposed. When appropriate, the facility offers counseling or other interventions designed to address and correct underlying reasons or motivations for the abusive behavior. Per agency policy, disciplinary action is prohibited when a resident, in good faith, makes a report of alleged seual abuse based upon a reasonable belief that the alleged conduct occurred. Agency policy prohibits all seual activity between residents and may discipline residents for such activity. All policies and discipline philosophy were reviewed with the PREA Coordinator and facility superintendent. Standard Medical and mental health screenings; history of seual abuse PREA Audit Report 20

21 The agency provided policy # ; PREA Screening, Classification for Housing, Programming, Education, and Work Assignments for Juveniles; as part of the pre-audit phase. As part of the pre-audit policy review, agency policy was missing two areas in the screening process as it relates to past seual victimization and past seual perpetration. Agency policy was not offering a follow-up meeting to either of these types of residents with a medical or mental health practitioner within 14 days of the intake screening. At the time of the on-site audit, the facility had modified its policy and trained staff who complete screenings as to the procedural changes. In interviews with staff that complete screenings, both were able to articulate policy and procedural changes as provided to the auditor. At the time of the audit, no residents had requested a follow-up meeting with a medical or mental health practitioner. Any information related to seual victimization or abusiveness that occurred in an institutional is strictly limited to medical and mental health practitioners and other staff as necessary. All information is used to develop treatment plans and manage security decisions to include housing, bed, work, education and program assignments. All medical and mental health practitioners are bound by State of Minnesota mandated reporting laws in regards to informed consent. Policy and procedure was reviewed and confirmed with facility nursing staff. Standard Access to emergency medical and mental health services The agency provided policy # , PREA Emergency Medical and Dental Services/Designated Providers, as part of the pre-audit phase. The auditor has reviewed this policy. Agency policy calls for timely, unimpeded access to emergency treatment and crisis intervention services for residents who are seual abuse victims. The agency provided a memorandum of understanding with Regina Medical Center to provide such medical services and a memorandum of understanding was provided with 360 Communities to provide crisis intervention services. Per agency policy, a resident victim of seual abuse if offered timely information about and access to emergency contraception and seually transmitted infectious prophylais, in accordance with professionally accepted standards of care, where medically appropriate. All treatment services are provided to resident victims at no cost. Standard Ongoing medical and mental health care for seual abuse victims and abusers PREA Audit Report 21