DRAFT

PREA Facility Audit Report: Final

Name of Facility: Cape May County Correctional Center

Facility Type: Prison / Jail

Date Interim Report Submitted: 01/02/2017

Date Final Report Submitted: 03/09/2017


Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the agency under review.
I have not included in the final report any personally identifiable information (PII) about any inmate/resident/detainee or staff member, except where the names of administrative personnel are specifically requested in the report template.
Auditor Full Name as Signed: Gerald Francis Grogan  Date of Signature: 03/09/2017


AUDITOR INFORMATION
Auditor name: Grogan , Gerald
Address:
Email: gfgrogan@yahoo.com
Telephone number:
Start Date of On-Site Audit: 12/05/2016
End Date of On-Site Audit: 12/07/2016


FACILITY INFORMATION
Facility name: Cape May County Correctional Center
Facility physical address: 125 Cerst Haven Road, Cape May Court House, New Jersy - 08210
Facility Phone
Facility mailing address: 4 Moore Road , Cape May Court House , New Jersy - 08210
The facility is:
             
Facility Type:
   


Primary Contact
Name: Louis Taylor III Title: PREA Compliance Manager
Email Address: louis.taylor@cmcsheriff.net Telephone Number: 609-465-1237


Warden/Superintendent
Name: Donald Lombardo Title: Warden
Email Address: donald.lombardo@cmcsheriff.net Telephone Number: 609-465-1256


Facility PREA Compliance Manager
Name: Louis Taylor III Title: Officer
Email Address: louis.taylor@cmcsheriff.net Telephone Number: 609-465-1237


Facility Health Service Administrator
Name: Kristi Siekierski RN Title: Health Service Adminstrator
Email Address: ksiekierski@correctcaresolutions.com Telephone Number: 609-465-1251


Facility Characteristics
Designed facility capacity: 188
Current population of facility: 246
Age Range Adults: 18-80 Youthful Residents:
Facility security level/inmate custody levels: Minimum/ Medium/ Maximum
Number of staff currently employed at the facility who may have contact with inmates:


AGENCY INFORMATION
Name of agency: Cape May County Sheriff's Office
Governing authority or parent agency (if applicable):
Physical Address: 9 North Main Street , Cape May Court House, New Jersy - 08210
Mailing Address:
Telephone number:


Agency Chief Executive Officer Information:
Name: Title:
Email Address: Telephone Number:


Agency-Wide PREA Coordinator Information
Name: Kourtney Perry Title: Detective First Class
Email Address: kourtney.perry@cmcsheriff.net Telephone Number: 609-465-1029


AUDIT FINDINGS

Narrative:
The auditor’s description of the audit methodology should include a detailed description of the following processes during the pre-audit, on-site 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.
During the pre-audit phase, I reviewed all policies related to PREA. The policies used the same language as the standards. Any policy corrections were noted for corrective action. During the on-site phase, I was given a tour of the entire facility. I observed the intake process, location of the screening instrument, holding cells with TVs that played the PREA education video. I also spoke with intake staff about the screening instrument and followup procedures. I toured the cell blocks. All blocks had Posters with PREA reporting procedures and telephone numbers. Cell blocks had a sleeping area and a separate area for showering and restroom. Other areas of the facility include classroom, laundry, kitchen, medical office. I requested and was given documents that demonstrated compliance with numerous standards, other documents will be provided during the corrective action phase. I was able to interview line staff from all shifts and rotations. Interviews with specialty staff were scheduled in-between inmate interviews and staff interviews. I was able to interview one inmate from each housing area and one inmate whom reported sexual abuse at another facility. The agency is currently under the corrective action phase. The agency was given a copy of the interim report noting areas of "Does not meet." I gave recommendations to the PREA manager to achieve compliance.


Facility Characteristics:
The auditor’s description of the audited facility should include details about the type of the facility, demographics and size of the inmate or resident 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.
Cape May County Correctional Facility is a small resort town facility. The population is low (240) compared to neighboring facilities. The facility comprises of one hallway with indirect supervision cell blocks located on either side. The jail holds men and women most of whom stated to me that they lived in the area. During the summertime the jail has more people from out of town. The housing units are split into two sections; a sleeping and day area and a separate area for showering and restrooms. The shower and restroom areas have obstructed views from the hallways. Special housing units are linear 2 man cells. There is a private shower area and access to phones. Medical and Mental health is provided by CCS. Food service is provided by ARMARK. The jail offers many educational and religious programs. The facility provides daily recreation.

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.
Number of standards exceeded: 1
Number of standards met: 44
Number of standards not met: 0
Exceeds standard: 1
Meets standard: : 29
Does not meet standard: 13

A summary of the standards that does not meet include:
115.11 agency plan to implement, prevent and detect sexual abuse. Agency strategy added to policy
118.13 Agency staffing plan
115.17 Hiring, promotion and employee evaluation questions.
115.22 post investigation referral policy on the web site.
115.31Training documentation (signatures)
115.32 Training documentation (signatures)
115.34 Complete specialized training
115.35 Complete specialized training
115.42 Document haw screening decisions are made.
115.64 Reporting and reports
115.71 Investigator training
118.86 Incident review team (format/reporting)
115.401 No audit conducted during the first audit cycle.


Standards
Auditor Overall Determination Definitions
  • Exceeds Standard
    (Substantially exceeds requirement of standard)

  • Meets Standard
    (substantial compliance; complies in all material ways with the stand for the relevant review period)

  • Does Not Meet Standard
    (requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.


115.11 Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a written policy that mandates a zero tolerance toward all forms of sexual abuse and sexual harassment in the facility. The policy includes definitions of prohibited behaviors regarding sexual abuse and sexual harassment. The policy includes sanctions for those found to have participated in prohibited behaviors. The agency has a designated PREA Coordinator as well as a PREA Compliance Manager. The PREA Coordinator reports directly to the Warden or the Executive Undersheriff. The PREA Compliance Manager reports to the Coordinator or the Warden. The PREA coordinator and the PREA compliance manager both have sufficient time and authority to manage all PREA responsibilities. This was determined following interviews with both.


(a)-2 SOP1131 does not contain an outline of the implementation process, prevention process or detection. The policy does contain an internal process.
I recommend that the PREA Coordinator prepare a report of the implementation process and add an outline to the policy. The agency SART agreement should be included.
(a)-5 The policy has a statement but doesn't describe a strategy.
I recommend adding a strategy to the statement.

The agency has now updated their policy; it includes an outline of the implementation process, prevention process, detection process and strategy.
The agency has also attached a copy of the County's SART agreement with the agency.
The agency has now mat all of the requirements of the standard.


115.12 Contracting with other entities for the confinement of inmates
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency does not contract with any other facilities to house inmates.


115.13 Supervision and monitoring
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Agency policy requires that intermediate-level or higher-level staff conduct unannounced rounds to identify and deter staff sexual abuse and sexual harassment. These rounds are conducted on all shifts. The policy prohibits staff from alerting other staff of the conduct of such rounds. I reviewed logs documenting supervisor rounds. The rounds covered all shifts. Interviews with staff and supervisors confirmed that staff does not alert others of the rounds.

115.13 (a)-1 The Agency needs to complete a staffing plan.
I will provide the PREA Coordinator with a staffing plan tool kit published by NIC as well as provide an example of a completed plan.
115.13 (c)-1 A review of the staffing plan should be attached by the review comity.

"The agency shall assess, determine, and document whether adjustments are needed to: (1) The staffing plan established pursuant to paragraph (a) of this section; (2) The facility’s deployment of video monitoring systems and other monitoring technologies; and (3) The resources the facility has available to commit to ensure adherence to the staffing plan."

During the corrective action phase, the PREA manager created a staffing plan using the "Staffing Plan Tool Kit" from the NIC website. The report contains calculations for staff levels on all shifts and review of the 9 elements required by the standards.
The agency has now met all of the requirements of the standard.


115.14 Youthful inmates
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The Agency has a policy to address youthful offenders that complies with the PREA Standards. The Agency reports that they have not held a youthful offender post 2012.


115.15 Limits to cross-gender viewing and searches
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The facility does not conduct cross-gender strip or cross-gender visual body cavity searches of inmates, unless its performed by medical staff. The facility does not permit cross-gender pat-down searches of female inmates, absent exigent circumstances. The facility does not restrict female inmates' access to regularly available programming or other out-of-cell opportunities in order to comply with this provision. Facility policy requires that all cross-gender strip searches and cross-gender visual body cavity searches be documented on form 711-A and accompanied by a narrative report. Facility policy requires that all cross-gender pat-down searches of female inmates be documented. The documentation must include: Why the search was not postponed, why there was not eligible staff to perform the search, what steps were taken to call eligible staff in, were the steps unsuccessful, was contraband found. The facility has a policy prohibiting staff from searching or physically examining a transgender or intersex inmate for the sole purpose of determining the inmate's genital status. All security staff have been trained on conducting cross-gender pat-down searches and searches of transgender and intersex inmates in a professional and respectful manner. The training material that was used, was developed by the Moss Group and obtained from the PRC website.

During the facility tour, I observed male staff announce their presence prior to entering the female housing unit as well as female staff announcing their presence before entering the male housing units. Interviews with inmates confirm these announcements. Staff can view day areas from hallways or by CCTV. Inmates are not allowed to be undressed in this area. Inmates confirm that they only dress in the shower area. The shower and restroom areas are obstructed from common view as well as CCTV.


115.16 Inmates with disabilities and inmates who are limited English proficient
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has established procedures to provide disabled inmates 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 by showing the PREA video (developed by the MOSS Group) to all inmates during intake. Providing reading material, displaying posters in hallways, cell blocks and work areas. Medical and Mental Health staff are available to assist mentally challenged inmates. The facility has Spanish speaking officers as well as officers that can sign ASL. The agency also has a language line available. The facility does not use inmate interpreters for PREA related cases. Staff confirms that inmate interpreters are not used.


115.17 Hiring and promotion decisions
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Agency policy prohibits hiring or promoting anyone who may have contact with inmates and prohibits enlisting the services of any contractor who may have contact with inmates who have been convicted of any felony. The hiring packet the investigator uses, asks about convictions but does not ask the questions specified by the standards. The agency needs to add those questions. The agency will need to add those questions to promotion documentation as well as yearly evaluations. The agency conducts ongoing criminal background checks for all employees, contractors and volunteers.

During the corrective action phase, the agency has revised the hiring packet questions to match the standard. The agency has added an affirmation to their annual employee evaluations and to their promotion acceptance letter.
The agency has now met all of the requirements of the standard.


115.18 Upgrades to facilities and technologies
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has not had any new construction or modifications.

The agency is getting ready for the construction of a new facility. This standard will apply during their next audit.


115.21 Evidence protocol and forensic medical examinations
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Administrative sexual abuse investigations are conducted by Internal Affairs. Criminal investigations are conducted by the county Prosecutors Office. The Agency is also a part of the county's SART (Sexual Assault Response Team). All services required by this standard are made available through the SART agreement. The SART agreement provides access to forensic medical examinations free of cost to the victim. (provided at the local hospital by SAFEs, SANEs or FNEs. A victim advocate from a rape crisis center. City and County governments in many states have required prosecutors to form SARTs. These SART agreements put in place a consistent and complete response to any sexual assault case.


115.22 Policies to ensure referrals of allegations for investigations
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency ensures that an administrative (IA) or criminal investigation (County Prosecutor) is completed for all allegations of sexual abuse and sexual harassment, including inmate-on-inmate sexual abuse and staff sexual misconduct. The agency requires that allegations of sexual abuse be referred for investigation to the Cape May County Prosecutor's Office whom has the legal authority to conduct criminal investigations, The agency's policy regarding the referral of allegations of sexual abuse for criminal investigation is not published on the agency website or made publicly available via other means. The agency documents all referrals of allegations of sexual abuse for criminal investigation.

The agency needs to put its referral policy on its website.

During the corrective action phase; the agency has posted its referral policy to the website.
The agency has now met all of the requirements of this standard


115.31 Employee training
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has trained all employees on the following: 1) Its zero-tolerance policy for sexual abuse and sexual harassment; (2) How to fulfill their responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures; (3) Inmates’ rights to be free from sexual abuse and sexual harassment; (4) The right of inmates and employees to be free from retaliation for reporting sexual abuse and sexual harassment; (5) The dynamics of sexual abuse and sexual harassment in confinement; (6) The common reactions of sexual abuse and sexual harassment victims; (7) How to detect and respond to signs of threatened and actual sexual abuse; (8) How to avoid inappropriate relationships with inmates; (9) How to communicate effectively and professionally with inmates, including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming inmates. Training is conducted through classroom and powerpoint instruction. I have reviewed the training material and interviewed the PREA manager who is also the instructor.

The agency needs to train employees on: How to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities.
The agency documents that employees have attended the training however, the agency needs to document that employees understand the training they have received through employee signature or electronic verification.

During the corrective action phase, the agency has trained all employees on how to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities. The agency has also provided a copy of the training with electronic signatures stating that the employee understands the training.
The agency has now met all of the requirements of the standard.


115.32 Volunteer and contractor training
  Auditor Overall Determination: Meets Standard
Auditor Discussion
All volunteers and contractors who have contact with inmates have been trained on their responsibilities under the agency's policies and procedures regarding sexual abuse and sexual harassment prevention, detection, and response. The level and type of training provided to volunteers and contractors is the same training given to all staff. All volunteers and contractors who have contact with inmates have been notified of the agency's zero-tolerance policy regarding sexual abuse and sexual harassment and informed how to report such incidents. Training records and Interviews conducted confirm that volunteers and contractors have received training and know their response and reporting duties.

The agency needs to document that volunteers understand the training.

The Agency has now added the the acknowledgement that volunteers and contractors understand the training they have received.


115.33 Inmate education
  Auditor Overall Determination: Meets Standard
Auditor Discussion
During the intake process, inmates are given PREA related reading material and required to watch a PREA video (MOSS Group). Inmate PREA education is available in formats accessible to all inmates, including those who are limited English proficient. This is done through Spanish translated reading material, Staff translators or through the use of a language line. Inmates whom are disabled will receive assistance from instructors, medical or mental health staff. The agency also has an officer that signs ASL. Documentation of inmate participation is kept in the inmate's records. The agency also provides PREA information in the inmate Handbook, PREA related posters and reporting instructions and options in all housing units. The determination was made during the facility walk through and inmate interviews.


115.34 Specialized training: Investigations
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The Agency investigator needs to complete training on: Conducting sexual abuse investigations in confinement settings.
The Agency needs to ask the investigator from the Prosecutor's Office to complete the training.

During the corrective action phase; agency investigators have completed the required training (conducting sexual abuse investigations in confinement settings)
The agency used the training provided by the National Institute of Corrections.
They have also sent a request to the Prosecutor's Office requesting that their investigator complete the training also.


115.35 Specialized training: Medical and mental health care
  Auditor Overall Determination: Meets Standard
Auditor Discussion
All medical and mental health staff have received the same training as correctional staff.
Medical and Mental health staff need to complete the specialized training required by this standard. I recommend using the training provided on the PREA website using a qualified instructor or completing the training online through NIC.
During the corrective action period, medical and mental health staff completed the NIC online courses for specialized training. The PREA manager provided copies of their certificates. The facility has now met the requirements of this standard.


115.41 Screening for risk of victimization and abusiveness
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency screens (upon admission to a the facility) for risk of sexual abuse victimization or sexual abusiveness toward other inmates. The risk assessment is conducted using an objective screening instrument. The screening instrument considers the following: (1) Whether the inmate has a mental, physical, or developmental disability; (2) The age of the inmate; (3) The physical build of the inmate; (4) Whether the inmate has previously been incarcerated; (5) Whether the inmate's criminal history is exclusively nonviolent; (6) Whether the inmate has prior convictions for sex offenses against an adult or child; (7) Whether the inmate is or is perceived to be gay, lesbian, bisexual, transgender, intersex, or gender nonconforming; (8) Whether the inmate has previously experienced sexual victimization; (9) The inmate's own perception of vulnerability; and (10) Whether the inmate is detained solely for civil immigration purposes. Agency policy prohibits disciplining inmates for refusing to answer or for not disclosing complete information. Information collected during screening is given to classification. That information is not shared with staff that are not in the "Need to know."


115.42 Use of screening information
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The classification department uses information from the risk screening to make housing, bed, work, education, and program assignments with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive. The facility reports that they have had no transgender or intersex inmates in the last 12 months.

After reviewing the documentation provided, the agency needs to document how each decision was determined.

During the corrective action phase; the agency provided me a report that is created on any inmate who's screening form indicates that some action is required.
The report contains information from a personal interview and recommendations for housing.

The agency now meets all of the requirements of the standard.


115.43 Protective Custody
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a policy prohibiting the placement of inmates at high risk for sexual victimization in involuntary segregated housing unless an assessment of all available alternatives has been made and a determination has been made that there is no available alternative means of separation from likely abusers. The agency reports that no inmates were held in involuntary segregation.


115.51 Inmate reporting
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has established procedures allowing for multiple internal ways for inmates to report privately to agency officials. They can tell any employee, call IA or the Prosecutor's office directly, submit a request slip. The agency has a policy mandating that staff accept reports of sexual abuse and sexual harassment made verbally, in writing, anonymously, and from third parties. Staff are required to document verbal reports immediately or before their shift ends. The agency has established procedures for staff to privately report sexual abuse and sexual harassment of inmates by reporting to IA or calling the County Prosecutor. The staff is informed of this procedure during training.


115.52 Exhaustion of administrative remedies
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Agency policy or procedure allows an inmate to submit a grievance regarding an allegation of sexual abuse at any time, regardless of when the incident is alleged to have occurred.
(b)-2 Agency policy conflicts with the standard: The agency shall not require an inmate to use any informal grievance process, or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse.
Policy states: An inmate is to use an informal grievance process, (attempt to resolve with staff), an alleged incident of sexual abuse before proceeding to a formal grievance.
This was policy error was corrected on site. The policy now reads, "An inmate is not required to use an informal grievance process, (attempt to resolve with staff), an alleged incident of sexual abuse before proceeding to a formal grievance.
The agency's policy and procedure allows an inmate to submit a grievance alleging sexual abuse without submitting it to the staff member who is the subject of the complaint. Decisions on the merits of any grievance or portion of a grievance alleging sexual abuse are made within 90 days of the filing of the grievance. Agency policy and procedure permits third parties, including fellow inmates, staff members, family members, attorneys, and outside advocates, to assist inmates in filing requests for administrative remedies relating to allegations of sexual abuse and to file such requests on behalf of inmates. The agency has a policy and established procedures for filing an emergency grievance alleging that an inmate is subject to a substantial risk of imminent sexual abuse. These must be answered within 48 hours and a final agency decision be issued within 5 days.


115.53 Inmate access to outside confidential support services
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The facility provides inmates with access to outside victim advocates for emotional support services related to sexual abuse by providing telephone numbers of agencies and providing access to telephones. The telephones are located in all cell blocks. The inmates are able to use the phones all day and evening till lock down. The inmates are aware that communication with these agencies are not monitored or recorded and these agencies duty to report. The facility maintains a memorandum of understanding with the Coalition Against Rape and Abuse Inc. (CARA). They provide inmates with emotional support services related to sexual abuse. A copy of the MOU was provided for the auditor.


115.54 Third-party reporting
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The facility provides a method to receive third-party reports of inmate sexual abuse or sexual harassment through its website or the Cape May Prosecutor's Office. Visitors are given information on how to report.


115.61 Staff and agency reporting duties
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency requires all staff to report immediately and according to agency policy any knowledge, suspicion, or information they receive regarding an incident of sexual abuse or sexual harassment that occurred in a facility, whether or not it is part of the agency. To report immediately any retaliation against inmates or staff who reported such an incident or any staff neglect or violation of responsibilities that may have contributed to an incident or retaliation. Staff does not share information to any one without a kneed to know. Interviews with line staff, medical staff and the Warden confirms staff knowledge of this policy.


115.62 Agency protection duties
  Auditor Overall Determination: Meets Standard
Auditor Discussion
When the facility learns that an inmate is subject to a substantial risk of imminent sexual abuse, it takes immediate action to protect the inmate by reassigning housing and filing an IA report. Officers interviewed stated that they would immediately remove the inmate from their housing unit and inform their supervisor.


115.63 Reporting to other confinement facilities
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a policy requiring that, upon receiving an allegation that an inmate was sexually abused while confined at another facility, the head of the facility (Warden) must notify the head of the facility or appropriate office of the agency or facility where sexual abuse is alleged to have occurred. The facility reports two occurrences. In each case the Warden contacted the Warden of the other facility. Both cases were investigated. The Case files note when the report was taken, and when the other agency was notified. In both cases, the agency was notified within 72 hours.


115.64 Staff first responder duties
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a first responder policy for allegations of sexual abuse. All staff members were able to explain during their interviews that they must: (1) Separate the alleged victim and abuser; (2) Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence; (3) If the abuse occurred within a time period that still allows for the collection of physical evidence, request that the alleged victim not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating; and (4) If the abuse occurred within a time period that still allows for the collection of physical evidence, ensure that the alleged abuser does not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating.
If the first staff responder is not a security staff member, the responder is required to request that the alleged victim not take any actions that could destroy physical evidence, and then notify security staff.

The agency policy and staff knowledge meet the requirements of the standard. The agency during the corrective action phase is going to provide staff reports for my review (redacting personal information/identifiers). Final determination on compliance will be made after I have reviewed these reports.

After a complete review of case files; I have determined that first responders as well as other staff and investigators have acted and preformed correctly.
The agency meets all requirements of the standard.


115.65 Coordinated response
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The facility has developed a written institutional plan to coordinate actions taken in response to an incident of sexual abuse among staff first responders, medical and mental health practitioners, investigators, and facility leadership. The agency's participation on the SART is also a part of this plan. Interviews with staff, supervisors and the PREA Manager confirms that all parties involved know their responsibilities if an incident occurs.


115.66 Preservation of ability to protect inmates from contact with abusers
  Auditor Overall Determination: Meets Standard
Auditor Discussion
I reviewed the collective bargaining agreement (article IV). There is nothing that prohibits or restricts the agency from conducting investigations or retaining information in the employee's personnel file. An interview with the IA investigator and the Warden confirmed compliance with this standard.


115.67 Agency protection against retaliation
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a policy to protect all inmates and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other inmates or staff. The PREA manager is responsible for monitoring compliance with this standard. The agency/facility monitors the conduct or treatment of inmates or staff who reported sexual abuse and of inmates who were reported to have suffered sexual abuse to see if there are any changes that may suggest possible retaliation by inmates or staff for a period of 90 days. Monitoring will continue beyond 90 days if necessary.
The agency reports no cases requiring monitoring.


115.68 Post-allegation protective custody
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a policy prohibiting the placement of inmates who allege to have suffered sexual abuse in involuntary segregated housing unless an assessment of all available alternatives has been made and a determination has been made that there is no available alternative means of separation from likely abusers. If an involuntary segregated housing assignment is made, the facility affords each such inmate a review every 30 days to determine whether there is a continuing need for separation from the general population.

The agency reports no involuntary segregated housing assignments.


115.71 Criminal and administrative agency investigations
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency/facility has a policy related to criminal and administrative agency investigations. Internal Affairs investigates all complaints. Criminal complaints are referred to the Cape May County Prosecutor's office. All case files are maintained in the IA office.

The agency will achieve compliance with this standard after investigators complete the specialized training.

Where sexual abuse is alleged, the agency shall use investigators who have received special training in sexual abuse investigations pursuant to § 115.34.

During the corrective action phase; The agency investigator and the prea manager completed the specialized training through the NIC on-line training portal.
The agency now meets all requirements of this standard.
The agency also provided a letter to the County Prosecutor, requesting that they complete the course as well.


115.72 Evidentiary standard for administrative investigations
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The IA investigator imposes a standard of a preponderance of the evidence or a lower standard of proof when determining whether allegations of sexual abuse or sexual harassment are substantiated. An interview with the investigator and a review of case files show compliance with this standard.


115.73 Reporting to inmates
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has a policy requiring that any inmate who makes an allegation that he or she suffered sexual abuse in an agency facility is informed, verbally or in writing, as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded following an investigation. For criminal investigations, the agency requests the relevant information from the Prosecutor's Office in order to inform the inmate of the outcome of the investigation. Following an inmate's allegation that a staff member has committed sexual abuse against the inmate, the agency subsequently informs the inmate (unless the agency has determined that the allegation is unfounded) whenever: • The staff member is no longer posted within the inmate's unit; • The staff member is no longer employed at the facility; • The agency learns that the staff member has been indicted on a charge related to sexual abuse within the facility; or • The agency learns that the staff member has been convicted on a charge related to sexual abuse within the facility. Following an inmate’s allegation that he or she has been sexually abused by another inmate in an agency facility, the agency subsequently informs the alleged victim whenever: • The agency learns that the alleged abuser has been indicted on a charge related to sexual abuse within the facility; or • The agency learns that the alleged abuser has been convicted on a charge related to sexual abuse within the facility.

These notifications or notated in the inmate's case file.


115.76 Disciplinary sanctions for staff
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Staff is subject to disciplinary sanctions up to and including termination for violating agency sexual abuse or sexual harassment policies. The disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) are commensurate with the nature and circumstances of the acts committed, the staff member's disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories. The agency reports no occurrences of staff requiring disciplinary action.
All terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, are reported to law enforcement agencies (unless the activity was clearly not criminal) and to any relevant licensing bodies.
The agency reports no occurrences of staff terminations related to PREA.
An interview with HR confirms no occurrences.


115.77 Corrective action for contractors and volunteers
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Agency policy requires that any contractor or volunteer who engages in sexual abuse be reported to law enforcement agencies (unless the activity was clearly not criminal) and to relevant licensing bodies. The facility takes appropriate remedial measures and considers whether to prohibit further contact with inmates in the case of any other violation of agency sexual abuse or sexual harassment policies by a contractor or volunteer.
The agency reports no violations.
An interview with HR confirms no occurrences.


115.78 Disciplinary sanctions for inmates
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Inmates are subject to disciplinary sanctions only pursuant to a formal disciplinary process following an administrative finding that an inmate engaged in inmate-on-inmate sexual abuse. Inmates are subject to disciplinary sanctions only pursuant to a formal disciplinary process following a criminal finding of guilt for inmate-on-inmate sexual abuse.
If the facility's Mental Health department offers therapy, counseling, or other interventions designed to address and correct the underlying reasons or motivations for abuse, the facility considers whether to require the offending inmate to participate in such interventions as a condition of access to programming or other benefits.
The agency disciplines inmates for sexual conduct with staff only upon finding that the staff member did not consent to such contact.
The agency prohibits disciplinary action for a report of sexual abuse made in good faith based upon a reasonable belief that the alleged conduct occurred, even if an investigation does not establish evidence sufficient to substantiate the allegation.
The agency prohibits all sexual activity between inmates. The agency deems such activity to constitute sexual abuse only if it determines that the activity is coerced.


115.81 Medical and mental health screenings; history of sexual abuse
  Auditor Overall Determination: Exceeds Standard
Auditor Discussion
All inmates at this facility who have disclosed any prior sexual victimization during a screening pursuant to §115.41 are offered a follow-up meeting with a medical or mental health practitioner. An interview with Medical and Mental Health reveals followup interviews occur within 72 hours. Medical and mental health staff maintain secondary materials (e.g., form, log) documenting compliance with the above required services. After review of case records, I found that most cases are reviewed in 24 hours. Information related to sexual victimization or abusiveness that occurred in an institutional setting is strictly limited to medical and mental health practitioners. Medical and mental health practitioners obtain informed consent from inmates before reporting information about prior sexual victimization that did not occur in an institutional setting, unless the inmate is under the age of 18.
An interview with Medical and Mental Health staff confirmed compliance with this standard.
All medical records are secured in the medical office.


115.82 Access to emergency medical and mental health services
  Auditor Overall Determination: Meets Standard
Auditor Discussion
Inmate victims of sexual abuse receive timely, unimpeded access to emergency medical treatment and crisis intervention services. These services are provided through the SART agreement. Medical treatment is done through the local hospital and crisis intervention services are provided through CARA. Medical and Mental Health staff determine the nature and scope of such services according to their professional judgment.
Inmate victims of sexual abuse while incarcerated are offered timely information about and timely access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with professionally accepted standards of care, where medically appropriate. Treatment services are provided to every victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident.


115.83 Ongoing medical and mental health care for sexual abuse victims and abusers
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The facility offers medical and mental health evaluation and, as appropriate, treatment to all inmates who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility. Female victims of sexual abusive vaginal penetration while incarcerated are offered pregnancy tests. If pregnancy results from sexual abuse while incarcerated, victims receive timely and comprehensive information about, and timely access to, all lawful pregnancy-related medical services. Inmate victims of sexual abuse while incarcerated are offered tests for sexually transmitted infections as medically appropriate. Treatment services are provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident.
Interviews with Medical and Mental health staff, The PREA Manager and the Warden confirm the services provided.


115.86 Sexual abuse incident reviews
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The facility has not had to conduct a sexual abuse incident review. The policy specifies that at the conclusion of every criminal or administrative sexual abuse investigation, unless the allegation has been determined to be unfounded, they will conduct a sexual abuse incident review within 30 days.

Because the facility has not had the need to conduct an incident review; I recommend attaching a document or form that outlines the review team process. The form should contain all elements required by the standard (115.86 (d), 115.86 (e)-1)
This will insure that the proper format and considerations are completed.

The agency has created a standardized form that will be used to conduct an incident review. The report format contains all elements required by the standard (115.86 (d), 115.86 (e)-1).


115.87 Data collection
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency collects accurate, uniform data for every allegation of sexual abuse at facilities under its direct control using a standardized instrument and set of definitions. The agency aggregates the incident-based sexual abuse data at least annually. The data includes, at a minimum, the data necessary to answer all questions from the most recent version of the Survey of Sexual Violence (SSV) conducted by the Department of Justice. The agency maintains, reviews, and collects data as needed from all available incident-based documents, including reports, investigation files, and sexual abuse incident reviews.


115.88 Data review for corrective action
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The Warden reviews data collected and aggregated pursuant to §115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, response policies, and training, including: • Identifying problem areas; • Taking corrective action on an ongoing basis; and • Preparing an annual report of its findings from its data review and any corrective actions for each facility, as well as the agency as a whole.


115.89 Data storage, publication, and destruction
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has published its sexual abuse data to its website. The agency maintains sexual abuse data collected pursuant to §115.87 for at least 10 years after the date of initial collection, unless federal, state, or local law requires otherwise.


115.401 Frequency and scope of audits
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency did not have an audit during the first audit cycle. To achieve compliance with this standard, the agency will provide a report that will discuss the agency’s plans for future audits during the upcoming years.

During the corrective action phase; the PREA Manager provided me a letter confirming on going intentions to comply with the PREA standards and on going audits.


115.403 Audit contents and findings
  Auditor Overall Determination: Meets Standard
Auditor Discussion
The agency has not had a prior audit.


Appendix: Provision Findings


115.11 (a) Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
Does the agency have a written policy mandating zero tolerance toward all forms of sexual abuse and sexual harassment? yes
Does the written policy outline the agency’s approach to preventing, detecting, and responding to sexual abuse and sexual harassment? yes


115.11 (b) Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
Has the agency employed or designated an agency-wide PREA Coordinator? yes
Is the PREA Coordinator position in the upper-level of the agency hierarchy? yes
Does the PREA Coordinator have sufficient time and authority to develop, implement, and oversee agency efforts to comply with the PREA standards in all of its facilities? yes


115.11 (c) Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
If this agency operates more than one facility, has each facility designated a PREA compliance manager? (N/A if agency operates only one facility.) na
Does the PREA compliance manager have sufficient time and authority to coordinate the facility’s efforts to comply with the PREA standards? (N/A if agency operates only one facility.) yes


115.12 (a) Contracting with other entities for the confinement of inmates
If this agency is public and it contracts for the confinement of its inmates with private agencies or other entities including other government agencies, has the agency included the entity’s obligation to comply with the PREA standards in any new contract or contract renewal signed on or after August 20, 2012? (N/A if the agency does not contract with private agencies or other entities for the confinement of inmates.) na


115.12 (b) Contracting with other entities for the confinement of inmates
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 inmates OR the response to 115.12(a)-1 is "NO".) na


115.13 (a) Supervision and monitoring
Does the agency ensure that each facility has developed a staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect inmates against sexual abuse? yes
Does the agency ensure that each facility has documented a staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect inmates against sexual abuse? yes
Does the agency ensure that each facility’s staffing plan takes into consideration the generally accepted detention and correctional practices in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration any judicial findings of inadequacy in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration any findings of inadequacy from Federal investigative agencies in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration any findings of inadequacy from internal or external oversight bodies in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration all components of the facility’s physical plant (including “blind-spots” or areas where staff or inmates may be isolated) in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration the composition of the inmate population in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration the number and placement of supervisory staff in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration the institution programs occurring on a particular shift in calculating adequate staffing levels and determining the need for video monitoring? yes
Does the agency ensure that each facility’s staffing plan takes into consideration any applicable State or local laws, regulations, or standards in calculating adequate staffing levels and determining the need for video monitoring? yes
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? yes
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 ? yes


115.13 (b) Supervision and monitoring
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


115.13 (c) Supervision and monitoring
In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined, and documented whether adjustments are needed to: The staffing plan established pursuant to paragraph (a) of this section? yes
In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined, and documented whether adjustments are needed to: The facility’s deployment of video monitoring systems and other monitoring technologies? yes
In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined, and documented whether adjustments are needed to: The resources the facility has available to commit to ensure adherence to the staffing plan? yes


115.13 (d) Supervision and monitoring
Has the facility/agency implemented a policy and practice of having intermediate-level or higher-level supervisors conduct and document unannounced rounds to identify and deter staff sexual abuse and sexual harassment? yes
Is this policy and practice implemented for night shifts as well as day shifts? yes
Does the facility/agency have a policy prohibiting staff from alerting other staff members that these supervisory rounds are occurring, unless such announcement is related to the legitimate operational functions of the facility? yes


115.14 (a) Youthful inmates
Does the facility place all youthful inmates in housing units that separate them from sight, sound, and physical contact with any adult inmates through use of a shared dayroom or other common space, shower area, or sleeping quarters? (N/A if facility does not have youthful inmates (inmates <18 years old).) na


115.14 (b) Youthful inmates
In areas outside of housing units does the agency maintain sight and sound separation between youthful inmates and adult inmates? (N/A if facility does not have youthful inmates (inmates <18 years old).) na
In areas outside of housing units does the agency provide direct staff supervision when youthful inmates and adult inmates have sight, sound, or physical contact? (N/A if facility does not have youthful inmates (inmates <18 years old).) na


115.14 (c) Youthful inmates
Does the agency make its best efforts to avoid placing youthful inmates in isolation to comply with this provision? (N/A if facility does not have youthful inmates (inmates <18 years old).) na
Does the agency, while complying with this provision, allow youthful inmates daily large-muscle exercise and legally required special education services, except in exigent circumstances? (N/A if facility does not have youthful inmates (inmates <18 years old).) na
Do youthful inmates have access to other programs and work opportunities to the extent possible? (N/A if facility does not have youthful inmates (inmates <18 years old).) na


115.15 (a) Limits to cross-gender viewing and searches
Does the facility always refrain from conducting any cross-gender strip or cross-gender visual body cavity searches, except in exigent circumstances or by medical practitioners? yes


115.15 (b) Limits to cross-gender viewing and searches
Does the facility always refrain from conducting cross-gender pat-down searches of female inmates in non-exigent circumstances? (N/A here for facilities with less than 50 inmates before August 20,2017.) yes
Does the facility always refrain from restricting female inmates’ access to regularly available programming or other out-of-cell opportunities in order to comply with this provision? (N/A here for facilities with less than 50 inmates before August 20,2017.) no


115.15 (c) Limits to cross-gender viewing and searches
Does the facility document all cross-gender strip searches and cross-gender visual body cavity searches? yes
Does the facility document all cross-gender pat-down searches of female inmates? yes


115.15 (d) Limits to cross-gender viewing and searches
Does the facility implement a policy and practice that enables inmates to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks? yes
Does the facility require staff of the opposite gender to announce their presence when entering an inmate housing unit? yes


115.15 (e) Limits to cross-gender viewing and searches
Does the facility always refrain from searching or physically examining transgender or intersex inmates for the sole purpose of determining the inmate’s genital status? yes
If an inmate’s genital status is unknown, does the facility determine genital status during conversations with the inmate, by reviewing medical records, or, if necessary, by learning that information as part of a broader medical examination conducted in private by a medical practitioner? yes


115.15 (f) Limits to cross-gender viewing and searches
Does the facility/agency train security staff in how to conduct cross-gender pat down searches in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs? yes
Does the facility/agency train security staff in how to conduct searches of transgender and intersex inmates in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs? yes


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


115.16 (b) Inmates with disabilities and inmates who are limited English proficient
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 inmates who are limited English proficient? yes
Do these steps include providing interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary? yes


115.16 (c) Inmates with disabilities and inmates who are limited English proficient
Does the agency always refrain from relying on inmate interpreters, inmate readers, or other types of inmate assistance except in limited circumstances where an extended delay in obtaining an effective interpreter could compromise the inmate’s safety, the performance of first-response duties under §115.64, or the investigation of the inmate’s allegations? yes


115.17 (a) Hiring and promotion decisions
Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates who has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? yes
Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates who has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? yes
Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates who has been civilly or administratively adjudicated to have engaged in the activity described in the two bullets immediately above? yes
Does the agency prohibit the enlistment of services of any contractor who may have contact with inmates who has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? yes
Does the agency prohibit the enlistment of services of any contractor who may have contact with inmates who has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? yes
Does the agency prohibit the enlistment of services of any contractor who may have contact with inmates who has been civilly or administratively adjudicated to have engaged in the activity described in the two bullets immediately above? yes


115.17 (b) Hiring and promotion decisions
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 inmates? yes


115.17 (c) Hiring and promotion decisions
Before hiring new employees who may have contact with inmates, does the agency: perform a criminal background records check? yes
Before hiring new employees who may have contact with inmates, does the agency: consistent with Federal, State, and local law, make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or any resignation during a pending investigation of an allegation of sexual abuse? yes


115.17 (d) Hiring and promotion decisions
Does the agency perform a criminal background records check before enlisting the services of any contractor who may have contact with inmates? yes


115.17 (e) Hiring and promotion decisions
Does the agency either conduct criminal background records checks at least every five years of current employees and contractors who may have contact with inmates or have in place a system for otherwise capturing such information for current employees? yes


115.17 (f) Hiring and promotion decisions
Does the agency ask all applicants and employees who may have contact with inmates directly about previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring or promotions? yes
Does the agency ask all applicants and employees who may have contact with inmates directly about previous misconduct described in paragraph (a) of this section in any interviews or written self-evaluations conducted as part of reviews of current employees? yes
Does the agency impose upon employees a continuing affirmative duty to disclose any such misconduct? yes


115.17 (g) Hiring and promotion decisions
Does the agency consider material omissions regarding such misconduct, or the provision of materially false information, grounds for termination? yes


115.17 (h) Hiring and promotion decisions
Does the agency provide information on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied to work? (N/A if providing information on substantiated allegations of sexual abuse or sexual harassment involving a former employee is prohibited by law.) yes


115.18 (a) Upgrades to facilities and technologies
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 inmates 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.) na


115.18 (b) Upgrades to facilities and technologies
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 inmates 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


115.21 (a) Evidence protocol and forensic medical examinations
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


115.21 (b) Evidence protocol and forensic medical examinations
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.) na
Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of the U.S. Department of Justice’s Office on Violence Against Women publication, “A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) na


115.21 (c) Evidence protocol and forensic medical examinations
Does the agency offer all victims of sexual abuse access to forensic medical examinations, whether on-site or at an outside facility, without financial cost, where evidentiarily or medically appropriate? yes
Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible? yes
If SAFEs or SANEs cannot be made available, is the examination performed by other qualified medical practitioners (they must have been specifically trained to conduct sexual assault forensic exams)? yes
Has the agency documented its efforts to provide SAFEs or SANEs? yes


115.21 (d) Evidence protocol and forensic medical examinations
Does the agency attempt to make available to the victim a victim advocate from a rape crisis center? yes
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? yes
Has the agency documented its efforts to secure services from rape crisis centers? yes


115.21 (e) Evidence protocol and forensic medical examinations
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
As requested by the victim, does this person provide emotional support, crisis intervention, information, and referrals? yes


115.21 (f) Evidence protocol and forensic medical examinations
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 (e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND administrative sexual abuse investigations.) no


115.21 (h) Evidence protocol and forensic medical examinations
If the agency uses a qualified agency staff member or a qualified community-based staff member for the purposes of this section, has the individual been screened for appropriateness to serve in this role and received education concerning sexual assault and forensic examination issues in general? (N/A if agency attempts to make a victim advocate from a rape crisis center available to victims per 115.21(d) above.) na


115.22 (a) Policies to ensure referrals of allegations for investigations
Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual abuse? yes
Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual harassment? yes


115.22 (b) Policies to ensure referrals of allegations for investigations
Does the agency have a policy and practice in place to ensure that allegations of sexual abuse or sexual harassment are referred for investigation to an agency with the legal authority to conduct criminal investigations, unless the allegation does not involve potentially criminal behavior? yes
Has the agency published such policy on its website or, if it does not have one, made the policy available through other means? yes
Does the agency document all such referrals? yes


115.22 (c) Policies to ensure referrals of allegations for investigations
If a separate entity is responsible for conducting criminal investigations, does such publication describe the responsibilities of both the agency and the investigating entity? (N/A if the agency/facility is responsible for criminal investigations. See 115.21(a).) yes


115.31 (a) Employee training
Does the agency train all employees who may have contact with inmates on its zero-tolerance policy for sexual abuse and sexual harassment? yes
Does the agency train all employees who may have contact with inmates on how to fulfill their responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures? yes
Does the agency train all employees who may have contact with inmates on inmates’ right to be free from sexual abuse and sexual harassment yes
Does the agency train all employees who may have contact with inmates on the right of inmates and employees to be free from retaliation for reporting sexual abuse and sexual harassment? yes
Does the agency train all employees who may have contact with inmates on the dynamics of sexual abuse and sexual harassment in confinement? yes
Does the agency train all employees who may have contact with inmates on the common reactions of sexual abuse and sexual harassment victims? yes
Does the agency train all employees who may have contact with inmates on how to detect and respond to signs of threatened and actual sexual abuse? yes
Does the agency train all employees who may have contact with inmates on how to avoid inappropriate relationships with inmates? yes
Does the agency train all employees who may have contact with inmates on how to communicate effectively and professionally with inmates, including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming inmates? yes
Does the agency train all employees who may have contact with inmates on how to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities? yes


115.31 (b) Employee training
Is such training tailored to the gender of the inmates at the employee’s facility? yes
Have employees received additional training if reassigned from a facility that houses only male inmates to a facility that houses only female inmates, or vice versa? no


115.31 (c) Employee training
Have all current employees who may have contact with inmates received such training? yes
Does the agency provide each employee with refresher training every two years to ensure that all employees know the agency’s current sexual abuse and sexual harassment policies and procedures? yes
In years in which an employee does not receive refresher training, does the agency provide refresher information on current sexual abuse and sexual harassment policies? yes


115.31 (d) Employee training
Does the agency document, through employee signature or electronic verification, that employees understand the training they have received? yes


115.32 (a) Volunteer and contractor training
Has the agency ensured that all volunteers and contractors who have contact with inmates have been trained on their responsibilities under the agency’s sexual abuse and sexual harassment prevention, detection, and response policies and procedures? yes


115.32 (b) Volunteer and contractor training
Have all volunteers and contractors who have contact with inmates been notified of the agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and informed how to report such incidents (the level and type of training provided to volunteers and contractors shall be based on the services they provide and level of contact they have with inmates)? yes


115.32 (c) Volunteer and contractor training
Does the agency maintain documentation confirming that volunteers and contractors understand the training they have received? no


115.33 (a) Inmate education
During intake, do inmates receive information explaining the agency’s zero-tolerance policy regarding sexual abuse and sexual harassment? yes
During intake, do inmates receive information explaining how to report incidents or suspicions of sexual abuse or sexual harassment? yes


115.33 (b) Inmate education
Within 30 days of intake, does the agency provide comprehensive education to inmates either in person or through video regarding: Their rights to be free from sexual abuse and sexual harassment? yes
Within 30 days of intake, does the agency provide comprehensive education to inmates either in person or through video regarding: Their rights to be free from retaliation for reporting such incidents? yes
Within 30 days of intake, does the agency provide comprehensive education to inmates either in person or through video regarding: Agency policies and procedures for responding to such incidents? yes


115.33 (c) Inmate education
Have all inmates received such education? yes
Do inmates receive education upon transfer to a different facility to the extent that the policies and procedures of the inmate’s new facility differ from those of the previous facility? yes


115.33 (d) Inmate education
Does the agency provide inmate education in formats accessible to all inmates including those who are limited English proficient? yes
Does the agency provide inmate education in formats accessible to all inmates including those who are deaf? yes
Does the agency provide inmate education in formats accessible to all inmates including those who are visually impaired? yes
Does the agency provide inmate education in formats accessible to all inmates including those who are otherwise disabled? yes
Does the agency provide inmate education in formats accessible to all inmates including those who have limited reading skills? yes


115.33 (e) Inmate education
Does the agency maintain documentation of inmate participation in these education sessions? yes


115.33 (f) Inmate education
In addition to providing such education, does the agency ensure that key information is continuously and readily available or visible to inmates through posters, inmate handbooks, or other written formats? yes


115.34 (a) Specialized training: Investigations
In addition to the general training provided to all employees pursuant to §115.31, does the agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its investigators have received training in conducting such investigations in confinement settings? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).) yes


115.34 (b) Specialized training: Investigations
Does this specialized training include techniques for interviewing sexual abuse victims? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).) yes
Does this specialized training include proper use of Miranda and Garrity warnings? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).) yes
Does this specialized training include sexual abuse evidence collection in confinement settings? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).) yes
Does this specialized training include the criteria and evidence required to substantiate a case for administrative action or prosecution referral? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).) yes


115.34 (c) Specialized training: Investigations
Does the agency maintain documentation that agency investigators have completed the required specialized training in conducting sexual abuse investigations? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).) yes


115.35 (a) Specialized training: Medical and mental health care
Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how to detect and assess signs of sexual abuse and sexual harassment? no
Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how to preserve physical evidence of sexual abuse? no
Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how to respond effectively and professionally to victims of sexual abuse and sexual harassment? no
Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how and to whom to report allegations or suspicions of sexual abuse and sexual harassment? no


115.35 (b) Specialized training: Medical and mental health care
If medical staff employed by the agency conduct forensic examinations, do such medical staff receive appropriate training to conduct such examinations? (N/A if agency medical staff at the facility do not conduct forensic exams.) na


115.35 (c) Specialized training: Medical and mental health care
Does the agency maintain documentation that medical and mental health practitioners have received the training referenced in this standard either from the agency or elsewhere? no


115.35 (d) Specialized training: Medical and mental health care
Do medical and mental health care practitioners employed by the agency also receive training mandated for employees by §115.31? yes
Do medical and mental health care practitioners contracted by and volunteering for the agency also receive training mandated for contractors and volunteers by §115.32? yes


115.41 (a) Screening for risk of victimization and abusiveness
Are all inmates assessed during an intake screening for their risk of being sexually abused by other inmates or sexually abusive toward other inmates? yes
Are all inmates assessed upon transfer to another facility for their risk of being sexually abused by other inmates or sexually abusive toward other inmates? yes


115.41 (b) Screening for risk of victimization and abusiveness
Do intake screenings ordinarily take place within 72 hours of arrival at the facility? yes


115.41 (c) Screening for risk of victimization and abusiveness
Are all PREA screening assessments conducted using an objective screening instrument? yes


115.41 (d) Screening for risk of victimization and abusiveness
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (1) Whether the inmate has a mental, physical, or developmental disability? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (2) The age of the inmate? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (3) The physical build of the inmate? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (4) Whether the inmate has previously been incarcerated? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (5) Whether the inmate’s criminal history is exclusively nonviolent? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (6) Whether the inmate has prior convictions for sex offenses against an adult or child? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (7) Whether the inmate is or is perceived to be gay, lesbian, bisexual, transgender, intersex, or gender nonconforming (the facility affirmatively asks the inmate about his/her sexual orientation and gender identity AND makes a subjective determination based on the screener’s perception whether the inmate is gender non-conforming or otherwise may be perceived to be LGBTI)? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (8) Whether the inmate has previously experienced sexual victimization? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (9) The inmate’s own perception of vulnerability? yes
Does the intake screening consider, at a minimum, the following criteria to assess inmates for risk of sexual victimization: (10) Whether the inmate is detained solely for civil immigration purposes? yes


115.41 (e) Screening for risk of victimization and abusiveness
In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening consider, when known to the agency: prior acts of sexual abuse? yes
In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening consider, when known to the agency: prior convictions for violent offenses? yes
In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening consider, when known to the agency: history of prior institutional violence or sexual abuse? yes


115.41 (f) Screening for risk of victimization and abusiveness
Within a set time period not more than 30 days from the inmate’s arrival at the facility, does the facility reassess the inmate’s risk of victimization or abusiveness based upon any additional, relevant information received by the facility since the intake screening? yes


115.41 (g) Screening for risk of victimization and abusiveness
Does the facility reassess an inmate’s risk level when warranted due to a: Referral? yes
Does the facility reassess an inmate’s risk level when warranted due to a: Request? yes
Does the facility reassess an inmate’s risk level when warranted due to a: Incident of sexual abuse? yes
Does the facility reassess an inmate’s risk level when warranted due to a: Receipt of additional information that bears on the inmate’s risk of sexual victimization or abusiveness? yes


115.41 (h) Screening for risk of victimization and abusiveness
Is it the case that inmates are not ever disciplined for refusing to answer, or for not disclosing complete information in response to, questions asked pursuant to paragraphs (d)(1), (d)(7), (d)(8), or (d)(9) of this section? yes


115.41 (i) Screening for risk of victimization and abusiveness
Has the agency implemented appropriate controls on the dissemination within the facility of responses to questions asked pursuant to this standard in order to ensure that sensitive information is not exploited to the inmate’s detriment by staff or other inmates? yes


115.42 (a) Use of screening information
Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Housing Assignments? yes
Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Bed assignments? yes
Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Work Assignments? yes
Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Education Assignments? yes
Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Program Assignments? yes


115.42 (b) Use of screening information
Does the agency make individualized determinations about how to ensure the safety of each inmate? yes


115.42 (c) Use of screening information
When deciding whether to assign a transgender or intersex inmate to a facility for male or female inmates, does the agency consider on a case-by-case basis whether a placement would ensure the inmate’s health and safety, and whether a placement would present management or security problems (NOTE: if an agency by policy or practice assigns inmates to a male or female facility on the basis of anatomy alone, that agency is not in compliance with this standard)? yes
When making housing or other program assignments for transgender or intersex inmates, does the agency consider on a case-by-case basis whether a placement would ensure the inmate’s health and safety, and whether a placement would present management or security problems? yes


115.42 (d) Use of screening information
Are placement and programming assignments for each transgender or intersex inmate reassessed at least twice each year to review any threats to safety experienced by the inmate? yes


115.42 (e) Use of screening information
Are each transgender or intersex inmate’s own views with respect to his or her own safety given serious consideration when making facility and housing placement decisions and programming assignments? yes


115.42 (f) Use of screening information
Are transgender and intersex inmates given the opportunity to shower separately from other inmates? yes


115.42 (g) Use of screening information
Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex inmates, does the agency always refrain from placing: lesbian, gay, and bisexual inmates in dedicated facilities, units, or wings solely on the basis of such identification or status? yes
Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex inmates, does the agency always refrain from placing: transgender inmates in dedicated facilities, units, or wings solely on the basis of such identification or status? yes
Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex inmates, does the agency always refrain from placing: intersex inmates in dedicated facilities, units, or wings solely on the basis of such identification or status? yes


115.43 (a) Protective Custody
Does the facility always refrain from placing inmates at high risk for sexual victimization in involuntary segregated housing unless an assessment of all available alternatives has been made, and a determination has been made that there is no available alternative means of separation from likely abusers? yes
If a facility cannot conduct such an assessment immediately, does the facility hold the inmate in involuntary segregated housing for less than 24 hours while completing the assessment? yes


115.43 (b) Protective Custody
Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Programs to the extent possible? yes
Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Privileges to the extent possible? yes
Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Education to the extent possible? yes
Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Work opportunities to the extent possible? yes
If the facility restricts access to programs, privileges, education, or work opportunities, does the facility document: The opportunities that have been limited? yes
If the facility restricts access to programs, privileges, education, or work opportunities, does the facility document: The duration of the limitation? yes
If the facility restricts access to programs, privileges, education, or work opportunities, does the facility document: The reasons for such limitations? yes


115.43 (c) Protective Custody
Does the facility assign inmates at high risk of sexual victimization to involuntary segregated housing only until an alternative means of separation from likely abusers can be arranged? yes
Does such an assignment not ordinarily exceed a period of 30 days? yes


115.43 (d) Protective Custody
If an involuntary segregated housing assignment is made pursuant to paragraph (a) of this section, does the facility clearly document: The basis for the facility’s concern for the inmate’s safety? yes
If an involuntary segregated housing assignment is made pursuant to paragraph (a) of this section, does the facility clearly document: The reason why no alternative means of separation can be arranged? yes


115.43 (e) Protective Custody
In the case of each inmate who is placed in involuntary segregation because he/she is at high risk of sexual victimization, does the facility afford a review to determine whether there is a continuing need for separation from the general population EVERY 30 DAYS? yes


115.51 (a) Inmate reporting
Does the agency provide multiple internal ways for inmates to privately report: Sexual abuse and sexual harassment? yes
Does the agency provide multiple internal ways for inmates to privately report: Retaliation by other inmates or staff for reporting sexual abuse and sexual harassment? yes
Does the agency provide multiple internal ways for inmates to privately report: Staff neglect or violation of responsibilities that may have contributed to such incidents? yes


115.51 (b) Inmate reporting
Does the agency also provide at least one way for inmates to report sexual abuse or sexual harassment to a public or private entity or office that is not part of the agency? yes
Is that private entity or office able to receive and immediately forward inmate reports of sexual abuse and sexual harassment to agency officials? yes
Does that private entity or office allow the inmate to remain anonymous upon request? yes
Are inmates detained solely for civil immigration purposes provided information on how to contact relevant consular officials and relevant officials at the Department of Homeland Security? yes


115.51 (c) Inmate reporting
Does staff accept reports of sexual abuse and sexual harassment made verbally, in writing, anonymously, and from third parties? yes
Does staff promptly document any verbal reports of sexual abuse and sexual harassment? yes


115.51 (d) Inmate reporting
Does the agency provide a method for staff to privately report sexual abuse and sexual harassment of inmates? yes


115.52 (a) Exhaustion of administrative remedies
Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not have administrative procedures to address inmate grievances regarding sexual abuse. This does not mean the agency is exempt simply because an inmate does not have to or is not ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of explicit policy, the agency does not have an administrative remedies process to address sexual abuse. no


115.52 (b) Exhaustion of administrative remedies
Does the agency permit inmates to submit a grievance regarding an allegation of sexual abuse without any type of time limits? (The agency may apply otherwise-applicable time limits to any portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is exempt from this standard.) yes
Does the agency always refrain from requiring an inmate to use any informal grievance process, or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency is exempt from this standard.) yes


115.52 (c) Exhaustion of administrative remedies
Does the agency ensure that: An inmate who alleges sexual abuse may submit a grievance without submitting it to a staff member who is the subject of the complaint? (N/A if agency is exempt from this standard.) yes
Does the agency ensure that: Such grievance is not referred to a staff member who is the subject of the complaint? (N/A if agency is exempt from this standard.) yes


115.52 (d) Exhaustion of administrative remedies
Does the agency issue a final agency decision on the merits of any portion of a grievance alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the 90-day time period does not include time consumed by inmates in preparing any administrative appeal.) (N/A if agency is exempt from this standard.) yes
If the agency claims the maximum allowable extension of time to respond of up to 70 days per 115.52(d)(3) when the normal time period for response is insufficient to make an appropriate decision, does the agency notify the inmate in writing of any such extension and provide a date by which a decision will be made? (N/A if agency is exempt from this standard.) yes
At any level of the administrative process, including the final level, if the inmate does not receive a response within the time allotted for reply, including any properly noticed extension, may an inmate consider the absence of a response to be a denial at that level? (N/A if agency is exempt from this standard.) yes


115.52 (e) Exhaustion of administrative remedies
Are third parties, including fellow inmates, staff members, family members, attorneys, and outside advocates, permitted to assist inmates in filing requests for administrative remedies relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.) yes
Are those third parties also permitted to file such requests on behalf of inmates? (If a third party files such a request on behalf of an inmate, the facility may require as a condition of processing the request that the alleged victim agree to have the request filed on his or her behalf, and may also require the alleged victim to personally pursue any subsequent steps in the administrative remedy process.) (N/A if agency is exempt from this standard.) yes
If the inmate declines to have the request processed on his or her behalf, does the agency document the inmate’s decision? (N/A if agency is exempt from this standard.) yes


115.52 (f) Exhaustion of administrative remedies
Has the agency established procedures for the filing of an emergency grievance alleging that an inmate is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from this standard.) yes
After receiving an emergency grievance alleging an inmate is subject to a substantial risk of imminent sexual abuse, does the agency immediately forward the grievance (or any portion thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which immediate corrective action may be taken? (N/A if agency is exempt from this standard.). yes
After receiving an emergency grievance described above, does the agency provide an initial response within 48 hours? (N/A if agency is exempt from this standard.) yes
After receiving an emergency grievance described above, does the agency issue a final agency decision within 5 calendar days? (N/A if agency is exempt from this standard.) yes
Does the initial response and final agency decision document the agency’s determination whether the inmate is in substantial risk of imminent sexual abuse? (N/A if agency is exempt from this standard.) yes
Does the initial response document the agency’s action(s) taken in response to the emergency grievance? (N/A if agency is exempt from this standard.) yes
Does the agency’s final decision document the agency’s action(s) taken in response to the emergency grievance? (N/A if agency is exempt from this standard.) yes


115.52 (g) Exhaustion of administrative remedies
If the agency disciplines an inmate for filing a grievance related to alleged sexual abuse, does it do so ONLY where the agency demonstrates that the inmate filed the grievance in bad faith? (N/A if agency is exempt from this standard.) yes


115.53 (a) Inmate access to outside confidential support services
Does the facility provide inmates with access to outside victim advocates for emotional support services related to sexual abuse by giving inmates mailing addresses and telephone numbers, including toll-free hotline numbers where available, of local, State, or national victim advocacy or rape crisis organizations? yes
Does the facility provide persons detained solely for civil immigration purposes mailing addresses and telephone numbers, including toll-free hotline numbers where available of local, State, or national immigrant services agencies? yes
Does the facility enable reasonable communication between inmates and these organizations and agencies, in as confidential a manner as possible? yes


115.53 (b) Inmate access to outside confidential support services
Does the facility inform inmates, prior to giving them access, of the extent to which such communications will be monitored and the extent to which reports of abuse will be forwarded to authorities in accordance with mandatory reporting laws? yes


115.53 (c) Inmate access to outside confidential support services
Does the agency maintain or attempt to enter into memoranda of understanding or other agreements with community service providers that are able to provide inmates with confidential emotional support services related to sexual abuse? yes
Does the agency maintain copies of agreements or documentation showing attempts to enter into such agreements? yes


115.54 (a) Third-party reporting
Has the agency established a method to receive third-party reports of sexual abuse and sexual harassment? yes
Has the agency distributed publicly information on how to report sexual abuse and sexual harassment on behalf of an inmate? yes


115.61 (a) Staff and agency reporting duties
Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding an incident of sexual abuse or sexual harassment that occurred in a facility, whether or not it is part of the agency? yes
Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding retaliation against inmates or staff who reported an incident of sexual abuse or sexual harassment? yes
Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities that may have contributed to an incident of sexual abuse or sexual harassment or retaliation? yes


115.61 (b) Staff and agency reporting duties
Apart from reporting to designated supervisors or officials, does staff always refrain from revealing any information related to a sexual abuse report to anyone other than to the extent necessary, as specified in agency policy, to make treatment, investigation, and other security and management decisions? yes


115.61 (c) Staff and agency reporting duties
Unless otherwise precluded by Federal, State, or local law, are medical and mental health practitioners required to report sexual abuse pursuant to paragraph (a) of this section? yes
Are medical and mental health practitioners required to inform inmates of the practitioner’s duty to report, and the limitations of confidentiality, at the initiation of services? yes


115.61 (d) Staff and agency reporting duties
If the alleged victim is under the age of 18 or considered a vulnerable adult under a State or local vulnerable persons statute, does the agency report the allegation to the designated State or local services agency under applicable mandatory reporting laws? yes


115.61 (e) Staff and agency reporting duties
Does the facility report all allegations of sexual abuse and sexual harassment, including third-party and anonymous reports, to the facility’s designated investigators? yes


115.62 (a) Agency protection duties
When the agency learns that an inmate is subject to a substantial risk of imminent sexual abuse, does it take immediate action to protect the inmate? yes


115.63 (a) Reporting to other confinement facilities
Upon receiving an allegation that an inmate was sexually abused while confined at another facility, does the head of the facility that received the allegation notify the head of the facility or appropriate office of the agency where the alleged abuse occurred? yes


115.63 (b) Reporting to other confinement facilities
Is such notification provided as soon as possible, but no later than 72 hours after receiving the allegation? yes


115.63 (c) Reporting to other confinement facilities
Does the agency document that it has provided such notification? yes


115.63 (d) Reporting to other confinement facilities
Does the facility head or agency office that receives such notification ensure that the allegation is investigated in accordance with these standards? yes


115.64 (a) Staff first responder duties
Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Separate the alleged victim and abuser? yes
Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence? yes
Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Request that the alleged victim not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred within a time period that still allows for the collection of physical evidence? yes
Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Ensure that the alleged abuser does not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred within a time period that still allows for the collection of physical evidence? yes


115.64 (b) Staff first responder duties
If the first staff responder is not a security staff member, is the responder required to request that the alleged victim not take any actions that could destroy physical evidence, and then notify security staff? yes


115.65 (a) Coordinated response
Has the facility developed a written institutional plan to coordinate actions among staff first responders, medical and mental health practitioners, investigators, and facility leadership taken in response to an incident of sexual abuse? yes


115.66 (a) Preservation of ability to protect inmates from contact with abusers
Are both the agency and any other governmental entities responsible for collective bargaining on the agency’s behalf prohibited from entering into or renewing any collective bargaining agreement or other agreement that limit the agency’s ability to remove alleged staff sexual abusers from contact with any inmates pending the outcome of an investigation or of a determination of whether and to what extent discipline is warranted? yes


115.67 (a) Agency protection against retaliation
Has the agency established a policy to protect all inmates and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other inmates or staff? yes
Has the agency designated which staff members or departments are charged with monitoring retaliation? yes


115.67 (b) Agency protection against retaliation
Does the agency employ multiple protection measures, such as housing changes or transfers for inmate victims or abusers, removal of alleged staff or inmate abusers from contact with victims, and emotional support services for inmates or staff who fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with investigations? yes


115.67 (c) Agency protection against retaliation
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct and treatment of residents or staff who reported the sexual abuse to see if there are changes that may suggest possible retaliation by inmates or staff? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct and treatment of inmates who were reported to have suffered sexual abuse to see if there are changes that may suggest possible retaliation by inmates or staff? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy any such retaliation? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor any inmate disciplinary reports? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor inmate housing changes? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor inmate program changes? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor negative performance reviews of staff? yes
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor reassignments of staff? yes
Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a continuing need? yes


115.67 (d) Agency protection against retaliation
In the case of inmates, does such monitoring also include periodic status checks? yes


115.67 (e) Agency protection against retaliation
If any other individual who cooperates with an investigation expresses a fear of retaliation, does the agency take appropriate measures to protect that individual against retaliation? yes


115.68 (a) Post-allegation protective custody
Is any and all use of segregated housing to protect an inmate who is alleged to have suffered sexual abuse subject to the requirements of § 115.43? yes


115.71 (a) Criminal and administrative agency investigations
When the agency conducts its own investigations into allegations of sexual abuse and sexual harassment, does it do so promptly, thoroughly, and objectively? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations. See 115.21(a).) yes
Does the agency conduct such investigations for all allegations, including third party and anonymous reports? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations. See 115.21(a).) yes


115.71 (b) Criminal and administrative agency investigations
Where sexual abuse is alleged, does the agency use investigators who have received specialized training in sexual abuse investigations as required by 115.34? no


115.71 (c) Criminal and administrative agency investigations
Do investigators gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data? yes
Do investigators interview alleged victims, suspected perpetrators, and witnesses? yes
Do investigators review prior reports and complaints of sexual abuse involving the suspected perpetrator? yes


115.71 (d) Criminal and administrative agency investigations
When the quality of evidence appears to support criminal prosecution, does the agency conduct compelled interviews only after consulting with prosecutors as to whether compelled interviews may be an obstacle for subsequent criminal prosecution? yes


115.71 (e) Criminal and administrative agency investigations
Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an individual basis and not on the basis of that individual’s status as inmate or staff? yes
Does the agency investigate allegations of sexual abuse without requiring an inmate who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a condition for proceeding? yes


115.71 (f) Criminal and administrative agency investigations
Do administrative investigations include an effort to determine whether staff actions or failures to act contributed to the abuse? yes
Are administrative investigations documented in written reports that include a description of the physical evidence and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings? yes


115.71 (g) Criminal and administrative agency investigations
Are criminal investigations documented in a written report that contains a thorough description of the physical, testimonial, and documentary evidence and attaches copies of all documentary evidence where feasible? yes


115.71 (h) Criminal and administrative agency investigations
Are all substantiated allegations of conduct that appears to be criminal referred for prosecution? yes


115.71 (i) Criminal and administrative agency investigations
Does the agency retain all written reports referenced in 115.71(f) and (g) for as long as the alleged abuser is incarcerated or employed by the agency, plus five years? yes


115.71 (j) Criminal and administrative agency investigations
Does the agency ensure that the departure of an alleged abuser or victim from the employment or control of the agency does not provide a basis for terminating an investigation? yes


115.71 (l) Criminal and administrative agency investigations
When an outside entity investigates sexual abuse, does the facility cooperate with outside investigators and endeavor to remain informed about the progress of the investigation? (N/A if an outside agency does not conduct administrative or criminal sexual abuse investigations. See 115.21(a).) yes


115.72 (a) Evidentiary standard for administrative investigations
Is it true that the agency does not impose a standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated? yes


115.73 (a) Reporting to inmates
Following an investigation into an inmate’s allegation that he or she suffered sexual abuse in an agency facility, does the agency inform the inmate as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded? yes


115.73 (b) Reporting to inmates
If the agency did not conduct the investigation into an inmate’s allegation of sexual abuse in an agency facility, does the agency request the relevant information from the investigative agency in order to inform the inmate? (N/A if the agency/facility is responsible for conducting administrative and criminal investigations.) yes


115.73 (c) Reporting to inmates
Following a inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The staff member is no longer posted within the inmate’s unit? yes
Following a inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The staff member is no longer employed at the facility? yes
Following a inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The agency learns that the staff member has been indicted on a charge related to sexual abuse in the facility? yes
Following a inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The agency learns that the staff member has been convicted on a charge related to sexual abuse within the facility? yes


115.73 (d) Reporting to inmates
Following an inmate’s allegation that he or she has been sexually abused by another inmate, does the agency subsequently inform the alleged victim whenever: The agency learns that the alleged abuser has been indicted on a charge related to sexual abuse within the facility? yes
Following an inmate’s allegation that he or she has been sexually abused by another inmate, does the agency subsequently inform the alleged victim whenever: The agency learns that the alleged abuser has been convicted on a charge related to sexual abuse within the facility? yes


115.73 (e) Reporting to inmates
Does the agency document all such notifications or attempted notifications? yes


115.76 (a) Disciplinary sanctions for staff
Are staff subject to disciplinary sanctions up to and including termination for violating agency sexual abuse or sexual harassment policies? yes


115.76 (b) Disciplinary sanctions for staff
Is termination the presumptive disciplinary sanction for staff who have engaged in sexual abuse? yes


115.76 (c) Disciplinary sanctions for staff
Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) commensurate with the nature and circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories? yes


115.76 (d) Disciplinary sanctions for staff
Are all terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, reported to: Law enforcement agencies(unless the activity was clearly not criminal)? yes
Are all terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, reported to: Relevant licensing bodies? yes


115.77 (a) Corrective action for contractors and volunteers
Is any contractor or volunteer who engages in sexual abuse prohibited from contact with inmates? yes
Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement agencies (unless the activity was clearly not criminal)? yes
Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing bodies? yes


115.77 (b) Corrective action for contractors and volunteers
In the case of any other violation of agency sexual abuse or sexual harassment policies by a contractor or volunteer, does the facility take appropriate remedial measures, and consider whether to prohibit further contact with inmates? yes


115.78 (a) Disciplinary sanctions for inmates
Following an administrative finding that an inmate engaged in inmate-on-inmate sexual abuse, or following a criminal finding of guilt for inmate-on-inmate sexual abuse, are inmates subject to disciplinary sanctions pursuant to a formal disciplinary process? yes


115.78 (b) Disciplinary sanctions for inmates
Are sanctions commensurate with the nature and circumstances of the abuse committed, the inmate’s disciplinary history, and the sanctions imposed for comparable offenses by other inmates with similar histories? yes


115.78 (c) Disciplinary sanctions for inmates
When determining what types of sanction, if any, should be imposed, does the disciplinary process consider whether an inmate’s mental disabilities or mental illness contributed to his or her behavior? yes


115.78 (d) Disciplinary sanctions for inmates
If the facility offers therapy, counseling, or other interventions designed to address and correct underlying reasons or motivations for the abuse, does the facility consider whether to require the offending inmate to participate in such interventions as a condition of access to programming and other benefits? yes


115.78 (e) Disciplinary sanctions for inmates
Does the agency discipline an inmate for sexual contact with staff only upon a finding that the staff member did not consent to such contact? yes


115.78 (f) Disciplinary sanctions for inmates
For the purpose of disciplinary action does a report of sexual abuse made in good faith based upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an incident or lying, even if an investigation does not establish evidence sufficient to substantiate the allegation? yes


115.78 (g) Disciplinary sanctions for inmates
Does the agency always refrain from considering non-coercive sexual activity between inmates to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between inmates.) yes


115.81 (a) Medical and mental health screenings; history of sexual abuse
If the screening pursuant to § 115.41 indicates that a prison inmate has experienced prior sexual victimization, whether it occurred in an institutional setting or in the community, do staff ensure that the inmate is offered a follow-up meeting with a medical or mental health practitioner within 14 days of the intake screening? yes


115.81 (b) Medical and mental health screenings; history of sexual abuse
If the screening pursuant to § 115.41 indicates that a prison inmate has previously perpetrated sexual abuse, whether it occurred in an institutional setting or in the community, do staff ensure that the inmate is offered a follow-up meeting with a mental health practitioner within 14 days of the intake screening? (N/A if the facility is not a prison.) yes


115.81 (c) Medical and mental health screenings; history of sexual abuse
If the screening pursuant to § 115.41 indicates that a jail inmate has experienced prior sexual victimization, whether it occurred in an institutional setting or in the community, do staff ensure that the inmate is offered a follow-up meeting with a medical or mental health practitioner within 14 days of the intake screening? yes


115.81 (d) Medical and mental health screenings; history of sexual abuse
Is any information related to sexual victimization or abusiveness that occurred in an institutional setting strictly limited to medical and mental health practitioners and other staff as necessary to inform treatment plans and security management decisions, including housing, bed, work, education, and program assignments, or as otherwise required by Federal, State, or local law? yes


115.81 (e) Medical and mental health screenings; history of sexual abuse
Do medical and mental health practitioners obtain informed consent from inmates before reporting information about prior sexual victimization that did not occur in an institutional setting, unless the inmate is under the age of 18? yes


115.82 (a) Access to emergency medical and mental health services
Do inmate victims of sexual abuse receive timely, unimpeded access to emergency medical treatment and crisis intervention services, the nature and scope of which are determined by medical and mental health practitioners according to their professional judgment? yes


115.82 (b) Access to emergency medical and mental health services
If no qualified medical or mental health practitioners are on duty at the time a report of recent sexual abuse is made, do security staff first responders take preliminary steps to protect the victim pursuant to § 115.62? yes
Do security staff first responders immediately notify the appropriate medical and mental health practitioners? yes


115.82 (c) Access to emergency medical and mental health services
Are inmate victims of sexual abuse offered timely information about and timely access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with professionally accepted standards of care, where medically appropriate? yes


115.82 (d) Access to emergency medical and mental health services
Are treatment services provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident? yes


115.83 (a) Ongoing medical and mental health care for sexual abuse victims and abusers
Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all inmates who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility? yes


115.83 (b) Ongoing medical and mental health care for sexual abuse victims and abusers
Does the evaluation and treatment of such victims include, as appropriate, follow-up services, treatment plans, and, when necessary, referrals for continued care following their transfer to, or placement in, other facilities, or their release from custody? yes


115.83 (c) Ongoing medical and mental health care for sexual abuse victims and abusers
Does the facility provide such victims with medical and mental health services consistent with the community level of care? yes


115.83 (d) Ongoing medical and mental health care for sexual abuse victims and abusers
Are inmate victims of sexually abusive vaginal penetration while incarcerated offered pregnancy tests? (N/A if all-male facility.) yes


115.83 (e) Ongoing medical and mental health care for sexual abuse victims and abusers
If pregnancy results from the conduct described in paragraph § 115.83(d), do such victims receive timely and comprehensive information about and timely access to all lawful pregnancy-related medical services? (N/A if all-male facility.) yes


115.83 (f) Ongoing medical and mental health care for sexual abuse victims and abusers
Are inmate victims of sexual abuse while incarcerated offered tests for sexually transmitted infections as medically appropriate? yes


115.83 (g) Ongoing medical and mental health care for sexual abuse victims and abusers
Are treatment services provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident? yes


115.83 (h) Ongoing medical and mental health care for sexual abuse victims and abusers
If the facility is a prison, does it attempt to conduct a mental health evaluation of all known inmate-on-inmate abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate by mental health practitioners? (NA if the facility is a jail.) na


115.86 (a) Sexual abuse incident reviews
Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse investigation, including where the allegation has not been substantiated, unless the allegation has been determined to be unfounded? yes


115.86 (b) Sexual abuse incident reviews
Does such review ordinarily occur within 30 days of the conclusion of the investigation? yes


115.86 (c) Sexual abuse incident reviews
Does the review team include upper-level management officials, with input from line supervisors, investigators, and medical or mental health practitioners? yes


115.86 (d) Sexual abuse incident reviews
Does the review team: Consider whether the allegation or investigation indicates a need to change policy or practice to better prevent, detect, or respond to sexual abuse? yes
Does the review team: Consider whether the incident or allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; gang affiliation; or other group dynamics at the facility? yes
Does the review team: Examine the area in the facility where the incident allegedly occurred to assess whether physical barriers in the area may enable abuse? yes
Does the review team: Assess the adequacy of staffing levels in that area during different shifts? yes
Does the review team: Assess whether monitoring technology should be deployed or augmented to supplement supervision by staff? yes
Does the review team: Prepare a report of its findings, including but not necessarily limited to determinations made pursuant to §§ 115.86(d)(1)-(d)(5), and any recommendations for improvement and submit such report to the facility head and PREA compliance manager? yes


115.86 (e) Sexual abuse incident reviews
Does the facility implement the recommendations for improvement, or document its reasons for not doing so? yes


115.87 (a) Data collection
Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities under its direct control using a standardized instrument and set of definitions? yes


115.87 (b) Data collection
Does the agency aggregate the incident-based sexual abuse data at least annually? yes


115.87 (c) Data collection
Does the incident-based data include, at a minimum, the data necessary to answer all questions from the most recent version of the Survey of Sexual Violence conducted by the Department of Justice? yes


115.87 (d) Data collection
Does the agency maintain, review, and collect data as needed from all available incident-based documents, including reports, investigation files, and sexual abuse incident reviews? yes


115.87 (e) Data collection
Does the agency also obtain incident-based and aggregated data from every private facility with which it contracts for the confinement of its inmates? (N/A if agency does not contract for the confinement of its inmates.) na


115.87 (f) Data collection
Does the agency, upon request, provide all such data from the previous calendar year to the Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.) na


115.88 (a) Data review for corrective action
Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Identifying problem areas? yes
Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Taking corrective action on an ongoing basis? yes
Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Preparing an annual report of its findings and corrective actions for each facility, as well as the agency as a whole? yes


115.88 (b) Data review for corrective action
Does the agency’s annual report include a comparison of the current year’s data and corrective actions with those from prior years and provide an assessment of the agency’s progress in addressing sexual abuse? no


115.88 (c) Data review for corrective action
Is the agency’s annual report approved by the agency head and made readily available to the public through its website or, if it does not have one, through other means? yes


115.88 (d) Data review for corrective action
Does the agency indicate the nature of the material redacted where it redacts specific material from the reports when publication would present a clear and specific threat to the safety and security of a facility? yes


115.89 (a) Data storage, publication, and destruction
Does the agency ensure that data collected pursuant to § 115.87 are securely retained? yes


115.89 (b) Data storage, publication, and destruction
Does the agency make all aggregated sexual abuse data, from facilities under its direct control and private facilities with which it contracts, readily available to the public at least annually through its website or, if it does not have one, through other means? yes


115.89 (c) Data storage, publication, and destruction
Does the agency remove all personal identifiers before making aggregated sexual abuse data publicly available? yes


115.89 (d) Data storage, publication, and destruction
Does the agency maintain sexual abuse data collected pursuant to § 115.87 for at least 10 years after the date of the initial collection, unless Federal, State, or local law requires otherwise? yes


115.401 (a) Frequency and scope of audits
During the three-year period starting on August 20, 2013, and during each three-year period thereafter, did the agency ensure that each facility operated by the agency, or by a private organization on behalf of the agency, was audited at least once.? (N/A before August 20, 2016.) no


115.401 (b) Frequency and scope of audits
During each one-year period starting on August 20, 2013, did the agency ensure that at least one-third of each facility type operated by the agency, or by a private organization on behalf of the agency, was audited? no


115.401 (h) Frequency and scope of audits
Did the auditor have access to, and the ability to observe, all areas of the audited facility? yes


115.401 (i) Frequency and scope of audits
Was the auditor permitted to request and receive copies of any relevant documents (including electronically stored information)? yes


115.401 (m) Frequency and scope of audits
Was the auditor permitted to conduct private interviews with inmates, residents, and detainees? yes


115.401 (n) Frequency and scope of audits
Were inmates permitted to send confidential information or correspondence to the auditor in the same manner as if they were communicating with legal counsel? yes


115.403 (f) Audit contents and findings
The agency has published on its agency website, if it has one, or has otherwise made publicly available, all Final Audit Reports within 90 days of issuance by auditor. The review period is for prior audits completed during the past three years PRECEDING THIS AGENCY AUDIT. In the case of single facility agencies, the auditor shall ensure that the facility’s last audit report was published. The pendency of any agency appeal pursuant to 28 C.F.R. § 115.405 does not excuse noncompliance with this provision. (N/A if there have been no Final Audit Reports issued in the past three years, or in the case of single facility agencies that there has never been a Final Audit Report issued.) na