Has the agency ensured that all volunteers and contractors who have contact with residents have been trained on their responsibilities under the agency’s sexual abuse and sexual harassment prevention, detection, and response policies and procedures? Yes No 115.232 (b) Have all volunteers and contractors who have contact with residents 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 residents)? Yes No 115.232 (c) Does the agency maintain documentation confirming that volunteers and contractors understand the training they have received? Yes No Auditor Overall Compliance Determination Exceeds Standard (Substantially exceeds requirement of standards) Meets Standard (Substantial compliance; complies in all material ways with the standard for the relevant review period) Does Not Meet Standard (Requires Corrective Action) Instructions for Overall Compliance Determination Narrative The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility. Standard 115.233: Resident education All Yes/No Questions Must Be Answered by the Auditor to Complete the Report 115.233 (a) During intake, do residents receive information explaining: The agency’s zero-tolerance policy regarding sexual abuse and sexual harassment? Yes No
Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct and treatment of residents who were reported to have suffered sexual abuse to see if there are changes that may suggest possible retaliation by residents or staff? Yes No Except in instances where the agency determines that a report of sexual abuse is unfounded, for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy any such retaliation? Yes No 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 resident disciplinary reports? Yes No 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 resident housing changes? Yes No 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 resident program changes? Yes No 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 No 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 No Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a continuing need? Yes No 115.267 (d) In the case of residents, does such monitoring also include periodic status checks? Yes No 115.267 (e) 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 No 115.267 (f) Auditor is not required to audit this provision. Auditor Overall Compliance Determination Exceeds Standard (Substantially exceeds requirement of standards)
Meets Standard (Substantial compliance; complies in all material ways with the standard for the relevant review period) Does Not Meet Standard (Requires Corrective Action) Instructions for Overall Compliance Determination Narrative The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility. Standard 115.287: Data collection All Yes/No Questions Must Be Answered by the Auditor to Complete the Report 115.287 (a) 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 No 115.287 (b) Does the agency aggregate the incident-based sexual abuse data at least annually? Yes No 115.287 (c) 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 No 115.287 (d) 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 No 115.287 (e) Does the agency also obtain incident-based and aggregated data from every private facility with which it contracts for the confinement of its residents? (N/A if agency does not contract for the confinement of its residents.) Yes No NA