Prison Rape Elimination Act (PREA) Audit Report Community Confinement Facilities

Transcription

1 Prison Rape Elimination Act (PREA) Audit Report Community Confinement Facilities Interim Final Date of Report 9/11/2017 Auditor Information Name: Tina Sallee Company Name: Click or tap here to enter text. Mailing Address: P.O. Box #373 City, State, Zip: Campbellsville, KY Telephone: Date of Facility Visit: 8/10/2017 Agency Information Name of Agency: Governing Authority or Parent Agency (If Applicable): Dismas Charities, Inc. Click or tap here to enter text. Physical Address: th Street City, State, Zip: Louisville, KY Mailing Address: th Street City, State, Zip: Louisville, KY Telephone: Is Agency accredited by any organization? Yes No The Agency Is: Military Private for Profit Private not for Profit Municipal County State Federal Agency mission: Dismas Charities, Inc. Healing The Human Spirit Since 1964 Mission Statement: To provide quality, cost-effective, community-based treatment services and programs to individuals in the criminal justice system and assist them in becoming positive productive members of their community. Agency Website with PREA Information: Dismas.com Agency Chief Executive Officer Name: Jan Kempf Title: Executive Vice-President/COO Telephone: Agency-Wide PREA Coordinator PREA Audit Report Page 1 of 76 Facility Name double click to change

2 Name: Joseph Theriot Title: Regional Vice-President/Agency-Wide PREA Coordinator Telephone: ext PREA Coordinator Reports to: Jan Kempf, Executive Vice-President/COO Number of Compliance Managers who report to the PREA Coordinator 33 Name of Facility: Dismas Charities Lexington Facility Information Physical Address: 909 Georgetown Street, Lexington, KY Mailing Address (if different than above): Click or tap here to enter text. Telephone Number: The Facility Is: Military Private for Profit Private not for Profit Municipal County State Federal Facility Type: Community treatment center Halfway house Restitution center Mental health facility Alcohol or drug rehabilitation center Other community correctional facility Facility Mission: Dismas Charities, Inc. Healing the Human Spirit Since 1964 Dismas Charities Mission Statement to provide quality, cost-effective, community-based treatment services and programs to individuals in the criminal justice system and assist them in becoming positive productive members of their community. Facility Website with PREA Information: Dismas.com Have there been any internal or external audits of and/or accreditations by any other organization? Director Name: Sheryl Fisher Title: Director Telephone: ext. 105 Facility PREA Compliance Manager Name: Sheryl Fisher Title: Director Telephone: ext. 105 Facility Health Service Administrator PREA Audit Report Page 2 of 76 Facility Name double click to change

3 Name: n/a Title: Click or tap here to enter text. Click or tap here to enter text. Telephone: Click or tap here to enter text. Designated Facility Capacity: Redacted Facility Characteristics Number of residents admitted to facility during the past 12 months Current Population of Facility: Redacted Redacted Number of residents admitted to facility during the past 12 months who were transferred Redacted from a different community confinement facility: Number of residents admitted to facility during the past 12 months whose length of stay in the facility was for 30 days or more: Redacted Number of residents admitted to facility during the past 12 months whose length of stay in Redacted the facility was for 72 hours or more: Number of residents on date of audit who were admitted to facility prior to August 20, 2012: 0 Age Range of Population: Adults Juveniles Youthful residents years of age Average length of stay or time under supervision: Facility Security Level: Resident Custody Levels: Click or tap here to enter text. Number of staff currently employed by the facility who may have contact with residents: Number of staff hired by the facility during the past 12 months who may have contact with residents: Number of contracts in the past 12 months for services with contractors who may have contact with residents: Physical Plant Number of Buildings: 2 Number of Single Cell Housing Units: 0 Number of Multiple Occupancy Cell Housing Units: Redacted Number of Open Bay/Dorm Housing Units: 0 Click or tap here to enter text. Redacted days Community Community Redacted Redacted Description of any video or electronic monitoring technology (including any relevant information about where cameras are placed, where the control room is, retention of video, etc.): The Central Monitoring Office (CMO) has video camera monitor that allows video monitoring from all internal and external cameras ((Redacted) cameras are strategically placed and monitor parking area, entrance into both buildings, main hallways of both buildings, stairwells of both buildings, kitchen and dining area, dayroom/tv areas, laundry areas, outside areas, and storage/storm shelter). The staff in the CMO provides constant monitoring of the cameras, including regulation of internal movement of visitors, staff, and residents throughout the facility (both buildings). The administrative building houses the administrative offices and each of the (Redacted) administrative offices have a video camera monitor for additional security. 0 PREA Audit Report Page 3 of 76 Facility Name double click to change

4 Medical Type of Medical Facility: Forensic sexual assault medical exams are conducted at: n/a University of Kentucky Chandler Medical Center Emergency Room Other Number of volunteers and individual contractors, who may have contact with residents, currently authorized to enter the facility: Number of investigators the agency currently employs to investigate allegations of sexual abuse: 1 0 PREA Audit Report Page 4 of 76 Facility Name double click to change

5 Audit Findings Audit Narrative The auditor s description of the audit methodology should include a detailed description of the following processes during the pre-onsite audit, onsite audit, and post-audit phases: documents and files reviewed, discussions and types of interviews conducted, number of days spent on-site, observations made during the site-review, and a detailed description of any follow-up work conducted during the post-audit phase. The narrative should describe the techniques the auditor used to sample documentation and select interviewees, and the auditor s process for the site review. Dismas Charities, Inc. operates the Dismas Charities Lexington located at 909 Georgetown Street, Lexington, KY which is a (Redacted) -bed community confinement facility (halfway house) for men and women. Dismas Charites, Inc./Dismas Charities Lexington operates under a contract with both the federal BOP (Bureau of Prisons) and KY DOC (Kentucky Department of Corrections). The federal BOP (Bureau of Prisons) is responsible for the custody and care of federal inmates/residents and oversees residential reentry centers (RRC s) also known as halfway houses, to provide assistance to inmates/residents who are nearing release into the community. RRC s (residential reentry centers) provide a safe, structured, supervised environment, as well as employment counseling, job placement, financial management assistance, and other programs and services. RRC s (residential reentry centers)/halfway houses help inmates/residents gradually rebuild their ties to the community and facilitate supervising activities during this readjustment period. Once awarded, the halfway house contracts are administered by the BOP (Bureau of Prisons) Residential Reentry Management (RRM) field offices, which include the published internal policy implementing the PREA regulations promulgated by the Attorney General on 8/20/2012 (updated 1/6/2014). (This date the facility housed (Redacted) federal inmates/residents.) The KY DOC (Kentucky Department of Corrections) mission to protect the citizens of the Commonwealth of Kentucky and to provide a safe, secure and humane environment for staff and offenders in carrying out the mandates of the legislative and judicial processes; and, to provide opportunities for offenders to acquire skills which facilitate non-criminal behavior. The Contract Management Branch of the KY DOC is responsible for overseeing community services centers (halfway houses) that house state probationers, inmates and parolees. Inmates/residents who are classified as community custody and are near their parole eligibility dates are placed in halfway houses. This integration program allows inmates/residents to become reacquainted with their families and the community and gives them a head start in seeking employment, enrolling in vocational schools and/or college programs, and having access to community substance abuse, medical, and mental health care/treatment. The KY DOC (Kentucky Department of Corrections) agency policy in compliance with Section of Prison Rape Elimination Act (PREA) Standards date filed 12/10/2013 and effective on 2/3/2014. (This date the facility housed (Redacted) state inmates/residents.) Dismas Charities Lexington is a community confinement facility/halfway house used to provide quality, cost-effective, community-based services and programs to individuals in the criminal justice system and assist them in becoming positive productive members of their community. This date the facility housed (Redacted) inmates/residents (Redacted). The facility was housed in two secured buildings. One building housed administrative offices and conference room. The second building housed (Redacted) multiple occupancy cell housing units, (Redacted) (this facility is smoke-free, which means no smoking on the property by residents, staff, and/or visitors). The average length of stay is approximately (Redacted) days. The Dismas Charities Lexington facility currently employs (Redacted) full-time staff and 1 volunteer who may have contact with the residents. Everyone who enters either building must identify themselves at the Central Monitoring Office (CMO) located in the main facility building. Residents are subjected to a pat-down search, hand-held metal detectors are available to staff as needed. The Central Monitoring Office (CMO) has video camera monitor PREA Audit Report Page 5 of 76 Facility Name double click to change

6 that allow video monitoring from all internal and external cameras ((Redacted) cameras are strategically placed (Redacted). The staff in the CMO provides constant monitoring of the cameras, including the regulation of internal movement of visitors, staff, and residents throughout the facility (both buildings). Administrative offices are secure and residents are not allowed access without supervision. The administrative building houses the offices (Redacted) (each of the (Redacted) administrative offices have a video camera monitor) for additional security. The PREA on-site audit was the second PREA audit for the Dismas Charities Lexington and was conducted by DOJ Certified PREA Auditor, Tina Sallee. During the pre-audit phase, the auditor reviewed a variety of documents provided by the agency. These documents included but were not limited to agency and facility policies and procedures demonstrating compliance with the PREA Community Confinement Standards, staffing plans, floor plans, protocols, training records, and other documents related to demonstrating compliance with the PREA Community Confinement Standards. This auditor did not receive any correspondence or requests from staff or residents prior to the on-site audit (a notice was posted with contact information for the PREA Auditor/audit date six weeks prior to the on-side audit as required). The on-site PREA Audit was conducted on Thursday 8/10/2017. An entrance meeting was held with Sheryl Fisher, Director, and Paul Hagan, Assistant Director. The on-site audit work plan was discussed, samples of residents and staff to be interviewed were selected, and specialized staff were identified. Also, additional pre-audit information was obtained. Following the entrance meeting a tour of the facility was led by Director and Assistant Director. All areas of the facility were viewed including administration areas, CMO (Central Monitoring Office) that has one monitor for (Redacted) cameras that cover inside and outside of buildings, kitchen and dining area, (Redacted) multiple occupancy cell housing units in this facility, and restrooms. PREA related informational posters were prominently posted and the PREA audit notice was also observed posted in the facility. Additionally, informational pamphlets regarding PREA and crisis services are given out during the intake/prea education/orientation for each resident immediately upon arrival at the facility; and PREA information posters/contact information are posted for both resident and staff access. No SAFE or SANE staff are employed at this facility; however, these professionals are provided at University of Kentucky Chandler Medical Center Emergency Room where forensic examinations would be conducted at no cost to the resident and/or to their family. Interviews were conducted with the Executive Vice-President/COO; the Regional Vice-President/Agency- Wide PREA Coordinator; the Director (also interviewed as a member of the Incident Review Team, a trained PREA Investigative Staff, the designated staff for monitoring volunteer PREA education/training, the designated staff member charged with monitoring retaliation and/or grievances); the Assistant Director (also interviewed as a member of the Incident Review Team, a trained PREA Investigative Staff); one Resident Monitor (interviewed as a random sample of staff regarding PREA training, a staff that conducts intake process which includes orientation of program/education regarding PREA, and a staff who performs screening for Risk Assessment for Victimization and/or Abusiveness); 3 male residents (one that identified as being gay); and 1 female resident. During the past 12 months, there have been two (2) administrative investigations of sexual harassment and/or sexual abuse. During the past 12 months, there have been zero (0) criminal investigations of sexual harassment and/or sexual abuse. Documentation and staff interviews confirmed that these two (2) (as all reports must be) were thoroughly investigated and the findings were one substantiated and the other unsubstantiated ; consequences were determined including but not limited to release/termination of placement of residents involved, a resident monitor staff accused was suspended without pay until investigation was completed (finding was unsubstantiated, but reportedly this staff resigned). Documentation and staff interviews confirmed that all allegations/reports of sexual harassment and/or sexual abuse be PREA Audit Report Page 6 of 76 Facility Name double click to change

7 referred immediately for investigation. The agency with the authority to conduct criminal investigations would be contingent on the supervision of the resident (federal residents are referred to BOP (Bureau of Prisons) and would include Lexington Police Department/Kentucky State Police) (state residents are referred to KY DOC (Kentucky Department of Corrections) and would include Lexington Police Department/Kentucky State Police). Mental health services can be provided locally and would be contingent on the supervision of the resident (federal residents would be provided services by Community Treatment Services, Federal Bureau of Prisons Reentry Services Division, Residential Reentry Management Branch and/or Windows of Discovery) and (state residents would be provided services by Bluegrass Rape Crisis Center (BRCC) if/when needed. The residents interviewed (including one resident that identified as gay) reported that they had been located in another adult correctional facility before coming to Dismas Charities Lexington and had reportedly heard about/knew of PREA and were complimentary of their thoughts and feelings regarding immediate intake/orientation to the program, the PREA education, and the safety and security of this facility. Documentation, staff and resident interviews confirmed that all residents do receive information on PREA and their right to not be sexually abused/harassed, how to report sexual abuse/harassment, their right not to be punished for reporting such immediately upon arriving at the facility during intake/orientation. Documentation, staff and resident interviews confirmed that all residents are assessed to ascertain risk of being sexually victimized and/or abusive and the facility uses this information to keep residents safe. Additionally, after residents are admitted into the facility they are provided additional information regarding sexual abuse/harassment with the assigned Counselor. Residents who have experienced trauma, abuse, or victimization and/or request it are provided additional services as needed. An exit conference was held with Sheryl Fisher, Director, and Paul Hagen, Assistant Director. Documents were timely and complete. Staff and resident interviews occurred efficiently. The entire facility was toured. Overall, the facility was well prepared for the PREA audit and performed well in all areas. After reviewing all pertinent information and after conducting resident and staff interviews, the auditor found that agency/facility leadership have clearly made PREA compliance a high priority and have devoted a significant amount of time and resources to PREA policy development, training of all staff and volunteers in the facility, and immediate education upon intake with all residents regarding PREA aspects. Facility Characteristics The auditor s description of the audited facility should include details about the facility type, demographics and size of the inmate, resident or detainee population, numbers and type of staff positions, configuration and layout of the facility, numbers of housing units, description of housing units including any special housing units, a description of programs and services, including food service and recreation. The auditor should describe how these details are relevant to PREA implementation and compliance. Dismas Charities, Inc. operates a halfway house/facility Dismas Charities Lexington, for both federal and state inmates/residents, located at 909 Georgetown Street, Lexington KY. The tour of the facility was conducted by the Director and the Assistant Director. The facility is housed in two secured buildings, the main building has (Redacted) multiple occupancy cell housing units (Redacted) outside areas. The second building houses administrative offices and conference room. Cameras were viewed and were mounted in hallways, stairwells, and common areas both inside and outside the facility and has adequate coverage with current camera system. There are currently (Redacted) cameras monitoring the facility (inside and outside both buildings) and all cameras can be viewed at the Central PREA Audit Report Page 7 of 76 Facility Name double click to change

8 Monitoring Office (CMO), also one monitor is located in each of the (Redacted) administrative offices (Redacted). The PREA audit notice and PREA posters containing PREA information are prominently posted for resident and staff access. The facility has not made a substantial expansion or modification to existing facility since last PREA on-site audit 12/23/2014 but facility has installed more cameras. Documentation and staff interviews confirmed the practice that any expansion or modifications to existing facility has and would in future take into consideration the effect of any modification, expansion, and/or updating of video monitoring system upon the agency/facility ability to protect residents and staff from sexual harassment/sexual abuse. Dismas Charities, Inc. and Dismas Charities Lexington has documentation of PREA Standards Implementation (revised 12/31/2011) and has been robust in the assignment of an Agency-Wide PREA Coordinator/Regional Vice- President Joseph Theriot, the development of the agency/facility written policy mandating zero-tolerance toward all forms of sexual harassment and/or sexual abuse, the training of all staff, the education of all residents immediately upon intake, the documentation to verify the facility s compliance with the PREA Community Confinement Standards to enhance safety and promote a zero-tolerance culture for sexual abuse and/or sexual harassment. Summary of Audit Findings The summary should include the number of standards exceeded, number of standards met, and number of standards not met, along with a list of each of the standards in each category. If relevant, provide a summarized description of the corrective action plan, including deficiencies observed, recommendations made, actions taken by the agency, relevant timelines, and methods used by the auditor to reassess compliance. Auditor Note: No standard should be found to be Not Applicable or NA. A compliance determination must be made for each standard. Number of Standards Exceeded: 13 Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard Number of Standards Met: 28 Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard ; Standard PREA Audit Report Page 8 of 76 Facility Name double click to change

9 Number of Standards Not Met: 0 Click or tap here to enter text. Summary of Corrective Action (if any) Type text here. All Yes/No Questions Must Be Answered by The Auditor to Complete the Report (a) Does the agency have a written policy mandating zero tolerance toward all forms of sexual abuse and sexual harassment? Does the written policy outline the agency s approach to preventing, detecting, and responding to sexual abuse and sexual harassment? (b) Has the agency employed or designated an agency-wide PREA Coordinator? Is the PREA Coordinator position in the upper-level of the agency hierarchy? Does the PREA Coordinator have sufficient time and authority to develop, implement, and oversee agency efforts to comply with the PREA standards in all of its facilities? Auditor Overall Compliance Determination PREVENTION PLANNING Standard : Zero tolerance of sexual abuse and sexual harassment; PREA coordinator PREA Audit Report Page 9 of 76 Facility Name double click to change

10 The narrative below must include a comprehensive discussion of all the evidence relied upon in making the The agency/facility has a written policy mandating zero tolerance toward all forms of sexual harassment and/or sexual abuse. The policy details the approaches Dismas Charities, Inc. and Dismas Charities Lexington uses to prevent, detect and respond to sexual harassment and/or sexual abuse in the facility. The definitions of prohibited behaviors are clearly defined, as are the sanctions for those who violate the policy. Policy is thorough and mirrors the PREA Community Confinement Standards. Policy is in use and staff were able to explain it to the auditor when asked. The agency has designated an Agency-Wide PREA Coordinator, Joseph Theriot, Regional Vice-President. He is very knowledgeable of PREA Community Confinement Standards/requirements, devotes sufficient time and effort in assisting agency and facility staff with PREA related topics, and has the authority to implement corrective actions. POLICY, MATERIALS, INTERVIEWS AND OTHER EVIDENCE REVIEWED -Completed Dismas Charities, Inc./Dismas Charities Lexington Pre-Audit Questionnaire -Dismas Charities, Inc. Mission Statement -Dismas Charities Lexington facility floor plans -Dismas Charities, Inc. Policy Sexual Abuse/Harassment/Misconduct Prevention Intervention, Procedure Dismas Charities, Inc. Sexual Abuse/Harassment/Misconduct Prevention Intervention For Residents -Dismas Charities, Inc. Sexual Abuse/Harassment/Misconduct Prevention Intervention Policy Statement- IMPLEMENTATION -Dismas Charities, Inc. Human Resources Policies and Procedures Manual, Page #15, #17, #18, #19 and Section #5 Development & Training Page #58 -Dismas Charities, Inc. Initial Employee Orientation Checklist that requires Employee/Supervisor signature of receipt and understanding -Dismas Charities, Inc. Staff/Volunteer Acknowledgement Sexual Abuse Prevention and Intervention that requires Staff/Volunteer Signature and Facility Director signature of receipt and understanding -Dismas Charities, Inc. Employee Handbook Page #10, #36, and #37 -Dismas Charities, Inc./facility resident education using resident manual and pamphlet (given to each new resident during intake titled Understanding the Prison Rape Elimination Act (PREA) for Resident (March 21, 2014) -PREA informational Posters and Brochures posted and displayed for resident and staff access in the facility -Dismas Charities, Inc. and Dismas Charities Lexington staff interviews including Executive Vice- President/COO; Regional Vice-President/Agency-Wide PREA Coordinator; Director; Assistant Director; a Resident Monitor; and the residents interviewed Standard : Contracting with other entities for the confinement of residents (a) If this agency is public and it contracts for the confinement of its residents with private agencies PREA Audit Report Page 10 of 76 Facility Name double click to change

11 (b) or other entities including other government agencies, has the agency included the entity s obligation to comply with the PREA standards in any new contract or contract renewal signed on or after August 20, 2012? (N/A if the agency does not contract with private agencies or other entities for the confinement of residents.) Yes No NA Does any new contract or contract renewal signed on or after August 20, 2012 provide for agency contract monitoring to ensure that the contractor is complying with the PREA standards? (N/A if the agency does not contract with private agencies or other entities for the confinement of residents OR the response to (a)-1 is "NO".) Yes No NA (c) If the agency has entered into a contract with an entity that fails to comply with the PREA standards, did the agency do so only in emergency circumstances after making all reasonable attempts to find a PREA compliant private agency or other entity to confine residents? (N/A if the agency has not entered into a contract with an entity that fails to comply with the PREA standards.) Yes No NA In such a case, does the agency document its unsuccessful attempts to find an entity in compliance with the standards? (N/A if the agency has not entered into a contract with an entity that fails to comply with the PREA standards.) Yes No NA Auditor Overall Compliance Determination The narrative below must include a comprehensive discussion of all the evidence relied upon in making the Dismas Charities, Inc./Dismas Charities Lexington is a private not for profit halfway house which contracts with both the federal BOP (Bureau of Prisons) (PREA standards updated 1/6/2014) and KYDOC (Kentucky Department of Corrections) (PREA standards effective on 2/3/2014) for both federal and state inmates/residents. Dismas Charities, Inc./Dismas Charities Lexington does not contract out for the confinement of its residents. Standard : Supervision and monitoring PREA Audit Report Page 11 of 76 Facility Name double click to change

12 (a) Does the agency develop for each facility a staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect residents against sexual abuse? Does the agency document for each facility a staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect residents against sexual abuse? Does the agency ensure that each facility s staffing plan takes into consideration the physical layout of each facility in calculating adequate staffing levels and determining the need for video monitoring? Does the agency ensure that each facility s staffing plan takes into consideration the composition of the resident population in calculating adequate staffing levels and determining the need for video monitoring? Does the agency ensure that each facility s staffing plan takes into consideration the prevalence of substantiated and unsubstantiated incidents of sexual abuse in calculating adequate staffing levels and determining the need for video monitoring? Does the agency ensure that each facility s staffing plan takes into consideration any other relevant factors in calculating adequate staffing levels and determining the need for video monitoring? (b) In circumstances where the staffing plan is not complied with, does the facility document and justify all deviations from the plan? (N/A if no deviations from staffing plan.) NA (c) In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to the staffing plan established pursuant to paragraph (a) of this section? In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to prevailing staffing patterns? In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to the facility s deployment of video monitoring systems and other monitoring technologies? PREA Audit Report Page 12 of 76 Facility Name double click to change

13 In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to the resources the facility has available to commit to ensure adequate staffing levels? Auditor Overall Compliance Determination The narrative below must include a comprehensive discussion of all the evidence relied upon in making the Documentation and staff interviews confirmed that the physical layout of this facility, the composition of the resident population, the current cameras/video monitors, and other relevant factors are used to calculate adequate staffing levels on an ongoing basis for the safety of the residents and the staff. The agency/facility policy meets all the elements of the standard. The staffing plan has been completed and meets all the elements of the standard. Staff interviews, resident interviews, and documentation confirmed the practice of supervision and monitoring. POLICY, MATERIALS, INTERVIEWS AND OTHER EVIDENCE REVIEWED -Completed Dismas Charities, Inc./Dismas Charities Lexington Pre-Audit Questionnaire -Dismas Charities Lexington staffing schedule -Dismas Charities, Inc. PERSONNEL policy STAFFING PATTERN Procedure 2.2 -Dismas Charities, Inc. PERSONNEL policy EMPLOYEE ORIENTATION Procedure 2.G -Dismas Charities, Inc. PERSONNEL policy USE OF VOLUNTEERS Procedure 2.C -Dismas Charities, Inc. PERSONNEL policy EMPLOYEE BACKGROUND CHECKS Procedure 2.I -Dismas Charities, Inc. PERSONNEL policy SEXUAL ABUSE INFORMATION Procedure 2.K -Dismas Charities, Inc. and Dismas Charities Lexington staff interviews including Executive Vice- President/COO; Regional Vice-President/Agency-Wide PREA Coordinator; Director; Assistant Director; a Resident Monitor; and the residents interviewed Standard : Limits to cross-gender viewing and searches (a) Does the facility always refrain from conducting any cross-gender strip or cross-gender visual body cavity searches, except in exigent circumstances or by medical practitioners? PREA Audit Report Page 13 of 76 Facility Name double click to change

14 (b) Does the facility always refrain from conducting cross-gender pat-down searches of female residents, except in exigent circumstances? (N/A if less than 50 residents) NA Commented [TS1]: Does the facility always refrain from restricting female residents access to regularly available programming or other outside opportunities in order to comply with this provision? (N/A if less than 50 residents) NA (c) Does the facility document all cross-gender strip searches and cross-gender visual body cavity searches? Yes No Does the facility document all cross-gender pat-down searches of female residents? Yes No (d) Does the facility implement policies and procedures that enable residents to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks? Does the facility require staff of the opposite gender to announce their presence when entering an area where residents are likely to be showering, performing bodily functions, or changing clothing? (e) Does the facility always refrain from searching or physically examining transgender or intersex residents for the sole purpose of determining the resident s genital status? If a resident s genital status is unknown, does the facility determine genital status during conversations with the resident, by reviewing medical records, or, if necessary, by learning that information as part of a broader medical examination conducted in private by a medical practitioner? (f) Does the facility/agency train security staff in how to conduct cross-gender pat down searches in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs? PREA Audit Report Page 14 of 76 Facility Name double click to change

15 Does the facility/agency train security staff in how to conduct searches of transgender and intersex residents in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs? Auditor Overall Compliance Determination The narrative below must include a comprehensive discussion of all the evidence relied upon in making the There are NO opposite sex pat searches. There are NO opposite sex strip searches. There are NO body cavity searches. Staff are trained in the various searches and search techniques. Agency/facility policy prohibits searching or physically examining a transgender or intersex resident for the sole purpose of determining the resident s genital status. This was confirmed during staff interviews. None of the cameras field of view included toilet-shower areas. All toilets have doors on stalls and all showers have curtains. Both review of policies and interviews with staff and residents confirmed that opposite gender staff announce their presence when entering into the dorm housing areas and/or restrooms. Staff and resident interviews confirmed that this is the policy and the practice. Residents in this facility can use the restroom, take a shower and/or change clothing in complete privacy. There have been no transgender and/or intersex residents, confirmed by documentation and staff interviews (even though they have not had to address this issue to date) staff have received training. POLICY, MATERIALS, INTERVIEWS AND OTHER EVIDENCE REVIEWED -Completed Dismas Charities, Inc./Dismas Charities Lexington Pre-Audit Questionnaire -Dismas Charities, Inc. PROGRAMS Searches and Contraband Procedure Dismas Charities, Inc. SECURITY AND ACCOUNTABILITY Searches and Contraband Procedure 11.D -Dismas Charities, Inc. INITIAL EMPLOYEE ORIENTATION CHECKLIST that does require Employee/Supervisor signature of receipt and understanding -Dismas Charities, Inc./facility resident education using resident manual and pamphlet (given to each new resident during intake titled Understanding the Prison Rape Elimination Act (PREA) for Resident (March 21, 2014) -Dismas Charities Lexington staff interviews including Director; Assistant Director; a Resident Monitor; and the residents interviewed Standard : Residents with disabilities and residents who are limited English proficient PREA Audit Report Page 15 of 76 Facility Name double click to change

16 (a) Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who are deaf or hard of hearing? Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who are blind or have low vision? Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who have intellectual disabilities? Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who have psychiatric disabilities? Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who have speech disabilities? Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Other? (if "other," please explain in overall determination notes.) Do such steps include, when necessary, ensuring effective communication with residents who are deaf or hard of hearing? Do such steps include, when necessary, providing access to interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary? Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities including residents who: Have intellectual disabilities? Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities including residents who: Have limited reading skills? PREA Audit Report Page 16 of 76 Facility Name double click to change

17 Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities including residents who: Are blind or have low vision? (b) Does the agency take reasonable steps to ensure meaningful access to all aspects of the agency s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to residents who are limited English proficient? Do these steps include providing interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary? (c) Does the agency always refrain from relying on resident interpreters, resident readers, or other types of resident assistants except in limited circumstances where an extended delay in obtaining an effective interpreter could compromise the resident s safety, the performance of first-response duties under , or the investigation of the resident s allegations? Auditor Overall Compliance Determination The narrative below must include a comprehensive discussion of all the evidence relied upon in making the Agency/facility policy has established procedures to provide residents with any disability and residents who are limited English proficient equal opportunity to participate in or benefit from all aspects of the agency s/facility s efforts to prevent, detect, and respond to sexual harassment/sexual abuse. POLICY, MATERIALS, INTERVIEWS AND OTHER EVIDENCE REVIEWED -Completed Dismas Charities, Inc./Dismas Charities Lexington Pre-Audit Questionnaire -Dismas Charities, Inc. Policy Sexual Abuse/Harassment/Misconduct Prevention Intervention-TRAINING Procedure Dismas Charities, Inc. PERSONNEL policy USE OF VOLUNTEERS Procedure 2.C -Dismas Charities, Inc. Initial PREA Screening Questionnaire (in English and in Spanish) -PREA informational Posters and Brochures posted and displayed for resident and staff access in the facility PREA Audit Report Page 17 of 76 Facility Name double click to change

18 (in English and in Spanish) -Dismas Charities Lexington staff interviews including Director; Assistant Director; a Resident Monitor; and the residents interviewed Standard : Hiring and promotion decisions (a) Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has been civilly or administratively adjudicated to have engaged in the activity described in the question immediately above? Does the agency prohibit the enlistment of services of any contractor who may have contact with residents who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? Does the agency prohibit the enlistment of services of any contractor who may have contact with residents who: Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Does the agency prohibit the enlistment of services of any contractor who may have contact with residents who: Has been civilly or administratively adjudicated to have engaged in the activity described in the question immediately above? (b) Does the agency consider any incidents of sexual harassment in determining whether to hire or promote anyone, or to enlist the services of any contractor, who may have contact with residents? (c) Before hiring new employees, who may have contact with residents, does the agency: Perform a criminal background records check? PREA Audit Report Page 18 of 76 Facility Name double click to change

19 Before hiring new employees, who may have contact with residents, does the agency: Consistent with Federal, State, and local law, make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or any resignation during a pending investigation of an allegation of sexual abuse? (d) Does the agency perform a criminal background records check before enlisting the services of any contractor who may have contact with residents? (e) Does the agency either conduct criminal background records checks at least every five years of current employees and contractors who may have contact with residents or have in place a system for otherwise capturing such information for current employees? (f) Does the agency ask all applicants and employees who may have contact with residents directly about previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring or promotions? Does the agency ask all applicants and employees who may have contact with residents directly about previous misconduct described in paragraph (a) of this section in any interviews or written self-evaluations conducted as part of reviews of current employees? Does the agency impose upon employees a continuing affirmative duty to disclose any such misconduct? (g) Does the agency consider material omissions regarding such misconduct, or the provision of materially false information, grounds for termination? (h) Unless prohibited by law, does the agency provide information on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied to work? (N/A if providing information on substantiated allegations of sexual abuse or sexual harassment involving a former employee is prohibited by law.) NA Auditor Overall Compliance Determination PREA Audit Report Page 19 of 76 Facility Name double click to change

20 The narrative below must include a comprehensive discussion of all the evidence relied upon in making the The agency/facility conducts extensive background and reference checks. There is an agency/facility policy to conduct background checks verified through documentation and staff interviews. The agency/facility policy addresses all the elements of this standard. The Federal Bureau of Prisons must give written approval for employees and volunteers before Dismas Corporate Office can approve a potential employee or volunteer. The following paperwork is submitted to the Bureau of Prison Residential Reentry Office including but not limited to the Employment Application, Educational Verification, Reference Verifications, Authorization for Release of Information (Bureau of Prison Form), complete set of fingerprints and RRC Contractor NCIC/NLETS Request Form (Bureau of Prison Form). POLICY, MATERIALS, INTERVIEWS AND OTHER EVIDENCE REVIEWED -Completed Dismas Charities, Inc./Dismas Charities Lexington Pre-Audit Questionnaire -Dismas Charities, Inc. PERSONNEL policy EMPLOYEE BACKGROUND CHECKS Procedure 2.I -Dismas Charities, Inc. POLICY MANUAL PERSONNEL Page #20 -Dismas Charities Lexington staff interviews including Director; Assistant Director Standard : Upgrades to facilities and technologies (a) If the agency designed or acquired any new facility or planned any substantial expansion or modification of existing facilities, did the agency consider the effect of the design, acquisition, expansion, or modification upon the agency s ability to protect residents from sexual abuse? (N/A if agency/facility has not acquired a new facility or made a substantial expansion to existing facilities since August 20, 2012, or since the last PREA audit, whichever is later.) Yes No NA (b) If the agency installed or updated a video monitoring system, electronic surveillance system, or other monitoring technology, did the agency consider how such technology may enhance the agency s ability to protect residents from sexual abuse? (N/A if agency/facility has not installed or updated a video monitoring system, electronic surveillance system, or other monitoring technology since August 20, 2012, or since the last PREA audit, whichever is later.) NA PREA Audit Report Page 20 of 76 Facility Name double click to change

21 Auditor Overall Compliance Determination The narrative below must include a comprehensive discussion of all the evidence relied upon in making the Agency/facility documentation and interviews confirmed than any and all future modifications/updating to this facility is based on the practice of considering the effect upon the facility s ability to protect residents and staff from sexual harassment/sexual abuse and/or allegations of sexual harassment/sexual abuse. POLICY, MATERIALS, INTERVIEWS AND OTHER EVIDENCE REVIEWED -Dismas Charities, Inc. Policy Sexual Abuse/Harassment/Misconduct Prevention Intervention Procedure Dismas Charities, Inc. and Dismas Charities Lexington staff interviews including Executive Vice- President/COO; Regional Vice-President/Agency-Wide PREA Coordinator; Director; Assistant Director Standard : Evidence protocol and forensic medical examinations (a) If the agency is responsible for investigating allegations of sexual abuse, does the agency follow a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence for administrative proceedings and criminal prosecutions? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) Yes No NA (b) RESPONSIVE PLANNING Is this protocol developmentally appropriate for youth where applicable? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) Yes No NA PREA Audit Report Page 21 of 76 Facility Name double click to change

22 Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of the U.S. Department of Justice s Office on Violence Against Women publication, A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents, or similarly comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) Yes No NA (c) Does the agency offer all residents who experience sexual abuse access to forensic medical examinations, whether on-site or at an outside facility, without financial cost, where evidentiarily or medically appropriate? Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible? If SAFEs or SANEs cannot be made available, is the examination performed by other qualified medical practitioners (they must have been specifically trained to conduct sexual assault forensic exams)? Has the agency documented its efforts to provide SAFEs or SANEs? Yes No (d) Does the agency attempt to make available to the victim a victim advocate from a rape crisis center? If a rape crisis center is not available to provide victim advocate services, does the agency make available to provide these services a qualified staff member from a community-based organization, or a qualified agency staff member? Has the agency documented its efforts to secure services from rape crisis centers? (e) As requested by the victim, does the victim advocate, qualified agency staff member, or qualified community-based organization staff member accompany and support the victim through the forensic medical examination process and investigatory interviews? Yes No As requested by the victim, does this person provide emotional support, crisis intervention, information, and referrals? (f) If the agency itself is not responsible for investigating allegations of sexual abuse, has the agency requested that the investigating entity follow the requirements of paragraphs (a) through PREA Audit Report Page 22 of 76 Facility Name double click to change