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Compliance
HIPAA
 
Privacy Statement
 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This policy also describes how THE BRIDGE may use other information about you. Please review it carefully.

 

Who We Are: This Notice describes the privacy practices of THE BRIDGE, their employees (including counselors, nurses, and treatment aides), and other individuals that work at THE BRIDGE. (THE BRIDGE refers to the THE BRIDGE's residential substance abuse treatment centers, intensive outpatient centers, counselor offices, and other facilities.)

  1.   Our Privacy Obligations: Certain laws require THE BRIDGE to maintain the privacy of medical
      and health information about you ("Protected Health Information") and to provide you with this
      Notice of our legal duties and privacy practices with respect to Protected Health Information.
      When we use or disclose Protected Health Information, we are required to abide by the terms
      of this Notice (or other notice in effect at the time of the use or disclosure).
  2.   Uses and Disclosures with Your Consent or Your Authorization

                         A.  Use and Disclosure With Your Consent. As a condition of treatment, except in an emergency or other special circumstances, we will ask you to read and sign a written consent ("Your Consent") to our use and disclosure of Protected Health Information for purposes of treatment provided to you, obtaining payment for services provided to you, and for our health care operations (e.g., internal administration, quality improvement, and customer service), as detailed below:

                            §    Treatment. We use and disclose Protected Health Information to provide treatment and
      other services to you; for example, to diagnose and treat your injury or illness. In addition,
      we may contact you to provide appointment reminders or information about treatment
      alternatives or other health-related benefits and services that may be of interest to you.

                            §    Payment. We may use and disclose Protected Health Information to obtain payment for 
     services that we provide to you at a BRIDGE facility. For example, we may use or disclose
     Protected Health Information to claim and obtain payment from your health insurer, HMO,
     or other company that arranges or pays the cost of some or all of your health care ("Your
     Payer"), and to verify that Your Payer will pay for health care.

                           §    Health Care Operations. At THE BRIDGE, we use and disclose Protected Health
     Information for our health care operations, which include internal administration and
     planning and various activities that improve the quality and cost effectiveness of the care
     that we deliver to you.   

                        B.   Use or Disclosure with Your Authorization. As described above, Your Consent only permits us to use Protected Health Information for purposes of treatment, payment, and our health care operations. We may use or disclose Protected Health Information for any reason other than treatment, payment, and health care operations only when (1) you give us your authorization on our authorization form ("Your Authorization") or (2) there is an exception described in Section IV below.

  1.   Uses and Disclosures Without Your Consent or Your Authorization

                         A.Use or Disclosure For Treatment, Payment, and Health Care Operations Without Your Consent or Your Authorization. At THE BRIDGE, we may use or disclose Protected Health Information for purposes of treatment, obtaining payment, and our health care operations without Your Consent or Your Authorization under the following three circumstances: (1) when you require emergency treatment; (2) when we are required by law to treat you and we attempt to obtain Your Consent, but are unable to obtain it; and (3) when we attempt to obtain Your Consent but are unable to obtain it due to substantial barriers to communicating with you (e.g., you are unconscious or otherwise incapacitated) and we reasonably infer that you would have consented in the absence of the barriers.

                        B. Disclosure to Relatives and Close Friends. When you are present in a BRIDGE facility and are capable of communicating, we may use or disclose Protected Health Information to a family member, other relative, a close personal friend, or to any other person identified by you, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative, or a close personal friend, we would disclose only information that is directly relevant to the person's involvement with your health care.

                        C. Fundraising Communications. We may contact you to request a tax deductible contribution to support important activities of THE BRIDGE. In connection with any fundraising, we may disclose to our fundraising staff demographic information about you (e.g., your name, address, and phone number) and dates of health care that we provided to you.

                        D. Marketing Communications. We may use or disclose Protected Health Information to identify health-related services and products that may be beneficial to your health and then contact you about the services and products. 

                        E. Public Health Activities. We may disclose Protected Health Information for the following public health activities and purposes: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability, as required by law and public health concerns; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk to contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work related illnesses and injuries or workplace medical surveillance.

                        F.  Victims of Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information without Your Consent or Authorization to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

                        G.  Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid.

                        H.  Judicial and Administrative Proceedings. We may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

                        I. Law Enforcement Officials. We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

                        J. Health or Safety. We may disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person's or the public's health or safety.

                        K. Specialized Government Functions. We may disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State.

                        L. Decedents. We may disclose Protected Health Information to a coroner or medical examiner as authorized by law.

                        M. Organ and Tissue Procurement. We may disclose Protected Health Information to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.

                        N. Research. We may use or disclose Protected Health Information without your consent or authorization if our Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure.

                       O.  Workers' Compensation. We may disclose Protected Health Information as necessary to comply with workers' compensation laws.

  1. Your Individual Rights

1.       For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to Protected Health Information, you may contact our Privacy Officer. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with the Director or us.

2.       Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment, and health care operations, (2) to individuals (such as a family member, other relative, close personal friend, or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.

3.       Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations.

4.       Right to Inspect and Copy Your Health Information. You may request access to your medical record file, as well as your enrollment, payment, claims adjudication, case, medical management records, and your billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you request a copy or copies of your record, you will be charged a cost-based fee for each copy.

5.       Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file, enrollment, payment, claims adjudication, case, medical management records, or billing records. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

6.       Right to Receive Paper Copy of This Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

  1. Effective Date and Duration of This Notice

1.       Effective Date. This Notice describes the privacy policy of THE BRIDGE that will become effective on or before April 14, 2003, the date that federal law specifies for these protections of Protected Health Information. Prior to the effective date, THE BRIDGE will continue to protect your Protected Health Information as required by other applicable laws, regulations, and policies.

2.       Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around THE BRIDGE Facilities, and on our Internet site at http://www.bridgeinc.org. You also may obtain any new notice by contacting the Privacy Officer.

  1. Privacy Officer
You may contact the Privacy Officer at:

Privacy Officer The Bridge, Inc.,
3232 Lay Springs Road, Gadsden, AL 35904
E-mail: compliance@bridgeinc.org

Prison Rape Elimination Act (PREA)

WHAT IS PREA

  • PREA addresses the detection, elimination and prevention of sexual
    assault in DYS facilities throughout Alabama.
  • PREA directs the collection and dissemination of information on the incidence of juvenile on juvenile sexual violence as well as staff sexual misconduct with juveniles in Alabama Department of Youth Services (ADYS) custody, or private providers contracting with ADYS, such as The Bridge.
Does PREA apply to The Bridge?
Yes, PREA applies to all Bridge residential programs contracted with the Alabama Department of Youth Services.


What is the evidence of The Bridge commitment to maintain a safe environment for juveniles?
The Bridge is committed to providing a safe environment for youth. All Bridge staff receive specialized training to ensure that this occurs through initial orientation and subsequent PREA refresher training topics.

When sufficient evidence exists, The Bridge does not hesitate to remove that employee and to support criminal prosecution of that employee.

How does PREA impact Bridge employees?  
PREA addresses the safety of juveniles while in a Bridge program - including sexual assault, sexual harassment, juvenile on juvenile sexual assault, and any sexual contact between staff and a juvenile whether or not the contact is alleged to be consensual. PREA pertains to the safety of juveniles or adjudicated offenders while in the custody of the criminal justice system including jail, detention, non-secure residential care, private contracted programs, and/or secure confinement. PREA also directs agencies to maintain data regarding juvenile on juvenile sexual assaults, nonconsensual sexual acts, and staff and juvenile sexual misconduct.
 
Can The Bridge be sued for not complying with PREA? 
No. PREA does not create any right to sue. However, there is an ethical responsibility to protect the safety of staff and those juveniles in custody. Failure to protect incarcerated juveniles can result in civil liability for the agency, supervisors, and staff, both personally and professionally.
 
What are the consequences for not complying with PREA? 
If The Bridge fails to comply with the PREA National Standards for juveniles, The Bridge will be removed as an eligible contract provider for ADYS residential programs.
 
Why should I be concerned with sexual misconduct at a facility?  
Sexual misconduct is not about sex, but about safety and security. Both are compromised whenever boundaries break down and a staff member becomes personal or intimate with a juvenile.

Staff sexual misconduct and juvenile on juvenile sexual assault undermines the mission of The Bridge by creating unstable living and working environments for the juveniles as well as their supervising staff members.
 
What about juveniles who either manipulate the system using PREA or make false allegations against staff?  
Staff are often concerned that addressing PREA-related issues in policy and procedure, and educating juveniles as to their right to be safe while in custody, may result in false accusations or false reports of staff misconduct. All allegations will be thoroughly and timely investigated and false allegations may be prosecuted.
 
 
What is The Bridge PREA Policy?
In compliance with Sections 115.311 and 115.322 of the Prison Rape Elimination Act (PREA) Standards, The Bridge has established a zero tolerance for incidents of juvenile sexual assault, rape or sexual harassment in any ADYS facility. The Bridge has implemented policies and procedures to ensure that the PREA Standards are upheld in all Bridge ADYS residential facilities. All allegations of sexual assault/harassment that meet the definitions of PREA are referred for investigations to the local Alabama Department of Human Resources and sheriff offices.
 
How do I report sexual abuse?
If you suspect sexual abuse has happened at a Bridge facility, you have several options for reporting.
  1. You may contact the PREA Compliance Staff:
PREA Program Manager- Angie Pate
Office Phone:  (256) 546-6324 x500
Gadsden Campus, 3232 Lay Springs Rd
Gadsden, AL 35904

PREA Coordinator- Kim Harden
Office Phone: (256) 546-6324 x229
Gadsden Campus, 3232 Lay Springs Rd
Gadsden, AL 35904
  1. If you prefer, you may call and report to the Sheriff or Police Department in the location where the allegations occurred. All reports are taken seriously and investigated as outlined in PREA and Bridge rules and procedures.
  2. You can report abuse by using a 3rd party form Click Here to download the form.
  3. Additionally, you may call and report to the Alabama Department of Youth Services ADYS PREA Coordinator at 334-215-3802; or you may call the ADYS Sexual Assault Hotline at 1-855-332-1594.
To whom does The Bridge report concerning PREA?
In compliance with PREA Standard §115.389 regarding publication of aggregated sexual abuse data, The Bridge is required to submit reports to the U.S. Department of Justice through the Survey of Sexual Violence Summary form.  The Bridge reports that on the 2012 U.S. Department of Justice Survey of Sexual Violence Summary form, The Bridge had no founded allegations of sexual abuse in our ADYS contract residential programs in 2012. The Bridge continues to educate all staff, students, contractors, and volunteers on PREA and the importance of protecting youth from sexual abuse. 

“In compliance with PREA Standard §115.389 regarding publication of aggregated sexual abuse data, The Bridge is required to submit reports to the U.S. Department of Justice through the Survey of Sexual Violence Summary form.  The Bridge reports that on the 2013 U.S. Department of Justice Survey of Sexual Violence Summary form, The Bridge had no founded allegations of sexual abuse in our ADYS contract residential programs in 2013. The Bridge continues to educate all staff, students, contractors, and volunteers on PREA and the importance of protecting youth from sexual abuse. “

How does the Bridge investigate abuse allegations?
POLICY
It is THE BRIDGE policy to ensure that an administrative or criminal investigation is completed for all allegations of sexual abuse, sexual assault, and sexual harassment. 
 
PROCEDURES 
  1. When THE BRIDGE conducts its own administrative investigations into allegations of sexual abuse and sexual harassment, it shall do so promptly, thoroughly, and objectively for all allegations, including third-party and anonymous reports. 
  2. The Program and QA Managers shall receive special training in sexual abuse investigations involving juvenile victims.
  3. THE BRIDGE shall refer all criminal investigations to the local law enforcement and department of human resource with jurisdiction to conduct such investigations.
  4. Investigators shall gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data; shall interview alleged victims, suspected perpetrators, and witnesses; and shall review prior complaints and reports of sexual abuse involving the suspected perpetrator. 
  5. THE BRIDGE shall not terminate an investigation solely because the source of the allegation recants the allegation. 
  6. The credibility of an alleged victim, suspect, or witness shall be assessed on an individual basis and shall not be determined by the person’s status as juvenile or staff. No facility shall require a juvenile who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a condition for proceeding with the investigation of such an allegation. 
  7. Administrative investigations shall include an effort to determine whether staff action or failures to act contributed to the abuse. All investigations shall be documented in written reports that include a description of the physical and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings. 
  8. Investigations shall be documented in a written report that contains a thorough description of physical, testimonial, and documentary evidence and attaches copies of all documentary evidence where feasible. 
  9. Substantiated allegations of conduct that appears to be criminal shall be referred to law enforcement, department of human resources, and department of youth services for further investigation. 
  10. THE BRIDGE shall contact DYS service monitors and/or DYS community residential program administration, and DYS licensing authorities within 24 hours of any alleged sexual abuse incident. 
  11. THE BRIDGE shall retain all written reports for as long as the alleged abuser is incarcerated or employed by the agency, plus five years, unless the abuse was committed by a juvenile and applicable law requires a shorter period of retention.  
  12. The departure of the alleged abuser or victim from the employment or control of the facility shall not provide a basis for terminating an investigation.
  13. When outside agencies investigate sexual abuse, THE BRIDGE shall cooperate with outside investigators and shall endeavor to remain informed about the progress of the investigation. 
  14. At the conclusion of all PREA investigations, the Campus Administrator shall complete THE BRIDGE Investigative Outcomes of Allegations of Sexual Abuse/assault or Sexual Harassment and submit it to THE BRIDGE PREA Coordinator. 
  15. THE BRIDGE shall impose no standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated.


PREA AUDIT REPORT INTERIM  X FINAL
JUVENILE FACILITIES
Date of report: Click here to enter text
 
Auditor Information
Auditor name: Georgeanna Mayo Murphy
Address: P.O. Box 81873 Mobile AL 36689
Email: GeorgeannaMurphy@yahoo.com
Telephone number: (251) 421-0604
Date of facility visit: March 9-11, 2016
Facility name: Kennington Addiction Treatment Center
Facility telephone number: (256)564-6324
Facility physical address: 3232 Lay Springs Road, Gadsden, AL35904 Facility mailing address: (if different from above) Click here to enter text.
The facility is: 口 Federal 口 State  口County 口 Military 口 Municipal 口 Private for profit   X Private not for profit
Facility type: 口 Correctional  口 Detention  X Other
Name of facility's Chief Executive Officer: Tim Naugher
Number of staff assigned to the facility in the last 12 months: 47
Designed facility capacity: 24
Current population of facility: 24
Facility security levels/Inmate custody levels: minimum
Age range of the population: 12-19
Name of PREA Compliance Manager: Angie Pate
Title: Lead Therapist/PREA Manager
E-mail address: a_pate@bridgeinc.org
Telephone number: (256)564-6324 ext, 406
Name of agency: The Bridge Inc.
Governing authority or parent agency: (if applicable)The Bridge Inc.
Physical address: 3232 Lay Springs Road, Gadsden, AL 35904
Mailing address: (if different from above) Click here to enter text.
Telephone number: (256)564-6324
Agency Chief Executive Officer
Name: Tim Naugher
Title: Executive Director
E-mail address: t_naugher@bridgeinc.org
Telephone number: (256)564-6324 ext. 202
Agency-wide PREA Coordinator
Name: Kim Harden
Title: Quality Assurance Manager
Email address: k_harden@bridgeinc.org
Telephone number: (256)564-6324 ext. 229

 
 
AUDIT FINDINGS
 
NARRATIVE
 
The Prison Rape Elimination Act (PREA) on-site audit of the Kennington Addiction Treatment Center in Gadsden, Alabama was conducted March 9-11, 2016 by Georgeanna Mayo Murphy, a U.S. Department of Justice Certified PREA Auditor for juvenile facilties. Pre-audit preparation included a thorough review of all documentation and materials submitted by the facility along with the data included in the completed PRE-Audit Questionnaire. The documentation reviewed included agency policies, procedures, forms, educational materials, training curriculum, organizational charts, posters, brochures and other PREA related materials that were provided to demonstrate compliance with the PREA standards. A review of the materials provided promted several questions that were qucily answered by the PREA Coordinater, Ms Kim Harden. One policy was updated and submitted to the Bridge Inc. management for review prior to the auditors arrival on-site,
 
During the two and a half day on-site audit, the auditor was provided access to an office in the facility to conduct interviews of administrative and human resources staff. Line Staff and resident interviews were conducted in a lounge in the facility that provided a venue for confidential interviews. Formal interviews were conducted with facility staff, residents and contract personnel. The auditor interviewed ten of the twenty-four residents from the facility. Eight line staff (TA) workers were interviewed along with three counselors/therapist, intake clerk and the program manager. The line staff workers interviewedwere made up of at least two member from each shift both male and female, Specialty staff wer also included in the interview process, the director of training, medical staff, cafeteria staff and maintenance employees. Administrative staff including the Agency Director, Mr. Tim Naugher, Associate Agency Director, Mr. Mark Spurlock, PREA Coordinator, Ms Kim Harden, and PREA Compliance Manager, Ms Angie Pate,
Resident were interviewed using the recommended DOJ protocols that question their knowledge of a variety of PREA protections specifically their knowledge of reporitng mechanisms available to them to report sexual abuse and sexual harassment. Staff were questioned using the DOJ protools tht question their PREA training and overall knowledge of the agency's zero tolerance policy, reporting mechanisms available to residents and staff, the response protcols when a resident alleges abuse, and first responder duties. The auditor reviewed 10 peronnel files of staff members to determine compliance with background check procedures and 10 employee training files to verify compliance with training policies and procedures. All files were found to be in order. Case files for 10 of the clients were reviewed to verify screening and intake procedures, resident education and other general areas mentioned in the standards. In the past 12 months the facility reported one third party report alleging sexual abuse and three reports alleging sexual harassment. The facility provided me with all the investigative information of each allegation and the administrative outcomes. Two staff members were terminated.
 
The auditor toured the facility escorted by the PREA Coordinator and observed the facility configuration, location of cameras, level of staff supervison, dorm layout including shower and toilet areas, placement of PREA posters and PREA informational resources, security monitoring, resident entrance and exit procedures from the day room to their assigned sleeping area, resident interaction with staff and programming. The auditor noted that there are eight rooms in the facility desined to be sleeping areas. There are three clients placed in each room and they share a common restroom/shower area. Policy allow only one resident be in ther restroom/shower are at any time. Notices of the PREA audit were posted throughout the facility. The auditor was give access to all the parts of the facility to review the DOJ tour protocol. The auditor talked informally with both residents and staff during multiple walk-throughs of the facility during the course of the visit.
 
The auditor was treated with great hospitality during the on-site visit, Clients and staff were made readily available to the auditor at all
times and were more than willing to participate. Both staff and residents were very knowledgeable abut the protections and requirements of PREA. It is clear that the leadership of the facility has worked very hard to meet compliance with the PREA Standards and have worked toward ensuring the sexual safety of the clients in their care.
 
DESCRIPTION OF FACILITY CHARACTERISTICS

The Kennington Addiction Treatment Center operates through the Bridge Incorporated which is a not for profit agency. The Bridge was established in 1974 to assist addicted individuals and combat the growing drug problem in northeast Alabama. In the mid 1990's the Bridge began working with the Alabama Department of Youth Services to provide adolescent substance use treatment. The Bridge is licensed by the Alabama Department of Youth Services. Three programs are housed on the grounds of the Bridge Inc. in Gadsden, Kennington is a 24 bed male facility that houses clients betweent the ages of 12-19 with drug abuse issues. There are eight rooms in the facility desined to be sleeping areas. There are three clients placed in each room and they share a common restroom/shower area, Clients share two large day rooms with a staff office in the middle. A camera monitoring system is located in the staff office which faces the clients bedrooms. Clients enjoy a large outdoor recreation area and indoor gym which is a stand alone building. The facility has eight over flow beds in a separate building but these beds have not been in use. The facility has a laundry room but residents are not allowed entrance into that area.
The Kennington facility also houses counselors/therapists for the clients in the program. Each client is assigned a therapist upon arrival to the facility. Clients can request to speak with their therapist at any time to discuss any issues the may behaving. The intake clerk is also located in the facility, She provides each resident with a PREA PowerPoint introduction upon admission to the facility. Residents are only searched by male staff except in exigent circumstances and these searches are always within view of the camera.
Clients attend class in portable buildings and escorted by facility staff from one point to another, Clients also have access to medical care while at the facility. A cafeteria is provided on the campus where clients eat their meals and receive snacks. Administrative offices are located in a building at the entrance of the campus. The average daily population of the facility is 24. There were 140 admits in the last 12 months.
 
SUMMARY OF AUDIT FINDINGS

During the past 12 months the Kenning Treatment facility reported one allegation of sexual abuse and three allegations of sexual harassment. The sexual abuse allegation is currently being investigated by the Etowah County Sheriff's Department and the Alabama Department of Human Resources, Administraive investigations led to the termination of one staff member.

Overall, the interviews of clients reflected a clear understand of the PREA protections and the agency's zero tolerance policy for sexual abuse and sexual harassment. Clients were very well versed on the options they have to report any sexual abuse or sexual harassment. Clients receive PREA training during the intake process by the intake clerk. She provides them with an individualized explaination of PREA and how it affects them during their stay at the facility. Clients are provided a more in-depth explanation of PREA during the orientation process. Clients are provided with a facility handbook of rules, a “Bridge-Safe” brochure, and “How to Report” business card. Posters are located throughout the facility with the PREA Hotline phone number prominently displayed. Clients were able to articulate to the auditor what they would do and who they would tell if they were sexually abused or harassed at the facility as well as what they would do if they knew another client was being harassed or abused. Clients consistently indicated they felt safe in the facility and did not fear retaliation if they did make an allegation,
All facility staff interviewed indicated they received detailed PREA training and could articulate the meaning of the zero tolerance policy. Staff were knowledgeable concerning their roles and responsibilities in preventing, reporting, and responding to sexual abuse and sexual harassment. Staff were well versed in the variety of reporting mechanisms for both themselves and residents. Staff were well trained on the duties of a first responder and showed the auditor the back of their ID badge which listed those duties. Different scenarios were given and each staff member walked the auditor through the first responder process. No staff member indicated they felt retaliation would be an issue if they made a report or participated in an investigation involving sexual abuse or sexual harassment of a client. The staff training director provided the auditor with the curriculum and forms used to train staff.

Clients are screened during the intake process for vlunerability to ensure safe housing and programming, Couselors/Therapists meet weekly to ensure clients are following the program and aid in maintaining a safe environment. Clients may be re-evlauated periodically for vulnerability if issues arise.
 
The facility has an MOU with the Etowah County Sheriff's Department to conduct all criminal investigations involving the sexual abuse of a client. They have an MOU with the Children's Hospital of Alabma to provide SANE and SAFE medical staff when doing the sexual assault exam on a client from the facility. They have an MOU with 2nd Chance to provide support services to sexual abuse victims and act as an adovate for the client.

It is clear that the leadership of the facility has worked very hard to meet compliance with the PREA Standards and has worked toward ensuring the sexual safety of the clients in their care

Number of standards exceeded: 4
Number of standards met 34
Number of standards not met: 0
Number of standards not applicable: 3

 
Standard 115.311 Zero tolerance of sexual abuse and sexual harassment; PREA Coordinator
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)
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.

The Kennington Treament Center has implemented a zero tolerance policy as detailed in Policy TBI-P-311 which comprehensively addresses the facility's approach to preventing, detecting, and responding to all forms of sexual abuse and sexual harassment. The policy contains the necessary definitions, sanctions and the foundation for training with residents, staff, volunteers, contract personnel and others.

The facility has a designated PREA Coordinator, Ms Kim Harden, her official title is Quality Assurance Manager. The PREA Coordinator reports directly the Executive Director, Tim Naugher. Ms Harden indicated that she has sufficient time and authority to develop, implement, and oversee effords toward PREA compliance and she has one PREA Compliance Manger who reports to her directly,

The facility has a designated PREA Compliance Manager, Angie Pate, Her official title is Lead Therapist. Ms Pate indicates that she has sufficient time and authority to develop, implement and oversee Kennington Treatment Center's efforts to comply with the PREA standards.

Policy TBI-P-311
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Agency Director
Kennington Organizational Chart
PRE-Audit Questionnaire
 
Standard 115.312 Contracting with other entities for the confinement of residents
口Exceeds Standard (substantially exceeds requirement of standard)
口Meets Standard (substantial compliance; complies in all material ways with the standard for the
relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.

The Kennington Treatment Facility does not contract with external entities to house or confine any of its residents. The Alabama Department of Youth Services (DYS) contracts bed space with the facility for residents sentenced to DYS by the court. The standard is therefore not applicable.
 
Interview with PREA Coordinator
Interview with Agency Director
 
Standard 115.313 Supervision and monitoring
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.

The Kennington Treatment Center has a formalized, written staffing plan that addresses the mandatory eleven elements required in the PREA Sandard. The facility maintains legal ratios per the facility state license from the Alabama Department of Youth Services. Staff ratios are 1:8 during waking hours and 1:12 during sleeping hours. Great care is taken to ensure the staffing minimums are maintained at all times. There were no exigent circumstances during this auditing period that left the facility below its staffing minimum. The staffing plan is revised annually to ensure compliance. The facility conductrs unannounced rounds on each shift to identify and deter sexual abuse and sexual harassment. The staff member conducting the roumds monitors to ensure staff are not alerting other staff members that rounds are being conducted. Rounds are documented on the “Supervisory Monitoring Log” form.
The facility’s is video monitoring system is very extensive and more cameras are installed as new blind spots are identified. While the auditor was there for the on-site vist a technician was on campus installing additional external cameras. Supervisory staff can access the facility camera system when not on campus to monitor activities if needed.
 
Policy TBI-P-311
Interview with PREA Coordinator
Interview with PREA Compliance Monitor
Interview with Agency Director
Interview with line staff
Staffing Plan/Annual Review Staff Schedules
Client Population Rosters
Interview with Program Manager
Interview with Training Director

Standard 115.315  Limits to cross-gender viewing and searches
口 Exceeds Standard (substantially exceeds requirement of standard)
X  Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
Kennington is an all male facility with both male and female line staff (TA). All rooms are doorm style with three residents sharing one restroom. Kennington policy prohibits cross-gender strip searches and has no exigent circumstances exceptions If a strip search is authorized it is conducted with a member of the medical staff and a same gender staff member. If a body cavity search is authorized it is conducted by a member of the medical staff only. The facility also prohibits any cross-gender pat-down searches except under exigent circumstances. Any time a pat-down search is authorized staff will complete form 115.315 “Same and Cross-Gender Pat-Down Searches”.
  
All pat-down searches are done so that the staff member and client are in view of the camera. None of the residents interviewed had ever been patted-down by a female staff member.
 
Facility policy prohibits staff from searching or physically examining a transgender or intersex resident for the sole purpose of determining the resident's genital status.
 
Kennington policy and practice ensures that residents are able to shower, perform bodily functions and change clothing in privacy. Policy and procedure require announcement when staff of the opposite gender enters the housing unit. Female staff do not enter any room occumpied by a male client or any toilet/restroom area. Interviews with staff and clients confirmed this as the policy and actual practice of the program on a consistent basis.
 
The facility has provided training for staff on the proper procedure for conducting a pat-down search on a client of the opposite gender or a transgender or intersex resident in a professional manner.
 
Policy TBI-P-115.315
Policy TBI-P-311 Same/Cross Gender Pat-Down Form
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interviews with Clients
Interviews with Staff
Client Search PowerPoint
 
Standard 115.316 Residents with disabilities and residents who are limited English proficient
 
X Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)  
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.
 
Kennington policy requires that clients with special needs have an equal opportunity to participate in or benefit from all aspects of the facility’s efforts to prevent, detect and respond to sexual abuse and harassment. Policy further prohibits the use of clients as interpreters when dealing with first responder situations or any allegation/investigation of sexual abuse or harassment. The facility has a contract with Optimal Phone Interpreters who provide foreign language interpreters as well sign language interpreters. PREA information is also provided in a format that can be easily understood for residents with intellectual disabilities, or low reading skills. Residents are given a hearing loss questionnaire as part of the medical screening by their counselor.
 
Policy TBI-P-311
Policy TBI-P-316
Optimal Phone Interpreters Brochure
Optimal Phone Interpreters Contract
Interview PREA Coordinator
Interview PREA Compliance Manager
Intterview line staff (TA)
Resident Training Information
Resident Training Log
Training PowerPoint
PREA Pamphlet 115.333

 
Standard 115.317 Hiring and promotion decisions
 
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington policy and procedure prohibits the hiring, enlisting of any contractor or volunteer or promotion of employee, 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; or has been civily or administratively adjudicated to have engaged in such activity. Kennington shall consider any incidents of sexual harassment, as defined by PREA, in determining whether to hire or promote anyone, or to enlist the services of any contractor/volunteer, who may have contact with clients. Before hiring new employees, promotions or contracting with any contractor or volunteer Kennington performs a nation-wide criminal background record check, Child Abuse and Neglect Report from the Alabama Department of Human Resources and contacts prior institutional employers for information on substantiated allegations of sexual abuse as well as any resignations which occurred during a pending investigation of an allegation of sexual abuse. The facility also requires all applicants and employees to disclose any previous misconduct in written applications or interviews for hiring or promotions and in any interviews or written self-evaluations conducted as part of the annual performance appraisals of current employees using the Bridge Form “PREA Employment/Appraisal Questionnaire”. Background checks for employees are conducted every five years.
 
Any material omissions regarding misconduct or the provision of materially false information, shall be considered grounds for termination.
 
Policy TBI-P-311
Policy TBI-P-317
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interviews with Agency Director
Interviews with Staff
Examination of Employee Files
Interview with Human Resources
 
Standard 115.318 Upgrades to facilities and technologies
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington reports that there have been no substantial expansions, modifications or retrofitting of the facility. The facility has installed external and internal cameras to eliminate blind spots. Cameras are strategically placed on all external entrances/exits, common areas, hallways, classrooms, etc, Cameras are monitored by line-staff (TA) in the staff office. Cameras can alos be monitored by administrative staff afterhours if needed.
  
The agency leadership considers a variety of factors when upgrading technology in the facility including primarily sight lines, blind spots, and inaccessible areas. Interviews with facility leadership indicate tht placement of cameras are discussed frequently to enhance safety for all clients.
 
Policy TBI-P-311
Policy TBI-P-318
Interview with PREA Coordinator
 Interview with PREA Compliance Manager
Interview with Agency Director
Interviews with Staff
Diagram of Facility
Facility Tour
 
Standard 115.321 Evidence protocol and forensic medical examinations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)
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.
 
Kennington refers all allegations regarding sexual assault to the Etowah County Sheriff's Office for criminal investigation purposes. The Sheriff's Department reports using the recommended uniform evidence protocol cited in the PREA Standard. Clients are taken to Children's Hospital of Alabama for all forensic examinations which are conducted by SANE/SAFE medical personnel at no cost to the victim. The facility has an agreement with both the Etowah County Sheriff's Department and Children’s Hosptial of Alabama. The facility provides victims with an advocate through a MOU with the 2"Chance Program. The facility also has a trained support staff member, Ms Conteria Williams.
 
Kennington conducts and internal investigation of employee misconduct in conjunction with law enforcement. The Campus Administrator, Program Manager PREA Manager and Compliance Director are responsible for conducting and administration of all allegations of sexual assault and/or sexual harassment.
 
Policy TBI-P-311
Policy TBI-P-321-322
MOU Etowah County Sheriff's Department
MOU Children's Hospital of Alabama
MOU 2nd Chance Program
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
 
Standard 115.322 Policies to ensure referrals of allegations for Investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies In all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington policy requires that all allegations of sexual abuse and sexual harassment be referred for investigation to appropriate law enforcement authorities. The Etowah County Sheriff's Department is the law enforcement agency that conducts all criminal investigations at the facility. The policy is posted on the facility's website. The facility also notifies the Alabama Department of Human Resources (DHR) to make a report. Both agencies conduct their own investigations based on the information provided by Kennington. The facility conducts an internal investigation of employee misconduct in conjunction with the law enforcement criminal investigation and the investigation by DHR. The Campus Administrator, Program Manager PREA Manager and Compliance Director are responsible for conducting and administration of all allegations of sexual abuse and/or sexual harassment.
 
The facility reports one allegation of sexual abuse in the past 12 months and three allegations of sexual harassment. The sexual abuse report was made by a third party (fellow client). The employee involved in the allegation of sexual abuse was terminated and is currently under investigation by the Etowah County Sheriff's Department and Alabama Deparment of Human Resources. The sexual harassment allegations were found to be unsubstantiated. The facility provided the auditor with all the information and findings regarding the sexual harassment complaints and the information regarding the sexual assault complaint.
 
Policy TBI-P-311
Policy TBI-P-321-322
MOU Etowah County Sheriff's Department
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Agency Director
 
Standard 115.331 Employee training
 
X Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington policy equires all new employees to have in-depth training on the Prison Rape Elimination Act. PREA training is conducted every two years for all employees as a refresher. Training staff ensure staff are retaining the information presented to them through the use of a post-test and signature verifying receipt. A review of the training materials and discussion with the training director show that staff receive training on all eleven specific topics found in the standard. The training is tailorerd to working with the unique needs of an all male population. During staff interviews it was evident that staff were well versed on the reporting options for themselves and clients, Red Flags, signs and symptoms of abuse and the importance of the duties of a first responder. All staff at the facility have been trained in PREA.
 
 
Policy TBI-P-311
Policy TBI-P-331,332,334,335
Interview with Training Director
Examination Training Curriculum
Examination of Employee Training Records
Inteviews with Employees
PREA Laminated First Responder Duties on back of ID cards
 
Standard 115.332 Volunteer and contractor training
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington requires all volunteers and contract personnel who may have contact with residents to be trained on the PREA requiremens. The training materials cover all required topics. All volunteers and contract personnel have received training in PREA and signed a form verifying receipt. Training is based on the amount of contact volunteers and contract personnel have with clients.
 
After interviewing contracted personnel (medical staff and teachers) it was evident they received and understood the information provided to them during PREA training.
 
Policy TBI-P-311
Policy TBI-P-331, 332, 334, 335
Interview with Training Director
Examination Training Curriculum
Examination of Training Records
Inteviews with Medical Staff
Inteviews with Teachers
PREA Laminated First Responder Duties on back of ID cards
Form 115.332
 
Standard 115.333 Resident education
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington reports that 140 clients were admitted to the facility in the past 12 months and all have been provided comprehensive age-appropriate
information during the intake process. The intake clerk goes over a PREA PowerPoint flip chart with each client individually. Clients receive PREA orientation within 24 hours of arrival. This is monitored by the PREA Compliance Manager to ensure all clients recive training. The PREA Manager also monitors the training of any resident with learning, language or disability barriers. Clients are provided orientation materials during intake, “Bridge-Safe Brochure", and “Your Safety is our Primary Concern” business card. The initial training and orientation training include zero tolerance policy, key definitions of certain conduct, how you can protect yourself, and how to report sexual abuse or harassment. Clients transferred from another agency are educated regarding their rights under PREA. PREA education is available to clients in many different formats for residents who are not English proficient, deaf, visually impaired, who have
limited reading skills.
 
Key information about PREA is continuously and readily available and visible to residents. Kennington displays PREA posters in common areas of the facility with the abuse hot-line number in bold print. The facility provides translation services through Optimal Language Services.
After interviews with the clients it was evident they received the proper training and were very knowledgeable about the zero tolerance policy, ways to be safe, and how to report.
 
Policy TBI-P-311
Policy TBI-P-333
Bridge Safe Brochure
Your Safety is our Primary Concern Business Card
Interview with Clients
Interview with Intake Clerk
Training Curriculum
Form 115.333
Resident Files
Interview with PREA Coordinator
Interview with PREA Compliance Manager
 
Standard 115.334  Specialized training: Investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington refers all allegations of sexual abuse to the Etowah County Sheriff's Department for criminal investigations. Kennington conducts an internal investigation of employee misconduct in conjunction with law enforcement. The Campus Administrator, Program Manager PREA Manager and Compliance Director are responsible for conducting and administration of all allegations of sexual assault and/or sexual harassment. The PREA Coordinator, Kim Harden and three other employee have received training in conducting investigations.
 
 
Policy TB-P-311
Policy TBl-P-332,334,335
Employee Training
Training Curriculum
Interview with PREA Coordinator
Interview with PREA Compliance Monitor
Interview with Agency Director
MOU Etowah County Sheriff's Department
 
Standard 115.335 Specialized training: Medical and mental health care
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington Treatment Program has nurses (RN's and LPN's) on staff to provide on-site medical care at the facility. A physican comes to the facility to provide medical care on a regulare basis including dental care, x-rays etc. Each client is assigned a counselor/therapist for the duration of their treatment. All medical and mental health staff are trained on the PREA information and sign an acknowledgement statement. Facility staff do not conduct forensic medical exams of clients who are victims of sexual abuse in the facility. Kennington contracts with Children’s Hospital of Alabama to to perfrom sexual assault kits by SANE and SAFE trained medical staff. The 2nd Chance program provides advocates for victims of sexual abuse.
 
After conducting interviews with medical staff and staff counselors/therapists it was evident that staff were vey knowledgeable about PREA related topics such as mandatory reporting, zero tolerance, rights of residents, etc.
 
Policy TBI-P-311
Policy TBI-P-331, 332,334,335
Interviews with medical staff
Interviews with counselors
Interviews with PREA Coordinator
Interviews with PREA Compliance Manager
Training Records Medical and Mental Health Staff
MOU Children's Hosptial of Alabama
MOU 2nd Chance Program
 
Standard 115.341 Screening for risk of victimization and abusiveness
 
X Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that counselors/therapists conduct the Intake Screening for Assaultive Behavior, Sexually Aggressive Behavior and Risk for Sexual Victimization Instrument during their admission process. Clients are also assessed by the medical staff and contract medical providers. Information from these assessments along with other data are used by the Program Manager to make room assignments and determine housing needs. This assessment occurs within 24 hours of the resident arriving at the facility. The facility reports that 140 clients were admitted to the facility in the past 12 months and all were screened as required by this standard.
 
The Screening Instrument covers all eleven topics as detailed in the standard. Additonal information received during the admission process is added in decisions regarding housing and programming needs.
 
The facility has implemented appropriate controls on the dissemination of the information received during the admission process. The information received by counselors during the admission process is kept locked in file drawers in their offices. A reasssment of the client is conducted by the counselor periodically to determine if their risk level has changed.
 
Policy TBI-P-311
Policy TBI-P-341
Ineterviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Clients
PREA From 115.341
PREA Form 115,341.1
 
Standard 115.342 Use of screening Information
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that counselors/therapists conduct the Intake Screening for Assaultive Behavior, Sexually Aggressive Behavior and Risk for Sexual Victimization Instrument during their admission process. Clients are also assessed by the medical staff and contract medical providers. Information from these assessments along with other data are used by the Program Manager to make room assignments and determine housing needs. This assessment occurs within 24 hours of the resident arriving at the facility. The facility reports that 140 clients were admitted to the facility in the past 12 months and all were screened as required by this standard.
The Screening Instrument covers all eleven topics as detailed in the standard. Additonal information received during the admission process is added in decisions regarding housing and programming needs.

The facility has implemented appropriate controls on the dissemination of the information received during the admission process. The information received by counselors during the admission process is kept locked in file drawers in their offices. A reasssment of the client is conducted by the counselor periodicallyto determine if their risk level has changed.
The facility does not use isolation so there have been no clients placed on isolation in the last 12 months. Residents who are at risk of sexual victimization will be moved to another program located on the campus (Mitchell). There is no special housing or bed assignement clients who identify as gay, bisexual, transgender or intersex. Housing arrangements for transgender or intersex clients are made on a case by case basis.
 
Policy TBI-P-311
Policy TBI-P-341
Ineterviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interviews with Clients
PREA From l 15.341
PREA Form 115,341.1
PREA Form I 14.342
 
Standard 115.351 Resident reporting
X Exceeds Standard (substantially exceeds requirement of Standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center provides clients with multiple internal and external ways to report sexual abuse, sexual harassment and retaliation. Clients receive education about reporting at the time of intake by the intake clerk and a comprehensive orientation with 24 hours of their arrival. Clients receive written information such as the Bridge Safe Brochure and a business card with a list of reporting options, Reporting methods include telling a staff member/volunteer/contract employee, written grievane procedure, calling the abuse hotline, having an third party submit an oral or written complaint on the client’s behalf and speaking to the DYS adovocate or their probation officer. Clients are provided access to the tools necessary to make a written report. Clients have access to phone calls with their parent, legal guardian, attorney and probation officer weekly. Clients also are allowed vists from their parent or legal guardian while in the program, Kennington policy allows unimpeded and free access to a phone in a private setting to call the Alabama PREA Hotline which is operated by the Alabama Department of Youth Services.
 
Interviews with clients clearly demonstrated that all were very knowledgeable about PREA and the variety of methods to report sexual abuse and sexual harassment. Clients know how to call the hotline, and file grievances. Clients told the auditor they could make a call to the PREA Hotline at any time. Clients also informed the auditor that they would not fear any intimidation or retaliaton if they reported sexual abuse or sexual harassment. Clients stated they felt safe in the facility. Interviews with line staff and counselors/therapists also demonstrated they were aware of the residents reporting options.
 
Policy TBI-P-311
Policy TBI-P-351
Form 115.351
Form 115.333
Client Complaint Form
Client DYS Grievance Form
Client Handbook
Bridge Safe Brochure
Reporting Card
Interviews with Staff
Interviews with Clients
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Client Orientaiton PowerPoint
 
Standard 115.352 Exhaustion of administrative remedies
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center has a formalized written grievance system for clients. Clients may submit a grievance regarding an allegation of sexual abuse or sexual harassment at any time. Clients may receive assistance in preparing and filing a grievance. Grievance boxes are located in the common areas and forms and writing utensils are made readily available to clients. Facility policy and procedure require that a decision on the merits of any grievance or portion of a grievance alleging sexual abuse be made within 90 of filing the grievance. In the past 12 months two grievance were filed alleging sexual abuse or sexual harassment. A final deciosn regarding both grievances was reached within the proper time frame.
 
The client handbook informs residents of the grievance process as well as training received during the orientation process. There is no time limit in which a resident may file a grievance concerning sexual abuse or sexual harassment. Clients do not have to attempt to resolve these type of disputes with staff or other clients before filing a grievance.
 
The facility policy provides emergency grievance procdurs however in the past 12 months no emergency grievances have been filed.
Interviews with clients and staff demonstrated a thorough understanding of the grievance process and procedures.
 
Clients also have an outside grievance option through the DYS Adovocate who vists the facility weekly and checks the DYS grievance box.
 
Policy TBI-P-311
Policy TBI-P-352
Grievance Form
DYS Grievance Form
Interview with Staff
Interview with Residents
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
 
Standard 115.353 Resident access to outside confidential support services
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff’s Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee.
Support services are offered through a contract with the 2nd Chance Program which provides an outside victim adovocate for emotional support services related to sexual abuse. Clients may also call the Rape Crisis Centers National Hotline which provides confidential support services. The facility also provides clients with reasonable access to their parents/legal guardians, attorneys, probation officers, DYS advocate and monitors through phone calls, visits and letters.
 
Policy TBI-P-311
Policy TBI-P-353,354
MOU 2nd Chance Program
Posters
Client Handbook
Interviews with Clients
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
 
Standard 115.354 Third-party reporting
口 Exceeds Standard (substantially exceeds requirement of standard)
X  Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff's Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee.
 
The facility provides clients with reasonable access to their parents/legal guardians, attorneys, probation officers, DYS advocate and monitors through phone calls, visits and letters. The third party reporting procedures are located on line on the facility website and are found in the pareny handbook.
 
Policy TBI-P-311
Policy TBT-P-353, 354
Posters
Client Handbook
Interviews with Clients
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Parent Handbook
Facility website
 
Standard 115.361 Staff and agency reporting duties
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that staff are required to immediately report any knowledge, suspicion or information regarding an incident of sexual abuse or sexual harassment that occurred in a program, whether or not it is part of The Bridge; knowledge of any retaliation against clients or staff who reported such an incident and any staff neglect or violation of responsibilities that may have contributed to an incident or retaliation. All staff are required to comply with their duties as a mandatrory child abuse reporter. Apart from reporting to the Program Manger, PREA Coordianator/Manager or investigative agencies staff are prohibited from revealing any information related to a sexual abuse report to anyone other than to the extent necessary to make treatment, investigations, and other security management decisions.
 
Policy TBI-P-311
Policy TBI-P-361
Employee Handbook
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Training information
 
Standard 115.362 Agency protection duties
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.

The facility reports that there have been no situations in the past 12 months where the facility determined a client was subject to substantial risk of sexual abuse, Review of policy and interviews with PREA Coordinator and Program Manager demonstrated the protective measures that would take place in the event it was found that a client was in imminent danger of being sexual abused.
Policy TBI-P-311
Policy TBI-P-362
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Training information
 
Standard 115.363 Reporting to other confinement facilities
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)
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.

The facility reports that in the past 12 months, the facility has received no allegations that a client was abused while confined in another facility. The policy clearly requires the Agency Director to report any abuse allegations received regarding a client abused at another facility to the head of the facility where the sexual abuse is alleged to have occurred. Policy requires this notification occur as soon as possible but no later than 72 hours of receiving the allegation.
 
Policy TBI-P-311
Policy TBI-P-363
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Interview with Agency Director
Training information
 
Standard 115.364 Staff first responder duties
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff's Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee,
The facility has a policy regarding the duties of first responders whether they be “security staff" or “non-security staff". The facility provides all staff with ID cards which have first responder duties listed on the back. Frist responder protocol forms detail what steps to take in the event the abuse took place within 72 hours or after 72 hours. Security staff who are first responders will separate the alleged victim and abuser, secure the crime scene, request that neither the victim or abuser destroy evidence (as detailed in the standard). If the staff is considered a "non-security staff" their duties are to notify security staff and request the allege victim not take any actions that may destroy evidence. Interviews with both security and non-secuirty staff showed they were very knowledgeable of their duties and how to carry them out.
 
Policy TBI-P-311
Policy TBI-P-364,365
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Interview with Agency Director
Interview with Food Service Employees
Interview with Teachers
Interview with Maintenance Staff
Interview with Training Director
Training information
 
Standard 115.365 Coordinated response
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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,

The facility has 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.
 
Policy TBI-P-311
Policy TBI-P-364,365
Written Institutional Plan
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Interview with Agency Director
 
Standard 115.366 Preservation of ability to protect residents from contact with abusers
口 Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
This standard is not applicable to the Kennington Treatment Center. Staff employeed by the facility are at will employees and can be terminated at any time. The facility does not participate in collective bargaining agreements.
 
Standard 115.367 Agency protection against retaliation
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The facility reports there have been no incidents of retaliation in the past 12 months. The Kennington Treatment Center has a policy to protect all juveniles and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other clients or staff. The Campus Administrator and PREA Manager are responsible for monitoring retaliation of staff and clients. The Campus Administrator and PREA Manager monitor the conduct or treatment of staff or clients who reported sexual abuse and clients who reported having sufferd abuse to see if there are any changes that may suggest possible retaliaton by clients or staff. This monitoring period last for no less than 90 days. The facility employes multiple protection measures, such as houing changes or transfers for juvenile victims or abusers, removal of alleged staff or juvenile abusers from contact with victims and emotional support services for clients or staff that fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with investigations. It is the policy of the facility to act promptly to remedy any such situation. Inteviews with staff and clients confirmed that they did not fear retaliation and knew that it would be monitored if a report was made.
 
Policy TBI-P-311
Policy TBI-P-367
Form 115.367
Form 115.371
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Interview with Campus Administrator
Interviews with line staff
Interviews with clients
Interviews with Teachers
Interviews with Medical Staff
 
Standard 115.368 Post-allegation protective custody
口 Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center reports they do no use isolation in their facility. There a no isolation rooms or single cells in the facility. The facility has rooms that house three clients. If a client rose to a level where his safety was in question he would be moved to another facility on campus (Mitchell) or restaffed by DYS, The standard is not applicable to the facility.
 
 
Standard 115.371 Criminal and administrative agency investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Criminal investigations are conducted by the Etowah County Sheriff’s Department and Administraive Investigations are conducted by trained staff members. Investigations are not terminated soley because the source of the allegation recants. The facility reports one substantiated allegation that was referred for criminal investigation. This allegation is currently being investigated by the Etowah County Sheriff's Department and Alabama Department of Human Resources. The administrative investigation led to the termination of the staff member involved. All written reports pertaining to administrative investations and criminal investigations are retained for as long as the alleged abuser is held at the facility or employed by the facility plus five years.
 
Policy TBI-P-311
Policy TBI-P-371,372
Form 115,371
Form 115,371.1
Interview with Investigative Staff
MOU with Etowah County Sheriff's Department
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
 Interview with Campus Administrator
Interview with Agency Director
 
Standard 115.372 Evidentiary standard for administrative investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center reports that they use a standard of proof no higher than that of a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated. Interviews with investigative staff cofirm compliance with this standard.
 
Policy TBI-P-372
Interview with Investigative staff
Interview with PREA Coordinator
Interview with PREA Compliance Manager
 
Standard 115.373 Reporting to residents
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff’s Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee.
 
There were also three allegations of sexual harassment by residents at the facility. Residents were notified of the outcome of the administrative investigation on all these allegations. The resident in the sexual abuse allegation was notified of the administrative investigation outcome but has not received information related to the criminal investigation outcome at this time.

The policy of the facility follows the criteria set forth in the standard. Interviews with residents and administrative staff along with the completed notification paperwork show that the facility is following policy procedure and practice.
 
Policy TBI-P-311
Policy TBI-P-373
Completed Notification Forms
Interviews with Residents
Interviews with PREA Coordinator
Interviews with PREA Compliance Manager
Interviews with Program Coordinator
MOU with Etowah County Sheriff's Department
  
 
Standard 115.376 Disciplinary sanctions for staff
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that staff will be subject to disciplinary sanctioins up to and including termination for violating agency sexual abuse or sexual harassment policies. Termination shall be the presumptive disciplinary sanction for staff who have engaged in sexul abuse, Disciplinary sanctions for violations of agency policies relating to sexual harassment shall be commensurate with the nature and circumstances of the acts committed, the staff member's disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories. All terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and to any relevant licensing bodies. Kennington shall retain investigative documentation and disciplinary information related to any case of sexual abuse, harassment, or misconduct in the employee file and/or juvenile file until seven years past minority status of the alleged juvenile victim. The personnel file shall be marked “Do Not Destroy” with the anticipated date for destruction.
No identifying juvenile information shall be maintained in the personnel file. The employee will not be eligible for re-employment with a Bridge program in any capacity either through internship, volunteer or contractor status. In the past 12 months one employee was terminated for sexual abuse which is now under investigation by the Etowah County Sheriff's Department.
 
Policy TBI-P-311
Policy TBI-P-376
Interview with PREA Coordinator
Interview with PREA Compliance Monitor
Interview with Agency Director
Investigative Information
 
Standard 115.377 Corrective action for contractors and volunteers
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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,

Kennington Treament Center reports that there have been zero contractors/volunteers reported to law enforcement or relevant licensing bodies in the past 12 months for engaging in sexual abuse of clients. Interviews with the PREA Coordinator and PREA Compliance Manager indicate that the practice conforms with this standard.
 
Policy TBI-P-311
Policy TBI-P-377
Bridge form 115.377 PREA
Brochure for Volunteers, Interns and Employees
  
Standard 115.378 Disciplinary sanctions for residents
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; compiles in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Facility reports that in the past 12 months there have been zero administrative findings of resident on resident sexual abuse at the facility; additionally, Kennington reports there have been zero criminal findings of guilt for resident on resident sexual abuse in the past 12 months. The facility prohibits isolation for any purpose therefore there are no reports of resident being placed on isolation as a disciplinary sanction. Kennington policy prohibits all sexual activity between residents. The facility reports that residents who commit PREA realted abuse or harassment would be counseled, moved to another program or referred back to the Alabama Department of Youth Services for restaffing.
 
It is the policy of the facility that disciplinary action will only be taken against a client for sexual contact with a staff member upon a finding that the staff member did not consent to such contact. A report of sexual abuse made in good faith based upon a reasonable belief that the alleged condcuct occurred shall not constitute falsely reporting an incident or lying even if the investigation does not establish evidence sufficient to substantiate the allegation.
 
Policy TBI-P-311
Policy TBI-P-378
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with clients
Interview with staff
Interview with counselors
 
Standard 115.381 Medical and mental health screenings; history of sexual abuse
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that all residents are screened for Assaultive Behavior, Sexually Aggressive Behavior, and Risk of Sexual Victimization upon admission. If the screening indicates that a client has experienced prior sexual victimization no matter where it occurred he is offered a follow-up meeting with the medical staff and a counselor within 14 days. If a client indicates he has been a sexual aggressor he will alos be offered a follow-up medical meeting with the medical staff and a counselor within 14 days. Medical and mental health practitioners obtain informed consent from residents before reporting information about prior sexual victimization or abusiveness.
 
Policy TBI-P-311
Policy TBI-P-381
PREA Intake Screening Form 1.15.34
PREA 115.381Consent form and Release of Information
Interview with Medical Staff
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Interview with Counselors
 
Standard 115.382 Access to emergency medical and mental health services
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that victims of sexual abuse in the facility receive immediate medical treatment. All forensic medical examinations are conducted by Children's Hospital of Alabama through an agreement with the facility. The 2nd Chance Program provides advocates for victims of sexual abuse.  Residents are offered tests for sexually transmitted infections as medically appropriate. Treatment is provided at no cost to the victim. Each client at the facility has an assigned counselor. Staff are trained in the duties of first responders to ensure the client is separated from the alleged abuser, the scene is secured and the proper person is notified (medical supervisor or program manager).

The one sexual abuse allegation which was made was through a third party report. The resident client the proper medical and mental heatlh care once the information was recived by staff.
 
Policy TBI-P-311
Policy TBI-P-383
MOU Children's Hospital of Alabama
MOU 2nd Chance Program
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Counselors
 
Standard 115.383  Ongoing medical and mental health care for sexual abuse victims and abusers
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kennington Treatment Center that victims of sexual abuse in the facility are offered medical and mental health evaluations. The treatment includes follow-up services, treatment plans and referrals for continued care following their transfer or placement in another facility. The level of medical care is consistent with that in the community. Kennington is a male treatment facility so pregnancy concerns are not applicable. Residents are offered tests for sexually transmitted infections as medically appropriate. Treatment is provided at no cost to the victim. Kennington will conduct a mental health evaluation of all known resident-on-resident abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate by mental health practitioners.

All forensic medical examinations are conducted by Children's Hospital of Alabama through an agreement with the facility. The 2nd Chance Program provides advocates for victims of sexual abuse. Each client at the facility has an assigned counselor.

The one sexual abuse allegation which was made was through a third party report. The client received the proper medical and mental heatlh care once the information was recived by staff.
 
Policy TBI-P-311
Policy TBI-P-383
MOU Children's Hospital of Alabama
MOU 2nd Chance Program
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Counselors
 
Standard 115.386 Sexual abuse Incident reviews
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
It is the policy of the Kenningron Treatment Center to conduct a sexual abuse incident review at the conclusion of every criminal or administrative sexual abuse investigation, unless the allegation was determined to be unfounded. There is currently one criminal investigation that is ongoing. The employee was terminated after an internal investigation found the claim to be substantiated. A review was completed once the internal investigation was concluded and recommendations were submitted to the agency head. These recommendation were implemented.
 
Policy TBI-P-311
Policy TBI-P-386
Interviews with PREA Coordinator
Interviews with PREA Compliance Manager
Rindings from Sexual Abuse Incident Review
Sexual Abuse Critical Incident Review Form
Incident Analysis Form
 
Standard 115.387 Data collection
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
The Kennington Treatment Center collects accurate data for every allegation of sexual abuse at the facility using a standardized instrument (The Survey of Sexual Violence used by the DOJ and BJS). This information is collected annually Kennington Treatment Center reviews data collected and aggregated in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies and training. The information is used to identify problem areas, corrective actions, and the prepration of the annual report. The annual report includes a comparision of the current year's data and corrective actions taken in prior years. The annual report is made readily available of the facility's website after approval by the agency director.
 
Policy TBI-P-311
Policy TBI-P-387
Survey of Sexual Violence
Interview with the PREA Coordinator
Interview with the PREA Compliance Manager
Interview with Agency Director
Annual Report
Agency Website
 
Standard 115.388 Data review for corrective action
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington Treatment Center reviews data collected and aggregated in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies and training. The information is used to identify problem areas, make corrective actions, and the prepration of the annual report. The annual report includes a comparision of the current year's data and corrective actions taken in prior years. The annual report is made readily available of the facility’s website after approval by the agency director.
 
Policy TBI-P-311
Policy TBI-P-388
Annual Report
Interview with PREA Coordinator
Interview with Agency Director
Agency website
 
Standard 115.389 Data storage, publication, and destruction
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)
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.
 
Kennington Treatment Center policy and procedure and practive ensure the incident based and aggregate data are securely retained. The aggregated data is made readily available to the public on the facilitiy's website. All personal identifiers are removed before the information is made public. Sexual abuse data is retained for at least 10 years after the date of the initial collection.
 
Policy IBI-P-389
Tour of facility
Interview with PREA Coordinator
lnterview with PREA Compliance Manager
Facility website

 
AUDITOR CERTIFICATION I certify that:
X The contents of this report are accurate to the best of my knowledge,
X No conflict of Interest exists with respect to my ability to conduct an audit of the agency under review, and
X I have not included in the final report any personally Identifiable information (PII) about any inmate or staff member, except where the names of administrative personnel are specifically requested in the report template,
 
Georgeanna Mayo Murphy                        04/06/2016
Auditor Signature                                         Date

 
Report Based on the Annual Survey of Sexual Violence for the Kennington ATC Program
     
Target Year 2015 2016
1.       On December 31 of the target year, how many males were held in the facility? (All male facility) 28 21
2.       Between January 1 and December 31 of the target year, how many juveniles were admitted to the facility? 140 113
3.       Between January 1 and December 31 of the target year, how many youth-on-youth non-consensual sexual acts were reported? 0 0
3a. Of those acts in #3, how many were substantiated? 0 0
3b. Of those acts in #3, how many were unsubstantiated? 0 0
3c. Of those acts in #3, how many were founded? 0 0
3d. Of those acts in #3, how many are still under investigation? 0 0
4.       Between January 1 and December 31 of the target year, how many youth-on-youth abusive sexual contact were reported? 0 0
4a. Of those acts in #4, how many were substantiated? 0 0
4b. Of those acts in #4, how many were unsubstantiated? 0 0
4c. Of those acts in #4, how many were founded? 0 0
4d. Of those acts in #4, how many are still under investigation? 0 0
5.       Between January 1 and December 31 of the target year, how many sexual harassment by another youth were reported? 0 1
5a. Of those acts in #5, how many were substantiated? 0 1
5b. Of those acts in #5, how many were unsubstantiated? 0 0
5c. Of those acts in #5, how many were founded? 0 0
5d. Of those acts in #5, how many are still under investigation? 0 0
6.       Between January 1 and December 31 of the target year, how many allegations of staff sexual misconduct were reported? 1 0
6a. Of those acts in #6, how many were substantiated? 0 0
6b. Of those acts in #6, how many were unsubstantiated? 0 0
6c. Of those acts in #6, how many were founded? 0 0
6d. Of those acts in #6, how many are still under investigation? 1 0
7.       Between January 1 and December 31 of the target year, how many allegations of staff sexual harassment were reported? 3 2
7a. Of those acts in #7, how many were substantiated? 0 0
7b. Of those acts in #7, how many were unsubstantiated? 3 2
7c. Of those acts in #7, how many were founded? 0 0
7d. Of those acts in #7, how many are still under investigation? 0 0
 
 
Report Based on the Annual Survey of Sexual Violence for the Mitchell ATC Program
     
Target Year 2015 2016
1.       On December 31 of the target year, how many males were held in the facility? (All male facility) 19 23
2.       Between January 1 and December 31 of the target year, how many juveniles were admitted to the facility? 94 103
3.       Between January 1 and December 31 of the target year, how many youth-on-youth non-consensual sexual acts were reported? 0 0
3a. Of those acts in #3, how many were substantiated? 0 0
3b. Of those acts in #3, how many were unsubstantiated? 0 0
3c. Of those acts in #3, how many were founded? 0 0
3d. Of those acts in #3, how many are still under investigation? 0 0
4.       Between January 1 and December 31 of the target year, how many youth-on-youth abusive sexual contact were reported? 1 0
4a. Of those acts in #4, how many were substantiated? 0 0
4b. Of those acts in #4, how many were unsubstantiated? 1 0
4c. Of those acts in #4, how many were founded? 0 0
4d. Of those acts in #4, how many are still under investigation? 0 0
5.       Between January 1 and December 31 of the target year, how many sexual harassment by another youth were reported? 0 1
5a. Of those acts in #5, how many were substantiated? 0 0
5b. Of those acts in #5, how many were unsubstantiated? 0 1
5c. Of those acts in #5, how many were founded? 0 0
5d. Of those acts in #5, how many are still under investigation? 0 0
6.       Between January 1 and December 31 of the target year, how many allegations of staff sexual misconduct were reported? 1 0
6a. Of those acts in #6, how many were substantiated? 0 0
6b. Of those acts in #6, how many were unsubstantiated? 1 0
6c. Of those acts in #6, how many were founded? 0 0
6d. Of those acts in #6, how many are still under investigation? 0 0
7.       Between January 1 and December 31 of the target year, how many allegations of staff sexual harassment were reported? 0 0
7a. Of those acts in #7, how many were substantiated? 0 0
7b. Of those acts in #7, how many were unsubstantiated? 0 0
7c. Of those acts in #7, how many were founded? 0 0
7d. Of those acts in #7, how many are still under investigation? 0 0
 
 

 
 
AUDIT FINDINGS  

1
PREA AUDIT: AUDITOR’S SUMMARY REPORT JUVENILE FACILITIES
Name of Facility: Mitchell Residential Program
Physical Address: 3232 Lay Springs Road Gadsden, Alabama 35904
Date report submitted: May 13, 2015 Auditor information: Glen E. McKenzie, Jr., M.S.H.P.
Address: 202 Walton Way, Suite 192-141, Cedar Park, Texas 78613
Email: GlenEMcKenzieJr.LLC@austin.rr.com
Telephone number: 512-576-1800
Date of facility visit: December 9-11, 2014 Facility Information
Facility Mailing Address: 3232 Lay Springs Road Gadsden, Alabama 35904
Telephone Number: 256-546-6324
The Facility is:
Military
County Federal
Private for profit
Municipal State
X Private not for profit
Facility Type:
Detention
Correction Other: Residential Treatment Center
Name of PREA Compliance Manager: Kim Harden Title: PREA Compliance Manager CComplianceCoordinatorManage/QCS
Email Address: k_harden@bridgeinc.org Telephone Number: 256-546-6324
Agency Information
Name of Agency: The Bridge, Inc.
Governing Authority or Parent Agency: The Bridge, Inc.
Physical Address: 3232 Lay Springs Road Gadsden, Alabama 35904
Mailing Address: (if different from above)
Telephone Number: 256-546-6324 Agency Chief Executive Officer
Name: Tim Naugher Title: Executive Director
Email Address: tnaugher@bridgeinc.org Telephone Number: 256-546-6324 ext. 202
Agency Wide PREA Coordinator
Name: Jim Herring Title: PREA Compliance Coordinator
Email Address: jherring@bridgeinc.org Telephone Number: 256-546-6324
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AUDIT FINDINGS
NARRATIVE:
The Bridge is a staff-secure 24 bed male residential substance abuse treatment program and is a private not-for profit agency. Its governing authority is The Bridge Board of Directors. The PREA Audit took place December 9th through December 11th, 2014, in Gadsden, Alabama. The evening before the audit the auditor met with the Corporate Compliance Director, Jim Herring, and the PREA Coordinator. Presently, Jim Herring also serves as the agency PREA Coordinator. A list of all staff by categories and a list of all residents by dorm were provided by email prior to the audit. On the morning of December 9, 2014, the auditor entered the facility for purposes of conducting an on sight tour of the facility and interviewing residents, staff members, volunteers and contractors. Prior to arrival the auditor reviewed pertinent agency policies, procedures, and related documentation used to demonstrate compliance with JUVENILE FACILITY PREA Standards. The pre-on-site review of documents contained in the Pre-Audit Questionnaire submitted by the facility prompted numerous questions. After much discussion with the PREA Compliance Coordinator and the Corporate Compliance Director, it was determined that the Pre-Audit Questionnaire was to be resubmitted with more complete and accurate information. Answers to remaining questions were resolved during the audit. The auditor interviewed ten (10) residents at random; no less than one (1) resident at the Mitchell program from each of the three (3) living units. Residents’ length of stay for those interviewed ranged from less than one (1) month to less than 120 days, with an average length of stay of 75 days. There were 16 residents assigned to the facility during the audit. There were no youth who identified themselves as lesbian, bisexual, gay, transgender or intersex residents nor were there any residents who needed translation services or other disability related services at the facility. No residents reported sexual abuse while at the facility. No residents had requested to speak with the auditor. All residents stated they felt very safe at the facility and could speak with any staff about any issues/concerns. The facility does not utilize isolation, but relies on increasing levels of staff supervision as appropriate and necessary.
Following the on-site tour, additional questions were answered by Executive and upper-level management staff. Staff, residents and contractor interviews followed and were conducted privately in an office in the Administration Building and the Training Building located adjacent to the Mitchell Program building. There are no SANE or SAFE staff employed at the facility. The program employs one full-time Registered Nurse who works Monday through Friday from 7:00 AM to 3:00 PM, and medical professionals are available at the local Riverview Hospital. The auditor reviewed the Memorandum of Understanding (MOU) between the facility and local rape crisis center (Second Chance). The Children’s Hospital Intervention Prevention (CHIP) Program, located in Birmingham, AL, has agreed to provide SANE and SAFE services. The auditor interviewed all members of the incident review team, the staff members charged with monitoring retaliation and all intake staff. Administrative investigations are conducted by facility staff and criminal investigations are conducted by the Etowah County Sheriff’s Department. There were no volunteers interviewed as none were at the facility during the audit. The auditor interviewed one (1) contractor during the audit. The auditor interviewed the Executive Director, the Associate Executive Director, the PREA Compliance Manager, the PREA Compliance Coordinator, 15 staff and ten (10) residents. No volunteers were available. It should be noted that due to the facility’s resident population and physical plant design, several staff served multiple responsibilities thereby reducing the overall number of specialized staff interviewed. The auditor interviewed a medical staff member and a mental health professional, along with intake staff. The mental health professionals (identified by the agency as counselors / therapists) conduct the risk assessments for risk of victimization and abusiveness. The Human Resource staff person was also interviewed. Also interviewed was middle to upper management staff that also conducts unannounced visits to the facility during all the shifts. The auditor recommended additional training should be provided to the PREA Compliance Manager and PREA Compliance Coordinator as well as to the Corporate Compliance Director who
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supervises the PREA Compliance Manager. Subsequent to the interim report, Jim Herring, Corporate Compliance Director assumed the role of the PREA Compliance Coordinator. Mr. Herring successfully completed additional PREA training on “PREA Coordinators’ Roles and Responsibilities Course” provided by the National Institute of Corrections on May 5, 2015 along with the Agency Chief Executive Officer, the Associate Executive Director, and the PREA Compliance Manager. A review of the course completion records verified these actions. Follow-up telephone interviews were conducted on May 7-11, 2015 with the Agency Chief Executive Officer, the Associate Executive Director, the Corporate Compliance Director/PREA Compliance Coordinator and the PREA Compliance Manager. The telephone interviews that each individual interviews knew and understood their specific duties and responsibilities.
The mission of The Bridge, Inc. is “to provide substance use treatment opportunities producing positive, lasting change by partnering with each adolescent, family and community through honor, excellence and integrity.” The Bridge utilizes a telephone operator service for interpretation services as needed. Any instances of sexual abuse are to be referred for possible criminal investigation.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The Bridge was founded in 1974 in Gadsden, Alabama as a local “Drug Alert Center.” A Gadsden minister, Ray Crowder, volunteered his time to assist addicted individuals and combat the growing drug problem in northeast Alabama. Reverend Crowder's vision and tenacity were the primary ingredients for the development of The Bridge. He enlisted the help of the Etowah Baptist Association and the Gadsden Kiwanis Club to place a “hot line” telephone in his home. The number of calls for help was both astounding and overwhelming. Crowder then contacted the Alabama Department of Mental Health regarding grant money to open a counseling center in Gadsden. He was successful in securing a grant to open The Bridge in July, 1974 with three employees and served 37 clients during the first year.
In the mid ‘90’s The Bridge began working with the Alabama Department of Youth Services (ADYS) and expanding services to include behavioral rehabilitation. In addition, the organization began opening community-based outpatient programs to increase the number of teens and families receiving substance abuse treatment services.
The Bridge Gadsden, AL campus is located approximately 60 miles northeast of Birmingham in Etowah County in the northeast region of Alabama.
The Bridge Mitchell program is an all-male, minimum staff-secured facility that serves male residents ranging in age from 12-19 years old who have been adjudicated to the Alabama Department of Youth Services. The program has a capacity of 24 juveniles; however, there were 16 residents there during the first day of the audit. The Bridge contracts with ADYS for placement and treatment of juveniles identified with substance abuse issues in two programs located on the Gadsden campus – Mitchell (24 beds) and Kennington (24 beds). Both the Mitchell and Kennington programs are licensed by the ADYS. The Bridge is also certified by the State of Alabama Department of Mental Health / Substance Abuse Services Division for the provision of residential and outpatient substance abuse treatment services.
The atmosphere was relatively relaxed and comfortable.
SUMMARY OF AUDIT FINDINGS:
Number of standards exceeded: 0
Number of standards met: 39
Number of standards not met: 0
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Number of standards Not Applicable: 2
Standard 115.311: Zero tolerance of sexual abuse and sexual harassment
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) An agency shall have a written policy mandating zero tolerance toward all forms of sexual abuse and sexual harassment and outlining the agency's approach to preventing, detecting, and responding to such conduct.
b) An agency shall employ or designate an upper-level, agency-wide PREA coordinator with sufficient time and authority to develop, implement, and oversee agency efforts to comply with the PREA standards in all of its facilities.
c) Where an agency operates more than one facility, each facility shall designate a PREA compliance manager with sufficient time and authority to coordinate the facility's efforts to comply with the PREA standards
Reviewed policies/documents
 TBI-P.311 Zero tolerance of sexual abuse and sexual harassment, pp 1-12;
 Policy HR-2015
 Employee Handbook, p. 4
 Organizational Charts
 Statement of Assurance
Interviewed Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, Associate Executive Director.
The initial agency policy TBI-P.311 Zero tolerance of sexual abuse and sexual harassment submitted did not define sexual harassment, but included sexual harassment as a component of sexual misconduct. An acceptable plan of corrective action was developed with the auditor during the on-site audit. During the on-site audit, the agency modified policy TBI-P.311 Zero tolerance of sexual abuse and sexual harassment to include the required definition of sexual harassment. Following the policy revision, training was provided all staff, contractors, volunteers and residents. The Employee Handbook and Resident Handbook were also revised to reflect the updated zero tolerance policy modifications. Additionally, a “Statement of Assurance” was submitted to the auditor wherein the Corporate Compliance Director/PREA Compliance Coordinator documented that all staff, residents, contractors and volunteers received training on the revised zero tolerance policy. The auditor viewed the updated training curricula and a sample of updated training records. Additionally, the auditor conducted additional telephone staff interviews to verify the receipt of training and to verify staff understood the training on the new zero tolerance policy.
Standard 115.312: Contract with other entities for the confinement of residents.
□ Exceeds Standard (substantially exceeds requirement of standard)
□ Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
X Not Applicable
The standard states:
a) A public agency that contracts for the confinement of its residents with private agencies or other entities, including other government agencies, shall include in any new contract or contract renewal the entity's obligation to adopt and comply with the PREA standards.
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(N/A if the agency does not contract with private agencies or other entities for the confinement of residents.)
b) Any new contract or contract renewal shall provide for agency contract monitoring to ensure that the contractor is complying with the PREA standards.
The Mitchell program does not contract with private agencies or other entities for the confinement of residents.
Standard 115.313: Supervision and Monitoring
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall ensure that each facility it operates shall develop, implement, and document a staffing plan that provides for adequate levels of staffing, and, where applicable, video monitoring, to protect residents against sexual abuse. In calculating adequate staffing levels and determining the need for video monitoring, facilities shall take into consideration:
(1) Generally accepted juvenile detention and correctional/secure residential practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4)Any findings of inadequacy from internal or external oversight bodies;
(5) All components of the facility's physical plant (including "blind spots" or areas where staff or residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of sexual abuse; and
(11) Any other relevant factors.
b) The agency shall comply with the staffing plan except during limited and discrete exigent circumstances, and shall fully document deviations from the plan during such circumstances
c) Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8 during resident waking hours and 1:16 during resident sleeping hours, except during limited and discrete exigent circumstances, which shall be fully documented. Only security staff shall be included in these ratios. Any facility that, as of the date of publication of this final rule, is not already obligated by law, regulation, or judicial consent decree to maintain the staffing ratios set forth in this paragraph shall have until October 1, 2017, to achieve compliance.
d) Whenever necessary, but no less frequently than once each year, for each facility the agency operates, in consultation with the PREA coordinator required by § 115.311, the agency shall assess, determine, and document whether adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility's deployment of video monitoring systems and other monitoring technologies; and
(4) The resources the facility has available to commit to ensure adherence to the staffing plan.
e) Each secure facility shall implement a policy and practice of having intermediate-level or higher level supervisors conduct and document unannounced rounds to identify and deter staff sexual abuse and sexual harassment. Such policy and practice shall be implemented for night shifts as well as day shifts. Each secure facility shall have a policy to prohibit staff from alerting other staff members that these supervisory rounds are occurring, unless such announcement is related to the legitimate operational functions of the facility.
Reviewed policies/documents:
 TBI-P.311 Zero tolerance of sexual abuse and sexual harassment, pp 12-13, (E),(F);
 PREA Annual Facility Assessment
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 Facility work schedule
 Supervisory Monitoring Logs
 Agency contract with ADYS stipulating staffing ratios
Reviewed Documentation of Supervisory Unannounced Rounds, Camera Review Check documents. Reviewed physical plant design showing video cameras with video monitoring/recording capabilities. Reviewed video feed of living units and video recordings. Recordings may be retained infinitely on individual separate computer files.
Interviewed PREA Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, Associate Executive Director, mid-management facility staff and facility staff.
Standard 115.315: Limits to cross gender viewing and searches
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The facility shall not conduct cross- gender strip searches or cross-gender visual body cavity searches (meaning a search of the anal or genital opening) except in exigent circumstances or when performed by medical practitioners.
b) The agency shall not conduct cross- gender pat-down searches except in exigent circumstances
c) The facility shall document and justify all cross-gender strip searches, cross-gender visual body cavity searches, and cross-gender pat-down searches.
d) The facility shall implement policies and procedures that enable residents to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks. Such policies and procedures shall require staff of the opposite gender to announce their presence when entering a resident housing unit. In facilities (such as group homes) that do not contain discrete housing units, staff of the opposite gender shall be required to announce their presence when entering an area where residents are likely to be showering, performing bodily functions, or changing clothing
e) The facility shall not search or physically examine a transgender or intersex resident for the sole purpose of determining the resident's genital status. If the resident's genital status is unknown, it may be determined during conversations with the resident, by reviewing medical records, or, if necessary, by learning that information as part of a broader medical examination conducted in private by a medical practitioner
f) The agency shall train security staff in how to conduct cross-gender pat-down searches, and searches of transgender and intersex residents, in a professional and respectful manner, and in the least intrusive manner possible, consistent with security need
Reviewed policies/documents:
 TBI-P315 Limits to cross gender viewing and searches, pp. 1-2
 Agency Training Curricula, Training logs
 Resident handbook
Interviewed security staff and residents. Staff stated the facility prohibits pat-down/strip searches as outlined in policies/training received. Residents stated that they had not received pat-down/strip searches at any time during their stay. Staff and residents also stated that when female staff enters the living units, they announce their presence. Residents stated they were always given privacy when using the restroom facilities or in their bedrooms.
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Standard 115.316: Residents with disabilities and residents who are limited English Proficient
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall take appropriate steps to ensure that residents with disabilities (including, for example, residents who are deaf or hard of hearing, those who are blind or have low vision, or those who have intellectual, psychiatric, or speech disabilities), have an equal opportunity to participate in or benefit from all aspects of the agency's efforts to prevent, detect, and respond to sexual abuse and sexual harassment. Such steps shall include, when necessary to ensure effective communication with residents who are deaf or hard of hearing, providing access to interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. In addition, the agency shall ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities, including residents who have intellectual disabilities, limited reading skills, or who are blind or have low vision. An agency is not required to take actions that it can demonstrate would result in a fundamental alteration in the nature of a service, program, or activity, or in undue financial and administrative burdens, as those terms are used in regulations promulgated under title II of the Americans With Disabilities Act, 28 CFR 35.164.
b) The agency shall take reasonable steps to ensure meaningful access to all aspects of the agency's efforts to prevent, detect, and respond to sexual abuse and sexual harassment to residents who are limited English proficient, including steps to provide interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary.
c) The agency shall not rely on resident interpreters, resident readers, or other types of resident assistants except in limited circumstances where an extended delay in obtaining an effective interpreter could compromise the resident's safety, the performance of first-response duties under § 115.364, or the investigation of the resident's allegations
Reviewed policies/documents:
 TBI-P.316 Juveniles with disabilities and juveniles who are limited English proficient
 Memorandum Access to Interpreters
 Interpretation Services Agreement with Optimal Phone Interpreters
 Resident handbook
Interviewed PREA Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Coordinator, PREA Compliance Manager, Associate Executive Director, mid-management facility staff and random staff who stated residents with disabilities and/or who are limited English proficient shall be provided with assistance at any time as necessary. There have been no incidences of interpreters needed during the review period.
Standard 115.317: Hiring and promotion decisions
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall not hire or promote anyone who may have contact with residents, and shall not enlist the services of any contractor who may have contact with residents, who
(1) Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other
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institution (as defined in 42 U.S.C. 1997);
(2) Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse; or
(3) Has been civilly or administratively adjudicated to have engaged in the activity described in paragraph (a) (2) of this section.
b) The agency shall consider any incidents of sexual harassment in determining whether to hire or promote anyone, or to enlist the services of any contractor, who may have contact with residents.
c) Before hiring new employees who may have contact with residents, the agency shall:
(1) Perform a criminal background records check;
(2) Consult any child abuse registry maintained by the State or locality in which the employee would work; and
(3) Consistent with Federal, State, and local law, make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or any resignation during a pending investigation of an allegation of sexual abuse.
d) The agency shall also perform a criminal background records check, and consult applicable child abuse registries, before enlisting the services of any contractor who may have contact with residents.
e) The agency shall either conduct criminal background records checks at least every five years of current employees and contractors who may have contact with residents or have in place a system for otherwise capturing such information for current employees.
f) The agency shall also ask all applicants and employees who may have contact with residents directly about previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring or promotions and in any interviews or written self-evaluations conducted as part of reviews of current employees. The agency shall also impose upon employees a continuing affirmative duty to disclose any such misconduct.
g) Material omissions regarding such misconduct, or the provision of materially false information, shall be grounds for termination.
h) Unless prohibited by law, the agency shall provide information on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied to work.
Reviewed policies/documents:
 TBI-P.317 Recruitment and Selection
 Samples of criminal record background checks, Employee Handbook, criminal background checks of staff promotions
Interviewed administrative and Human Resources staff for hiring practices who stated criminal background checks are regularly conducted on new hires/promotions/contractors of those who may come into contact with residents.
Standard 115.318: Upgrades to facilities and technology
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) When designing or acquiring any new facility and in planning any substantial expansion or modification of existing facilities, the agency shall consider the effect of the design, acquisition, expansion, or modification upon the agency's ability to protect residents from sexual abuse.
b) When installing or updating a video monitoring system, electronic surveillance system, or other monitoring technology, the agency shall consider how such technology may enhance the agency's ability to protect residents from sexual abuse.
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Reviewed policies/documents/equipment:
 Video Camera Surveillance
 November 2013 installation invoice of additional CCTV cameras/DVR
 PREA Annual Facility Assessment
Interviewed Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, Associate Executive Director, mid-management facility staff. The auditor viewed live video feed of camera coverage which seemed adequate. There were no incidents which had occurred during the audit period and consequently there were no recordings to observe.
Standard 115.321: Evidence protocol and forensic medical examinations
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) To the extent the agency is responsible for investigating allegations of sexual abuse, the agency shall follow a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence for administrative proceedings and criminal prosecutions.
b) The protocol shall be developmentally appropriate for youth and, as appropriate, shall be adapted from or otherwise based on the most recent edition of the U.S. Department of Justice's Office on Violence Against Women publication, "A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents," or similarly comprehensive and authoritative protocols developed after 2011.
c) The agency shall offer all residents who experience sexual abuse access to forensic medical examinations whether on-site or at an outside facility, without financial cost, where evidentiarily or medically appropriate. Such examinations shall be performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible. If SAFEs or SANEs cannot be made available, the examination can be performed by other qualified medical practitioners. The agency shall document its efforts to provide SAFEs or SANEs.
d) The agency shall attempt to make available to the victim a victim advocate from a rape crisis center. If a rape crisis center is not available to provide victim advocate services, the agency shall make available to provide these services a qualified staff member from a community-based organization or a qualified agency staff member.
e) As requested by the victim, the victim advocate, qualified agency staff member, or qualified community-based organization staff member shall accompany and support the victim through the forensic medical examination process and investigatory interviews and shall provide emotional support, crisis intervention, information, and referrals
f) To the extent the agency itself is not responsible for investigating allegations of sexual abuse, the agency shall request that the investigating agency follow the requirements of paragraphs (a) through (e) of this section.
g) The requirements of paragraphs (a) through (f) of this section shall also apply to:
(1) Any State entity outside of the agency that is responsible for investigating allegations of sexual abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for investigating allegations of sexual abuse in juvenile facilities.
h) For the purposes of this standard, a qualified agency staff member or a qualified community-based staff member shall be an individual who has been screened for appropriateness to serve in this role and has received education concerning sexual assault and forensic examination issues in general.
Reviewed policies/documents:
 TBI.P-321 322 Special Investigations
 A National Protocol for Sexual assault Medical Forensic Examinations Adults/Adolescents
 Cooperative Agreement Between The Bridge, Inc. and The Children’s Hospital of Alabama d/b/a CHIPS
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Center,
 Memorandum of Understanding between The Bridge, Inc. and 2nd Chance Crisis Center
 Resident Handbook,
 Facility posters for Sexual Assault Services Program
 Memorandum of Understanding with the Etowah County Sheriff’s Department
 Interagency Investigative Agreement – Etowah County Multidisciplinary Child Abuse Team
 Telephone calls made by auditor to the Etowah County Sheriff’s Department
 Interviewed PREA Compliance Manager, random staff and residents
 Interviewed Associate Executive Director, PREA Compliance Manger, random staff and residents
It should be noted again that while the agency conducts administrative investigations into allegations of sexual abuse, criminal investigations are conducted by the Etowah County Sheriff’s Department. The agency has in place a Memorandum of Understanding with the Etowah County Sheriff’s Department which will conduct criminal investigations into criminal allegations of sexual abuse. The agency has asked the Sheriff’s Department to utilize "A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents," or similarly comprehensive and authoritative protocols developed after 2011”.
Standard 115.322: Policies to ensure referrals of allegations for investigations
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall ensure that an administrative or criminal investigation is completed for all allegations of sexual abuse and sexual harassment
b) The agency shall have in place a policy to ensure that allegations of sexual abuse or sexual harassment are referred for investigation to an agency with the legal authority to conduct criminal investigations, unless the allegation does not involve potentially criminal behavior. The agency shall publish such policy on its website or, if it does not have one, make the policy available through other means. The agency shall document all such referrals.
c) If a separate entity is responsible for conducting criminal investigations, such publication shall describe the responsibilities of both the agency and the investigating entity.
d) Any state entity responsible for conducting administrative or criminal investigations of sexual abuse or sexual harassment in juvenile facilities shall have in place a policy governing the conduct of such investigations.
e) Any Department of Justice component responsible for conducting administrative or criminal investigations of sexual abuse or sexual harassment in juvenile facilities shall have in place a policy governing the conduct of such investigations.
Reviewed policies/documents:
 TBI.P-321 322 Special Investigations
 A National Protocol for Sexual assault Medical Forensic Examinations Adults/Adolescents
 Resident Handbook
 Facility posters for Sexual Assault Services Program
 Memorandum of Understanding with the Etowah County Sheriff’s Department
 Interagency Investigative Agreement – Etowah County Multidisciplinary Child Abuse Team
 PREA policy on website http://www.bridgeinc.org/pages/?pageID=53
Interviewed Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, Associate Executive Director, mid-management facility staff and random residents. In the past 12 months, there were zero (0)
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allegations of sexual abuse or harassment
Standard 115.331: Employee training
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall train all employees who may have contact with residents on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures;
(3) Residents' right to be free from sexual abuse and sexual harassment;
(4) The right of residents and employees to be free from retaliation for reporting sexual abuse and sexual harassment;
(5) The dynamics of sexual abuse and sexual harassment in juvenile facilities;
(6) The common reactions of juvenile victims of sexual abuse and sexual harassment;
(7) How to detect and respond to signs of threatened and actual sexual abuse and how to distinguish between consensual sexual contact and sexual abuse between residents;
(8) How to avoid inappropriate relationships with residents;
(9) How to communicate effectively and professionally with residents, including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming residents;
(10) How to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities; and
(11) Relevant laws regarding the applicable age of consent.
b) Such training shall be tailored to the unique needs and attributes of residents of juvenile facilities and to the gender of the residents at the employee's facility. The employee shall receive additional training if the employee is reassigned from a facility that houses only male residents to a facility that houses only female residents or vice versa.
c) All current employees who have not received such training shall be trained within one year of the effective date of the PREA standards, and the agency shall provide each employee with refresher training every two years to ensure that all employees know the agency's current sexual abuse and sexual harassment policies and procedures. In years in which an employee does not receive refresher training, the agency shall provide refresher information on current sexual abuse and sexual harassment policies.
d) The agency shall document, through employee signature or electronic verification that employees understand the training they have received.
Reviewed policies/documents:
 TBI.P-311, 331 332 334 335 Sexual Abuse/Assault/Harassment Training
 Prison Rape Elimination Act (PREA) Mandatory Staff / Volunteer / Contractor Training
 PREA Orientation for staff – Facts We Want You To Know.
 Employee/Volunteer Basic Training Acknowledgements
 Sample of training records and training acknowledgement documents
 Meeting minutes providing information about PREA between training sessions
 Statement of Assurance
Interviewed Corporate Compliance Director/PREA Compliance Manager, PREA Compliance Coordinator, random staff, and facility trainer. After the audit, all employees were trained on the revised zero-tolerance policy TBI.P-311 as evidenced by the Statement of Assurance and follow-up telephone interviews with staff.
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Standard 115.332 Volunteer and contractor training
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall ensure that all volunteers and contractors who have contact with residents have been trained on their responsibilities under the agency's sexual abuse and sexual harassment prevention, detection, and response policies and procedures
b) The level and type of training provided to volunteers and contractors shall be based on the services they provide and level of contact they have with residents, but all volunteers and contractors who have contact with residents shall be notified of the agency's zero-tolerance policy regarding sexual abuse and sexual harassment and informed how to report such incidents
c) The agency shall maintain documentation confirming that volunteers and contractors understand the training they have received.
Reviewed policies/documents:
 TBI.P-331 332 334 335 Sexual Abuse/Assault/Harassment Training
 Prison Rape Elimination Act (PREA) Mandatory Staff/Volunteer/Contractor Training
 PREA Orientation for staff – Facts We Want You To Know.
 Contractor/Volunteer Training Acknowledgements
 Sample of training contractor record
 Contract Private Provider Receipt of PREA
 Staff meeting minutes providing information about PREA between training sessions
 Statement of Assurance
Interviewed random contractor who confirmed the receipt and documentation of PREA training. Following the audit, training was provided to contractors on the updated zero tolerance policy.
Standard 115.333: Resident Education
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) During the intake process, residents shall receive information explaining, in an age appropriate fashion, the agency's zero tolerance policy regarding sexual abuse and sexual harassment and how to report incidents or suspicions of sexual abuse or sexual harassment.
b) Within 10 days of intake, the agency shall provide comprehensive age-appropriate education to residents either in person or through video regarding their rights to be free from sexual abuse and sexual harassment and to be free from retaliation for reporting such incidents, and regarding agency policies and procedures for responding to such incidents.
c) Current residents who have not received such education shall be educated within one year of the effective date of the PREA standards, and shall receive education upon transfer to a different facility to the extent that the policies and procedures of the resident's new facility differ from those of the previous facility.
d) The agency shall provide resident education in formats accessible to all residents, including those who are
13
limited English proficient, deaf, visually impaired, or otherwise disabled, as well as to residents who have limited reading skills.
e) The agency shall maintain documentation of resident participation in these education sessions.
f) In addition to providing such education, the agency shall ensure that key information is continuously and readily available or visible to residents through posters, resident handbooks, or other written formats.
Reviewed policies/documents:
 TBI-P.333 Resident Education
 PREA Orientation – Facts We Want You To Know
 Resident handbook, specifically information on PREA
 PREA posters posted on all living units – English and Spanish
 Juvenile Confirmation of Receipt of PREA Info
 BRIDGE SAFE – Client Safety Guide for residents
 Alabama Department of Youth Services “What you should know about sexual abuse and assault”
 Statement of Assurance
Interviewed intake staff and random residents. After the audit, residents received training on the revised zero-tolerance of sexual abuse and sexual harassment policy.
Standard 115.334: Specialized training: Investigations
□ Exceeds Standard (substantially exceeds requirement of standard)
□ Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
X Not Applicable
The standard states:
a) In addition to the general training provided to all employees pursuant to § 115.331, the agency shall ensure that, to the extent the agency itself conducts sexual abuse investigations, its investigators have received training in conducting such investigations in confinement settings.
b) Specialized training shall include techniques for interviewing juvenile sexual abuse victims, proper use of Miranda and Garrity warnings, sexual abuse evidence collection in confinement settings, and the criteria and evidence required to substantiate a case for administrative action or prosecution referral.
c) The agency shall maintain documentation that agency investigators have completed the required specialized training in conducting sexual abuse investigations.
d) Any State entity or Department of Justice component that investigates sexual abuse in juvenile confinement settings shall provide such training to its agents and investigators who conduct such investigations.
Reviewed policies/documents:
 TBI.P-331 332 334 335 Sexual Abuse/Assault/Harassment Training
 Prison Rape Elimination Act (PREA) Mandatory Staff/Volunteer/Contractor Training
 Training records/acknowledgements and Certificates
Interviewed Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, telephone call to Etowah County Sheriff’s Department
The facility and ADYS conduct administrative investigations and the Etowah County Sheriff’s Department conducts criminal investigations as per their Memorandum of Understanding.
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Standard 115.335: Specialized training: Medical and mental health care
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall ensure that all full-and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in:
(1) How to detect and assess signs of sexual abuse and sexual harassment;
(2) How to preserve physical evidence of sexual abuse;
(3) How to respond effectively and professionally to juvenile victims of sexual abuse and sexual harassment and;
(4) How and to whom to report allegations or suspicions of sexual abuse and sexual harassment.
b) If medical staff employed by the agency conduct forensic examinations, such medical staff shall receive the appropriate training to conduct such examinations.
c) The agency shall maintain documentation that medical and mental health practitioners have received the training referenced in this standard either from the agency or elsewhere.
d) Medical and mental health care practitioners shall also receive the training mandated for employees under § 115.331 or for contractors and volunteers under § 115.332, depending upon the practitioner's status at the agency.
Reviewed policies/documents:
 TBI.P-331 332 334 335 Sexual Abuse/Assault/Harassment Training
 Prison Rape Elimination Act (PREA) Mandatory Staff/Volunteer/Contractor Training
 The Bridge, Inc. Training Sign-in Sheet – PREA Refresher Training
 Medical Receipt of PREA
 PREA Specialized Medical/Mental Health Training Acknowledgement
Interviewed medical and mental health staff
The agency does not conduct forensic examinations; rather they will be conducted at Children’s Hospital Intervention Prevention (CHIP) Program, located in Birmingham, AL.
Standard 115.341: Screening for risk of victimization and abusiveness
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Within 72 hours of the resident's arrival at the facility and periodically throughout a resident's confinement, the agency shall obtain and use information about each resident's personal history and behavior to reduce the risk of sexual abuse by or upon a resident.
b) Such assessments shall be conducted using an objective screening instrument.
c) At a minimum, the agency shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) Any gender nonconforming appearance or manner or identification as lesbian, gay, bisexual, transgender, or intersex, and whether the resident may therefore be vulnerable to sexual abuse;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
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(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The resident's own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate heightened needs for supervision, additional safety precautions, or separation from certain other residents.
d) This information shall be ascertained through conversations with the resident during the intake process and medical and mental health screenings; during classification assessments; and by reviewing court records, case files, facility behavioral records, and other relevant documentation from the resident's files.
e) The agency shall implement appropriate controls on the dissemination within the facility of responses to questions asked pursuant to this standard in order to ensure that sensitive information is not exploited to the resident's detriment by staff or other residents.
Reviewed policies/documents:
 TBI-P.311 Zero tolerance of sexual abuse and sexual harassment; PREA Coordinator, pp 4-6
 PREA Form 115.341 Alabama Department of Youth Services Intake Screening for Assaultive Behavior, Sexually Aggressive Behavior, and Risk for Sexual Victimization.
 The Bridge, Inc. Physical and Health Screening Intake form
 Resident Handbook
 Completed Screening Tool
 Youth records
Interviewed Corporate Compliance Coordinator/PREA Compliance Coordinator, PREA Compliance Manager, staffs responsible for risk screening, random residents. Interviews confirmed the facility does not permit the use of isolation, residents are screened within 72 hours or earlier of placement and screened monthly thereafter. There were no youth identified as lesbian, gay, bisexual, transgender or intersex. All youth stated they felt safe at the facility.
Standard 115.342: Use of screening information
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall use all information obtained pursuant to § 115.341 and subsequently to make housing, bed,
program, education, and work assignments for residents with the goal of keeping all residents safe and free from sexual abuse.
b) Residents may be isolated from others only as a last resort when less restrictive measures are inadequate to keep them and other residents safe, and then only until an alternative means of keeping all residents safe can be arranged. During any period of isolation, agencies shall not deny residents daily large-muscle exercise and any legally required educational programming or special education services. Residents in isolation shall receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work opportunities to the extent possible.
c) Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in particular housing, bed, or other assignments solely on the basis of such identification or status, nor shall agencies consider lesbian, gay, bisexual, transgender, or intersex identification or status as an indicator of likelihood of being sexually abusive.
d) In deciding whether to assign a transgender or intersex resident to a facility for male or female residents, and in making other housing and programming assignments, the agency shall consider on a case-by-case basis whether a placement would ensure the resident's health and safety, and whether the placement would present management or security problems
e) Placement and programming assignments for each transgender or intersex resident shall be reassessed at least twice each year to review any threats to safety experienced by the resident.
f) A transgender or intersex resident's own views with respect to his or her own safety shall be given serious
16
consideration
g) Transgender and intersex residents shall be given the opportunity to shower separately from other residents.
h) If a resident is isolated pursuant to paragraph (b) of this section, the facility shall clearly document:
(1) The basis for the facility's concern for the resident's safety; and
(2) The reason why no alternative means of separation can be arranged.
i) Every 30 days, the facility shall afford each resident described in paragraph (h) of this section a review to determine whether there is a continuing need for separation from the general population.
Reviewed policies/documents:
 TBI-P.342 368 Placement of residents in housing, bed, program, education and work Assignments; Post allegation protection custody
 The Bridge, Inc. Physical and Health Screening Intake form
 Dorm Unit Placement – DYS form 115.342
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, staffs responsible for risk screening, medical/mental health staff, and random residents. Interviews confirmed the facility does not permit the use of isolation, no youth had identified themselves as lesbian, gay, bisexual, transgender or intersex and that housing/bed/program assignments are based upon screening information.
Standard 115.351: Resident Reporting
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall provide multiple internal ways for residents to privately report sexual abuse and sexual harassment, retaliation by other residents or staff for reporting sexual abuse and sexual harassment, and staff neglect or violation of responsibilities that may have contributed to such incidents.
b) The agency shall also provide at least one way for residents to report abuse or harassment to a public or private entity or office that is not part of the agency and that is able to receive and immediately forward resident reports of sexual abuse and sexual harassment to agency officials, allowing the resident to remain anonymous upon request. Residents detained solely for civil immigration purposes shall be provided information on how to contact relevant consular officials and relevant officials at the Department of Homeland Security.
c) Staff shall accept reports made verbally, in writing, anonymously, and from third parties and shall promptly document any verbal reports.
d) The facility shall provide residents with access to tools necessary to make a written report.
e) The agency shall provide a method for staff to privately report sexual abuse and sexual harassment of residents.
Reviewed policies/documents:
 TBI-P.351 Resident Reporting
 Resident Handbook
 Staff Orientation Handbook
 BRIDGE SAFE – Client Safety Guide for residents
 Juvenile Confirmation of Receipt of PREA Info
 Facility posters - Sexual Assault Services Program
 Memorandum of Understanding (MOU) between the facility and rape crisis center (Second Chance) for toll free Hotline reporting
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 PREA policy on website http://www.bridgeinc.org/pages/?pageID=53
 The Bridge, Inc. form - Third Party Reporting for Alleged Sexual Abuse, Sexual Assault and Sexual Harassment
Interviewed PREA Compliance Manager, random residents/staff. Interviews and observations confirmed multiple ways of private/verbal/third party allegation reporting (to include staff neglect/violation of responsibilities). The facility does not house residents for civil immigration.
Standard 115.352: Exhaustion of administrative remedies
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) An agency shall be exempt from this standard if it does not have administrative procedures to address resident grievances regarding sexual abuse.
b) (1) The agency shall not impose a time limit on when a resident may submit a grievance regarding an allegation of sexual abuse.
(2) The agency may apply otherwise-applicable time limits on any portion of a grievance that does not allege an incident of sexual abuse.
(3) The agency shall not require a resident to use any informal grievance process, or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse.
(4)Nothing in this section shall restrict the agency's ability to defend against a lawsuit filed by a resident on the ground that the applicable statute of limitations has expired
c) The agency shall ensure that
1) A resident who alleges sexual abuse may submit a grievance without submitting it to a staff member who is the subject of the complaint, and
2) Such grievance is not referred to a staff member who is the subject of the complaint.
d) (1) The agency shall 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.
(2) Computation of the 90-day time period shall not include time consumed by residents in preparing any administrative appeal.
(3) The agency may claim an extension of time to respond, of up to 70 days, if the normal time period for response is insufficient to make an appropriate decision. The agency shall notify the resident in writing of any such extension and provide a date by which a decision will be made.
(4) At any level of the administrative process, including the final level, if the resident does not receive a response within the time allotted for reply, including any properly noticed extension, the resident may consider the absence of a response to be a denial at that level.
e) (1) Third parties, including fellow residents, staff members, family members, attorneys, and outside advocates, shall be permitted to assist residents in filing requests for administrative remedies relating to allegations of sexual abuse, and shall also be permitted to file such requests on behalf of residents.
(2) If a third party, other than a parent or legal guardian, files such a request on behalf of a resident, the facility may require as a condition of processing the request that the alleged victim agree to have the request filed on his or her behalf, and may also require the alleged victim to personally pursue any subsequent steps in the administrative remedy process.
(3) If the resident declines to have the request processed on his or her behalf, the agency shall document the resident's decision.
(4) A parent or legal guardian of a juvenile shall be allowed to file a grievance regarding allegations of sexual abuse, including appeals, on behalf of such juvenile. Such a grievance shall not be conditioned upon the juvenile agreeing to have the request filed on his or her behalf.
f) (1) The agency shall establish procedures for the filing of an emergency grievance alleging that a resident is subject to a substantial risk of imminent sexual abuse.
(2) After receiving an emergency grievance alleging a resident is subject to a substantial risk of imminent
18
sexual abuse, the agency shall 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, shall provide an initial response within 48 hours, and shall issue a final agency decision within 5 calendar days. The initial response and final agency decision shall document the agency's determination whether the resident is in substantial risk of imminent sexual abuse and the action taken in response to the emergency grievance.
g) The agency may discipline a resident for filing a grievance related to alleged sexual abuse only where the agency demonstrates that the resident filed the grievance in bad faith.
Reviewed policies/documents:
 TBI-P.352 Exhaustion of Administrative Remedies: Youth Grievance Procedures
 Resident Handbook
 Grievance forms
 Prison Rape Elimination Act (PREA) Mandatory Staff/Volunteer/Contractor Training
 Department of Youth Services Extension Request
Standard 115.353: Resident access to outside confidential support services
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The facility shall provide residents with access to outside victim advocates for emotional support
services related to sexual abuse, by providing, posting, or otherwise making accessible mailing addresses and telephones, including toll free hotline numbers where available, of local, State, or national victim advocacy or rape crisis organizations, and, for persons detained solely for civil immigration purposes, immigrant services agencies. The facility shall enable reasonable communication between residents and these organizations and agencies, in as confidential a manner as possible.
b) The facility shall inform residents, prior to giving them access, of the extent to which such communications will be monitored and the extent to which reports of abuse will be forwarded to authorities in accordance with mandatory reporting laws.
c) The agency shall maintain or attempt to enter into memoranda of understanding or other agreements with community service providers that are able to provide residents with confidential emotional support services related to sexual abuse. The agency shall maintain copies of agreements or documentation showing attempts to enter into such agreements.
d) The facility shall also provide residents with reasonable and confidential access to their attorneys or other legal representation and reasonable access to parents or legal guardians.
Reviewed policies/documents:
 TBI-P.353 354 Resident access to outside support services and legal representation & Third-party reporting
 Resident Handbook
 Rape Crisis Resources telephone numbers and address lists
 Memorandum of Understanding (MOU) between the facility and rape crisis center (Second Chance) for toll free Hotline reporting
 PREA policy on website http://www.bridgeinc.org/pages/?pageID=53
 Sexual Assault Services Program posters on living units
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, random residents,
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Standard 115.354: Third-party reporting
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall establish a method to receive third-party reports of sexual abuse and sexual harassment and shall distribute publicly information on how to report sexual abuse and sexual harassment on behalf of a resident.
Reviewed policies/documents:
 PREA Written Institutional Plan, The Bridge, Inc.
 The Bridge, Inc. form - Third Party Reporting for Alleged Sexual Abuse, Sexual Assault and Sexual Harassment
 Resident Handbook
 Rape Crisis Resources telephone numbers and address lists
 Memorandum of Understanding (MOU) between the facility and rape crisis center (Second Chance) for toll free Hotline reporting
 PREA policy on website http://www.bridgeinc.org/pages/?pageID=53
 Sexual Assault Services Program posters on living units
Interviewed agency administrators, random staff and residents who confirmed knowledge of multiple methods of third-party reporting of sexual abuse and sexual harassment.
Standard 115.361: Staff and agency reporting duties
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall require all staff to report immediately and according to agency policy any knowledge, suspicion, or information they receive regarding an incident of sexual abuse or sexual harassment that occurred in a facility, whether or not it is part of the agency; retaliation against residents or staff who reported such an incident; and any staff neglect or violation of responsibilities that may have contributed to an incident or retaliation.
b) The agency shall also require all staff to comply with any applicable mandatory child abuse reporting laws
c) Apart from reporting to designated supervisors or officials and designated State or local services agencies, staff shall be prohibited from revealing any information related to a sexual abuse report to anyone other than to the extent necessary, as specified in agency policy, to make treatment, investigation, and other security and management decisions.
d) (1) Medical and mental health practitioners shall be required to report sexual abuse to designated supervisors and officials pursuant to paragraph (a) of this section, as well as to the designated State or local services agency where required by mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation of services of their duty to report and the limitations of confidentiality
e) (1) Upon receiving any allegation of sexual abuse, the facility head or his or her designee shall promptly report the allegation to the appropriate agency office and to the alleged victim's parents or legal guardians, unless the facility has official documentation showing the parents or legal guardians should not be notified.
(2) If the alleged victim is under the guardianship of the child welfare system, the report shall be made
20
to the alleged victim's caseworker instead of the parents or legal guardians.
(3) If a juvenile court retains jurisdiction over the alleged victim, the facility head or designee shall also report the allegation to the juvenile's attorney or other legal representative of record within 14 days of receiving the allegation.
f) The facility shall report all allegations of sexual abuse and sexual harassment; including third-party and anonymous reports, to the facility's designated investigators.
Reviewed policies/documents:
 TBI-P.311 Zero tolerance of sexual abuse and sexual harassment p. 6 (B)
 TBI-P.361 Staff and agency reporting duties
Interviews of Facility Executive Director, Associate Executive Director, Corporate Compliance Director/PREA Coordinator, PREA Compliance Manager, Medical/Mental Health staffs, random staff
Standard 115.362: Agency protection duties
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) When an agency learns that a resident is subject to a substantial risk of imminent sexual abuse, it shall take immediate action to protect the resident.
Reviewed policies/documents:
 TBI-P.362 Agency protection duties
 Prison Rape Elimination Act (PREA) Mandatory Staff / Volunteer / Contractor Training
 Critical Incident form
There have been zero (0) incidents requiring immediate action required concerning allegation of sexual contact.
Interviewed of Facility Executive Director, Associate Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, random staff
Standard 115.363: Reporting to other confinement facilities
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Upon receiving an allegation that a resident was sexually abused while confined at another facility, the head of the facility that received the allegation shall notify the head of the facility or appropriate office of the agency where the alleged abuse occurred and shall also notify the appropriate investigative agency.
b) Such notification shall be provided as soon as possible, but no later than 72 hours after receiving the allegation.
c) The agency shall document that it has provided such notification.
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d) The facility head or agency office that receives such notification shall ensure that the allegation is investigated in accordance with these standards.
Reviewed policies/documents:
 TBI-P.363 Reporting to other confinement facilities
Interviewed Facility Executive Director, Associate Executive Director Corporate Compliance Director/PREA Compliance Coordinator. No instances of abuse allegations were reported while resident(s) were confined at another facility.
Standard 115.364: Staff first responder duties
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Upon learning of an allegation that a resident was sexually abused, the first staff member to respond to the report shall be required to:
(1) Separate the alleged victim and abuser;
(2) Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence;
(3) If the abuse occurred within a time period that still allows for the collection of physical evidence, request that the alleged victim not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating; and
(4) If the abuse occurred within a time period that still allows for the collection of physical evidence, ensure that the alleged abuser does not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating
b) If the first staff responder is not a security staff member, the responder shall be required to request that the alleged victim not take any actions that could destroy physical evidence, and then notify security staff.
Reviewed policies/documents:
 TBI-P.364 365 Staff first responder duties & Coordinated Response
 First responder checklist and guidelines
Zero (0) allegations of sexual abuse were reported.
Interviewed Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager, first responders and random staff
Standard 115.365: Coordinated response
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The facility shall develop a written institutional plan to coordinate actions taken in response to an incident of sexual abuse among staff first responders, medical and mental health practitioners, investigators, and
22
facility leadership.
Reviewed policies/documents:
 PREA Written Institutional Plan, The Bridge, Inc.
Interview with Facility Executive Director, Associate Executive Director, Corporate Compliance Director/PREA Compliance Coordinator
Standard 115.366: Preservation of ability to protect residents from contact with abusers.
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Neither the agency nor any other governmental entity responsible for collective bargaining on the agency's behalf shall enter into or renew any collective bargaining agreement or other agreement that limits the agency's ability to remove alleged staff sexual abusers from contact with residents pending the outcome of an investigation or of a determination of whether and to what extent discipline is warranted.
b) Nothing in this standard shall restrict the entering into or renewal of agreements that govern:
(1) The conduct of the disciplinary process, as long as such agreements are not inconsistent with the provisions of Standard 115.372 and 115.376; or
(2) Whether a no-contact assignment that is imposed pending the outcome of an investigation shall be expunged from or retained in the staff member’s personnel file following a determination that the allegation of sexual abuse is not substantiated.
Reviewed policies/documents:
 TBI-P.311 Zero tolerance of sexual abuse and sexual harassment p. 1
 TBI-P.366 Preservation of ability to protect residents from contact with abusers
Interviewed Agency Executive Director, Corporate Compliance Director/PREA Compliance Coordinator
There are no labor unions or collective bargaining groups at the facility. There have been no new or renewed contracts in the past year; however, any contracts developed or renewed will allow alleged staff sexual abusers to be removed from contact with residents pending the outcome of the investigation and a determination of discipline.
Standard 115.367: Agency protection against retaliation
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall establish a policy to protect all residents and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other residents or staff and shall designate which staff members or departments are charged with monitoring retaliation.
b) The agency shall employ multiple protection measures, such as housing changes or transfers for resident victims or abusers, removal of alleged staff or resident abusers from contact with victims, and
23
emotional support services for residents or staff who fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with investigations.
c) For at least 90 days following a report of sexual abuse, the agency shall monitor the conduct or treatment of residents or staff who reported the sexual abuse and of residents who were reported to have suffered sexual abuse to see if there are changes that may suggest possible retaliation by residents or staff, and shall act promptly to remedy any such retaliation. Items the agency should monitor include any resident disciplinary reports, housing or program changes, or negative performance reviews or reassignments of staff. The agency shall continue such monitoring beyond 90 days if the initial monitoring indicates a continuing need.
d) In the case of residents, such monitoring shall also include periodic status checks.
e) If any other individual who cooperates with an investigation expresses a fear of retaliation, the agency shall take appropriate measures to protect that individual against retaliation.
f) An agency’s obligation to monitor shall terminate if the agency determines that the allegation is unfounded.
Reviewed policies/documents:
 TBI-P.311 Zero tolerance of sexual abuse and sexual harassment p. 1
 TBI-P.367 The Bridge Protections Against Retaliation
 Executive Director Memo – Notification of PREA Roles
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator (designated staff member charged with monitoring for retaliation). There were no residents at the facility who reported a sexual abuse incident at the time of the audit. There were no incidents of retaliation occurring in the past 12 months. The facility does not utilize isolation.
Standard 115.368: Post allegation protective custody
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Any use of segregated housing to protect a resident who is alleged to have suffered sexual abuse shall be subject to the requirements of § 115.342.
Reviewed policies/documents:
 TBI-P.342 368 Placement of residents in housing, bed, program, education, and work Assignments; Post allegation protective custody, p. 1
Interviewed the Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator. The facility does not use segregated housing to protect a resident who is alleged to have suffered sexual abuse.
Standard 115.371: Criminal and administrative agency investigations
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
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The standard states:
a) When the agency conducts its own investigations into allegations of sexual abuse and sexual harassment, it shall do so promptly, thoroughly, and objectively for all allegations, including third-party and anonymous reports.
(N/A if the agency does not conduct any form of administrative or criminal investigations of sexual abuse or sexual harassment. See 115.321 (a)
b) Where sexual abuse is alleged, the agency shall use investigators who have received special training in sexual abuse investigations involving juvenile victims pursuant to § 115.334.
c) Investigators shall gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data; shall interview alleged victims, suspected perpetrators, and witnesses; and shall review prior complaints and reports of sexual abuse involving the suspected perpetrator.
d) The agency shall not terminate an investigation solely because the source of the allegation recants the allegation.
e) When the quality of evidence appears to support criminal prosecution, the agency shall conduct compelled interviews only after consulting with prosecutors as to whether compelled interviews may be an obstacle for subsequent criminal prosecution
f) The credibility of an alleged victim, suspect, or witness shall be assessed on an individual basis and shall not be determined by the person's status as resident or staff. No agency shall require a resident who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a condition for proceeding with the investigation of such an allegation
g) Administrative investigations:
1) Shall include an effort to determine whether staff actions or failures to act contributed to the abuse; and
2) Shall be documented in written reports that include a description of the physical and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings.
h) Criminal investigations shall be documented in a written report that contains a thorough description of physical, testimonial, and documentary evidence and attaches copies of all documentary evidence where feasible.
i) Substantiated allegations of conduct that appears to be criminal shall be referred for prosecution.
j) The agency shall retain all written reports referenced in paragraphs (g) and (h) of this section for as long as the alleged abuser is incarcerated or employed by the agency, plus five years, unless the abuse was committed by a juvenile resident and applicable law requires a shorter period of retention.
k) The departure of the alleged abuser or victim from the employment or control of the facility or agency shall not provide a basis for terminating an investigation.
l) Any State entity or Department of Justice component that conducts such investigations shall do so pursuant to the above requirements.
m) When outside agencies investigate sexual abuse, the facility shall cooperate with outside investigators and shall endeavor to remain informed about the progress of the investigation.
Reviewed policies/documents:
 TBI-P.371 372 Referrals of Sexual Abuse/Assault/Harassment Allegations for Investigations
 Interagency Investigative Agreement – Etowah County Multidisciplinary Child Abuse Team
 PREA Written Institutional Plan, The Bridge, Inc.
 Memorandum of Understanding with Etowah County Sheriff’s Department
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, PREA Compliance Manager. The agency conducts administrative investigations only. There were no residents assigned to the facility who reported a sexual abuse allegation. The agency has a Memorandum of Understanding with the Etowah County Sheriff’s Department which has agreed to conduct criminal investigations.
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Standard 115.372: Evidentiary standards for administrative investigations
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall impose no standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated.
Reviewed policies/documents:
 TBI-P.371 372 Referrals of Sexual Abuse/Assault/Harassment Allegations for Investigations, p.3
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator
Standard 115.373: Reporting to residents
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Following an investigation into a resident's allegation of sexual abuse suffered in an agency facility, the agency shall inform the resident as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded.
b) If the agency did not conduct the investigation, it shall request the relevant information from the investigative agency in order to inform the resident.
c) Following a resident's allegation that a staff member has committed sexual abuse against the resident, the agency shall subsequently inform the resident (unless the agency has determined that the allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge related to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a charge related to sexual abuse within the facility.
d) Following a resident's allegation that he or she has been sexually abused by another resident, the agency shall subsequently inform the alleged victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related to sexual abuse within the facility; or
2) The agency learns that the alleged abuser has been convicted on a charge related to sexual abuse within the facility.
e) All such notifications or attempted notifications shall be documented.
f) An agency’s obligation to report under this standard shall terminate if the resident is released from the agency’s custody.
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Reviewed policies/documents:
 TBI-P.373 Reporting to Juveniles Following a Sexual Assault, p. 1, III (A), p. 2(C)
 Interagency Investigative Agreement – Etowah County Multidisciplinary Child Abuse Team
 Juvenile Notification of Investigative Outcome DYS Form 115.373
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator. There were no residents at the facility who had reported alleged sexual abuse.
Standard 115.376: Disciplinary sanctions for staff
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Staff shall be subject to disciplinary sanctions up to and including termination for violating agency sexual abuse or sexual harassment policies.
b) Termination shall be the presumptive disciplinary sanction for staff who has engaged in sexual abuse.
c) Disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) shall be commensurate with the nature and circumstances of the acts committed, the staff member's disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories.
d) All terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and to any relevant licensing bodies.
Reviewed policies/documents:
 TBI-P.376 Disciplinary sanctions for staff
 Employee Handbook
 Employee Handbook Acknowledgement
Interviewed the Corporate Compliance Director/PREA Compliance Coordinator
There were no allegations of sexual abuse/harassment. Violations of agency policy require that staff be terminated and notifications be made to law enforcement agencies and to relevant licensing bodies.
Standard 115.377: Corrective action for contractors and volunteers
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Any contractor or volunteer who engages in sexual abuse shall be prohibited from contact with residents and shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and to relevant licensing bodies.
b) The facility shall take appropriate remedial measures, and shall consider whether to prohibit further contact
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with residents, in the case of any other violation of agency sexual abuse or sexual harassment policies by a contractor or volunteer.
Reviewed policies/documents:
 TBI-P.377 Corrective Actions for contractors and volunteers.
 ADYS Critical Incident Report Form DYS Form 8.12
 Interagency Investigative Agreement – Etowah County Multidisciplinary Child Abuse Team
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, HR staff. There were no allegations concerning contractors/volunteers during the review period.
Standard 115.378: Disciplinary sanctions for residents
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) A resident may be subject to disciplinary sanctions only pursuant to a formal disciplinary process following an administrative finding that the resident engaged in resident-on-resident sexual abuse or following a criminal finding of guilt for resident-on-resident sexual abuse.
b) Any disciplinary sanctions shall be commensurate with the nature and circumstances of the abuse committed, the resident's disciplinary history, and the sanctions imposed for comparable offenses by other residents with similar histories. In the event a disciplinary sanction results in the isolation of a resident, agencies shall not deny the resident daily large-muscle exercise or access to any legally required educational programming or special education services. Residents in isolation shall receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work opportunities to the extent possible.
c) The disciplinary process shall consider whether a resident's mental disabilities or mental illness contributed to his or her behavior when determining what type of sanction, if any, should be imposed.
d) If the facility offers therapy, counseling, or other interventions designed to address and correct underlying reasons or motivations for the abuse, the facility shall consider whether to offer the offending resident participation in such interventions. The agency may require participation in such interventions as a condition of access to any rewards-based behavior management system or other behavior-based incentives, but not as a condition to access to general programming or education.
e) The agency may discipline a resident for sexual contact with staff only upon a finding that the staff member did not consent to such contact.
f) For the purpose of disciplinary action, a report of sexual abuse made in good faith based upon a reasonable belief that the alleged conduct occurred shall not constitute falsely reporting an incident or lying, even if an investigation does not establish evidence sufficient to substantiate the allegation
g) An agency may, in its discretion, prohibit all sexual activity between residents and may discipline residents for such activity. An agency may not, however, deem such activity to constitute sexual abuse if it determines that the activity is not coerced.
Reviewed policies/documents:
 TBI-P.378 Disciplinary sanctions for residents
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, Mental Health staff. There has not been any substantiated resident on resident or resident with staff sexual abuse. The facility does not use isolation.
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Standard 115.381: Medical and mental health screenings; history of sexual abuse
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) If the screening pursuant to §115.341 indicates that a resident has experienced prior sexual victimization, whether it occurred in an institutional setting or in the community, staff shall ensure that the resident is offered a follow-up meeting with a medical or mental health practitioner within 14 days of the intake screening.
b) If the screening pursuant to §115.341 indicates that a resident has previously perpetrated sexual abuse, whether it occurred in an institutional setting or in the community, staff shall ensure that the resident is offered a follow-up meeting with a mental health practitioner within 14 days of the intake screening.
c) Any information related to sexual victimization or abusiveness that occurred in an institutional setting shall be strictly limited to medical and mental health practitioners and other staff, as necessary, to inform treatment plans and security and management decisions, including housing, bed, work, education, and program assignments, or as otherwise required by Federal, State, or local law.
d) Medical and mental health practitioners shall obtain informed consent from residents before reporting information about prior sexual victimization that did not occur in an institutional setting, unless the resident is under the age of 18.
Reviewed policies/documents:
 TBI-P.381 Medical and mental health screenings; history of sexual abuse
 ADMH Nursing Assessment and Nursing notes
Interviewed staff responsible for risk screening and mental health staff. There was one (1) resident who disclosed prior victimization during screening which was reported. The resident reported that the victimization occurred more than two (2) months prior to admission. The resident was seen by the medical provider within three (3) days of screening and was seen by a contract psychiatrist on the forth (4th) day of admission. No further issues were identified with the resident and resident stated he was satisfied with treatment outcomes.
Standard 115.382: Access to emergency medical and mental health services
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) Resident victims of sexual abuse shall receive timely, unimpeded access to emergency medical treatment and crisis intervention services, the nature and scope of which are determined by medical and mental health practitioners according to their professional judgment.
b) If no qualified medical or mental health practitioners are on duty at the time a report of recent abuse is made, staff first responders shall take preliminary steps to protect the victim pursuant to § 115.362 and shall immediately notify the appropriate medical and mental health practitioners.
c) Resident victims of sexual abuse while incarcerated shall be offered timely information about and timely access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with professionally accepted standards of care, where medically appropriate.
d) Treatment services shall be provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident
Reviewed policies/documents:
 TBI-P.382 Access to emergency medical and mental health services
Interviewed Corporate Compliance Director/PREA Compliance Coordinator, Associate Executive Director, mental health staff and first responder staffs and random residents. Interviews confirmed treatment services are to be provided at
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no cost to the resident.
Standard 115.383: Ongoing medical and mental health care for sexual abuse victims and abusers
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The facility shall offer medical and mental health evaluation and, as appropriate, treatment to all residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility.
b) The evaluation and treatment of such victims shall include, as appropriate, follow-up services, treatment plans, and, when necessary, referrals for continued care following their transfer to, or placement in, other facilities, or their release from custody.
c) The facility shall provide such victims with medical and mental health services consistent with the community level of care.
d) Resident victims of sexually abusive vaginal penetration while incarcerated shall be offered pregnancy tests.
e) If pregnancy results from conduct specified in paragraph (d) of this section, such victims shall receive timely and comprehensive information about and timely access to all lawful pregnancy-related medical services.
f) Resident victims of sexual abuse while incarcerated shall be offered tests for sexually transmitted infections as medically appropriate.
g) Treatment services shall be provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident.
h) The facility shall attempt to conduct a mental health evaluation of all known resident-on-resident abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate by mental health practitioners.
Reviewed policies/documents:
 TBI-P.383 Ongoing medical and mental health services for sexual abuse victims or abusers.
Interviewed Corporate Compliance Director/PREA Compliance Coordinator, Associate Executive Director, PREA Compliance Coordinator and mental health staff. There were no residents victimized by sexual abuse who required ongoing medical or mental health services. This facility is a male only resident facility.
Standard 115.386: Sexual abuse incident reviews
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The facility shall conduct a sexual abuse incident review at the conclusion of every sexual abuse investigation, including where the allegation has not been substantiated, unless the allegation has been determined to be unfounded.
b) Such review shall ordinarily occur within 30 days of the conclusion of the investigation.
c) The review team shall include upper-level management officials, with input from line supervisors, investigators, and medical or mental health practitioners
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d) The review team shall:
(1) Consider whether the allegation or investigation indicates a need to change policy or practice to better prevent, detect, or respond to sexual abuse;
(2) Consider whether the incident or allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; or, gang affiliation; or was motivated or otherwise caused by other group dynamics at the facility;
(3) Examine the area in the facility where the incident allegedly occurred to assess whether physical barriers in the area may enable abuse;
(4) Assess the adequacy of staffing levels in that area during different shifts;
(5) Assess whether monitoring technology should be deployed or augmented to supplement supervision by staff; and
(6) Prepare a report of its findings, including but not necessarily limited to determinations made pursuant to paragraphs (d)(1)-(d)(5) of this section, and any recommendations for improvement and submit such report to the facility head and PREA compliance manager.
e) The facility shall implement the recommendations for improvement, or shall document its reasons for not doing so.
Reviewed policies/documents:
 TBI-P.386 Sexual abuse incident reviews
 Critical incident review form
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator, Incident Review Team members
Standard 115.387: Data collection
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) and c) The agency shall collect accurate, uniform data for every allegation of
sexual abuse at facilities under its direct control using a standardized instrument and set of definitions.
The incidentbased data collected shall include, at a minimum, the data necessary to answer all questions from the most recent version of the Survey of Sexual Violence conducted by the Department of Justice
b) The agency shall aggregate the incident-based sexual abuse data at least annually
d) The agency shall maintain, review, and collect data as needed from all available incident-based documents, including reports, investigation files, and sexual abuse incident reviews.
e) The agency also shall obtain incident-based and aggregated data from every private facility with which it contracts for the confinement of its residents. (N/A if agency does not contract for the confinement of its residents)
f) Upon request, the agency shall provide all such data from the previous calendar year to the Department of Justice no later than June 30.
Reviewed policies/documents:
 TBI-P.387 Data Collection
 Survey of Sexual Violence - 5
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator
Standard 115.388: Data Review for corrective action
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the
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relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall review data collected and aggregated pursuant to § 115.387 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including:
(1) Identifying problem areas;
(2) Taking corrective action on an ongoing basis; and
(3) Preparing an annual report of its findings and corrective actions for each facility, as well as the agency as a whole.
b) Such report shall include a comparison of the current year's data and corrective actions with those from prior years and shall provide an assessment of the agency's progress in addressing sexual abuse.
c) The agency's report shall be approved by the agency head and made readily available to the public through its website or, if it does not have one, through other means.
d) The agency may redact specific material from the reports when publication would present a clear and specific threat to the safety and security of a facility, but must indicate the nature of the material redacted.
Reviewed policies/documents:
 TBI-P.388 Data review for corrective action
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator
Standard 115.389: Data storage, publication and destruction
□ Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
□ Does NOT meet Standard (requires corrective action)
The standard states:
a) The agency shall ensure that data collected pursuant to § 115.387 are securely retained.
b) The agency shall make all aggregated sexual abuse data, from facilities under its direct control and private facilities with which it contracts, readily available to the public at least annually through its website or, if it does not have one, through other means.
c) Before making aggregated sexual abuse data publicly available, the agency shall remove all personal identifiers.
d) The agency shall maintain sexual abuse data collected pursuant to §115.387 for at least 10 years after the date of its initial collection unless Federal, State, or local law requires otherwise.
Reviewed policies/documents:
 5.1.2-B Corporate PREA Policy/Procedure, p. 25
 http://www.bridgeinc.org/pages/?pageID=53
 PREA Annual Facility Review Assessment meeting minutes 6/27/14
Interviewed Facility Executive Director, Corporate Compliance Director/PREA Compliance Coordinator.
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Any questions about PREA standards, required documentation or process please refer to the PREA Resource Center website under Juvenile Standards.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under review.
____ Glen E. McKenzie, Jr. May 14, 2015
Auditor Signature Date
 
 
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