Policy – Alpha Emergence Behavioral Health

Alpha Emergence Behavioral Health

PRISON RAPE ELIMINATION ACT POLICY AND PROCEDURES MANUAL

PURPOSE

This document provides guidelines and procedures to reduce the risk of sexual abuse and sexual harassment in the Alpha Emergence Behavioral Health (AEBH) Residential Sex Offender Treatment program. It is also a written plan to coordinate actions taken in response to an incident of sexual abuse, among staff, residents, volunteers, contractors and facility leadership. AEBH is committed to a zero-tolerance standard for sexual abuse and sexual harassment either by staff or by other residents.

AEBH investigates all matters of sexual abuse/harassment, staff sexual misconduct and residential client sexual misconduct vigorously through the facility’s supervisory staff, the agency’s administrative personnel (residential Clinical Director, and Executive Director), the policy and outside law enforcement, as directed by the incident.
Residents, staff, contractors, visitors, volunteers, or any other individuals who have business with AEBH are subject to disciplinary action and/or criminal sanctions, including dismissal or termination of contracted services, if determined to have engaged in sexual abuse/harassment or staff sexual misconduct of a resident. A violation of this policy may result in termination from AEBH.
Clients/Residents, staff contractors, volunteers, and others deemed necessary by AEBH’s administration must receive training on sexual abuse/harassment/staff and client/residential sexual misconduct prevention and detection.
All employees, contractors and volunteers of AEBH shall sign the PREA Acknowledgment Statement. As required by the Prison Rape Elimination Act, AEBH shall conduct criminal background records checks on all new hires. Additionally, AEBH will conduct criminal background records checks on permanent or temporary employees and contractors, volunteers and interns at least every five years.
AEBH maintains multiple ways for clients/residents and staff to report allegations of sexual abuse/harassment/staff sexual misconduct and sexual abuse/harassment perpetrated by clients/residents, contractors, or volunteers. Clients/Residents who falsely report information will be reviewed for possible termination from AEBH’s treatment program and/or possible criminal statutes.
At intake, case management staff shall meet with clients/residents to complete a PREA Risk Assessment.
AEBH must maintain a sexual abuse response team (SART). Sart provides a victim-centered coordinated team response. SART offers supportive services to the alleged victim of sexual abuse, and ensures the victim to a continuum of services.
A client/resident who alleges that he has been the victim of sexual abuse perpetrated by another client/resident, staff, contractor, or volunteer is offered access to psychological services, medical services, and a sexual abuse advocate. In cases of substantiated sexual harassment or sexual misconduct, residents have access to psychological services and educational materials.
AEBH must follow the PREA policy.
AEBH’s Outpatient Program Coordinator will serve as the PREA Coordinator. The PREA Coordinator has sufficient time and authority for the development, implementation, and oversight of AEBH’s compliance with the PREA standards in the Residential Sex Offender Treatment Program.
AEBH does not contract with other entities for the confinement of residents.
DEFINITIONS
Agency PREA Coordinator– An upper-level, administrator with sufficient time and authority to be responsible for the development, implementation, and oversight if AEBH’s residential treatment program’s compliance with the PREA standards. The PREA Coordinator will be AEBH’s Outpatient Program Coordinator.
Agency PREA Compliance Manager– The PREA Compliance Manager coordinates communication with the alleged victim and with the alleged perpetrator and coordinates follow-up of incidents of resident sexual abuse and sexual harassment within the treatment program. The PREA Compliance Manager will serve as the team lead of all PREA after action reviews. The PREA Compliance Manager will be AEBH’s Residential Clinical Director.
Community Confinement Facility– Means a community treatment center, halfway house, restitution center, mental heal facility, alcohol or drug rehabilitation center, or other community correctional facility (including residential re-entry centers), other than a juvenile facility, in which individuals reside as part of a term of imprisonment or as a condition of pretrial release or post-release supervision, while participating in gainful employment, employment search efforts, community service, vocational training, treatment, educational programs, or similar facility-approved programs during non-residential hours.
Forensic Evidence Collection– The collection of evidence from the patient during the medical forensic exam within a 120 hour time period, unless exigent circumstances exist (e.g. extended hostage situation, patient has visible and/or significant trauma from the abuse, or patient has not cleansed him/herself since the abuse).
Gender Nonconforming– A person whose appearance or manner does not conform to traditional societal gender expectations.
Intersex– A person whose sexual or reproductive anatomy or chromosomal pattern does not seem to fit typical definitions of male or female. Intersex medical conditions are sometimes referred to as disorders of sex development.
Transgender– A person whose gender identity (internal sense of feeling male or female) is different from the person’s assigned sex at birth.
Intimate Parts– Include the primary genital area, groin, anus, inner thigh, buttocks, breast of a human being, or any clothing covering one of these areas (see Minn. Stat 609.341, subd. 5, and subd.11)
Sexual Abuse:
Sexual abuse of a client/resident by a staff member, contractor, or volunteer when the victim does not consent and is coerced into such acts by overt or implied threats of violence, or is unable to consent or refuse. These include any of the following actions:
Contact between the penis and the vulva or the penis and the anus, including penetration, however slight; b. Contact between the mouth and the penis, vulva, or anus; c. Contact between the mouth and any body part when the staff member, contractor, or volunteer has the intent to abuse, arouse, or gratify sexual desire; d. Penetration of the anal or genital opening, however slight, by a hand, finger, or object, that is unrelated to official duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or gratify sexual desire; e. Any intentional contact, either directly or through the clothing, with the genitalia, anus, groin, breast, inner thigh, or the buttocks, that is unrelated to official duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or gratify sexual desire; f. Any attempt, threat, or request by a staff member, contractor, or volunteer to engage in the activities described above in letters a through e; g. Any display by a staff member, contractor, or volunteer of his or her unconvered genitalia, buttocks, or breast in the presence of a resident, and h. Voyeurism by a staff member, contractor, or volunteer that involves an invasion of a resident’s privacy by staff for reasons unrelated to official duties such as: i. Peering at a resident who is using a toilet in the residence to perform bodily functions; ii. Requiring a client/resident to expose his buttocks, genitals or breasts; or taking images of all or part of a client’s/resident’s naked body or of a client/resident performing bodily functions, regardless of what the staff member does with the images afterwards.
Sexual abuse of a client/resident by another client/resident includes any of the following acts, if the victim does not consent, is coerced into such act by overt or implied threats of violence, or is unable to consent or refuse:
Contact between the penis and the vulva or the penis and the anus, including penetration, however slight; b. Contact between the mouth and the penis, vulva, or anus; c. Penetration of the anal or genital opening of another person, however slight, by a hand, finger, object, or other instrument; and d. Any other intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or the buttocks of another person, excluding contact incidental to a physical altercation.
Sexual Abuse Advocate– An individual specifically trained to offer advocacy, support, crisis intervention, information, and referrals to a victim of sexual abuse.
Sexual Abuse Response Team (SART)– A team of staff which may include AEBH’s Clinical Director, case supervisors, case managers and auxiliary staff. The team is managed by the Clinical Director. The purpose of the team is to ensure a holistic approach to investigations and support for victims.
Sexual Abuse Forensic Examination– A process performed by a sexual abuse nurse examiner (SANE) during which the medical forensic history and evidence is obtained from the patient. The SANE must offer the resident information on sexually transmitted infections, and other non-acute medical concerns.
Sexual Coercion– Compelling or inducing another person to engage in sexual abuse by deceit, threats, force or intimidation for personal favors.
Sexual Harassment–
Client/Resident to Client/Resident sexual harassment includes repeated and unwelcome sexual advances, requests for sexual favors, or verbal comments, gestures, or actions of a derogatory or offensive sexual nature by one client/resident or clients/residents directed towards another.
Staff to Client/Resident sexual harassment includes repeated verbal comments or gestures of a sexual nature to a client/resident or clients/residents by a staff member, contractor, or volunteer, including demeaning references to gender, sexually suggestive or derogatory comments about body or clothing, or obscene language or gestures.
Staff Sexual Misconduct– The following acts when performed by agency staff, contractors, or volunteers when directed at a client/resident for the purpose of gratifying the sexual desire(s) of any person, encouraging a client/resident to engage in staff sexual misconduct, or that have sexual undertones:
Making any of the following:
Comments about a client’s/resident’s body, looks, or conduct intended to arouse or gratify the sexual desire of any person, or to abuse, humiliate, harass, or degrade any person. b. Sexually oriented statements or gestures in the presence of a client/resident; or c. Demeaning statements based on gender or sexual orientation in the presence of a client/resident.
Giving or accepting personal letters, pictures, phone calls, or contact information with a client/resident, or his family, without express authorization of the appointing authority.
Engaging in discussions about personal information with a client/resident, or his family, or to encourage a client/resident to engage in communication or conduct with a staff person that would constitute staff sexual misconduct.
Dealing, offering, receiving, or giving favors or attention to a client/resident for purposes of grooming, bribing, or otherwise seeking to engage a client/resident in activities prohibited by policy.
Discussing or preventing clients/residents, staff, contract workers, and/or volunteers from:
Making good faith reports of staff sexual misconduct; or b. Providing, in good faith, information regarding sexual misconduct where a client/resident is the alleged victim, including such examples as, making threats, bribes, or acts of coercion toward a resident, staff, contract worker, or volunteer. This does not include short-term temporary delays in reporting necessary to ensure safety/security in the facility or instances where the staff, contract worker, or volunteer would not reasonably have known under the circumstances that he/she was in violation of this policy.
Attempting to perform acts prohibited by this policy.
Aiding or abetting another person to perform acts prohibited by this policy, including intentionally failing to report knowledge of another staff, contract worker, or volunteer engaging in staff sexual misconduct or other acts prohibited by this policy.
Substantiated Allegation– An allegation that was investigated and determined to have occurred.
Unfounded Allegation– An allegation that was investigated and determined not to have occurred.
Unsubstantiated– An allegation that was investigated and produced insufficient evidence to make a final determination as to whether or not the event occurred.

III. PROCEDURES – PREVENTION PLANNING

AEBH’s main office where treatment is conducted and two bedrooms exist for clients/residents shall be known as Fremont. Fremont is staffed 24 hours per day, seven days per week with paid, trained staff who are dressed and awake. Qualified staff provide for the safe and secure supervision of clients/residents. The other facility where the remainder of the clients/residents sleep shall be known as Portland. Portland is staffed 12 hour per day, seven days per week (the period of time when clients/residents are physically at Portland) with paid, trained staff who are dressed and awake. Qualified staff provide for the safe and secure supervision of clients/residents.
It is AEBH’s policy that no employee shall make a request for, or engage in sexual harassment or sexual conduct with any client/resident or former client/resident of AEBH. No residential staff shall be employed by AEBH without prior investigation to determine if the individual had or proposed sexual contact with clients/residents or former clients/residents within the past five years.
AEBH will perform a criminal background records check prior to making any job offers to applicants working in AEBH’s residential treatment facilities. This policy also applies to contracted and volunteer workers.
Prior to making a job offer to any applicant to work in AEBH’s residential treatment programs, the applicant, in writing, shall authorize AEBH to contact all former employers for the past five years (prison, jail, lockup, community treatment facility, juvenile facility or other institution). These employers will be contacted for information to inquire if the applicant engaged in sexual abuse or harassment of clients/residents or former clients/residents during time of employment.
AEBH will contact all former institutional employers of the applicant employed within the required five-year period requesting information above.
AEBH will not employ any applicant, contractor, or volunteer who has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse; or has been civilly or administratively adjudicated to have engaged in the activity described above.
AEBH will consider all incidents of sexual harassment in determining whether to hire or promote anyone, or to enlist the services of any contractor or volunteer, who may have contact with clients/residents.
AEBH will conduct criminal background records checks at least every 5 years on current employees, contractors, and volunteers who have contact with clients/residents.
AEBH will ask all applicants and employees who may have contact with clients/residents directly about previous misconduct described in paragraph “B” of this section in written applications or interviews for hiring or promotions and in any interviews or written self-evaluations conducted as part of reviews of current employees. AEBH will also impose upon employees a continuing affirmative duty to disclose any such misconduct.
Material omissions regarding such misconduct, or the provision of materially false information, shall be grounds for termination.
Upon receiving a signed release by a former employee referencing Minnesota Statute 626.87, AEBH shall provide information to an institutional employer for whom the employee has applied to work on substantiated allegations of sexual abuse or sexual harassment.
AEBH’s staff must be able to recognize the signs of sexual abuse and sexual harassment and understand their responsibility in the detection, prevention, response, and reporting of an alleged sexual abuse or sexual harassment.
Shift staffing plans and deployment of video monitoring systems or technology shall be assessed, at least annually, for adjustments and documented by the PREA Compliance Manager and communicated to the agency PREA Coordinator.
AEBH shall implement policies and procedures that enable clients/residents to shower, perform bodily functions, and change clothing without staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine room checks. All staff, regardless of gender, must announce, their intention to enter a resident’s room during times that the resident is likely to be dressing or undressing. It is not necessary for staff to announce their presence when security checks are being made while residents are sleeping.
AEBH will, to the degree possible within limited resources and applicable laws, protect client/resident victims and reporters of sexual abuse, sexual solicitation, sexual harassment and sexual coercion from retaliation.
When designing or acquiring any new facility and in planning any substantial expansion modification of existing facilities, AEBH shall consider the effect of the design, acquisition, expansion, or modification upon the agency’s ability to protect clients/residents from sexual abuse.
When installing or updating a video monitoring system, electronic surveillance system, or other monitoring technology, the agency shall consider how such technology may enhance the agency’s ability to protect clients/residents from sexual abuse.
AEBH shall ensure that the facility it operates develops and documents a staffing plan that provides for adequate levels of staffing to protect clients/residents against sexual abuse. Any deviations from the facility staffing plan will be documented with justification.
AEBH’s staff shall not search or physically examine any client/resident for the sole purpose of determining the client’s/resident’s genital status. If the client’s/resident’s genital status is unknown, it may be determined during conversations with the resident, by reviewing medical records, or if necessary, by learning that information as part of a broader medical examination by a medical practitioner.
The agency shall not place gay, bisexual, transgender, or intersex clients/residents in dedicated rooms solely on the basis of such identification or status, unless such placement is in a dedicated room established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting such clients/residents.
AEBH does not authorize or permit pat searches on any client/resident.
At no time will AEBH allow a strip search or body visual cavity search to be conducted on a client/resident.
AEBH is an intense, cognitively demanding treatment program. AEBH cannot accommodate clients/residents who are deaf, have profound intellectual disabilities or cannot read or write, or who are blind in it’s treatment program.
RESPONSIVE PLANNING
AEBH’s residential treatment facilities will follow a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence for administrative proceedings and criminal prosecutions. Clients/residents will be referred to a local hospital for a forensic medical examination.
Upon receiving a report of alleged sexual abuse, staff will notify their Supervisor and/or any other Supervisor up to and including: the PREA Coordinator, PREA Compliance Manager (Residential Clinical Director), Program Supervisors, or the Night staff manager.
To the extent possible, staff shall attempt to secure the area to preserve any evidence that may assist the investigation process. Staff should document what was seen and heard, or otherwise observed at the scene, and safeguard any evidence (i.e. bed sheets, fluids on floor, victim’s and perpetrator’s clothing).
Allegations of sexual abuse or sexual harassment which involves potentially criminal behavior will be referred to the Minneapolis Police Department for investigation.
AEBH will inform the victim of what will happen next (i.e. the incident will be reported to an available clinical supervisor, the PREA Compliance Manager and the PREA Coordinator, the victim will be offered a forensic medical examination for evidence collection, an investigation will be conducted, the victim will be asked to provide information to the investigator, and the victim and any witnesses will be provided protections from retaliation).
Staff will complete an incident report detailing initial information given to staff from the victim or third party. Staff should ask victim for only basic information about the incident (i.e. Who was there? What happened? Where did the incident occur? When?). The report shall be given to the PREA Compliance Manager and PREA Coordinator.
The PREA Coordinator will ensure that the Executive Director is informed of any sexual abuse allegations and results of any investigations.
Forensic medical examinations in the community will be provided free of charge to the victim. The victim will be provided with unimpeded access to emergency and crisis intervention services, which will also be provided free of charge to the victim. SARS Nurses are located at Abbott Northwestern Hospital, Methodist Hospital and Hennepin County Medical Center.
Victim advocates from the Sexual Violence Center can be available at the forensic medical examination. This service is available to all Hennepin County residents, including individuals residing in AEBH’s residential treatment facilities no matter what their legal status. A Memorandum of Understanding (MOU) has been signed between AEBH and the Sexual Violence Center.
If requested by the victim, a victim advocate, qualified agency staff member, or qualified community-based organization staff member can accompany and support the victim through the forensic medical examination process and investigatory interviews and provides emotional support, crisis intervention, information, and referrals.
TRAINING AND EDUCATION
Staff Training
AEBH’s employee’s will receive training, based on PREA employee training standards. All current employees who have not received such training shall be trained within one year of the effective date of the PREA standards. AEBH shall provide each employee with refresher training every two years to ensure that all employees know the agency’s current sexual abuse and sexual harassment policies and procedures. During the years in which an employee does not receive refresher training, AEBH shall provide refresher information on current sexual abuse and sexual harassment policies.
Upon hire and annually thereafter, AEBH will provide targeted PREA training on the following:
AEBH’s zero-tolerance policy for sexual abuse and sexual harassment; b. AEBH’s sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures; c. Clients’/Residents’ rights to be free from sexual abuse and sexual harassment; d. The right of clients/residents and employees to be free from retaliation for reporting sexual abuse and sexual harassment; e. The dynamics of sexual abuse and sexual harassment in a residential treatment facility; f. The common reactions of sexual abuse and sexual harassment victims; g. How to detect and respond to signs of threatened and actual sexual abuse; h. How to avoid inappropriate relationships with clients/residents; i. How to communicate effectively and professionally with clients/residents, including gay, bisexual, transgender, intersex, or gender nonconforming residents; and j. How to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities.
Gender specific training will be provided to the gender of the residents at the employee’s facility.
AEBH will document, through employee signature or electronic verification, that employees understand the training they have received.
Training participation may be offered in-house, online, webinars, conferences, etc. Training topics will be added and offered based upon the annual training needs as assessed by the PREA Complaince Manager and the PREA Coordinator.
AEBH will provide training as needed for staff to conduct administrative investigations.
Volunteer and Contractor Training
AEBH will ensure that all volunteers and contractors who have contact with clients/residents have been trained on their responsibilities under AEBH’s sexual abuse and sexual harassment prevention, detection, and response policies and procedures.
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 clients/residents. Training needs for volunteers and contractors will be assessed by the PREA Compliance Manager and PREA Coordinator.
All volunteers and contractors who have contact with clients/residents will be trained on AEBH’s Zero-Tolerance Policy regarding Sexual Abuse and Sexual Harassment and how to report such incidents.
AEBH will maintain documentation confirming that volunteers and contractors understand the training they have received.
Client/Resident Education
During the intake process, clients/residents shall receive information explaining AEBH’s zero-tolerance policy regarding sexual abuse and sexual harassment, how to report incidents or suspicions of sexual abuse or sexual harassment, their rights to be free from sexual abuse and sexual harassment and to be free from retaliation for reporting such incidents, and regarding agency policies and procedures for responding to such incidents.
AEBH is an intense, cognitively demanding treatment program. As such, AEBH will provide resident education in formats accessible to all residents; however, AEBH’s treatment program cannot accommodate those who are limited English proficient, deaf, visually impaired, or otherwise disabled, as well as, residents who are unable to read or write.
AEBH will maintain documentation of a client’s/resident’s participation in these education sessions in a client’s/resident’s file.
AEBH will ensure that key information is continuously and readily available or visible to clients/residents through posters, resident handbooks, or other written formats.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION AND ABUSIVENESS

AEBH clients/residents will be assessed for their risk of being sexually abused by others or sexually abusive toward others.

Within 72 hours of intake, clients/residents will be assessed to determine whether they meet specific criteria indicating vulnerability to sexual abuse. As a sexual offender treatment program, all of our clients/residents have a history of sexually abusive behavior. Residents may not be disciplined for refusing to answer, or failing to disclose information in regards to the assessment questions.
Potential Victim:During initial case management meeting, residents will be assessed, utilizing an objective screening tool, to specifically determine their vulnerability as indicated by the following risk factors:
The client/resident has a mental, physical, or developmental disability; b. The client/resident has previously experienced sexual victimization; c. The client’s/resident’s physical stature; d. The client’s/resident’s age; e. Whether the client/resident has previously been in a residential facility or incarcerated; f. Client’s/resident’s criminal history is exclusively non-violent; g. Client/resident is or is perceived the be gay, bisexual, transgender, intersex, or gender nonconforming; h. Client/resident has prior convictions for sex offenses against an adult or child (All of AEBH’s clients have sex offending histories); i. Client’s/resident’s own perception of vulnerability.
A client/resident should be designated with and identified for vulnerability if:
Three or more of the above criteria apply; or b. One or more of these factors apply with sufficient documentation by the reviewer to warrant concern.
Potential Aggressor: All of AEBH’s clients/residents have a sexual offending history.During the initial meeting with the case supervisor, clients/residents will be assessed to specifically determine if there are indications that they are prone to victimize other clients/residents especially in regard to sexual behavior. Staff will assess this based on a client’s/resident’s criminal history, pre-sentence evaluations, institutional misconduct reports, police records, etc. Indications include the following:
Client/resident has institutional incidents of sexually abusing others;
Client/resident has prior acts of violent sexual abuse (non-institutional);
Client/resident has convictions for violent offenses;
Client/resident has prior violence within institutional settings.
The Case Supervisor will reassess each client’s/resident’s risk of victimization or abusiveness within 30 days after the initial meeting based upon any additional, relevant information received by AEBH since the initial screening.
A client’s/resident’s risk level will be reassessed when warranted due to a referral, request, incident of sexual abuse, or receipt of additional information that bears on the client’s/resident’s risk of sexual victimization or abusiveness.
To ensure confidentiality and sensitivity of information of the client’s/resident’s responses on the assessment, assessment information will be kept in the client’s/resident’s confidential file and not shared with outside agencies.
Use of screening information shall be used to determine rooming assignments with the goal of keeping separate those clients/residents at high risk of being sexually victimized from those at high risk of being sexually abusive.
Clients/Residents considered high risk for sexual victimization will be placed in room assignments on an individualized basis. AEBH will determine how to best keep residents safe from sexual victimization. Housing decisions in general and specifically housing for more vulnerable clients is detemined by the consensus of the staff. This is discussed at daily staff meetings.
AEBH is a treatment facility for male sex offenders only. AEBH shall consider on a case-by-case basis whether a placement would ensure the client’s/resident’s health and safety, and whether the placement would present management or security problems.
A transgender or intersex resident’s own views with respect to his own safety shall be given serious consideration.
AEBH does not have group showering. All clients/residents including transgender and intersex clients/residents are able to shower separately from other residents.
AEBH does not place gay, bisexual, transgender or intersex clients/residents in dedicated facilities, rooms or floors solely on the basis of such identification or status, unless such placement is in a dedicated facility, room, or floor established in connection with a consent decree, legal settlement, or legal judgement for the purpose of protecting such clients/residents.

VII. REPORTING

Client/Resident Reporting
AEBH maintains multiple ways for clients/residents and staff to report allegations of sexual abuse/harassment/staff sexual misconduct perpetrated by other clients/residents, staff contractors or volunteers. Upon program entry, clients/residents are informed of ways they can report sexual abuse. These include verbal and/or written reports to any facility staff or the agency PREA Coordinator. Additionally, clients/residents are informed they may also contact local sexual abuse resources or local law enforcement.
Clients/residents are encouraged to report when either of the following conditions exists:
The client/resident has been or is currently a victim of sexual abuse, sexual solicitation, sexual harassment or sexual coercion; or b. The client/resident has knowledge of sexual abuse; sexual solicitation, sexual harassment or sexual coercion having occurred or occurring in a correctional facility.

i.) Clients/Residents who report to AEBH staff that they have been sexually abused or have knowledge of another client/resident who has been sexually abused, sexually solicited, sexually harassed or sexually coerced, do so with the understanding that AEBH staff will investigate and where appropriate, refer to local law enforcement;

ii.) Information provided by clients/residents to AEBH staff will be subject to verification by investigators. Information provided in confidential communications to AEBH staff listed below will be shared consistent with and according to the standards required by state statute, professional licensure, and ethical standards.

– Case Manager, Night Staff Manager Case Supervisor
– PREA Compliance Manager (Program Clinical Director)
– Executive Director
– PREA Coordinator

iii.) When interviewing clients/residents concerning sexual abuse, sexual solicitation, sexual harassment and sexual coercion, all AEBH staff will inform clients/residents of any limits to confidentiality prior to conducting the interview;

iv.) If the report is delayed, a client/resident shall be referred to local community medical/mental health agencies as appropriate;

v.) Contact appropriate authorities (local law enforcement, MN DOC, referral agencies in outside states for the particular client/resident);

vi.) Complete incident report;

vii.) Notify PREA Compliance Manager and PREA Coordinator.

PREA information collected during investigations or intake assessments is considered sensitive and should only be shared with those staff with a need to know as part of their assigned duties.
Under no circumstances should access to treatment resources be denied a client/resident victim solely because the client/resident will not fully disclose details to investigators or community health services staff.
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 client/resident or staff.
Clients/residents who allege sexual abuse and sexual harassment by staff or other clients/residents, and whose allegations are proven by investigators to be false will be held accountable through all means available to the agency.
Staff Reporting
When a client/resident reports incidents of sexual abuse, sexual solicitation, sexual harassment or sexual coercion to AEBH staff members, or staff members observe such incidents, staff will, except as noted elsewhere in agency policy, contact the PREA Compliance Manager and PREA Coordinator. Staff may privately report allegations to the PREA Compliance Manager, PREA Coordinator, or Executive Director.
The PREA Compliance Manager or designee will initiate action as outlined in this policy to mitigate:
Immediate harm to the victim or reporter; and/or
b. Damage to potential crime scenes or evidence.
Staff shall accept reports made verbally, in writing, anonymously, and from third parties, and shall promptly document any reports. Upon notification by a client/resident that he has been sexually abused or coerced into unwanted sexual contact, the staff member shall immediately complete an incident report and notify the PREA Compliance Manager and PREA Coordinator.

VIII. OFFICIAL RESPONSE FOLLOWING A CLIENT/RESIDENT REPORT/COORDINATED RESPONSE

Should a client/resident report a sexual abuse/assault by another client/resident, the following protocol should be followed:

Staff will immediately separate the alleged victim and abuser.
If the report is made immediately following the abuse/assault and the victim has not showered, the victim shall remain in the accompaniment of staff and be instructed not to shower or change clothes, brush their teeth, etc. Ensure the alleged abuser does not take any actions that could destroy physical evidence as appropriate (washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, and eating).
The staff shall immediately contact 911 for police and ambulance to respond if the victim is in need of medical attention. Staff is to request a police officer from the sexual abuse/assault unit.
After hours, the staff on duty shall contact the PREA Compliance Manager and PREA Coordinator for additional instructions and support (may need additional staff to report to facility).
During business hours, the PREA Compliance Manager or designee shall be contacted as soon as possible. The PREA Compliance Manager will be responsible for notifying the PREA Coordinator, who will notify the Executive Director as appropriate.
The PREA Compliance Manager or designee will contact the referring agency and inform them of the situation. In cooperation with the local authorities, AEBH will determine the status of the accused. If the accused is not immediately taken into custody, AEBH management will evaluate and determine if the accused will be removed/terminated from the treatment program.
Staff are to secure the area where the abuse took place, restricting it from client and staff access until the area is released by the police responding to the incident.
Staff should attempt to obtain a written statement from the victim. Staff will also prepare a written report detailing what the client/resident reported to the staff member, additional information regarding observed evidence, actions taken, etc.
At any time, the client/resident victim may refuse to participate in the process and not proceed with the investigation/reporting. The client/resident shall not be punished for refusing to cooperate with the investigation.
AEBH will work with community resources and the client/resident to ensure that communications with community resources/advocates are confidential to the extent allowable by law. Prior to referral to a community resource, AEBH will inform client/resident of the extent to which client/resident may expect such communications to remain confidential.
There is no other facility for the client/resident victim to be transferred.
The client/resident may also report a sexual abuse/assault through a grievance form. The client/resident shall be separated from the accused and the victim shall be encouraged to report the incident to the police and receive medical attention/evaluation. The same attention and services will be offered to a client/resident who reports a sexual abuse days or weeks after the alleged abuse.
If the abuse is reported as having taken place during the offenders’ incarceration in a MN DOC correctional facility, the PREA Compliance Manager will contact Deb Wein and MN DOC PREA Coordinator at 651-361-7780/cell 651-775-06630, email: Debra.Wein@state.mn.uswithin 72 hours of report. If the abuse occurred in another facility other than DOC, the PREA Compliance Manager will contact the facility head.
Allegations received from other facilities and agencies will be investigated in accordance with the PREA standards.
All allegations of sexual abuse/assault shall be taken seriously by staff, recognized as traumatic to the client/resident victim and staff shall be sensitive at all times to the needs and emotions of the victim.
Confidentiality and client/resident privacy shall be maintained at all times, with only those who have a direct “need to know” having access to the personal information and details of the victim and alleged perpetrator.
If a client/resident does not believe his accusations of sexual abuse/assault were responded to appropriately, he does not feel safe as a result of the abuse, or any other concerns regarding the alleged abuse, he may submit a written grievance following the grievance chain of command up to the agency Executive Director. The decision and response of the agency Executive Director is final.
As the needs of the client/resident victim are being met, the agency shall assemble the Sexual Abuse Response Team (SART), which may include: the client/resident’s Case Manager, Case Supervisor, PREA Compliance Manager, PREA Coordinator, and Executive Director.
The SART will ensure that the clients are safe and the victim is being cared for physically and emotionally.
The SART will ensure that policies and procedures are being followed.
The SART will review the incident and evaluate what possible warning signs were missed, if anything could have been done to prevent the abuse, what can be done to prevent an abuse from happening again in the same manner/location, etc.
SART will ensure that the referring agencies are kept informed and information is relayed between appropriate parties.
The SART will maintain investigative records of alleged sexual abuse or abuses for seven years.
AEBH will monitor the conduct/treatment of clients/residents or staff who have reported sexual abuse or cooperated with investigations, including any client’s/resident’s disciplinary reports, rooming changes, or program changes, for at least 90 days following their report or cooperation to assess changes that may suggest possible retaliation by clients/residents or staff. In each instance, the designated monitor will be approved by the agency PREA Coordinator in an attempt to insure that the monitor has no connection to the incident and is in a position to impartially monitor the situation.
If an allegation that is reported to and investigated by the appropriate legal authority does not result in criminal charges or disciplinary actions from that body, AEBH reserves the right to conduct an internal investigation. This investigation seeks to determine risk that the abuse/misconduct occurred and will provide AEBH with the opportunity to take the appropriate actions according to agency policy.
Incident reports, investigations and results on client/resident sexual abuse/misconduct will be retained for seven years; statistical data on sexual abuse/assault will be retained for ten years.
INVESTIGATIONS POLICY

It is the general policy of AEBH that all incidents of suspected sexual harassment or sexual abuse be adequately addressed through inquiry or investigation.

Sexual Harassment:When allegations of sexual harassment are made, investigations shall take place under the following guidelines:
Client/Resident to Client/Resident:The PREA Compliance Manager, his/her designee or the PREA Coordinator shall conduct an investigation questioning all parties involved to determine what happened and direct action to prevent further incidents. The Minnesota Department of Corrections licensing authority will be notified of the findings and the PREA Compliance Manager/designee or PREA Coordinator shall file appropriate reports.
Staff to Client/Resident:The PREA Compliance Manager, designee and the PREA Coordinator shall conduct an investigation questioning all relevant parties to determine what happened. The Minnesota Department of Corrections licensing authority shall be notified of findings and consulted in determination of actions to be taken.
If the PREA Compliance Manager is involved in the allegations:His/her immediate supervisor shall conduct the investigation as noted above.
Sexual Abuse:When allegations of sexual abuse/assault are made, the following shall happen:
Contact local authorities immediately, if a client/resident reports a sexual assault. If the PREA Compliance Manager or PREA Coordinator is available, he/she shall take responsibility for contacting authorities. If the PREA Compliance Manager is not available, on duty staff must contact authorities without delay.
If the allegations or quality of evidence suggest a crime has been committed, do not conduct further interview of the victim or perpetrator until cleared to do so by prosecuting authority.
AEBH will not impose a standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated.
If there is a possibility of new physical evidence to be used:
a) Secure the area where the alleged abuse took place and do not allow residents to enter the area until police personnel have cleared the area;
b) Do not touch anything in the area where the alleged abuse took place other than to preserve the life or safety of an individual;
c) Move the alleged victim to a secure area until authorities arrive;
d) If conditions allow, direct the alleged perpetrator to remain in an area where they can be observed until authories arrive;
e) AEBH staff shall cooperate with all aspects of the investigation by local authorities. The PREA Compliance Manager and PREA Coordinator shall endeavor to remain informed about the progress of the investigation and notify the Minnesota Department of Corrections licensing authority of the results as appropriate;
f) AEBH’s PREA Compliance Manager/designee or PREA Coordinator shall conduct administrative investigation;
g) Any substantiated allegations of conduct that appears criminal will be referred for prosecution.
Reporting to Clients/Residents:In the event of a client/resident allegation of sexual abuse, the PREA Compliance Manager shall:
Following an investigation into a client/resident’s allegation that he suffered sexual abuse in AEBH’s facility, the PREA Compliance Manager shall inform the client/resident as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded.

2.If the agency did not conduct the investigation, it shall request the relevant information from the investigative agency in order to inform the client/resident.

Following a client’s/resident’s allegation that he was sexually abused by another client/resident, AEBH will inform the alleged victim when:
AEBH learns that the alleged abuser has been indicted on a charge related to the sexual abuse;
AEBH learns that the alleged abuser has been convicted on a charge related to the sexual abuse.
Following a client/resident’s allegation that a staff member has committed sexual abuse against the client/resident and the findings are substantiated or unsubstantiated; the PREA Compliance Manager shall inform the client/resident whenever:
The staff member is no longer employed at the facility;
The agency learns that the staff member has been indicted on a charge related to the sexual abuse within the facility;
The agency learns that the staff member has been convicted on a charge related to the sexual abuse within the facility.
All such notifications or attempted notifications shall be documented by the PREA Compliance Manager.
The PREA Compliance Manager’s obligation to report shall terminate if the client/resident is released from AEBH’s program.
The departure of the alleged victim from the program or alleged abuser from employment or control of the program or agency shall not provide basis for terminating an investigation.
DISCIPLINE

It is the policy of AEBH that all staff will be subject to disciplinary sanctions up to and including termination for violating the sexual harassment and sexual abuse policies.

Staff that has engaged in sexual abuse, sexual coercion, or sexual harassment will be terminated from AEBH.
Disciplinary sanctions for violating the sexual abuse or sexual harassment policy but not for actually engaging in sexual abuse will be based on the following:
The nature and circumstances of the acts committed.
The staff member’s disciplinary history.
The sanctions imposed for similar offenses by other staff with similar histories.
All staff, contractor, and volunteer terminations or resignations resulting from criminal sexual abuse will be referred to law enforcement.
All contractor and volunteers who violate AEBH’s sexual abuse and/or sexual harassment policies will be prohibited from further contact with clients/residents. Where applicable, law enforcement and licensing agencies will be notified.
Clients/residents will be subject to disciplinary sanctions through a formal disciplinary process following;
An administrative finding that the client/resident engaged in client/resident – on – client/resident sexual abuse.
Following a criminal finding of guilt for client/resident – on – client/resident sexual abuse.
Sexual abuse/assault/harassment/coercion are serious misconduct violations for clients/residents in AEBH’s program. Any form of such sexual behavior will result in termination from the program.
A client/resident’s report of sexual abuse made in good faith and based on reasonable belief will not be disciplined for falsely reporting an incident, even if the investigation does not establish evidence sufficient to substantiate the allegation.
AEBH will discipline a client/resident for sexual contact with staff only upon a finding that the staff member did not consent to such contact.
MEDICAL AND MENTAL CARE

It is the intention of AEBH that there will be no long-term forfeiture of services for victims of sexual abuse, sexual coercion, sexual harassment or sexual solicitation. Recognizing that the safety of the victim is paramount, room assignments will be taken into consideration.

Medical access to services for victims of sexual abuse will be handled in the community.
Timely, unimpeded access to emergency medical treatment without financial cost as determined by the medical practitioners’ professional judgment.
Testing and prophylactic treatment for sexually transmitted disease (STD).
Referral to community mental health services.
Communication with community sexual abuse advocate regarding any information deemed not confidential.
Mental health services for victims of sexual abuse will be referred to community mental health practitioners:
Timely, unimpeded acces to appropriate mental health evaluation services without financial cost as determined by the mental health treatment providers’ professional judgment.
Comprehensive information of limits of confidentiality and duty to report.
Completion of a mental health evaluation.

XII. DATA COLLECTION AND REVIEW

AEBH shall collect information related to the purposes outlined at the beginning of this policy; specifically to gather data that will help AEBH reduce the risk that sexual abuse and/or sexual harassment would occur within AEBH’s facilities.
The agency PREA Coordinator shall be responsible to identify the specific data that must be collected and to work with the PREA Compliance Manager from AEBH to assure data is submitted within the required time frame. This data will be compiled into quarterly and annual reports for submission to the Executive Director. The purpose of these reports is to:
Establish a baseline of data documenting the prevalence of incidents involving sexual abuse as determined from all available sources; including misconduct reports, unusual incident reports, and resident grievances.
Provide information to AEBH’s leadership concerning where efforts are needed for the improvement of agency operations related to the reduction of sexual abuse.
Document that there is accountability for those who perpetrate sexual abuse by tracking:
The adjudication of misconduct reports related to sexual abuse including the disposition of each case;
The status of investigations conducted by the local law enforcement, MN DOC Office of Special Investigations or referring agencies from states outside Minnesota concerning suspected incidents of sexual abuse;
Referrals of sexual abuse cases for prosecution, including the status and outcome of such efforts within the judicial system;
The retention of all written reports referenced as long as the alleged abuser is incarcerated by the MN DOC, plus five years.
Document that victims of sexual abuse receive appropriate follow-up care as outlined in this policy.
Compile information collected directly from the client/resident population by means of various survey methods which relate to the prevalence of sexual abuse within the agency, including the circumstances that contribute to this kind of behavior, in order to provide insight into potential strategies for its reduction or elimination by:
Identifying problem areas;
Taking corrective action on an ongoing basis;
Preparing an annual report of its findings and corrective actions for AEBH’s facilities;
Including an assessment of the agency’s progress in addressing sexual abuse by comparing the current year’s data and corrective actions with those from prior years;
Ensuring that the agency’s report shall be approved by the agency head and made readily available to the public through its website;
Redacting specific material from the reports when publication would present a clear and specific threat to the safety and security of a facility, and indicating the nature of the material redacted.
Ensure that annual audits include inspection for areas and situations where sexual abuse may be likely to occur and recommend mitigation for those areas and situations.
Collect and compile data and coordinate surveys to ensure continuity of services, operational improvements, and establishment of baselines.
Produce an annual summary for the Executive Director on the frequency and severity of sexual abuse/sexual harassment within AEBH’s facilities including trends during the year, comparisons to previous years, and deficiencies identified in the annual audit.
Before making aggregated sexual abuse data public, AEBH will remove all personal identifiers to ensure confidentiality is maintained.

PREA AUDIT: AUDITOR’S SUMMARY REPORT
COMMUNITY CONFINEMENT FACILITIES

Name of Facility: AEBH Human Services, Inc.
Physical Address: 2712 Fremont Avenue South, Minneapolis, MN 55408
Date of Report: 6/22/15

Auditor Information: Timothy Pippo
Address: 3800 Braddock Ave NE, Buffalo, MN 55313
Email: tim.pippo@co.wright.mn.us
Phone: 763-684-2380
Date of facility visit: 5/29/15

Facility Information
Telephone number: 612-872-8218
The facility is: Private not for profit
Facility type: Community treatment center
Name of Facility Head: Richard Weinberger Title: Clinical Director
Email address: RickW@AEBHservices.org Telephone number: 612-872-8218 ext. 15
Name of PREA Compliance Manager: Richard Weinberger Title: Clinical Director

Agency Information
Name of agency: AEBH Human Services, Inc.
Physical address: 2712 Fremont Avenue South, Minneapolis MN 55408
Telephone number: 612-872-8218

Agency Chief Executive Director
Name: Gerald T. Kaplan Title: CEO
Email address: GTK@AEBHservices.org Telephone number: 612-872-8218 ext. 17

Agency-Wide PREA Coordinator
Name: Riki Kravitz Title: Outpatient Program Coordinator
Email address: RikiK@AEBHservices.org Telephone number: 612-822-1357

AUDIT FINDINGS

NARRATIVE:

AEBH Human Services is an intensive Residential Treatment Program for adult males that have a past history of, and or a criminal conviction for sexually deviant behavior. The Treatment Program is nationally recognized for its leadership and innovation for the treatment of sexual offenders. Staff members are comprised of psychologists, counselors and therapists (majority of which are licensed) along with staff that perform security functions. Most staff members have more than one responsibility pertaining to the Agency PREA Policy. The agency refers to the residents as clients. Clients of the facility are committed to a long term multi-phase program that is usually at least 13 months in duration. Treatment consists of individual and group counseling sessions trending towards Behavior Modification. Clients gain more privileges with each phase of the program that they complete up until graduation from the program. The facility is one of few in-patient options for sexual offenders throughout the United States. Some clients are allowed into the program through an interstate compact. The facility operates under a conditional license from the Minnesota Department of Corrections and abides by Minnesota 2920 Rules Governing Adult Community-Based Residential Correctional Facilities.

The facility has two buildings it utilizes to house clients. The building located at 3341 Portland Ave South, Minneapolis, MN (known as Portland) is used as a dormitory for clients. All clients that are assigned house at this location occupy their rooms only in the evening and are monitored by security staff overnight. They are transported to and from the building located at 2712 Fremont Ave South, Minneapolis, MN (known as Fremont) each morning starting around 7:00am. The Fremont building is where all meals are served and where all programming functions take place.

On May 29, 2015 Timothy Pippo, Certified PREA Auditor conducted an on-site audit of AEBH Human Services. I arrived at the facility on Fremont Ave at 7:30am. I was met by the Clinical Director and PREA Compliance Manager Richard Weinberger and was later joined by Riki Kravitz the Agency Outpatient Program Coordinator and PREA Coordinator. I physically toured the building located on Portland Avenue. The facility was at maximum capacity of 23 residents housed; on the day of the audit. Three residents met definitions to qualify them as being part of the LGBTI community. The facility has had 0 reports of sexual abuse or harassment within the last 12 months.

DESCRIPTION OF FACILITY CHARACTERISTICS:

The facility consists of two buildings. The Portland building is a two story renovated apartment building located in a residential area in South Minneapolis. The building is used mainly for sleeping purposes. There are 6 bedrooms and 2 private bathrooms located on the first floor and 3 bedrooms along with 2 private bathrooms located on the second floor, for a total capacity of 16 residents. The basement of the facility has a laundry room along with a television lounge area. The staff office is located in the basement also. This building is staffed from 8:00pm to 8:00am or any time residents are present. The residents are transported to and from the Fremont building every day for meals and programing. The building on Fremont Ave is a 3 story renovated house located in a residential neighborhood in South Minneapolis. This building has two bedroom’s on the second floor along with 1 private bathroom. This building can house 7 residents. The third floor of the building is utilized for office space. The main floor of this portion of the facility has a lounge area, staff offices and a kitchen. Residents take turns cooking meals as part of their housing duties assigned to them. The basement of the house has a laundry area and a large classroom area used for group counseling sessions. This building is staffed 24hrs/day.

Mission:

AEBH’s mission is to reduce the incidence of the victimization of innocent people by providing treatment to sex offenders, their families, and sexual abuse victims; to reduce the pain and suffering caused by sexual abuse, and to be an educational resource for other agencies, and the public.

The primary objective of the program is to modify deviant criminal and antisocial behavior; i.e., to reduce the likelihood of that behavior recurring. In addition to improved emotional and mental health, the program emphasizes adaptive behavior which generally falls into three basic areas:

Meaningful interpersonal relationships and family interaction, including appropriate sexual behavior and social skills.
Appropriate work behavior and responsible self-support skills.
Healthy, responsible interactions with the community.

SUMMARY OF AUDIT FINDINGS

Number of standards exceeded: 0
Number of standards met: 35
Number of standards not met: 0
Number of standards not applicable: 4

Standard Number 115.211 Zero tolerance of sexual abuse and sexual harassment; PREA Coordinator

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

a) The agency has a policy that covers this standard that is available to all staff.
b) The agency has a designated PREA Coordinator that is also the Outpatient Program Director. Interviews with the PREA Coordinator and the Agency CEO assured the fact that this person has adequate time to take on these responsibilities.

Standard Number 115.212 Contracting with other entities for the confinement of residents

Not applicable

The Agency does not contact with any outside vendors or agencies for treatment or security reasons.

Standard Number 115.213 Supervision and monitoring

Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
a) The Agency has a documented staffing plan that follows the agency PREA policy page 5.
b) The Agency never varies from the staffing plan; staff is obligated to remain on duty until relieved. A
c) Interviews with the CEO and PREA Coordinator confirmed adherence to this portion of the standard. Agency policy page 7 refers to this standard also.

Standard Number 115.215 Limits to cross-gender viewing and searches

Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
a) The facility does not perform any strip searches or body cavity searches of any kind.
b) The agency does not allow any pat searches of any kind by any gender. Interviews with residents and staff members confirmed no pat searches.
c) The facility never performs any cross-gender searches of any kind.
d) Agency policy page 7 along with interviews with staff members and residents confirm compliance with this standard. Female auxiliary counselors that perform security rounds announce themselves when entering a house area during non-routine room checks. Both buildings have private shower areas and female staff members never enter an occupied bathroom. Residential rules prescribe the male residents to be fully clothed when not in bed sleeping or using a bathroom.
e) The facility is male only and only Transgender males of Intersex residents identifying as males would be allowed in the treatment program. All staff members are trained sexual therapists or counselors and are well versed on how to interview residents about gender identity. There were no transgender or intersex residents housed on the day of the audit.
f) The facility does not perform pat searches on any residents for any reason.

Standard Number 115.216 Residents with disabilities and residents who are limited English proficient

Not Applicable

The facility’s physical design is not fitted for residents with physical disabilities. All residents are pre-screened before acceptance into the program. The agency would be unable to make all of its rigorous programming available to residents with limited English or vocabulary skills. Interviews with staff members however confirmed that they would obtain an interpreter if needed to communicate with any person reporting sexual abuse or harassment.

Standard Number 115.217 Hiring and promotion decisions

Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
a) Agency policy page 6 and 7 along with Employee Handbook page 18 refer to this standard.
b) Employee Handbook page 34 and Agency policy refer to zero tolerance of sexual harassment.
c) d) e) Criminal background checks for all employees are mandated by MN Rule 2920.400 and also by Agency policy. The agency utilizes the Minnesota Bureau of Criminal Apprehension to complete criminal history checks.
f) g) Agency policy page 7 and Employee Handbook page 34 and 23 refer to employee reviews. The facility incorporates the three qualifiers from section a) of this standard in employee reviews.
h) Interviews confirmed that the Agency would notify other agencies of allegations as permitted by law.

Standard Number 115.218 Upgrades to facilities and technologies

Meets standard

The facility has not had any major upgrades in the last year. An interview with the Agency Executive Director and the PREA Coordinator confirmed that the facility would follow their policy and take into account PREA considerations when determining any new upgrades to the facility.

Standard Number 115.221 Evidence protocol and forensic medical examinations

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

a) Agency policy page 8 covers this standard. The facility also has a “Sexual Assault Checklist” outlining correct procedures for staff to follow.
b) Outlined protocols follow the standard.
c) The facility would use one of three local hospitals for SAFE or SANE examinations. Hennepin County Medical Center in Minneapolis has 24/7 nurse examiners available as posted on web-site http://www.hcmc.org/services/sars/index.html. Methodist Hospital is located in St. Louis Park MN and provides the same services as Hennepin County Medical Center. The third hospital is Abbott Northwestern Hospital in Minneapolis and it offers 24/7 nurse examiners as listed on this web-site http://www.allinahealth.org/Health-Conditions-and-Treatments/Sexual-assault-care-services/
d) e) The Agency has a signed MOU with “Sexual Violence Center” Minneapolis that confirms advocacy and support services for AEBH Human Services residents.
f) g) The Agency will utilize Minneapolis Police Department for sexual abuse investigations.
h) The Sexual Violence Center would provide trained individuals for support of this portion of the standard.

Standard Number 115.222 Policies to ensure referrals of allegations for investigations

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

a) Agency policy page 8 spells out mandatory investigations for all allegations of sexual abuse or sexual harassment.
b) c) The facility will use Minneapolis Police Department for sexual abuse allegations as posted on the Agency web-site at http://AEBHservices.org/index.php/prea-policy.
d) e) Minneapolis Police Department has specialized sex crime investigators. The police department has investigative procedures on its web-site http://www.ci.minneapolis.mn.us/police/policy/mpdpolicy 10-200 10-200

Standard Number 115.231 Employee Training

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

a) Agency policy page 9 and 10 refer to this standard. All employees were trained using the protocols from an online PREA course “educorr” this information is located at web-site http://educorr.com/. This training course covers all 10 subsections of this standard.
b) Interviews with female staff members indicated that they received appropriate training.
c) Policy meets this requirement of the standard. Most staff members are highly educated sexual therapists or counselors.
d) The agency provided me with signed documents of completion of training requirements.

Standard Number 115.232 Volunteer and contractor training

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

PREA policy page 10 covers this standard. The agency does not have any volunteers and an interview with the facility maintenance person confirmed that he had been trained on the agency policies and procedures. The agency has signed documentation of the training received.

Standard Number 115.233 Resident education

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

a) Policy page 11 and the Resident Handbook page 76 provide direction for resident training.
b) The facility has weekly house meetings for all residents and PREA considerations are or may be discussed during these meetings.
c) The facility pre-screens clients that it allows in the program and does not have the capability to allow persons of limited abilities or disabilities into the program. Interviews with staff members indicated they would obtain interpreters if needed. There have been no limited English proficient or residents with disabilities house in the facility in the last 12 months.
d) The facility requires and has documentation of resident signatures on intake forms and resident handbooks.
e) The facility has posters throughout both buildings and provides information in the resident handbook.

Standard Number 115.234 Specialized training: Investigations

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

The agency does not conduct criminal sexual abuse investigations; Minneapolis Police Department will perform criminal investigations with trained officers. The agency will investigate all and any allegations of sexual abuse/harassment and does have an incident review team that has received specialized training through the National Institute of Corrections online course for PREA Investigations.

Standard Number 115.235 Specialized training: Medical and mental health care

Not Applicable

The agency does not employ or contract with any Medical or Mental Health practitioners that would treat any resident that were sexually victimized. All residents would be transported to Hennepin County Medical Center, Methodist Hospital or Abbott Northwestern Hospital for care. The PRC FAQ General #8 refers to non-applicability of this standard.

Standard Number 115.241 Screening for risk of victimization and abusiveness

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

a) Policy pages 11, 12, 13 refer to screening of residents. Interviews with residents confirmed that the screening was completed.
b) The agency has one person that does risk assessments for the facility. An interview with him indicated that most residents receive the screening before they are admitted to the facility.
c) d) The facility uses a vulnerability assessment tool that covers all the requirements set forth by the standard.
e) All residents of AEBH Human Services have a sexual offending history; therefore the screening is adapted to the unique makeup of the residents.
f) g) Each resident has an assigned case worker. The case workers are constantly monitoring each client and taking sexual vulnerability or aggressiveness into consideration.
h) Policy does not indicate discipline for failure to answer screening questions but the treatment program dwells on the resident’s sexual past frequently.
i) The agency provides strict controls on any resident information dissemination.

Standard Number 115.242 Use of screening information

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

a) Agency policy page 12 and 13 refer to this standard. Interviews with staff substantiated the fact that they use the screening to determine housing assignments. New residents are housed in the Fremont house that has more staff supervision; the treatment program itself determines the level of supervision of clients.
b) Since the facility only accommodates 23 residents, each person receives special consideration.
c) d) Only Transgender or Intersex persons identifying as male would be allowed in the treatment program and their personal views would be taken into consideration.
e) The facility has only private showers.
f) The facility would house persons of LGBTI definitions on an individual basis. There were no Transgender or Intersex residents housed in the facility within the last year. I interviewed a resident that identified as Gay; this resident was satisfied with the housing assignment and protections given.

Standard Number 115.251 Resident reporting

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

a) Policy page 13 and 14 and Resident Handbook page 76 provide direction for resident reporting.
b) Interviews with residents confirmed their knowledge of how to report privately.
c) d) Both staff and Residents reported that they were confident that they could report through a third-party person.

Standard Number 115.252 Exhaustion of administrative remedies

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

The agency has a grievance procedure for residents spelled out on page 60 of the Resident Handbook. The agency would, however, treat each and every grievance concerned with sexual abuse/harassment as an emergency grievance and respond to the grievance immediately. Staff interviews affirmed that they would react immediately and appropriately to any potential of a resident being in imminent danger of sexual abuse.

Standard Number 115.253 Resident access to outside confidential support services

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

a) Agency policy page 13 and 14 refer to this standard. The Resident Handbook page 77 has phone numbers listed for the Minnesota Department of Corrections Sexual Assault Helpline and the Minneapolis Sexual Violence Center and the agency PREA coordinator.
b) The Resident Handbook and postings in the facility advise the residents of the confidentiality of reporting. Interviews with residents showed confidence that they may have access to outside agencies for support purposes.
c) The agency has a signed MOU with Sexual Violence Center Minneapolis; the MOU meets the requirements of this standard. There have been no reports made to outside agencies within the last 12 months.

Standard Number 115.254 Third-party reporting

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

Policy and the Resident Handbook have information for third-party reporting. Interviews with residents affirmed that they knew they could have someone report for them no their behalf and staff interviews affirmed that they would accept third-party reports. The agency has this information posted on their web-site as part of their policy.

Standard Number 115.261 Staff and agency reporting duties

Meets standard (substantial compliance complies in all material ways with the standard for the relevant review period)

a) Policy page 14 and 15 pertain to this standard along with the Employee Handbook page 33 and 34.
b) All employees are obliged to adhere to the “American Psychological Association Ethical Principles of Psychologists and Code of Conduct”
c) The agency will utilize local hospitals for medical and mental health treatment. These hospitals operate under federal and state guidelines.
d) The facility only treats male adults.
e) Agency policy and interviews with staff members indicated that they would report all and any allegations or incidents to superiors.

Standard Number 115.262 Agency protection duties

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

Agency policy page 15 prioritizes the safety of at risk residents. Interviews with staff members uphold the priority of a safe environment for staff and clients.

Standard Number 115.263 Reporting to other confinement facilities

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

Policy page 16 correlates with this standard. Most residents were previously incarcerated in a Minnesota Correctional Facility. The agency is required by contract to notify the MN Department of Corrections of any sexual assaults reported to them. Residents are asked upon intake if they were ever sexually abused or committed sexual abuse in a confinement setting before. The facility would relay any reports of sexual abuse to any other agency within 72 hours. There have been no residents making such reports within the last year.

Standard Number 115.264 Staff first responder duties

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

a) Policy pages 15, 16, and 17 cover this standard. AEBH Human Services has a limited number of staff members therefore all staff persons are considered first responders and have been trained to react as such. The facility has protocols for first responders to follow. Interviews confirmed that staff members are well versed on how to respond to sexual assault situations.
b) The only non-security staff member was trained on how to correctly respond to an incident.

Standard Number 115.265 Coordinated response

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

The facility has developed a “Sexual Assault Response Checklist” and a PREA Flow Chart for an incident of Staff on Resident Sexual Assault. AEBH Human Services has also formed a Sexual Assault Response Team.

Standard Number 115.266 Preservation of ability to protect residents from contact with abusers

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

The agency does not have a collective bargaining agreement with its employees. Staff members are “At Will” employees and are subject to any discipline and or termination not legally prohibited. There have been no employees disciplined for violations of PREA policies in the last 12 months.

Standard Number 115.267 Agency protection against retaliation

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

The agency PREA policy page 17 covers this standard. The facility has a PREA Compliance Manager tasked to monitor retaliation; however interviews with Case Managers and Case Supervisors confirmed that they also would monitor retaliation within the facility for the entire stay of the resident. The facility has no means to separate abusers from victims within the buildings, so abusers or persons retaliating would be removed from the program. Interviews reinforced the fact that all facility personnel are educated in determining whether a client is a subject of retaliation or not. There have been zero reports of retaliation in the facility in the last year.

Standard Number 115.271 Criminal and administrative agency investigations

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

a) Policy pages 17, 18, and 19 pertain to this standard.
b) The agency will utilize Minneapolis Police Department for investigations of sexual abuse.
c) d) e) The Minneapolis Police Department has its policy and procedure for evidence collection posted on this web-site.
http://www.ci.minneapolis.mn.us/police/policy/mpdpolicy 10-400 10-400

The agency has an investigative team made up by the PREA Coordinator and the PREA Compliance Manager. Interviews with these team members confirmed their knowledge of the standards requirements. The Executive Director of the Agency made assurances that the Agency has a good rapport with the Minneapolis Police Department and that the facility would comply with subsections f) g) h) i) j) k) and l) of the standard. The agency has never had to do an investigation of Sexual abuse/harassment in this facility.

Standard Number 115.272 Evidentiary standard for administrative investigations

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

Agency policy page 18 and interviews with the investigative team confirm adherence to the standard of evidence outlined in this standard.

Standard Number 115.273 Reporting to residents

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

Policy page 19 covers all aspects of this standard and spells out the facilities obligation and roles in keeping residents informed of any investigation involving them. There have been 0 investigations within the facility in the last 12 months.

Standard Number 115.276 Disciplinary sanctions for staff

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

Agency Policy page 20 and Employee Handbook page 24 explain disciplinary sanctions for employees up to and including termination for violation of agency policies. Employees of AEBH Human Services are “At Will” employees and are subject to termination and prosecution for criminal charges. There has been 0 staff members disciplined for violation of Agency PREA policies within the last year.

Standard Number 115.277 Corrective action for contractors and volunteers

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

The agency would discipline up to termination of any person that is contacted to do work in the facility. The agency does not have any volunteers. Any criminal acts would be reported to Minneapolis Police Department immediately for prosecution. There have been no contractor employees disciplined for PREA policy violation in the facility in the last year.

Standard Number 115.278 Disciplinary sanctions for residents

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

Policy page 20 and Resident Handbook page 9 describe sanctions for residents. The agency also abides by MN Rule 2920.5700 in regards to resident discipline. The facility has no restrictive confinement for residents that may have to be separated from victims. The facility would have the aggressor removed from the facility and terminated from the program.

Abusive Residents would be transported to Hennepin County Jail or back to a Minnesota Correctional Facility. If the resident were under probation, the governing Probation Officer would also be involved in the discipline. There have been 0 residents disciplined for violation of Agency PREA policies within the last 12 months.

Standard Number 115.282 Access to emergency medical and mental health services

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

Policy page 21 and facility “Sexual Assault Checklist” implore staff to seek immediate medical attention for victims of sexual abuse. Residents would be transported immediately to an area hospital for emergency medical and mental health care.

Standard Number 115.283 Ongoing medical and mental health care for sexual abuse victims and abusers

Not Applicable

Policy page 20 refers to this standard. The facility is not equipped to provide ongoing medical care. The agency will ensure that the victim is offered medical and mental health care in whichever facility they are transferred to.

Standard Number 115.286 Sexual abuse incident reviews

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

a) Policy page 22 covers this standard. The facility will investigate any and all allegations or incidents of sexual abuse/harassment.
b) Interviews indicated that reviews would occur within a week of an investigation.
c) The agency review team is made up of the Executive Director, Clinical Director and the Outpatient Program Coordinator.
d) e) Interviews with the review team indicated that they would take all factors that are outlined in this standard into consideration when reviewing an incident and making recommendations to prevent a future incident.

Standard Number 115.287 Data Collection

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

The facility would use the Minnesota Statewide Supervision Special Incident Report form for any sexual assault/harassment incidents. The Agency has an annual report and posts data concerning current year sexual assault incidents on its web-site.

Standard Number 115.288 Data review for corrective action

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

Agency Policy page 21 and 22 cover this standard substantially. Interviews with the Executive Director and the PREA Coordinator confirmed that they would consider any data collected and take corrective measures based on the data. The agency posts its statistical data on its web-site at https://alphaemergence.org/policy

Standard Number 115.289 Data storage, publication and destruction

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

Agency policy page 22 refers to data maintenance. The facility is governed by MN Rule 2920.4800 concerning data retention and follows Minnesota State Statutes relating to data publication.

AUDITOR CERTIFICATION:

The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under review.

_____________Timothy Pippo______________ __________June 22, 2015__________

Annual Report

Prison Rape Elimination Act

The Prison Rape Elimination Act (PREA) was passed in 2003 with unanimous support from both parties in Congress. The purpose of the act was to “provide for the analysis of the incidence and effects of prison rape in Federal, State, and local institutions and to provide information, resources, recommendations and funding to protect individuals from prison rape”. (Prison Rape Elimination Act, 2003). In addition to creating a mandate for significant research from the Bureau of Justice Statistics and through the National Institute of Justice, funding through the Bureau of Justice Assistance and the National Institute of Corrections supported major efforts in many state correctional, juvenile detention, community corrections, and jail systems.

The act also created the National Prison Rape Elimination Commission and charged it with developing draft standards for the elimination of prison rape. Those standards were published in June 2009, and were turned over to the Department of Justice for review and passage as a final rule. That final rule became effective August 20, 2012.

In 2010, the Bureau of Justice Assistance funded the National PREA Resource Center to continue to provide federally funded training and technical assistance to states and localities, as well as to serve as a single-stop resource for leading research and tools for all those in the filed working to come into compliance with the federal standards.

AEBH Human Services has a zero tolerance policy toward all forms of sexual abuse and sexual harassment in our facility, under the Prison Rape Elimination Act (PREA) (28 CFR 115.11) 2003. We will enforce all federal, state, and local laws pertaining to all instances of alleged sexual misconduct. All reports are fully investigated, which includes both allegations of sexual abuse and sexual harassment.

To report any incident of sexual abuse or sexual harassment please contact AEBH Human Services at (612) 872-8218 and the Minneapolis Police Department at (612) 673-3000 or by dialing 911. The Minneapolis Police Department handles all investigations regarding sexual misconduct in our facility.

Complaints for 2014/2015:

May 29, 2014 — May 29, 2015

Client on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Staff on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Complaints for 2015/2016:

May 30, 2015 — May 29, 2016

Client on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Staff on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Complaints for 2016/2017:

May 30, 2016 — May 29, 2017

Client on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Staff on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Complaints for 2017/2018:

May 30, 2017 — May 29, 2018

Client on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Staff on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Complaints for 2018/2019:

May 30, 2018 — May 29, 2019

Client on Client Complaints

Sexual Abuse Unfounded Allegations: 2 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 2 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Staff on Client Complaints

Sexual Abuse Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

Sexual Harassment Unfounded Allegations: 0 Unsubstantiated Allegations: 0 Substantiated Allegations: 0

These statistics reveal a minimum amount of incidents of sexual misconduct within the facility. This reflects AEBH Human Services’ dedication to its zero tolerance policy towards sexual abuse and sexual harassment. This also reflects the training AEBH’s staff receives to achieve this goal.

*There is a current, ongoing investigation regarding allegations of client on client sexual assault. The police are currently handling the investigation. There are questions as to the legitimacy of the allegations by the alleged victim. According to the detective investigating the matter, upon completion of the investigation, the case might be referred to the Hennepin County Attorney’s office for possible charges against the alleged victim.