‌PREA Facility Audit Report: Final

Name of Facility: Southeastern Correctional Institution

Facility Type: Prison / Jail

Date Interim Report Submitted: NA

Date Final Report Submitted: 03/06/2025

Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the agency under review.
I have not included in the final report any personally identifiable information (PII) about any inmate/resident/detainee or staff member, except where the names of administrative personnel are specifically requested in the report template.
Auditor Full Name as Signed: Valerie Wolfe Mahfood	Date of Signature: 03/06/2025

AUDITOR INFORMATION
Auditor name:	Mahfood, Valerie Wolfe
Email:	wolfemahfood@aol.com
Start Date of On- Site Audit:	01/09/2025
End Date of On-Site Audit:	01/11/2025

FACILITY INFORMATION
Facility name:	Southeastern Correctional Institution
Facility physical address:	5900 B.I.S. Road, Lancaster, Ohio - 43130
Facility mailing address:

Primary Contact

Name:	Thomas Hendrix
Email Address:	thomas.hendrix@drc.ohio.gov
Telephone Number:	7405916236

Warden/Jail Administrator/Sheriff/Director
Name:	Norman Robinson
Email Address:	Norman.Robinson@drc.ohio.gov
Telephone Number:	7406534324

Facility PREA Compliance Manager
Name:	Thomas Hendrix
Email Address:	thomas.hendrix@drc.ohio.gov
Telephone Number:	(740) 653-4324 x4473

Facility Health Service Administrator On-site
Name:	Connie Starner
Email Address:	connie.starner@drc.ohio.gov
Telephone Number:	740-653-4324

Facility Characteristics
Designed facility capacity:	1595
Current population of facility:	1394
Average daily population for the past 12 months:	1413
Has the facility been over capacity at any point in the past 12 months?	No
What is the facility’s population designation?	Mens/boys

In the past 12 months, which population(s) has the facility held? Select all that apply (Nonbinary describes a person who does not identify exclusively as a boy/man or a girl/woman. Some people also use this term to describe their gender expression. For definitions of “intersex” and “transgender,” please see https://www.prearesourcecenter.org/ standard/115-5)
Age range of population:	19-78
Facility security levels/inmate custody levels:	1&2
Does the facility hold youthful inmates?	No
Number of staff currently employed at the facility who may have contact with inmates:	334
Number of individual contractors who have contact with inmates, currently authorized to enter the facility:	24
Number of volunteers who have contact with inmates, currently authorized to enter the facility:	93

AGENCY INFORMATION
Name of agency:	Ohio Department of Rehabilitation and Correction
Governing authority or parent agency (if applicable):
Physical Address:	4545 Fisher Road, Suite D, Columbus, Ohio - 43228
Mailing Address:
Telephone number:

Agency Chief Executive Officer Information:

Name:
Email Address:
Telephone Number:

Agency-Wide PREA Coordinator Information
Name:	David Kollar	Email Address:	david.kollar@drc.ohio.gov

‌Facility AUDIT FINDINGS
Summary of Audit Findings
The OAS automatically populates the number and list of Standards exceeded, the number of Standards met, and the number and list of Standards not met. Auditor Note: In general, no standards should be found to be "Not Applicable" or "NA." A compliance determination must be made for each standard. In rare instances where an auditor determines that a standard is not applicable, the auditor should select "Meets Standard” and include a comprehensive discussion as to why the standard is not applicable to the facility being audited.
Number of standards exceeded:
9	115.11 - Zero tolerance of sexual abuse and sexual harassment; PREA coordinator 115.18 - Upgrades to facilities and technologies 115.33 - Inmate education 115.34 - Specialized training: Investigations 115.35 - Specialized training: Medical and mental health care 115.65 - Coordinated response 115.71 - Criminal and administrative agency investigations 115.83 - Ongoing medical and mental

	health care for sexual abuse victims and abusers 115.401 - Frequency and scope of audits
Number of standards met:
36
Number of standards not met:
0

‌POST-AUDIT REPORTING INFORMATION
‌GENERAL AUDIT INFORMATION
‌On-site Audit Dates
1. Start date of the onsite portion of the audit:	2025-01-09
2. End date of the onsite portion of the audit:	2025-01-11
‌Outreach
10. Did you attempt to communicate with community-based organization(s) or victim advocates who provide services to this facility and/or who may have insight into relevant conditions in the facility?	Yes No
a. Identify the community-based organization(s) or victim advocates with whom you communicated:	Just Detention International, Sexual Assault Response Network of Central Ohio
‌AUDITED FACILITY INFORMATION
14. Designated facility capacity:	1595
15. Average daily population for the past 12 months:	1413
16. Number of inmate/resident/detainee housing units:	6
17. Does the facility ever hold youthful inmates or youthful/juvenile detainees?	Yes No Not Applicable for the facility type audited (i.e., Community Confinement Facility or Juvenile Facility)

‌Audited Facility Population Characteristics on Day One of the Onsite Portion of the Audit
‌Inmates/Residents/Detainees Population Characteristics on Day One of the Onsite Portion of the Audit
18. Enter the total number of inmates/ residents/detainees in the facility as of the first day of onsite portion of the audit:	1435
19. Enter the total number of inmates/ residents/detainees with a physical disability in the facility as of the first day of the onsite portion of the audit:	15
20. Enter the total number of inmates/ residents/detainees with a cognitive or functional disability (including intellectual disability, psychiatric disability, or speech disability) in the facility as of the first day of the onsite portion of the audit:	7
21. Enter the total number of inmates/ residents/detainees who are Blind or have low vision (visually impaired) in the facility as of the first day of the onsite portion of the audit:	4
22. Enter the total number of inmates/ residents/detainees who are Deaf or hard-of-hearing in the facility as of the first day of the onsite portion of the audit:	2
23. Enter the total number of inmates/ residents/detainees who are Limited English Proficient (LEP) in the facility as of the first day of the onsite portion of the audit:	43
24. Enter the total number of inmates/ residents/detainees who identify as lesbian, gay, or bisexual in the facility as of the first day of the onsite portion of the audit:	31

25. Enter the total number of inmates/ residents/detainees who identify as transgender or intersex in the facility as of the first day of the onsite portion of the audit:	10
26. Enter the total number of inmates/ residents/detainees who reported sexual abuse in the facility as of the first day of the onsite portion of the audit:	16
27. Enter the total number of inmates/ residents/detainees who disclosed prior sexual victimization during risk screening in the facility as of the first day of the onsite portion of the audit:	59
28. Enter the total number of inmates/ residents/detainees who were ever placed in segregated housing/isolation for risk of sexual victimization in the facility as of the first day of the onsite portion of the audit:	0
29. Provide any additional comments regarding the population characteristics of inmates/residents/detainees in the facility as of the first day of the onsite portion of the audit (e.g., groups not tracked, issues with identifying certain populations):	Inmates were allowed to self-select out of and/or into all targeted categories during the interview process. As such, while facility records may or may not include inmates currently within targeted categories, targeted protocols were still completed for any inmate who self-selected into any targeted protocol at the time of the interview. Also, it should be noted that if there were not sufficient numbers of inmates assigned to the facility within a targeted group, oversampling was done in other targeted groups to ensure the minimum number of targeted interviews were conducted.
‌Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite Portion of the Audit
30. Enter the total number of STAFF, including both full- and part-time staff, employed by the facility as of the first day of the onsite portion of the audit:	326

31. Enter the total number of VOLUNTEERS assigned to the facility as of the first day of the onsite portion of the audit who have contact with inmates/residents/detainees:	95
32. Enter the total number of CONTRACTORS assigned to the facility as of the first day of the onsite portion of the audit who have contact with inmates/residents/detainees:	28
33. Provide any additional comments regarding the population characteristics of staff, volunteers, and contractors who were in the facility as of the first day of the onsite portion of the audit:	NA
‌INTERVIEWS
‌Inmate/Resident/Detainee Interviews
‌Random Inmate/Resident/Detainee Interviews
34. Enter the total number of RANDOM INMATES/RESIDENTS/DETAINEES who were interviewed:	21
35. Select which characteristics you considered when you selected RANDOM INMATE/RESIDENT/DETAINEE interviewees: (select all that apply)	Age Race Ethnicity (e.g., Hispanic, Non-Hispanic) Length of time in the facility Housing assignment Gender Other None

If "Other," describe:	Custody, Job Assignment, Program Activity, Physical Characteristics, Psychological Characteristics, Primary Language Spoken, or other distinguishing factors amongst population.
36. How did you ensure your sample of RANDOM INMATE/RESIDENT/DETAINEE interviewees was geographically diverse?	Housing rosters
37. Were you able to conduct the minimum number of random inmate/ resident/detainee interviews?	Yes No
38. Provide any additional comments regarding selecting or interviewing random inmates/residents/detainees (e.g., any populations you oversampled, barriers to completing interviews, barriers to ensuring representation):	No barriers to completing random interviews were noted.
‌Targeted Inmate/Resident/Detainee Interviews
39. Enter the total number of TARGETED INMATES/RESIDENTS/DETAINEES who were interviewed:	21
As stated in the PREA Auditor Handbook, the breakdown of targeted interviews is intended to guide auditors in interviewing the appropriate cross-section of inmates/residents/detainees who are the most vulnerable to sexual abuse and sexual harassment. When completing questions regarding targeted inmate/resident/detainee interviews below, remember that an interview with one inmate/resident/detainee may satisfy multiple targeted interview requirements. These questions are asking about the number of interviews conducted using the targeted inmate/ resident/detainee protocols. For example, if an auditor interviews an inmate who has a physical disability, is being held in segregated housing due to risk of sexual victimization, and disclosed prior sexual victimization, that interview would be included in the totals for each of those questions. Therefore, in most cases, the sum of all the following responses to the targeted inmate/resident/detainee interview categories will exceed the total number of targeted inmates/ residents/detainees who were interviewed. If a particular targeted population is not applicable in the audited facility, enter "0".
40. Enter the total number of interviews conducted with inmates/residents/ detainees with a physical disability using the "Disabled and Limited English Proficient Inmates" protocol:	4

41. Enter the total number of interviews conducted with inmates/residents/ detainees with a cognitive or functional disability (including intellectual disability, psychiatric disability, or speech disability) using the "Disabled and Limited English Proficient Inmates" protocol:	4
42. Enter the total number of interviews conducted with inmates/residents/ detainees who are Blind or have low vision (i.e., visually impaired) using the "Disabled and Limited English Proficient Inmates" protocol:	1
43. Enter the total number of interviews conducted with inmates/residents/ detainees who are Deaf or hard-of-hearing using the "Disabled and Limited English Proficient Inmates" protocol:	1
44. Enter the total number of interviews conducted with inmates/residents/ detainees who are Limited English Proficient (LEP) using the "Disabled and Limited English Proficient Inmates" protocol:	1
45. Enter the total number of interviews conducted with inmates/residents/ detainees who identify as lesbian, gay, or bisexual using the "Transgender and Intersex Inmates; Gay, Lesbian, and Bisexual Inmates" protocol:	3
46. Enter the total number of interviews conducted with inmates/residents/ detainees who identify as transgender or intersex using the "Transgender and Intersex Inmates; Gay, Lesbian, and Bisexual Inmates" protocol:	4

47. Enter the total number of interviews conducted with inmates/residents/ detainees who reported sexual abuse in this facility using the "Inmates who Reported a Sexual Abuse" protocol:	4
48. Enter the total number of interviews conducted with inmates/residents/ detainees who disclosed prior sexual victimization during risk screening using the "Inmates who Disclosed Sexual Victimization during Risk Screening" protocol:	5
49. Enter the total number of interviews conducted with inmates/residents/ detainees who are or were ever placed in segregated housing/isolation for risk of sexual victimization using the "Inmates Placed in Segregated Housing (for Risk of Sexual Victimization/Who Allege to have Suffered Sexual Abuse)" protocol:	0
49. Select why you were unable to conduct at least the minimum required number of targeted inmates/residents/ detainees in this category:	Facility said there were "none here" during the onsite portion of the audit and/or the facility was unable to provide a list of these inmates/residents/detainees. The inmates/residents/detainees in this targeted category declined to be interviewed.

49. Discuss your corroboration strategies to determine if this population exists in the audited facility (e.g., based on information obtained from the PAQ; documentation reviewed onsite; and discussions with staff and other inmates/residents/detainees).	Reviewed facility documentation. Asked random staff if any inmates were ever placed in segregated housing for the risk of sexual victimization or for having alleged to have been a victim of sexual abuse. Asked all inmates who reported sexual abuse or sexual victimization if they had ever placed in segregated housing for the risk of sexual victimization or for having alleged to have been a victim of sexual abuse. Reviewed current assignment rosters, interviewed inmates having previously disclosed sexual abuse or filed sexual abuse/harassment allegations to determine if said inmates had been placed in segregation for filing said allegations.
50. Provide any additional comments regarding selecting or interviewing targeted inmates/residents/detainees (e.g., any populations you oversampled, barriers to completing interviews):	Inmates were allowed to self-select out of and/or into all targeted categories during the interview process. As such, while facility records may or may not include inmates within targeted categories, targeted protocols were still completed for any inmate who self-selected into any targeted protocol at the time of the interview. Also, it should be noted that if there were not sufficient numbers of inmates assigned to the facility within a targeted group, oversampling was done in other targeted groups to ensure the minimum number of targeted interviews were conducted.
‌Staff, Volunteer, and Contractor Interviews
‌Random Staff Interviews
51. Enter the total number of RANDOM STAFF who were interviewed:	12

52. Select which characteristics you considered when you selected RANDOM STAFF interviewees: (select all that apply)	Length of tenure in the facility Shift assignment Work assignment Rank (or equivalent) Other (e.g., gender, race, ethnicity, languages spoken) None
If "Other," describe:	Gender, race, ethnicity, languages spoken, or other distinguishing factors amongst staff relative to their employment.
53. Were you able to conduct the minimum number of RANDOM STAFF interviews?	Yes No
54. Provide any additional comments regarding selecting or interviewing random staff (e.g., any populations you oversampled, barriers to completing interviews, barriers to ensuring representation):	No barriers to completing random staff interviews were noted.
‌Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties. Therefore, more than one interview protocol may apply to an interview with a single staff member and that information would satisfy multiple specialized staff interview requirements.
55. Enter the total number of staff in a SPECIALIZED STAFF role who were interviewed (excluding volunteers and contractors):	15
56. Were you able to interview the Agency Head?	Yes No

57. Were you able to interview the Warden/Facility Director/Superintendent or their designee?

Yes No

58. Were you able to interview the PREA Coordinator?

Yes No

59. Were you able to interview the PREA Compliance Manager?

Yes No

NA (NA if the agency is a single facility agency or is otherwise not required to have a PREA Compliance Manager per the Standards)

60. Select which SPECIALIZED STAFF roles were interviewed as part of this audit from the list below: (select all that apply)

Agency contract administrator

Intermediate or higher-level facility staff responsible for conducting and documenting unannounced rounds to identify and deter staff sexual abuse and sexual harassment

Line staff who supervise youthful inmates (if applicable)

Education and program staff who work with youthful inmates (if applicable)

Medical staff

Mental health staff

Non-medical staff involved in cross-gender strip or visual searches

Administrative (human resources) staff

Sexual Assault Forensic Examiner (SAFE) or Sexual Assault Nurse Examiner (SANE) staff

Investigative staff responsible for conducting administrative investigations

Investigative staff responsible for conducting criminal investigations

Staff who perform screening for risk of victimization and abusiveness

Staff who supervise inmates in segregated housing/residents in isolation

Staff on the sexual abuse incident review team

Designated staff member charged with monitoring retaliation

First responders, both security and non-security staff

Intake staff

	Other
If "Other," provide additional specialized staff roles interviewed:	Commissary, Laundry, Grievance, Mailroom Staff, Training Staff, Law Library, and SAFE/ SANE staff associated with the local hospital/ rape crisis center
61. Did you interview VOLUNTEERS who may have contact with inmates/ residents/detainees in this facility?	Yes No
61. Enter the total number of VOLUNTEERS who were interviewed:	3
61. Select which specialized VOLUNTEER role(s) were interviewed as part of this audit from the list below: (select all that apply)	Education/programming Medical/dental Mental health/counseling Religious Other
62. Did you interview CONTRACTORS who may have contact with inmates/ residents/detainees in this facility?	Yes No
62. Enter the total number of CONTRACTORS who were interviewed:	2

62. Select which specialized CONTRACTOR role(s) were interviewed as part of this audit from the list below: (select all that apply)	Security/detention Education/programming Medical/dental Food service Maintenance/construction Other
63. Provide any additional comments regarding selecting or interviewing specialized staff.	At the time of the onsite audit, there weren’t any volunteers present. Electronic contact information and/or telephone numbers were obtained for multiple volunteers. Communication with said volunteers was established.
‌SITE REVIEW AND DOCUMENTATION SAMPLING
‌Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas of the audited facilities." In order to meet the requirements in this Standard, the site review portion of the onsite audit must include a thorough examination of the entire facility. The site review is not a casual tour of the facility. It is an active, inquiring process that includes talking with staff and inmates to determine whether, and the extent to which, the audited facility's practices demonstrate compliance with the Standards. Note: As you are conducting the site review, you must document your tests of critical functions, important information gathered through observations, and any issues identified with facility practices. The information you collect through the site review is a crucial part of the evidence you will analyze as part of your compliance determinations and will be needed to complete your audit report, including the Post-Audit Reporting Information.
64. Did you have access to all areas of the facility?	Yes No
‌Was the site review an active, inquiring process that included the following:
65. Observations of all facility practices in accordance with the site review component of the audit instrument (e.g., signage, supervision practices, cross-gender viewing and searches)?	Yes No

66. Tests of all critical functions in the facility in accordance with the site review component of the audit instrument (e.g., risk screening process, access to outside emotional support services, interpretation services)?	Yes No
67. Informal conversations with inmates/ residents/detainees during the site review (encouraged, not required)?	Yes No
68. Informal conversations with staff during the site review (encouraged, not required)?	Yes No
69. Provide any additional comments regarding the site review (e.g., access to areas in the facility, observations, tests of critical functions, or informal conversations).	NA
‌Documentation Sampling
Where there is a collection of records to review-such as staff, contractor, and volunteer training records; background check records; supervisory rounds logs; risk screening and intake processing records; inmate education records; medical files; and investigative files-auditors must self-select for review a representative sample of each type of record.
70. In addition to the proof documentation selected by the agency or facility and provided to you, did you also conduct an auditor-selected sampling of documentation?	Yes No
71. Provide any additional comments regarding selecting additional documentation (e.g., any documentation you oversampled, barriers to selecting additional documentation, etc.).	Additional document sampling was done both at random, as well as in coordination with comments received from inmates and staff during the interview process.

‌SEXUAL ABUSE AND SEXUAL HARASSMENT ALLEGATIONS AND INVESTIGATIONS IN THIS FACILITY
‌Sexual Abuse and Sexual Harassment Allegations and Investigations Overview
Remember the number of allegations should be based on a review of all sources of allegations (e.g., hotline, third-party, grievances) and should not be based solely on the number of investigations conducted. Note: For question brevity, we use the term “inmate” in the following questions. Auditors should provide information on inmate, resident, or detainee sexual abuse allegations and investigations, as applicable to the facility type being audited.
72. Total number of SEXUAL ABUSE allegations and investigations overview during the 12 months preceding the audit, by incident type:
		# of sexual abuse allegations	# of criminal investigations	# of administrative investigations	# of allegations that had both criminal and administrative investigations
	Inmate-on-inmate sexual abuse	12	0	0	12
	Staff-on-inmate sexual abuse	4	0	0	4
	Total	16	0	0	16

73. Total number of SEXUAL HARASSMENT allegations and investigations overview during the 12 months preceding the audit, by incident type:
		# of sexual harassment allegations	# of criminal investigations	# of administrative investigations	# of allegations that had both criminal and administrative investigations
	Inmate-on-inmate sexual harassment	0	0	0	0
	Staff-on-inmate sexual harassment	0	0	0	0
	Total	0	0	0	0

‌Sexual Abuse and Sexual Harassment Investigation Outcomes
‌Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal investigation was referred for prosecution and resulted in a conviction, that investigation outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors should provide information on inmate, resident, and detainee sexual abuse investigation files, as applicable to the facility type being audited.

Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding the audit:

Ongoing
Referred for Prosecution
Indicted/ Court Case Filed

Convicted/ Adjudicated

Acquitted
Inmate-on-inmate sexual abuse
0
0
0
0
0
Staff-on-inmate sexual abuse
0
0
0
0
0
Total
0
0
0
0
0
Administrative SEXUAL ABUSE investigation outcomes during the 12 months preceding the audit:

	Ongoing	Unfounded	Unsubstantiated	Substantiated
Inmate-on-inmate sexual abuse	0	1	11	0
Staff-on-inmate sexual abuse	0	2	2	0
Total	0	3	13	0

‌Sexual Harassment Investigation Outcomes

Note: these counts should reflect where the investigation is currently. Do not double count. Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors should provide information on inmate, resident, and detainee sexual harassment investigation files, as applicable to the facility type being audited.

76. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months preceding the audit:
77. Administrative SEXUAL HARASSMENT investigation outcomes during the 12 months preceding the audit:
‌Sexual Abuse and Sexual Harassment Investigation Files Selected for Review
‌Sexual Abuse Investigation Files Selected for Review
78. Enter the total number of SEXUAL ABUSE investigation files reviewed/ sampled:	12

	Ongoing	Referred for Prosecution	Indicted/ Court Case Filed	Convicted/ Adjudicated	Acquitted
Inmate-on-inmate sexual harassment	0	0	0	0	0
Staff-on-inmate sexual harassment	0	0	0	0	0
Total	0	0	0	0	0

	Ongoing	Unfounded	Unsubstantiated	Substantiated
Inmate-on-inmate sexual harassment	0	0	0	0
Staff-on-inmate sexual harassment	0	0	0	0
Total	0	0	0	0

79. Did your selection of SEXUAL ABUSE investigation files include a cross-section of criminal and/or administrative investigations by findings/outcomes?	Yes No NA (NA if you were unable to review any sexual abuse investigation files)
‌Inmate-on-inmate sexual abuse investigation files
80. Enter the total number of INMATE-ON-INMATE SEXUAL ABUSE investigation files reviewed/sampled:	10
81. Did your sample of INMATE-ON-INMATE SEXUAL ABUSE investigation files include criminal investigations?	Yes No NA (NA if you were unable to review any inmate-on-inmate sexual abuse investigation files)
82. Did your sample of INMATE-ON-INMATE SEXUAL ABUSE investigation files include administrative investigations?	Yes No NA (NA if you were unable to review any inmate-on-inmate sexual abuse investigation files)
‌Staff-on-inmate sexual abuse investigation files
83. Enter the total number of STAFF-ON-INMATE SEXUAL ABUSE investigation files reviewed/sampled:	2
84. Did your sample of STAFF-ON-INMATE SEXUAL ABUSE investigation files include criminal investigations?	Yes No NA (NA if you were unable to review any staff-on-inmate sexual abuse investigation files)

85. Did your sample of STAFF-ON-INMATE SEXUAL ABUSE investigation files include administrative investigations?	Yes No NA (NA if you were unable to review any staff-on-inmate sexual abuse investigation files)
‌Sexual Harassment Investigation Files Selected for Review
86. Enter the total number of SEXUAL HARASSMENT investigation files reviewed/sampled:	0
86. Explain why you were unable to review any sexual harassment investigation files:	No allegations of sexual harassment were filed during the audit time frame.
87. Did your selection of SEXUAL HARASSMENT investigation files include a cross-section of criminal and/or administrative investigations by findings/outcomes?	Yes No NA (NA if you were unable to review any sexual harassment investigation files)
‌Inmate-on-inmate sexual harassment investigation files
88. Enter the total number of INMATE-ON-INMATE SEXUAL HARASSMENT investigation files reviewed/sampled:	0
89. Did your sample of INMATE-ON-INMATE SEXUAL HARASSMENT files include criminal investigations?	Yes No NA (NA if you were unable to review any inmate-on-inmate sexual harassment investigation files)

90. Did your sample of INMATE-ON-INMATE SEXUAL HARASSMENT investigation files include administrative investigations?	Yes No NA (NA if you were unable to review any inmate-on-inmate sexual harassment investigation files)
‌Staff-on-inmate sexual harassment investigation files
91. Enter the total number of STAFF-ON-INMATE SEXUAL HARASSMENT investigation files reviewed/sampled:	0
92. Did your sample of STAFF-ON-INMATE SEXUAL HARASSMENT investigation files include criminal investigations?	Yes No NA (NA if you were unable to review any staff-on-inmate sexual harassment investigation files)
93. Did your sample of STAFF-ON-INMATE SEXUAL HARASSMENT investigation files include administrative investigations?	Yes No NA (NA if you were unable to review any staff-on-inmate sexual harassment investigation files)
94. Provide any additional comments regarding selecting and reviewing sexual abuse and sexual harassment investigation files.	All cases are investigated at an administrative level, as well as referred for criminal investigation/prosecution. The Ohio State Highway Patrol, in consultation with the District Attorney as appropriate, determines if the allegations will also be pursued at a criminal level.

‌SUPPORT STAFF INFORMATION
‌DOJ-certified PREA Auditors Support Staff
95. Did you receive assistance from any DOJ-CERTIFIED PREA AUDITORS at any point during this audit? REMEMBER: the audit includes all activities from the pre-onsite through the post-onsite phases to the submission of the final report. Make sure you respond accordingly.	Yes No
‌Non-certified Support Staff
96. Did you receive assistance from any NON-CERTIFIED SUPPORT STAFF at any point during this audit? REMEMBER: the audit includes all activities from the pre-onsite through the post-onsite phases to the submission of the final report. Make sure you respond accordingly.	Yes No
‌AUDITING ARRANGEMENTS AND COMPENSATION
97. Who paid you to conduct this audit?	The audited facility or its parent agency My state/territory or county government employer (if you audit as part of a consortium or circular auditing arrangement, select this option) A third-party auditing entity (e.g., accreditation body, consulting firm) Other
Identify the name of the third-party auditing entity	American Correctional Association

Standards

Auditor Overall Determination Definitions

Exceeds Standard
(Substantially exceeds requirement of standard)
Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant review period)
Does Not Meet Standard (requires corrective actions)

Auditor Discussion Instructions

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

115.11	Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 Ohio Department of Rehabilitation and Correction (ODRC) Bureau of Operational Compliance (BOC) Hierarchical Chart, 2024 Southeastern Correctional Institution (SCI) Organizational Chart SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews: Agency Head Agency PREA Coordinator Facility Warden PREA Compliance Manager

Intermediate or Higher-Level Facility Staff
Random Staff

Site Review Observations:
The Ohio Department of Rehabilitation and Correction PREA Coordinator, along with the Assistant PREA Coordinator, oversee the Southeastern Correctional Institution (SCI) PREA program.
The SCI Operational Compliance Manager, who serves as the facility based PREA Compliance Manager, is physically assigned to the SCI and maintains a permanent office, with routine activities, within said institution as a function of assignment.

Standard Subsections:

The Ohio Department of Rehabilitation and Correction (ODRC) has a policy; namely, 79-ISA-01, Prison Rape Elimination, 10-1-24, that mandates zero tolerance toward all forms of sexual abuse and sexual harassment. Additionally, this policy outlines the agency’s approach to preventing, detecting, and responding to such actions. As a function of this, the agency’s policy is designed to provide guidance in “prevention and tracking techniques for sexual misconduct directed toward incarcerated person (IP) victims by staff persons or another IP.”
The ODRC has employed and designated an upper-level agency-wide PREA Coordinator. As noted through discussions with said PREA Coordinator, this person’s sole responsibility within the agency is to facilitate the ODRC’s PREA program. Hence, this individual does have sufficient time and authority to further the agency mission of zero tolerance toward all forms of sexual abuse and sexual harassment. In excess of the PREA Standards, the ODRC has also allotted for the assignment of an Assistant PREA Coordinator, who provides an additional level of supervision in developing, implementing, and overseeing agency efforts to comply with the PREA Standards in all of its facilities.
The ODRC operates multiple correctional facilities. As such, each facility, to include the SCI, has designated a PREA Compliance Manager. Within the ODRC, this position is maintained by the facility-based Operational Compliance Manager. The SCI Operational Compliance Manager, herein referenced as the PREA Compliance Manager (PCM), has affirmed having sufficient time and authority to coordinate the facility’s efforts to comply with the PREA Standards.

Reasoning & Findings Statement:

This standard establishes agency expectations of zero-tolerance for sexual abuse and sexual harassment of incarcerated persons. In developing these expectations, the ODRC has created specific policies to prevent, detect, and respond to allegations of sexual abuse and sexual harassment of incarcerated persons. The agency has designated an upper-level agency-wide PREA Coordinator to oversee its zero-tolerance program. In excess of the PREA Standards, the ODRC has also allotted for the assignment of an Assistant PREA Coordinator, who provides an additional level of supervision in developing, implementing, and overseeing agency efforts to comply with the PREA Standards in all of its facilities. Lastly, this standard requires that each

facility within the agency, to include the SCI, has designated a PREA Compliance Manager. Within the ODRC, this position is maintained by the facility-based Operational Compliance Manager. The SCI Operational Compliance Manager, herein referenced as the PREA Compliance Manager (PCM), has affirmed having sufficient time and authority to coordinate the facility’s efforts to comply with the agency’s zero-tolerance policy. In doing this, the SCI has further developed its own unit based coordinated response plan to ensure the agency’s overall zero-tolerance policy is applicable to any unique circumstances of the individual facility. In developing these mandatory positions and policies, the ODRC, and by extension the SCI, have exceeded the requirements of this standard.

115.12	Contracting with other entities for the confinement of inmates
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 ODRC Memo, PREA Standard 115.12, 7-11-24 ODRC Mandatory Use Contract For: Operation, Management, and Purchase of Correctional Facilities, 7-1-24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews: Agency PREA Coordinator Agency Contract Administrator Site Review Observations: The SCI is a publicly operated correctional facility through the Ohio Department of Rehabilitation and Correction. Standard Subsections: The ODRC does contract for the confinement of incarcerated persons with private agencies; namely, CoreCivic and Management & Training Corporation. Agency policy requires that “all new or renewed contracts for the confinement of ODRC IPs must include a provision that the contractor will adopt and comply with PREA standards” (79-ISA-01). As noted by the agency contract administrator, as well as demonstrated through the review of agency documents, the ODRC does require contracted entities to adopt and comply with the PREA Standards. Agency policy requires that “any new contract or contract renewal shall provide for contract monitoring to ensure the contractor is complying with PREA standards”

(79-ISA-01). As noted by the agency contract administrator, all contracts provide for agency contract monitoring to ensure that the contractor complies with the PREA Standards.

Reasoning & Findings Statement:

This standard requires that all private entities contracting with the ODRC must comply the PREA Standards. As evidenced by the ODRC PREA Audit Schedule and demonstrated through the public posting of facility audits via the ODRC website, all contracted facilities have been audited for their compliance with the PREA Standards. As indicated by documentation review, as well as affirmed by conversations with agency staff, the ODRC does require that any contracted entity maintains those within its custody in accordance with the agency’s zero-tolerance policy on sexual abuse and sexual harassment of incarcerated persons. To ensure said compliance, the ODRC provides for an agency liaison for facility-based contract monitoring and to ensure all employees, contractors, and volunteers who have contact with incarcerated persons have been properly trained on the agency’s zero-tolerance policy specific to the prevention, detection, and response of allegations regarding sexual abuse and harassment within contracted facilities. As such, the ODRC, and by extension the SCI, has satisfied all provisions within this standard.

115.13	Supervision and monitoring
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 50-PAM-02, Incarcerated Person (IP) Communication/Weekly Rounds, 11-4-24 10-SAF-22, Body Worn Camera, 8-1-23 310-SEC-31, Security Inspections and Challenges, 7-22-24 DRC-1189 E, PREA Staffing Plan Deviation, 02/17 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI PREA Staffing Plan: 11-16-23, 11-12-24 SCI Shift Roster, First, Second, Third Shift: December 5, 2024, January 9-11, 2025

SCI List of Camera Locations, 2024
SCI Employee Visit Record, Unannounced Rounds, December 30, 2024 – January 2, 2025
SCI Employee Visit Record, Unannounced Rounds, M Dorm: September 13 – 27, 2024; August 22 - October 2, 2024
SCI Employee Visit Record, Unannounced Rounds, TPU: September 9 – 12, 2024; September 9-26, 2024

Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Intermediate or Higher-Level Facility Staff
Random Staff
Random Inmates

Site Review Observations:
All incarcerated person housing areas contain at least one security staff post that is continuously monitored by staff. All areas of high incarcerated person traffic are assigned permanent staffing positions while in operation.
During the site review, supervisory staff were observed making routine and frequent rounds throughout the facility. All random staff interviewed did indicate that supervisory staff were available to them and routinely conducted unannounced rounds within the facility.
During supervisory rounds, ranking officials were observed reviewing required documentation completed by line staff as a function of their duty posts.
During the onsite portion of the audit, current SCI Employee Visit Records (chronological logs) were inspected throughout the facility to ensure staff were conducting, and properly documenting, unannounced rounds and, were appropriate, opposite gender announcements. Supervisory signatures were observed in red ink.
All uniform staff wore body cameras.

Reviewed 2024 SCI Staffing Plan on site.

Standard Subsections:

As required by agency policy (79-ISA-01), “each institution shall develop, document, and make its best efforts to comply with a staffing plan that provides for adequate levels of staff and, where applicable, video monitoring, to protect IPs against sexual misconduct. In calculating staffing levels and determining the need for video monitoring, the institution shall consider:
- Generally accepted correctional practices,
- Any judicial, federal investigative and internal/external oversight agency findings of inadequacy,
- The facility’s physical plant including blind-spots or areas where staff or IPs may be isolated,
- The composition of the incarcerated population,
- The number and placement of supervisory staff,
- Institutional programs occurring on a particular shift,
- The prevalence of substantiated and unsubstantiated incidents of sexual abuse,
- Applicable state or local laws, regulations, standards, or any other relevant factors.”

The SCI has developed a staffing plan so that adequate staffing levels are routinely available to ensure the custody and safety of all incarcerated persons housed within the facility. Since the last PREA Audit, the SCI has maintained an average of 1,411 incarcerated persons assigned to the facility. The SCI staffing plan was predicated on having 1,595 incarcerated persons assigned to the facility. During interviews with random staff, said employees consistently remarked that supervisory staff were routinely conducting unannounced rounds and were available to them when needed. As well, interviews with incarcerated persons indicated that supervisory staff were routinely conducting unannounced rounds. Additionally, there weren’t any (0) incarcerated persons who indicated that they were unable to attend routine activities on a regular basis due to a shortage of staff.

(B) Agency policy (79-ISA-01) requires “if circumstances arise where the staffing plan is not complied with, the managing officer’s designees must document and justify all deviations on the staffing plan.” During the audit time frame, the SCI has not

deviated from the facility staffing plan. As noted by the SCI Warden, all deviations, when they occur, are documented as required.

Per policy (79-ISA-01), “at least annually, the facility, in consultation with the agency PREA coordinator, shall assess the staffing plan, the facility’s deployment of video monitoring technologies, and the facility resources to determine if adjustments are needed.” As noted by the SCI Warden, and confirmed by the ODRC PREA Coordinator, the SCI does conduct an annual assessment of its staffing plan. At that time, the facility/agency does assess, determine, and document whether adjustments to the SCI staffing plan are necessary, the resources the facility has available to commit to ensure adherence to the staffing plan, as well as the facility’s deployment of video monitoring systems and other monitoring technologies. As discussed with the SCI warden, and confirmed through a review of the 2024 SCI Staffing Plan, the SCI does adhere to this requirement.
Agency policy (310-SEC-31) requires that a shift supervisor shall conduct unannounced rounds in each IP occupied area at least once per shift to deter sexual abuse and sexual harassment. Additionally, agency policy (50-PAM-02) requires “the managing officer, deputy wardens, and duty officers to make unannounced visits to the institution’s living and activity areas at least weekly to encourage informal contact with staff and incarcerated persons (IPs) and to informally observe living and working conditions. In addition, each institution shall maintain a system of two-way communication between all levels of staff and IPs.” The timing of the onsite portion of the audit allowed for the observation of staff from all shifts. In this, it was noted that unannounced rounds were properly documented by both line and supervisory staff. As well, numerous housing and officer station logs were reviewed onsite. These logs, which were documented by supervisors using red ink, reflected a historic pattern of supervisory presence throughout the facility. Additionally interviews with supervisory staff confirm that unannounced rounds are being conducted as required for all shifts. These rounds are conducted at random, using different timing intervals, travel patterns, and other means to make the presence of supervisory staff less predictable. Lastly, as required by policy (50-PAM-02) “staff shall not alert other staff members that supervisory rounds are occurring unless such an announcement is related to the legitimate operational function of the facility.” Interviews with random staff reflect their awareness of policy prohibiting them from notifying co-workers that said rounds are occurring. As well, interviews with random incarcerated persons all reflect that supervisors are routinely walking about the facility. During the onsite portion of the audit, it was further observed that both staff and incarcerated persons seemed comfortable with the presence of supervisory staff within department and housing areas; thus, further supporting the fact that supervisory staff are routinely present throughout the facility.

Reasoning & Findings Statement:

The standard provides that adequate staffing levels are assessed and maintained, as well as video monitoring technology is used to its fullest potential to promote the safety of not only the incarcerated persons assigned to the facility, but also the well-being of all correctional employees, contractors, and volunteers within the compound. The SCI does conduct an annual assessment of its staffing levels, with the last assessment being finalized within the audit time frame. During the audit time frame, the SCI has not deviated from its staffing plan. Supervisory staff note, as well as documentation confirms, that unannounced rounds are being conducted on a regular and routine basis. Both random staff and incarcerated persons generally agree that supervisor rounds are routinely conducted. Lastly, despite the SCI having hundreds of stationary video cameras throughout its institutional grounds, to take full advantage of monitoring technologies, uniform officers also wear body cameras attached to their shirts. As such, the SCI facility has meet the compliance requirements of this standard.

115.14	Youthful inmates
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 52-RCP-01, Reception Admission Procedures, 5-6-24 71-SOC-05, Incarcerated Youth Policy, 3-27-23 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews: Agency PREA Coordinator Facility Warden PREA Compliance Manager

Random Staff
Random/Targeted Inmates

Site Review Observations:
While conducting the onsite review, the auditor did not observe any incarcerated persons who appeared excessively youthful.
In reviewing incarcerated person documents, the auditor did not observe any birthdays to be less than 18 years before the date of the onsite review.
All incarcerated persons interviewed stated that they were at least 18 years of age and/or did not have any knowledge of any incarcerated person assigned to the SCI who was not at least 18 years of age.

Standard Subsections:

Agency policy (52-RCP-01) prohibits the placement of any incarcerated person less than 18 years of age in a housing unit within sight or sound of any incarcerated person over the age of 18 years. As well, incarcerated persons less than 18 years of age may not have any physical contact with incarcerated persons over the age of 18 years by way of a shared dayroom or other common space, shower area, or sleeping quarters. Agency policy (71-SOC-05) further requires that should incarcerated persons less than 18 years of age be within sight or sound of incarcerated persons who are 18 years of age or older, or be able to have physical contact with such persons, staff must maintain direct supervision of incarcerated persons less than 18 years of age.
As SCI does not house any incarcerated persons less than 18 years of age, the facility has most certainly maintained absolute sight and sound separation between incarcerated persons less than 18 years of age and incarcerated persons more than 18 years of age.
As SCI does not house any incarcerated persons less than 18 years of age, unit administration has absolutely avoided placing any incarcerated persons less than 18 years of age within isolation in order to prevent said person from living within sight and sound of incarcerated persons more than 18 years of age. Hence, the SCI has not denied any incarcerated persons less than 18 years of age the ability to engage in daily large-muscle exercise or to participate in other programs or work opportunities

due to said placement.

Reasoning & Findings Statement:

This standard requires that the agency ensures sight and sound separation between incarcerated persons less than 18 years of age and incarcerated persons more than 18 years of age. Alternatively, the standard requires that there is direct staff supervision when incarcerated persons less than 18 years of age and incarcerated persons more than 18 years of age have the possibility of sight, sound, or physical contact. The State of Ohio prohibits the assignment of incarcerated persons less than 18 years of age to adult housing units. Since SCI contains only adult housing units, SCI is prohibited from receiving, and subsequently housing, incarcerated persons less than 18 years of age. As such, the facility maintains an absolute and constant sight, sound, and physical barrier between incarcerated persons less than 18 years of age and incarcerated persons more than 18 years of age. This given, the SCI has met the requirements of this standard.

115.15	Limits to cross-gender viewing and searches
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-05, Lesbian, Gay, Bisexual, Transgender, Intersex (LGBTI) Policy, 7-9-18 310-SEC-01, Incarcerated Individual and Physical Plant Searches, 2-15-22 310-SEC-30, Constant Watch, 1-31-24 10-SAF-22, Body Worn Camera, 8-1-23 ODRC PREA Pat Down Video Script ODRC Patdown of Female, Transgender and Intersex Offenders Video SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI List of Areas and Cameras, 2024 SCI Employee PREA Training, FY24 SCI Opposite Gender Announcement Training Memo, Pre-Audit SCI Opposite Gender Announcements Training Memo, 3-6-25 Interviews: Facility Warden PREA Compliance Manager

Intermediate or Higher-Level Facility Staff
Random Staff
Random Inmates
Inmates Who Identify as Lesbian, Gay, Bisexual, Transgender, or Intersex Site Review Observations:
During the onsite inspection, staff were routinely observed making cross-gender announcements when persons of the opposite gender entered incarcerated person housing areas.
The SCI has an opposite gender annunciator installed in all incarcerated person housing areas. When activated, the annunciator, with consideration for ADA limited incarcerated persons, emits a loud audible alarm, as well as flashing yellow lights, to indicate that opposite gender staff are entering the housing unit.
Posted notice of opposite gender staff working within areas where incarcerated persons might be in a state of undress were observed throughout the facility.
Supervisory staff were observed conducting their routine security checks within incarcerated person housing areas. Cross-gender announcements and supervisory rounds, both unannounced rounds and scheduled rounds, were subsequently documented on chronical activity logs.
Privacy shields were in place inhibiting view into all incarcerated person toilets.
Privacy shields were observed and/or available in medical examination rooms.
Privacy curtains were observed in all shower areas.
Video surveillance was not trained to areas where incarcerated persons might routinely be in a state of undress.

Standard Subsections:

Agency policy (310-SEC-01) requires that “employees must always display the highest degree of professionalism when conducting searches.” Additionally, said policy prohibits staff from conducting “cross-gender strip searches or cross-gender visual body cavity searches (meaning a search of the anal or genital opening) except in exigent circumstances or when performed by medical practitioners.” As noted by the SCI PCM, there has not been any cross-gender strip or cross-gender visual body cavity searches conducted during the audit time frame. Both interviews with random staff and incarcerated persons confirmed that staff do not conduct such searches. Lastly, agency policy (10-SAF-22) requires same-gender staff to have body cameras disengaged when conducting strip or visual body cavity searches to protect the privacy of incarcerated persons. Interviews with random staff confirm their adherence to agency policy.
The SCI is designated to house incarcerated persons who are biologically male. Interviews with random staff confirm adherence to agency policy (310-SEC-01) prohibiting “cross-gender pat-down searches of female incarcerated individuals, absent exigent circumstances.” As well, interviews with incarcerated persons reflect that the facility has never denied any female incarcerated person access to a regularly available program or out of cell activity due to an inability to conduct same-gender searches of incarcerated persons.

Agency policy (310-SEC-01) requires that “the institution shall not conduct cross-gender strip searches or cross-gender visual body cavity searches (meaning a search of the anal or genital opening) except in exigent circumstances or when performed by medical practitioners.” While staff at the facility have not engaged any cross-gender strip searches of its male incarcerated persons during the audit time frame, all random staff interviewed understood that under exigent circumstances, should the need arise, such searches would require justification. As well, since the SCI does not house female incarcerated persons, no female incarcerated persons have ever been subject to a cross-gender search.
Agency policy (79-ISA-01) requires that “all institutions shall ensure IPs are able to shower, perform bodily functions, and change clothing without non-medical staff of the opposite gender viewing their breasts, buttocks, or genitalia except in exigent circumstances or when such viewing is incidental to routine cell checks, which includes viewing via video camera.” During the onsite portion of the audit, inspections were conducted of all areas where incarcerated persons might routinely be expected in a state of undress. It was noted that all such areas allowed for modesty barriers to inhibit opposite gender viewing of the breasts, buttocks, or genitalia of incarcerated persons, except in exigent circumstances or when such viewing is incidental to routine cell checks. Agency policy (79-ISA-01) further requires that “all employees, contractors, interns, and volunteers of the opposite-gender, whether assigned to the unit or not, shall make the following announcement upon their arrival in the housing unit: ‘Opposite gender in housing unit.’” However, it should be noted that the SCI is equipped with an enhanced opposite gender annunciator system. As such, policy (79-ISA-01) requires “when the PREA buzzer at the entrances of each housing unit is utilized, the verbal announcement of opposite gender staff is not necessary. It is replaced with the activation of the audible sound, which must have the ability to be heard at the farthest point within the housing unit. The only exceptions will be from 10:00 pm to 8:00 am at which time the verbal announcement shall be made instead of the use of the PREA buzzer.” During the onsite portion of the audit, it was observed that when activated, the annunciator, with consideration for ADA limited incarcerated persons, emits a loud audible alarm, as well as flashing yellow lights, to indicate that opposite gender staff are entering a housing unit. When tested, this alarm was loud enough to be heard at the farthest point of the housing unit. During random staff interviews, all opposite-gender day-shift staff confirmed their routine use of the annunciator system. Opposite-gender night-shift staff confirmed their routine use of verbal announcements. However, as several incarcerated persons interviewed stated that opposite gender staff do not routinely make known their presence, additional training was completed to ensure staff on all shifts have been reminded of this agency requirement. Lastly, a review of video surveillance throughout the facility found that cameras were not trained to areas where incarcerated persons would routinely be in a state of undress.
Agency policy (79-ISA-05) mandates that “staff shall not search or physically examine a transgender or intersex incarcerated person for the sole purpose of determining the incarcerated person’s genital status. If the genital status is unknown, it may be determined through conversations with the incarcerated person or by

reviewing medical records. If staff members are unable to determine the incarcerated person’s genital status, the incarcerated person shall be referred to medical for a broader medical examination conducted in private by a medical practitioner.” In interviewing random staff, it was clearly expressed that if the gender of incarcerated persons is unknown, conducting strip searches to determine their genital status would be inappropriate. Rather, random staff generally expressed that to determine gender they would contact the medical department, their supervisor, reference agency documents, or simply ask the incarcerated person. In interviewing incarcerated persons, there weren’t any (0) transgender, intersex, gay, lesbian, or bisexual incarcerated persons who stated that they had ever been searched or physically examined for the sole purpose of determining their genital status.

(F) Agency policy (79-ISA-01) dictates that “all security staff shall be trained on how to conduct cross-gender pat-down searches and searches of transgender and intersex IPs to ensure professionalism and to utilize the least intrusive manner possible consistent with security needs.” Furthermore, agency policy (310-SEC-01) provides clear instructions on how staff will perform searches of any incarcerated person, to include transgender persons. During interviews, all random staff affirmed their obligation to conduct searches in a professional manner and only for security purposes. Facility documentation reflects that 100% of SCI security staff have been trained on conducting said searches in a professional and least intrusive manner as possible consistent with security needs. Additionally, it should be noted that training on proper pat-downs is received on an annual basis.

Reasoning & Findings Statement:

This standard places limits on cross-gender searches, to include pat-downs, strip searches, and visual body cavity searches. Thus, the ODRC has developed agency-wide policies prohibiting cross-gender pat searches of female incarcerated persons, as well as cross-gender strip searches and visual body cavity searches of all incarcerated persons in the absence of exigent circumstances. If exigent circumstances arise that require staff to engage in cross-gender strip or visual body cavity searches, policy subsequently requires these searches to be properly documented. It should be noted, however, that during the audit time frame, the SCI has not engaged any cross-gender strip or visual body cavity searches. When same-sex strip searches and visual body cavity searches are performed of transgender and intersex incarcerated persons, the agency further requires staff to ensure professionalism and to utilize the least intrusive manner possible consistent with security needs. Interviews with both random staff and incarcerated persons confirmed that staff do not conduct either cross-gender strip searches or cross-gender visual body cavity searches. Lastly, facility records reflect that all security staff have been trained on the proper procedures for conducting pat searches on transgender or intersex incarcerated persons, which require said searches to be performed in a professional and least intrusive manner as possible. This standard further places limits on opposite gender viewing of incarcerated persons’ breasts, buttocks, and genitalia. During onsite observations of the facility, there weren’t any (0) areas of the facility identified as not having, or otherwise missing, modesty barriers to inhibit opposite gender viewing of incarcerated persons in areas where it is expected that

they may be in a state of undress. An extensive review of live video surveillance demonstrates that cameras are not trained in areas where incarcerated persons would routinely be in a state of undress. Agency policy also requires body-worn cameras to be disengaged when conducting strip searches of incarcerated persons. Throughout the facility, notices are clearly posted to advise all incarcerated persons that individuals of the opposite gender are routinely present within the facility, to include within incarcerated person housing areas. Lastly, to ensure all incarcerated persons are given the utmost in modesty protection, the agency requires opposite gender staff to announce their presence upon entering housing areas where incarcerated persons may be in a state of undress. For opposite gender announcements, all incarcerated person housing units within the SCI are equipped with the enhanced opposite gender annunciator system. When activated, the annunciator, with consideration for incarcerated persons with ADA limitations, emits a very loud audible alarm, as well as flashing yellow lights, to indicate that opposite gender staff are entering the housing unit. During the onsite portion of the audit process, this annunciator was routinely observed as opposite gender staff entered all housing areas, as well as other areas that might contain incarcerated persons in any state of undress. However, as several incarcerated persons interviewed stated that opposite gender staff do not routinely make known their presence, additional training was completed to ensure staff on all shifts have been reminded of this agency requirement. As such, no further action is needed. The SCI has demonstrated an overall compliance with this standard.

115.16	Inmates with disabilities and inmates who are limited English proficient
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 52-RCP-01, Reception Admission Procedures, 5-6-24 64-DCM-02, Incarcerated persons with Disabilities, 4-17-23 71-SOC-06, Special Needs Inmates, 3-5-18 ODRC Mandatory Use Contract For: Translation and Interpretation Service, 2-1-23 ODRC How to Use Interpreter Instructions, nd ODRC ADA Accommodations, Language Services, 10-28-22

ODRC Staffing Training PREA PowerPoint Slides, Inmates with Disabilities and LEP, FY23
ODRC Incarcerated person Handbook, Appendix A, 52-RCP-10, PREA Information, English
ODRC Incarcerated person Handbook, Appendix A, 52-RCP-10, PREA Information, Spanish
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Employee PREA Training, FY24
SCI Incarcerated Individual Orientation Acknowledgement Form, ADA Accommodation: 6-21-24, 6-27-24
SCI Incarcerated Individual Orientation Acknowledgement Form: Language Accommodation: 11-21-23a, 11-21-23b

Interviews:
Agency Head
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Intermediate or Higher-Level Facility Staff
Random Staff
Inmates with Disabilities
Inmates with Limited English Proficiency

Site Review Observations:
Correctional staff assigned to housing areas entered each area within the building to loudly announce information, to include when opposite gender staff entered the housing area.

The opposite gender annunciator system emitted a very loud audible alarm, as well as flashing yellow lights, to indicate that opposite gender staff were entering the housing units.
Handicap accommodations were easily recognizable and accessible throughout the facility.
PREA Notices, as well as other advisement notices, were posted in languages spoken by significant portions of the incarcerate person population; namely English and Spanish.
PREA information is also available in large print.
Vocalink Language Services are available for staff to communicate with incarcerate persons who do not speak English.
Hallenross & Associates Services are available for staff to communicate with incarcerated persons who are hearing impaired.
Staff translators are also available if needed.
Observed ODRC’s Incarcerated person PREA Educational Video with Director Chambers Smith, which was available in English and Spanish. Close captioning was available, in both English and Spanish. Also, an ASL interpreter was present in the video to sign the spoken word.

Standard Subsections:

(A) ODRC policy (64-DCM-02) prohibits discrimination “against individuals on the basis of disabilities in the provision of services, program assignments, and other activities, as well as in making administrative decisions, and to promote reasonable accommodations to incarcerated persons when a demonstrated need exists.” In fact, the ODRC policy (71-SOC-06) states that “it is the policy of the Ohio Department of Rehabilitation and Correction (DRC) to provide an initial classification process for newly received inmates who shall identify inmates with special needs, as set forth by the stated definitions, and in accordance with the Ohio Plan for Productive Prisons. Special programming may be provided, as resources allow, for inmates with special needs who are unable to participate in mainstream institutional programming or who require specialized program development based on the nature of their needs.” With that in mind, the ODRC has developed agency-wide policies (79 ISA-01, 71-SOC-06, 64-DCM-02, 52-RCP-10) to enhance communication efforts with disabled incarcerated persons; such as those with hearing, vision, speech, or other physical disabilities; psychiatric or other intellectual disabilities, or those with limited English proficiency; so as to provide these incarcerated persons with an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment. PREA educational information is provided in

writing, verbally, as well as presented in video format (available in English and Spanish). The video format includes both a deaf interpreter and closed caption. The SCI maintains a mandatory for use contract for translation and interpretation services to assist incarcerated persons who do not speak a language common to SCI staff. This translations service can be used to translate PREA, as well other confidential information, into any language spoken by any incarcerated person. As well, the agency maintains a contract for interpretation services, such as American Sign Language, for those incarcerated persons with hearing disabilities. Interviews with random staff interviews, as well as interviews with other staff, all demonstrated the need for staff to obtain qualified interpreters for all security sensitive concerns, to include the translation of PREA related matters. Additionally, all staff were aware that incarcerated persons could not be used to translate during a sexual abuse or sexual harassment investigation or alleged incident. During the audit time frame, there have not been any (0) instances of SCI staff using incarcerated person interpreters for PREA related matters. Incarcerated persons with disabilities, to include those with limited English proficiency, were also interviewed. These persons all stated that their disabilities either did not prevent them from understanding and having the subsequent ability to access the facility’s PREA program or that the facility had made accommodations for their disabilities.

The ODRC has taken meaningful steps to ensure that incarcerated persons with limited English proficiency can benefit from its efforts to prevent, detect, and respond to sexual abuse and sexual harassment. Most significantly, the agency has provided all PREA related literature, as well as the PREA informational video, in both English and Spanish, the primary language spoken by most incarcerated persons outside of English. The agency has also engaged a mandatory use contract for translation and interpretation services for any incarcerated person who does not speak English, as well as deaf translation services for those who cannot hear a spoken language. As demonstrated during the onsite portion of the audit, these interpreters can interpret effectively, accurately, and impartially, both receptively and expressively, using necessary specialized vocabulary to understand and articulate specific points of conversation between the auditor and incarcerated persons with limited English proficiency.
Agency policy (64-DCM-02) requires that interpretation services for sexual abuse or sexual harassment allegations “may be provided only by qualified contract interpreters. In the event of any emergency during which a qualified contract interpreter cannot be made readily available, a qualified correctional staff member may assist with interpreting, but only if confidentiality will not be violated.” As discussed during random staff interviews, SCI staff indicated that at no time would another incarcerated person be used to translate allegations of sexual abuse or sexual harassment. Furthermore, as noted by the SCI PCM, the facility has not relied on incarcerated persons to interpret, or provide other types of incarcerated person assistants, in response to allegations of sexual abuse or sexual harassment.

Accordingly, there isn’t any facility documentation of any such incidents to review.

Reasoning & Findings Statement:

The standard provides that all incarcerated persons assigned to the SCI, to include those with disabilities and limited English proficiency, can benefit from the agency’s efforts to prevent, detect, and respond to incidents of sexual abuse and sexual harassment. Hence, it is necessary for the agency to provide additional measures to ensure incarcerated persons with disabilities; either cognitive, physical, or cultural, have equal access to PREA information, programs, and support services relative to those affected by sexual abuse and sexual harassment. The ODRC recognizes this need and has created policies to address it. To ensure persons with disabilities and limited English proficiency have equal access to the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, the agency has taken steps to ensure that the incarcerated person population is aware of translation services via a posted notice within the Inmate Handbook. The SCI routinely stocks PREA informational brochures, as well as shows the PREA informational video in English and Spanish, the most commonly spoken language at the SCI outside of English. Additionally, the SCI offers a listing of other types of resources available to incarcerated persons, as well as contact information for those resources, in both English and Spanish. Lastly, it should be noted that at no time within the audit time frame, has SCI used incarcerated persons as interpreters to help agency staff communicate with other incarcerated persons regarding allegations of sexual abuse or sexual harassment. Rather, when needed, qualified contract interpreters are used, with qualified correctional staff being used as an alternative. As well, American Sign Language video interpretation can be used for those incarcerated persons with hearing impairments. Accordingly, the SCI has met the provisions within this standard.

115.17	Hiring and promotion decisions
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 34-PRO-07, Background Investigations, 5-1-24 31-SEM-02, Standards of Employee Conduct, 12-1-24

ODRC DRC-1667 E, Prison Rape Elimination Act (PREA) Questionnaire for Prior Institutional Employers Form, 10/23
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Employee PREA Training, FY24
SCI Employee/Contractor Criminal Background Checks Spreadsheet, 11-27-24
SCI Background Investigation Checklist, Employee: 11-27-19, 8-23-24, 9-23-24a, 9-23-24b, 11-1-24, 11-21-24
SCI Background Investigation Checklist, Contractors: 2-11-22, 3-20-20
SCI Background Investigation Checklist, Volunteers: 9-1-21, 9-8-21
SCI Background Check Authorization: 12-17-14, 9-5-24a, 9-5-24b
SCI Required Criminal History and PREA Interview Questions, Employee: 8-22-24
SCI Background Investigation, Local Law Enforcement Worksheet: 8-23-24
SCI Authority for Release of Information: 8-22-24
SCI Job Application: 8-14-24

Interviews:
Administrative (Human Resources) Staff
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager

Site Review Observations:
Review of additional employee/contractor files onsite for required PREA/ criminal background documentation.
Review of SCI employee PREA training tracking spreadsheet

Review of SCI background investigation database

Standard Subsections:

The ODRC has developed agency-wide policies (31-SEM-02, 34-PRO-07, 79-ISA-01) that prohibit the hiring or promotion of employees and contracted workers who have engaged in sexual abuse, been convicted of engaging or attempting to engage in a sexual activity with incarcerated persons, or have been civilly or administratively adjudicated to have engaged in a sexual activity with incarcerated persons while in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution. The agency also has policies that stipulate prior to all hiring and promotional decisions of employees and contract workers, any incidents of sexual harassment will be considered. Prior to hiring any new employee or contract worker at the facility level, ODRC Human Resource staff ensure that criminal background checks have been conducted on the prospective employee. As well, as noted by SCI Human Resource staff, ODRC/SCI Human Resource staff ensure that all previous institutions of employment are contacted to determine if candidates have any previously substantiated claims of sexual abuse or resigned during a pending investigation of such claims. Conversely, policy also requires that the SCI cooperates with other correctional and law enforcement agencies to ensure that accurate information regarding PREA related employment laws are effectively shared between agencies. Employee, contractor, and volunteer files were reviewed onsite to confirm adherence to agency policy.
ODRC policy (34-PRO-07) requires the facility to consider any incidents of sexual harassment in determining whether to hire/promote anyone who may have contact with incarcerated persons. Likewise, in speaking with the ODRC Human Resource representative, agency policy requires Human Resource staff to also verify contractor employment history. Employee and contractor files were reviewed onsite to confirm adherence to agency policy.
Before hiring or promoting employees, policy (34-PRO-07, 79-ISA-01) requires the agency to perform criminal background checks. Policy (34-PRO-07) also requires the agency to conduct checks with prior employers for any applicant previously employed by a correctional facility. Within the audit time frame, SCI has hired 52 persons who may have contract with incarcerated persons. All such persons received a criminal records background check. Employee and contractor files were reviewed onsite to confirm adherence to agency policy.
Agency policy requires that prior to enlisting the services of any contractors who

may have contact with incarcerated persons, the agency shall perform criminal background records checks on said contractors. During the audit time frame, the SCI has processed 6 such criminal background records checks. An examination of SCI’s background investigation spreadsheet reflects that all persons contracted with the SCI received an initial background check, as well as, where applicable, required subsequent checks within the required time frame. Contractor files were reviewed onsite to confirm adherence to agency policy.

Once employed, agency policy (34-PRO-07, 79-ISA-01) requires that criminal background checks are conducted every five years to ensure that said persons have not been found to have engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution. Per LOCK Human Resource staff, employees have an affirmative duty to report any contact they may have had with other law enforcement agencies and to report any sexual misconduct they may have been found guilty of at any other institution (31-SEM-02). Furthermore, employees are made aware that failing to provide this information, or providing false information regarding sexual misconduct, is grounds for employee discipline, to include termination of employment (31-SEM-02). A review of SCI’s current background investigation spreadsheet reflects that all persons working at the SCI have received their initial criminal background check, as well as, where applicable, required subsequent checks within the required time frame. Employee files were reviewed onsite to confirm adherence to agency policy.
All applicants are required to submit a Personal History Questionnaire form (79-ISA-01). This document directly asks employees who may have contact with incarcerated persons to disclose any previous sexual misconduct that may have
occurred in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution. All employees are required to submit a PREA Annual Acknowledgement form disclosing any previous sexual misconduct that may have occurred in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution. Lastly, as discussed with Human Resource staff and required by policy (31-SEM-02), the ODRC does impose a continuing affirmative duty on all employees to disclose any misconduct found within Section A of this standard.
Employee and contractor files were reviewed onsite to confirm adherence to agency policy.
Agency policy (31-SEM-02) expressly advises employees that material omissions or providing false information regarding the aforementioned misconduct is grounds for termination. In speaking with Human Resource staff, adherence to this policy was confirmed.

(H) Agency policy (31-SEM-02) allows that unless prohibited by law, the ODRC shall provide information on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied (34-PRO-07). In speaking with Human Resource staff, adherence to this policy was confirmed.

Reasoning & Findings Statement:

This standard requires the agency, and by extension the facility, to consider the sexual safety of incarcerated persons in all hiring and promotion decisions within the agency. The agency has numerous policies in place to ensure that end. As well, the SCI Human Resource Department has developed standardized tracking methods to ensure timely reviews, and subsequent reviews, of applicants and continuing employees/contractors are conducted as required. Review of employee and contractor training files reflect that the SCI Human Resource Department complies with agency policy. As such, the SCI clearly meets the requirements of this standard.

115.18	Upgrades to facilities and technologies
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 10-SAF-22, Body Worn Camera, 8-1-23 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI PREA Staffing Plan: 11-16-23, 11-12-24 SCI List of Camera Locations, 2024 Interviews: Agency Head

Agency PREA Coordinator
Facility Warden
PREA Compliance Manager

Site Review Observations:
Observed video monitoring technologies present within the facility.
Reviewed live video surveillance across the facility.
Observed body worn cameras on uniform correctional staff.
Reviewed 2024 SCI Staffing Plan on site.

Standard Subsections:

Per the SCI PCM, the SCI has not acquired any new facility or made any substantial expansion or modification to the existing facility since the last PREA audit. However, as noted by the SCI warden, if there was a substantial expansion to the facility, the agency would consider the effect of the design, acquisition, expansion, and modification upon the agency’s ability to protect incarcerated persons from sexual abuse and sexual harassment.
Per the SCI PCM, the SCI has updated the video monitoring system, electronic surveillance system, or other monitoring technology since the last PREA audit. Specifically, the facility has significantly increased the number of cameras available throughout the facility, as well as their capabilities. Additionally, as observed during the onsite portion of the audit, all uniform staff have body worn cameras attached to their shirts.

Reasoning & Findings Statement:

The SCI has not made a substantial expansion or modification to the existing facility since the last PREA audit. As a part of the annual staffing review, the effective use of all current video monitoring devices, as well as the potential benefits of adding additional monitoring devices, is always considered. Exceeding the standard, the agency, and by extension the SCI, has also equipped all uniformed staff with body

worn cameras. To ensure modesty measures are in place during all staff interactions with incarcerated persons, the agency has developed appropriate protocol for the utilization of these body worn cameras during staff interactions with incarcerated persons. Specifically, as appropriate, these devices are terminated when staff are supervising incarcerated persons who might be in a state of undress, such as when performing strip searches of incarcerated individuals. But outside of those times, body worn cameras can help provide for the awareness of actions by incarcerated persons and correctional staff, as well as other events occurring within their environments. In all staffing decisions, as well as decisions involving the use of video monitoring technology, to include the use of individualized body worn cameras by correctional staff, the SCI has sought to maximize its ability to protect incarcerated persons from sexual abuse and sexual harassment. As such, the agency, and by extension the SCI, has exceeded in this requirement.

115.21	Evidence protocol and forensic medical examinations
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 68-MED-15, Bureau of Medical Services Co-Payment Procedures, 7-8-24 B-11, Medical Care Guidelines for Sexual Contact or Recent Sexual Abuse, 3-6-23 ODRC PREA Victim Support Persons Training Lesson Plan, 1-18-18 ODRC Memo, PREA Coordinator, Availability of Forensic Medical Examinations ODRC MOU with Ohio State University (OSU) Hospital, 7-1-21 ODRC MOU with Ohio State Highway Patrol (OSHP), 9-27-24 OSHP #103.07, Sexual Assault Evidence Collection and Analysis, 10/2019 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI MOU with the Sexual Assault Response Network of Central Ohio (SARNCO),

2-9-23

SCI PREA Incident Report Application: 1-2-24, 1-3-24
SCI Incident Report: 1-2-24a, 1-2-24b
SCI Sexual Abuse First Responder Checklist: 12-29-23
SCI OSHP Notification Email: 1-2-24, 2-2-24
SCI Offender Information Summary: 1-2-24
SCI Medical Exam Report: 1-2-24
SCI Laboratory Report, DNA: 1-29-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24
SCI Notification of Sexual Abuse Investigation Outcome, 2-2-24
SCI Approved List of PREA Victim Support Person Staff, 8-14-24
SCI PREA Victim Support Person Certification: 1-9-15a, 1-9-15b, 1-9-15c, 1-9-15d, 1-17-17, 8-31-21a, 8-31-21b, 8-31-21c, 8-31-23a, 8-31-23b

Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Investigative Staff
Random Staff
Medical Staff
Mental Health Staff
SAFE and/or SANE Personnel of the Local Hospital/Rape Crisis Clinic
Community-Based Victim Advocacy Staff
Inmates Who Reported Sexual Abuse

Site Review Observations:

Observed Medical Department and privacy screens/limitations.
Observed interview rooms and protocol for confidential interviews.

Standard Subsections:

While investigating allegations of sexual abuse, the agency does follow a uniform evidence protocol to maximize the protentional for obtaining usable physical evidence for administrative proceedings and criminal prosecutions. As noted by both the institutional investigator and the OSHP officer, the SCI maintains strict adherence to evidence collection protocols. As well, a review of documented investigations reflects the agency’s adherence to said requirements.
Agency policy (70-ISA-02) requires that “the evidence is collected in accordance with the Ohio State Highway Patrol (OSHP) Sexual Evidence and Collection and Analysis Protocol and the Ohio Department of Health Sexual Assault Evidence Collection Kit Protocol and a National Protocol of Sexual Assault Medical Forensic Examinations Adult/Adolescents (Second Addition – April 2013).” As noted by the institutional investigator and the OSHP officer, evidence is collected in accordance with agency protocols. As well, a review of documented investigations reflects the agency’s adherence to said requirements.
Agency policy (B-11) allows incarcerated persons having suffered recent sexual abuse to receive a forensic exam by a qualified Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible. Agency policy (68-MED-15) requires that “IPs shall not be charged a co-pay for medical services initiated by policy-defined staff reporting requirements, such as, but not limited to, sexual assaults, use of force, and accidents that occur while performing job duties.” Interviews with investigative and medical staff confirm adherence to agency policy specific to the availability of SAFE/SANE staff. As well, a review of documented investigations reflects the agency’s adherence to said requirements. The facility utilizes Fairfield Medical Center for forensic exams. Within the audit time frame, the SCI has facilitated one (1) such exam.
The SCI has a memorandum of understanding (MOU) with a local rape crisis center, the Sexual Assault Response Network of Central Ohio, to provide victim advocate services for incarcerated persons. As well, in accordance with policy

(79-ISA-02), the facility also has trained staff to act as advocates “if a victim advocate

from a rape crisis center is not available to provide victim advocate services…. Upon notification of an allegation of abuse, the institution victim support person shall meet with the victim.” The victim support person will also coordinate with the rape crisis center, as well as other victim support persons, to ensure a continuum of advocacy services is available as requested by the incarcerated person. As noted by the PCM, there are sufficient victim support persons assigned to the SCI to ensure adequate coverage of facility needs. As well, documentation reflects there are sufficient victim support persons assigned to all shifts at the SCI to ensure more than adequate coverage.

Agency policy (79-ISA-02) allows that “the victim support person shall accompany the victim to the hospital, accompany and support the victim through the forensic medical examination process. The victim support person shall provide emotional support, crisis intervention, information, and referrals.” Alternatively, the designated local rape crisis center may provide these services. During the course of staff interviews, VSPs were interviewed. These individuals were able to provide more specific insight into the roles and responsibilities of a victim support person.
Agency policy (79-ISA-02) mandates that the Ohio State Highway Patrol (OSHP) is responsible for investigating criminal allegations of sexual abuse. To this effect, a MOU between the ODRC and the OSHP ensures that all investigations are conducted in accordance with the requirements of paragraphs (a) through (e) of this section.
The auditor is not required to audit this provision.
As noted by the ODRC PREA Coordinator, all victim support persons must undergo training specific to sexual assault and forensic examination issues. A review of the ODRC training curriculum illustrates the nature of this training. As well, through a memorandum of understanding with the local rape crisis center, the Sexual Assault Response Network of Central Ohio, the agency has ensured that all persons who have contact with incarcerated persons assigned to the SCI have been appropriately screened and trained, along with having received education concerning sexual assault and forensic examination issues in general.

Reasoning & Findings Statement:

This standard concerns evidence protocol and forensic medical examinations. The ODRC, and by extension the SCI, has numerous policies in place to ensure proper accountability during evidence collection and the forensic exam process. During the

audit time frame, the SCI initiated the evidence protocol and forensic medical examination process once (1). As evidenced during the interview process, facility staff are aware of the policies and procedures required of sexual abuse investigations. As well, SCI staff have standard practices in place to ensure the proper flow of the evidence collection process. The SCI also has trained staff who can service as Victim Support Persons during the forensic evidence collection process. Lastly, a MOU is in force between the SCI and the Sexual Assault Response Network of Central Ohio to ensure that incarcerated persons are afforded access to a local rape crisis center advocate. With all these factors in mind, the SCI has certainly met the requirements of this standard.

115.22	Policies to ensure referrals of allegations for investigations
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 ODRC Statement of Facts, PREA Coordinator, 9-24-24 OSHP #103.07, Evidence Collection and Analysis, 10/19 Ohio Administrative Code 5120-9-24, 5-31-24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI PREA Incident Report Application: 1-2-24, 1-3-24 SCI Incident Report: 1-2-24a, 1-2-24b, 1-3-24 SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24 SCI Voluntary Statement: 1-3-24a, 1-3-24b SCI OSHP Notification Email: 1-2-24, 1-8-24 SCI OSHP Disposition Notification: 1-8-24, 2-2-24 SCI Offender Information Summary: 1-2-24

SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24
SCI Laboratory Report, DNA: 1-29-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24
SCI Notification of Sexual Abuse Investigation Outcome: 1-8-24, 2-2-24

Interviews:
Agency Head
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Investigative Staff
Medical Staff
Mental Health Staff
SAFE and/or SANE Personnel of the Local Hospital/Rape Crisis Clinic
Community-Based Victim Advocacy Staff
Inmates Who Reported Sexual Abuse

Site Review Observations:
Observed Medical Department and privacy screens/limitations.

Standard Subsections:

(A) Policy (79-ISA-02, AR 5120-9-24, OSHP 103.07) requires that administrative or criminal investigations are completed for all allegations of sexual abuse and sexual harassment. Specifically, 79-ISA-02 requires that “all allegations of sexual misconduct and/or retaliation shall be administratively and/or criminally investigated.” Per the SCI Investigator, any allegations received will be investigated. During the audit time frame, the SCI received sixteen (16) allegations of sexual abuse and sexual

harassment. Documentation review reflects all allegations were investigated in accordance to policy.

The ODRC has published its policy (79-ISA-02) requiring all allegations of sexual abuse or sexual harassment to be referred to the Ohio State Highway Patrol, an external law enforcement agency with legal authority to conduct criminal investigations. The ODRC has published this policy, as well as the criminal investigation process, on its agency website. As noted by the SCI Investigator, all referrals to the OSHP are documented by the agency. Documentation review reflected that referrals for all allegations of sexual abuse and sexual harassment were made during the audit time frame.
In accordance with 79-ISA-02, “the agency PREA Coordinator/designee shall maintain a document that describes the responsibilities of the ODRC and the OSHP for criminal investigation.” Those responsibilities are then listed in detail in Appendix A of that same policy. A review of the agency website noted the publication of all policies specific to the investigation process.
The State of Ohio has enacted administrative code (Rule 5120-9-24) to address criminal investigations within the ODRC. It is further noted that the OSHP is responsible for conducting criminal investigations of sexual abuse and sexual harassment within the ODRC. As such, the OSHP does have a policy in place, complete with evidence protocol, for conducting said investigations. These policies are publicly available for review on the agency website.
The auditor is not required to audit this provision.

Reasoning & Findings Statement:

This standard requires the proper investigation of all allegations of sexual abuse and sexual harassment. Furthermore, allegations of a criminal nature are required to be referred to the Ohio State Highway Patrol, an external law enforcement agency with legal authority to conduct criminal investigations. All such referrals are documented. The ODRC policy detailing the investigative and referral process, as well as each component’s responsibility within that policy, is publicly available for review on the agency website. Within the audit time frame, the SCI has referred all criminal allegations of sexual abuse and sexual harassment to the OSHP. In reviewing all investigative documentation, as well as interviewing SCI and OSHP investigative staff, it is clear that the SCI has maintained compliance with all requirements of the

investigative process and OSHP referrals. As such, the SCI has met the requirements of this standard for the relevant review period.

115.31	Employee training
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 39-TRN-02, In-Service Training, 4-1-24 39-TRN-10, Employee Orientation Training, 5-1-24 ODRC PREA Zero Tolerance PowerPoint Training Lesson Plan w/ Test, FY23 ODRC PREA for All Employees PowerPoint Training Lesson Plan w/ Test, FY24 ODRC Appropriate Communication with LGBTI Offenders Training Lesson Plan w/ Test ODRC Appropriate Supervision of the LGBTI and Sex Offender Population Lesson Plan, 8-5-14 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI PREA Acknowledgement Form, Employee: 12-31-24 Interviews: Facility Warden PREA Compliance Manager Administrative (Human Resources) Staff Medical Staff Mental Health Staff Random Staff Site Review Observations: Random review of employee files, as well as matched review of employee files to employees interviewed, to confirm documentation of required PREA training. Standard Subsections: (A) Policy (39-TRN-10) requires “all employees to complete orientation training prior to independently commencing any job assignment.” Among many other facets, this training requires, at a minimum, that employees are aware of the sexual abuse and sexual harassment policies. As verified by Human Resource staff, training on the agency’s zero-tolerance policy for sexual abuse and sexual harassment is initially

performed as a function of the hiring process. This Sexual Abuse Prevention and Response training is a comprehensive analysis of state laws and PREA standards. A review of training curriculum for the PREA Rape Elimination Class reflects the agency’s zero-tolerance policy for sexual abuse and sexual harassment, as well as discussions on how employees may fulfill their responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures. Employees are also informed that incarcerated persons have a right to be free from sexual abuse and sexual harassment, to be free from retaliation for reporting said abuse and harassment, the dynamics of sexual abuse/harassment, reactions to sexual abuse/harassment, how to detect and respond to signs of threatened and actual sexual abuse, how to avoid inappropriate relationships with incarcerated persons, how to comply with relevant mandatory reporting laws specific to reporting abuse to outside authorities, and how to communicate effectively and professionally with incarcerated persons; including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming incarcerated persons. During random staff interviews, all employees confirmed receipt of said training. Additionally, a random review of employee files confirmed receipt of said training for all employee files reviewed.

A review of the current training curriculum reflects the educational materials to be appropriate for the gender of incarcerated persons held within the SCI. Additionally, as noted by the PCM, staff who are transferred from a facility holding a different gender of incarcerated persons receive additional training tailored to the gender needs of those person incarcerated within the SCI. More specifically, agency policy (39-TRN-10) requires that “all employees who transfer to an institution that houses IPs of a different gender shall receive training tailored to that gender of IPs as part of their orientation training and in accordance with PREA Standard 115.31b.” During the audit time frame, the SCI has not had any (0) employees reassigned from facilities housing opposite gender incarcerated persons. However, as noted by Human Resource staff, such should a transfer occur, new employees to the facility would be provided with PREA orientation appropriate for the gender of incarcerated persons assigned to the facility.
Agency policy (39-TRN-02) requires all ODRC employees to complete annual training. A review of SCI PREA Training Completion Report for the audit time frame reflects that all actively employed staff have received their initial PREA training, as well as continued training as appropriate based on agency policy (39-TRN-02,

79-ISA-01). As noted by Human Resource staff, SCI employees receive training specific to the agency’s zero-tolerance policy for sexual abuse and sexual harassment during their pre-service academy. After one year of employment, as well as every year of subsequent employment, SCI staff are required to participate in in-service training. This training provides all staff with annual refreshers on the agency’s zero-tolerance policy. A review of the SCI PREA Training Completion Report reflects initial and continuing training schedules have all been maintained.

(D) All training is electronically verified and documented upon completion of the ODRC PREA online training curriculum. Additionally, employees must demonstrate their understanding of the material discussed within the training curriculum via the

successful completion of a mastery test. A documentation review does reflect the test provided is comprehensive specific to the wealth of material discussed within the PREA course.

Reasoning & Findings Statement:

This standard captures the absolute need for all ODRC employees to fully comprehend the agency’s zero-tolerance policy regarding sexual abuse and sexual harassment of incarcerated persons. Accordingly, the training curriculum for this subject matter, as listed in subsection (a) of this standard, is exceptionally detailed. The training provided to staff of the SCI is tailored to the gender of incarcerated person assigned to the facility. If staff are transferred to the SCI from a facility that does not house the same gender of incarcerated persons, said staff are provided gender specific training as a function of the facility’s orientation program. In excess of this standard, all staff assigned to the SCI receive complete training on agency protocol regarding the PREA standards, as well as agency sexual abuse and sexual harassment policies, on an annual basis. Additionally, in excess of the PREA standards, employees must demonstrate their mastery of the subject matter by way of a comprehensive test at the end of the curriculum. This training is then documented via an employee signature or an electronic verification of staff having completed the course. The SCI then maintains an overall master list of all staff having completed said training. During staff interviews, all employees affirmed their having received significant amounts of training as related to the PREA standards. When asked the series of questions noted within Subsection A of this standard, all staff knew and understood their responsibilities within the agency’s zero-tolerance policy. With all this in mind, the ODRC, and by extension, the SCI, have met the requirements of this standard.

115.32	Volunteer and contractor training
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 39-TRN-12, Contractor Orientation, 4-1-24 71-SOC-01, Recruitment, Training, and Supervision of Volunteers, 9-24-23 ODRC Standards of Conduct for Contractors, Volunteers and Interns, 11/2012 ODRC PREA Contractor/Volunteer Training Video ODRC PREA Contractor/Volunteer Training Script SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Medical and Mental Health PREA Training, FY24

SCI PREA Training Session Report, Contractors: 7-31-24
SCI PREA Medical and Mental Health Test: 7-31-24
SCI PREA Training Session Report, Volunteers: 3-28-24
SCI PREA Acknowledgement Form, Volunteer: 3-28-24, 12-31-24
SCI PREA Training Session Report, Contractors: 5-21-24
SCI Training Acknowledgement Form, Contractor: 5-21-24 Interviews:
Facility Warden
PREA Compliance Manager
Administrative (Human Resources) Staff
Medical Staff
Mental Health Staff
Contractors Who May Have Contact with Inmates
Volunteers Who May Have Contact with Inmates Site Review Observations:
Random review of contractor and volunteer files, as well as matched review of contractor and volunteer files to those interviewed, to confirm documentation of required PREA training.

Standard Subsections:

Agency policy (39-TRN-12) dictates that “it is the policy of the ODRC to provide all contractors with security orientation appropriate to the contract service provided. The orientation shall occur before services are rendered.” Policy (79-ISA-01) further requires that “all routine volunteers, special event volunteers, Long Term Contractors and Non-Escorted Contractors who have contact with IPs shall be notified of ODRC’s zero-tolerance regarding sexual misconduct and how to report such incidents. All contractors, interns, and volunteers shall also be trained on their responsibilities regarding sexual misconduct prevention, detection, and response.” In excess of the PREA Standards, full-time contractors are also required to complete refresher training on the agency’s sexual abuse and sexual harassment policies on an annual basis. Specifically, policy (39-TRN-12) requires “annual PREA refresher training shall be completed by all contractors who are assigned to prisons to provide services equivalent to that of full-time staff.” As noted by the SCI PCM, and in excess of the PREA standards, all routine volunteers are also given annual PREA refresher training. During the audit time frame, the SCI has had 117 volunteers and contract workers within the facility who could have contact with incarcerated persons. As affirmed by the SCI PCM, 100% of those persons have received appropriate PREA training, dependent on their level of contact with incarcerated persons, prior to their entrance into the facility. Volunteer and contractor files were randomly reviewed onsite for receipt of required training documentation. Additionally, when interviewed, both contractors and volunteers confirmed their initial receipt of PREA training, as well as subsequent annual trainings as appropriate.
Agency policy (79-ISA-01) dictates that contractors and volunteers will receive

“the level and type of training… based on the services they provide and the level of contact they have with incarcerated persons.” A review of the training curriculum for contractors and volunteers reflects that all such persons are provided, among many other areas of discussion, with information regarding the agency’s zero-tolerance policy specific to sexual abuse and sexual harassment, as well as how to report such incidents. Interviews with contractors and volunteers reflect their awareness of this information. A review of training acknowledgments also supports that all contractors and volunteers are made aware of their responsibilities within the agency’s zero-tolerance policy.

(C) Agency policy (79-ISA-01) requires that “all training shall be documented on the PREA Contractor/Volunteer/Intern Training Acknowledgement” form. As confirmed by the SCI PCM, all training is documented, with those persons receiving such training signing their acknowledgements of such. A review of training acknowledgments signed by contractors and volunteers reflects that the facility does, in fact, both document the required training and maintain documentation confirming that volunteers and contractors understood the training they have received.

Reasoning & Findings Statement:

Agency policy requires that all contractors, interns, and volunteers receive training on the agency’s zero tolerance of sexual abuse and sexual harassment policy prior to their ability to render any services to incarcerated persons. This training is provided appropriate to the level and type of services that contractors, interns, and volunteers will provide, as well as the level of contact these providers will have with incarcerated persons. In excess of the PREA standard, all full-time contractors, as well as routine volunteers also receive continuing PREA education via annual training the agency’s zero tolerance of sexual abuse and sexual harassment policy. The facility does maintain documentation to support the training provided to all contractors, interns, and volunteers. In speaking with contractors and volunteers, all persons stated that they had received this training prior to their providing any services on the facility, as well as on an annual basis. Lastly, all contractors and volunteers interviewed were also able to articulate their awareness of the agency’s zero-tolerance policy, as well as their responsibilities specific to reporting concerns of sexual abuse and sexual harassment. In total, the SCI has met the requirements of this standard.

115.33	Inmate education
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24

52-RCP-01, Reception Admission Procedures, 5-6-24
52-RCP-10, Incarcerated Person Orientation, 11-4-24
64-DCM-02, Incarcerated persons with Disabilities, 4-17-23
71-SOC-06, Special Needs Inmates, 3-5-18
ODRC Mandatory Use Contract For: Translation and Interpretation Service, 2-1-23
ODRC How to Use Interpreter Instructions, nd
ODRC ADA Accommodations, Language Services, 10-28-22
ODRC Staffing Training PREA PowerPoint Slides, Inmates with Disabilities and LEP, FY23
ODRC Incarcerated Person Handbook, Appendix A, 52-RCP-10, PREA Information, English,
ODRC Incarcerated Person Handbook, Appendix A, 52-RCP-10, PREA Information, Spanish,
1-6-20
ODRC PREA Incarcerated Person Poster – Incidents or Suspicions of Sexual Abuse, Harassment, and Retaliation, English
ODRC PREA Incarcerated Person Poster – Incidents or Suspicions of Sexual Abuse, Harassment, and Retaliation, Spanish
ODRC PREA Incarcerated Person Poster – Restrictive Housing Incarcerated persons, English
ODRC PREA Incarcerated Person Poster – Restrictive Housing Incarcerated persons, Spanish
ODRC PREA Incarcerated Person Poster, Family & Friends, Break the Silence, English
ODRC PREA Incarcerated Person Poster, Family & Friends, Break the Silence, Spanish
ODRC PREA Incarcerated Person Education Video with Director Chambers-Smith
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI End the Violence Educational Intake Pamphlet

SCI Incarcerated Person Transfer List: 8-14-24

SCI Incarcerated Individual Orientation Acknowledgement Form, Initial Training: 9-14-11, 6-26-15, 5-10-18, 11-14-18, 4-26-19, 9-27-19, 8-10-21, 10-26-21, 1-31-22,
2-16-22, 3-4-22, 3-15-22a, 3-15-22b, 5-26-22, 2-16-23, 2-22-23, 3-6-23, 3-23-23,
7-21-23, 8-10-23, 10-24-23, 11-3-23, 11-21-23a, 11-21-23b, 12-12-23, 2-12-24,
3-21-24, 6-7-24, 6-21-24, 6-27-24, 7-10-24, 7-26-24, 8-1-24, 8-12-24, 8-14-24,
8-29-24, 10-1-24, 10-2-24, 10-31-24a, 10-31-24b, 10-31-24c, 10-31-24d, 11-8-24,
11-14-24, 12-18-24, 12-27-24, 12-30-24
SCI Incarcerated Individual Orientation Acknowledgement Form, Subsequent Training: 9-21-11, 6-30-15, 5-15-18, 11-21-18, 5-1-19, 10-3-19, 8-11-21, 10-27-21,

2-2-22, 2-18-22, 3-9-22, 3-16-22a, 3-16-22b, 6-1-22, 2-22-23, 3-1-23, 3-9-23, 3-29-23,

7-26-23, 8-16-23, 10-25-23, 11-8-23, 11-21-23a, 11-21-23b, 12-13-23, 2-14-24,

3-27-24, 6-12-24, 6-26-24, 7-3-24, 7-17-24, 7-31-24, 8-8-24, 8-14-24, 8-21-24, 9-4-24,

10-2-24, 10-8-24, 11-6-24a, 11-6-24b, 11-6-24c, 11-6-24d, 11-14-24, 11-20-24,

12-19-24, 1-2-25a, 1-2-25b

SCI Incarcerated Individual Orientation Acknowledgement Form, ADA Accommodation, Initial Training: 6-21-24, 6-27-24
SCI Incarcerated Individual Orientation Acknowledgement Form, ADA Accommodation, Subsequent Training: 6-26-24, 6-29-24
SCI Incarcerated Individual Orientation Acknowledgement Form, Language Accommodation, Initial Training: 11-21-23a, 11-21-23b
SCI Incarcerated Individual Orientation Acknowledgement Form, Language Accommodation, Subsequent Training: 11-21-23a, 11-21-23b

Interviews:
Agency PREA Coordinator
PREA Compliance Manager
Intake Staff
Staff Who Perform Screening for Risk of Victimization and Abusiveness
Random Inmates

Site Review Observations:

Observed the incarcerated person reception area.
Observed PREA Risk Screening process.
Observed PREA informational postings in incarcerated person Housing, Education, Library, Law Library, and other areas of high traffic.
Observed a variety of PREA related materials and information available for incarcerated person use within the facility libraries and on facility-based incarcerated person computer terminals.
Observed incarcerated person PREA training video.
Reviewed incarcerated person files for documentation of PREA training.

Standard Subsections:

Agency policy (52-RCP-01) requires that upon admission into the ODRC reception center, “each IP shall also be provided with a verbal explanation and written information regarding sexual abuse consistent with ODRC Policy 79-ISA-01, Prison Rape Elimination.” Agency policy (52-RCP-10) further requires that immediately upon receipt into a more permanent unit of assignment, “each IP shall be issued a facility orientation handbook and shall sign for receipt of the handbook on an Incarcerated Person Orientation Checklist (DRC4141).” A review of the SCI intake process demonstrated how this initial information is provided to all incarcerated persons upon their entry into the facility. Interviews with intake staff further explained the process. The SCI PCM further notes that of the 1,294 incarcerated persons assigned to the facility during the audit time frame, 100% have received their initial and subsequent PREA training. In speaking with incarcerated persons, all but five (5) such persons stated they had, in fact, been given initial information on the agency’s zero-tolerance policy when they arrived at the facility, with a more comprehensive education being provided within seven days. Of those five (5) incarcerated persons, a review of incarcerated person training documentation reflects all such persons received both their initial and subsequent PREA training regarding the agency’s zero-tolerance policy specific to sexual abuse and sexual harassment, to including reporting information.
In excess of the PREA standards, ODRC policy (79-ISA-01) requires “within seven

(7) calendar days of arrival at a reception center or parent institution, all IPs shall be provided comprehensive education through the viewing of the PREA education video. The PREA education video shall inform the IP of their rights to be free from sexual abuse, sexual harassment, and retaliation for reporting such incidents. The PREA education video shall also include the ODRC policies and procedures for responding to such incidents.” A review of the incarcerated person PREA education video does

provide a comprehensive explanation of the agency’s zero-tolerance policy specific to sexual abuse and sexual harassment. Within the audit time frame, the SCI has received 1,294 incarcerated persons whose length of stay was more than thirty days. Of these, 100% were provided a more comprehensive explanation of the PREA process. In speaking with random incarcerated persons, all such persons knew of at least one way to report allegations of sexual abuse and sexual harassment, as well as the agency’s responsibility to protect them from such.

Per the Agency PREA Coordinator, all incarcerated persons assigned to the ODRC as of January 2014 were provided comprehensive education on the agency’s zero-tolerance policy against sexual abuse and sexual harassment. Specifically, these persons were required to watch the PREA training video entitled Prison Rape Elimination Act: Fighting Back Through Awareness. All incarcerated persons subsequently received into the ODRC have been required to watch the current PREA orientation film during reception. As such, there aren’t any persons incarcerated within the agency who have not yet received information regarding such. Furthermore, as noted by SCI Intake staff, every incarcerated person transferring into SCI, regardless of how long the incarcerated person has been within ODRC custody, will participate in facility orientation, including a comprehensive component on sexual abuse and sexual harassment prevention, as well as facility reporting and response procedures.
Agency policy (79-ISA-01) dictates that “staff shall make appropriate provisions for IPs not fluent in English, those with low literacy levels, and those with disabilities that hinder their ability to understand the information in the manner provided… the agency PREA coordinator shall ensure those with disabilities have an equal opportunity to participate in or benefit from all aspects of the ODRC’s efforts to prevent, detect, and respond to sexual misconduct.” Agency policy (52-RCP-10) also requires that “facility orientation handbooks shall be translated into the IP’s native language, where possible” and will contain Prison Rape Elimination Act information specific to the unit of assignment. As noted by the agency PREA Coordinator, accommodations are provided to incarcerated persons as necessary to help with their understanding and subsequent ability to utilize the PREA reporting processes. In speaking with Intake staff, accommodation strategies were discussed for incarcerated persons with limited English proficiency, deaf, visually impaired, those with limited reading skills, as well as those incarcerated persons who are otherwise disabled. All PREA information is provided in several alternative formats to ensure incarcerated persons with disabilities, to include those with limited English proficiency, have equal opportunity to receive, understand, and utilize the PREA process as necessary to promote the sexual safety of all incarcerated persons assigned to the ODRC, and more specifically, the SCI. PREA brochures and informational posters are provided in both English and Spanish, the two most common languages spoken within the SCI. The PREA Incarcerated Person Education Video is available in two languages: English and Spanish. These videos contain a deaf interpreter, as well as closed captioning in

the appropriate spoken language of the video. PREA informational posters are available in large print for the visually impaired. Translation services are available for incarcerated persons who don’t speak English. As well, per policy (64-DCM-02), the agency will provide reasonable accommodations to all incarcerated persons in need of ADA accommodations, both physical and cognitive, to ensure said incarcerated persons have equal opportunity to benefit from the agency’s zero-tolerance stance against sexual abuse and sexual harassment.

Agency policy (79-ISA-01) requires that “the IP’s participation in the orientation and education sessions… shall be documented on the Incarcerated Person Orientation Checklist.” As noted by the SCI PCM, this documentation is then maintained within each incarcerated person’s agency file. A review of random incarcerated person files reflects the presence of said documentation.
Agency policy (79-ISA-01) requires that information specific to the agency’s zero-tolerance against sexual abuse and sexual harassment policy “is continuously and readily available” using materials such as posters, handbooks, and pamphlets. As noted by Intake staff, while incarcerated persons are provided personal copies of the ODRC Incarcerated person Orientation Handbook (available in English and Spanish) upon receipt into the ODRC system, if requested, they are also loaned an additional copy of the Incarcerated Person Orientation Handbook for 14 days following their SCI facility orientation. This material, as well as a wealth of other PREA related information, is continuously available within the facility’s Law Library. It is also continuously available via each incarcerated person’s tablet. During the onsite portion of the audit, informational advisements identifying hotline numbers and local rape crisis center contact information were predominantly displayed in all housing units in both English and Spanish. Additionally, PREA awareness posters, in both English and Spanish, were displayed throughout the facility in areas such as the receiving and discharge department, medical, behavioral health, and the Law Library. Posters for third party reporting, such as reporting done by family, friends, and other incarcerated person advocates, were also posted in both English and Spanish within visitation area and the facility front lobby.

Reasoning & Findings Statement:

This standard requires that all persons incarcerated within the ORDC are provided a comprehensive education specific to the agency’s zero-tolerance policy against sexual abuse and sexual harassment. This information must be provided in a manner that each incarcerated person can understand, to include accommodations for limited English proficiency, as well as other physical or cognitive disabilities. In that, the SCI has demonstrated its compliance with agency policy by ensuring all incarcerated individuals received into the facility are provided an initial overview of this

information immediately upon facility intake. The SCI has also exceeded standard requirements by ensuring all incarcerated persons are given a comprehensive orientation of the agency’s PREA program within seven (7) days of facility intake. This ensures that all incarcerated persons within the SCI are cognizant of the agency’s zero-tolerance policy toward sexual abuse and sexual harassment, as well as have subsequent access to, and can effectively utilize, the PREA reporting mechanism. In speaking with incarcerated persons assigned to the SCI, all incarcerated persons stated that they were aware of PREA and its purpose within the facility. While incarcerated persons were collectively aware of the policy and their rights to varying degrees, all incarcerated persons interviewed were specifically aware of at least one, but generally more, methods by which they could report allegations of sexual abuse or sexual harassment. Accordingly, the SCI has exceeded the requirements of this standard.

115.34	Specialized training: Investigations
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 11-15-21 ODRC Training for Trainers: Specialized PREA Training for Correctional Investigators, 12-11-13 NCIC Investigating Sexual Abuse in a Confinement Setting Training Homepage ODRC MOU with Ohio State Highway Patrol (OSHP), 9-27-24 OSHP #103.07, Sexual Assault Evidence Collection and Analysis, 10/2019 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Staff Certificate of Training, NIC PREA Investigating Sexual Abuse in a Confinement Setting: 5-6-14, 6-14-17, 1-31-22 SCI Staff Certificate of Training, NIC PREA: Coordinators’ Roles and Responsibilities, 6-14-17 Interviews: Agency PREA Coordinator Facility Warden PREA Compliance Manager Administrative (Human Resources) Staff SCI Investigative Staff Ohio State Highway Patrol Trooper Site Review Observations:

Observed investigative training certifications.
Reviewed agency training records documenting investigative training curriculums.

Standard Subsections:

Per policy (79-ISA-01), all employees receive training related to the prevention, detection, response, and investigation of sexual misconduct during New Employee Orientation. Additionally, “prior to conducting a PREA investigation, all investigators shall receive specialized training which shall include, but not be limited to, conducting investigations in a confinement setting, interviewing techniques for sexual abuse victims, proper use of Garrity warnings, sexual abuse evidence collection and the criteria and evidence required to substantiate a case for administrative action or prosecution referral” (79-ISA-01). In interviewing SCI investigative staff, said staff confirmed participation in such courses. Additionally, training curriculums and employee training certifications provided additional documentation to support facility compliance.
Per policy (79-ISA-01), all employees receive training related to the prevention, detection, response, and investigation of sexual misconduct during New Employee Orientation. Additionally, “prior to conducting a PREA investigation, all investigators shall receive specialized training which shall include, but not be limited to, conducting investigations in a confinement setting, interviewing techniques for sexual abuse victims, proper use of Garrity warnings, sexual abuse evidence collection and the criteria and evidence required to substantiate a case for administrative action or prosecution referral.” In interviewing SCI investigative staff, said staff confirmed participation in related courses. Additionally, training curriculums and employee training certifications provided additional documentation to support facility compliance.
Agency policy (79-ISA-01) mandates that all specialized training for investigators “shall be documented on the PREA Training Session Report (DRC1680).” In speaking with SCI investigators, it was noted that appropriate training had been completed and was subsequently documented via agency records. A review of training certifications confirms that such documentation is maintained within agency files for all investigators currently utilized within the SCI.
While the auditor is not required to audit this provision, it should be noted that via a MOU with the Ohio State Highway Patrol, an agency with legal jurisdiction to investigate all criminal allegations within the prison system, the ODRC has ensured that any OSHP officer assigned to any ODRC correctional institution has received training specific to conducting investigations in a confinement setting. In speaking with the OSHP officer assigned to the SCI, completion of this training was confirmed.

Reasoning & Findings Statement:

The standard requires that all persons employed by the agency who investigate allegations of sexual abuse and sexual harassment have received appropriate training of investigating such within a confinement setting. Agency documentation confirms the receipt of such training for all SCI investigators. Additionally, all investigators within the SCI have received specialized training for interviewing sexual abuse

victims, for the proper use of Miranda and Garrity warnings, for sexual abuse evidence collection in confinement settings, and for the criteria and evidence required to substantiate a case for administrative action or prosecution referral. Interviews with agency staff confirm receipt of this training. As such, the SCI has met the requirements of this standard. In excess of this standard, the ODRC has negotiated a MOU with the Ohio State Highway Patrol, an agency with legal jurisdiction to investigate all criminal allegations within the prison system. As a product of this MOU, all OSHP officers assigned to any ODRC correctional institution have received training specific to conducting investigations in a confinement setting. In speaking with the OSHP officer assigned to the SCI, completion of this training was confirmed. As such, the ODRC, and by extension the SCI, has exceeded the requirements of this standard.

115.35	Specialized training: Medical and mental health care
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 ODRC PREA Medical & Mental Health Specialized Training Online Lesson Plan, FY22 ODRC PREA Medical & Mental Health Specialized Training Online Lesson Plan, FY23 ODRC PREA Medical & Mental Health Specialized Training Online Lesson Plan, FY24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Medical and Mental Health PREA Training, FY24 SCI PREA Training Session Report, Contractors: 7-31-24 SCI PREA Medical and Mental Health Test: 7-31-24 Interviews: Agency PREA Coordinator Facility Warden PREA Compliance Manager Administrative (Human Resources) Staff Medical Staff Mental Health Staff SAFE and/or SANE Personnel of the Local Hospital/Rape Crisis Clinic Site Review Observations: Review of facility training records Standard Subsections:

Agency policy (79-ISA-01) requires that “all full and part-time medical and behavioral health staff and contractors shall receive specialized training to include, but not be limited to:
- How to detect and assess signs of sexual misconduct,
- How to preserve physical evidence of sexual abuse,
- How to respond effectively and professionally to victims of sexual misconduct, and
- How and to whom to report allegations or suspicions of sexual abuse.”

In speaking with SCI medical and mental health staff, all such staff confirmed their having received such training. Additionally, a review of the training curriculum for medical and mental health staff clearly indicates this material, along with significant levels of other related material, is provided during specialized training for medical and mental health staff. In speaking with the SCI PCM, it was noted that the SCI has 32 medical and mental health care practitioners who regularly work at the SCI, with 100% having received both the general PREA training required of all staff, as well as the specialized training required of medical and mental health staff. A review of agency training records document staff participation in initial and/or continuing training requirements.

As noted within policy (79-ISA-02), “all victims of sexual abuse shall have access to forensic medical examinations at an outside facility without financial cost where evidentiary or medically appropriate.” In speaking with medical staff, adherence to this policy was confirmed. Additionally, in speaking with staff from the local hospital; namely, Fairfield Medical Center, the continuous availability of SANE/SAFE nurses, or other qualified staff, was confirmed.
Agency policy (79-ISA-01) requires that “all full and part-time medical and behavioral health staff and contractors shall receive specialized training.” Policy further requires that all such training is documented either on a paper form (DRC 1680) if completed within a classroom setting or electronically if completed online. Evidence of documented training was reviewed to ensure compliance with this protocol.
As confirmed via interviews with medical and mental health contracted staff, said positions are required to complete both the generalized PREA training provided to all facility staff, as well as the specialized training required only of medical and mental health staff. In excess of the PREA Standards, full-time medical and mental health contractors are also required to complete refresher training on the agency’s sexual abuse and sexual harassment policies on an annual basis. Specifically, policy

(39-TRN-12) requires “annual PREA refresher training shall be completed by all contractors who are assigned to prisons to provide services equivalent to that of full-time staff.”

Reasoning & Findings Statement:

This standard requires that all medical and mental health care practitioners are provided both the generalized training on the agency’s zero-tolerance against sexual abuse and sexual harassment, as well as specialized training on how to detect and assess signs of sexual abuse and sexual harassment, how to preserved physical evidence of sexual abuse, how to respond effectively and professionally to victims of

sexual abuse and sexual harassment, as well as how and to whom to report allegations or suspicions of sexual abuse and sexual harassment. The ODRC, and by extension the SCI, has clearly exceeded the requirements of this standard by requiring these trainings to not only be completed prior to medical and mental health staff having any contact with incarcerated persons, but also by requiring these trainings to be renewed on an annual basis. SCI medical and mental health staff confirm that said staff have received all required and continuing education classes specific to their professional role in assisting victims of sexual abuse and sexual harassment. Also, medical service staff of Fairfield Medical Center the local hospital where all forensic examinations are conducted, confirm that all persons conducting SANE/SAFE exams are properly certified to perform such. Documentation of agency training verifies that medical and mental health staff receive not only the generalized PREA training provided to all staff, but also specialized training specific to their medical and mental health roles within the agency. As such, the SCI has exceeded the requirements of this standard.

115.41	Screening for risk of victimization and abusiveness
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-04, PREA Risk Assessments and Accommodation Strategies, 10-20-24 67-MNH-02, Mental Health Screening and Mental Health Classification, 10-1-24 ODRC PREA Assessment Weighted Measurement User Guide, 1-24-24 ODRC PREA Assessment Process, PREA Coordinator SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Incident Report: 1-3-24 SCI Incarcerated person Transfer List: 8-14-24 SCI PREA 72-Hour Assessment Process: 9-14-11, 6-26-15, 5-10-18, 11-14-18, 4-26-19, 9-27-19, 8-10-21, 10-26-21, 1-31-22, 2-16-22, 3-4-22, 3-15-22a, 3-15-22b, 5-26-22, 2-16-23, 2-22-23, 3-6-23, 3-23-23, 7-19-23, 7-21-23, 8-10-23, 10-24-23, 11-3-23, 12-12-23, 12-21-23a, 12-21-23b, 2-12-24, 3-21-24, 6-7-24, 6-21-24, 6-27-24, 7-10-24, 7-26-24, 8-1-24, 8-14-24a, 8-14-24b, 8-15-24, 8-29-24, 10-1-24, 10-2-24, 11-8-24, 11-14-24, 12-18-24, 12-27-24, 12-20-24 SCI 30-Day Reassessment: 7-14-14, 5-30-18, 5-22-19, 10-15-19, 8-27-21, 11-16-21, 2-18-22, 3-4-22, 3-30-22a, 3-30-22b, 6-13-22, 8-23-22, 3-9-23, 3-16-23, 3-31-23, 4-19-23, 8-7-23, 8-9-23, 8-28-23, 11-21-23, 1-3-24, 1-8-24, 3-4-24, 4-11-24, 6-26-24, 7-8-24, 7-15-24, 7-25-24, 8-12-24, 8-19-24, 9-6-24, 9-9-24a, 9-9-24b, 9-17-24, 10-16-24, 11-19-24, 12-2-24a, 12-2-24b, 1-2-25, 1-8-25 SCI Special Assessment: 1-4-24, 1-8-24, 7-17-24 SCI Training Points Bulletin, October 2024

SCI Training Notice Email, 1-13-25
SCI Training Notice, n.d.
SCI 30-Day Risk Assessment Training, 3-6-25
SCI PREA Training Session Report, 3-6-25 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Intake Staff
Medical Staff
Mental Health Staff
Staff Who Perform Screening for Risk of Victimization and Abusiveness
Inmates Who Identify as Lesbian, Gay, Bisexual, Transgender, or Intersex
Inmates Who Reported Sexual Abuse
Limited English Proficient Inmates
Disabled Inmates
Random Inmates

Site Review Observations:
Observed PREA screening demonstration.
Observed housing formats and locations.
Reviewed incarcerated person files for documentation of risk screening.

Standard Subsections:

Agency policy (79-ISA-04) advises staff that “all IPs shall be assessed for risk of sexual victimization or abusiveness upon arrival of intake and upon transfer to another institution.” Interviews with SCI Intake and Medical staff confirm initial assessments are done as a function of the Intake process. During the onsite assessment of the facility, Intake staff demonstrated the intake process step-by-step while providing detailed information on the initial education, assessment, housing, and programmatic assignment process all incarcerated persons receive on their first day of assignment at the SCI.
As noted by Intake and Medical staff, initial assessments occur immediately upon reception. These initial assessments are then reviewed by Unit Management staff to ensure their completeness. Per policy, “unit management shall complete the screening within seventy-two (72) hours of the IP’s arrival at the facility.” Interviews with Risk Screening staff confirm adherence to this policy. During the audit time frame, the SCI received 1,294 incarcerated persons into the facility. As noted by the SCI PCM, 100% of said persons did receive an initial risk screening within 72 hours of receipt. A random review of risk screening documentation reflects that all initial screenings were completed within the 72-hour time frame.
Agency policy (79-ISA-01) mandates that “all IPs shall be screened and assessed upon admission to ODRC and for all subsequent intra-system transfers for their risk of

being a victim of sexual abuse or their likelihood of committing sexual abuse.” The PREA screening assessment is conducted using an objective screening instrument. A review of the twenty-one (21) question survey provided to incarcerated persons does not present with either an implicit bias or leading statements. The PREA Assessment Process does not contain value statements, bias language, or implied negative consequences for affirmative answers to any of the questions asked. Rather, it is a strictly utilitarian form that was administered in a nonjudgmental manner during a mock screening demonstration. To determine an incarcerated person’s risk of sexual victimization, an incarcerated person is asked sixteen (16) questions. To determine an incarcerated person’s risk of sexual abusiveness, he is asked another five (5) questions.

The PREA Assessment Process does consider, at a minimum, if the incarcerated person has a mental, physical, or developmental disability. It considers the age of the incarcerated person, the incarcerated person’s physical build, whether the incarcerated person has previously been incarcerated, whether the incarcerated person’s criminal history is exclusively nonviolent, whether the incarcerated person has prior convictions for sex offenses against an adult or child, whether the incarcerated person has previously experienced sexual victimization, the incarcerated person’s own perception of vulnerability, and whether the incarcerated person is or is perceived to be gay, lesbian, bisexual, transgender, intersex, or gender nonconforming. Incarcerated persons are explicitly asked if they are gay, lesbian, bisexual, transgender, intersex, or gender nonconforming/gender nonbinary. Incarcerated persons are then asked if others perceive them as the same. Risk screeners are allowed to enter their subjective perception of the incarcerated person’s gender expression, as well as any additional information regarding the incarcerated person’s sexual safety. It should be noted that the ODRC does not detain incarcerated persons solely for immigration purposes. During incarcerated person interviews, the majority incarcerated persons stated that they had, in fact, been asked the aforementioned questions upon their receipt into the SCI. However, a number of incarcerated individuals did not remember or denied having received an initial risk assessment. While records reflect that all such persons did, in fact, receive an initial risk assessment, to ensure all incarcerated persons recognize the risk screening process in action, additional training has been provided to risk screeners to help the screeners in making incarcerated persons more aware of, and clarify, the initial risk assessment process.
The initial risk screening process also considers an incarcerated person’s probability of being sexually abusive toward other persons. In assessing incarcerated persons for their risk of being sexually abusive, the PREA Assessment Form does consider prior acts of sexual abuse, prior convictions for violent offenses, and the history of prior institutional violence or sexual abuse. Along with observing the screening process, the auditor also reviewed PREA Assessment Forms completed within the auditing time frame. All forms were filled out in their entirety, with incarcerated persons having generally provided relevant answers to each of the questions asked. It should further be noted that Intake and Medical staff both confirmed that incarcerated persons may refuse to answer any question on the

survey or may refuse participation in the entire survey without the threat of negative consequences.

Agency policy (79-ISA-04) requires that “no sooner than fifteen (15) calendar days, but no later than thirty (30) calendar days from the IP’s arrival at any institution, the IP shall be reassessed (30 Day Review) regarding their risk of victimization or abusiveness based upon any additional, relevant information received since that institution’s intake screening of the IP.” As noted by the SCI PCM, within the audit time frame, 100% of the 1,294 incarcerated persons with a length of stay in the facility for 30 days or more, were reassessed for their risk of sexual victimization or of being sexually abusive within 30 days after their arrival to the SCI. In speaking with SCI Unit Management staff, their adherence to this policy was confirmed. Additionally, a review of documentation specific to said assessments confirmed both initial and subsequent assessments were generally provided within the required time frames. However, a number of incarcerated individuals did not remember or denied having received a subsequent risk assessment. While records reflect that all such persons did, in fact, receive subsequent risk assessments, to ensure all incarcerated persons recognize the subsequent risk screening process in action, additional training was provided to risk screeners. This training was designed to assist screeners in ways to help incarcerated persons be more aware of, and clarify, the subsequent risk assessment process.
Agency policy (79-ISA-04) requires that “risk assessments shall be completed upon admission, transfer, initiation, and conclusion of investigations into substantiated or unsubstantiated allegations, referral due to mental health concerns and/or referrals due to concerns of substantial imminent risk of sexual abuse. Risk assessments shall also be completed on IPs who return from court or during their annual security review if one has not been completed previously.” In speaking with the SCI PCM, risk assessments done after investigations and referral processes were explained in detail. A review of documentation demonstrating subsequent risk assessments and referrals supports the facility’s application of the subsequent risk assessment and referral process.
Agency policy (79-ISA-04) advises that “IPs shall not be disciplined for refusing to answer or for not disclosing complete information in response to questions concerning mental, physical, or developmental disabilities; whether the IP is perceived to be gay, lesbian, bisexual, transgender, intersex, or gender non-conforming; whether the IP has previously experienced sexual victimization; or the IP’s perception of their own vulnerability.” In speaking with the SCI PCM, adherence to this policy was affirmed. In speaking with random incarcerated persons, as well as those who were, or may have been perceived as, disabled, lesbian, gay, bisexual, transgender, intersex, or limited English proficient, none (0) expressed having experienced any discipline or retaliation for refusing to answer or disclose information during the risk screening process.
Agency policy (79-ISA-04) requires that “staff shall ensure the sensitive assessment information is not exploited and that any documents obtained from the assessment are secured.” In speaking with random staff, all such staff expressed an

understanding that information obtained as a function of sexual abuse or sexual harassment allegations, investigations, or other related processes was considered confidential and discussed only on a need-to-know basis. As well, in speaking with risk screeners, the confidentiality of the assessment process was clearly understood. All operative staff interviewed whose job roles were associated with the PREA Assessment Form affirmed the information obtained by way of said document was considered restricted, and as such, was not distributed to unauthorized staff. Lastly, the auditor observed that completed PREA Assessment Forms did require authorized credentials to access said documents within the ODRC electronic data base.

Reasoning & Findings Statement:

This standard requires that all incarcerated persons are properly screened for their risk of being sexually victimized or sexually abusive. This screening is done to ensure all incarcerated persons are provided meaningful protection against such abuse while incarcerated. As a foundation of this protection, the ODRC has developed an objective instrument, the PREA Assessment Form, that is administered and scored at the facility level as a simple fact assessment each time an incarcerated person is received upon the facility, at the initiation and conclusion of investigations into substantiated or unsubstantiated allegations, and when referrals are made due to mental health concerns and/or referrals due to concerns of substantial imminent risk of sexual abuse. The SCI has demonstrated the use of the PREA assessment process as required by policy. All assessments are ordinarily completed within 72 hours of intake, with subsequent assessments generally performed no later than 30 days after intake. All interviewed staff were knowledgeable of the confidentiality of the risk assessment, as well as an incarcerated person’s right to refuse participation in the assessment process. A review of documentation supporting the risk assessment process reflects the facility’s overall adherence to agency policy. However, a number of incarcerated individuals did not remember or denied having received a subsequent risk assessment. While records reflect that all such persons did, in fact, receive subsequent risk assessments, to ensure all incarcerated persons recognize the subsequent risk screening process in action, additional training was provided to risk screeners. This training was designed to assist screeners in ways to help incarcerated persons be more aware of, and clarify, the subsequent risk assessment process. With this in mind, the SCI has met compliance with this standard.

115.42	Use of screening information
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-04, PREA Risk Assessments and Accommodation Strategies, 10-20-24

79-ISA-05, Lesbian, Gay, Bisexual, Transgender, Intersex (LGBTI) Policy, 7-9-18
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Incident Report: 1-3-24
SCI Incarcerated person Transfer List: 8-14-24
SCI PREA 72-Hour Assessment Process: 9-14-11, 6-26-15, 5-10-18, 11-14-18,
4-26-19, 9-27-19, 8-10-21, 10-26-21, 1-31-22, 2-16-22, 3-4-22, 3-15-22a, 3-15-22b,
5-26-22, 2-16-23, 2-22-23, 3-6-23, 3-23-23, 7-19-23, 7-21-23, 8-10-23, 10-24-23,
11-3-23, 12-12-23, 12-21-23a, 12-21-23b, 2-12-24, 3-21-24, 6-7-24, 6-21-24, 6-27-24,
7-10-24, 7-26-24, 8-1-24, 8-14-24a, 8-14-24b, 8-15-24, 8-29-24, 10-1-24, 10-2-24,
11-8-24, 11-14-24, 12-18-24, 12-27-24, 12-20-24
SCI 30-Day Reassessment: 7-14-14, 5-30-18, 5-22-19, 10-15-19, 8-27-21, 11-16-21,
2-18-22, 3-4-22, 3-30-22a, 3-30-22b, 6-13-22, 8-23-22, 3-9-23, 3-16-23, 3-31-23,
4-19-23, 8-7-23, 8-9-23, 8-28-23, 11-21-23, 1-3-24, 1-8-24, 3-4-24, 4-11-24, 6-26-24,
7-8-24, 7-15-24, 7-25-24, 8-12-24, 8-19-24, 9-6-24, 9-9-24a, 9-9-24b, 9-17-24,
10-16-24, 11-19-24, 12-2-24a, 12-2-24b, 1-2-25, 1-8-25
SCI Special Assessment: 1-4-24, 1-8-24, 7-17-24
SCI New PREA Classification Report, 1-8-25
SCI PREA Accommodation Strategy: 7-2-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Intermediate or Higher-Level Facility Staff
Intake Staff
Medical Staff
Mental Health Staff
Staff Who Perform Screening for Risk of Victimization and Abusiveness
Random Staff
Inmates Who Identify as Lesbian, Gay, Bisexual, Transgender, or Intersex
Disabled Inmates
Limited English Proficient Inmates Site Review Observations:
Observed PREA screening process.
Reviewed incarcerated person files.
Observed incarcerated person housing, work assignments, and other programmatic assignments.

Standard Subsections:

(A) Agency policy (79-ISA-04) provides “the procedures for employees to follow when screening incarcerated persons for risk of sexual victimization and abusiveness, and to establish the processes for the use and sharing of screening information to inform housing, bed, work, education, and programming assignments.” As noted by Risk Screening staff, the use of the PREA Assessment Form provides staff with an objective

instrument to make informed decisions on institutional assignments to help keep separate those incarcerated persons at high risk of being sexually victimized from those at high risk of being sexually abusive. Documentation review of a SCI PREA Accommodation Strategy Team (PAST) Meeting reflects the institutionalized and intelligent use of the information gained from the PREA assessment process.

Agency policy (79-ISA-04) requires those making “a PREA accommodation strategy to make individualized determinations about how to ensure the safety of each IP.” In speaking with the agency PREA Coordinator, the SCI Warden, the SCI PCM, and SCI Risk Screeners, all staff confirmed that the needs of each incarcerated person are reviewed on an individual basis. In speaking with incarcerated persons assigned to the SCI, most persons stated that SCI administrative staff did take concerns for the sexual safety of incarcerated persons seriously. As well, all incarcerated persons assigned to the SCI stated that they had no fear for their own sexual safety or any concerns of being sexually assaulted while assigned to the SCI.
Agency policy (79-ISA-05) dictates that “staff shall consider on a case-by-case basis whether the housing assignment for a transgender or intersex inmate would ensure the inmate’s health and safety and whether the placement would prevent management or security problems.” In speaking with the agency PREA Coordinator, the SCI Warden, the SCI PCM, and SCI Risk Screeners, staff confirm that the genital status of an incarcerated person is not the only determining factor in assigning an incarcerated person to a facility designated for male or female incarcerated persons or in making other housing or program assignments. Rather, the genital status of incarcerated persons is only one of many factors considered for the overall health and security of all incarcerated persons assigned to any facility.
Agency policy (79-ISA-05) notes that “it is the responsibility of the PREA Accommodation Strategy Team to reassess (special screening) all transgender and intersex inmates housed at their facility at least every six (6) months regarding their placement and programming assignments using the PREA Assessment Strategy. Specific attention shall be given to any threats to safety experienced by the inmate.” Per the SCI PCM, all transgender and intersex incarcerated persons are assessed at least every six months to review and concerns or threats to their safety. In speaking with transgender and intersex incarcerated individuals, all such persons interviewed stated that PREA Accommodation Strategy Team meetings were held with them at least every six (6) months as required. Documentation specific to PREA Accommodation Strategy Team meetings did reflect that said meetings were regularly conducted as required.
Agency policy (79-ISA-05) dictates that “the transgender or intersex inmate’s own views shall be given serious consideration during the classification process and shall be documented.” In speaking with the SCI PCM, adherence to this policy was confirmed. Additionally, documentation specific to PREA Accommodation Strategy Team meetings did reflect that the views of the incarcerated person were a considered factor within the team meeting.
Agency policy (79-ISA-05) mandates that “transgender and intersex inmates shall

be given the opportunity to shower separately from other inmates.” In speaking with the SCI PCM, adherence to this policy was confirmed. In speaking with transgender and intersex incarcerated persons, all such persons stated that facility staff does provide them with the opportunity to shower separately from other incarcerated persons.

(G) Agency policy (79-ISA-05) mandates that “LGBTI inmates shall not be placed in dedicated facilities, units, or wings solely on the basis of such identification unless placement in a dedicated facility, unit, or wing has been established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting such inmates.” As noted by the SCI PCM, the SCI is not under any such consent decree. As such, there isn’t any dedicated housing within the SCI for lesbian, gay, bisexual, transgender, or intersex (LGBTI) incarcerated persons. Accordingly, all such incarcerated persons are housed throughout the facility in accordance with security and other classification needs. In speaking with LGBTI incarcerated persons, none (0) stated that they had been housed, nor was there any housing dedicated for LGBTI incarcerated persons.

Reasoning & Findings Statement:

This standard works to ensure the appropriate use of information gained via the risk assessment process for sexual victimization and sexual abusiveness. The ODRC has developed policies and protocols to ensure the intelligent use of this information to inform housing, bed, work, education, and program assignments with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive. In response, the SCI has demonstrated consistent adherence to these agency policies. Among other factors, said policies require SCI staff to make individualized determinations regarding the sexual safety of transgender and intersex incarcerated persons. Along with the use of PREA Accommodation Strategy Team meetings, incarcerated persons deemed to be at a higher risk of sexually victimization are routinely monitored by unit staff and provided numerous avenues to speak with unit administration as needed. Interviews with the agency PREA Coordinator and the SCI PCM reflect that facility staff have discretion in managing the safety of individual incarcerated persons assigned to the SCI. In managing the safety of incarcerated persons, documentation demonstrates that incarcerated persons’ own views regarding their own safety are given serious consideration specific to facility operations. Transgender incarcerated persons are allowed to shower separately from the general population. Additionally, transgender incarcerated persons are reviewed every six months specific to their placement and programming assignments. As such, agency policy meets, and SCI adheres to, the requirements of this standard.

115.43	Protective Custody
	Auditor Overall Determination: Meets Standard
	Auditor Discussion

Documents:

79-ISA-01, Prison Rape Elimination, 10-1-24
79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI New PREA Classification Report, 1-8-25 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Designated Staff Member Charged with Monitoring Retaliation
Incident Review Team Member
Intermediate or Higher-Level Facility Staff
Staff Who Supervise Inmates in Segregated Housing
Inmates Who Reported Sexual Abuse
Random Inmate Interviews
Targeted Inmate Interviews Site Review Observations:
Observed custody housing assignments.

Standard Subsections:
Agency policy (79-ISA-02) dictates that “IPs at high risk for victimization shall not be placed in involuntary RH or LPH unless an assessment of all available alternatives has been made and a determination has been made that there is no available alternative means of separation from likely abusers. If an Imminent Risk of Sexual Abuse (DRC1187) assessment cannot be completed immediately, the IP may be held in involuntary RH or LPH for less than twenty-four (24) hours while completing the assessment.” Interviews with incarcerated persons did not suggest that SCI utilizes any form of restrictive housing as a primary means of involuntary separation for investigatory purposes. In speaking with the SCI PCM and the SCI Warden, staff confirm that there has not been any (0) incarcerated persons placed in the Involuntary Transitional Program Unit during the audit time frame. As such, there wasn’t any relevant documentation to review.
Policy (79-ISA-02) mandates that if incarcerated persons are placed in restrictive housing for being at a high risk of sexual victimization, said incarcerated persons “shall have access to programs, privileges, education, and work opportunities to the extent possible. If access is restricted, staff shall document: opportunities that have been limited, duration of limitations, (and) reasons for such limitation.” Interviews with incarcerated persons did not suggest that SCI utilizes any form of restrictive housing as a primary means of involuntary separation for investigatory purposes. In speaking with the SCI PCM and the SCI Warden, staff confirm that there has not been

any (0) incarcerated persons placed in the Involuntary Transitional Program Unit during the audit time frame. As such, there wasn’t any relevant documentation to review.

Agency policy (79-ISA-02) requires that “involuntary TPU assignments shall only be arranged until alternative means of separation from likely abusers can be done and shall not ordinarily exceed thirty (30) calendar days.” Interviews with incarcerated persons did not suggest that SCI utilizes any form of restrictive housing as a primary means of involuntary separation for investigatory purposes. In speaking with the SCI PCM and the SCI Warden, staff confirm that there has not been any (0) incarcerated persons placed in the Involuntary Transitional Program Unit during the audit time frame. As such, there wasn’t any relevant documentation to review.
Agency policy (79-ISA-02) requires that “the PREA Involuntary Placement in RH/LPH (DRC1184) shall be completed if an involuntary TPU assignment is made pursuant to this section. Staff shall clearly document the basis for the concern for the IP’s safety and the reason why no alternative means could be arranged.” Interviews with incarcerated persons did not suggest that SCI utilizes any form of restrictive housing as a primary means of involuntary separation for investigatory purposes. In speaking with the SCI PCM and the SCI Warden, staff confirm that there has not been any (0) incarcerated persons placed in the Involuntary Transitional Program Unit during the audit time frame. As such, there wasn’t any relevant documentation to review.
Agency policy (79-ISA-02) requires that if an involuntary segregated housing assignment is utilized, “every thirty (30) calendar days, unit management shall afford each IP a review to determine whether there is a continuing need for separation from the general population.” Interviews with incarcerated persons did not suggest that SCI utilizes any form of restrictive housing as a primary means of involuntary separation for investigatory purposes. In speaking with the SCI PCM and the SCI Warden, staff confirm that there has not been any (0) incarcerated persons placed in the Involuntary Transitional Program Unit during the audit time frame. As such, there wasn’t any relevant documentation to review.

Reasoning & Findings Statement:

This standard works to ensure that incarcerated persons at risk of sexual victimization are not simply housed inside of involuntary protective custody as a de facto management solution for administrative safety concerns. Agency policy explicitly mandates that staff refrain from placing incarcerated persons at high risk for sexual victimization in the Involuntary Transitional Program Unit unless an assessment of all available alternatives has been made and there are no other available means of separation from likely abusers. Correctional staff routinely assigned to work within Segregated Housing were interviewed. While these staff confirmed that incarcerated persons assigned to the Involuntary Transitional Program Unit for high risk of sexual victimization would be afforded similar activities as incarcerated persons within general population, to the best of their knowledge, there has not been any such incarcerated persons assigned to such housing within the audit time frame. In speaking with the SCI PCM and the SCI Warden, staff confirmed that there has not been any (0) incarcerated persons placed in the Involuntary Transitional Program Unit

for risk of sexual safety during the audit time frame. Additionally, no incarcerated persons stated that they had been placed in such housing. As such, there wasn’t any relevant documentation to review. In total, the SCI has satisfied all component parts of this standard.

115.51	Inmate reporting
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 01-COM-08, Incident Reporting and Notification, 3-27-23 ODRC Incarcerated Person Handbook, Appendix A, 52-RCP-10, PREA Information, English, 1-6-20 ODRC Incarcerated Person Handbook, Appendix A, 52-RCP-10, PREA Information, Spanish, 1-6-20 ODRC PREA Incarcerated Person Poster – Incidents or Suspicions of Sexual Abuse, Harassment, and Retaliation, English ODRC PREA Incarcerated Person Poster – Incidents or Suspicions of Sexual Abuse, Harassment, and Retaliation, Spanish ODRC PREA Incarcerated Person Poster – Restrictive Housing Incarcerated persons, English ODRC PREA Incarcerated Person Poster – Restrictive Housing Incarcerated persons, Spanish ODRC PREA Incarcerated Person Poster, Family & Friends, Break the Silence, English ODRC PREA Incarcerated Person Poster, Family & Friends, Break the Silence, Spanish ODRC PREA Incarcerated Person Education Video with Director Chambers-Smith ODRC MOU with ODYS, 10-11-23 ODRC Employee Handbook, Department Policies, PREA ODRC PREA Training for all Employees, FY24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Incident Report: 1-3-24, 5-14-24 SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI PREA Victim Support Person Certification: 1-9-15a, 1-9-15b, 1-9-15c, 1-9-15d, 1-17-17, 8-31-21a, 8-31-21b, 8-31-21c, 8-31-23a, 8-31-23b SCI Verbal Report (Facility-to-Facility) Notification, 1-19-24

SCI Inmate Reporting via Tablet, 1-30-25
SCU Inmate Report via Reporting Hotline, January 2025 Interviews:
Agency Head
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Random Staff
Just Detention International
Community-Based Victim Advocacy Staff
Random Inmates
Inmates Who Disclosed Sexual Victimization During Risk Screening
Inmates Who Reported Sexual Abuse Site Review Observations:
Observed PREA Risk Screening assessments.
Observed PREA Risk Screening process.
Observed informational posters throughout the facility advising incarcerated persons of various reporting mechanisms for allegations of sexual abuse and sexual harassment.
Observed numerous PREA educational and reporting references available for incarcerated person use within the facility Law Library and computer terminals.
Reviewed documentation related to incarcerated person reports of sexual abuse and sexual harassment.
Observed PREA informational video.
Tested PREA Hotline number incarcerated persons can use to engage incarcerated person reporting of sexual abuse and sexual harassment.

Standard Subsections:

(A) Agency policy (79-ISA-02) details multiple internal ways for incarcerated persons to privately report sexual abuse and sexual harassment, retaliation by other incarcerated persons or staff for reporting sexual abuse and sexual harassment, and staff neglect or violation of responsibilities that may have contributed to such incidents. “An IP may report allegations of sexual misconduct or retaliation by other IPs or staff verbally or in writing. In addition, IPs may report staff neglect or violations of responsibilities that may have contributed to incidents of sexual misconduct. Allegations may be reported to any staff member, volunteer, or contractor.” As noted by the SCI PCM, incarcerated persons are given detailed instructions of their ability to make reports of sexual abuse or sexual harassment during the comprehensive PREA education provided within seven (7) days of their receipt into the SCI. This education includes contact information for internal and external reporting agencies. During interviews with Random Staff, as persons were aware of an incarcerated person’s right to report allegations of sexual abuse and sexual harassment and their right to be free from measures of retaliation for having reported said abuse. When interviewing incarcerated persons, all incarcerated persons were equally aware of

their right to report allegations of sexual abuse and sexual harassment and to be free from measures of retaliation for having reported said abuse. During random and targeted interviews with incarcerated persons, all were able to articulate at least one manner by which a report could be made, with most incarcerated persons being able to provide multiple reporting methods. As noted during documentation review, instructions on reporting mechanisms, as well as points of contacts for each of those methods, are published in the Incarcerated Person Orientation Handbook. As well, reporting information is continuously displayed on awareness posters located throughout the facility, to include all incarcerated person housing areas, as well as continuously available via incarcerated person tablets.

Agency policy (79-ISA-02) states that “IPs may also report allegations to an outside entity that is not part of the ODRC by using the phone number and/or address provided. This outside entity shall then report the allegations to the agency PREA Coordinator/Designee. IPs shall be given the opportunity to remain anonymous upon request to the outside entity.” As noted by the SCI PCM, all incarcerated persons are provided information on, and access to, a PREA Reporting Hotline. This hotline reports directly to an outside entity, the Ohio Department of Youth Services, which can receive and immediately forward incarcerated person reports of sexual abuse and sexual harassment to agency officials, such as the ODRC PREA Coordinator’s Office. Reports to the Ohio Department of Youth Services may also be made anonymously. The facility did have, and supplied for review, a memorandum of understanding with the Ohio Department of Youth Services to ensure the continued facilitation of these calls. In speaking with Random Staff, all such persons were aware of the PREA Hotline and incarcerated person’s ability to access it free of charge. Interviews with incarcerated persons reflected their knowledge of the PREA hotline and their ability to make reports of sexual abuse and sexual harassment using that no-fee option. As noted during documentation review, instructions on reporting mechanisms, to include making reports to outside entities via the PREA Hotline, have been published in the Incarcerated Person Orientation Handbook. As well, reporting information is continuously displayed on awareness posters located throughout the facility, to include all incarcerated person housing areas, as well as continuously available via incarcerated person tablets. To test the functionality of the PREA Reporting Hotline, the auditor conducted a test of the phone number commonly referenced by incarcerated persons. This test was conducting utilizing random phones within incarcerated person housing areas. Confirmation responses were received the same business day. Lastly, as noted by the SCI PCM, the SCI does not detain incarcerated persons solely for civil immigration purposes.
Agency policy (79-ISA-02) requires staff to accept all reports of sexual abuse and sexual harassment made verbally, in writing, anonymously, and from third parties. Agency policy (01-COM-08) further requires that “all incidents occurring within an ODRC facility or office must be reported verbally and via submitted form as required and described in this policy. Such reports shall be on Incident Report (DRC1000), and if needed, Incident Report Supplement (DRC1001).” All employees interviewed stated that they would act on any report of sexual abuse or sexual harassment regardless of the manner by which they became aware of that information. In doing so, many staff

stated that they would document all such reports via a DRC1000 and all staff stated they would document the information as soon as possible following the allegations being presented to them. All incarcerated persons interviewed affirmed their right to make either verbal or written reports of sexual abuse and sexual harassment. Most incarcerated persons were also aware that they could make reports of sexual abuse and sexual harassment via third party or anonymously. The overwhelming majority of incarcerated persons interviewed stated that they believed SCI staff would take any complaint of sexual safety seriously and act accordingly to address their concerns.

(D) Per policy (Employee Handbook), staff have an affirmative duty to report any knowledge, suspicion, or information they may have regarding sexual abuse, sexual harassment, or retaliation against incarcerated persons or staff for having reported such abuse. Nonetheless, per policy (79-ISA-02), “staff may privately report sexual misconduct by completing an Incident Report (DRC1000), marked confidential and submitting it directly to the Operational Compliance Manager or agency PREA Coordinator.” During interviews with Random Staff, staff were generally aware that they could make private or anonymous reports of sexual abuse and sexual harassment.

Reasoning & Findings Statement:

This standard ensures that incarcerated persons have multiple internal avenues to report allegations of sexual abuse and sexual harassment. Agency policy allows for these reports to be made verbally, in writing, anonymously, and by a third-party.

These reports can be made to any staff, contractor, intern, or volunteer in person, as well as a host of employees within unit administration via paper kites or electronically through incarcerated person tablets. Incarcerated persons can also make reports of sexual abuse and sexual harassment to a designated outside entity, the Ohio Department of Youth Services, which can receive and immediately forward incarcerated person reports of sexual abuse and sexual harassment to agency officials, such as the ODRC PREA Coordinator’s Office. Reports to the Ohio Department of Youth Services may also be made anonymously. The facility did have, and supplied for review, a memorandum of understanding with the Ohio Department of Youth Services to ensure the continued facilitation of these calls. In speaking with the SCI PCM, it was noted that all incarcerated persons are provided detailed instructions, contact persons, phone numbers, e-mail addresses, and physical addresses for correspondence where allegations of sexual abuse, sexual harassment, and retaliation for reporting such may be reported. In interviewing Random Staff, all employees were aware that incarcerated persons could report allegations of sexual abuse and sexual harassment verbally, in writing, anonymously, and through a third party. When receiving verbal reports of sexual abuse and sexual harassment, all staff recognized the need to take immediate action to protect the incarcerated person in question and the need to document the verbal complaint as soon as possible. In speaking with incarcerated persons, all persons were aware of their right to be free from sexual abuse and sexual harassment, as well as their right not to suffer retaliation for having reported such abuse. All incarcerated persons understood their right to make verbal and written complaints, with most understanding their right to make anonymous and third-party complaints. In speaking with incarcerated persons,

it was noted that all incarcerated persons were aware of the reporting hotline, with most incarcerated persons being aware that reports to that hotline could also be made free of charge and anonymously. Lastly, the auditor conducted a testing of the PREA Reporting Hotline number commonly referenced by incarcerated persons. A confirmation response was received the same business day. As such, it is evident that the SCI has met the requirements of this standard.

115.52	Exhaustion of administrative remedies
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 ODRC Statement of Fact, PREA Coordinator SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Grievance Referrals: 3-7-24, 4-9-24, 4-10-24, 5-8-24, 5-21-24, 5-27-24, 8-8-24, 9-25-24, 11-15-24, Interviews: Facility Warden PREA Compliance Manager Investigative Staff Random Inmates Site Review Observations: Reviewed complaint submission process. Standard Subsections: (A) Agency policy (79-ISA-02) states that “any IP grievance (i.e. informal complaint resolution, notification of grievance, related appeal forms, etc.) filed regarding a complaint of sexual abuse or sexual harassment shall be immediately reported to the Institution Investigator for proper handing in accordance to this policy.” Per the agency PREA Coordinator, the ODRC does not utilize the incarcerated person grievance process as its administrative procedure for handling allegations of sexual abuse or sexual harassment. While ODRC incarcerated persons are not prohibited from utilizing any grievance related form (ICR, NOG, Appeal forms) to communicate sexual abuse and sexual harassment allegations in writing, it is important to note that any such form containing allegations of sexual abuse or sexual harassment are

referred to the Institution Investigator for processing immediately upon receipt. All investigations into allegations of sexual abuse or sexual harassment are done in accordance with agency policy (79-ISA-02). Agency policy (79-ISA-02) adheres to all time constraints referenced in PREA Standard 115.52. It is also important to note that the ODRC does educate incarcerated persons (incarcerated person handbooks and DRC Policy 79-ISA-02) that any PREA allegations received on grievance forms will be immediately channeled to the Institutional Investigator for proper handling.

Documentation review supports SCI’s adherence to agency policy.

Agency policy (79-ISA-02) does not permit incarcerated persons to submit grievances regarding allegations of sexual abuse and sexual harassment. However, agency policy (79-ISA-02) clearly states that “there shall be no time limit on when an IP may report sexual misconduct. A sexual abuse or sexual harassment complaint may be submitted at any time.” However, as discussed with the SCI Institution Investigator, when incarcerated persons are provided education on filing reports of sexual abuse or sexual harassment, they are advised that, per policy (79-ISA-02), “a timely compliant is essential to providing services and proper investigation. Acceptance of a late complaint does not waive the applicable statues of limitations with respect to any related lawsuit.” Documentation review supports SCI’s adherence to agency policy.
Agency policy (79-ISA-02) does not permit incarcerated persons to submit grievances regarding allegations of sexual abuse and sexual harassment. Nonetheless, incarcerated persons may still submit reports of sexual abuse and sexual harassment without first attempting to resolve the complaint informally or through the person with whom the complaint is against. Per agency policy
(79-ISA-02), “all reports of sexual harassment shall be investigated by the institution Operation Compliance Manager and all reports of sexual abuse and retaliation shall be investigated by the institution investigator.” Documentation review supports SCI’s adherence to agency policy.
Agency policy (79-ISA-02) does not permit incarcerated persons to submit grievances regarding allegations of sexual abuse and sexual harassment. However, agency policy (79-ISA-02) clearly states that “a final decision on all allegations of sexual abuse shall be issued by the Institution Investigator within ninety (90) calendar days of the initial filing. If ninety (90) calendar days is not sufficient to make an appropriate decision, the institution investigator may extend the decision up to seventy (70) additional calendar days. The IP shall be notified in writing of such extension and be provided a date by which a decision will be made.” In speaking with the Institution Investigator, it was noted that all efforts are made to investigate sexual abuse and sexual harassment allegations within 90 calendar days. But if additional time is needed, incarcerated persons are notified of the delay and given an approximate date of when the investigation will be completed. Documentation review supports SCI’s adherence to agency policy.
Agency policy (79-ISA-02) does not permit incarcerated persons to submit grievances regarding allegations of sexual abuse and sexual harassment. Nonetheless, agency policy (79-ISA-02) does allow third parties, including fellow

incarcerated persons, staff members, family members, attorneys, and outside advocates, to assist incarcerated persons in filing complaints of sexual abuse or sexual harassment. Additionally, per the Institution Investigator, third parties may also file complaints on behalf of incarcerated persons. In that event, it was noted that the Institution Investigator would speak with the incarcerated person to obtain any additional information prior to continuing the investigation. Documentation review supports SCI’s adherence to agency policy.

Agency policy (79-ISA-02) does not permit incarcerated persons to submit grievances regarding allegations of sexual abuse and sexual harassment. However, agency policy (79-ISA-02) does allow incarcerated persons to file complaints of sexual abuse and sexual harassment. If the complaint is deemed of substantial risk of imminent sexual abuse, it “shall immediately be forwarded to the Institution Investigator, Operation Compliance Manager, Unit Management Chief, and shift supervisor. Upon receipt of a report, security staff shall take immediate action to employ protection measures to ensure the IP’s safety.” As noted by the Institution Investigator, the incarcerated person will then be provided an initial response to the allegations within 48 hours, with a final disposition being provided within five (5) calendar days. Per agency policy (79-ISA-02), “a documented final decision shall be made within five (5) calendar days of the initial report and shall be documented by the managing officer’s designee on the Imminent Risk of Sexual Abuse (DRC1187) and a copy sent to the institution investigator. The report shall document the institution’s determination whether the IP is at substantial risk of imminent sexual abuse and the action taken.” Documentation review supports SCI’s adherence to agency policy.
Agency policy (79-ISA-02) does not permit incarcerated persons to submit grievances regarding allegations of sexual abuse and sexual harassment. However, agency policy (79-ISA-02) does allow incarcerated persons to file complaints of sexual abuse and sexual harassment. Agency policy (79-ISA-02) states that “disciplinary action may be taken when it is determined that an IP made a false report of sexual misconduct…However, no IP reporting sexual misconduct shall be issued a conduct report for lying based solely on the fact their allegations could not be substantiated or that the IP later recanted their allegation.” In speaking with the Institution Investigator, adherence to said policy was confirmed. Documentation review supports SCI’s adherence to agency policy.

Reasoning & Findings Statement:

This standard ensures that all sexual abuse and sexual harassment grievances presented by incarcerated persons are processed within a reasonable time frame so that corrective action necessary to prevent or deter sexual abuse and sexual harassment is available in a timely manner. Additionally, this standard works to remove administrative barriers that may prevent incarcerated persons from filing grievances to notifying agency officials of sexual abuse and sexual harassment.

However, ODRC policy (79-ISA-02) does not permit incarcerated persons to submit grievances alleging sexual abuse and sexual harassment. Hence, as the ODRC does not have administrative procedures to address grievances from incarcerated persons regarding sexual abuse and sexual harassment, the ODRC is exempt from this

standard. Nonetheless, the standard is still applicable to the ODRC in that administrative measures are available to address allegations presented by incarcerated persons specific to sexual abuse and sexual harassment. That said, the agency still investigates those allegations; it simply does so by using a different mechanism. In this, the Institution Investigator, in coordination with unit administration, process such allegations as formal sexual abuse or sexual harassment investigations. In doing so, all time frames, as well as other requirements set forth within these provisions are followed inside of the ODRC sexual abuse and sexual harassment investigation process. Documentation review supports SCI’s adherence to agency policy. With that in mind, the SCI has demonstrated adherence to the agency’s policy regarding administrative remedies for sexual abuse and sexual harassment complaints.

115.53	Inmate access to outside confidential support services
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 52-RCP-10, PREA Information from Incarcerated Person Handbook, English 52-RCP-10, PREA Information from Incarcerated Person Handbook, Spanish ODRC Contact Information for Rape Crisis Programs in Ohio SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Local Rape Crisis Contact Poster, English SCI Local Rape Crisis Contact Poster, Spanish SCI MOU with the Sexual Assault Response Network of Central Ohio (SARNCO), 2-9-23 SCI Memo Confidential Calls for Emotional Support Services, 3-7-23 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI PREA Victim Support Person Certification: 1-9-15a, 1-9-15b, 1-9-15c, 1-9-15d, 1-17-17, 8-31-21a, 8-31-21b, 8-31-21c, 8-31-23a, 8-31-23b Interviews: Agency PREA Coordinator Facility Warden PREA Compliance Manager Medical Staff Mental Health Staff SAFE and/or SANE Personnel of the Local Hospital/Rape Crisis Clinic Mailroom Staff Random Staff

Just Detention International
Community-Based Victim Advocacy Staff
Random Inmates
Inmates Who Disclosed Sexual Victimization During Risk Screening
Inmates Who Reported Sexual Abuse Site Review Observations:
Reviewed PREA Risk Screening Assessment
Review of distributed information upon SCI reception at Intake areas.
Observed informational posters throughout the facility advising incarcerated persons of various reporting mechanisms for allegations of sexual abuse and sexual harassment.
Observed numerous PREA educational and reporting references available for incarcerated person use within the facility Law Library, tablet, and via computer terminal access on incarcerated person housing areas.
Observed informational posters throughout the facility advising incarcerated persons of contact information for the local rape crisis center associated with the PREA Hotline number granting access to confidential rape crisis counseling services.
Observed informational notices for incarcerated persons to contact any rape crisis program within the State of Ohio, as well as the statewide Ohio Sexual Violence Helpline.
Observed visitation area designated for members of an approved victim advocate service.
Tested PREA Hotline number incarcerated persons can use for access to confidential rape crisis counseling services.

Standard Subsections:

(A) Policy (79-ISA-01) requires that the ODRC “shall attempt to identify rape crisis centers that can provide victim advocate services.” Agency policy (79-ISA-01) further requires that the ODRC “shall maintain or attempt to enter into memoranda of understanding or other agreements with community service providers that are able to provide IPs with confidential emotional support services related to sexual abuse.” As identified by the ODRC PREA Coordinator, the SCI has entered into a memorandum of understanding with a local rape crisis center; namely, the Sexual Assault Response Network of Central Ohio, to provides advocacy services to incarcerated persons assigned to the SCI. The SCI Incarcerated Person Handbook provides contact information for this local rape crisis center. Additionally, awareness posters are displayed throughout the facility, in both English and Spanish, advising all incarcerated persons of their ability to contact this advocacy service free of charge. In excess of the standard, the SCI makes available the contact information for dozens of rape crisis centers throughout the entire State of Ohio. Notices of how to obtain this contact information, as well as how toll-free calls to these centers can be made, is posted in all incarcerated person housing areas, as well as the facility Law Library. Furthermore, to assist incarcerated persons with their ability to continue counseling relationships with rape crisis centers post-release, these agencies are sorted by county. This reference includes the contact person, physical address, phone number,

and website address for Ohio rape crisis programs. It also includes the contact information for a local rape crisis center; namely, the Sexual Assault Response Network of Central Ohio. During incarcerated person interviews, many were aware that detailed contacted information was provided to them via their Incarcerated Person Handbook; however, all were aware that telephone contact information was provided via the awareness posters located throughout the facility.

Per policy (79-ISA-01) the agency does provide toll-free telephone calls to rape crisis advocates and hotlines. Policy (79-ISA-01) also allows that communication between incarcerated persons and advocates within these rape crisis centers is as confidential as possible; however, “IPs must be notified that telephone calls are not confidential” in the event that, for security reasons, it becomes necessary to monitor said conversations. In speaking with Mailroom staff, it was further noted that outgoing mail to rape crisis centers may be sealed and sent to rape crisis advocates without undue prison inspection. Additionally, the agency allows Victim Support Persons, specifically trained for this purpose by the agency, to provide incarcerated persons with emotional support related to sexual abuse and sexual harassment.

Per the agency PREA coordinator, the ODRC does not detain incarcerated persons solely for civil immigration purposes. Nonetheless, information on how to contact relevant consular officials is available in the facility’s Law Library. When interviewed, all incarcerated persons knew that the agency provided free rape crisis support services to incarcerated persons in need of such assistance. Additionally, all incarcerated persons were aware of at least one means by which they could contact rape crisis support services, with most incarcerated persons knowing that they could access those services by way of the phone number (aka the PREA Hotline) provided via the sexual abuse awareness posters located throughout the facility and in all housing areas.

(B) Per policy (79-ISA-01) incarcerated persons are notified that calls to the rape crisis center hotline number are subject to monitoring. When interviewed, most incarcerated persons indicated their awareness, by way of the information provided on the sexual abuse posters or via the sexual abuse prevention video, that calls made to the PREA Rape Crisis Hotline were monitored. Incarcerated persons were also generally aware that conversations with rape crisis counselors were not completely anonymous and could be reported back to the facility if their discussions triggered mandatory reporting laws. To test the functionality of the PREA Rape Crisis Hotline, the auditor conducted a test of the phone number commonly referenced by incarcerated persons. This test was conducting utilizing a random phone within an incarcerated person housing area. The call was answered by a rape crisis counselor of the Sexual Assault Response Network of Central Ohio, who then confirmed the line was active and functioning as required. Additionally, it should also be noted that if incarcerated persons wished to speak with rape advocacy counselors in private, arrangements to do so could be made through their unit management staff. To ensure a functional relationship existed between SCI and rape crisis centers for which incarcerated persons might seek assistance or referrals, communication was established with both the Sexual Assault Response Network of Central Ohio and Just Detention International. Neither agency indicated that it had experienced any

negative interactions with administrative staff of the SCI.

The SCI has negotiated a contract between itself and Sexual Assault Response Network of Central Ohio to help provide rape crisis support services as requested by incarcerated persons assigned to the SCI. The SCI does maintain, and did supply, a contract for review.

Reasoning & Findings Statement:

This standard ensures that all incarcerated persons have access to outside confidential support services for sexual abuse and sexual harassment advocacy counseling. In providing this access, the SCI has given incarcerated persons mailing addresses and toll-free numbers for local, State, and national victim advocacy and rape crisis organizations. The SCI does have a memorandum of understanding in effect with the Sexual Assault Response Network of Central Ohio, which is a local rape crisis center to the facility. Via posted notice in SCI Orientation Handbooks, incarcerated persons are made aware that communications with rape crisis advocates will be monitored. In excess of the standard requirements, the SCI has also provided all incarcerated persons with a listing of contact information for rape crisis centers in each Ohio county. This more detailed listing of advocacy centers is provided to help incarcerated persons reach counseling centers located within their home counties so as to increase the availability, and subsequent probability, of continued counseling care upon release. When interviewed, all SCI staff and incarcerated persons were aware that the facility provided some measure of counseling services, free of charge, for victims of sexual abuse and sexual harassment. Additionally, most incarcerated persons were aware that they could access those services by way of the rape crisis advocacy posters posted throughout the facility. With all of these factors in mind, the SCI has exceeded the minimum requirements of this standard.

115.54	Third-party reporting
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 01-COM-08, Incident Reporting and Notification, 3-27-23 ODRC Website Email Address for Third Party Reporting ODRC Incarcerated Person Handbook, Appendix A, 52-RCP-10, PREA Information, English, 1-6-20 ODRC Incarcerated Person Handbook, Appendix A, 52-RCP-10, PREA Information, Spanish, 1-6-20 ODRC PREA Incarcerated Person Poster – Incidents or Suspicions of Sexual Abuse,

Harassment, and Retaliation, English

ODRC PREA Incarcerated Person Poster – Incidents or Suspicions of Sexual Abuse, Harassment, and Retaliation, Spanish
ODRC PREA Incarcerated Person Poster – Restrictive Housing Incarcerated persons, English
ODRC PREA Incarcerated Person Poster – Restrictive Housing Incarcerated persons, Spanish
ODRC PREA Incarcerated Person Poster, Family & Friends, Break the Silence, English
ODRC PREA Incarcerated Person Poster, Family & Friends, Break the Silence, Spanish
ODRC PREA Incarcerated Person Education Video with Director Chambers-Smith
ODRC MOU with ODYS, 10-11-23
ODRC Employee Handbook, Department Policies, PREA
ODRC PREA Training for all Employees, FY24
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Employee PREA Training, FY24
SCI Incident Report: 1-3-24, 5-14-24
SCI Approved List of PREA Victim Support Person Staff, 8-14-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Investigative Staff
Random Inmates
ODRC Website Third Party Reporting Coordinator
Just Detention International
Community-Based Victim Advocacy Staff Site Review Observations:
Observed PREA reporting information available in the Law Library, via incarcerated person tablets, and/or via computer terminal access in incarcerated person housing areas.
Observed informational posters providing third-party reporting contact information for the family, friends, and other advocates of incarcerated persons within the general visitation, legal visitation, and front office areas.
Review ODRC website specific to PREA and third-party reporting methods
Tested ODRC online third-party reporting system.
Tested PREA Hotline number incarcerated persons can use to engage third-party reporting.
Observed informational postings and other publications throughout the incarcerated person housing areas.

Standard Subsections:

(A) Policy (79-ISA-02) encourages the use of third-party reporting. Specifically, policy

(79-ISA-02) notes that “it is the policy of the ODRC to provide a safe, humane, and appropriately secure environment, free from the threat of sexual misconduct for all IPs by maintaining clear procedures for reporting, detecting, responding, and investigating misconduct.” Accordingly, the agency allows for multiple means of reporting any allegation of sexual abuse or sexual misconduct, to include third-party reporting. In discussing reporting processes with random staff, it was understood that regardless of how staff become aware of any allegation of sexual abuse or sexual harassment, appropriate action must be taken to investigate those allegations.

During interviews with the agency PREA Coordinator, it was noted that all allegations of sexual abuse or sexual harassment would be reviewed regardless of the source of that allegation. It was further noted that the agency has designed third-party reporting systems for incarcerated persons, advocates for incarcerated persons, and outside entities to make such reports on behalf of incarcerated persons. During interviews with incarcerated persons, most believed that the facility would accept, and take seriously, any allegations of sexual abuse reported by a third party, to include allegations presented by other incarcerated persons. During the onsite review, signage throughout the facility encouraged incarcerated persons to third-party report if needed. As well, public notices on PREA reporting, specifically third-party reporting, were available for review by the family, friends, and advocates of incarcerated persons in both the facility’s Front Lobby and Visitation Room.

Additionally, public notice on third-party PREA reporting is available to the general public on the agency’s website. Documentation specific to third-party reporting was reviewed. This documentation indicated that SCI staff would accept, and does process, third-party PREA allegations to the same extent as complaints made by affected incarcerated persons. Additionally, to test the functionality of the PREA Reporting Hotline, which could be used for third-party reports by incarcerated persons, the auditor conducted a test of the phone number commonly referenced by incarcerated persons. This test was conducted utilizing a random phone within an incarcerated person housing area. A confirmation response was received the same business day. To test the functionality of the PREA online reporting system available to the friends, family, and other advocates of incarcerated persons on the ODRC website, the auditor conducted a test of the online reporting system. This test was conducted using a random email address not designated from the auditing agency. A confirmation response was received the same business day. Lastly, while incarcerated persons are not encouraged to utilize rape counseling support service centers as reporting avenues, they will also serve in this capacity if explicitly requested by the incarcerated person. With this in mind, the auditor solicited incarcerated person contact information from a rape counseling center central to the SCI and from a nationally based referral service. The referral service, Just Detention International, indicated that it did not receive any (0) complaints of sexual abuse or sexual harassment from incarcerated persons assigned to the SCI within the reporting time frame. The Sexual Assault Response Network of Central Ohio (SARNCO), a local rape counseling advocacy service, was also contacted and asked to provide relevant information specific to the SCI PREA audit. SARNCO indicated that it does provide services to incarcerated persons assigned to the SCI. During this encounter, SARNCO advocates did not experience any difficulties accessing or speaking with incarcerated individuals.

Reasoning & Findings Statement:

This standard works to ensure the friends, family, and other advocates of incarcerated persons have at least one (1) means by which to make third-party reports of sexual abuse and sexual harassment. To ensure knowledge of this methodology, this standard also requires the agency to publicly distribute information on how to report sexual abuse and sexual harassment on behalf of an incarcerated person. In this regard, the ODRC, and by extension the SCI, have clearly exceeded the requirements of this standard. In fact, the ODRC has made third-party reporting as easily accessible as reporting by the principal party. By any method conceivable, a third-party advocate may contact any employee, contractor, intern, or volunteer of the ODRC to make third-party reports of sexual abuse and sexual harassment.

Incarcerated persons are provided information on third-party reporting, which can be used for their family and friends to advocate on their behalf, or it can be used for incarcerated persons to advocate on behalf of other incarcerated persons. Advocates for incarcerated persons are also given information on third-party reporting via institutional awareness posters publicly displayed the SCI Front Lobby, as well as in its Visitation Room. Third-party reporting information is also available to the general public on the ODRC website. Third-party reporting methods commonly used by incarcerated persons, family and friends, as well as incarcerated persons advocates were tested to ensure functionality. All methods of communication received responsive comments within a reasonable time frame. Accordingly, the ODRC, and by extension the SCI, have met the requirements of this standard.

115.61	Staff and agency reporting duties
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 79-ISA-04, PREA Risk Assessments and Accommodation Strategies, 10-20-24 01-COM-08, Incident Reporting and Notification, 3-27-23 39-TRN-12, Contractor Orientation, 4-1-24 ODRC PREA Zero Tolerance PowerPoint Training Lesson Plan w/ Test ODRC PREA Contractor/Volunteer Training Video ODRC PREA Contractor/Volunteer Training Script SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Medical and Mental Health PREA Training, FY24 SCI Staff Certificate of Training, NIC PREA Investigating Sexual Abuse in a

Confinement Setting: 5-6-14, 6-14-17, 1-31-22

SCI Staff Certificate of Training, NIC PREA: Coordinators’ Roles and Responsibilities, 6-14-17
SCI OSHP Notification Email: 1-2-24, 1-8-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Investigative Staff
Medical Staff
Mental Health Staff
First Responders
Random Staff
Random Inmates
Inmates Who Reported Sexual Abuse
Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations:
Reviewed employee, contractor, and volunteer training records.

Standard Subsections:

Agency policy (79-ISA-01, 01-COM-08) mandates that all employees must immediately report all knowledge, suspicion, or information of any sexual misconduct that occurred within the correctional institution. “Staff shall also report retaliation against IPs or staff who report such incidents, and any staff neglect or violation of responsibilities that may be contributed to an incident or retaliation” (79-ISA-02). In speaking with Random Staff, their duty to report any awareness, or even suspicion, of sexual abuse or sexual harassment was consistently acknowledged. A review of employee, contractor, and volunteer training records, as well as training curriculum records, reflects that all persons delivering services inside of SCI have received, at the minimum, their initial PREA training, including acknowledgment of their affirmative duty responsibilities.
Agency policy (79-ISA-02) notifies all staff that “any information related to sexual victimization or abusiveness that occurred in an institutional setting shall be strictly limited to medical and mental health practitioners and other staff, as necessary, to inform treatment plans and security and management decision, including housing, bed, work, education, and program assignments, or as required by law. Staff shall not reveal any information related to a sexual abuse report to anyone other than to the extent necessary.” As confirmed by the Institution Investigator, employees are directed to limit their discussions of sexual abuse and sexual harassment allegations to only those authorized to know said information. Random staff interviews confirm that facility employees are aware of the sensitive and confidential nature of said complaints. In speaking with the SCI PCM, the totality and reasoning surrounding the confidential investigatory process was clearly explained.

Agency policy (79-ISA-02) requires “any information related to sexual victimization or abusiveness that occurred in an institutional setting shall be strictly limited to medical and behavioral health practitioners and other staff, as necessary, to inform treatment plans and security and management decisions, including housing, bed, work, education, and program assignments, or as required by law. Staff shall not reveal any information related to a sexual abuse report to anyone other than to the extent necessary.” During interviews with medical and mental health service staff, the need for said staff to inform incarcerated persons (at the initiation of professional services) of their duty to report, as well as to their limitations of confidentiality, was affirmed.
Agency policy (79-ISA-04) mandates “if the alleged victim is under the age of eighteen (18) or considered a vulnerable adult as defined by this policy, the institution shall report the allegation on an Incident Report (DRC1000) and send it to the Institutional Investigator who will then report the allegation to the OSHP.” All incarcerated persons incarcerated within the SCI are legally classified as adults. As such, there are no juveniles assigned to the SCI. However, per policy (79-ISA-04), the facility may still have persons classified as vulnerable adults. Per policy (79-ISA-04), vulnerable adults are “incarcerated persons that have been identified as having an intellectual and/or developmental disability (IDD).” As noted by the Institution Investigator, if an incarcerated person is considered a vulnerable adult, the reports of prior sexual victimization must be forwarded to the OSHP. During the audit time frame, SCI did not have any (0) instances of required reporting for vulnerable adults.
Policy (79-ISA-01, 79-ISA-02) mandates that all allegations of sexual abuse and sexual harassment, including third-party and anonymous reports, are referred to the Institution Investigator for processing. When interviewing Random Staff, all employees affirmatively responded that any reports of sexual abuse and sexual harassment received by them would be immediately referred to supervisory and/or other entities appropriate for further investigations. Documentation reviews reflect that all such reports received within the audit time frame were forwarded to the SCI Institution Investigator for review.

Reasoning & Findings Statement:

This standard ensures an effective and efficient response to allegations of sexual abuse and sexual harassment. Paramount to this process is the understanding that all staff and facility officials, regardless of their capacity inside the institution, have an absolute duty to report any knowledge, information, or even suspicion of sexual abuse or sexual harassment, as well as any knowledge, information, or suspicion of any retaliation having occurred for anyone who has reported allegations of sexual abuse and sexual harassment. The ODRC, and by extension, the SCI, has numerous policies in place directing staff of their reporting responsibilities. Interviews with First Responders, Random Staff, Medical Staff, and Mental Health Staff reflect their complete awareness of agency reporting requirements, to include the confidential nature of the reporting process. Considering this, policy requires that all medical and mental health staff disclose their limits of confidentially and obtain informed consent prior to the initiation of services. All allegations of sexual abuse and sexual harassment, to include third-party and anonymous reports, are sent to the SCI

Institution Investigator for review. The SCI is an adult facility. As such, there are no (0) incarcerated persons assigned to the institution who are under the age of eighteen

(18) years. However, in the event a vulnerable adult alleges sexual abuse, Institution Investigators are aware of their reporting duties to designated state authorities. Interviews with SCI staff expressed their compliance with agency policy. Training records and course curriculums document employee, contactor, and volunteer training specific to mandatory reporting requirements. In interviewing SCI medical and mental health staff, the process of limited confidential and informed consent used by said staff was explained in detail. In total, the SCI has complied with all provisions within this standard and has thus met all requirements therein.

115.62	Agency protection duties
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24 Interviews: Agency PREA Coordinator Facility Warden PREA Compliance Manager Designated Staff Member Charged with Monitoring Retaliation Incident Review Team Member Intermediate or Higher-Level Facility Staff Investigative Staff Intake Staff Staff Who Perform Screening for Risk of Victimization and Abusiveness Medical Staff Mental Health Staff Random Staff Random Inmates Inmates Who Reported Sexual Abuse Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations:

Review of sexual abuse and sexual harassment investigations.
Review of retaliation monitoring documentation.

Standard Subsections:

(A) Per agency policy (79-ISA-01, 79-ISA-02), when the SCI learns that an incarcerated person is subject to a substantial risk of imminent sexual abuse, agency officials have an affirmative duty to take immediate action to protect the incarcerated person. Specifically, policy (79-ISA-02) requires that “security staff shall take immediate action to employ protection measures to ensure the IP’s safety.” In speaking with the SCI PCM, SCI Facility Warden, SCI Unit Manager, and Random Staff, a multitude of protective measures, such as housing changes, transfers, and no contact orders, were discussed as a means of immediately increasing the safety of incarcerated persons.

A plethora of possible options were discussed specific to incarcerated person protection measures. During the audit time frame, however, the SCI did not find any evidence that any (0) incarcerated persons assigned to the facility were at a substantial risk of sexual abuse. As such, the facility did not have any (0) documentation for review. Likewise, no protective actions were required.

Reasoning & Findings Statement:

This standard works to ensure that the SCI takes appropriate measures upon learning that any incarcerated person is subject to a substantial risk of imminent sexual abuse. Specifically, this standard requires that immediate action is taken to protect the incarcerated person. To that end, the ODRC, and by extension, the SCI, has policies in place to promote the safety of all incarcerated persons who might otherwise be victims, or potential victims, of sexual abuse and sexual harassment.

Agency policy (79-ISA-01, 79-ISA-02) requires staff to take immediate action to ensure the safety of all incarcerated persons who are at a high risk of sexual victimization.

Provided there are no other alternative options available to ensure the incarcerated person’s safety, policy (79-ISA-02) further allows the facility to immediately increase the safety of the at-risk incarcerated person by placing said incarcerated person in the Involuntary Transitional Program Unit. However, placement in Involuntary Transitional Program Unit housing would only be used if no other general housing assignments available could ensure incarcerated person safety. During the audit time frame, the SCI did not receive any (0) reports from incarcerated persons who were at a substantial risk of sexual abuse. In interviewing Random Staff, all persons were asked specifically what actions would be taken if an incarcerated person presented as a high risk for sexual victimization. Unequivocally, all staff responded that they would take immediate action to protect the potential victim. Additionally, supervisory staff were questioned as to their role in this potentially dangerous situation. While supervisory staff did provide a more technical and inclusive response, they too, were centrally focused on protecting the incarcerated person. With this in mind, SCI staff have clearly articulated their responsibilities within this standard. As well, a review of investigative reports supports the fact that the SCI is committed to engaging its protection duties.

115.63	Reporting to other confinement facilities
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 01-COM-08, Incident Reporting and Notification, 9-1-21 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Verbal Report (Facility-to-Facility) Notification, 1-19-24 SCI Warden to Warden Notification, Outgoing: 5-1-24 SCI Warden to Warden Notification, Incoming: 6-4-24 SCI Incident Report: 4-30-24 SCI PREA Incident Report Application, 6-6-24 SCI Memorandum to File: 6-4-24 SCI Health Services Clinical Encounter, 6-3-24 SCI Psychology Services, Sexual Abuse Intervention, 6-3-24 SCI OSHP Notification: 6-6-24, 6-12-24 SCI OSHP Disposition, 6-12-24 SCI Notification of Sexual Abuse Investigative Outcome, 6-12-24 SCI Offender Information Summary, 6-6-24 Interviews: Agency Head Facility Warden PREA Compliance Manager Inmates Who Reported Sexual Abuse Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations: Review of facility-to-facility referral process. Standard Subsections: (A) Agency policy (79-ISA-02) requires that “upon receiving an allegation that an IP was sexually abused while confined at another institution/facility, the managing officer of the institution that received the allegation shall notify the managing officer of the institution/facility or appropriate office of the agency where the alleged abuse occurred.” In speaking with the SCI Warden, adherence to this policy was confirmed. A review of documents within the audit time frame reflects that there has been two (2) such referrals made from SCI to another facility. (B) Agency policy (79-ISA-02) requires that “such notification shall be provided as

soon as possible, but no later than seventy-two (72) hours after receiving the allegation.” The SCI Warden confirmed that all notices are sent by the Warden's Office to the destination facility as soon as possible, but certainly within 72 hours. A review of documents with the audit time frame reflects compliance with agency policy.

Agency policy (79-ISA-02) requires that “the notification shall be documented on an Incident Report (DRC1000).” In speaking with the SCI Warden, adherence to this policy was confirmed. A review of documents with the audit time frame reflects compliance with agency policy.
Agency policy (79-ISA-02) requires “the managing officer or agency office that receives such notification shall ensure the allegation sis investigated in accordance with applicable provisions of this policy.” In speaking with the SCI Warden and SCI Institution Investigator, adherence to this policy was confirmed. During the audit time frame, the SCI did receive four (4) outgoing allegations of sexual abuse and sexual harassment from other facilities.

Reasoning & Findings Statement:

This standard requires the timely communication of sexual abuse and sexual harassment across facilities within a correctional agency or even across agencies themselves. The ODRC has policies in place to ensure that its staff, as well as the staff from other possible agencies, are provided sufficient due process with respect to the timely notification of incarcerated person allegations involving sexual abuse and sexual harassment. Within the audit time frame, the SCI has received two (2) incoming allegations of sexual abuse and sexual harassment from incarcerated persons who reported such at other facilities. Within the audit time frame, the SCI received four (4) outgoing allegations of sexual abuse and sexual harassment from incarcerated persons who reported to SCI staff that such an incident occurred at another facility. In speaking with the SCI Warden, a detailed explanation of this process, to include required reporting timelines for use when necessary, was provided. Documentation relevant to this reporting process was reviewed and found to be in compliance with the requirements of this standard. Hence, agency policy, documentation review, and an in-depth explanation of the collaborative notification process all reflect that the SCI has satisfied the provisions of this standard.

115.64	Staff first responder duties
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23

01-COM-08, Incident Reporting and Notification, 3-27-23
310-SEC-01, Incarcerated Individual and Physical Plant Searches, 2-15-22
Appendix A, Investigator Protocol
Appendix D, Sexual Abuse First Responder Checklist
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI PREA Training Roster, FY24
SCI Approved List of PREA Victim Support Person Staff, 8-14-24
SCI PREA Incident Report Application: 1-2-24, 1-3-24, 3-5-24
SCI Incident Report: 1-2-24a, 1-2-24b, 1-3-24, 3-5-24a, 3-5-24b,
SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24, 3-5-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24
SCI Voluntary Statement: 1-3-24a, 1-3-24b, 3-5-24
SCI OSHP Notification Email: 1-2-24, 1-8-24, 3-5-24, 3-25-24
SCI OSHP Disposition Notification: 1-4-24, 1-8-24, 2-2-24, 3-22-24
SCI Offender Information Summary: 1-2-24, 1-4-24a, 1-4-24b, 1-8-24, 3-5-24a, 3-5-24b
SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24, 3-5-24
SCI Laboratory Report, DNA: 1-29-24
SCI Request for Protective Control, 3-5-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24, 3-5-24
SCI Notification of Sexual Abuse Investigation Outcome: 1-8-24, 2-2-24, 3-25-24
SCI Sexual Abuse Incident Review: 1-17-24, 4-1-24 Interviews:
Facility Warden
PREA Compliance Manager
SCI Investigative Staff
Ohio State Highway Patrol Trooper
Intermediate or Higher-Level Facility Staff
Random Staff
First Responders
Random Inmates
Inmates Who Reported Sexual Abuse
Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations:
Review of employee training records.
Review of investigator narrative case files.

Standard Subsections:

(A) Agency policy (79-ISA-02) requires the first responding security staff member to immediately “separate the alleged victim and abuser.” After ensuring the safety of the victim, policy (79-ISA-02) requires staff to “preserve and protect any crime scene until appropriate steps can be taken to collect any evidence.” First responding security staff must also “request the alleged victim not take any actions that could

destroy physical evidence, (and) ensure the alleged abuser does not take any actions that could destroy physical evidence.” Interviews with Random Staff and Security First Responders evidenced an overall understanding of policy. Within the audit time frame, SCI has received sixteen (16) allegations from incarcerated persons who claim to have been victims of sexual abuse. Of those allegations, SCI security staff were notified within a time period that still allowed for the collection of physical evidence four (4) times, of which, the security staff member did take appropriate action to preserve and protect the crime scene, as well as any physical evidence available for collection. Documentation review confirms that the first responding security staff member did take appropriate action to mitigate further allegations of sexual abuse, along with preserving and protecting any possible evidence that might still available for collection from both the victim and the alleged abuser (79-ISA-02, 03E-10).

(B) Agency policy (79-ISA-02) requires that “the first non-security or the first line security staff member to respond to the report shall be required to separate the alleged victim and abuser, (and) request the alleged victim not take any actions that could destroy physical evidence and then notify the security shift supervisor.” When interviewing a Non-Security First Responder, the role of that individual within the reporting process was recalled. In that, adherence to agency policy was maintained. Within the audit time frame, SCI received sixteen (16) allegations from incarcerated persons who claim to have been victims of sexual abuse. Twelve (12) of those allegations were made to non-security staff. Documentation review confirms that the first responding non-security staff member did take appropriate action to mitigate further allegations of sexual abuse, preserve and protect any possible evidence, and to immediately notify security staff of the allegations.

Reasoning & Findings Statement:

This standard works to ensure both security and non-security staff understand their role in responding to allegations of sexual abuse. Agency policy clearly describes the function of each first responder, with security and non-security staff being equally responsible for separating the alleged victim and abuser, as well as preserving and protecting any possible evidence either at the scene or on the victim. Interviews with First Responders reflect that both security and non-security staff have been trained on those responsibilities. As well, during contractor and volunteer interviews, it was noted that all contractors and volunteers understood the absolute need to protect the victim, as well as a need to preserve and protect the crime scene or evidence that could be available. A review of employee, contractor, and volunteer training records and class curriculums reflect staff have received required training specific to the preservation of evidence regarding allegations of sexual abuse and sexual harassment. SCI documentation in response of allegations of sexual abuse also reflect staff awareness of their responsibilities when responding to such allegations. As such, the SCI has satisfied all requirements of this standard.

115.65	Coordinated response
	Auditor Overall Determination: Exceeds Standard

Auditor Discussion

Documents:

79-ISA-01, Prison Rape Elimination, 10-1-24
79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Designated Staff Member Charged with Monitoring Retaliation
Incident Review Team Member
Intermediate or Higher-Level Facility Staff
Investigative Staff
Medical Staff
Mental Health Staff
SAFE and/or SANE Personnel of the Local Hospital/Rape Crisis Clinic
Random Staff

Site Review Observations:
Review of facility level procedures.

Standard Subsections:
The SCI has developed a written institutional plan; namely, SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24, to coordinate actions taken amongst staff, contractors, interns, volunteers, first responders, medical staff, mental health staff, investigators, and facility leadership in response to alleged incidents of sexual abuse. In excess of this standard, the SCI Sexual Abuse Coordinated Response Plan also includes immediate response protocol to address allegations of sexual harassment.

Reasoning & Findings Statement:

This standard works to ensure the facility has developed a calculated response plan to assist first responders and supervisory staff in the immediate processes needed for an effective and efficient response to allegations of sexual abuse. As required by this standard, the SCI has developed a written institutional plan; namely, SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24, to coordinate actions taken amongst staff, contractors, interns, volunteers, first responders, medical staff, mental health staff, investigators, and facility leadership in response to alleged incidents of sexual abuse. In excess of this standard, the SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24, also includes immediate response protocol to address allegations of sexual harassment. Within this response plan, the roles of all facility

staff are discussed and, perhaps even more importantly, the way those roles interact with one another are outlined. This policy is a conveniently written overview of departmental responsibilities, equipped with notification and referral reminders.

When asked, various departmental staff were able to articulate their role within the response plan. As well, during incarcerated person interviews, many were able to specify the responsibilities of responding staff. Accordingly, the SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24, has been clearly institutionalized throughout facility culture. In total, the SCI has exceeded the requirements of this standard.

115.66	Preservation of ability to protect inmates from contact with abusers
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 State of Ohio and the Ohio Civil Service Employees Association, Legislative Draft, 7-2-24 State of Ohio and the State Council of Professional Educators OEA/NEA, 7-6-21 State of Ohio and Service Employees International Union District 1199, The Health Care and Social Service Union, Change to Win, CLC, 8-9-21 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews: Agency Head Agency Contract Administrator Agency PREA Coordinator Facility Warden PREA Compliance Manager Administrative (Human Resources) Staff Inmates Who Reported Sexual Abuse Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations: Reviewed agency labor contracts. Standard Subsections:

Agency policy (79-ISA-01) does not allow any governmental entity responsible for collective bargaining to limit the agency’s ability to remove alleged staff sexual abusers from contact with incarcerated persons pending the outcome of an investigation or of a determination of whether, and to what extent, discipline is warranted. In fact, the current contract between the State of Ohio and the Ohio Civil Service Employees Association provides ODRC with the exclusive right to “hire and transfer employees, suspend, discharge and discipline employees.” The current contract between the State of Ohio and the State Council of Professional Educators OEA/NEA, as well as the Service Employees International Union District 1199, provides ODRC with the exclusive right to “hire and transfer employees, suspend, discharge and discipline employees for just cause.” This ensures that the ODRC retains the management rights to remove alleged staff sexual abusers from contact with incarcerated persons pending the outcome of an investigation or of a determination of whether and to what extent discipline is warranted.
The auditor is not required to audit this provision.

Reasoning & Findings Statement:

This standard requires that an agency continuously preserve its ability to protect incarcerated persons from having contact with persons who may have sexually abused them pending the outcome of an investigation or of a determination of whether and to what extend discipline is warranted. The ODRC has met this responsibility. Agency policy (79-ISA-01) allows for employees to be “subject to disciplinary sanctions up to and including termination for violating ODRC sexual misconduct policies. Terminations for violations of ODRC sexual misconduct policy, or resignations by staff that would have been terminated if not for their resignation, shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and reported to any relevant licensing bodies.” In speaking with the SCI Warden and the Institution Investigator, the process of suspending or separating an employee from employment as a function of a negative sexual abuse or sexual harassment investigation finding was explained. It was also noted that the ODRC; and more specifically, the SCI unit administration, has no reservations about discharging employees for engaging in sexual abuse and sexual harassment. Hence, the SCI has satisfactorily met the requirements of this standard.

115.67	Agency protection against retaliation
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23

SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Approved List of PREA Victim Support Person Staff, 8-14-24
SCI Incident Report: 2-9-23
SCI PREA Incident Report Application, 30-Day Review, 3-7-24
SCI PREA Incident Report Application, 60-Day Review, 4-9-24
SCI PREA Incident Report Application, 90-Day Review, 5-8-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Institutional Investigator
Designated Staff Member Charged with Monitoring Retaliation
Random Staff
Random Inmates
Inmates Who Reported Sexual Abuse
Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations:
Reviewed sexual abuse/harassment investigative case files.
Reviewed retaliation monitoring logs.

Standard Subsections:

Agency policy (79-ISA-02) requires the SCI to “protect all IPs and staff who report sexual misconduct or cooperate with sexual misconduct investigations from retaliation by other IPs or staff. The institution investigator shall monitor retaliation resulting from cases of sexual abuse. The OCM shall monitor retaliation resulting from cases of sexual harassment.” In speaking with the PREA Compliance Manager, it was confirmed that the SCI PCM monitors all retaliation resulting from cases of sexual harassment. The SCI Institution Investigator monitors all retaliation resulting from cases of sexual abuse. Documentation review for retaliation monitoring supports adherence to agency policy.
Per policy (79-ISA-02), the institution shall employ multiple protection measures for incarcerated persons and staff who fear retaliation for reporting sexual misconduct or for cooperating with investigations. At a minimum, these protection measures will include “reviewing IP discipline, housing changes program changes, job changes, negative performance review, and reassignment of staff.” In speaking with the SCI PCM and Institution Investigator, adherence to agency policy was confirmed. Additionally, documentation review for retaliation monitoring supports facility adherence to agency policy.
Agency policy (79-ISA-02) requires that “for at least ninety (90) calendar days following the report so sexual misconduct, there shall be monitoring of the conduct and treatment of IPs or staff who reported the sexual misconduct and of IPs who were

reported to have suffered sexual misconduct to see if there are changes that may suggest possible retaliation by IPs or staff.” If evidence is found to suggest retaliation, immediate action must be taken to remedy any such retaliation. In speaking with the SCI PCM and Institution Investigator, adherence to agency policy was confirmed. It was further noted that monitoring includes reviewing IP discipline history, any housing, job, or program changes, as well as any negative performance review or any reassignment of staff. As noted by the SCI PCM and Institution Investigator, retaliation monitoring can continue beyond 90 days if there is a continuing need for such monitoring. Documentation review for retaliation monitoring supports facility adherence to agency policy. Lastly, per the SCI PCM, there has not been any (0) incidents of retaliation during the audit time frame.

Agency policy (79-ISA-02) requires that “periodic status checks shall occur at least every thirty (30) calendar days during the monitoring period. In speaking with the SCI PCM and Institution Investigator, adherence to agency policy was confirmed. Additionally, documentation review for retaliation monitoring supports facility adherence to agency policy.
Agency policy (79-ISA-02) requires that if incarcerated persons, staff, or “any other individual who cooperates with an investigation expresses a fear of retaliation, appropriate measures shall be taken to protect that individual against retaliation.” In speaking with the SCI PCM and Institution Investigator, adherence to agency policy was confirmed. Additionally, documentation review for retaliation monitoring supports facility adherence to agency policy.
The auditor is not required to audit this provision.

Reasoning & Findings Statement:

This standard works to ensure agency protection against retaliation for reporting sexual abuse and sexual misconduct, as well as having cooperated with an investigation regarding such. To ensure this end, the ODRC has developed policies to ensure an active retaliation monitoring system, which provides for in-person status checks of incarcerated persons. As a function of the retaliation monitoring process, the ODRC has enacted multiple protections measures for early onset detection of retaliation should it ever occur. During the audit time frame, however, the SCI has not experienced any (0) such incidents of retaliation. In speaking with the SCI PCM and Institution Investigator, their responsibilities within the retaliation monitoring process, which does include in-person status checks for incarcerated persons, was clearly explained. Additionally, in speaking with incarcerated persons who had filed previous allegations of sexual abuse and sexual harassment, none (0) noted that they had ever experienced retaliation for participating in a PREA related facility investigation. Documentation review reflects that SCI staff are performing retaliation monitoring in accordance to policy. Given the totality of the policies provided, document review, and staff knowledge regarding the process, the SCI has satisfied the requirements of this standard.

115.68	Post-allegation protective custody
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-04, PREA Risk Assessments and Accommodation Strategies, 10-20-24 64-DCM-01, Protection from Harm and Inappropriate Supervision, 7-10-23 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI Incident Report: 2-9-23 SCI PREA Incident Report Application, 30-Day Review, 3-7-24 SCI PREA Incident Report Application, 60-Day Review, 4-9-24 SCI PREA Incident Report Application, 90-Day Review, 5-8-24 Interviews: Facility Warden PREA Compliance Manager Designated Staff Member Charged with Monitoring Retaliation Random Staff Staff Who Supervise Inmates in Segregated Housing Random Inmates Inmates Who Reported Sexual Abuse Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations: Observed the Involuntary Transitional Program Unit. Standard Subsections: (A) Agency policy (79-ISA-04) notes that “IPs at high risk for victimization shall not be placed in involuntary transitional program unit (TPU) under restrictive housing (RH) or limited privilege housing (LPH) conditions unless an assessment of all available alternatives has been made and it has been determined there is no available alternative means of separation from likely abusers.” Agency policy (79-ISA-04) further requires that “involuntary TPU assignments shall only be until alternative means of separation from likely abusers can be arranged and shall not ordinarily exceed thirty (30) calendar days. Every thirty (30) calendar days, unit management shall afford each IP a review to determine whether there is a continuing need for separation from general population.” As noted by the SCI PCM, within the audit time frame, the SCI has not placed any (0) incarcerated persons who have alleged sexual abuse or who are at a high risk of sexual abuse in the Involuntary Transitional Program Unit pending completion of their assessment.

Reasoning & Findings Statement:

The standard works to ensure that incarcerated persons reporting allegations of sexual abuse are not simply segregated as an automatic response for ensuring their physical safety. To this effect, the ODRC has policies in place prohibiting the placement of incarcerated persons who allege to have suffered sexual abuse in involuntary segregated housing; namely, the Involuntary Transitional Program Unit, unless an assessment of all available alternatives has been made and a determination has been reached that there is no available alternative means of separation from likely abusers. Additionally, the ODRC has policies in place requiring that if an involuntary segregated housing assignment is made, the facility must review each incarcerated person every 30 days to determine whether there is a continuing need for separation from the general population. Interviews with the SCI Warden and the SCI PCM did acknowledge that when no other alternatives existed, incarcerated persons would be placed in involuntary segregated housing. However, it was noted that the use involuntary segregated housing would be considered only as the last available option, and even at that, only as a temporary measure. During the audit time frame, the SCI did not place any (0) incarcerated person alleging sexual abuse or sexual harassment within involuntary segregated housing. Also, in speaking with incarcerated persons who had filed previous allegations of sexual abuse and sexual harassment, none (0) stated that they had been placed in involuntary segregated housing as a consequence of their reports. As such, the SCI has satisfied the requirements of this provision.

115.71	Criminal and administrative agency investigations
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 ODRC Record Retention Schedule, 2/2014 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Staff Certificate of Training, NIC PREA Investigating Sexual Abuse in a Confinement Setting: 5-6-14, 6-14-17, 1-31-22 SCI Staff Certificate of Training, NIC PREA: Coordinators’ Roles and Responsibilities, 6-14-17 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI PREA Incident Report Application: 1-2-24, 1-3-24, 3-5-24, 5-12-24 SCI Incident Report: 1-2-24a, 1-2-24b, 1-3-24, 3-5-24a, 3-5-24b, 5-12-24a, 5-12-24b

SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24, 3-5-24, 5-12-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24
SCI Voluntary Statement: 1-3-24a, 1-3-24b, 3-5-24, 5-12-24
SCI OSHP Notification Email: 1-2-24, 1-8-24, 3-5-24, 3-25-24, 5-15-24, 5-21-24
SCI OSHP Disposition Notification: 1-4-24, 1-8-24, 2-2-24, 3-22-24, 5-21-24
SCI Offender Information Summary: 1-2-24, 1-4-24a, 1-4-24b, 1-8-24, 3-5-24a, 3-5-24b, 5-15-24, 9-9-24
SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24, 3-5-24, 5-12-24
SCI Laboratory Report, DNA: 1-29-24
SCI Request for Protective Control, 3-5-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24, 3-5-24, 5-12-24
SCI Notification of Sexual Abuse Investigation Outcome: 1-8-24, 2-2-24, 3-25-24, 5-21-24
SCI Sexual Abuse Incident Review: 1-17-24, 4-1-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Investigative Staff
Ohio State Highway Patrol Trooper
Inmates Who Reported Sexual Abuse
Inmates Who Disclosed Sexual Victimization During Risk Screening Site Review Observations:
Reviewed investigator training certifications.
Reviewed agency training records documenting investigator training curriculums.
Reviewed twelve (12) sexual abuse/sexual harassment case files.

Standard Subsections:

Agency policy (79-ISA-02) requires that when the "institution conducts its own investigation into allegations of sexual abuse and sexual harassment, it shall do so promptly, thoroughly, and objectively for all allegations, including third-party and anonymous reports." In speaking with the SCI Institution Investigator, SCI PCM, and OSHP trooper, adherence to agency policy was confirmed. Documentation review further supports that all investigations were completed as required by policy and within the designated time limits.
Per policy (79-ISA-01), all employees receive training related to the prevention, detection, response, and investigation of sexual misconduct during New Employee Orientation. Additionally, “prior to conducting a PREA investigation, all investigators shall receive specialized training which shall include, but not be limited to, conducting investigations in a confinement setting, interviewing techniques for sexual abuse victims, proper use of Garrity warnings, sexual abuse evidence collection and the criteria and evidence required to substantiate a case for administrative action or prosecution referral” (79-ISA-01). In interviewing SCI and OSHP investigative staff,

said staff confirmed participation in numerous related courses. Additionally, training curriculums and employee training certifications provided additional documentation to support facility compliance.

Agency policy (79-ISA-02) requires that “Institution Investigators and, where appropriate, OCMs gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data; shall interview alleged victims, suspected perpetrators, and witnesses; and shall review prior complaints and report of sexual abuse involving suspected perpetrator.” In speaking with the SCI Institution Investigator, SCI PCM, and OSHP trooper, adherence to agency policy was confirmed. Documentation review further supports that all investigations were completed as required by policy, to include the collection and review of all relevant evidence.
Agency policy (79-ISA-02) allows that “when the quality of evidence appears to support criminal prosecution, the ODRC shall conduct compelled interviews only after consulting with OSHP as to whether compelled interviews may be an obstacle for subsequent criminal prosecution.” In speaking with the OSHP trooper, it was noted that communications with the District Attorney’s officer were continuous. Documentation review further supports that all investigations were completed as required by policy, to include the collection and review of all relevant evidence.
Agency policy (79-ISA-02) requires that “the credibility of an alleged victim, suspect, or witness shall be assessed on an individual basis and shall not be determined by the person’s status as IP or staff. No institution shall require an IP who alleges sexual abuse to submit to a polygraph examination or other truth telling device as a condition for proceeding with the investigation of such an allegation.” The SCI Institution Investigator, as well as the OSHP Trooper, confirm that the credibility of the interviewed subject is, in fact, determined on an individual basis considering the totality of the evidence presented. Documentation review further supports that all investigations were completed as required by policy, to include the credibility assessments being made based on an objective review of the available evidence.
Agency policy (79-ISA-02) requires that “administrative investigations shall include an effort to determine whether staff actions or failures to act contributed to the abuse and shall be documented in written reports that include a description of the physical and testimonial evidence, the reason behind credibility assessments, and investigative facts and findings.” The SCI PCM confirms that staff actions, or their failure to act, are considered as a routine function of the investigative process. Documentation review further supports that all investigations were completed as required by policy, to include descriptive details of the investigation and factors influencing credibility assessments.
Agency policy (79-ISA-02) requires that “all criminal investigations shall be documented in a written report that contains a thorough description of physical, testimonial, and documentary evidence. Copies of documentary evidence shall be attached when feasible.” Interviews with SCI and OSHP investigative staff, as well as reviewed documentation, supports the facility’s adherence to this policy.

Agency policy (79-ISA-2) requires that “substantiated allegations of conduct that appear to be criminal shall be referred for prosecution.” Interviews with SCI and OSHP investigative staff, as well as reviewed documentation, supports the facility’s adherence to this policy. In fact, as noted by the OSHP investigator, all criminal cases, except those determined as unfounded, are referred to the District Attorney’s Office for review. As such, during the audit time frame, the OSHP has referred thirteen (13) such cases for prosecutorial review.
Agency policy (79-ISA-01) requires that “all case records associated with allegations of sexual misconduct or retaliation including incident reports, investigation reports, offender information, case disposition, medical and counseling evaluation findings, and recommendations for post-release treatment and/or counseling shall be securely retained in accordance with the ODRC records retention schedule as defined in ODRC Policy 07-ORD-01, Records Management Program.” As noted with the Record Retention Schedule, 2014, all ODRC Special Investigation Case Files, to include all sexual abuse and sexual harassment investigations, are retained “10 years after inmate has reached final release, expiration of sentence, death, or 10 years after employee is no longer employed by the agency.” After that time, the documents may be shredded or otherwise deleted. It should further be noted that all criminal investigation files maintained by the OSHP are held indefinitely at the SCI Central Records Unit inside of the OSHP’s General Headquarters. In speaking with the SCI Institution Investigator, adherence to agency policy was confirmed.
Agency policy (79-ISA-02) mandates that “the departure of the alleged abuser or victim from the employment or control of the institution or ODRC shall not provide a basis for terminating an investigation.” Interviews with investigative staff, as well as reviewed documentation, supports the facility’s adherence to this policy.
The auditor is not required to audit this provision.
Agency policy (79-ISA-02) requires that “when outside agencies investigate sexual abuse, the facility shall cooperate with outside investigators and shall endeavor to remain informed about the progress of the investigation.” In speaking with the SCI PCM and Institution Investigator, it was noted that the OSHP trooper, per a MOU between ODRC and OSHP, maintains an office inside of the facility and generally visits the facility on a regular basis. This fact was also confirmed via interview with the OSHP Trooper. As noted by all interviewed persons, this arrangement facilitates communication between agency staff and the OSHP; thus ensuring that ODRC staff remain informed on the progress of all sexual abuse criminal investigations.

Reasoning & Findings Statement:

This standard works to encourage objective investigations of sexual abuse and sexual harassment allegations. In doing so, it is absolutely necessary that sexual abuse and sexual harassment investigations, including investigations initiated by a third-party or anonymously, are completed promptly, thoroughly, and efficiently. A vital part of that efficiency is active communication between administrative and criminal investigators. For this, it is important to note that the Ohio State Highway Patrol (OSHP) operates as the law enforcement branch inside of the ODRC and maintains an office inside of the

SCI. This arrangement, which clearly exceeds the requirements of this standard, thus allows for not only routine communication with a law enforcement agency, but also with the District Attorney’s Office. While the SCI conducts its own administrative investigations via agency staff, the OSHP trooper is still given notice of each sexual abuse and sexual harassment allegation filed within the SCI. This allows all allegations to be reviewed by law enforcement personnel to determine if criminal investigations are needed in conjunction with administrative investigations. The OSHP, of course, conducts all criminal investigations for allegations of sexual abuse and sexual harassment filed within the SCI. To work as a criminal investigator within the ODRC, personnel must have law enforcement credentials. As well, to perform criminal or administrative investigations, SCI and OSHP staff must have met additional training requirements for conducting sexual abuse and sexual harassment investigations within a confinement setting. In excess of the requirements of this standard, by way of an MOU between the OSHP and the ODRC, OSHP troopers must also complete additional training for investigating sexual abuse in a confinement setting prior to their assignment within a correctional institution. As a function of that assignment, OSHP staff do have the authority to investigate criminal cases within the SCI, to include collecting evidence, as well as interviewing victims, suspected perpetrators, and witnesses. SCI Institution Investigators have been trained on the standard of evidence, as well as due process and procedural requirements required to support a finding of guilt in administrative investigations. OSHP officers have been trained on the standard of evidence, as well as due process and procedural requirements required to support a finding of guilt in criminal cases. As confirmed through interviews with SCI and OSHP investigative staff, OSHP troopers and SCI investigators work collaboratively under a memorandum of understanding to facilitate communication between the two agencies. Lastly, it is noted that all sexual abuse and sexual harassment investigations are referred to the OSHP trooper to determine if the allegations necessitate a criminal investigation and/or subsequent criminal prosecution. As such, the SCI has clearly exceeded the requirements of this standard.

115.72	Evidentiary standard for administrative investigations
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation Policy, 7-24-17 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Staff Certificate of Training, NIC PREA Investigating Sexual Abuse in a Confinement Setting: 5-6-14, 6-14-17, 1-31-22

SCI Staff Certificate of Training, NIC PREA: Coordinators’ Roles and Responsibilities, 6-14-17
SCI Approved List of PREA Victim Support Person Staff, 8-14-24
SCI PREA Incident Report Application: 1-2-24, 1-3-24, 3-5-24, 5-12-24
SCI Incident Report: 1-2-24a, 1-2-24b, 1-3-24, 3-5-24a, 3-5-24b, 5-12-24a, 5-12-24b
SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24, 3-5-24, 5-12-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24
SCI Voluntary Statement: 1-3-24a, 1-3-24b, 3-5-24, 5-12-24
SCI OSHP Notification Email: 1-2-24, 1-8-24, 3-5-24, 3-25-24, 5-15-24, 5-21-24
SCI OSHP Disposition Notification: 1-4-24, 1-8-24, 2-2-24, 3-22-24, 5-21-24
SCI Offender Information Summary: 1-2-24, 1-4-24a, 1-4-24b, 1-8-24, 3-5-24a, 3-5-24b, 5-15-24, 9-9-24
SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24, 3-5-24, 5-12-24
SCI Laboratory Report, DNA: 1-29-24
SCI Request for Protective Control, 3-5-24
SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24, 3-5-24, 5-12-24
SCI Notification of Sexual Abuse Investigation Outcome: 1-8-24, 2-2-24, 3-25-24, 5-21-24
SCI Sexual Abuse Incident Review: 1-17-24, 4-1-24 Interviews:
Facility Warden
PREA Compliance Manager
Investigative Staff
Inmates Who Reported Sexual Abuse Site Review Observations:
Reviewed procedures for processing sexual abuse/sexual harassment allegations.
Reviewed twelve (12) sexual abuse and sexual harassment case files.

Standard Subsections:
Agency policy (79-ISA-02) clearly establishes that “the ODRC shall impose no standard higher than a preponderance of the evidence in determining whether allegations of sexual misconduct are substantiated.” In speaking with the SCI Institution Investigator, the allegations are determined substantiated, unsubstantiated, or unfounded based on the preponderance of the evidence. For substantiated claims, this simply means that the weight of the evidence must indicate that the allegations are more likely to be true than not true. Documentation review confirms facility compliance with agency standards.

Reasoning & Findings Statement:

This standard works to ensure an objective evidentiary standard for administrative investigations. ODRC policy does require that investigative staff impose no standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated. In speaking with the SCI Institution Investigator, it was noted that standard is simply more than half.

Documentation review supports the facility’s adherence to agency policy. Accordingly, the SCI has met the requirement of this standard.

115.73	Reporting to inmates
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation Policy, 7-24-17 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI Staff Certificate of Training, NIC PREA Investigating Sexual Abuse in a Confinement Setting: 5-6-14, 6-14-17, 1-31-22 SCI Staff Certificate of Training, NIC PREA: Coordinators’ Roles and Responsibilities, 6-14-17 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI PREA Incident Report Application: 1-2-24, 1-3-24, 3-5-24, 3-28-24, 5-12-24, 5-14-24 SCI Incident Report: 1-2-24a, 1-2-24b, 1-3-24, 3-5-24a, 3-5-24b, 5-12-24a, 5-12-24b, 5-14-24 SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24, 3-5-24, 5-12-24, 5-14-24 SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24 SCI Voluntary Statement: 1-3-24a, 1-3-24b, 3-5-24, 5-12-24, 5-14-24 SCI Inmate Request: 5-11-24 SCI Notice of Interview/Conference: 5-24-24 SCI Acknowledgement and Waiver of Right to Representation: 5-24-24 SCI OSHP Notification Email: 1-2-24, 1-8-24, 3-5-24, 3-25-24, 5-15-24a, 5-15-24b, 5-21-24, 5-31-24 SCI OSHP Disposition Notification: 1-4-24, 1-8-24, 2-2-24, 3-22-24, 5-21-24, 5-31-24 SCI Offender Information Summary: 1-2-24, 1-4-24a, 1-4-24b, 1-8-24, 3-5-24a, 3-5-24b, 5-14-24, 5-15-24, 9-9-24 SCI Employee Identification Form SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24, 3-5-24, 5-12-24, 5-14-24 SCI Laboratory Report, DNA: 1-29-24 SCI Medical Exam Report, 5-14-24 SCI Request for Protective Control, 3-5-24 SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24, 3-5-24, 5-12-24, 5-14-24

SCI Notification of Sexual Abuse Investigation Outcome: 1-8-24, 2-2-24, 3-25-24, 5-21-24, 5-31-24
SCI Sexual Abuse Incident Review: 1-17-24, 4-1-24 Interviews:
Facility Warden
PREA Compliance Manager
Designated Staff Member Charged with Monitoring Retaliation
Investigative Staff
Ohio State Highway Patrol Trooper
Inmates Who Reported Sexual Abuse Site Review Observations:
Reviewed procedures for processing sexual abuse and sexual harassment allegations.
Reviewed twelve (12) sexual abuse investigative case files.

Standard Subsections:

Agency policy (79-ISA-02) requires that “following an investigation into an IP’s allegation that they suffered sexual abuse in an institution, the institution investigator shall inform the IP as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded.” In speaking with the SCI Institution Investigator, adherence to agency policy was confirmed. In speaking with incarcerated persons, most stated that they had received a written notification of the investigation’s disposition. Additionally, documentation review confirms incarcerated persons are provided notice of the disposition, of which they sign to acknowledge the notification process.
Agency policy (79-ISA-02) further requires that “If the ODRC did not conduct the investigation, it shall request the relevant information from the OSHP to inform the IP.” In speaking with the OSHP Trooper assigned to the SCI, adherence to agency policy was confirmed. Additionally, documentation review confirms incarcerated persons are provided notice of the disposition, of which they sign to acknowledge the notification process.
Agency policy (79-ISA-02) requires that “upon completion of an IP sexual abuse allegation against a staff member (unless unfounded), the institution investigator shall inform the IP of the following:
- The staff member is no longer posted within the IP’s unit,
- The staff member is no longer employed at the facility,
- The institution learns that the staff member has been indicted on a charge related to sexual abuse within the institution,
- The institution learns that the staff member has been convicted on a charge related to sexual abuse within the institution.

In speaking with the SCI Institution Investigator, adherence to agency policy was confirmed.

Agency policy (79-ISA-02) requires that “upon completion of an IP sexual abuse allegation against another IP (unless unfounded), the institution investigator shall inform the IP victim of the following:
- The institution learns that the alleged abuser has been indicted on a charge related to the sexual abuse within the institution,
- The institution learns that the alleged abuser has been convicted on a charge related to sexual abuse within the institution.

In speaking with the SCI Institution Investigator, adherence to agency policy was confirmed.

Agency policy (79-ISA-02) requires that “all such IP notifications or attempted notifications shall be issued in writing and documented.” Agency policy further requires that said notifications are signed by the incarcerated person. In speaking with the SCI Institution Investigator, adherence to agency policy was confirmed. Additionally, documentation review confirms incarcerated persons are provided documented notice of the disposition, of which they sign to acknowledge the notification process.
Auditor is not required to audit this provision.

Reasoning & Findings Statement:

This standard works to ensure incarcerated persons are provided notification of final disposition to any allegations of sexual abuse and sexual harassment that have been reported to agency staff. ODRC policy requires these notifications to be documented. SCI and OSHP investigative staff confirm their providing written notifications to incarcerated persons when their allegations are determined substantiated, unsubstantiated, or unfounded. Additionally, SCI investigative staff confirm having informed incarcerated persons who had filed substantiated sexual abuse and sexual harassment allegations against agency staff or other incarcerated persons upon a change in the housing status for the abusive incarcerated person, a change in job status for the abusive employee, as well as the indictment or conviction of either person related to sexual abuse within the institution. Within the audit time frame, SCI documentation reflects incarcerated persons are notified in writing of the final disposition to sexual abuse and sexual harassment claims as required by policy. Also, in speaking with incarcerated persons who have filed sexual abuse and sexual harassment claims, those persons generally state that they were provided with a final disposition to their claims. As such, the SCI is operating in accordance with all parts of this standard.

115.76	Disciplinary sanctions for staff
	Auditor Overall Determination: Meets Standard
	Auditor Discussion

Documents:

79-ISA-01, Prison Rape Elimination, 10-1-24
79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23
31-SEM-02, Standards of Employee Conduct, 12-1-24
31-SEM-07, Unauthorized Relationships, 10-4-16
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Employee PREA Training, FY24 Interviews:
Facility Warden
PREA Compliance Manager
Investigative Staff
Ohio State Highway Patrol Trooper
Random Staff
Inmates Who Reported Sexual Abuse Site Review Observations:
Review of staff disciplinary protocols for sexual abuse and sexual harassment determinations
Standard Subsections:
Agency policy (79-ISA-01) clearly advises staff that “in accordance with ODRC Policy 31-SEM-02, Standards of Employee Conduct, all employees shall be subject to disciplinary sanctions up to and including termination for violating ODRC sexual misconduct policies.” In speaking with Human Resource staff, termination for violating agency sexual abuse and sexual harassment policies is the presumptive disciplinary sanction. Interviews with the SCI Warden, the SCI PCM, and the SCI Institution Investigator confirm their awareness of agency policy and willingness to pursue disciplinary action against any SCI who engages in sexual abuse and sexual harassment of incarcerated persons assigned to the SCI. Interviews with Random Staff reflect employee awareness of the ODRC’s zero-tolerance policies for engaging in sexual abuse and sexual harassment of incarcerated persons.
Agency policies (79-ISA-01, 31-SEM-02, 31-SEM-07) advises all personnel that any perpetrator of a sexual abuse or sexual harassment will be dealt with through discipline or prosecution to the fullest extent permitted by law. As noted by Human Resource staff, termination is the presumptive disciplinary sanction for staff who engage in sexual abuse of an incarcerated person. Within the audit time frame, there had not been any (0) employees who have been terminated, or resigned prior to termination, due to having engaged in appropriate sexual relationships with incarcerated persons.
Agency policies (79-ISA-01, 31-SEM-02, 31-SEM-07) stipulates disciplinary sanctions

for violations of agency policies relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) shall be commensurate with the nature and circumstances of the acts committed, the staff member's disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories.

Interviews with the SCI Warden, the SCI PCM, the SCI Institution Investigator, as well as Human Resource staff confirm their adherence to agency policy specific to employee disciplinary and termination processes for any employee found to be engaging in acts of sexual abuse or sexual harassment. Within the audit time frame, there has not been any (0) employees assigned to the SCI disciplined for violation of agency policy related to sexual abuse or sexual harassment.

Agency policy (79-ISA-01) requires that notes that “terminations for violations of ODRC sexual misconduct policy, or resignations by staff that would have been terminated if not for their resignation, shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and reported to any relevant licensing bodies.” Interviews with the SCI Warden, the SCI PCM, the SCI Institution Investigator, as well as Human Resource staff confirm their adherence to agency policy specific to employee disciplinary and termination processes for any employee found to be engaging in acts of sexual abuse or sexual harassment. Within the audit time frame, there has not been any (0) employees assigned to the SCI disciplined for violation of agency policy related to sexual abuse or sexual harassment.

Reasoning & Findings Statement:

This standard works to ensure staff who engage in sexual abuse and sexual harassment of incarcerated persons are subject to disciplinary sanctions up to and including termination for violating agency sexual abuse and sexual harassment policies. The ODRC has made the consequences of engaging in sexual abuse and sexual harassment of incarcerated persons exceptionally clear. During interviews with employees, contractors, volunteers, and incarcerated persons, all such persons were aware of the agency’s zero-tolerance policy against sexual abuse and sexual harassment. During the audit time frame, there had not been any (0) employees of the SCI who have violated any aspects of the agency’s sexual abuse or sexual harassment policies. In total, the SCI has satisfied all requirements of this standard.

115.77	Corrective action for contractors and volunteers
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 39-TRN-12, Contractor Orientation, 4-1-24 71-SOC-01, Recruitment, Training, and Supervision of Volunteers, 9-24-23 ODRC Standards of Conduct for Contractors, Volunteers and Interns, 11/2012

ODRC PREA Contractor/Volunteer Training Video
ODRC PREA Contractor/Volunteer Training Script
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24
SCI Employee PREA Training, FY24
SCI Medical and Mental Health PREA Training, FY24
SCI PREA Training Session Report, Contractors: 7-31-24
SCI PREA Medical and Mental Health Test: 7-31-24
SCI PREA Training Session Report, Volunteers: 3-28-24
SCI PREA Acknowledgement Form, Volunteer: 3-28-24
SCI PREA Training Session Report, Contractors: 5-21-24
SCI Training Acknowledgement Form, Contractor: 5-21-24 Interviews:
Agency Contract Administrator
Facility Warden
Investigative Staff
Administrative (Human Resources) Staff
Contractors Who May Have Contact with Inmates
Volunteers Who May Have Contact with Inmates Site Review Observations:
Review contractor/volunteer files.

Standard Subsections:

Agency policy (79-ISA-01) requires that “any contractor, intern, or volunteer who engages in sexual misconduct is prohibited from contact with IPs and shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and to relevant licensing bodies.” Interviews with contractors and volunteers indicate their awareness of the agency’s zero-tolerance policy toward sexual abuse and sexual harassment of incarcerated persons. A review of contractor/volunteer files, as well as sexual abuse and sexual harassment training materials indicates that all such persons receive training specific to agency policy regarding zero-tolerance for sexual abuse and sexual harassment of incarcerated persons. During the audit time frame, there weren’t any (0) contractors or volunteers reported to law enforcement, as well as any relevant licensing bodies, for engaging in sexual abuse of inmates.
Agency policy (79-ISA-01) states that “the facility shall take appropriate remedial measures and terminate the contract or volunteer arrangement with contractors, interns, or volunteers or shall demand that the offending employee of a contractor be excluded from providing services under the contract.” Agency policy (71-SOC-01) further states that “the managing officer/designee may suspend/terminate a volunteer for any alleged violation of the Standards of Conduct for Contractors/ Volunteers (DRC4376) or any activity which threatens the orderly operation or security of the facility or APA region or safety of the volunteer, staff, or supervise.” Interviews with contractors and volunteers indicate their awareness of the agency’s

zero-tolerance policy toward sexual abuse and sexual harassment of incarcerated persons. A review of contractor/volunteer files, as well as sexual abuse and sexual harassment training materials indicates that all such persons receive training specific to agency policies regarding zero-tolerance for the sexual abuse and sexual harassment of incarcerated persons. In speaking with the SCI Warden, it was noted that remedial measures would be taken against any contractor or volunteer who violated institutional policy specific to the sexual abuse or sexual harassment of incarcerated persons. Agency documentation reflects the SCI takes appropriate action in prohibiting contractors/volunteers from further contact with incarcerated persons if found in violation of the agency’s zero-tolerance against sexual abuse and sexual harassment policy.

Reasoning & Findings Statement:

This standard works to ensure contractors and volunteers who engage in sexual abuse and sexual harassment of incarcerated persons are reported to law enforcement agencies, unless the activity was clearly not criminal, and to relevant licensing bodies. The ODRC has made the consequences of engaging in sexual abuse and sexual harassment of incarcerated persons exceptionally clear. During interviews with employees, contractors, volunteers, and incarcerated persons, all such persons were aware of the agency’s zero-tolerance policy against sexual abuse and sexual harassment. During the audit time frame, there have not been any (0) contractors or volunteers of the SCI who have violated the agency’s sexual abuse or sexual harassment policies. As such, there isn’t any facility documentation for review.

Accordingly, the SCI has satisfied all requirements of this standard.

115.78	Disciplinary sanctions for inmates
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 56-DSC-01, Conduct Report and Hearing Officer Procedures, 8-7-23 Ohio Administrative Code, Rule 5120-9-06, Inmate Rules of Conduct, 5-31-24 Ohio Administrative Code, Rule 5120-9-08, Disciplinary Procedures for Violations of Inmate Rules of Conduct Before the Rules Infraction Board, 4-15-24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Incarcerated Individual Orientation Acknowledgement Form, Initial Training: 9-14-11, 6-26-15, 5-10-18, 11-14-18, 4-26-19, 9-27-19, 8-10-21, 10-26-21, 1-31-22, 2-16-22, 3-4-22, 3-15-22a, 3-15-22b, 5-26-22, 2-16-23, 2-22-23, 3-6-23, 3-23-23,

7-21-23, 8-10-23, 10-24-23, 11-3-23, 11-21-23a, 11-21-23b, 12-12-23, 2-12-24,

3-21-24, 6-7-24, 6-21-24, 6-27-24, 7-10-24, 7-26-24, 8-1-24, 8-12-24, 8-14-24,

8-29-24, 10-1-24, 10-2-24, 10-31-24a, 10-31-24b, 10-31-24c, 10-31-24d, 11-8-24,

11-14-24, 12-18-24, 12-27-24, 12-30-24

SCI Incarcerated Individual Orientation Acknowledgement Form, Subsequent Training: 9-21-11, 6-30-15, 5-15-18, 11-21-18, 5-1-19, 10-3-19, 8-11-21, 10-27-21,
2-2-22, 2-18-22, 3-9-22, 3-16-22a, 3-16-22b, 6-1-22, 2-22-23, 3-1-23, 3-9-23, 3-29-23,
7-26-23, 8-16-23, 10-25-23, 11-8-23, 11-21-23a, 11-21-23b, 12-13-23, 2-14-24,
3-27-24, 6-12-24, 6-26-24, 7-3-24, 7-17-24, 7-31-24, 8-8-24, 8-14-24, 8-21-24, 9-4-24,
10-2-24, 10-8-24, 11-6-24a, 11-6-24b, 11-6-24c, 11-6-24d, 11-14-24, 11-20-24,
12-19-24, 1-2-25a, 1-2-25b
SCI Incarcerated Individual Orientation Acknowledgement Form, ADA Accommodation, Initial Training: 6-21-24, 6-27-24
SCI Incarcerated Individual Orientation Acknowledgement Form, ADA Accommodation, Subsequent Training: 6-26-24, 6-29-24
SCI Incarcerated Individual Orientation Acknowledgement Form, Language Accommodation, Initial Training: 11-21-23a, 11-21-23b
SCI Incarcerated Individual Orientation Acknowledgement Form, Language Accommodation, Subsequent Training: 11-21-23a, 11-21-23b
SCI Conduct Report: 9-20-24 Interviews:
Facility Warden
PREA Compliance Manager
Investigative Staff
Medical Staff
Mental Health Staff
Random Staff
Random Inmates

Site Review Observations:
Review of incarcerated person disciplinary files.

Standard Subsections:

(A) Agency policy (56-DSC-01) notes that “it is the policy of the ODRC that the disciplinary process for IPs will be carried out promptly and fairly, allow those directly affected by an IP rule infraction to provide input into the disciplinary process, to not punish IPs for being seriously mentally ill, and to abide by the Ohio Administrative Codes (OACs).” This policy provides standards associated with all disciplinary hearings, to includes hearings related to incarcerated person-on-incarcerated person sexual abuse and sexual harassment. Agency policy (79-ISA-02) further notes that following an administrative finding that an incarcerated person engaged in incarcerated person-on-incarcerated person sexual abuse, said incarcerated person is subject to disciplinary sanctions pursuant to formal disciplinary processes and “shall be given appropriate programming and interventions if determined to be necessary by Behavioral Health services in consultation with sex offender services.” Interviews

with Random Staff confirmed staff awareness of these sanctions. During the audit time frame, the SCI has not had any (0) administrative findings of incarcerated person-on-incarcerated person sexual abuse.

Agency policy (56-DSC-01) ensures that disciplinary sanctions imposed are commensurate with the nature and circumstances of the abuse committed, the incarcerated person’s disciplinary history, and the sanctions imposed for comparable offenses by other incarcerated persons with similar histories. As well, sanctions consider aggravating and mitigating factors. Interviews with the SCI Warden, SCI PCM, and SCI Institution Investigator confirm that the SCI utilizes a progressive disciplinary structure in the processing of all violations of the Ohio Administrative Code.
When determining an incarcerated person’s disciplinary sanctions, agency policy (79-ISA-02, 56-DSC-01, 5120-9-08) does consider how an incarcerated person’s mental disabilities or mental illness contributed to his behavior. SCI disciplinary documentation reflects that the mental disabilities of incarcerated persons are, in fact, given consideration during the disciplinary process. As well, review of disciplinary hearing documentation does reflect the mental state of incarcerated persons is given consideration during the sentencing phase of disciplinary proceedings. Interviews with the SCI Warden, SCI PCM, and SCI Institution Investigator confirm that the SCI utilizes a progressive disciplinary structure in the processing of all violations of the Ohio Administrative Code.
Agency policy (79-ISA-02) requires that “all incarcerated persons found guilty of sexual abuse shall be given appropriate programming and interventions if determined to be necessary by mental health services in consultation with sex offender services.” Interviews with SCI Medical staff and SCI Mental Health staff indicate that programming and/or interventions services are provided to incarcerated persons found to have engaged in sexual abuse.
Agency policy (79-ISA-02) allows that “the ODRC may discipline an IP for sexual contact and/or sexual conduct with staff only upon a finding that the staff member did not consent to such contact or conduct.” Interviews with the SCI PCM and SCI Institution Investigator confirm that the SCI does not impose disciplinary sanctions against incarcerated persons who are victims of sexual abuse or sexual harassment.
Per agency policy (79-ISA-02), “no IP reporting sexual misconduct shall be issued a conduct report for lying based solely on the fact their allegations could not be substantiated or that the IP later recanted their allegation.” Rather, as noted by the SCI Institution Investigator during interview, a report made in good faith, based on a reasonable belief that the alleged conduct did occur, doesn’t rise to the level of false reporting even if the investigation does not establish sufficient evidence to substantiate the allegations. Interviews with incarcerated persons who had previously reported allegations of sexual abuse confirmed SCI adherence to agency policy.
In accordance to the Ohio Administrative Code (5120-9-06, 5120-9-08), the agency clearly distinguishes between consensual sex, which is still a violation of ODRC policy, and incarcerated person-on-incarcerated person non-consensual sexual

conduct/contact, which is defined as when one or more incarcerated persons engage in sexual conduct, including sexual contact, with another incarcerated person against his or her will or by use of force, threats, intimidation, or other coercive actions.

Reasoning & Findings Statement:

This standard works to ensure that incarcerated persons are afforded progressive disciplinary sanctions pursuant to administrative or criminal findings of guilt for incarcerated person-on-incarcerated person sexual abuse. ODRC policy does require a progressive disciplinary system, which allows for the consideration of aggravating and mitigating factors. Specifically, a review of the agency’s disciplinary policies, as well as SCI disciplinary documentation, reflects that the mental health and of an incarcerated person is given serious consideration in sentencing and availability of subsequent mental health services. Within the audit time frame, the SCI has not processed any (0) administrative or criminal findings of guilt regarding incarcerated person-on-incarcerated person sexual abuse that occurred at the SCI. In considering agency policies, facility procedures, staff interviews, and incarcerated person comments, SCI is compliant with disciplinary standards as required under this provision.

115.81	Medical and mental health screenings; history of sexual abuse
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 79-ISA-04, PREA Risk Assessments and Accommodation Strategies, 10-20-24 67-MNH-02, Mental Health Screening and Mental Health Classification, 10-1-24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI PREA 72-Hour Assessment Process: 9-14-11, 6-26-15, 5-10-18, 11-14-18, 4-26-19, 9-27-19, 8-10-21, 10-26-21, 1-31-22, 2-16-22, 3-4-22, 3-15-22a, 3-15-22b, 5-26-22, 2-16-23, 2-22-23, 3-6-23, 3-23-23, 7-19-23, 7-21-23, 8-10-23, 10-24-23, 11-3-23, 12-12-23, 12-21-23a, 12-21-23b, 2-12-24, 3-21-24, 6-7-24, 6-21-24, 6-27-24, 7-10-24, 7-26-24, 8-1-24, 8-14-24a, 8-14-24b, 8-15-24, 8-29-24, 10-1-24, 10-2-24, 11-8-24a, 11-8-24b, 11-14-24a, 11-14-24b, 12-18-24, 12-27-24, 12-20-24 SCI 30-Day Reassessment: 7-14-14, 5-30-18, 5-22-19, 10-15-19, 8-27-21, 11-16-21, 2-18-22, 3-4-22, 3-30-22a, 3-30-22b, 6-13-22, 8-23-22, 3-9-23, 3-16-23, 3-31-23, 4-19-23, 8-7-23, 8-9-23, 8-28-23, 11-21-23, 1-3-24, 1-8-24, 3-4-24, 4-11-24, 6-26-24, 7-8-24, 7-15-24, 7-25-24, 8-12-24, 8-19-24, 9-6-24, 9-9-24a, 9-9-24b, 9-17-24, 10-16-24, 11-19-24, 12-2-24a, 12-2-24b, 1-2-25, 1-8-25

SCI Special Assessment: 1-4-24, 1-8-24, 7-17-24
SCI Referral to Holistic Services, 5-10-24
SCI Mental Health Note: 5-14-24, 11-19-24
SCI New Classifications Report with PAST, 9-10-24
SCI PAST, 5-30-24
SCI Notification OSHP, 12-3-24 Interviews:
PREA Compliance Manager
Intake Staff
Investigative Staff
Medical Staff
Mental Health Staff
Staff Who Perform Screening for Risk of Victimization and Abusiveness
Inmates Who Reported Sexual Victimization During Risk Screening Site Review Observations:
Observed Medical/Mental Health Departments and Risk Screening Areas.
Review of Medical/Mental Health PREA Screening Forms.

Standard Subsections:

Agency policy (79-ISA-04) requires that upon arrival, all SCI incarcerated persons will be screened for sexual abuse risk factors. “If the assessment indicates the IP is at risk or has experienced prior sexual victimization, whether it occurred in an institution setting or in the community, staff shall offer a follow-up meeting with a mental health practitioner within fourteen (14) calendar days of the intake screening” (79-ISA-04). Additionally, agency policy (67-MNH-02) allows that “any institutional employee can make a referral to Behavioral Health if they suspect an IP is currently being victimized through a human trafficking incident at their institution or if the IP discloses to the employee that they had been victimized through a human trafficking incident prior to their incarceration.” In speaking with the SCI PCM, it was noted that any staff member, contractor, or volunteer can make such a referral. Per the SCI PCM, within the audit time frame, 100% of incarcerated persons received at the SCI who disclosed prior victimization during screening were offered a follow-up meeting with a medical or mental health practitioner. Conversations with medical and mental health staff confirmed the institutionalization of this practice. Interviews with incarcerated persons who reported previous sexual victimization at Intake confirmed that they were seen by mental health services either the same day as Intake. Lastly, a review of SCI mental health referrals verifies that said recommendations are being made within agency policy.
Per policy (79-ISA-04), persons with a history of being sexually abusive must be referred for mental health services within 14 calendar days. In speaking with Mental Health staff, it is noted that the nature of the referral is in accordance with the individualized needs of each incarcerated person. As noted by the SCI Operational Compliance Manager, within the audit time frame, 100% of incarcerated persons

received at the SCI who had previously perpetrated sexual abuse, as indicated during the screening, were offered a follow-up meeting with a mental health practitioner.

Per policy (79-ISA-04), regular mental health referrals are addressed within a timeframe consistent with the nature of the referral and within 14 days of the intake screening. Review of PREA assessment documentation verifies SCI’s adherence to agency policy.
Per policy (79-ISA-02) and in accordance with the Prison Rape Elimination Act (PREA) Standards, 28 C.F.R. 115.81, any information related to sexual victimization or abusiveness that occurred in an institutional setting shall be strictly limited to medical and mental health practitioners and other staff, as necessary, to inform treatment plans and security and management decisions, including housing, bed, work, education, and program assignments, or as otherwise required by federal, state, or local laws. As noted by medical and mental health staff during the interview process, medical and mental health practitioners shall obtain informed consent from incarcerated persons before reporting information about prior sexual victimization that did not occur in an institutional setting.
Per policy (79-ISA-04) and in accordance with the Prison Rape Elimination Act (PREA) Standards, 28 C.F.R. §115.81, any information related to sexual victimization or abusiveness that occurred in an institutional setting shall be strictly limited to medical and mental health practitioners and other staff, as necessary, to inform treatment plans and security and management decisions, including housing, bed, work, education, and program assignments, or as otherwise required by federal, state, or local laws. As noted by medical and mental health staff during the interview process, medical and mental health practitioners shall obtain informed consent from incarcerated persons before reporting information about prior sexual victimization that did not occur in an institutional setting, unless the incarcerated person is under the age of 18 years or considered a vulnerable adult. In speaking with medical and mental health staff, it was noted that staff do require informed consent prior to reporting incidents of prior sexual victimization that did not occur in an institutional setting for all persons except juveniles and individuals with developmental disabilities.

Reasoning & Findings Statement:

Within the audit time frame, 100% of incarcerated persons who had disclosed prior victimization during risk screening were offered a follow-up meeting with a medical or mental health practitioner. Within the audit time frame, 100% of incarcerated persons who had previously perpetrated sexual abuse as indicated during risk screening were offered a follow-up meeting with a medical or mental health practitioner. As noted by medical and mental health staff, the SCI is providing routine and regular medical screens and other health services in accordance to qualified medical assessments, as well as to policy. Documentation specific to the PREA Assessment Form for medical and mental health staff reflects the appropriate use of the screening tool to determine necessary housing and medical needs. Lastly, per agency, all incarcerated persons except juveniles and individuals with developmental disabilities, are required to provide informed consent prior to facility staff reporting information about prior

sexual victimization that did not occur in an institutional setting. As such, the facility is meeting all provisions as established within this standard.

115.82	Access to emergency medical and mental health services
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 B-11, Medical Care Guidelines for Sexual Conduct or Recent Sexual Abuse, 3-6-23 67-MNH-09, Suicide Prevention, 10-1-24 68-MED-15, Bureau of Medical Services Co-Payment Procedures, 7-8-24 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI On-Call Psychiatry, 10-8-24 SCI Incident Report, 5-14-24 SCI Medical Notes, 5-14-24 SCI Medical Exam Report, 5-14-24 SCI Referral to Holistic Services, 5-15-24 SCI Mental Health Note, 5-21-24 Interviews: PREA Compliance Manager Medical Staff Mental Health Staff SAFE and/or SANE Personnel of the Local Hospital/Rape Crisis Clinic Community-Based Victim Advocacy Staff Security Staff and/or Non-Security Staff Who Have Acted As First Responders Random Staff Site Review Observations: Observed Medical Department Review of Medical/Mental Health Screening Form Standard Subsections:

In accordance with the ODRC Office of Correctional Health Care policy (B-11), “all incarcerated persons who report sexual conduct and/or recent sexual abuse shall be escorted to incarcerated person health services as soon as possible after the reported conduct or recent sexual abuse.” In interviewing medical and mental health staff, said staff confirmed the ability to treat incarcerated persons in accordance with their professional medical judgement. It was further noted by medical and/or mental health staff, and confirmed within policy (B-11), that “if evidentiary or medically appropriate, the patient will be transported to the Emergency Department (ED) for examination, treatment, and counseling.”
Policy (68-MED-01) requires the facility to maintain twenty-four (24) hour medical coverage, to include an on-call physician. Policy (67-MNH-09) further requires that “each institution shall develop a written plan for twenty-four (24) hour emergency mental health service availability. The plan shall include an onsite emergency crisis intervention.” In speaking with medical and mental health staff, 24-hour availability of qualified medical and mental health practitioners was affirmed. Additionally, staffing requirements, and subsequent scheduling documentation, confirms the continuous availability of qualified medical and mental health staff. Lastly, during interviews with first responders, as well as random security staff, all personnel recognized with immediacy the need to notify medical staff of any sexual abuse allegations.
Policy (B-11) requires that “each patient who is treated for sexual conduct or recent sexual abuse will be offered timely and appropriate prophylactic information and treatment for sexually transmitted diseases.” In speaking with medical staff, adherence to this policy was confirmed. In speaking with SANE/SAFE personnel, it was further noted that all medical precautions, to include appropriate prophylactic information and treatment for sexually transmitted diseases, are given to victims of sexual abuse. Incarcerated persons who had previously made allegations of sexual abuse also confirmed that they had received medical and/or mental health treatment in a timely manner.
Policy (79-ISA-02) notes that “all victims of sexual abuse shall have access to forensic medical examinations at an outside facility without financial cost where evidentiary or medically appropriate. The service shall be provided to the alleged victim regardless of whether the victim names the alleged abuser or cooperates with any investigation arising out of the incident.” In speaking with medical staff, adherence to this policy was confirmed. Additionally, incarcerated persons who had previously received medical treatment for allegations of sexual abuse generally confirmed that they were not charged a medical fee for said services.

Reasoning & Findings Statement:

This standard is designed to provide incarcerated persons access to emergency

medical and mental health services. In this, facility staff are meeting all the provisions within this standard. Policy (B-11) allows that upon receipt of an incarcerated person into the Medical Department, medical staff shall determine the incarcerated person’s course of treatment; specifically, what is medically indicated based on evidence collection or physical trauma. Incarcerated person interviews further acknowledge that incarcerated persons are provided appropriate medical and mental health treatment. Lastly, documentation reflecting access to medical and mental health care, to include outside services, was reviewed. In reviewing the totality of the information provided, the SCI has met the minimums provisions of this standard via emergency (24-hour) access to qualified medical staff. The SCI has meet the minimums provisions of this standard by not only providing timely access to mental health services, but also by ensuring that a qualified mental health practitioner is available 24-hours a day.

115.83	Ongoing medical and mental health care for sexual abuse victims and abusers
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-02, Prison Sexual Misconduct Reporting, Response, Investigation, and Prevention of Retaliation, 9-24-23 67-MNH-02, Mental Health Screening and Mental Health Classification, 10-1-24 67-MNH-04, Transfer and Discharge of the Mental Health Caseload, 8-19-24 67-MNH-15, Mental Health Treatment, 10-1-24 B-11, Medical Care Guidelines for Sexual Contact or Recent Sexual Abuse, 3-6-23 DOJ, U.S. Department of Justice, Office of Violence Against Women, Sexual Assault Medical Forensic Examinations, Adults/Adolescents, Second Edition, April, 2013 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Employee PREA Training, FY24 SCI MOU with the Sexual Assault Response Network of Central Ohio (SARNCO), 2-9-23 SCI Approved List of PREA Victim Support Person Staff, 8-14-24 SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24, 3-5-24, 5-12-24, 5-14-24 SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24, 3-5-24, 5-12-24, 5-14-24 SCI Sick Call Notes: 1-2-24

SCI Laboratory Report, DNA: 1-29-24
SCI Laboratory/Diagnostic Test Results: 1-3-24, 1-4-24a, 1-4-24b
SCI Medical Exam Report: 5-14-24
SCI Referral to Holistic Services, 5-10-24
SCI Mental Health Note: 5-14-24, 11-19-24 Interviews:
PREA Compliance Manager
Medical Staff
Mental Health Staff

Site Review Observations:
Observed Medical Department
Review of Medical and Mental Health PREA Screening Forms Standard Subsections:

Policy (79-ISA-02) requires that all allegations of sexual assault must be evaluated immediately by the facility health staff. In this, “medical services shall follow Medical Protocol B-11, Medical Care Guidelines for Sexual Conduct or Recent Sexual Abuse, which includes instructions for assuring appropriate examination, documentation, transport to the local emergency department, testing for sexually transmitted diseases, counseling, prophylactic treatment, follow-up, and referral for mental health evaluation.” In speaking with medical and mental health staff, adherence to this policy was confirmed. In speaking with correctional staff, there were no instances where any staff indicated that the medical or mental health departments had ever, or would ever, refuse to provide medical or mental health treatment to any incarcerated person who claimed to have been a victim of sexual abuse. In speaking with incarcerated persons who were receiving mental health treatment services, most confirmed that upon making their allegations, or upon facility transfer, they were automatically placed on the mental health rosters of their assigned facility.
In reviewing a collection of mental health policies, it is evident that the ODRC offers continuing mental health services to incarcerated persons throughout their assignment to the ODRC and even upon their release from the agency. Specifically, policies (67-MNH-02, 67-MNH-04, 67-MNH-15) require that mental health services are “notified of all requests to transfer an incarcerated individual on the Mental Health Caseload… All transferred incarcerated individuals shall be screened at the receiving institution in accord with ODRC Policy… At that time, the individual shall be scheduled for appropriate continued mental health care… All Mental Health Treatment Plans for C1 and C2 classifications shall include a goal and intervention that addresses re-entry needs.”
Policy (79-ISA-02, 67-MNH-15) requires that all victims of sexual abuse shall receive timely, unimpeded access to emergency medical treatment and crisis intervention services, the nature and scope of which are determined by medical and mental health practitioners according to their professional judgment. If not referred to

an outside hospital emergency department, the incarcerated person is treated in the facility infirmary after evaluation by a primary care provider. In each instance, as confirmed by medical and mental health staff, related services are provided in accordance with the judgement of qualified health care providers.

Within the audit time frame, SCI has not had any (0) biological females incarcerated at the facility. Accordingly, pregnancy tests are not medically appropriate.
Within the audit time frame, SCI has not had any (0) biological females incarcerated at the facility. Accordingly, pregnancy services are not medically appropriate.
Policy (B-11) requires that when medically appropriate, the following tests will be ordered: serology for syphilis (RPR), GC and chlamydia, HIV, HBV, and HCV. Additionally, “each patient who is treated for sexual conduct or recent sexual abuse will be offered timely and appropriate prophylactic information and treatment for sexually transmitted diseases.” In speaking with medical staff, it was noted that all incarcerated persons are provided medical services as appropriate for the nature of their concerns. In speaking with incarcerated persons who had previously alleged sexual abuse, agency adherence to this policy was confirmed.
Policy (79-ISA-02) notes that “all victims of sexual abuse shall have access to forensic medical examinations at an outside facility without financial cost where evidentiary or medically appropriate. The service shall be provided to the alleged victim regardless of whether the victim names the alleged abuser or cooperates with any investigation arising out of the incident.” In speaking with medical staff, as well as the SAFE/SANE personnel of the local medical center, adherence to this policy was confirmed. Additionally, SCI incarcerated persons who had previously received medical treatment for allegations of sexual abuse also confirmed that they were not charged a medical fee for said services.
Policy (79-ISA-02) requires that “mental health services shall attempt to conduct an evaluation on all known abusers within sixty (60) calendar days of learning of such history and offer treatment when deemed appropriate.” In speaking with mental health staff, it was noted that while agency policy allows for 60 days to evaluate abusers, to help ensure the safekeeping of all incarcerated persons, any known abusers are generally evaluated at a much faster rate. SCI documentation reflects adherence to this criterion. Specifically, 100% of all known abusers entering the facility have been scheduled for an evaluation by mental health services within the required time frame.

Reasoning & Findings Statement:

This standard is designed to ensure ongoing medical and mental health care for sexual abuse victims and abusers. The SCI offers qualified and coordinated medical and mental health care regardless of an incarcerated person’s ability to pay for said services. As appropriate, incarcerated persons are provided the opportunity to attend follow-up treatments, for both medical and mental health services. Once established, agency policy requires that access to said treatment follows the incarcerated person

throughout the ODRC system and can be coordinated with community care upon the incarcerated person’s release from the ODRC. The medical and mental health services provided are consistent with the community level of care. Additionally, because this level of care is coordinated to ensure that incarcerated persons receive every aspect of sexual abuse treatment, addressing both medical and mental health needs on a regular and timely basis, without regard to cost, the opportunity for treatment received in this institutional setting far exceeds that of individuals receiving similar treatments within the community. Accordingly, the SCI Medical and Mental Health Departments have collectively exceeded the provisions of this standard.

115.86	Sexual abuse incident reviews
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 79-ISA-03, Sexual Abuse Review Team, 11-13-23 SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI PREA Incident Report Application: 1-2-24, 1-3-24, 3-5-24, 3-28-24, 5-12-24, 5-14-24 SCI Incident Report: 1-2-24a, 1-2-24b, 1-3-24, 3-5-24a, 3-5-24b, 5-12-24a, 5-12-24b, 5-14-24 SCI Sexual Abuse First Responder Checklist: 12-29-23, 1-3-24, 3-5-24, 5-12-24, 5-14-24 SCI Voluntary Statement: 1-3-24a, 1-3-24b, 3-5-24, 5-12-24, 5-14-24 SCI Inmate Request: 5-11-24 SCI Notice of Interview/Conference: 5-24-24 SCI Acknowledgement and Waiver of Right to Representation: 5-24-24 SCI OSHP Notification Email: 1-2-24, 1-8-24, 3-5-24, 3-25-24, 5-15-24a, 5-15-24b, 5-21-24, 5-31-24 SCI OSHP Disposition Notification: 1-4-24, 1-8-24, 2-2-24, 3-22-24, 5-21-24, 5-31-24 SCI Offender Information Summary: 1-2-24, 1-4-24a, 1-4-24b, 1-8-24, 3-5-24a, 3-5-24b, 5-14-24, 5-15-24, 9-9-24 SCI Employee Identification Form SCI Medical Exam Report: 1-2-24, 1-3-24, 1-4-24, 3-5-24, 5-12-24, 5-14-24 SCI Sick Call Notes: 1-2-24 SCI Laboratory Report, DNA: 1-29-24 SCI Laboratory/Diagnostic Test Results: 1-3-24, 1-4-24a, 1-4-24b SCI Medical Exam Report, 5-14-24 SCI Referral to Holistic Services, 5-10-24 SCI Mental Health Note: 5-14-24, 11-19-24 SCI Request for Protective Control, 3-5-24

SCI PREA Victim Support Person Activity Report: 1-2-24, 1-3-24, 3-5-24, 5-12-24,
5-14-24
SCI Notification of Sexual Abuse Investigation Outcome: 1-8-24, 2-2-24, 3-25-24, 5-21-24, 5-31-24
SCI Sexual Abuse Incident Review: 1-17-24, 4-1-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager
Incident Review Team Member Site Review Observations:
Reviewed Incident Review Team procedures.

Standard Subsections:

Policy (79-ISA-03) states that the Sexual Abuse Review Team (SART) “shall review all sexual abuse incidents, unless determined to be unfounded, within thirty (30) calendar days of the conclusion of investigation.” During the audit time frame, the SCI received fourteen (14) sexual abuse allegations, excluding only unfounded incidents. Accordingly, per the SCI PCM, the SCI has engaged fourteen (14) Sexual Abuse Review Team meetings. In speaking with the SCI PCM, the SCI Warden, and the SCI Institutional Investigator, each person explained their role within the incident review process.
Policy (79-ISA-03) requires the Sexual Abuse Review Team (SART) to “review all sexual abuse incidents, unless determined to be unfounded, within thirty (30) calendar days of the conclusion of investigation.” During the audit time frame, the SCI received fourteen (14) sexual abuse allegations, excluding only unfounded incidents. Accordingly, per the SCI PCM, the SCI has engaged fourteen (14) Sexual Abuse Review Team meetings. Documentation evidencing the practice of Sexual Abuse Review Teams was reviewed to ensure timely compliance.
Policy (79-ISA-03) requires that “each managing officer shall designate a Sexual Abuse Review Team (SART). The SART shall, at a minimum, consist of:
1. Institution Operational Compliance Manager (PCM) – Chair;
2. A Deputy Warden;
3. Institutional Investigator;
4. Designated Victim Support Person;
5. Any other staff that may have relevant input, such as unit staff, line supervisors, medical and mental health professionals.”

Documentation was reviewed to ensure SART meetings did contain the proper personnel mixture.

(D) Policy (79-ISA-03) requires that “the SART shall consider:

a. Whether the allegation or investigation indicates a need to change policy or

practice to better prevent, detect, or respond to sexual abuse;

Whether the incident or allegation was motivated by race, ethnicity, gender identity, lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; or gang affiliation; or was motivated or otherwise caused b other group dynamics at the facility;
Whether the area in the facility where the incident allegedly occurred contains physical barriers in the area may enable abuse;
The adequacy of staffing levels in that area during different shifts;
Whether monitoring technology should be deployed or augmented to supplement supervision by staff.
Following consideration, “the SART shall complete the Sexual Abuse Case Review in the electronic PREA Incident Reporting System and document the committee findings,” as well as any recommendations for improvement.

(E) Upon completion of the incident review report, the “managing officer shall implement the recommendations outlined in the Sexual Abuse Case Review for improvement or shall document its reasons for not doing so.” In speaking with the SCI Warden, the responsibilities of the managing officer to implement SART recommendations was explained.

Reasoning & Findings Statement:

During the audit time frame, the SCI received fourteen (14) sexual abuse allegations, excluding only unfounded incidents. As such, it was necessary to engage the Sexual Abuse Review Team upon the conclusion of each investigation, with the exception of unfounded investigations. A review of documentation reflects the timely convergence of those designated staff members. In speaking with the SCI PCM, the SCI Warden, and the SCI Institutional Investigator, each person explained their role within the incident review process. As such, it is evident that the facility has procedures in place to engage incident reviews and that staff are knowledge in their obligations to the team. Accordingly, SCI has satisfied the requirements of this standard.

115.87	Data collection
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 ODRC 2021 Annual Internal Report on Sexual Assault Data ODRC 2022 Annual Internal Report on Sexual Assault Data ODRC 2023 Annual Internal Report on Sexual Assault Data ODRC PREA Incident Packet Instructions SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24

SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager Site Review Observations:
Extensive review of agency website/PREA section
Reviewed 2023 PREA Outcome Measures Standard Subsections:

Policy (79-ISA-01) provides all staff within the ODRC a standardized set of definitions specific to sexual abuse/sexual harassment allegations. Policy (79-ISA-01) further mandates that all “institution investigators shall report allegations of sexual misconduct they investigated on their monthly reports, along with the dispositions of same. This information should also be provided to the Bureau of Research for compilation and analysis.” In speaking with the SCI Institution Investigator, adherence to this provision was confirmed.
Policy (79-ISA-01) further requires that “the institution investigators shall ensure all fields in the PREA Incident Reporting System as provided by the agency PREA coordinator are accurately completed. This data shall be aggregated at least annually.” In speaking with the SCI Institution Investigator, adherence to this provision was confirmed.
Per the ODRC Annual Internal Report on Sexual Assault Data (2020 & 2019), “the ODRC completes the U.S. Department of Justice, Bureau of Justice Statistics Survey of Sexual Victimization report.” Furthermore, as confirmed by the ODRC PREA Coordinator, the data includes all information necessary to answer all questions from the most recent version of the Survey of Sexual Violence (SSV) conducted by the Bureau of Justice Statistics.
Policy (79-ISA-01) requires that “all case records associated with allegations of sexual misconduct or retaliation including incident reports, investigation reports, incarcerated person information, case disposition, medical and counseling evaluation findings, and recommendations for post-release treatment and/or counseling shall be securely retained in accordance with the DRC records retention schedule.” The ODRC PREA Coordinator confirmed the agency’s overall adherence to this policy. As well, the SCI PCM and SCI Institution Investigator confirmed that the above reference sources were continuously used to inform the agency’s annual statistical reports.
Policy (79-ISA-01) mandates that “the agency PREA coordinator/designee must ensure all aggregated sexual misconduct data received from private facilities with which it contracts is readily available to the public at least annually through the DRC internet site.” The ODRC PREA Coordinator confirmed the agency’s overall adherence,

as well as the specific adherence of the agency’s three ODRC private facilities, to this policy. Review of the agency’s website finds this information readily available: https://drc.ohio.gov/prea

(F) Policy (79-ISA-01) requires that the PREA Coordinator provide aggregated data on sexual abuse and sexual harassment occurring within the ODRC to the Department of Justice (DOJ); specifically, the Bureau of Justice Statistics, on an annual basis. As confirmed by the PREA Coordinator, said data is provided to the DOJ no later than June 30th of each year.

Reasoning & Findings Statement:

This standard works to ensure that specific data relative to promoting sexual safety within a correctional institution is collected on a monthly basis. That data is then aggregated and made available for public review. The SCI has complied with the timely collection of said data and subsequently furnishes it to appropriate entities as required. Hence, the SCI has met all provisional requirements and is in compliance with this standard.

115.88	Data review for corrective action
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: 79-ISA-01, Prison Rape Elimination, 10-1-24 ODRC 2021 Annual Internal Report on Sexual Assault Data ODRC 2022 Annual Internal Report on Sexual Assault Data ODRC 2023 Annual Internal Report on Sexual Assault Data SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews: Agency Head Agency PREA Coordinator Facility Warden PREA Compliance Manager Site Review Observations: Extensive review of agency website/PREA section Reviewed 2023 PREA Outcome Measures Standard Subsections:

Policy (79-ISA-01) requires the PREA Coordinator to prepare and aggregate data related to sexual abuse and sexual harassment across all ODRC facilities. Following which, the ODRC then uses that data to assess and improve the effectiveness of its sexual abuse prevention, detection, response policies, and training. Specifically, the ODRC works to identify problem areas, take corrective action on an ongoing basis, and prepares an annual report of its findings from the data review and any corrective actions for each facility, as well as the agency as a whole. The PREA Coordinator confirmed adherence to this policy. As well, the ODRC Annual Internal Report on Sexual Assault Data for years 2021, 2022, and 2023 does reflect the intelligent use of said data.
Policy (79-ISA-01) requires that annual statistical reports “shall include a comparison of the current year’s data and corrective actions with those from prior years and shall provide an assessment of the DRC’s progress in addressing sexual misconduct.” The PREA Coordinator confirms adherence to this policy. As well, the ODRC Annual Internal Report on Sexual Assault Data for years 2021, 2022, and 2023 does reflect a comparative analysis across years.
Policy (79-ISA-01) requires that upon completion of each year’s Annual Internal Report on Sexual Assault Data, “the report shall be approved by the Director and posted on the DRC internet site.” A review of the ODRC website indicates that upon approval from the agency director, the report is then made available to the public through the ODRC website. The PREA Coordinator confirms adherence to this policy. Furthermore, a review of the ODRC website finds all agency PREA reports publicly available: https://drc.ohio.gov/prea
Policy (79-ISA-01) requires that “any information redacted from the report due to a clear and specific threat to the safety and security of the facility must indicate the reason for redaction.” In speaking with the agency PREA Coordinator, it was noted that should the agency need to redact specific information other than publicly identifying statistics, proper procedural restraints would be applied.

Reasoning & Findings Statement:

This standard works to determine if agency, and by extension, facility base staff use aggregated data to promote the overall safety and security of the facility. In speaking with the agency-wide PREA Coordinator, SCI PCM, and the SCI Warden, the manner in which person utilized the data to improve overall institutional safety, based on their role within the agency, was explained. Hence, the SCI has demonstrated clear compliance with each of the provisions, and as such, has reached the goal of the standard.

115.89	Data storage, publication, and destruction
	Auditor Overall Determination: Meets Standard
	Auditor Discussion

Documents:

79-ISA-01, Prison Rape Elimination, 10-1-24
ODRC PREA Webpage
ODRC Record Retention Schedule
SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24
SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews:
Agency PREA Coordinator
Facility Warden
PREA Compliance Manager Site Review Observations:
Extensive review of agency website/PREA section Standard Subsections:

Policy (Records Retention) requires all aggregated data to be retained permanently. The PREA Coordinator confirms agency compliance with this directive. As well, review of the agency website reflects the collection of all annual aggregated reports previously published pursuant to §115.87.
Policy (Records Retention) requires all aggregated data to be retained permanently. The PREA Coordinator confirms agency compliance with this directive. As well, review of the agency website reflects the collection of all annual aggregated reports previously published pursuant to §115.87. This data is made readily available to the public through the ODRC website.
Policy (79-ISA-01) requires “all personal identifiers must be removed from publicly available data,” such as all annually produced statistical reports published on the agency’s website.
Policy (Records Retention) requires all aggregated data to be retained permanently. The PREA Coordinator confirms agency compliance with this directive. As well, review of the agency website reflects the collection of all annual aggregated reports previously published pursuant to §115.87. This data is made readily available to the public through the ODRC website.

Reasoning & Findings Statement:

This standard works to ensure both public availability and agency integrity in the presentation of aggregated sexual abuse data. In reviewing agency documents and speaking with staff, it is more than apparent that both the ODRC PREA Coordinator, as well as the administration of the SCI, operate with transparency in government. As such, the facility has clearly obtained each provision, and thus, satisfactorily achieve overall compliance.

115.401	Frequency and scope of audits
	Auditor Overall Determination: Exceeds Standard
	Auditor Discussion
	Documents: ODRC PREA Webpage ODRC Record Retention Schedule SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 SCI Audit Notices, English and Spanish Interviews: Agency PREA Coordinator Facility Warden PREA Compliance Manager Random/Targeted Staff Random/Targeted Inmates Site Review Observations: Onsite inspection of the entire SCI Review of documentation available via the ODRC PREA website Standard Subsections: As evidenced by presence of facility audits on the ODRC website, and confirmed by the PREA Coordinator, PREA Audits have been completed at all ODRC correctional facilities to provide for at least one-third of each facility type operated by the Agency being audited during each audit year. This is Audit Year 1 of Cycle 5. (H) The auditor had full access to all areas of the facility. (I) All documents requested by the auditor were received in a timely manner. The auditor was permitted to conduct private interviews with incarcerated persons. Incarcerated persons were permitted to correspond with the auditor using privileged mail processes. Reasoning & Findings Statement: Both the PREA Coordinator and the SCI PCM were exceptionally prepared for this review. The auditor was provided the PAQ well in advance of arriving to the facility. The auditor was given unrestricted access to the institution and provided with all reference materials requested. The auditor was provided with a convenient location

from which to interview both employees and staff in a confidential manner. Agency staff ensured that the flow of interview traffic was never restricted and that the auditor was able to attend all requested incarcerated person functions throughout the facility as needed. The auditor did not experience any significant barriers, at any stage of the audit, that were under the control of either the agency or the SCI. Accordingly, SCI has exceeded the provisions of this standard.

115.403	Audit contents and findings
	Auditor Overall Determination: Meets Standard
	Auditor Discussion
	Documents: ODRC PREA Webpage ODRC Record Retention Schedule SCI 03-E-01, Sexual Misconduct Zero Tolerance Policy, 9-11-24 SCI 03-E-02, Sexual Abuse Coordinated Response Plan, 9-12-24 Interviews: Agency PREA Coordinator Site Review Observations: Review of documentation available via the ODRC PREA website Standard Subsections: (F.) A review of the agency website reflects that the ODRC has published all final audit reports for prior audits completed during the last three years preceding this audit. The PREA Coordinator affirms that all facilities within the ODRC have been audited, and their reports subsequently published, on the agency’s website. Reasoning & Findings Statement: The function of this standard is to promote transparency in government by ensuring that all facility audits are available for public review, by way of, for example, the agency’s website. In this case, the ODRC does have an agency website and has made all facility PREA reports conveniently accessible to the public.

Appendix: Provision Findings
115.11 (a)	Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
	Does the agency have a written policy mandating zero tolerance toward all forms of sexual abuse and sexual harassment?	yes
	Does the written policy outline the agency’s approach to preventing, detecting, and responding to sexual abuse and sexual harassment?	yes
115.11 (b)	Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
	Has the agency employed or designated an agency-wide PREA Coordinator?	yes
	Is the PREA Coordinator position in the upper-level of the agency hierarchy?	yes
	Does the PREA Coordinator have sufficient time and authority to develop, implement, and oversee agency efforts to comply with the PREA standards in all of its facilities?	yes
115.11 (c)	Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
	If this agency operates more than one facility, has each facility designated a PREA compliance manager? (N/A if agency operates only one facility.)	yes
	Does the PREA compliance manager have sufficient time and authority to coordinate the facility’s efforts to comply with the PREA standards? (N/A if agency operates only one facility.)	yes
115.12 (a)	Contracting with other entities for the confinement of inmates
	If this agency is public and it contracts for the confinement of its inmates with private agencies or other entities including other government agencies, has the agency included the entity’s obligation to comply with the PREA standards in any new contract or contract renewal signed on or after August 20, 2012? (N/A if the agency does not contract with private agencies or other entities for the confinement of inmates.)	yes
115.12 (b)	Contracting with other entities for the confinement of inmates
	Does any new contract or contract renewal signed on or after August 20, 2012 provide for agency contract monitoring to ensure	yes

	that the contractor is complying with the PREA standards? (N/A if the agency does not contract with private agencies or other entities for the confinement of inmates.)
115.13 (a)	Supervision and monitoring
	Does the facility have a documented staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect inmates against sexual abuse?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: Generally accepted detention and correctional practices?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: Any judicial findings of inadequacy?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: Any findings of inadequacy from Federal investigative agencies?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: Any findings of inadequacy from internal or external oversight bodies?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: All components of the facility’s physical plant (including “blind-spots” or areas where staff or inmates may be isolated)?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: The composition of the inmate population?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: The number and placement of supervisory staff?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: The institution programs occurring on a particular shift?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into	yes

	consideration: Any applicable State or local laws, regulations, or standards?
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: The prevalence of substantiated and unsubstantiated incidents of sexual abuse?	yes
	In calculating adequate staffing levels and determining the need for video monitoring, does the staffing plan take into consideration: Any other relevant factors?	yes
115.13 (b)	Supervision and monitoring
	In circumstances where the staffing plan is not complied with, does the facility document and justify all deviations from the plan? (N/A if no deviations from staffing plan.)	yes
115.13 (c)	Supervision and monitoring
	In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined, and documented whether adjustments are needed to: The staffing plan established pursuant to paragraph (a) of this section?	yes
	In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined, and documented whether adjustments are needed to: The facility’s deployment of video monitoring systems and other monitoring technologies?	yes
	In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined, and documented whether adjustments are needed to: The resources the facility has available to commit to ensure adherence to the staffing plan?	yes
115.13 (d)	Supervision and monitoring
	Has the facility/agency implemented a policy and practice of having intermediate-level or higher-level supervisors conduct and document unannounced rounds to identify and deter staff sexual abuse and sexual harassment?	yes
	Is this policy and practice implemented for night shifts as well as day shifts?	yes
	Does the facility/agency have a policy prohibiting staff from alerting other staff members that these supervisory rounds are occurring, unless such announcement is related to the legitimate operational functions of the facility?	yes

115.14 (a)	Youthful inmates
	Does the facility place all youthful inmates in housing units that separate them from sight, sound, and physical contact with any adult inmates through use of a shared dayroom or other common space, shower area, or sleeping quarters? (N/A if facility does not have youthful inmates (inmates <18 years old).)	na
115.14 (b)	Youthful inmates
	In areas outside of housing units does the agency maintain sight and sound separation between youthful inmates and adult inmates? (N/A if facility does not have youthful inmates (inmates <18 years old).)	na
	In areas outside of housing units does the agency provide direct staff supervision when youthful inmates and adult inmates have sight, sound, or physical contact? (N/A if facility does not have youthful inmates (inmates <18 years old).)	na
115.14 (c)	Youthful inmates
	Does the agency make its best efforts to avoid placing youthful inmates in isolation to comply with this provision? (N/A if facility does not have youthful inmates (inmates <18 years old).)	na
	Does the agency, while complying with this provision, allow youthful inmates daily large-muscle exercise and legally required special education services, except in exigent circumstances? (N/A if facility does not have youthful inmates (inmates <18 years old).)	na
	Do youthful inmates have access to other programs and work opportunities to the extent possible? (N/A if facility does not have youthful inmates (inmates <18 years old).)	na
115.15 (a)	Limits to cross-gender viewing and searches
	Does the facility always refrain from conducting any cross-gender strip or cross-gender visual body cavity searches, except in exigent circumstances or by medical practitioners?	yes
115.15 (b)	Limits to cross-gender viewing and searches
	Does the facility always refrain from conducting cross-gender pat-down searches of female inmates, except in exigent circumstances? (N/A if the facility does not have female inmates.)	na
	Does the facility always refrain from restricting female inmates’ access to regularly available programming or other out-of-cell opportunities in order to comply with this provision? (N/A if the	na

	facility does not have female inmates.)
115.15 (c)	Limits to cross-gender viewing and searches
	Does the facility document all cross-gender strip searches and cross-gender visual body cavity searches?	yes
	Does the facility document all cross-gender pat-down searches of female inmates (N/A if the facility does not have female inmates)?	na
115.15 (d)	Limits to cross-gender viewing and searches
	Does the facility have policies that enables inmates to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks?	yes
	Does the facility have procedures that enables inmates to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks?	yes
	Does the facility require staff of the opposite gender to announce their presence when entering an inmate housing unit?	yes
115.15 (e)	Limits to cross-gender viewing and searches
	Does the facility always refrain from searching or physically examining transgender or intersex inmates for the sole purpose of determining the inmate’s genital status?	yes
	If an inmate’s genital status is unknown, does the facility determine genital status during conversations with the inmate, by reviewing medical records, or, if necessary, by learning that information as part of a broader medical examination conducted in private by a medical practitioner?	yes
115.15 (f)	Limits to cross-gender viewing and searches
	Does the facility/agency train security staff in how to conduct cross-gender pat down searches in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs?	yes
	Does the facility/agency train security staff in how to conduct searches of transgender and intersex inmates in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs?	yes

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

	with inmates with disabilities including inmates who: Have intellectual disabilities?
	Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with inmates with disabilities including inmates who: Have limited reading skills?	yes
	Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with inmates with disabilities including inmates who: are blind or have low vision?	yes
115.16 (b)	Inmates with disabilities and inmates who are limited English proficient
	Does the agency take reasonable steps to ensure meaningful access to all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to inmates who are limited English proficient?	yes
	Do these steps include providing interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary?	yes
115.16 (c)	Inmates with disabilities and inmates who are limited English proficient
	Does the agency always refrain from relying on inmate interpreters, inmate readers, or other types of inmate assistance except in limited circumstances where an extended delay in obtaining an effective interpreter could compromise the inmate’s safety, the performance of first-response duties under §115.64, or the investigation of the inmate’s allegations?	yes
115.17 (a)	Hiring and promotion decisions
	Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates who has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?	yes
	Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates who has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?	yes
	Does the agency prohibit the hiring or promotion of anyone who	yes

	may have contact with inmates who has been civilly or administratively adjudicated to have engaged in the activity described in the two bullets immediately above?
	Does the agency prohibit the enlistment of services of any contractor who may have contact with inmates who has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?	yes
	Does the agency prohibit the enlistment of services of any contractor who may have contact with inmates who has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?	yes
	Does the agency prohibit the enlistment of services of any contractor who may have contact with inmates who has been civilly or administratively adjudicated to have engaged in the activity described in the two bullets immediately above?	yes
115.17 (b)	Hiring and promotion decisions
	Does the agency consider any incidents of sexual harassment in determining whether to hire or promote anyone who may have contact with inmates?	yes
	Does the agency consider any incidents of sexual harassment in determining whether to enlist the services of any contractor who may have contact with inmates?	yes
115.17 (c)	Hiring and promotion decisions
	Before hiring new employees who may have contact with inmates, does the agency perform a criminal background records check?	yes
	Before hiring new employees who may have contact with inmates, does the agency, consistent with Federal, State, and local law, make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or any resignation during a pending investigation of an allegation of sexual abuse?	yes
115.17 (d)	Hiring and promotion decisions
	Does the agency perform a criminal background records check before enlisting the services of any contractor who may have contact with inmates?	yes

115.17 (e)	Hiring and promotion decisions
	Does the agency either conduct criminal background records checks at least every five years of current employees and contractors who may have contact with inmates or have in place a system for otherwise capturing such information for current employees?	yes
115.17 (f)	Hiring and promotion decisions
	Does the agency ask all applicants and employees who may have contact with inmates directly about previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring or promotions?	yes
	Does the agency ask all applicants and employees who may have contact with inmates directly about previous misconduct described in paragraph (a) of this section in any interviews or written self-evaluations conducted as part of reviews of current employees?	yes
	Does the agency impose upon employees a continuing affirmative duty to disclose any such misconduct?	yes
115.17 (g)	Hiring and promotion decisions
	Does the agency consider material omissions regarding such misconduct, or the provision of materially false information, grounds for termination?	yes
115.17 (h)	Hiring and promotion decisions
	Does the agency provide information on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied to work? (N/A if providing information on substantiated allegations of sexual abuse or sexual harassment involving a former employee is prohibited by law.)	yes
115.18 (a)	Upgrades to facilities and technologies
	If the agency designed or acquired any new facility or planned any substantial expansion or modification of existing facilities, did the agency consider the effect of the design, acquisition, expansion, or modification upon the agency’s ability to protect inmates from sexual abuse? (N/A if agency/facility has not acquired a new facility or made a substantial expansion to existing facilities since August 20, 2012, or since the last PREA audit, whichever is later.)	na
115.18 (b)	Upgrades to facilities and technologies

	If the agency installed or updated a video monitoring system, electronic surveillance system, or other monitoring technology, did the agency consider how such technology may enhance the agency’s ability to protect inmates from sexual abuse? (N/A if agency/facility has not installed or updated a video monitoring system, electronic surveillance system, or other monitoring technology since August 20, 2012, or since the last PREA audit, whichever is later.)	yes
115.21 (a)	Evidence protocol and forensic medical examinations
	If the agency is responsible for investigating allegations of sexual abuse, does the agency follow a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence for administrative proceedings and criminal prosecutions? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.)	yes
115.21 (b)	Evidence protocol and forensic medical examinations
	Is this protocol developmentally appropriate for youth where applicable? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.)	yes
	Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of the U.S. Department of Justice’s Office on Violence Against Women publication, “A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/ Adolescents,” or similarly comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.)	yes
115.21 (c)	Evidence protocol and forensic medical examinations
	Does the agency offer all victims of sexual abuse access to forensic medical examinations, whether on-site or at an outside facility, without financial cost, where evidentiarily or medically appropriate?	yes
	Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible?	yes
	If SAFEs or SANEs cannot be made available, is the examination performed by other qualified medical practitioners (they must have been specifically trained to conduct sexual assault forensic exams)?	yes

	Has the agency documented its efforts to provide SAFEs or SANEs?	yes
115.21 (d)	Evidence protocol and forensic medical examinations
	Does the agency attempt to make available to the victim a victim advocate from a rape crisis center?	yes
	If a rape crisis center is not available to provide victim advocate services, does the agency make available to provide these services a qualified staff member from a community-based organization, or a qualified agency staff member? (N/A if the agency always makes a victim advocate from a rape crisis center available to victims.)	yes
	Has the agency documented its efforts to secure services from rape crisis centers?	yes
115.21 (e)	Evidence protocol and forensic medical examinations
	As requested by the victim, does the victim advocate, qualified agency staff member, or qualified community-based organization staff member accompany and support the victim through the forensic medical examination process and investigatory interviews?	yes
	As requested by the victim, does this person provide emotional support, crisis intervention, information, and referrals?	yes
115.21 (f)	Evidence protocol and forensic medical examinations
	If the agency itself is not responsible for investigating allegations of sexual abuse, has the agency requested that the investigating agency follow the requirements of paragraphs (a) through (e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND administrative sexual abuse investigations.)	yes
115.21 (h)	Evidence protocol and forensic medical examinations
	If the agency uses a qualified agency staff member or a qualified community-based staff member for the purposes of this section, has the individual been screened for appropriateness to serve in this role and received education concerning sexual assault and forensic examination issues in general? (N/A if agency always makes a victim advocate from a rape crisis center available to victims.)	yes
115.22 (a)	Policies to ensure referrals of allegations for investigations

	Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual abuse?	yes
	Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual harassment?	yes
115.22 (b)	Policies to ensure referrals of allegations for investigations
	Does the agency have a policy and practice in place to ensure that allegations of sexual abuse or sexual harassment are referred for investigation to an agency with the legal authority to conduct criminal investigations, unless the allegation does not involve potentially criminal behavior?	yes
	Has the agency published such policy on its website or, if it does not have one, made the policy available through other means?	yes
	Does the agency document all such referrals?	yes
115.22 (c)	Policies to ensure referrals of allegations for investigations
	If a separate entity is responsible for conducting criminal investigations, does the policy describe the responsibilities of both the agency and the investigating entity? (N/A if the agency/facility is responsible for criminal investigations. See 115.21(a).)	yes
115.31 (a)	Employee training
	Does the agency train all employees who may have contact with inmates on its zero-tolerance policy for sexual abuse and sexual harassment?	yes
	Does the agency train all employees who may have contact with inmates on how to fulfill their responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures?	yes
	Does the agency train all employees who may have contact with inmates on inmates’ right to be free from sexual abuse and sexual harassment	yes
	Does the agency train all employees who may have contact with inmates on the right of inmates and employees to be free from retaliation for reporting sexual abuse and sexual harassment?	yes
	Does the agency train all employees who may have contact with inmates on the dynamics of sexual abuse and sexual harassment in confinement?	yes

	Does the agency train all employees who may have contact with inmates on the common reactions of sexual abuse and sexual harassment victims?	yes
	Does the agency train all employees who may have contact with inmates on how to detect and respond to signs of threatened and actual sexual abuse?	yes
	Does the agency train all employees who may have contact with inmates on how to avoid inappropriate relationships with inmates?	yes
	Does the agency train all employees who may have contact with inmates on how to communicate effectively and professionally with inmates, including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming inmates?	yes
	Does the agency train all employees who may have contact with inmates on how to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities?	yes
115.31 (b)	Employee training
	Is such training tailored to the gender of the inmates at the employee’s facility?	yes
	Have employees received additional training if reassigned from a facility that houses only male inmates to a facility that houses only female inmates, or vice versa?	yes
115.31 (c)	Employee training
	Have all current employees who may have contact with inmates received such training?	yes
	Does the agency provide each employee with refresher training every two years to ensure that all employees know the agency’s current sexual abuse and sexual harassment policies and procedures?	yes
	In years in which an employee does not receive refresher training, does the agency provide refresher information on current sexual abuse and sexual harassment policies?	yes
115.31 (d)	Employee training
	Does the agency document, through employee signature or electronic verification, that employees understand the training they have received?	yes
115.32 (a)	Volunteer and contractor training

	Has the agency ensured that all volunteers and contractors who have contact with inmates have been trained on their responsibilities under the agency’s sexual abuse and sexual harassment prevention, detection, and response policies and procedures?	yes
115.32 (b)	Volunteer and contractor training
	Have all volunteers and contractors who have contact with inmates been notified of the agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and informed how to report such incidents (the level and type of training provided to volunteers and contractors shall be based on the services they provide and level of contact they have with inmates)?	yes
115.32 (c)	Volunteer and contractor training
	Does the agency maintain documentation confirming that volunteers and contractors understand the training they have received?	yes
115.33 (a)	Inmate education
	During intake, do inmates receive information explaining the agency’s zero-tolerance policy regarding sexual abuse and sexual harassment?	yes
	During intake, do inmates receive information explaining how to report incidents or suspicions of sexual abuse or sexual harassment?	yes
115.33 (b)	Inmate education
	Within 30 days of intake, does the agency provide comprehensive education to inmates either in person or through video regarding: Their rights to be free from sexual abuse and sexual harassment?	yes
	Within 30 days of intake, does the agency provide comprehensive education to inmates either in person or through video regarding: Their rights to be free from retaliation for reporting such incidents?	yes
	Within 30 days of intake, does the agency provide comprehensive education to inmates either in person or through video regarding: Agency policies and procedures for responding to such incidents?	yes
115.33 (c)	Inmate education
	Have all inmates received the comprehensive education referenced in 115.33(b)?	yes

	Do inmates receive education upon transfer to a different facility to the extent that the policies and procedures of the inmate’s new facility differ from those of the previous facility?	yes
115.33 (d)	Inmate education
	Does the agency provide inmate education in formats accessible to all inmates including those who are limited English proficient?	yes
	Does the agency provide inmate education in formats accessible to all inmates including those who are deaf?	yes
	Does the agency provide inmate education in formats accessible to all inmates including those who are visually impaired?	yes
	Does the agency provide inmate education in formats accessible to all inmates including those who are otherwise disabled?	yes
	Does the agency provide inmate education in formats accessible to all inmates including those who have limited reading skills?	yes
115.33 (e)	Inmate education
	Does the agency maintain documentation of inmate participation in these education sessions?	yes
115.33 (f)	Inmate education
	In addition to providing such education, does the agency ensure that key information is continuously and readily available or visible to inmates through posters, inmate handbooks, or other written formats?	yes
115.34 (a)	Specialized training: Investigations
	In addition to the general training provided to all employees pursuant to §115.31, does the agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its investigators receive training in conducting such investigations in confinement settings? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)	yes
115.34 (b)	Specialized training: Investigations
	Does this specialized training include techniques for interviewing sexual abuse victims? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)	yes
	Does this specialized training include proper use of Miranda and	yes

	Garrity warnings? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)
	Does this specialized training include sexual abuse evidence collection in confinement settings? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)	yes
	Does this specialized training include the criteria and evidence required to substantiate a case for administrative action or prosecution referral? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)	yes
115.34 (c)	Specialized training: Investigations
	Does the agency maintain documentation that agency investigators have completed the required specialized training in conducting sexual abuse investigations? (N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)	yes
115.35 (a)	Specialized training: Medical and mental health care
	Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how to detect and assess signs of sexual abuse and sexual harassment? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners who work regularly in its facilities.)	yes
	Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how to preserve physical evidence of sexual abuse? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners who work regularly in its facilities.)	yes
	Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how to respond effectively and professionally to victims of sexual abuse and sexual harassment? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners who work regularly in its facilities.)	yes
	Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in how and to whom to report allegations or	yes

	suspicions of sexual abuse and sexual harassment? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners who work regularly in its facilities.)
115.35 (b)	Specialized training: Medical and mental health care
	If medical staff employed by the agency conduct forensic examinations, do such medical staff receive appropriate training to conduct such examinations? (N/A if agency medical staff at the facility do not conduct forensic exams or the agency does not employ medical staff.)	yes
115.35 (c)	Specialized training: Medical and mental health care
	Does the agency maintain documentation that medical and mental health practitioners have received the training referenced in this standard either from the agency or elsewhere? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners who work regularly in its facilities.)	yes
115.35 (d)	Specialized training: Medical and mental health care
	Do medical and mental health care practitioners employed by the agency also receive training mandated for employees by §115.31? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners employed by the agency.)	yes
	Do medical and mental health care practitioners contracted by or volunteering for the agency also receive training mandated for contractors and volunteers by §115.32? (N/A if the agency does not have any full- or part-time medical or mental health care practitioners contracted by or volunteering for the agency.)	yes
115.41 (a)	Screening for risk of victimization and abusiveness
	Are all inmates assessed during an intake screening for their risk of being sexually abused by other inmates or sexually abusive toward other inmates?	yes
	Are all inmates assessed upon transfer to another facility for their risk of being sexually abused by other inmates or sexually abusive toward other inmates?	yes
115.41 (b)	Screening for risk of victimization and abusiveness
	Do intake screenings ordinarily take place within 72 hours of arrival at the facility?	yes
115.41 (c)	Screening for risk of victimization and abusiveness
	Are all PREA screening assessments conducted using an objective	yes

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

	Whether the inmate is detained solely for civil immigration purposes?
115.41 (e)	Screening for risk of victimization and abusiveness
	In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening consider, as known to the agency: prior acts of sexual abuse?	yes
	In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening consider, as known to the agency: prior convictions for violent offenses?	yes
	In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening consider, as known to the agency: history of prior institutional violence or sexual abuse?	yes
115.41 (f)	Screening for risk of victimization and abusiveness
	Within a set time period not more than 30 days from the inmate’s arrival at the facility, does the facility reassess the inmate’s risk of victimization or abusiveness based upon any additional, relevant information received by the facility since the intake screening?	yes
115.41 (g)	Screening for risk of victimization and abusiveness
	Does the facility reassess an inmate’s risk level when warranted due to a referral?	yes
	Does the facility reassess an inmate’s risk level when warranted due to a request?	yes
	Does the facility reassess an inmate’s risk level when warranted due to an incident of sexual abuse?	yes
	Does the facility reassess an inmate’s risk level when warranted due to receipt of additional information that bears on the inmate’s risk of sexual victimization or abusiveness?	yes
115.41 (h)	Screening for risk of victimization and abusiveness
	Is it the case that inmates are not ever disciplined for refusing to answer, or for not disclosing complete information in response to, questions asked pursuant to paragraphs (d)(1), (d)(7), (d)(8), or (d)(9) of this section?	yes
115.41 (i)	Screening for risk of victimization and abusiveness
	Has the agency implemented appropriate controls on the dissemination within the facility of responses to questions asked pursuant to this standard in order to ensure that sensitive	yes

	information is not exploited to the inmate’s detriment by staff or other inmates?
115.42 (a)	Use of screening information
	Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Housing Assignments?	yes
	Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Bed assignments?	yes
	Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Work Assignments?	yes
	Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Education Assignments?	yes
	Does the agency use information from the risk screening required by § 115.41, with the goal of keeping separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Program Assignments?	yes
115.42 (b)	Use of screening information
	Does the agency make individualized determinations about how to ensure the safety of each inmate?	yes
115.42 (c)	Use of screening information
	When deciding whether to assign a transgender or intersex inmate to a facility for male or female inmates, does the agency consider, on a case-by-case basis, whether a placement would ensure the inmate’s health and safety, and whether a placement would present management or security problems (NOTE: if an agency by policy or practice assigns inmates to a male or female facility on the basis of anatomy alone, that agency is not in compliance with this standard)?	yes
	When making housing or other program assignments for transgender or intersex inmates, does the agency consider, on a case-by-case basis, whether a placement would ensure the inmate’s health and safety, and whether a placement would	yes

	present management or security problems?
115.42 (d)	Use of screening information
	Are placement and programming assignments for each transgender or intersex inmate reassessed at least twice each year to review any threats to safety experienced by the inmate?	yes
115.42 (e)	Use of screening information
	Are each transgender or intersex inmate’s own views with respect to his or her own safety given serious consideration when making facility and housing placement decisions and programming assignments?	yes
115.42 (f)	Use of screening information
	Are transgender and intersex inmates given the opportunity to shower separately from other inmates?	yes
115.42 (g)	Use of screening information
	Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex inmates, does the agency always refrain from placing: lesbian, gay, and bisexual inmates in dedicated facilities, units, or wings solely on the basis of such identification or status? (N/A if the agency has a dedicated facility, unit, or wing solely for the placement of LGBT or I inmates pursuant to a consent degree, legal settlement, or legal judgement.)	yes
	Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex inmates, does the agency always refrain from placing: transgender inmates in dedicated facilities, units, or wings solely on the basis of such identification or status? (N/A if the agency has a dedicated facility, unit, or wing solely for the placement of LGBT or I inmates pursuant to a consent degree, legal settlement, or legal judgement.)	yes
	Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex inmates, does the agency always refrain from placing: intersex inmates in dedicated facilities, units, or wings solely on the basis of such identification or status? (N/A if the agency has a dedicated facility, unit, or wing	yes

	solely for the placement of LGBT or I inmates pursuant to a consent degree, legal settlement, or legal judgement.)
115.43 (a)	Protective Custody
	Does the facility always refrain from placing inmates at high risk for sexual victimization in involuntary segregated housing unless an assessment of all available alternatives has been made, and a determination has been made that there is no available alternative means of separation from likely abusers?	yes
	If a facility cannot conduct such an assessment immediately, does the facility hold the inmate in involuntary segregated housing for less than 24 hours while completing the assessment?	yes
115.43 (b)	Protective Custody
	Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Programs to the extent possible?	yes
	Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Privileges to the extent possible?	yes
	Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Education to the extent possible?	yes
	Do inmates who are placed in segregated housing because they are at high risk of sexual victimization have access to: Work opportunities to the extent possible?	yes
	If the facility restricts any access to programs, privileges, education, or work opportunities, does the facility document the opportunities that have been limited? (N/A if the facility never restricts access to programs, privileges, education, or work opportunities.)	yes
	If the facility restricts access to programs, privileges, education, or work opportunities, does the facility document the duration of the limitation? (N/A if the facility never restricts access to programs, privileges, education, or work opportunities.)	yes
	If the facility restricts access to programs, privileges, education, or work opportunities, does the facility document the reasons for such limitations? (N/A if the facility never restricts access to programs, privileges, education, or work opportunities.)	yes
115.43 (c)	Protective Custody

	Does the facility assign inmates at high risk of sexual victimization to involuntary segregated housing only until an alternative means of separation from likely abusers can be arranged?	yes
	Does such an assignment not ordinarily exceed a period of 30 days?	yes
115.43 (d)	Protective Custody
	If an involuntary segregated housing assignment is made pursuant to paragraph (a) of this section, does the facility clearly document: The basis for the facility’s concern for the inmate’s safety?	yes
	If an involuntary segregated housing assignment is made pursuant to paragraph (a) of this section, does the facility clearly document: The reason why no alternative means of separation can be arranged?	yes
115.43 (e)	Protective Custody
	In the case of each inmate who is placed in involuntary segregation because he/she is at high risk of sexual victimization, does the facility afford a review to determine whether there is a continuing need for separation from the general population EVERY 30 DAYS?	yes
115.51 (a)	Inmate reporting
	Does the agency provide multiple internal ways for inmates to privately report: Sexual abuse and sexual harassment?	yes
	Does the agency provide multiple internal ways for inmates to privately report: Retaliation by other inmates or staff for reporting sexual abuse and sexual harassment?	yes
	Does the agency provide multiple internal ways for inmates to privately report: Staff neglect or violation of responsibilities that may have contributed to such incidents?	yes
115.51 (b)	Inmate reporting
	Does the agency also provide at least one way for inmates to report sexual abuse or sexual harassment to a public or private entity or office that is not part of the agency?	yes
	Is that private entity or office able to receive and immediately forward inmate reports of sexual abuse and sexual harassment to agency officials?	yes
	Does that private entity or office allow the inmate to remain	yes

	anonymous upon request?
	Are inmates detained solely for civil immigration purposes provided information on how to contact relevant consular officials and relevant officials at the Department of Homeland Security? (N/A if the facility never houses inmates detained solely for civil immigration purposes.)	na
115.51 (c)	Inmate reporting
	Does staff accept reports of sexual abuse and sexual harassment made verbally, in writing, anonymously, and from third parties?	yes
	Does staff promptly document any verbal reports of sexual abuse and sexual harassment?	yes
115.51 (d)	Inmate reporting
	Does the agency provide a method for staff to privately report sexual abuse and sexual harassment of inmates?	yes
115.52 (a)	Exhaustion of administrative remedies
	Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not have administrative procedures to address inmate grievances regarding sexual abuse. This does not mean the agency is exempt simply because an inmate does not have to or is not ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of explicit policy, the agency does not have an administrative remedies process to address sexual abuse.	yes
115.52 (b)	Exhaustion of administrative remedies
	Does the agency permit inmates to submit a grievance regarding an allegation of sexual abuse without any type of time limits? (The agency may apply otherwise-applicable time limits to any portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is exempt from this standard.)	yes
	Does the agency always refrain from requiring an inmate to use any informal grievance process, or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency is exempt from this standard.)	yes
115.52 (c)	Exhaustion of administrative remedies
	Does the agency ensure that: An inmate who alleges sexual abuse may submit a grievance without submitting it to a staff member who is the subject of the complaint? (N/A if agency is exempt from	yes

	this standard.)
	Does the agency ensure that: Such grievance is not referred to a staff member who is the subject of the complaint? (N/A if agency is exempt from this standard.)	yes
115.52 (d)	Exhaustion of administrative remedies
	Does the agency issue a final agency decision on the merits of any portion of a grievance alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the 90-day time period does not include time consumed by inmates in preparing any administrative appeal.) (N/A if agency is exempt from this standard.)	yes
	If the agency claims the maximum allowable extension of time to respond of up to 70 days per 115.52(d)(3) when the normal time period for response is insufficient to make an appropriate decision, does the agency notify the inmate in writing of any such extension and provide a date by which a decision will be made? (N/A if agency is exempt from this standard.)	yes
	At any level of the administrative process, including the final level, if the inmate does not receive a response within the time allotted for reply, including any properly noticed extension, may an inmate consider the absence of a response to be a denial at that level? (N/A if agency is exempt from this standard.)	yes
115.52 (e)	Exhaustion of administrative remedies
	Are third parties, including fellow inmates, staff members, family members, attorneys, and outside advocates, permitted to assist inmates in filing requests for administrative remedies relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.)	yes
	Are those third parties also permitted to file such requests on behalf of inmates? (If a third party files such a request on behalf of an inmate, the facility may require as a condition of processing the request that the alleged victim agree to have the request filed on his or her behalf, and may also require the alleged victim to personally pursue any subsequent steps in the administrative remedy process.) (N/A if agency is exempt from this standard.)	yes
	If the inmate declines to have the request processed on his or her behalf, does the agency document the inmate’s decision? (N/A if agency is exempt from this standard.)	yes
115.52 (f)	Exhaustion of administrative remedies

	Has the agency established procedures for the filing of an emergency grievance alleging that an inmate is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from this standard.)	yes
	After receiving an emergency grievance alleging an inmate is subject to a substantial risk of imminent sexual abuse, does the agency immediately forward the grievance (or any portion thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which immediate corrective action may be taken? (N/A if agency is exempt from this standard.).	yes
	After receiving an emergency grievance described above, does the agency provide an initial response within 48 hours? (N/A if agency is exempt from this standard.)	yes
	After receiving an emergency grievance described above, does the agency issue a final agency decision within 5 calendar days? (N/A if agency is exempt from this standard.)	yes
	Does the initial response and final agency decision document the agency’s determination whether the inmate is in substantial risk of imminent sexual abuse? (N/A if agency is exempt from this standard.)	yes
	Does the initial response document the agency’s action(s) taken in response to the emergency grievance? (N/A if agency is exempt from this standard.)	yes
	Does the agency’s final decision document the agency’s action(s) taken in response to the emergency grievance? (N/A if agency is exempt from this standard.)	yes
115.52 (g)	Exhaustion of administrative remedies
	If the agency disciplines an inmate for filing a grievance related to alleged sexual abuse, does it do so ONLY where the agency demonstrates that the inmate filed the grievance in bad faith? (N/A if agency is exempt from this standard.)	yes
115.53 (a)	Inmate access to outside confidential support services
	Does the facility provide inmates with access to outside victim advocates for emotional support services related to sexual abuse by giving inmates mailing addresses and telephone numbers, including toll-free hotline numbers where available, of local, State, or national victim advocacy or rape crisis organizations?	yes
	Does the facility provide persons detained solely for civil immigration purposes mailing addresses and telephone numbers,	na

	including toll-free hotline numbers where available of local, State, or national immigrant services agencies? (N/A if the facility never has persons detained solely for civil immigration purposes.)
	Does the facility enable reasonable communication between inmates and these organizations and agencies, in as confidential a manner as possible?	yes
115.53 (b)	Inmate access to outside confidential support services
	Does the facility inform inmates, prior to giving them access, of the extent to which such communications will be monitored and the extent to which reports of abuse will be forwarded to authorities in accordance with mandatory reporting laws?	yes
115.53 (c)	Inmate access to outside confidential support services
	Does the agency maintain or attempt to enter into memoranda of understanding or other agreements with community service providers that are able to provide inmates with confidential emotional support services related to sexual abuse?	yes
	Does the agency maintain copies of agreements or documentation showing attempts to enter into such agreements?	yes
115.54 (a)	Third-party reporting
	Has the agency established a method to receive third-party reports of sexual abuse and sexual harassment?	yes
	Has the agency distributed publicly information on how to report sexual abuse and sexual harassment on behalf of an inmate?	yes
115.61 (a)	Staff and agency reporting duties
	Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding an incident of sexual abuse or sexual harassment that occurred in a facility, whether or not it is part of the agency?	yes
	Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding retaliation against inmates or staff who reported an incident of sexual abuse or sexual harassment?	yes
	Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities that may have contributed to an incident of sexual	yes

	abuse or sexual harassment or retaliation?
115.61 (b)	Staff and agency reporting duties
	Apart from reporting to designated supervisors or officials, does staff always refrain from revealing any information related to a sexual abuse report to anyone other than to the extent necessary, as specified in agency policy, to make treatment, investigation, and other security and management decisions?	yes
115.61 (c)	Staff and agency reporting duties
	Unless otherwise precluded by Federal, State, or local law, are medical and mental health practitioners required to report sexual abuse pursuant to paragraph (a) of this section?	yes
	Are medical and mental health practitioners required to inform inmates of the practitioner’s duty to report, and the limitations of confidentiality, at the initiation of services?	yes
115.61 (d)	Staff and agency reporting duties
	If the alleged victim is under the age of 18 or considered a vulnerable adult under a State or local vulnerable persons statute, does the agency report the allegation to the designated State or local services agency under applicable mandatory reporting laws?	yes
115.61 (e)	Staff and agency reporting duties
	Does the facility report all allegations of sexual abuse and sexual harassment, including third-party and anonymous reports, to the facility’s designated investigators?	yes
115.62 (a)	Agency protection duties
	When the agency learns that an inmate is subject to a substantial risk of imminent sexual abuse, does it take immediate action to protect the inmate?	yes
115.63 (a)	Reporting to other confinement facilities
	Upon receiving an allegation that an inmate was sexually abused while confined at another facility, does the head of the facility that received the allegation notify the head of the facility or appropriate office of the agency where the alleged abuse occurred?	yes
115.63 (b)	Reporting to other confinement facilities
	Is such notification provided as soon as possible, but no later than 72 hours after receiving the allegation?	yes

115.63 (c)	Reporting to other confinement facilities
	Does the agency document that it has provided such notification?	yes
115.63 (d)	Reporting to other confinement facilities
	Does the facility head or agency office that receives such notification ensure that the allegation is investigated in accordance with these standards?	yes
115.64 (a)	Staff first responder duties
	Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Separate the alleged victim and abuser?	yes
	Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence?	yes
	Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Request that the alleged victim not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred within a time period that still allows for the collection of physical evidence?	yes
	Upon learning of an allegation that an inmate was sexually abused, is the first security staff member to respond to the report required to: Ensure that the alleged abuser does not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred within a time period that still allows for the collection of physical evidence?	yes
115.64 (b)	Staff first responder duties
	If the first staff responder is not a security staff member, is the responder required to request that the alleged victim not take any actions that could destroy physical evidence, and then notify security staff?	yes
115.65 (a)	Coordinated response
	Has the facility developed a written institutional plan to coordinate actions among staff first responders, medical and mental health practitioners, investigators, and facility leadership taken in	yes

	response to an incident of sexual abuse?
115.66 (a)	Preservation of ability to protect inmates from contact with abusers
	Are both the agency and any other governmental entities responsible for collective bargaining on the agency’s behalf prohibited from entering into or renewing any collective bargaining agreement or other agreement that limit the agency’s ability to remove alleged staff sexual abusers from contact with any inmates pending the outcome of an investigation or of a determination of whether and to what extent discipline is warranted?	yes
115.67 (a)	Agency protection against retaliation
	Has the agency established a policy to protect all inmates and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other inmates or staff?	yes
	Has the agency designated which staff members or departments are charged with monitoring retaliation?	yes
115.67 (b)	Agency protection against retaliation
	Does the agency employ multiple protection measures, such as housing changes or transfers for inmate victims or abusers, removal of alleged staff or inmate abusers from contact with victims, and emotional support services for inmates or staff who fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with investigations?	yes
115.67 (c)	Agency protection against retaliation
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct and treatment of inmates or staff who reported the sexual abuse to see if there are changes that may suggest possible retaliation by inmates or staff?	yes
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct and treatment of inmates who were reported to have suffered sexual abuse to see if there are changes that may suggest possible retaliation by inmates or staff?	yes
	Except in instances where the agency determines that a report of	yes

	sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy any such retaliation?
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor any inmate disciplinary reports?	yes
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor inmate housing changes?	yes
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor inmate program changes?	yes
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor negative performance reviews of staff?	yes
	Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor reassignments of staff?	yes
	Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a continuing need?	yes
115.67 (d)	Agency protection against retaliation
	In the case of inmates, does such monitoring also include periodic status checks?	yes
115.67 (e)	Agency protection against retaliation
	If any other individual who cooperates with an investigation expresses a fear of retaliation, does the agency take appropriate measures to protect that individual against retaliation?	yes
115.68 (a)	Post-allegation protective custody
	Is any and all use of segregated housing to protect an inmate who is alleged to have suffered sexual abuse subject to the requirements of § 115.43?	yes
115.71 (a)	Criminal and administrative agency investigations
	When the agency conducts its own investigations into allegations	yes

	of sexual abuse and sexual harassment, does it do so promptly, thoroughly, and objectively? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations. See 115.21(a).)
	Does the agency conduct such investigations for all allegations, including third party and anonymous reports? (N/A if the agency/ facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations. See 115.21(a).)	yes
115.71 (b)	Criminal and administrative agency investigations
	Where sexual abuse is alleged, does the agency use investigators who have received specialized training in sexual abuse investigations as required by 115.34?	yes
115.71 (c)	Criminal and administrative agency investigations
	Do investigators gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data?	yes
	Do investigators interview alleged victims, suspected perpetrators, and witnesses?	yes
	Do investigators review prior reports and complaints of sexual abuse involving the suspected perpetrator?	yes
115.71 (d)	Criminal and administrative agency investigations
	When the quality of evidence appears to support criminal prosecution, does the agency conduct compelled interviews only after consulting with prosecutors as to whether compelled interviews may be an obstacle for subsequent criminal prosecution?	yes
115.71 (e)	Criminal and administrative agency investigations
	Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an individual basis and not on the basis of that individual’s status as inmate or staff?	yes
	Does the agency investigate allegations of sexual abuse without requiring an inmate who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a condition for proceeding?	yes
115.71 (f)	Criminal and administrative agency investigations
	Do administrative investigations include an effort to determine whether staff actions or failures to act contributed to the abuse?	yes

	Are administrative investigations documented in written reports that include a description of the physical evidence and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings?	yes
115.71 (g)	Criminal and administrative agency investigations
	Are criminal investigations documented in a written report that contains a thorough description of the physical, testimonial, and documentary evidence and attaches copies of all documentary evidence where feasible?	yes
115.71 (h)	Criminal and administrative agency investigations
	Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?	yes
115.71 (i)	Criminal and administrative agency investigations
	Does the agency retain all written reports referenced in 115.71(f) and (g) for as long as the alleged abuser is incarcerated or employed by the agency, plus five years?	yes
115.71 (j)	Criminal and administrative agency investigations
	Does the agency ensure that the departure of an alleged abuser or victim from the employment or control of the agency does not provide a basis for terminating an investigation?	yes
115.71 (l)	Criminal and administrative agency investigations
	When an outside entity investigates sexual abuse, does the facility cooperate with outside investigators and endeavor to remain informed about the progress of the investigation? (N/A if an outside agency does not conduct administrative or criminal sexual abuse investigations. See 115.21(a).)	yes
115.72 (a)	Evidentiary standard for administrative investigations
	Is it true that the agency does not impose a standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated?	yes
115.73 (a)	Reporting to inmates
	Following an investigation into an inmate’s allegation that he or she suffered sexual abuse in an agency facility, does the agency inform the inmate as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded?	yes

115.73 (b)	Reporting to inmates
	If the agency did not conduct the investigation into an inmate’s allegation of sexual abuse in an agency facility, does the agency request the relevant information from the investigative agency in order to inform the inmate? (N/A if the agency/facility is responsible for conducting administrative and criminal investigations.)	na
115.73 (c)	Reporting to inmates
	Following an inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the inmate has been released from custody, does the agency subsequently inform the resident whenever: The staff member is no longer posted within the inmate’s unit?	yes
	Following an inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The staff member is no longer employed at the facility?	yes
	Following an inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The agency learns that the staff member has been indicted on a charge related to sexual abuse in the facility?	yes
	Following an inmate’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The agency learns that the staff member has been convicted on a charge related to sexual abuse within the facility?	yes
115.73 (d)	Reporting to inmates
	Following an inmate’s allegation that he or she has been sexually abused by another inmate, does the agency subsequently inform the alleged victim whenever: The agency learns that the alleged abuser has been indicted on a charge related to sexual abuse within the facility?	yes
	Following an inmate’s allegation that he or she has been sexually	yes

	abused by another inmate, does the agency subsequently inform the alleged victim whenever: The agency learns that the alleged abuser has been convicted on a charge related to sexual abuse within the facility?
115.73 (e)	Reporting to inmates
	Does the agency document all such notifications or attempted notifications?	yes
115.76 (a)	Disciplinary sanctions for staff
	Are staff subject to disciplinary sanctions up to and including termination for violating agency sexual abuse or sexual harassment policies?	yes
115.76 (b)	Disciplinary sanctions for staff
	Is termination the presumptive disciplinary sanction for staff who have engaged in sexual abuse?	yes
115.76 (c)	Disciplinary sanctions for staff
	Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) commensurate with the nature and circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories?	yes
115.76 (d)	Disciplinary sanctions for staff
	Are all terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, reported to: Law enforcement agencies(unless the activity was clearly not criminal)?	yes
	Are all terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, reported to: Relevant licensing bodies?	yes
115.77 (a)	Corrective action for contractors and volunteers
	Is any contractor or volunteer who engages in sexual abuse prohibited from contact with inmates?	yes
	Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement agencies (unless the activity was clearly not criminal)?	yes

	Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing bodies?	yes
115.77 (b)	Corrective action for contractors and volunteers
	In the case of any other violation of agency sexual abuse or sexual harassment policies by a contractor or volunteer, does the facility take appropriate remedial measures, and consider whether to prohibit further contact with inmates?	yes
115.78 (a)	Disciplinary sanctions for inmates
	Following an administrative finding that an inmate engaged in inmate-on-inmate sexual abuse, or following a criminal finding of guilt for inmate-on-inmate sexual abuse, are inmates subject to disciplinary sanctions pursuant to a formal disciplinary process?	yes
115.78 (b)	Disciplinary sanctions for inmates
	Are sanctions commensurate with the nature and circumstances of the abuse committed, the inmate’s disciplinary history, and the sanctions imposed for comparable offenses by other inmates with similar histories?	yes
115.78 (c)	Disciplinary sanctions for inmates
	When determining what types of sanction, if any, should be imposed, does the disciplinary process consider whether an inmate’s mental disabilities or mental illness contributed to his or her behavior?	yes
115.78 (d)	Disciplinary sanctions for inmates
	If the facility offers therapy, counseling, or other interventions designed to address and correct underlying reasons or motivations for the abuse, does the facility consider whether to require the offending inmate to participate in such interventions as a condition of access to programming and other benefits?	yes
115.78 (e)	Disciplinary sanctions for inmates
	Does the agency discipline an inmate for sexual contact with staff only upon a finding that the staff member did not consent to such contact?	yes
115.78 (f)	Disciplinary sanctions for inmates
	For the purpose of disciplinary action does a report of sexual abuse made in good faith based upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an incident or lying, even if an investigation does not establish	yes

	evidence sufficient to substantiate the allegation?
115.78 (g)	Disciplinary sanctions for inmates
	If the agency prohibits all sexual activity between inmates, does the agency always refrain from considering non-coercive sexual activity between inmates to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between inmates.)	yes
115.81 (a)	Medical and mental health screenings; history of sexual abuse
	If the screening pursuant to § 115.41 indicates that a prison inmate has experienced prior sexual victimization, whether it occurred in an institutional setting or in the community, do staff ensure that the inmate is offered a follow-up meeting with a medical or mental health practitioner within 14 days of the intake screening? (N/A if the facility is not a prison).	yes
115.81 (b)	Medical and mental health screenings; history of sexual abuse
	If the screening pursuant to § 115.41 indicates that a prison inmate has previously perpetrated sexual abuse, whether it occurred in an institutional setting or in the community, do staff ensure that the inmate is offered a follow-up meeting with a mental health practitioner within 14 days of the intake screening? (N/A if the facility is not a prison.)	yes
115.81 (c)	Medical and mental health screenings; history of sexual abuse
	If the screening pursuant to § 115.41 indicates that a jail inmate has experienced prior sexual victimization, whether it occurred in an institutional setting or in the community, do staff ensure that the inmate is offered a follow-up meeting with a medical or mental health practitioner within 14 days of the intake screening? (N/A if the facility is not a jail).	na
115.81 (d)	Medical and mental health screenings; history of sexual abuse
	Is any information related to sexual victimization or abusiveness that occurred in an institutional setting strictly limited to medical and mental health practitioners and other staff as necessary to inform treatment plans and security management decisions, including housing, bed, work, education, and program assignments, or as otherwise required by Federal, State, or local law?	yes
115.81 (e)	Medical and mental health screenings; history of sexual abuse
	Do medical and mental health practitioners obtain informed consent from inmates before reporting information about prior	yes

	sexual victimization that did not occur in an institutional setting, unless the inmate is under the age of 18?
115.82 (a)	Access to emergency medical and mental health services
	Do inmate victims of sexual abuse receive timely, unimpeded access to emergency medical treatment and crisis intervention services, the nature and scope of which are determined by medical and mental health practitioners according to their professional judgment?	yes
115.82 (b)	Access to emergency medical and mental health services
	If no qualified medical or mental health practitioners are on duty at the time a report of recent sexual abuse is made, do security staff first responders take preliminary steps to protect the victim pursuant to § 115.62?	yes
	Do security staff first responders immediately notify the appropriate medical and mental health practitioners?	yes
115.82 (c)	Access to emergency medical and mental health services
	Are inmate victims of sexual abuse offered timely information about and timely access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with professionally accepted standards of care, where medically appropriate?	yes
115.82 (d)	Access to emergency medical and mental health services
	Are treatment services provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident?	yes
115.83 (a)	Ongoing medical and mental health care for sexual abuse victims and abusers
	Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all inmates who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility?	yes
115.83 (b)	Ongoing medical and mental health care for sexual abuse victims and abusers
	Does the evaluation and treatment of such victims include, as appropriate, follow-up services, treatment plans, and, when necessary, referrals for continued care following their transfer to, or placement in, other facilities, or their release from custody?	yes
115.83 (c)	Ongoing medical and mental health care for sexual abuse

	victims and abusers
	Does the facility provide such victims with medical and mental health services consistent with the community level of care?	yes
115.83 (d)	Ongoing medical and mental health care for sexual abuse victims and abusers
	Are inmate victims of sexually abusive vaginal penetration while incarcerated offered pregnancy tests? (N/A if "all male" facility. Note: in "all male" facilities there may be inmates who identify as transgender men who may have female genitalia. Auditors should be sure to know whether such individuals may be in the population and whether this provision may apply in specific circumstances.)	na
115.83 (e)	Ongoing medical and mental health care for sexual abuse victims and abusers
	If pregnancy results from the conduct described in paragraph § 115.83(d), do such victims receive timely and comprehensive information about and timely access to all lawful pregnancy-related medical services? (N/A if "all male" facility. Note: in "all male" facilities there may be inmates who identify as transgender men who may have female genitalia. Auditors should be sure to know whether such individuals may be in the population and whether this provision may apply in specific circumstances.)	na
115.83 (f)	Ongoing medical and mental health care for sexual abuse victims and abusers
	Are inmate victims of sexual abuse while incarcerated offered tests for sexually transmitted infections as medically appropriate?	yes
115.83 (g)	Ongoing medical and mental health care for sexual abuse victims and abusers
	Are treatment services provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident?	yes
115.83 (h)	Ongoing medical and mental health care for sexual abuse victims and abusers
	If the facility is a prison, does it attempt to conduct a mental health evaluation of all known inmate-on-inmate abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate by mental health practitioners? (NA if the facility is a jail.)	na

115.86 (a)	Sexual abuse incident reviews
	Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse investigation, including where the allegation has not been substantiated, unless the allegation has been determined to be unfounded?	yes
115.86 (b)	Sexual abuse incident reviews
	Does such review ordinarily occur within 30 days of the conclusion of the investigation?	yes
115.86 (c)	Sexual abuse incident reviews
	Does the review team include upper-level management officials, with input from line supervisors, investigators, and medical or mental health practitioners?	yes
115.86 (d)	Sexual abuse incident reviews
	Does the review team: Consider whether the allegation or investigation indicates a need to change policy or practice to better prevent, detect, or respond to sexual abuse?	yes
	Does the review team: Consider whether the incident or allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; gang affiliation; or other group dynamics at the facility?	yes
	Does the review team: Examine the area in the facility where the incident allegedly occurred to assess whether physical barriers in the area may enable abuse?	yes
	Does the review team: Assess the adequacy of staffing levels in that area during different shifts?	yes
	Does the review team: Assess whether monitoring technology should be deployed or augmented to supplement supervision by staff?	yes
	Does the review team: Prepare a report of its findings, including but not necessarily limited to determinations made pursuant to §§ 115.86(d)(1)-(d)(5), and any recommendations for improvement and submit such report to the facility head and PREA compliance manager?	yes
115.86 (e)	Sexual abuse incident reviews
	Does the facility implement the recommendations for improvement, or document its reasons for not doing so?	yes

115.87 (a)	Data collection
	Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities under its direct control using a standardized instrument and set of definitions?	yes
115.87 (b)	Data collection
	Does the agency aggregate the incident-based sexual abuse data at least annually?	yes
115.87 (c)	Data collection
	Does the incident-based data include, at a minimum, the data necessary to answer all questions from the most recent version of the Survey of Sexual Violence conducted by the Department of Justice?	yes
115.87 (d)	Data collection
	Does the agency maintain, review, and collect data as needed from all available incident-based documents, including reports, investigation files, and sexual abuse incident reviews?	yes
115.87 (e)	Data collection
	Does the agency also obtain incident-based and aggregated data from every private facility with which it contracts for the confinement of its inmates? (N/A if agency does not contract for the confinement of its inmates.)	yes
115.87 (f)	Data collection
	Does the agency, upon request, provide all such data from the previous calendar year to the Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.)	yes
115.88 (a)	Data review for corrective action
	Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Identifying problem areas?	yes
	Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Taking corrective action on an ongoing basis?	yes
	Does the agency review data collected and aggregated pursuant	yes

	to § 115.87 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Preparing an annual report of its findings and corrective actions for each facility, as well as the agency as a whole?
115.88 (b)	Data review for corrective action
	Does the agency’s annual report include a comparison of the current year’s data and corrective actions with those from prior years and provide an assessment of the agency’s progress in addressing sexual abuse?	yes
115.88 (c)	Data review for corrective action
	Is the agency’s annual report approved by the agency head and made readily available to the public through its website or, if it does not have one, through other means?	yes
115.88 (d)	Data review for corrective action
	Does the agency indicate the nature of the material redacted where it redacts specific material from the reports when publication would present a clear and specific threat to the safety and security of a facility?	yes
115.89 (a)	Data storage, publication, and destruction
	Does the agency ensure that data collected pursuant to § 115.87 are securely retained?	yes
115.89 (b)	Data storage, publication, and destruction
	Does the agency make all aggregated sexual abuse data, from facilities under its direct control and private facilities with which it contracts, readily available to the public at least annually through its website or, if it does not have one, through other means?	yes
115.89 (c)	Data storage, publication, and destruction
	Does the agency remove all personal identifiers before making aggregated sexual abuse data publicly available?	yes
115.89 (d)	Data storage, publication, and destruction
	Does the agency maintain sexual abuse data collected pursuant to § 115.87 for at least 10 years after the date of the initial collection, unless Federal, State, or local law requires otherwise?	yes
115.401 (a)	Frequency and scope of audits

	During the prior three-year audit period, did the agency ensure that each facility operated by the agency, or by a private organization on behalf of the agency, was audited at least once? (Note: The response here is purely informational. A "no" response does not impact overall compliance with this standard.)	yes
115.401 (b)	Frequency and scope of audits
	Is this the first year of the current audit cycle? (Note: a “no” response does not impact overall compliance with this standard.)	yes
	If this is the second year of the current audit cycle, did the agency ensure that at least one-third of each facility type operated by the agency, or by a private organization on behalf of the agency, was audited during the first year of the current audit cycle? (N/A if this is not the second year of the current audit cycle.)	na
	If this is the third year of the current audit cycle, did the agency ensure that at least two-thirds of each facility type operated by the agency, or by a private organization on behalf of the agency, were audited during the first two years of the current audit cycle? (N/A if this is not the third year of the current audit cycle.)	na
115.401 (h)	Frequency and scope of audits
	Did the auditor have access to, and the ability to observe, all areas of the audited facility?	yes
115.401 (i)	Frequency and scope of audits
	Was the auditor permitted to request and receive copies of any relevant documents (including electronically stored information)?	yes
115.401 (m)	Frequency and scope of audits
	Was the auditor permitted to conduct private interviews with inmates, residents, and detainees?	yes
115.401 (n)	Frequency and scope of audits
	Were inmates permitted to send confidential information or correspondence to the auditor in the same manner as if they were communicating with legal counsel?	yes
115.403	Audit contents and findings

(f)
	The agency has published on its agency website, if it has one, or has otherwise made publicly available, all Final Audit Reports. The review period is for prior audits completed during the past three years PRECEDING THIS AUDIT. The pendency of any agency appeal pursuant to 28 C.F.R. § 115.405 does not excuse noncompliance with this provision. (N/A if there have been no Final Audit Reports issued in the past three years, or, in the case of single facility agencies, there has never been a Final Audit Report issued.)	yes

‌PREA Facility Audit Report: Final

Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding the audit:

Administrative SEXUAL ABUSE investigation outcomes during the 12 months preceding the audit:

‌Sexual Harassment Investigation Outcomes