PREA

Prison Rape Elimination Act of 2003 (PREA)


204 Depot St is committed to providing a safe environment free from sexual abuse for the residents in our care. To this end, 204 Depot St has developed policies in accordance with the Prison Rape Elimination Act of 2003 (PREA).

Zero Tolerance Policy
204 Depot St has a Zero Tolerance Policy regarding sexual assault, sexual harassment and sexual activity. All residents in our programs have a right to be free from sexual assault or harassment, as well as free from retaliation for reporting. There is no “consensual” sexual activity between residents or between staff and residents at 204 Depot St. (PREA Standard 115.311)

204 Depot has installed a 16 – camera video surveillance system to help monitor the program and to use recording to help investigate any sexual abuse or harassment allegation that is made.

Reporting
Residents are encouraged to report sexual harassment or assault by another student or a staff member. They may report to any staff member, to an outside agency (phone numbers on posters throughout the program), or anonymously by writing it down and submitting it to our grievance box in the dining area.

204 Depot St accepts third-party reports of sexual assault or sexual harassment from a friend or family member of a resident (PREA Standard 115.354). If you suspect sexual abuse, you may call 204 Depot St at (802) 442-6156 or to make an anonymous report, you can call the proper authorities at (800)-649-5285. All reports are taken seriously and investigated.

Staff must report any knowledge or suspicion of sexual harassment or sexual assault to their supervisor or Program Manager immediately. The staff member will then contact the proper authorities to report the allegation.

There is often concern that addressing PREA-related issues in policy and procedure, and educating students as to their right to be free from sexual abuse, may result in false accusations or false reports of staff misconduct. All allegations will be thoroughly and timely investigated and knowingly false allegations may be prosecuted.

Investigative Policy
204 Depot St will ensure that an administrative investigation is completed for all allegations of sexual abuse and sexual harassment. Allegations of sexual abuse or sexual harassment will be referred for investigation to Centralized Intake at (800)-649-5285 with the legal authority to conduct criminal investigations, unless the allegation does not involve potentially criminal behavior. (PREA Standard 115.322). You will find Vermont’s Department and Children and Families investigation policy HERE

Annual and Aggregated Sexual Abuse Data
In compliance with 204 Depot St’s PREA Policies, regarding publication of annual reporting and aggregated sexual abuse data, 204 Depot St will report each year using the U.S. Department of Justice Survey of Sexual Violence Summary form, regarding founded allegations of sexual abuse in our programs (PREA Standards 115.388 &115.389). The Annual Report can be found HERE. 204 Depot St continuously educates all staff, residents, contractors, and volunteers on PREA Standards regarding the importance of protecting residents from sexual abuse or harassment.

 

 

FINAL AUDITOR’S SUMMARY REPORT

National PREA Resource Center

Bureau of Justice Assistance

U.S. Department of Justice

 

 

Name of Facility: Seall Inc. 204 Depot Street Program
Physical Address: 204 Depot Street, Bennington, VT 05201
Date report submitted: April 11, 2016
Auditor information
Name: Sharon Pette, MSC
Email: sharon@rapidesi.com
Telephone number: (B) 212-677- 5093 or (C) 503-910-9873
Date of facility visit: August 10, 11, and 12, 2015
Facility Information
Facility Mailing Address: SAME AS ABOVE
Telephone Number: 802-442-6156
The Facility is: Military County                     Federal
Private not for profit Municipal                  State: Contracted by State of Vermont AHS   DCF
 

Facility Type:

Community Residential – Juvenile Justice Detention
Name of PREA Compliance Manager: Capri Pelzer             Title: PREA Coordinator
Email Address: capri.pelzer@gmail.com                                                                                                                      Telephone Number: 802-442-6521
Agency Information
Name of Agency: Seall Inc.
Governing Authority: Seall Inc.
Physical Address: 204 Depot Street, VT   05201
Mailing Address: Same as above
Telephone Number: 802-442-6521
Agency Chief Executive Officer
Name: Jim Henry                                                                                     Title: Executive Director
Email Address: seallinc@gmail.com      Telephone Number: 802-442-4997
Agency Wide PREA Coordinator
Name: Jim Henry                                                                                     Title: Executive Director/Agency PREA Coordinator
Email Address: seallinc@gmail.com      Telephone Number: 802-442-4997

AUDIT PROCESS OVERVIEW

The State of Vermont Administration of Human Services, Department of Children and Families (AHS DCF) contracted with an independent auditor, Sharon Pette of Effective System Innovations (ESI) on October 4, 2014 to conduct government mandated audits. The purpose of these audits was to determine the degree of compliance with the federal Prison Rape Elimination Act (PREA) standards. The Seal Inc. 204 Depot Street program was among the contracted programs required to undergo an audit.

Several weeks in advance of the audit, posters were hung throughout the facility announcing the upcoming audit. These posters explained the purpose of the audit and provided youth and staff with the auditor’s contact information. More specifically, six notification fliers were posted in the kitchen, living room (2), recreation room, staff office, and in the upstairs staircase. Pictures were sent to the auditor verifying the posters were hung consistent with DOJ auditing expectations. Prior to the onsite audit, the Depot Street Facility PREA Compliance Manager submitted the Pre-Audit tool and supporting documents to the auditor. A comprehensive evaluation of agency policies, facility procedures, program documents, and other relevant materials was conducted prior to the on-site visit.

The initial on-site portion of the audit spanned a three-day period: August 10th, 11th, and 12th, 2015. During the on-site review the auditor conducted an extensive facility tour which involved visual inspection of the two story home, including the basement which serves as a recreation area for youth. During the tour the auditor gathered relevant information about programming, supervision, program purpose, and daily operations through conversations with the Executive Director of Seall Inc., Mr. Jim Henry and the Depot Street PREA Facility Compliance Manager, Mr. Capri Pelzer. Information about the 204 Depot Street facility as it relates to federal PREA standards is provided in the body of this report.

During the initial on-site, the auditor conducted interviews with agency leadership, direct care staff, and youth. The requisite interviews were conducted consistent with DOJ expectations in content and approach, as well as the method for selecting staff to be interviewed (i.e. Facility PREA Compliance Manager, specialized staff, random staff, and youth). At the time of the onsite review, the Depot Street Program Director position was vacant. The Program Director job responsibilities were being shared by the Seall Inc. Executive Director and the Facility PREA Compliance Manager. The Seall Inc. Executive Director, Mr. Henry, also serves as the Agency PREA Coordinator for 204 Depot Street. Depot Street is the only Seall Inc. program subject to federal PREA requirements. It is important to note that the Depot Street Program serves as a short- term crisis stabilization program which does not employ or contract with specialized staff (i.e. nurses, clinical counselors, etc.). The small size of the Depot Street program and several staff vacancies contributed to the total number of staff interviews being significantly less than the number of interviews typically conducted during PREA audits. Over the three-day program visit a total of 18 interviews were conducted. More specifically, the initial audit process included:

• An interview with the Seall Inc. Executive Director (who also serves as the Agency PREA Coordinator and at the time of the onsite review was serving as the Interim 204 Depot Street Program Director)

• An interview with the Facility PREA Compliance Manager
• An interview with the Depot Street Case Manager
• Seven interviews with direct care staff
• Six interviews with youth (represents 86% of youth residing in the Depot Street Program at the time of the onsite visit)
• An interview with the State of Vermont Residential Licensing Special Investigations Unit (RLSI) Director (conducted prior to the on-site visit)
• An interview with the Director of the local community advocacy organization (this individual also serves on the Seall Inc. Board of Directors and on the agency’s Personnel Committee)

In addition, the audit process included reviewing 20 youth files (paper format). The auditor reviewed files for all youth currently in the program (N=7) and 22% of all youth discharged from the Depot Street program in the past 12 months (i.e. total of 60 youth discharged between February and August of 2015). In addition, the auditor reviewed all investigation reports of sexual harassment and sexual abuse occurring 18 months prior to the review.

As part of the file review process the auditor also reviewed all training records for current Depot Street program staff (N=18). At the time of the onsite review Seall Inc. had two contracted clinicians whose roles involved training staff and providing clinical feedback on youth case plans. These contractors do not have any interaction with Depot Street youth. The program had one student intern working at the program at the time of the site visit. Staff personnel records (100%; N=18) were reviewed to determine whether requisite criminal background checks were conducted consistent with PREA standards.

Shortly following the completion of the initial on-site portion of the audit, a one-hour debriefing meeting was held with the Seall Inc. Executive Director to summarize preliminary audit findings. The auditor provided feedback regarding 204 Depot Street program strengths and areas for improvement. In addition, required actions for Seall Inc. Depot Street to achieve full PREA compliance were discussed.

Throughout the audit review process, as well as in the debriefing meeting, agency and program leadership were made aware of additional PREA requirements and next steps. Conversations included, but was not limited to, describing the purpose of the 180-day corrective action period and explaining the federal requirement that the final PREA audit report must be made publically available. The Executive Director of Seall Inc. and the Depot Street Facility PREA Compliance Manager expressed a sincere commitment to achieving compliance with all PREA standards.

Three weeks prior to the end of the corrective action period, the auditor made a second on-site visit to verify the new practices were fully implemented. The two-day site visit included interviewing the Agency Director, Depot Program Director, PREA Compliance Manager, teacher, case manager, direct care staff, and all youth in the program (N=8). In addition, employee files and training records were reviewed. Information gathered from the second site visit confirmed that new practices consistent with PREA standards are in place.

It is important to note that although the State of Vermont Agency of Human Services, Department for Children and Families (AHS DCF) contracts with the Seall Inc. organization to provide program services to youth at 204 Depot Street, for the purposes of this report the “agency” is considered Seall Inc. This ensures consistency in the interpretation and application of the PREA standards.

AGENCY AND PROGRAM/FACILITY DESCRIPTION

Seall Inc. is a small not-for-profit organization which operates the community residential program, 204 Depot Street. The State of Vermont Administration of Human Services, Department for Children and Families (AHS DCF) contracts with the Seall Inc. to provide residential program services to youth. The Seall Inc. infrastructure includes a full time Executive Director who serves as the Agency PREA Coordinator and who, at the time of the onsite review, was also serving as the interim Program Director for the 204 Depot Street program. The Executive Director is also responsible for conducting all personnel related investigations. The Seall Inc. has a governing board who oversees agency fiscal and personnel related activities. The board meets on a monthly basis and includes members of the community, including the Director of the local children’s advocacy group.

The Depot Street program is a residential program located in Bennington, Vermont. The program houses males between the ages of 13 and 18 years old who are in the custody of AHS DCF or on DCF probation. Youth in the program fall within three categories: Delinquent youth (those with criminal charges); Child In Need of Services (youth whose parents’ rights have been terminated); and an Uncontrollable Child (youth whose violent behaviors towards family members has caused a referral to the Depot Street program). The primary purpose of the 204 Depot Street program is to provide crisis stabilization services to youth prior to returning youth back home or placing youth in a long term residential treatment program.

The facility has the physical capacity to serve eight youth. The length of stay ranges from 24 hours to up to 90 days. The average length of stay is approximately 20 days and the vast majority of youth remain in the program less than one month. On the first day of the onsite audit there were seven youth in the program. On the final two days of the initial on-site visit, there were eight youth in the Depot Street program. Over the past 12 months the program served 118 youth with an average daily population of seven. There were 60 youth discharged back home or to a residential treatment program in the span of a six-month period (February 1st to July 31, 2015). At the time of the initial on-site review, there were no youth who identified as transgendered, gay, or bisexual. However, during the second onsite visit one youth identified himself as gay and another youth stated he was bisexual. Both of these youth were interviewed.

The Seall Inc. 204 Depot Street program is located in a community residential setting and is not enclosed by a perimeter fence. The physical program is a two story house with a basement. The basement is equipped with a washer and dryer as well as a ping pong table and free weights. The first floor of the residential home has a living room area, a kitchen, a dining area, two staff offices, a conference/education room, and a staff bathroom. The second floor has eight bedrooms and one bathroom. There is an entrance to the attic that is locked and to which only staff may enter. All bedroom windows and bedroom doors are alarmed while youth are sleeping.

SUMMARY OF AUDIT FINDINGS

The success of any initiative depends on a variety of factors and requires support from executive level managers. An interview with the Executive Director, Mr. Jim Henry, revealed Seall Inc. is committed to keeping youth safe and free from sexual abuse and harassment. Recently, Mr. Henry reallocated funds and converted a direct care staff position to a half time Facility PREA Coordinator position. This position is held by Mr. Capri Pelzer. The creation of this new position provides evidence that Mr. Henry is dedicated to aligning agency and program practices with federal PREA regulations.

During the initial on-site visit the Depot Street program was in the initial stages of implementing PREA requirements. At that time, the program had already implemented a number of important elements to better align with PREA standards. Some of these included training all staff on PREA; regularly conducting unannounced rounds for all shifts; and creating tracking sheets to track PREA related information (i.e. resident education, staff training, etc.). Since the Program Director position was filled in September 2015, there have been additional positive changes made to the program. The new Program Director, Mr. Dominic Ruggeri, has extensive experience in the field of human services and has a solid understanding of the PREA standards. An interview revealed he is committed to ensuring the PREA standards are upheld in daily practice. In addition, two interviews with the Depot Street PREA Compliance Manager, Mr. Pelzer, revealed that he also shares this same commitment to keeping youth free from sexual abuse and sexual harassment.

During the two onsite visits, youth interviews confirmed that all youth understand their right to be free from abuse and harassment and understood how to make a report if they were being abused. When several youth were asked the question, “What kinds of things can you get away with here at Park Street?” all youth responded similarly – that youth are under constant and close supervision. One youth captured this well by stating, “You can’t get away with anything. Staff are everywhere!” Depot Street requires staff to be present with youth at all times. Youth interviews confirmed that youth are always with staff and are never alone with other residents.

Interviews also supported that staff are professional and dedicated to ensuring youth are safe and receive the services they need in order to turn their lives around. In addition, all staff clearly understood their first responder duties and knew what they needed to do in the event a youth alleged sexual abuse.

During the six-month corrective action period, the Seall 204 Depot leadership, the PREA Compliance Manager, and the State of Vermont Department for Children and Families leadership all demonstrated dedication to aligning program practices with PREA standards. Evidence of this commitment included frequent communication with the auditor, timely post-audit document submission, and implementing all required actions put forth in the initial audit findings report. This level of commitment has resulted in the Seall 204 Depot Street program achieving full compliance with federal DOJ PREA standards.

Although the program did not originally meet compliance on 34 of the PREA standards, following the initial on-site audit, the Seall agency and Depot Street program made important changes to achieve compliance. Some of the program’s key accomplishments include:

• Repositioning existing cameras to provide better monitoring of youth and installing seven additional surveillance cameras;
• Developing a coordinated response plan to effectively respond to allegations of sexual abuse or sexual assault
• Developing a more comprehensive PREA training for program staff, volunteers, and contractors.
• Adopting and implementing a formal vulnerability assessment tool to assess a youth’s risk to perpetrate or become a victim of sexual abuse or assault.
• Using the vulnerability risk information to guide decisions regarding treatment planning, bed placement, education assignments, and safety and security.
• Creating agency policies for each PREA standard to guide staff practice. Enhancements made to agency PREA policies has resulted in clearer expectations with regard to responsibilities in detecting, reporting, and handling reports of sexual abuse and assault.
• Making significant progress in securing a Memorandums of Understanding with the local advocacy agency and mental health counseling agency to provide victims of sexual abuse or assault with rape crisis and follow-up services.
• Creating a webpage to house required PREA information
• Developing an annual report detailing progress on PREA implementation and incident data and posting this report on the agency’s website.

The chart below displays the results from the initial audit report and compares it with the number of standards in compliance at the close of the six-month corrective action period. The dedication and hard work has allowed Depot Street program to “Exceed” the minimum requirements on one standard and “Meet” compliance on the remaining standards.

Category Initial Report Total Final

Report Total

Number of Standards Exceeded 0 1
Number of Standards Met 6 39
Number of Standards Not Met 34 0
Number of Standards N/A 1 1
Percent of Compliance with PREA Standards 15% 100%

It is important to note that the intention of this report is to provide the reader with a summary of audit findings and highlight some examples of evidence supporting these findings. The narrative in this report is not an “all inclusive” list of the evidence needed to sufficiently meet PREA standards. However, for each standard that was successfully met, interviews, observations, and review of additional documents during the on-site visit verified that practices employed by the 204 Depot Street program are consistent with agency policies and federal PREA expectations.

◻ 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)

The Seall Inc. 204 Depot Street program has formal documents that set forth clear expectations with regard to zero tolerance for all forms of sexual abuse and sexual harassment. This information is found in: 1) The “Seall Inc. Employee Handbook”; 2) The “204 Depot Street Stabilization Program Handbook” provided to youth at intake; and 3) The “Employee Responsibilities with PREA” pamphlet. It is important to note that “Seall Inc. Employee Handbook” serves as the policy guide informing staff of agency expectations and rules. Information regarding zero tolerance for sexual harassment is found in this staff manual. More specifically the handbook states, “Seall Inc. will not, under any circumstances, condone or tolerate conduct which may constitute sexual harassment on the part of any of its employees. It is our policy that all employees have the right to work in an environment free from any type of illegal discrimination, including sexual harassment. It is a violation of this policy for an employee to engage in sexual harassment and any employee of Seall Inc. found to have engaged in such conduct will be subject to immediate discipline, up to and including discharge. Seall Inc. is committed and required by law to take action if it learns of potential sexual harassment, even if the aggrieved employee does not wish to formally file a complaint” (page 21).

The Seall Inc. Employee Handbook also clearly explains its zero tolerance with regard to retaliation for filing a sexual harassment claim. The handbook states, “It is, also, expressly prohibited for an employee of SEALL to retaliate against employees who bring sexual harassment charges or assist in investigating charges. Retaliation is a violation of this policy and may result in discipline, up to and including termination. No employee will be discriminated against, or discharged, because of bringing or assisting in the investigation of a complaint of sexual harassment” (page 22).

The “Employee Responsibilities with PREA” pamphlet states, “There is a zero tolerance with regard to sexual misconduct. Residents have the right to be free from sexual abuse and sexual harassment. Residents and staff have the right to be free from retaliation for reporting sexual abuse and sexual harassment.” The pamphlet also includes important information about signs a youth may display if they have been victimized, and who to call if a youth alleges sexual abuse. The auditor encourages the Facility Compliance Manager to enhance this pamphlet to include more detailed information as it relates to PREA standards. These additions may include but not be limited to providing definitions of sexual abuse, sexual harassment, retaliation, and zero tolerance and describing the immediate response by staff when a youth alleges sexual abuse (i.e. separating victim and abuser, preserving physical evidence, refraining from interrogating the victim or perpetrator, writing an incident report, etc.).

The State of Vermont regulations further supports the Depot Street zero tolerance policy. The State of Vermont AHS DCF Residential Licensing and Special Investigations unit (RLSI) is responsible for licensing all community residential facilities in Vermont. State regulations prohibit residential

programs from hiring or continuing to employ any person substantiated for child abuse or neglect (“State of Vermont Department for Youth and Families: Licensing Regulations for Residential Treatment Programs in Vermont,” Standard 402). In addition, regulations require all residential treatment programs to have written policies and procedures for the orientation of new staff to the program and must include “…child/youth grievance process…policies regarding zero-tolerance for sexual abuse, procedures for reporting suspected incidents of child abuse and neglect, etc.” (“State of Vermont, DCF Licensing Regulations for Residential Treatment Programs,” Standard 414, page 17).

Seall Inc. has a designated Agency PREA Coordinator, Mr. Jim Henry who is also the agency’s Executive Director. Interviews indicate he has a clear understanding of his role as it relates to PREA. Due to the fact that 204 Depot Street is the only juvenile program within Seall Inc. that is subject to PREA standards, Mr. Henry has sufficient time and authority to develop, implement, and oversee agency efforts to comply with the federal PREA requirements.

In the summer 2015, Seall Inc. secured resources to convert a direct care staff position at 204 Depot Street to a half time Facility PREA Coordinator position. This position is held by Mr. Capri Pelzer who is responsible for ensuring facility compliance with these federal standards. Due to the small size of the Depot Street program Mr. Pelzer has sufficient time to perform the PREA related job responsibilities. Interviews and observations while onsite also provided evidence that Mr. Pelzer has the autonomy and authority to make decisions to ensure Depot Street is in full compliance.

The auditor encourages Seall Inc. to update the agency and program organizational charts to reflect the Agency PREA Coordinator and Depot Street PREA Facility Compliance Manager titles.

◻ 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)
 N/A – The facility does not contract with private agencies for the confinement of residents

The Seall Inc. agency does not contract with private entities for the confinement of youth. Although the State of Vermont Department for Children and Families contracts with Seall Inc. to provide residential treatment services for 204 Depot Street youth, for the purposes of this report the Seall Inc. is considered the “agency.” Therefore, this standard is N/A.

 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)

Currently, the Depot Street program operates using a 1:3 staff to youth ratio in the mornings, afternoon, and early evenings. During sleeping hours there are always two staff on shift responsible for monitoring eight program youth (translating to a 1:4 staffing ratio). The Depot Street program exceeds PREA staffing ratios which require a minimum staff-to-youth ratio of 1:8 during waking hours and 1:16 during sleeping hours. Youth and staff interviews and auditor observations while on site, verified Depot Street is exceeding federal expectations in the area of staff to youth ratios. Youth reported they are never left alone with other youth and are not able to “get away with” being in another resident’s room because the level of staff supervision is too strict.

The 204 Depot Street program is equipped with a camera surveillance system which includes 16 cameras strategically placed throughout the residence (i.e. first floor, second floor, and the basement). In October 2013, recognizing there were several blind spots throughout the house, the Seall Inc. Executive Director made a request to the Seall Inc. Board of Directors to install additional cameras in the 204 Depot Street program. This request was granted and nine additional cameras were installed in March 2014. In September 2015, following the on-site visit, four additional cameras were installed (two in the basement, one on the second floor, and one on the first floor) and several other cameras were repositioned to provide better monitoring and supervision. During the second on-site visit facility tour, the auditor confirmed that the original blind spots have been eliminated. The current surveillance system allows managers to view live feed from 16 different cameras on a large computer screen located in the staff office at 204 Depot Street. The system stores video footage up to 30 days, allowing the program to review incidents when necessary. The Program Director and the Executive Director are able to view live footage from all camera angles remotely. The current camera surveillance system provides adequate coverage throughout the facility.

All windows and bedroom doors are alarmed during the evening hours. There are two overnight staff – one stationed outside the youth bedrooms and one on the first floor. This ensures youth are safe in their rooms during sleeping hours. In addition, staff are required to check on all residents a minimum of four times throughout the night and document these checks in a staff log. Observations and interviews confirmed that this practice is fully embedded in the program’s daily operations.

The Depot Street Program Director and Seall Inc. Executive Director conduct unannounced rounds a minimum of three times per month. A formal tracking form is used to document these rounds. This form has specific questions about whether staff were positioned correctly, whether they were equipped with radios, and whether staff reported any issues during the visit. Information from this form is then transferred to a tracking sheet that lists each staff member and corresponding shift. This allows Depot Street leadership to check in with all staff and shifts throughout the month. Furthermore, this level of tracking ensures each staff member is visited at least once every six months. Interviews revealed that these rounds are not announced in advance and staff are not aware when these check-ins will occur. Review of the tracking sheet indicated this practice is fully embedded in the program, as Depot Street leadership has been conducting these rounds for over a year. The tracking sheet verifies that all shifts were visited several times, including the 12:30 – 4:30 AM shift. The auditor applauds Seall Inc. for recognizing the value of these unannounced management rounds and for its organization in tracking these check-ins.

During the corrective action period, Depot program made significant enhancements to supervision and monitoring of youth which has allowed the program to “Exceed” the minimum standard requirements. Some of these important changes include:
• Investing money in purchasing additional surveillance cameras
• Re-modeling the upstairs bathroom to have better staff line of sight and to prevent “grooming” behaviors of youth (i.e. playing with their feet under the bathroom stalls)
• Creating a policy that describes conducting unannounced rounds (and consistently conducting these rounds)
• Creating a policy that establishes the practice of reviewing the formal staffing plan annually
• Creating a formal tool, “Annual Review Form – Supervision and Monitoring” to conduct the annual staffing plan review, ensuring all required areas are discussed.
• Conducting and documenting the annual staffing plan review
• Enhancing policy to more clearly describe staff positioning, staff communication (through hand held radios), minimum staffing levels, a detailed plan of staff to youth ratios will be maintained when staff member calls in sick, etc.

While on site, these new practices were confirmed through the two facility tours, staff and youth interviews, and documentation review. The auditor applauds the Depot program in its significant progress in this area of supervision and monitoring.

◻ 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)

The Depot Street program does not conduct strip searches or visual body cavity searches (meaning a search of the anal or genital opening). Youth and staff interviews verified that strip searches are never conducted. The program does however, conduct pat searches of youth at designated times throughout the day. The Depot Street PREA training provided to staff includes a description of the Depot Street search practice and puts forth the expectation that only male staff will conduct pat searches – cross gender searches will only be conducted in exigent circumstances. In the event a cross gendered pat search is necessary staff are instructed to document these searches in the unit log. Review of Depot Street incident logs revealed there was one incident in the past twelve months in which a cross gendered search was necessary (i.e. two-person restraint, law enforcement was called, and youth needed to be patted down before being sent to their rooms for safety reasons). During interviews, youth and staff reported that cross gender pat searches are not conducted by female staff. As of August 2017, facilities which house less than 50 youth, will be prohibited from conducting cross gender search practice. Therefore, the auditor applauds Depot Street for meeting this federal regulation ahead of the targeted deadline.

Youth residing in the Depot Street program have privacy when using the bathroom and when changing their clothes. The youth bathroom is located on the second floor and is equipped with a shower and two bathroom stalls. A staff member is required to be positioned outside of the

bathroom so that youth feet can be seen. The shower area is set up in a way that ensures youth are not being viewed by staff while showering. The State of Vermont DCF Residential Licensing requirements support compliance with part (d) of this standard. State regulations dictate, “…a residential treatment program shall provide toilets and baths or showers which allow for individual privacy unless a child/youth requires assistance” (Standard 727). The 204 Depot Street program had a state licensing visit on 6/15/2015 and received a letter confirming their license renewal in July 2015. Youth interviews confirmed that youth have privacy when showering, toileting, and changing clothes.

Youth are required to change clothes in the bathroom or in their rooms with the door closed. They are not permitted to come out of their rooms unless they are fully clothed. Before entering a youth’s room, staff are trained to first knock and ask to enter. All youth verified staff follow this procedure of knocking and asking before entering.

During the corrective action period, the program updated their policy to address the knock and announce provision. The policy now states female staff are not permitted to supervise male residents while they perform hygiene activities or when waking. In addition, the program has implemented the practice of stationing overnight female staff on the first floor while male staff supervise all youth on the second floor (where bedrooms are located). In addition, the program has adopted the practice of writing the name of the female staff on duty on a white board located on the second floor. Youth are required to look at this board prior to going to bed. This will better ensure youth are aware when female staff will be on the second floor in the rare circumstance that two females staff are working the overnight shift.

In support of this standard, the program added a question to the intake sheet to ask intersex and transgendered youth by whom they would prefer to be searched. The program also created a short video demonstrating for staff the proper method for searching Depot youth and has included this as a part of the annual PREA training.

◻ 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)

On the day the youth arrives to the 204 Depot Street program, the Facility PREA Coordinator or Program Director meets with the youth to review written program materials. Among the information provided to the youth is the resident handbook. This handbook includes information about the program rules and youth rights. Staff reported that the Depot Street program has not had a resident with a disability or limited English proficiency and therefore, has not had to access interpretive services.

During the corrective action period, the program developed a policy to support provisions in this standard. The policy describes that Depot staff will work with DCF staff to ensure translation services are provided. In addition, the policy states that other youth residents will never be

permitted to translate for other program youth. The State of Vermont has several policies that outline that DCF is responsible for ensuring all youth with special needs are accommodated. Staff interviews conducted during the second onsite verified they are aware of the process for accessing these interpretation services. The PREA Compliance Coordinator and other program leadership stated that in the event a youth had disabilities (i.e. deaf or hard of hearing, blind or have low vision, or those who have intellectual, psychiatric, or speech disabilities) he would work with DCF to arrange interpreter services to translate the PREA information within the ten-day timeframe.

◻ 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)

The Depot Street program does not hire or promote any individuals who have engaged in sexual abuse in a prison, jail, lockup, community confinement facility, or juvenile facility. The Depot Street program also does not hire or promote any individuals who have been convicted of engaging or attempting to engage in sexual activity that was facilitated by force, or coercion, or if the victim did not or could not consent.

The State of Vermont AHS DCF licensing regulations dictate background checks must be conducted “upon hire and every three years thereafter, on all employees, board member/trustees, volunteers, student interns, and others who may have unsupervised contact with children/youth in the program” (page 16, section 412). These state licensing regulations specify that these checks must be completed prior to having any unsupervised contact with youth and that documentation must be maintained (page 16, section 413). The regulations also specify background checks must include consulting three distinct databases: 1) Vermont Criminal Information Center; 2) Vermont Child Protection Registry; and 3) Adult Abuse Registry. Review of Depot Street personnel files (N = 18) revealed that all current Depot Street staff, contractors, and interns have received criminal background checks prior to beginning work with youth. File reviews also verified that these extensive background checks are conducted every three years, consistent with agency policies and state regulations. This exceeds federal PREA expectations which require background checks to be conducted once every five years.

The executed Fiscal Year 2016 contract between the Seall Inc. and the State of Vermont specifically requires, “the Grantee agrees not to employ any individual, use any volunteer, or otherwise provide reimbursement to any individual in the performance of services connected with this agreement, who provides care, custody, treatment, transportation, or supervision to children or vulnerable adults if there is a substantiation of abuse or neglect or exploitation against that individual” (page 25). The contract also specifies the abuse registries and databases Seall Inc. is required to consult when conducting background checks on potential employees. The auditor applauds the State of Vermont and Seall Inc. for its commitment to ensuring the safety of youth in its care.

The Seall Inc. Employee Handbook explains the agency’s formal progressive discipline process used to address undesirable staff behaviors and performance issues. The handbook clearly states, Seall Inc. reserves the right to combine or skip steps depending upon the facts of each situation and the nature of the offense…The Behavior that is illegal is not subject to progressive discipline and may be reported to local law enforcement. Theft, intoxication at work, fighting and other acts of violence are also not subject to progressive discipline and may be grounds for immediate termination” (page 17).

During the corrective action period, the program created policy to support provisions in this standard. The policy now states the program will consider history of sexual harassment when hiring or promoting staff. In support of this new policy, the program added a question to the employment application requiring applicants to disclose previous allegations or convictions of sexual harassment. During the second onsite visit, the auditor reviewed the five employees hired in the past five months. Criminal history checks had been conducted on all five employees consistent with agency policy and state regulations.

◻ 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)

The 204 Depot Street program is equipped with a camera surveillance system which includes 16 cameras strategically placed throughout the residence (i.e. first floor, second floor, and basement). In October 2013, recognizing there were several blind spots with the current camera system, the Seall Inc. Executive Director made a request to the Seall Inc. Board of Directors to install additional cameras in the 204 Depot Street program. This request was granted and nine additional cameras were installed in March 2014. The decision and discussion to increase the number of cameras was documented in monthly Seall Inc. Board meeting minutes.

In September 2015, following the on-site visit, four additional cameras were installed (two in the basement, one on the second floor, and one on the first floor). Several other cameras were repositioned to provide better monitoring and supervision of program youth. During the second on-site visit facility tour, the auditor confirmed that the original blind spots have been eliminated. The program has implemented the practice of including discussion of surveillance technology as part of the annual staffing plan review. These discussions are formally documented.

◻ 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)

The Seall Inc. Executive Director is responsible for conducting administrative/personnel investigations related to any violations of agency policies, including ethical misconduct. The AHS DCF Residential Licensing Special Investigations unit (RLSI), in partnership with local law enforcement, is responsible for conducting criminal investigations for sexual abuse or misconduct.

Following the initial onsite audit, the program was required to develop a process for ensuring victims of sexual abuse are examined by a certified Sexual Assault Nurse Examiner (SANE) or a Sexual Assault Forensic Examiner (SAFE). The Depot program developed a coordinated response plan that ensures youth will be offered a forensic plan by a SANE. Since the program does not employ medical staff, it was necessary to work with the local hospital and the local victim advocacy agency to ensure this protocol is in place. Policy and procedures obtained from the Southwestern Vermont Medical Center (SVMC) describes the process for handling sexual assaults. The hospital policy requires sexual assault victims in which the assault occurred in less than 24 hours be examined by a SANE. The procedures also describe steps for providing post- exposure prophylaxis and emergency contraception. This process was confirmed through communications with the Director of the SANE program at SVMC. The hospital policy references the Vermont Center for Prevention and Treatment of Sexual Abuse Guidelines (2006) as well as the Vermont SANE Program (2006). These standards are consistent with the requirements in this PREA standard.

During the corrective action period, the Seall Inc. Depot program established a formal with a local advocacy agency, Project Against Violent Encounters (PAVE). This organization provides advocacy and crisis intervention services to survivors of domestic and sexual violence. This comprehensive MOU was executed in early April 2016, following the second onsite audit visit. The MOU clearly maps out the responsibilities of the engaged parties and includes PAVE advocates responding to crisis within one hour; accompanying the youth through the forensic evaluation process if requested by the victim; and accompanying the youth during the investigative interviews. The Depot program currently uses United Counseling Services (UCS), a local mental health agency, to provide counseling services to youth in need. The Seall Inc. Executive Director has confirmed with the UCS Program Director via email and through telephone calls that UCS is prepared to provide mental health counseling services to victims of sexual abuse. These services will be provided immediately at the hospital when youth are preparing for the SANE exam as well as in the weeks following the sexual abuse or assault incident. UCS has also entered into an MOU with Southwestern Vermont Medical Center (SVMC) to provide these mental health services as part of the SANE crisis response process. UCS employ masters level clinicians who are licensed in the state of Vermont. These MOUs ensures the victim is provided with crisis intervention services and the necessary follow-up support and mental health services.

◻ 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)

In the event a youth alleges sexual abuse, Depot Street staff members are required by State of Vermont DCF to immediately contact Centralized Intake and Emergency Services (CIES) by calling Vermont’s Child Abuse Hotline. This practice is dictated by state and agency level regulations. The Seall Inc. Employee Handbook provides a description of the mandatory reporting law (Vermont State Law Title 33, Chapter 49) and explains, “If you suspect, or have a ‘reasonable cause to believe’, any incident of child abuse, neglect or sexual contact among residents you are required by law to report this to The Department of Children and Families, Centralized Intake Unit, within 24 hours” (page 39). In addition, agency policy also addresses sexual activity among residents and requires all incidents of sexual activity between residents to be reported within 24 hours to the Department of Children and Families, Centralized Intake Unit (page 39).

The Seall Inc. Employee Handbook provides a definition of sexual harassment and explains how sexual harassment will be handled in the organization (pages 21-24). The detailed description clearly states that complaints of sexual harassment will be investigated and addressed promptly within the program. The handbook also provides information about the consequences for retaliating against the individual filing the complaint; the process for notifying the person filing the complaint; and cites other agencies who can conduct impartial investigations into the sexual harassment allegation (i.e. Vermont Attorney General’s Office, VT Human Rights Commission, or Equal Employment Opportunity Commission). The Seall Inc. Employee Handbook also provides the agency’s Board of Directors the authority to direct the Executive Director to launch an investigation. The handbook clearly states, “In all instances, the Board of Directors retains the prerogative to determine when circumstances warrant an investigation and, in conformity with this policy and applicable laws and regulations, the appropriate investigative process to be employed” (page 26). Interviews with the Executive Director and review of 204 Depot Street incident reports revealed that all sexual harassment grievances are investigated by Seall Inc. In order to align with PREA standards the agency will need to enhance this existing policy to describe how it will address sexual harassment between residents.

The State of Vermont DCF has several policies (Numbers 50, 51, 52, 54, 56, 57 and 66) that detail the investigation process and the role of RLSI social workers who conduct investigations. However, the language and content in these policies best describes situations in which youth are living in foster care settings or at home. The policies that most directly apply to the Depot Street program are: Policy 54 “Investigating Reports of Child Abuse or Neglect in Regulated Facilities;” Policy 57 “Risk of Harm/Sexual Abuse Investigations;” and Policy 66 “Interviewing Children in Custody.” Federal PREA standards requires a policy detailing how sexual abuse investigations are conducted and the responsibilities of the agency and the investigating body. Current Vermont policies need to be enhanced in order to adequately meet this PREA standard.

Within the time frame January 2014 through July 2015, there were a total of two incidents involving youth alleging sexual abuse. In both incidents, the Depot Street program leadership team were made aware of these allegations by RLSI unit investigators (i.e. youth were no longer in the Depot Street program when these disclosures were made about a staff member who worked at the Depot Street program).

During the corrective action period, the program developed a policy to address provisions in this standard and support the existing State of Vermont residential licensing regulations. The policy

now clearly states that Depot staff are required to report all allegations of sexual abuse or sexual assault immediately to the State of Vermont Centralized Intake. These reports can be received from any source – verbal report from youth, 3rd party, suggestion/grievance box, etc.

The Residential Licensing and Special Investigations Unit (RLSI) is responsible for conducting all investigations of abuse for youth residing in community residential programs in Vermont. Once an allegation is called into the Centralized Intake Unit there is a process for determining whether a case is “accepted” or “not accepted” for investigation. All cases that are “not accepted” are required to be reviewed by a supervisor who confirms or denies this decision. If the case is accepted, a Primary RLSI Investigator is assigned and the investigation process begins. If an incident appears that it may result in a criminal case, the investigative lead assigned to the case contacts the local police department. If law enforcement chooses, they will work alongside DCF RLSI to interview the victim and alleged perpetrator. Seall Inc. has included a link to the State of Vermont DCF Policy 241 on its website which addresses the investigation process.

◻ 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)

All new Seall Inc. Depot Street employees receive training in confidentiality, PREA, mandatory reporting, and professional boundaries. These trainings are listed in Seall Inc. Employee Handbook (pages 5-6). The mandatory PREA training involves all staff viewing the “Keeping Kids Safe” video (produced by the Georgia Department of Juvenile Justice) as well as reviewing a PowerPoint presentation. During the corrective action period, the Depot Street program significantly enhanced the PREA training for staff. The training now addresses all areas required by PREA. In addition, the program now requires staff to sign a statement indicating they understand the zero tolerance policy, that they are required to report allegations of sexual abuse and other relevant information. The program submitted these signed documents to verify compliance with this provision. The Depot Street has created a policy dictating all staff must participate in a PREA training each year. The Depot Facility PREA Coordinator has created and populated a tracking sheet to ensure all program staff have completed the requisite training.

State of Vermont residential licensing regulations require all residential treatment programs to have written policies and procedures for the orientation of new program staff. The regulations require that staff training “…occur within the first 30 days of employment and include, but is not limited to…child/youth grievance process…policies regarding zero-tolerance for sexual abuse, procedures for reporting suspected incidents of child abuse and neglect, etc.” (“State of Vermont Department for Children and Families: Licensing Regulations for Residential Treatment Programs” section 414, page 17).

◻ 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)

The PREA Standard requires “all volunteers and contractors who have contact with residents have been be trained on their responsibilities under agencies policies and procedures regarding sexual abuse and sexual harassment, prevention, detection, and response.” The 204 Depot Street program contracts with two mental health clinicians and at the time of the on-site audit, one college student had just completed his internship at the program. The role of the two contracted mental clinicians is to provide clinical guidance to staff with regard to treatment planning for youth as well as provide training during staff meetings. During the corrective action period and under advisement from the PREA Resource Center, although the two clinicians do not have direct contact with youth, the clinicians completed the PREA training. Signature forms were submitted to the auditor for verification.

The PREA Compliance Manager has added all volunteers to the PREA training tracking chart. The program should consider revising future contract language with clinical consultants to require these individuals to complete the PREA training on an annual basis.

◻ 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)

On the day a youth arrives to the Depot Street program, he is provided the “204 Depot Street Stabilization Program Handbook” to review. This handbook provides basic information about the program rules, a resident’s rights, how to file a grievance, mandatory reporting, and how a youth may report abuse by calling the Vermont abuse hotline. The handbook states, “Residents have the right to expect that they will be treated respectfully, impartially and fairly, and will be addressed in a dignified conversational manner…Residents have the right to be free of corporal punishment, harassment, intimidation, threats, harm, assault, humiliation by any juvenile or staff member” (page 4).

Within ten days of a youth’s arrival to the program, the Facility PREA Coordinator meets with the youth to review the “PREA Notice to Program Residents.” This six-page document provides detailed information about zero tolerance, definitions of sexual misconduct and sexual harassment, how to report abuse, right to be free from retaliation, and what to do if a youth has been sexually abuse (i.e. do not shower, brush teeth, toilet, etc.). The program has recently enhanced the training to include having youth watch a video about zero tolerance. The education video is a product of a collaborative effort between the Office of Justice and the Idaho State Police and is catered to a juvenile justice youth audience. The video addresses zero tolerance, definitions of sexual abuse

and harassment, avenues to report abuse, steps to take if abused, what the investigation process looks like, retaliation, and other critical information as it relates to PREA.

Following this PREA education session, all youth sign a form that declares, “I (name of youth) acknowledge that I understand all the guidelines of PREA while at 204 Depot Street program. I have also received a copy of these guidelines.” The PREA Compliance Manager stores these signed forms in the youth’s individual treatment file. Additionally, the Compliance Manager records completion of this education session on a formal Excel tracking sheet.

During the initial onsite visit, review of a random sample of youth files and interviews revealed all program youth have received PREA education. Due to the fact that the program is in its initial stages of PREA implementation, youth who arrived to the program in 2014 did not complete the education session within the ten day PREA requirement. All youth interviewed (n=6) understood their rights and were able to explain how they would report sexual abuse and/or sexual harassment. During the second on-site visit, review of youth files indicate the Depot Street program is following agency policy. A random sample of youth who were discharged from the program since January 2016 (N=12) indicated they received the PREA training within the ten-day time frame and had signed the signature forms attesting that they had received the training. All program youth were interviewed (N=7) and each youth verified they were trained in PREA and understood how to report in the event someone had sexually abused or assaulted them while in the Depot program.

To date, the Depot Street program has not had any youth who have needed translation services or had any need for other accommodations. However, in the event a youth has special needs (ESL, visual disability, etc.) the Depot Street PREA Compliance Manager would work with DCF to ensure PREA materials were translated within the ten-day time frame. This information is put forth in Seall Inc. policy as is the requirement that youth must sign a form stating they understand their rights and how to report abuse.

◻ 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)

All State of Vermont Residential Licensing and Special Investigation (RLSI) unit staff are required to complete specialized training. An interview with the Senior Social Worker of the RLSI unit indicated that the single investigator assigned to the Depot program has received at least a two- day training that includes child development, interviewing techniques, and other areas critical to conducting effective investigations. In addition, he has been formally trained by the National Center Advocacy Council on forensic interviewing of children. Review of training records verified that all RLSI staff have been trained on the fundamentals of conducting investigations and several investigators have been trained in advanced interviewing techniques.

In addition, during the corrective action period (August 2015), the RLSI unit investigator successfully completed the DOJ endorsed training developed by the National Institute of

Corrections, “PREA: Investigating Sexual Abuse in a Confinement Setting.” This training, coupled with the previously mentioned trainings allows Transition House to adequately meet provisions put forth in this standard. A copy of the training completion form was sent to the auditor for verification. These training records are maintained by the State of Vermont RLSIU in an electronic training record. Following the on-site audit, a conference call with the Senior Social Worker of RLSI verified the safe storage of these records as well as process for training future investigators who work with the Depot program.

To support this practice the State of Vermont DCF Policy 241 “Licensing Residential Treatment Programs and Regulatory Interventions” states, “RLSI social workers conducting child safety interventions in PREA-compliant RTPs must receive specialized training in conducting investigations in confinement settings, techniques for interviewing child/youth sexual abuse victims, and understanding law enforcement’s 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. The National Institute of Corrections Investigating Sexual Abuse in a Confinement Setting Course was designed to meet the requirements of 28 CFR 115.334(b) and generates a certificate at the completion of the training. The RLSI Director shall maintain documentation that RLSI social workers have completed the required specialized training” (page 6). The auditor applauds DCF for memorializing this expectation in policy as a way of demonstrating its commitment and accountability to this practice.

◻ 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)

As previously mentioned, the 204 Depot Street program contracts with two mental health clinicians who are responsible for providing clinical guidance on youth treatment plans and training staff on specific treatment topics (i.e. trauma informed care, positive reinforcement, etc.). As part of the Clinical Social Work licensure process, these individuals are required to complete various academic courses that directly address the provisions in this standard (i.e. detecting signs of sexual abuse). Although these two clinicians do not have any direct contact, the PREA standard specifically state, “the agency shall ensure that all full and part-time medical and mental health care practitioners who work regularly in facilities have been trained in….” (Standard 115.335 (a)). The Department of Justice PREA Resource Center has advised the auditor that all contractors and volunteers (regardless if they have direct contact with youth) must be formally trained on the basic PREA information, including the agency’s policy and protocol on responding to incidents of sexual abuse. During the corrective action period, these clinicians were formally trained on PREA and signature forms submitted to the auditor for verification.

The 204 Depot Street program does not employ or contract with any nurses or physicians and therefore, the program does not conduct any forensic evaluations. In the event a youth alleges sexual abuse, the victim would be taken to the local hospital for a medical examination by a SANE.

◻ 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)

All Depot Street youth undergo an intake process on the day they arrive to the program. This intake process involves interviewing the youth and gathering information from legal documents. During the corrective action period, the Depot Street program adopted a formal standardized and objective instrument to assess a youth’s risk to be victimized or to perpetrate sexual assault. In January 2016, the program began conducting assessments on all new intakes using the “Vulnerability Assessment Instrument” developed by Colorado Division of Youth Corrections. This instrument measures key risk factors such as gender nonconforming appearance or manner; identification as lesbian, gay, bisexual, transgender, or intersex; level of emotional and cognitive development; physical size and stature; intellectual, developmental, and physical disabilities; the resident’s own perception of vulnerabilities, etc. These assessments are conducted by the Depot PREA Compliance Manager and the Program Director. The program has created a program policy supporting the requirements set forth in this standard.

During the second on-site visit, the auditor verified the adoption of the practice of using the vulnerability assessment by reviewing a random sample of youth files (for youth placed in the program in January and February 2016). All files reviewed (N=7) had completed assessments and these assessments were completed within the 72-hour requirement. The auditor concludes this practice is fully embedded in the program.

The Seall Inc. Employee Handbook sets forth expectations for staff with regard to confidentiality. More specifically the handbook states, “All employees are required to maintain such information in strict confidence…failure to comply with this policy could result in disciplinary action, up to and including termination. This section also refers to the confidential information regarding former or current residents of our programs. This includes, but is not limited to: names of residents and/or their families, treatments, past histories and behaviors” (page 20). Seall Inc. requires all employees to sign a confidentiality agreement as a condition of employment.

To better protect the sensitive information obtained from the vulnerability tool, the Depot Street program has created a separate folder for each youth. This information is stored off site in a locked cabinet at the main Seall Inc. building. Access to these files is limited to the PREA Compliance Manager and the Agency PREA Coordinator.

◻ 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)

As previously mentioned, the program recently adopted the practice of assessing all youth at risk to perpetrate and be victimized. At the bottom of the assessment instrument, the program has begun documenting how this information is used. For example, if a youth scored high risk for victimization they indicate that they are placing youth in a particular room to better ensure their safety. In addition, Depot added a question on the vulnerability instrument asking if youth with a history of sexual perpetration or victimization, wished to meet with a mental health professional. Review of completed vulnerability tools from youth entering the program in March 2016 indicate this information is being consistently documented.

The Depot Street program does not use isolation. However, the program does separate youth from other residents if they have run away from the program and have been returned. This segregation period involves sitting at the dining room table for 24 – 72 hours. While on this status, youth are permitted to eat dinner with other youth and are permitted to exercise daily.

PREA standards require specific practices when working with transgendered and intersex youth. Standard 115.342 (e) requires “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 resident.” In addition, the standard requires a transgender or intersex resident’s own views with respect to his own safety be given serious consideration when making housing, programming, and other decisions. The Depot Street program developed a policy that reflects the language in this standard. In addition, the PREA training provided to staff has been enhanced to convey this information.

All Depot Street residents shower separately in a single stall shower. Therefore, transgender and intersex residents are never required to shower with other 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)

The 204 Depot Street program has multiple avenues by which residents can report sexual abuse, sexual harassment, or retaliation by other residents or staff. The Depot Street “PREA Notice to Residents” explains possible ways to report abuse including telling a staff member, DCF social worker, lawyer, family member or Guardian Ad Litum (page 4). The notice also provides the telephone numbers for the Depot Street PREA Compliance Manager and the State of Vermont DCF Special Investigations Unit. In addition, the youth handbook provides the phone number for Disability Rights Vermont (page 3-4). During the corrective action period, the resident handbook was revised to clearly state youth are permitted to make anonymous reports and will have privacy when making a report of sexual abuse or sexual harassment.

The youth handbook describes a written grievance process in which a youth may fill out a written “Resident’s Grievance Form” and submit it to the Program Director (page 3). The agency grievance process allows the youth to submit the grievance to the Executive Director or the

President of the Board of Directors if the Program Director or Executive Director are the source of the allegation.

During the second onsite visit, youth interviews indicate youth are aware of several ways to report abuse and that these methods may be done so anonymously. All youth interviewed articulated that would tell a staff member if another youth or a staff member was harming them while in the program. The vast majority of youth also referenced at least one external source they could contact if they did not feel safe confiding in Depot Street staff. Most youth stated they would tell their DCF worker, parents, or lawyer. Several posters with the State of Vermont abuse hotline number are displayed throughout the program. In addition, at the close of the corrective action period, the Seall Inc. Executive Director had scheduled PAVE representatives (the local advocacy agency) to come to the Depot Street program to provide information to youth and staff regarding the services they provide. As part of this process, PAVE agreed to bring brochures that will now be distributed to youth when they arrive at the Depot program.

The Depot Street program did not receive any reports of sexual abuse during the six-month corrective action period. However, there was one incident of sexual harassment between youth (August 2015). The program handled the situation appropriately by discussing zero tolerance, definition of sexual harassment, etc. during a house meeting. The youth who was responsible for the sexual harassment was given appropriate consequences for his actions.

Onsite interviews with staff revealed that staff understand their responsibilities as mandatory reporters and understood that they were permitted to file a report on behalf of a youth. As previously mentioned, the agency Employee Handbook states that all Seall Inc. employees are mandatory reporters and cites Vermont State law (page 39). Staff are permitted to call the State of Vermont DCF Centralized Intake Unit if they wish to make an anonymous report abuse or harassment occurring in the program. Interviews with youth and staff also verified that staff are required to accept all reports of abuse and are not allowed to ask youth what they are writing when placing comments in the suggestion/grievance box. This suggestion box is checked daily by the PREA Compliance Manager and the Program Director.

◻ 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)

Youth are allowed to file a grievance at any time while at Depot Street and are not required to use an informal grievance process such as attempting to resolve the issue with the staff member who may be the subject of the grievance. The Depot Street “PREA Notice to Residents” informs residents that they should make a report of sexual abuse, assault, misconduct or sexual harassment “in any way that is comfortable” for youth (page 3) and provides a list of ways to report. Among the methods for reporting is telling “any staff member” (page 4) The notice also states that there is no time limit to making a report and specifically states that there is no time period on reporting any incident even “if it occurred days, months, or years ago” (page 4).

Onsite interviews with youth and staff confirmed that youth are not required to work with the alleged abuser to resolve a grievance. In addition, staff understood there is no “statute of limitation” to report abuse and that any allegations must be responded to immediately. The Depot program has created a policy to support its current practice and the provisions in this standard (i.e. suggestion box, anonymous reporting, etc.)

◻ 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)

As previously stated, the Seall Inc. 204 Depot Street youth handbook declares that any suspected or alleged incident of child abuse will be reported to DCF Centralized Intake within 24 hours. The youth handbook provides the contact information for the DCF child abuse hotline as well as for Disability Rights Vermont (a statewide advocacy group).

During the corrective action period, the program implemented a new practice to better ensure privacy when youth are communicating with lawyers. Depot staff will dial the phone number, confirm the number was dialed correctly (asking by name if the person on the other end is that person), and handing the phone to the youth. Staff will monitor youth from outside the door with the door open but will not be within earshot of the conversation. During the second onsite visit, youth reported that they are now afforded more privacy when talking with their lawyers.

As previously mentioned, during the corrective action period the Seall Inc. Depot program established a formal with a local advocacy agency, Project Against Violent Encounters (PAVE). This organization provides advocacy and crisis intervention services to survivors of domestic and sexual violence. This comprehensive MOU was executed in early April 2016, following the second onsite audit visit. The MOU clearly maps out the responsibilities of the engaged parties and includes PAVE advocates responding to crisis within one hour; accompanying the youth through the forensic evaluation process if requested by the victim; and accompanying the youth during the investigative interviews.

◻ 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)

During the corrective action period, the Seall Inc. developed a webpage for the Depot Street that includes all required PREA information. The webpage provides information about the agency’s zero tolerance policy; the process for making a 3rd party report; the State of Vermont policy describing the investigatory process for incidents of sexual abuse; and the Depot Street program’s annual report that includes progress on implementing PREA and sexual abuse incident data. The

auditor has reviewed the webpage and all the links are in working order.

In order to ensure a broader net was cast, the Depot Street Program Director visited all 12 regional DCF offices to distribute Depot Street program information and PREA pamphlets (which includes third party reporting information). The auditor applauds the program for its additional efforts in this area.

◻ 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)

The State of Vermont’s child abuse reporting law (Title 33, Chapter 49) states that if a person has reasonable cause to believe that a child has been abused or neglected, he or she must make a report to the Department for Children and Families (DCF). In support of this law, the Seall Inc. Employee Handbook clearly states that all staff are mandatory reporters and are required to contact DCF Centralized Intake Unit if they “have ‘reasonable cause to believe’ any incident of child abuse, neglect or sexual contact among residents” (page 39). Additionally, the Seall Inc. Sexual Harassment Policy embedded in the employee handbook prohibits any retaliation for a staff member filing a grievance of sexual harassment and declares, “participants are entitled to protection from retaliation for having participated in an investigation” (page 34).

During the corrective action period the program developed policy and procedures to ensure effective and immediate response to sexual abuse allegations. A checklist was created that provides a step by step process of who to call and the specific telephone numbers to call in the event a youth alleges sexual abuse or sexual assault. A copy of this response protocol is displayed in both staff offices. All staff have been formally trained on the response protocol. Onsite interviews indicate staff understand the steps in responding to the crisis and that they are mandatory reporters. They were all aware of the first responder checklist. The Depot Street policy also indicates that Depot is responsible for informing DCF of the allegations and that DCF is responsible for contacting the parents or legal guardian.

◻ 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)

Interviews revealed staff were formally trained on and understand how to ensure youth are kept safe in the event they are at imminent risk for sexual abuse. This process involves taking immediate action to separate the alleged perpetrator and victim. This directive was provided to staff as part of the Depot Street PREA training. In addition, the State of Vermont DCF residential licensing regulations specifically require, “A Residential Treatment Program will supervise and separate

the accused individual(s) and the victim(s) whose behavior cause report to the Department for Children and Families unless or until otherwise instructed by the Special Investigation Unit and/or Residential Licensing Unit” (Standard 119, page 7).

During the corrective action period, Depot Street developed a coordinated response plan that includes immediately protecting youth and ensuring their safety. They have also enhanced existing policy to make clear that if a staff member, volunteer or contractor was accused of sexual abuse s/he would immediately be suspended with pay and would be directed to leave the facility immediately.

◻ 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)

The Depot Street program has not had an incident in which a youth disclosed to a Depot Street staff member that they were sexually abused while in a prior placement/facility. During the initial onsite visit, interviews with Depot Street leaders and RLSI management staff, indicated there was a need to clarify who is responsible for notifying the program director or superintendent of the prior placement. During the corrective action the State of Vermont DCF Policy 241 “Licensing Residential Treatment Programs and Regulatory Interventions” was enhanced to specifically describe these responsibilities. The policy now states, “Upon receiving information or an allegation that a child/youth was sexually abused or harassed while placed at another RTP, RLSI shall confirm a report was made to Centralized Intake and Emergency Services and notify the program administrator where the suspected abuse occurred within 72 hours. Notification will occur by phone or email and RLSI will document the notification in FSDNet.” In support of this process, the Depot Street Policy 363 were revised to more clearly describe that DCF is responsible for reporting the allegation to the facility in which the abuse allegedly occurred.

◻ 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)

As previously mentioned, the Depot Street “PREA Notice to Residents” guides youth to take action to preserve evidence in the event they have been sexually abused. The notice directs youth to not shower, brush teeth, or wash their clothes (page 5). During the corrective action period, the program developed policy to support provisions in this standard. In addition, the resident handbook was updated to instruct youth not to use the restroom (in addition to not brushing teeth, showering, etc.). All staff have been trained on the protocol for effectively preserving evidence as part of the PREA training. Onsite interviews with staff indicate staff understand the steps to effectively respond to allegations of sexual abuse/assault.

Recently, the program introduced first responder scenario training into their monthly team meetings in order to better prepare staff for this type of crisis situation. One such scenario is “how do you respond if a youth alleges a staff member has abused them and the staff is currently on duty with you?” A signed roster verifying training completion was submitted to the auditor as further compliance.

◻ 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)

The Seall Inc. Employee Handbook describes in detail how incidents of sexual harassment will be handled. This description includes information regarding the various roles during the investigation process (i.e. the Executive Director, the Depot Street Program Director, the Board of Directors, the investigation subjects, the investigators, and the investigation participants). In addition, the handbook states that if an investigation of sexual harassment leads Seall Inc. to believe there is criminal activity involved, law enforcement will be contacted (page 36). The auditor applauds Seall Inc. for recognizing the importance of ensuring parties involved in a sexual harassment investigation are clear on their role, responsibilities, and expectations.

During the corrective action period, the program developed a written institutional plan to ensure a coordinated response to reports of sexual abuse or sexual assault. The plan delineates the roles of first responders, investigators, victim advocates, and facility leadership. To ensure that staff respond immediately and effectively to sexual abuse or assault allegations, the program created the “Sexual Assault Allegation Checklist” which details specific steps to take as part of the coordinated plan. Staff are required to initial each of the steps (i.e. call 911, centralized intake, Program Director, offer mental health services, forensic exam at no cost to victim, etc.). This completed document will be securely stored with other sensitive PREA information.

The Depot Street program has revised its policy to include specific notifications that first responders must make. This includes Centralized Intake; the hospital in order to alert them of the sexual assault (providing them advance warning so they can secure SANE when youth arrives); local law enforcement, local advocacy center (PAVE); and United Counseling Services. Agency policy also clearly states staff is responsible for arranging for transportation to the hospital if required. In addition, the policy clearly delineates the responsibilities of all involved parties (PREA Compliance Coordinator, First Responders, On Call Staff, the Program Manager and DCF). This includes a quality control check performed by the PREA Compliance Manager to ensure all notifications have been made, services to youth were offered, and the alleged perpetrator (staff member) was placed on leave /suspended immediately (until the conclusion of the investigation).

All staff have been formally trained on the coordinated response plan and corresponding checklist. A training roster was submitted to the auditor for verification. The Depot Street program will require all staff to be formally trained on this coordinated response a minimum of once per year. The Depot Street PREA Compliance Manager will be responsible for tracking this information.

◻ 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)

The Seall Inc. has not entered into a collective bargaining agreement that would prevent the removal of staff who have been alleged to have sexually abused a resident and are awaiting the outcome of an investigation (or while waiting for a determination of the extent of the discipline). The Seall Inc. Employee Handbook clearly states that the agency reserves the right to terminate an employee at any time, foregoing the usual progressive discipline process. Therefore, the Seall Inc. 204 Depot Street program is in compliance with this PREA standard.

◻ 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)

The Seall Inc. Depot Street “PREA Notice to Residents” explains the program’s zero tolerance policy for retaliation for filing a grievance or for cooperating with an investigation. This notice clearly states, “Retaliation is intimidation to prevent a client from filing a complaint or participating in an investigation. 204 Depot Street program prohibits anyone from interfering with an investigation, including intimidation or retaliation against witnesses. If you believe you are being unfairly treated or punished in some way because you filed a complaint or assisted in the investigation of a complaint, please report this immediately to the Program Supervisor or PREA Coordinator” (page 5).

The Seall Inc. Employee Handbook addresses retaliation with regard to sexual harassment among staff members. The handbook explains, “It is, also, expressly prohibited for an employee of SEALL to retaliate against employees who bring sexual harassment charges or assist in investigating charges. Retaliation is a violation of this policy and may result in discipline, up to and including termination. No employee will be discriminated against, or discharged, because of bringing or assisting in the investigation of a complaint of sexual harassment….it shall be a violation of this policy for an employee who learns of the investigation or complaint to take any retaliatory action which affects the working environment of any person involved in the investigation” (pages 22-23).

As stated previously, the State of Vermont residential licensing regulations require the alleged perpetrator and victim to be separated in the event of a sexual abuse allegation (Standard 119, page 7). Depot Street leadership stated their practice would be to immediately separate the victim and perpetrator. Additionally, leadership reported that the alleged perpetrator would be removed from the program once claim was substantiated. During the corrective action period, the Depot PREA Compliance Manager enhanced the tracking chart to ensure youth receive follow up services and that possible retaliation is carefully monitored for a minimum of 90 days.

◻ 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)

Onsite interviews confirmed the Depot Street program does not use isolation. During the corrective action period, the program enhanced the policy to clearly state that if a youth had to be temporarily separated from the group, they would continue to receive education services, special education services, and daily large muscle exercise. Depot Street leadership staff stated that the perpetrator (youth) would be placed in the classroom where youth could be monitored either by staff sitting with him or via cameras. This would be temporary until victim was brought to the hospital. The perpetrator would be removed from the program immediately by DCF.

◻ 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)

Residential Licensing and Special Investigations (RLSI) is a unit, housed in the Agency of Human Services, Family Services Division, Department for Children and Families (DCF). RLSI is responsible for investigating allegations of sexual abuse involving staff and youth as well as youth- on-youth sexual abuse in private regulated facilities. When a mandatory reporter calls the DCF abuse hotline, a Centralized Intake and Emergency Services (CIES) social worker records the information in a statewide database, FSDNet. A CIES supervisor determines whether to “accept” or “not accept” the report for investigation of child sexual abuse based on statutory criteria. If the report is accepted for investigation of possible child sexual abuse, the case is assigned and an investigation is formally launched by an RLSI investigator. If the report is not accepted by CIES supervisor for investigation, a second supervisor reviews the report, also based on statutory criteria. The supervisor conducting the “second read” makes the final determination. This means if the “first read” supervisor doesn’t accept the report for investigation and the “second read” supervisor disagrees; the report is accepted, assigned and an investigation is formally launched by an RLSI investigator.

If the case is “not accepted” by both reviewers, then the case will not be investigated as child sexual abuse and the report is rerouted to RLSI for regulatory review. In other words, if the case does not meet the statutory threshold for sexual abuse, RLSI will investigate or cause the facility to investigate the same alleged incident.

When a report has been accepted for investigation of child sexual abuse the RLSI Investigator contacts the Bennington Police Department’s Special Investigations Unit to conduct a joint investigation. During the course of the investigation, if evidence substantiates allegations of child

sexual abuse, the case is immediately referred to legal counsel to make a decision on whether to pursue criminal prosecution. This practice is supported by State of Vermont AHS Policy 52 “Child Safety Interventions: Investigations and Assessments which describes situations in which joint investigations must be conducted. The policy requires DCF to contact law enforcement for assistance if the alleged perpetrator of child sexual abuse is ten years or older (page 4).

Interviews with RLSI staff revealed that if evidence substantiates allegations of sexual abuse, the case is referred to legal counsel for possible criminal prosecution. This process is the same whether the alleged sexual abuse has occurred between staff and youth or between two Depot Street program residents.

State of Vermont Policy 54 “Investigating Reports of Child Abuse or Neglect in Regulated Facilities” states, “When the alleged perpetrator has continued access to alleged victim, or if other children may be at risk, the investigation will commence within 24 hours. In other cases, the investigation will commence within 72 hours. The operations manager must approve any waiver of this requirement” (page 1). Review of one of the two sexual abuse investigation reports from Depot Street program revealed that DCF supervisor overrode this timeframe due to the local law enforcement investigator not being immediately available. The investigation for this particular incident began nine days after the incident was reported.

The Seall Inc. agency provides a breadth of information with regard to conducting personnel investigations. The Seall Inc. Employee Handbook describes in detail its policy on sexual harassment; criteria for launching an investigation; who is responsible for conducting investigations into “improper government activities;” how staff will be handled during an investigation (i.e. administrative leave); who will be notified about the outcome of the investigation; local law enforcement will be contacted if an investigation leads to possible criminal activity, to name a few. The auditor applauds the Seall Inc. for providing significant details to its employees around these matters.

The State of Vermont AHS has a number of policies that describe the investigation process (e.g. Policies 50, 51, 52, 54, 56, 57, 60, and 66). While many of these policies address some of the PREA standards they are not reflective of investigations conducted in juvenile justice facilities (i.e. many of these policies reflect investigations in community settings). Under Vermont law, the RLSI is not required to investigate every allegation of “sexual abuse” as defined by PREA standards. Vermont does not consider all youth-on-youth sexual activities to be “abuse”. The Vermont AHS policy dictates that if the youth-to-youth interactions indicate “the alleged perpetrator used force, threat or coercion to victimize the child and/or the victim did not have an opportunity to consent” (page 8) or if “there is a five year developmental or chronological age differential” (page 9) this is considered abuse and would be thoroughly investigated.

In the past 18 months, there were two reports in which Depot Street youth alleged sexual abuse by the same staff member. Both incidents were accepted by CIES and investigated by RLSI. One allegation involved a Depot Street staff member inappropriately interacting with youth, but did not involve any physical contact. This report was not substantiated for sexual abuse, although the staff member was terminated from Depot Street because of her inappropriate boundaries.

The second sexual abuse report involved a youth disclosing he had sexual intercourse with a staff member while at a previous placement and again, when he had run away from the Depot Street program. At the time of the youth’s disclosure, the youth was not at the Depot Street program nor was the staff member. The report of sexual abuse was a joint investigation conducted by RLSI and the local police. The report of sexual abuse was substantiated by RLSI and the police charged the perpetrator (staff member). The perpetrator pled guilty to the charges of sexual misconduct.

Review of sexual abuse investigative reports prepared by RLSI indicate there is a thorough and collaborative investigation process. Both investigations were conducted in collaboration with the special investigations unit of local law enforcement. Information was gathered through extensive interviews including with victim, alleged perpetrator, and potential witnesses. Detailed information about the events, individual statements, and timeframes were well documented in the investigation reports.

With regard to allegations of sexual harassment, AHS DCF policies do not require RLSI to investigate incidents of sexual harassment between youth. However, although a sexual harassment allegation would not be “accepted” as a report of sexual abuse, RLSI is notified of these reports and often delegates investigation of the incident to the program. RLSI ensures these incidents are properly investigated by closely monitoring the program. This may involve mapping out clear deliverables/expectations and requiring the program report back to RLSI on progress made in addressing the identified issues. In cases in which there have been allegations of sexual harassment against staff, volunteers, and contractors and any allegations of retaliation, the Depot Street Executive Director would conduct personnel investigations. The auditor encourages Seall Inc. to consider creating an investigation team to provide perspective and expertise when investigating personnel issues. The agency may consider involving members of the Seall Inc. Board of Directors Personnel Committee since their current role centers on human resource related issues within the agency. It is important for the Depot Street program to remember that all investigations of sexual harassment must be investigated and responded to consistent with PREA regulations, including sexual harassment allegations between residents. During the corrective action period, Depot provided an example of how it is effectively handling sexual harassment allegations between residents. This incident and the corresponding details, has been documented on the PREA tracking chart maintained by the PREA Compliance Manager.

Review of State of Vermont AHS DCF policies and RLSI staff interviews verified that there is significant effort on behalf of investigators to determine whether staff actions or failures to act contributed to abuse. Sexual abuse investigations are conducted promptly and once an investigation is completed, information is summarized in a written report that contains a thorough description of physical, testimonial, and documentary evidence. These final reports are stored in the electronic system, FSDNet. At the conclusion of sexual abuse investigations, a formal letter detailing the outcome of the investigation is sent to the program in which the youth resides, indicating whether the report was substantiated or unsubstantiated. Interviews revealed that polygraph tests are not used by DCF RLSI to determine whether a victim’s allegation is true. In addition, the RLSI does not terminate a sexual abuse investigation if a youth recants the allegation. All RLSI investigation employees are required to complete specialized training. As described under Standard 115.334, all RLSI employees assigned to the Depot Street program have completed specialized training on conducting sexual abuse investigations. Most recently, the investigator

completed the National Institute of Corrections online course entitled, “PREA: Investigating Sexual Abuse in a Confinement Setting.” During the corrective action period, the State of Vermont revised Policy 241 to include language requiring this training. The auditor applauds RLSI for its commitment to ensuring its investigators are thoroughly trained in this area of specialization.

Recent revisions to the State of Vermont Policy 241 “Licensing Residential Treatment Programs and Regulatory Interventions” addresses several critical pieces of the investigation process. For example, the policy now clearly states:
• The use of a polygraph examination or other truth-telling devices as a condition for proceeding with the child safety intervention and/or criminal investigation is prohibited;
• Written investigative reports must include descriptions of physical and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings;
• Programs are required to conduct a sexual abuse incident reviews at the conclusion of every sexual abuse investigation and RLSI social workers must participate on these reviews and make recommendations for improvement
• RLSI social workers will collaborate with law enforcement in the gathering and preserving direct and circumstantial evidence and when interviewing child/youth victims, alleged actors, and witnesses.

During the corrective action period, the auditor held a conference call with the RLSI Senior Social Worker who oversees the RLSI investigators, in order to verify the components of the investigative process.

◻ 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)

Interviews conducted with RLSI investigative staff indicate that DCF RLSI imposes a standard of preponderance of evidence for proof, or a lower standard, when determining whether allegations of sexual abuse or sexual harassment are substantiated. During the corrective action period, the State of Vermont DCF Policy 241 was revised to more clearly reflect current practice related to conducting investigations. The policy now states, “…a substantiated report means the Commissioner or the Commissioner’s designee (RLSI for the purposes of this policy) has determined after investigation that a report is based upon accurate and reliable information that would lead a reasonable person to believe the child has been abused or neglected. The substantiation standard described above is consistent with the “reasonable belief standard” or “reasonable suspicion standard”, which is lower than the “preponderance of evidence standard” and meets the requirements of 28 CFR 115.372.”

Similarly, interviews with Seall Inc. Executive Director reveal that this definition is also used when investigating personnel matters.

◻ 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)

The State of Vermont DCF Policy 54 “Investigating Reports of Child Abuse or Neglect in Regulated Facilities” states, “The SIU Chief will notify the district office and the appropriate licensing and program units of the following: whether or not the referral has been accepted as a report; if the report is not accepted, what further actions the SIU will take, if any; and, if the report was accepted, the case determination, including any necessary follow-up by the district.” Interviews with RLSI unit staff confirmed current practice is consistent with policy expectations.

Once a sexual abuse investigation is completed, the final report is stored in the electronic state system, FSDNet. A formal letter detailing the outcome of the investigation is sent to the Program Director of the facility in which the youth currently resides. Victims are notified of the determination, regardless of the investigation outcome (i.e. whether the case was substantiated or unsubstantiated). Since the State of Vermont does not include an “unfounded” investigatory finding, notifying the victim regardless of the outcome is required in order to achieve compliance with this PREA standard. An example RLSI unit notification letter was provided to the auditor. The letter provides sufficient information further supporting compliance with this PREA standard.

During the corrective action period, the program expanded language in its policy to describe specific situations in which youth (victim) will be kept informed (i.e. staff no longer works in the program, been indicted on a charge related to sexual abuse at the program, etc.). Additionally, the policy clear states the PREA Compliance Manager is responsible for following up with DCF RLSI to gather information regarding progress of the investigation. During the second on-site visit, interviews with the PREA Coordinator and Program Director indicate they clearly understand their responsibilities for notifying youth. The PREA Coordinator has included notifications and corresponding deadlines on the Excel PREA tracking chart.

◻ 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)

The Seall Inc. Employee Handbook describes in detail its zero tolerance, sexual harassment, and discipline policies. With regard to progressive discipline, the handbook clearly states, “Behavior that is illegal is not subject to progressive discipline and may be reported to local law enforcement. Theft, intoxication at work, fighting and other acts of violence are also not subject to progressive discipline and may be grounds for immediate termination” (page 17). The agency handbook also states, “Seall reserves the right to combine and skip steps depending upon the circumstances of each situation and the nature of the offense. Furthermore, employees may be terminated without prior notice or disciplinary action” (page 19).

As cited elsewhere in this report, Seall Inc. upholds that in the course of a personnel investigation, when criminal activity appears to be involved, the RLSI unit and local law enforcement will be notified immediately. More specifically the employee handbook puts forth, “If an investigation leads Seall Inc. to conclude that a crime has probably been committed, the results of the investigation shall be reported to the States Attorney or other appropriate law enforcement agency. If an investigation leads Seall Inc. to conclude that a staff member has engaged in conduct less than criminal, the Board of Directors shall be notified and shall engage in determining proper resolution of the matter, consistent with established personnel procedures” (page 36).

Seall Inc. appropriately disciplines staff who are substantiated for sexual abuse or sexual harassment. Review of investigation reports as well as personnel files support that the consequences given for unethical behaviors in the workplace were commensurate with the level of misconduct. As previously mentioned, the Depot Street program had one staff member who was alleged to have had inappropriate non-physical contact with youth. Upon receiving information that the staff member was being investigated for sexual misconduct in another treatment program, the Depot Street Program Director suspended the staff immediately. The Seall Inc. leadership maintained close contact with RLSI in an effort to stay informed of the investigation progress. It was revealed that the staff member had continued to contact the youth/victim through social media. This was a violation of Seall Inc. policy and therefore the staff was promptly terminated.

The State of Vermont RLSI unit licensing regulations specifically direct that a residential treatment program may not continue to employ any person who has been substantiated for child abuse or neglect (“AHS DCF Licensing Regulations for Residential Treatment Programs in Vermont,” Standard 402). Agency policies and existing practice supports compliance with this PREA standard.

◻ 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)

All contractors and volunteers are subject to agency policies and protocols related to sexual abuse and harassment. Information derived from interviews and additional evidence described in Standard 115.376 of this report, support compliance with this PREA standard. There have been no volunteers, interns, or contractors working at the 204 Depot Street program who have violated these policies to date.

◻ 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)

The Depot Street youth handbook states, “Discipline must be firm, fair and consistent for everyone’s safety. As its goal: discipline is to modify or change behavior. All rules must be enforceable and disciplinary action must be in accordance with state and federal regulations” (page 3). The youth manual and the Seall Inc. Employee Handbook do not describe appropriate consequences for specific youth behaviors.

In the past 12 months there have been no criminal or administrative findings of guilt for resident- on-resident sexual abuse at the Depot Street program. During the interviews with the Executive Director it was mentioned that in the event a youth sexually abused another resident, the alleged abuser be placed on a one-to-one status and moved to another program as soon as possible.

As previously mentioned, the Depot Street “PREA Notice to Residents” addresses retaliation and clearly states that youth shall not be retaliated against for filing a complaint or participating in an investigation (page 5). The resident handbook also states youth will not be punished if allegations of sexual abuse are made in “good faith” (Section 4). During the corrective action period the program revised its policy to provide additional details of how the program handles incidents of sexual harassment (i.e. all incidents will be investigated, youth interviewed, tracked by PREA Coordinator, etc.). In addition, the policy now states that reports of sexual abuse made in good faith based will not be punished; sexual activity is prohibited between residents; and that all consequences will be monitored. The program upholds that a youth would be immediately removed from the program to a temporary location if he sexually assaulted another resident or staff member. The Depot Street Program Director would work with DCF to ensure this happens quickly. Interviews conducted during the second on-site visit verified that these practices are in place.

◻ 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)

The Seall Inc. Depot Street program does not currently conduct formal mental health and medical screenings when a youth arrives to the program. During the corrective action period the program developed a policy to support the provisions in this standard. The policy now states that if a youth discloses at intake they have either been a victim of sexual abuse or have sexually perpetrated, Depot staff will work with DCF workers to ensure youth is seen by mental health professional within 14 days of disclosure.

Recently, the program added a question to the bottom of the vulnerability assessment tool conducted at intake to capture this information. The question asks youth if they were ever offered counseling services and if he would like to see a counselor regarding his sexual abuse/assault history. Youth are required to initial these questions to indicate that these services were offered. If the youth indicates they do want to speak with a clinician, the Program Director or PREA Compliance Manager will contact DCF via phone and email to ensure these services are provided within the 14-day timeframe. This contact is documented at the bottom of the vulnerability tool. In addition, the email to the DCF social worker is printed and attached to the vulnerability tool.

These documents are placed in the youth’s PREA folder, which is stored in a separate locked file cabinet in the main Seall Inc. building. This file cabinet is only accessible by the Agency PREA Coordinator and Depot Street PREA Compliance Manager. The PREA Compliance Manager is responsible for following up with DCF to ensure these services are provided within the 14-day timeframe. During the second onsite visit, interviews and file reviews confirmed this practice is in place.

◻ 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)

During the corrective action period, the Depot Street program developed a coordination plan to ensure effective response to allegations of sexual abuse. The plan provides a detailed step-by-step process in responding to allegations of sexual abuse and/or assault. To assist staff in dealing effectively with crisis, the program created a “Sexual Assault Allegation Checklist” which is used to ensure all steps in the response process are taken. Each step on the checklist must be initialed by the staff who completed the step. The checklist includes contacting local advocacy representatives to provide crisis services and transporting youth to the hospital immediately. The coordinated response plan also includes calling the hospital to let them know that there has been an allegation of sexual abuse or sexual assault and that the youth will need to see a SANE. Depot Street policy also states that all staff will complete an annual training on how staff should interact with a victim of sexual abuse while awaiting the arrival of victim advocates/crisis service workers.

In the event of sexual abuse or assault allegation, youth would be taken to Southwestern Vermont Medical Center (SVMC), since Depot Street program does not employ medical staff. The SVMC hospital policy and procedures describes the process for handling sexual assaults. The hospital policy requires sexual assault victims in which the assault occurred in less than 24 hours be examined by a SANE. The procedures also describe steps for providing post-exposure prophylaxis and emergency contraception. The hospital policy references the Vermont Center for Prevention and Treatment of Sexual Abuse Guidelines (2006) as well as the Vermont SANE Program (2006). These standards are consistent with the requirements in this PREA standard.
The Depot Street’s Policy 382 states that emergency contraception and access to sexually transmitted infections (STI) prophylaxis will be provided to victims of sexual abuse or assault without cost to them. In addition, emergency contraception and STI testing and treatment is part of the hospital’s SANE examination protocol.

◻ 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)

At the time of the initial onsite visit, the Depot Street program did not have a policy specifically describing how it will ensure ongoing medical and mental health care for sexual abuse victims. During the corrective action period, the program developed a policy to support provisions in this standard. Since the Depot program does not currently employ mental health clinicians, the Depot program would contact United Counseling Services (UCS) as part of the crisis response plan. UCS would also provide any follow-up mental health treatment services the victim may need. The Depot program would work closely with the DFS social worker and UCS to ensure the youth is provided with adequate treatment while in the Depot program. This would include any follow-up mental health treatment while youth remains in the program; a continuation of treatment services if youth is released from the program; and in the case of a resident-on-resident abuse situation, a mental health evaluation within 60 days of the incident.

As previously mentioned, the hospital’s SANE process includes pregnancy testing, emergency contraception, sexually transmitted disease testing. Several Depot Street policies state any mental health or medical treatment services needed will be the responsibility of the Depot Street program while youth is in the Depot program.

◻ 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)

The State of Vermont and the Seall Inc. both use two categories for concluding the outcome of investigations for sexual abuse and sexual harassment (respectively): Substantiated or Unsubstantiated. The term “unfounded” is not used when describing a possible outcome of an investigation case. PREA standards require all sexual abuse incidents that have been investigated, be subject to a formal review process within 30 days. Since the term “unfounded” is not used, according to PREA standards, all cases of sexual abuse would need to be formally reviewed by the incident review committee.

During the corrective action period, the Depot Street program developed policy to support provisions in this standard. The policy describes the sexual incident review committee will be held within one week of the final investigation report being issued. This exceeds the minimum PREA standard which requires the committee to convene within 30 days of the conclusion of the investigation. The policy defines the committee as including PREA personal (Agency Coordinator and Facility Compliance Manager), Depot Street Program Manager, investigators, and medical and mental health practitioners.

In addition, recent policy revisions now specifically address what the incident committee must consider during these reviews. For example: If the incident or allegation was motivated by race; ethnicity; gender identity: lesbian, gay, bisexual, transgender, intersex identification, status or perceived status; or, gang affiliation; or resulting from other group dynamics at the facility; whether the staff levels where the incident occurred are adequate; whether monitoring technology should be considered or augmented to supplement staff supervision; and other areas required by

the provisions set forth in these standards. The policy also now requires the practice of generating a formal summary report to capture the committee’s discussion and decisions made during the incident review meeting.

The State of Vermont Policy 241 clearly states, RLSI investigators are required to participate in the sexual abuse incident review committee. Since the Depot program has implemented this practice, there have been no incidents of sexual abuse allegations and therefore, the auditor was not able to review hard evidence that this process has been implemented. That said, given the program’s commitment to meeting the PREA standards and their response to incidents of sexual harassment, the auditor is confident the program will adhere to their policy in the event of a sexual abuse allegation.

During the second onsite visit, interviews revealed that program leadership and the PREA Compliance Manager understand the practice of conducting incident reviews of all sexual abuse investigations (substantiated or not substantiated). They were able articulate what would be discussed during these meetings and who comprises the sexual abuse incident review committee.

◻ 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)

The State of Vermont has included language in its Fiscal Year 2016 contract with Seall Inc. requiring collection of PREA related data. The contract specifically states, “In accordance with State Licensing Regulations and §115.387 of the PREA National Standards, contractor will collect accurate and uniform data for every allegation of sexual abuse. Contractor will aggregate the incident-based sexual abuse data at least annually. Contractor will provide sexual abuse and sexual harassment data, admission and adjudication data, and the most recent version of the Survey of Sexual Violence conducted by the Department of Justice to the State Licensing Authority and Juvenile Justice Director no later than January 30 each calendar year.” This contract language provides evidence that Seall Inc. Depot Street is in compliance with provisions a, b, and c in this PREA standard. During the corrective action period the Depot PREA Compliance Manager created a comprehensive tracking sheet that includes all required DOJ variables. The Depot Street program submitted completed DOJ surveys to the State of Vermont DCF prior to the January 30th deadline, which is consistent with the State of Vermont contract expectations.

During the corrective action period, Seall Inc. Depot developed a policy which sets forth clear expectations with regard to annual data collection, document submission to DCF, using the information from the DOJ survey to make program improvements, and developing an annual report detailing sexual abuse data and related PREA information. This chart was reviewed during the second onsite visit for verification. This sensitive data is maintained by the PREA Compliance Manager. All additional information related to incidents of sexual abuse and sexual harassment are retained in the main Seall Inc. building in a locked file cabinet.

The Seall Inc. Employee Manual provides clear definitions of sexual harassment for staff members (page 22). The Depot Street PREA Notice to Residents provides definitions and examples of sexual harassment by staff as well as examples of unwanted sexual behaviors between residents that would warrant a report to staff or DCF Centralized Intake Unit (pages 2-3).

◻ 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)

During the corrective action period, the Depot Street program developed an annual report to highlight progress with implementing PREA standards. This is the first year the program has created this report. The program will include comparison data in the 2016 report. This practice is supported by the Depot Street Policy 388 which requires Board of Director approval of the report and states that the report will be made available in February of the following year. The policy describes the need to redact specific material prior to publication if it would present a threat to the safety and security of the program. The auditor confirmed that the 2015 report referenced above included all of the essential elements and is now posted on the Seall Inc. Depot Street website.

◻ 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)

The Seall Inc. program has a policy titled, “Document Retention and Destruction Policy” which provides guidance regarding the retention and destruction of agency records. The policy explains, “Records containing confidential and proprietary information will be securely maintained, controlled, and protected to prevent unauthorized access. All records generated and received by the organization are the property of the organization. No employee, by virtue of their position, has any personal or property right to such records even though they may have developed or compiled them. The unauthorized destruction, removal, or use of such records is prohibited” (page 1). The policy also specifies that electronic files will be subject to the same retention period as prescribed in this agency policy.

The policy referenced above directs personnel files to be retained and safely stored for 10 years following the termination of employment (pages 4 and 5). At the time of the initial onsite visit, the policy did not provide specific information regarding sexual abuse incident reports or youth case files. During the corrective action period, the Depot program created policy to support new practices related to data. The program policy now states, “204 Depot will ensure safe storage of any information/data related to a resident who was found guilty or was a victim of sexual abuse or harassment while in our program. This information can be collected from incident reports, investigation files, and sexual abuse/harassment reviews. This information will be kept in a locked

file cabinet that contains any PREA files for at least ten years after the date of its initial collection. The PREA Coordinator and the Executive Director will have keys to this file cabinet. Any data will be readily available to the public at least annually through an impending website and its Annual Report, which is published during the first quarter of each New Year. All personal identifiers will be removed from such data.”

Interviews during the second onsite visit confirmed that Seall Inc. Depot program leadership are aware of this new practice. Review of tracking charts maintained by the PREA Compliance Manager verify that this information is being tracked. The 2015 annual report, detailing progress in implementing PREA standards, and sexual abuse incident data is now posted on the agency website.

The State of Vermont’s Family Services Division (FSD) Policy 305 (effective May 2015) requires sexual abuse incident data be collected from all facilities under its control and that these data be retained for at least ten years. This retention period applies to investigative reports for incidents of sexual abuse (housed in the electronic database, FSDNet).

The following information is provided as a way of demonstrating compliance with federal PREA Standards 115.401 through 115.405. This audit represents the first PREA audit for the Seall Inc. 204 Depot Street program. Since the audit was conducted in August 2015, the Seall Inc. agency is in compliance with Standard 115.401 (a) and (b) which requires facilities that house juvenile justice youth to undergo a PREA audit by August 2016.

The auditor is a federal PREA auditor certified by the Department of Justice. She has not received any financial compensation from the agency being audited. There are no other conflicts of interest, as defined by Standard 115.402 and 115.403, between the auditor and the Seall Inc. 204 Depot Street program.

The audit was conducted consistent with Department of Justice PREA expectations. Some of the highlights demonstrating compliance in this area include conducting extensive review of program materials, protocols, agency policies, staff records, youth files, various internal/external reports, licensing reports and conducting a facility tour. The process also included two on-site visits (5 months apart) which included interviews with several staff, contractors, youth, and the local victim advocacy group. During the corrective action period revised documents were reviewed, feedback provided to the Agency PREA Coordinator, and several follow-up telephone interviews were conducted (i.e. State of Vermont DCF Policy Manager, Senior Social Worker for DCF RLSI, victim advocacy organization, to name a few).

Throughout the audit review process, as well as in the onsite debriefing meeting, agency and program leadership were made aware of additional PREA requirements and next steps. Conversations included, but was not limited to, describing the purpose of the 180-day corrective action period and explaining the federal requirement that the final PREA audit report must be made

available to the public. Seall Inc. and the Depot Street leadership team have expressed a sincere commitment to continue to uphold compliance with all PREA standards.

 

AUDITOR CERTIFICATION:

Program Audited: Seall Inc., 204 Depot Street Program

Date of On-Site Review: August 10, 11, and 12, 2015

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.

Sharon Pette, MSC, GBSS

Certified DOJ PREA Auditor