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Prison Rape Elimination Act (PREA) Audit Report
Community Confinement Facilities
☐ Interim ☒ Final
Date of Report July 17, 2019
Auditor Information
Name: Timothy Pippo
Email: pippoconsulting@gmail.com
Company Name: TP Consulting
Mailing Address: PO Box 151
City, State, Zip: Annandale, MN 55302
Telephone: 763/274/8397
Date of Facility Visit: June 19, 2019 Agency Information
Name of Agency:
Alpha Human Services Inc.
Governing Authority or Parent Agency (If Applicable):
Alpha Human Services Inc.
Physical Address: 2712 Fremont Av S
City, State, Zip: Minneapolis, MN 55408-1122
Mailing Address: 2712 Fremont Av S
City, State, Zip: Minneapolis, MN 55408-1122
Telephone: 612/872/8218
Is Agency accredited by any organization? ☒ Yes ☒ No
The Agency Is:
☐ Military
☐ Private for Profit
☒ Private not for Profit
☐ Municipal
☐ County
☐ State
☐ Federal Agency mission: Alpha'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.
Agency Website with PREA Information: http://alphaservices.org/index.php/prea-policy/prea-policy/
Agency Chief Executive Officer
Name: Gerald Kaplan
Title: Executive Director
Email: gtk@alpahservices.org
Telephone: 612/872/8218 ext. 17 Agency-Wide PREA Coordinator
Name: Riki Kravitz
Title: Outpatient Program Coordinator


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Email: rikik@alphaservices.org
Telephone: 612/822/1357
PREA Coordinator Reports to:
Executive Director
Number of Compliance Managers who report to the PREA Coordinator 1
Facility Information
Name of Facility: Alpha Human Services
Physical Address: 2712 Fremont Av S Minneapolis MN 55408
Mailing Address (if different than above):
Telephone Number: 612/872/8218
The Facility Is:
☐ Military
☐ Private for Profit
☒ Private not for Profit
☐ Municipal
☐ County
☐ State
☐ Federal
Facility Type:
☐ Community treatment center
☐ Halfway house
☐ Restitution center
☐ Mental health facility
☐ Alcohol or drug rehabilitation center
☒ Other community correctional facility Facility Mission: Alpha'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.
Facility Website with PREA Information: http://alphaservices.org/index.php/prea-policy/prea-policy/
Have there been any internal or external audits of and/or
accreditations by any other organization? ☒ Yes ☒ No Director
Name: Gerald Kaplan
Title: Executive Director
Email: gtk@alpahservices.org
Telephone: 612/872/8218 ext. 17 Facility PREA Compliance Manager
Name: Rick Weinberger
Title: Inpatient Clinical Director
Email: rickw@alphaservices.org
Telephone: 612/872/8218 ext. 15 Facility Health Service Administrator
Name: N/A
Title:
Email:
Telephone:

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Facility Characteristics
Designated Facility Capacity: 23
Current Population of Facility: 18
Number of residents admitted to facility during the past 12 months
24
Number of residents admitted to facility during the past 12 months who were transferred from a different community confinement facility:
14
Number of residents admitted to facility during the past 12 months whose length of stay in the facility was for 30 days or more:
23
Number of residents admitted to facility during the past 12 months whose length of stay in the facility was for 72 hours or more:
24
Number of residents on date of audit who were admitted to facility prior to August 20, 2012:
0
Age Range of
Population:
☒ Adults
18-67
☐ Juveniles
☐ Youthful residents
Average length of stay or time under supervision:
13 months
Facility Security Level:
Minimum
Resident Custody Levels:
Minimum
Number of staff currently employed by the facility who may have contact with residents:
17
Number of staff hired by the facility during the past 12 months who may have contact with residents:
4
Number of contracts in the past 12 months for services with contractors who may have contact with residents:
2 Physical Plant
Number of Buildings: 2
Number of Single Cell Housing Units: 4
Number of Multiple Occupancy Cell Housing Units:
7
Number of Open Bay/Dorm Housing Units:
0
Description of any video or electronic monitoring technology (including any relevant information about where cameras are placed, where the control room is, retention of video, etc.):
None
Medical
Type of Medical Facility:
None
Forensic sexual assault medical exams are conducted at:
Hennepin County Medical Center Other
Number of volunteers and individual contractors, who may have contact with residents, currently authorized to enter the facility:
0
Number of investigators the agency currently employs to investigate allegations of sexual abuse:
3

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Audit Findings
Audit Narrative
Alpha Human Services Inc. 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 that have at least Masters Degrees in Psycho-Sexual behavior (majority of which are licensed psychologists) 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 (MNDOC) and abides by Minnesota Chapter 2920 Rules Governing Adult Community-Based Residential Correctional Facilities (MN Rule) and Minnesota Chapter 2965 Rules for Adult Sex Offender Treatment Programs (MN Rule). These rules provide guidance for the facility to follow concerning staffing levels, screening requirements, grievance policies, staff and client disciplinary procedures and numerous areas concerning community confinement. The Facility has a treatment program so they have a Special Services Registration with the Minnesota Department of Human Services (MN DHS) related to Group Residential Housing.. This is the second PREA Audit for Alpha Human Services. The facility successfully passed an audit on May 29, 2015.The facility has an operational capacity of 23 clients and an average daily population of 19 clients. There were 18 clients in the program on the day of the audit. On June 19, 2019 I conducted an on-site audit of the facility. Prior to the audit I received electronic documents that pertained to the agency PREA Policy. I first had meeting with the PREA Compliance Manager and the Administrative Assistant. I was then given a complete tour of the facility and was able to communicate with clients about their knowledge of the facilities zero tolerance policy toward sexual misconduct. During the tour I observed my Pre-Audit Posters containing information to contact me privately display in numerous conspicuous areas of the building. I also observed large posters displaying the zero tolerance policy toward sexual misconduct while in the program. Other posters contained information on how to report allegations along with toll free phone numbers to the Sexual Violence Center, Local Police, the PREA Coordinator and the MNDOC Sexual Assault Helpline. The facility has 1 pending allegation of client on client sexual abuse that is being investigated by the Minneapolis Police Department. I then proceeded to interview 10 clients chosen from a client occupancy roster. The interview included 9 random clients and 1 resident that met the targeted criteria. I also interviewed 9 staff members on the day of the audit. I was given a private office to conduct my interviews. I conducted an exit interview with the Executive Director, the PREA Coordinator and the PREA Compliance Manager. I concluded the audit with a tour of the 2nd building of the facility that is utilized as a sleeping quarters for clients. Following the on-site audit I maintained contact with the PREA Coordinator and the PREA Compliance Manager and requested clarification on certain items and received items pertaining to PREA Compliance through e-mails. I also conducted phone interviews with a Sergeant Detective from the Minneapolis Police Department, a night shift security staff member of the facility, the Executive Director of Sexual Violence Center Minneapolis and a representative from the Hennepin Assault Response Team. Alpha Human Services runs a treatment program for adult male sex offenders. The nature of the treatment program and the commitment of the staff members demonstrate their efforts to maintain a culture of zero tolerance of sexual misconduct within the facility.

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Facility Characteristics
Alpha Human Services Inc. is comprised of two buildings located in a residential area of South Minneapolis Minnesota. The facility Board and Care License is through the City of Minneapolis The main building is a renovated 3 story house located at 2712 Fremont Av S Minneapolis, MN (Fremont) and the 2nd building is a renovated 2 story home located about 1.5 miles away at 3341 Portland Av S Minneapolis, MN (Portland). The first floor of the Fremont house has 3 staff offices for individual therapists. There is a kitchen where clients prepare meals. This floor has 1 private bathroom with a shower. The dining area also serves as a group therapy meeting room. There is also an office that serves as a nurse station (the nurse only serves as the medication director). There is a lobby lounge area for the clients and a desk work area for senior clients. The basement of this house has a lounge TV room that is used as a group meeting room also and a laundry room. The second floor of the house has a staff office. There is one private bathroom with a shower. In the front of the building is a computer room for client to use. There is one bedroom with 3 beds and one bedroom with 4 beds for a total of 7 clients housed at the Fremont house. The third floor of this house has office space for staff only, no clients are allowed on this floor unless escorted. The basement of the Portland house has a staff office and a recreation room. The first floor has 2 private bathrooms with showers and a 6 person bedroom area along with a 5 person bedroom area. The second floor has a 5 person bedroom area with one private bathroom/shower for a total of 16 residents. Clients housed at Portland are transported from the Portland house to the Fremont house every day at 8:00 AM for programing and meals and then are transported back to Portland at 8:00 PM every day. Fremont is staffed 24 hours per day 7 days a week and Portland is staffed 12 hours per day 7 days per week. Portland house is staffed by security persons when clients are occupying it. Staff members are required to do hourly well-being checks on every client and record these checks using a guard tour system https://www.guard1.com/Company/Contact-Us.aspx I was given examples of completed tours. The majority of staff members are therapists that provide counseling and therapy sessions on a daily basis. Treatment programs are mandatory. The facility has a part time nurse that only deals with client medication. Clients gain privileges for length of stay, behavior and treatment success, such as weekend furloughs. Every client has a case manager that tracks the progress of the clients. Most clients are also supervised by a State assigned Probation Officer. The facility maintains progress reports with the Probation Officers.
Summary of Audit Findings
Number of Standards Exceeded: 0
Number of Standards Met: 41
115.211 Through and including 115.403

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Number of Standards Not Met: 0
Summary of Corrective Action (if any)
Concerning Standard 115.241. The agency performs an intensive screening and risk assessment of individuals before accepting them into the treatment program. This screening is performed by the Intake Director and was acceptable to meet this standard. The facility has in place a PREA Risk Assessment Tool but was not utilizing the tool because of the extensive screening process by the Intake Director. I recommended that the facility also use the PREA Risk Assessment Tool as a secondary assessment that was more defined toward the requirements of the standard. The facility started to use this tool after the on-site audit and I was provided with copies of completed assessments to verity the use of the tool.
PREVENTION PLANNING
Standard 115.211: Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
All Yes/No Questions Must Be Answered by The Auditor to Complete the Report
115.211 (a)
 Does the agency have a written policy mandating zero tolerance toward all forms of sexual abuse and sexual harassment? ☒ Yes ☐ No
 Does the written policy outline the agency’s approach to preventing, detecting, and responding to sexual abuse and sexual harassment? ☒ Yes ☐ No
115.211 (b)
 Has the agency employed or designated an agency-wide PREA Coordinator? ☒ Yes ☐ No
 Is the PREA Coordinator position in the upper-level of the agency hierarchy? ☒ Yes ☐ No
 Does the PREA Coordinator have sufficient time and authority to develop, implement, and oversee agency efforts to comply with the PREA standards in all of its facilities? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐ Exceeds Standard (Substantially exceeds requirement of standards)

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☒ Meets Standard (Substantial compliance; complies in all material ways with the standard for the relevant review period)
☐ Does Not Meet Standard (Requires Corrective Action)
a. The agency has a policy that mandates zero tolerance toward any type of sexual misconduct within the facility. The policy is comprehensive and includes definitions. The policy provides guidance and outlines staff responsibilities to detect, deter and respond to sexual misconduct allegations and incidents. b. The agency has designated the Outpatient Program Coordinator as the PREA Coordinator. This person is highly experienced in Community Confinement and is well organized and an active participant in educating clients as to the zero tolerance policy. Interviews with the PREA Coordinator and the Executive Director showed that this person has ample time as is dedicated to the effort to comply with the PREA Standards.
Standard 115.212: Contracting with other entities for the confinement of residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.212 (a)
 If this agency is public and it contracts for the confinement of its residents with private agencies or other entities including other government agencies, has the agency included the entity’s obligation to comply with the PREA standards in any new contract or contract renewal signed on or after August 20, 2012? (N/A if the agency does not contract with private agencies or other entities for the confinement of residents.) ☐ Yes ☐ No ☒ NA
115.212 (b)
 Does any new contract or contract renewal signed on or after August 20, 2012 provide for agency contract monitoring to ensure that the contractor is complying with the PREA standards? (N/A if the agency does not contract with private agencies or other entities for the confinement of residents OR the response to 115.212(a)-1 is "NO".) ☐ Yes ☐ No ☒ NA
115.212 (c)
 If the agency has entered into a contract with an entity that fails to comply with the PREA standards, did the agency do so only in emergency circumstances after making all reasonable attempts to find a PREA compliant private agency or other entity to confine residents? (N/A if the agency has not entered into a contract with an entity that fails to comply with the PREA standards.) ☐ Yes ☐ No ☒ NA

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 In such a case, does the agency document its unsuccessful attempts to find an entity in compliance with the standards? (N/A if the agency has not entered into a contract with an entity that fails to comply with the PREA standards.) ☐ Yes ☐ No ☒ NA
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)
The facility does not contract with any outside agency for the security of clients. All staff members work for Alpha Human Services Inc.
Standard 115.213: Supervision and monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.213 (a)
 Does the agency develop for each facility a staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect residents against sexual abuse? ☒ Yes ☐ No
 Does the agency document for each facility a staffing plan that provides for adequate levels of staffing and, where applicable, video monitoring, to protect residents against sexual abuse? ☒ Yes ☐ No
 Does the agency ensure that each facility’s staffing plan takes into consideration the physical layout of each facility in calculating adequate staffing levels and determining the need for video monitoring? ☒ Yes ☐ No
 Does the agency ensure that each facility’s staffing plan takes into consideration the composition of the resident population in calculating adequate staffing levels and determining the need for video monitoring? ☒ Yes ☐ No
 Does the agency ensure that each facility’s staffing plan takes into consideration the prevalence of substantiated and unsubstantiated incidents of sexual abuse in calculating adequate staffing levels and determining the need for video monitoring? ☒ Yes ☐ No
 Does the agency ensure that each facility’s staffing plan takes into consideration any other relevant factors in calculating adequate staffing levels and determining the need for video monitoring? ☒ Yes ☐ No

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115.213 (b)
 In circumstances where the staffing plan is not complied with, does the facility document and justify all deviations from the plan? (N/A if no deviations from staffing plan.) ☐ Yes ☐ No ☒ NA
115.213 (c)
 In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to the staffing plan established pursuant to paragraph (a) of this section? ☒ Yes ☐ No
 In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to prevailing staffing patterns? ☒ Yes ☐ No
 In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to the facility’s deployment of video monitoring systems and other monitoring technologies? ☒ Yes ☐ No
 In the past 12 months, has the facility assessed, determined, and documented whether adjustments are needed to the resources the facility has available to commit to ensure adequate staffing levels? ☒ 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)
a. The facility has a documented staffing plan that provides adequate staffing levels to provide for the safety and security of the facility. The plan also meets the requirements of MN Rule 2920.3700, requirements of MN Rule 2965.0080 and follows Agency Policy III. The facility also has staffing patterns documented. The staffing plan takes into consideration any previous incidents of sexual misconduct and considers video monitoring but neither building has video monitoring capabilities. b. The staffing plan is never varied from. Staff members are obligated to remain on duty until relieved. Supervisors may also be on-call to support staffing levels. c. The staffing plan was recently reviewed in 2019. Interviews with the Executive Director, the PREA Coordinator and the PREA Compliance Manager all revealed that the staffing plan is assessed on an on-going basis.

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Standard 115.215: Limits to cross-gender viewing and searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.215 (a)
 Does the facility always refrain from conducting any cross-gender strip or cross-gender visual body cavity searches, except in exigent circumstances or by medical practitioners? ☒ Yes ☐ No
115.215 (b)
 Does the facility always refrain from conducting cross-gender pat-down searches of female residents, except in exigent circumstances? (N/A if less than 50 residents) ☐ Yes ☐ No ☒ NA
 Does the facility always refrain from restricting female residents’ access to regularly available programming or other outside opportunities in order to comply with this provision? (N/A if less than 50 residents) ☐ Yes ☐ No ☒ NA
115.215 (c)
 Does the facility document all cross-gender strip searches and cross-gender visual body cavity searches? ☒ Yes ☐ No
 Does the facility document all cross-gender pat-down searches of female residents? ☒ Yes ☐ No
115.215 (d)
 Does the facility implement policies and procedures that enable residents to shower, perform bodily functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell checks? ☒ Yes ☐ No
 Does the facility require staff of the opposite gender to announce their presence when entering an area where residents are likely to be showering, performing bodily functions, or changing clothing? ☒ Yes ☐ No
115.215 (e)
 Does the facility always refrain from searching or physically examining transgender or intersex residents for the sole purpose of determining the resident’s genital status? ☒ Yes ☐ No
 If a resident’s genital status is unknown, does the facility determine genital status during conversations with the resident, by reviewing medical records, or, if necessary, by learning that

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information as part of a broader medical examination conducted in private by a medical practitioner? ☒ Yes ☐ No
115.215 (f)
 Does the facility/agency train security staff in how to conduct cross-gender pat down searches in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs? ☒ Yes ☐ No
 Does the facility/agency train security staff in how to conduct searches of transgender and intersex residents in a professional and respectful manner, and in the least intrusive manner possible, consistent with security needs? ☒ 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)
a. Policy forbids searches of any client at any time. Interviews with clients and all staff members indicated that no pat searches or strip searches ever occur in the facility. b. The treatment program is a male only facility. c. There are never any strip or body cavity searches performed in the facility at any time. d. Policy III provides for no cross gender supervision viewing of clients by female staff members. All the shower and bathroom areas of both buildings are private. Clients are required to change clothing in the bathroom areas only. Female staff members announce themselves on the very few occasions that they enter bedroom areas. Interviews with both clients and staff members show that clients are never unclothed in front of female staff members. e. The facility does not perform any pat or strip searches of any clients. Transgender clients would have to identify as male to be included in the program. f. Staff members never conduct any pat, strip or body cavity searches of any nature.
Standard 115.216: Residents with disabilities and residents who are limited English proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.216 (a)
 Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,

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Residents who are deaf or hard of hearing? ☒ Yes ☐ No

 Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who are blind or have low vision? ☒ Yes ☐ No
 Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who have intellectual disabilities? ☒ Yes ☐ No
 Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who have psychiatric disabilities? ☒ Yes ☐ No
 Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Residents who have speech disabilities? ☒ Yes ☐ No
 Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment, including: Other? (if "other," please explain in overall determination notes.) ☒ Yes ☐ No
 Do such steps include, when necessary, ensuring effective communication with residents who are deaf or hard of hearing? ☒ Yes ☐ No
 Do such steps include, when necessary, providing access to interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary? ☒ Yes ☐ No
 Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities including residents who: Have intellectual disabilities? ☒ Yes ☐ No
 Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities including residents who: Have limited reading skills? ☒ Yes ☐ No
 Does the agency ensure that written materials are provided in formats or through methods that ensure effective communication with residents with disabilities including residents who: Are blind or have low vision? ☒ Yes ☐ No
115.216 (b)

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 Does the agency take reasonable steps to ensure meaningful access to all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to residents who are limited English proficient? ☒ Yes ☐ No
 Do these steps include providing interpreters who can interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary? ☒ Yes ☐ No
115.216 (c)
 Does the agency always refrain from relying on resident interpreters, resident readers, or other types of resident assistants except in limited circumstances where an extended delay in obtaining an effective interpreter could compromise the resident’s safety, the performance of first-response duties under §115.264, or the investigation of the resident’s allegations? ☒ 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)
.
a. Alpha Human Services prescreens all potential males that may be allowed into the treatment program. Both buildings are not handicapped accessible and the programing is only provided in English, therefore the program does not accept persons with disabilities or non-English speaking persons and would deny them entering the program. b. Policy does framework procedures for assisting such clients but the program has never had the need to provide interpreters. c. Policy does provide for interpreters if necessary and the supervisors stated that they would do everything possible to get assistance if ever needed.
Standard 115.217: Hiring and promotion decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.217 (a)
 Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No

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 Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? ☒ Yes ☐ No
 Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has been civilly or administratively adjudicated to have engaged in the activity described in the question immediately above? ☒ Yes ☐ No
 Does the agency prohibit the enlistment of services of any contractor who may have contact with residents who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No
 Does the agency prohibit the enlistment of services of any contractor who may have contact with residents who: Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? ☒ Yes ☐ No
 Does the agency prohibit the enlistment of services of any contractor who may have contact with residents who: Has been civilly or administratively adjudicated to have engaged in the activity described in the question immediately above? ☒ Yes ☐ No
115.217 (b)
 Does the agency consider any incidents of sexual harassment in determining whether to hire or promote anyone, or to enlist the services of any contractor, who may have contact with residents? ☒ Yes ☐ No
115.217 (c)
 Before hiring new employees, who may have contact with residents, does the agency: Perform a criminal background records check? ☒ Yes ☐ No
 Before hiring new employees, who may have contact with residents, does the agency: Consistent with Federal, State, and local law, make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or any resignation during a pending investigation of an allegation of sexual abuse? ☒ Yes ☐ No
115.217 (d)
 Does the agency perform a criminal background records check before enlisting the services of any contractor who may have contact with residents? ☒ Yes ☐ No
115.217 (e)

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 Does the agency either conduct criminal background records checks at least every five years of current employees and contractors who may have contact with residents or have in place a system for otherwise capturing such information for current employees? ☒ Yes ☐ No
115.217 (f)
 Does the agency ask all applicants and employees who may have contact with residents directly about previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring or promotions? ☒ Yes ☐ No
 Does the agency ask all applicants and employees who may have contact with residents directly about previous misconduct described in paragraph (a) of this section in any interviews or written self-evaluations conducted as part of reviews of current employees? ☒ Yes ☐ No
 Does the agency impose upon employees a continuing affirmative duty to disclose any such misconduct? ☒ Yes ☐ No
115.217 (g)
 Does the agency consider material omissions regarding such misconduct, or the provision of materially false information, grounds for termination? ☒ Yes ☐ No
115.217 (h)
 Unless prohibited by law, does the agency provide information on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied to work? (N/A if providing information on substantiated allegations of sexual abuse or sexual harassment involving a former employee is prohibited by law.) ☒ Yes ☐ No ☐ NA
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)
a. Alpha Human Services Inc. Policy prohibits hiring any person including contractors that has a history of sexual misconduct of any nature civil or criminal. The Executive Director assured me during interviews that persons with a history of sexual misconduct would not be employed or allowed entrance into the facility. b. Sexual Harassment is also considered when hiring persons and is strictly defined in the Employee Handbook. c. Criminal History checks are performed on all potential employees and candidates are required to give permission to the agency to do prior employment checks.

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d. Criminal History checks are performed on all contract persons. e. Criminal History checks are performed at least every 5 years of employment and are done through the MN DHS and the “Minnesota Bureau of Criminal Apprehension”. The checks also include the “Federal Bureau of Investigation”. f. Policy requires self-disclosure statements from all employees. The self-disclosure is also done annually and I was provided with documents that proved adherence to this standard. g. Falsification of any information is considered grounds for termination according to Policy and the Employee Handbook. h. The Executive Director stated that any employer would be provided with a former employees misconduct reports if requested and an implied consent form was provided.
Standard 115.218: Upgrades to facilities and technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.218 (a)
 If the agency designed or acquired any new facility or planned any substantial expansion or modification of existing facilities, did the agency consider the effect of the design, acquisition, expansion, or modification upon the agency’s ability to protect residents from sexual abuse? (N/A if agency/facility has not acquired a new facility or made a substantial expansion to existing facilities since August 20, 2012, or since the last PREA audit, whichever is later.) ☐ Yes ☐ No ☒ NA 115.218 (b)
 If the agency installed or updated a video monitoring system, electronic surveillance system, or other monitoring technology, did the agency consider how such technology may enhance the agency’s ability to protect residents from sexual abuse? (N/A if agency/facility has not installed or updated a video monitoring system, electronic surveillance system, or other monitoring technology since August 20, 2012, or since the last PREA audit, whichever is later.) ☐ Yes ☐ No ☒ NA
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)
a. Alpha Human Services has not done any expansions or modifications to the facility at either building. b. The facility does not have video monitoring at either building.

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RESPONSIVE PLANNING
Standard 115.221: Evidence protocol and forensic medical examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.221 (a)
 If the agency is responsible for investigating allegations of sexual abuse, does the agency follow a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence for administrative proceedings and criminal prosecutions? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA 115.221 (b)
 Is this protocol developmentally appropriate for youth where applicable? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
 Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of the U.S. Department of Justice’s Office on Violence Against Women publication, “A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
115.221 (c)
 Does the agency offer all residents who experience sexual abuse access to forensic medical examinations, whether on-site or at an outside facility, without financial cost, where evidentiarily or medically appropriate? ☒ Yes ☐ No
 Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible? ☒ Yes ☐ No
 If SAFEs or SANEs cannot be made available, is the examination performed by other qualified medical practitioners (they must have been specifically trained to conduct sexual assault forensic exams)? ☒ Yes ☐ No
 Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
115.221 (d)

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 Does the agency attempt to make available to the victim a victim advocate from a rape crisis center? ☒ Yes ☐ No
 If a rape crisis center is not available to provide victim advocate services, does the agency make available to provide these services a qualified staff member from a community-based organization, or a qualified agency staff member? ☒ Yes ☐ No
 Has the agency documented its efforts to secure services from rape crisis centers? ☒ Yes ☐ No
115.221 (e)
 As requested by the victim, does the victim advocate, qualified agency staff member, or qualified community-based organization staff member accompany and support the victim through the forensic medical examination process and investigatory interviews? ☒ Yes ☐ No
 As requested by the victim, does this person provide emotional support, crisis intervention, information, and referrals? ☒ Yes ☐ No
115.221 (f)
 If the agency itself is not responsible for investigating allegations of sexual abuse, has the agency requested that the investigating entity follow the requirements of paragraphs (a) through (e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
115.221 (g)
 Auditor is not required to audit this provision.
115.221 (h)
 If the agency uses a qualified agency staff member or a qualified community-based staff member for the purposes of this section, has the individual been screened for appropriateness to serve in this role and received education concerning sexual assault and forensic examination issues in general? (Check N/A if agency attempts to make a victim advocate from a rape crisis center available to victims per 115.221(d) above.) ☐ Yes ☐ No ☒ NA
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)

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a. The agency will only do Administrative Investigations b. The Minneapolis Police Department http://www.ci.minneapolis.mn.us/police/about/investigations/police_about_sexcrimes would do all criminal investigations of sexual abuse incidents or allegations. The Police Department would follow appropriate protocols for investigations. c. Forensic Exams are arranged by the “Hennepin Assault Response Team” as verified by an interview with a representative of this service. https://www.hennepinhealthcare.org/support-services/violence-assault-and-abuse-resources/ and performed by Sexual Assault Nurse Examiners and would normally occur at “Hennepin County Medical Center” https://www.hennepinhealthcare.org/support-services/violence-assault-and-abuse-resources/ d. The facility would use “Sexual Violence Center” https://www.sexualviolencecenter.org/ for support services for residents that are victims of sexual abuse. The facility has a signed Memorandum of Understanding (MOU) with the center to provide such services. e. A conversation with the Executive Director of the sexual violence center confirmed that counseling, advocacy and support services would be provided to residents of Alpha Human Services that are victims. f. Policy and the MOU require adherence to the protocols outlined in this standard.
Standard 115.222: Policies to ensure referrals of allegations for investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.222 (a)
 Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual abuse? ☒ Yes ☐ No
 Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual harassment? ☒ Yes ☐ No
115.222 (b)
 Does the agency have a policy and practice in place to ensure that allegations of sexual abuse or sexual harassment are referred for investigation to an agency with the legal authority to conduct criminal investigations, unless the allegation does not involve potentially criminal behavior? ☒ Yes ☐ No
 Has the agency published such policy on its website or, if it does not have one, made the policy available through other means? ☒ Yes ☐ No
 Does the agency document all such referrals? ☒ Yes ☐ No 115.222 (c)

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 If a separate entity is responsible for conducting criminal investigations, does such publication describe the responsibilities of both the agency and the investigating entity? [N/A if the agency/facility is responsible for conducting criminal investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
115.222 (d)
 Auditor is not required to audit this provision.
115.222 (e)
 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)
a. Policy requires investigation of all and any allegations or incidents of sexual abuse or sexual harassment. The Executive Director, the PREA Coordinator and the PREA Compliance Manager all assured me that every allegation or incident of sexual abuse would be referred for criminal investigation. The one allegation in May of 2019 is under investigation by the Minneapolis Police Department. b. The facility currently has one sexual abuse allegation that is being investigated by the Minneapolis Police Department and also being investigated by the facility Administrative Investigators. Policy and procedure require all potential criminal acts be referred for criminal investigation. Information about criminal investigations is posted on the agency web-site http://alphaservices.org/index.php/prea-policy/ c. The Minneapolis Police Department is listed as the responsible investigating authority for the facility.
TRAINING AND EDUCATION
Standard 115.231: Employee training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.231 (a)

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 Does the agency train all employees who may have contact with residents on: Its zero-tolerance policy for sexual abuse and sexual harassment? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: How to fulfill their responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and response policies and procedures? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: Residents’ right to be free from sexual abuse and sexual harassment ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: The right of residents and employees to be free from retaliation for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: The dynamics of sexual abuse and sexual harassment in confinement? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: The common reactions of sexual abuse and sexual harassment victims? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: How to detect and respond to signs of threatened and actual sexual abuse? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: How to avoid inappropriate relationships with residents? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: How to communicate effectively and professionally with residents, including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming residents? ☒ Yes ☐ No
 Does the agency train all employees who may have contact with residents on: How to comply with relevant laws related to mandatory reporting of sexual abuse to outside authorities? ☒ Yes ☐ No
115.231 (b)
 Is such training tailored to the gender of the residents at the employee’s facility? ☒ Yes ☐ No
 Have employees received additional training if reassigned from a facility that houses only male residents to a facility that houses only female residents, or vice versa? ☒ Yes ☐ No
115.231 (c)
 Have all current employees who may have contact with residents received such training? ☒ Yes ☐ No

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 Does the agency provide each employee with refresher training every two years to ensure that all employees know the agency’s current sexual abuse and sexual harassment policies and procedures? ☒ Yes ☐ No
 In years in which an employee does not receive refresher training, does the agency provide refresher information on current sexual abuse and sexual harassment policies? ☒ Yes ☐ No
115.231 (d)
 Does the agency document, through employee signature or electronic verification, that employees 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)
a. All employees are trained on the agency zero tolerance policy and on procedures of how to detect, respond and deter sexual misconduct in the facility. Interviews with staff members indicated that they had received and understood the training. The facility uses curriculum from “Educorr” http://educorr.com/ for training employees on PREA Standards. The employees also receive training in the Employee Handbook concerning code of conduct. The therapists all have degrees in Psychology and sexual deviant behavior and abide by the “American Psychological Association’s Ethical Principals of Psychologists and Code of Conduct”. b. The facility only houses Adult Male residents. c. All current employees have received the training and refresher training is provided at least every two years but because of the make-up of the clients it is basically on-going in the facility. d. Receipt of training is documented and I received signed documents verifying completion of the training.
Standard 115.232: Volunteer and contractor training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.232 (a)
 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)

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 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)
a. The facility uses only two contract staff, the Nurse and the Intake Director. Interviews with both of these persons revealed that they had received training on the zero tolerance policy. The facility does not have any volunteers. b. Both contractors have received training on how to report allegations and or incidents to supervisors. c. The facility maintains training receipt on all contractors.
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
 During intake, do residents receive information explaining: How to report incidents or suspicions of sexual abuse or sexual harassment? ☒ Yes ☐ No
 During intake, do residents receive information explaining: Their rights to be free from sexual abuse and sexual harassment? ☒ Yes ☐ No
 During intake, do residents receive information explaining: Their rights to be free from retaliation for reporting such incidents? ☒ Yes ☐ No

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 During intake, do residents receive information regarding agency policies and procedures for responding to such incidents? ☒ Yes ☐ No
115.233 (b)
 Does the agency provide refresher information whenever a resident is transferred to a different facility? ☒ Yes ☐ No
115.233 (c)
 Does the agency provide resident education in formats accessible to all residents, including those who: Are limited English proficient? ☒ Yes ☐ No
 Does the agency provide resident education in formats accessible to all residents, including those who: Are deaf? ☒ Yes ☐ No
 Does the agency provide resident education in formats accessible to all residents, including those who: Are visually impaired? ☒ Yes ☐ No
 Does the agency provide resident education in formats accessible to all residents, including those who: Are otherwise disabled? ☒ Yes ☐ No
 Does the agency provide resident education in formats accessible to all residents, including those who: Have limited reading skills? ☒ Yes ☐ No
115.233 (d)
 Does the agency maintain documentation of resident participation in these education sessions? ☒ Yes ☐ No
115.233 (e)
 In addition to providing such education, does the agency ensure that key information is continuously and readily available or visible to residents through posters, resident handbooks, or other written formats? ☒ 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)

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a. Every client is provided with a PREA client information packet which contains information about the agency zero tolerance policy and how to report any allegations or incidents of sexual abuse or sexual harassment including toll free numbers to report to a third-party. The packet is given to each client upon intake into the facility. All clients revealed during interviews that they had received and understood the information given to them and it was completed shortly after intake. b. Alpha Human Services only has one facility. c. The program is not designed to include clients with disabilities or non-English skills but policy provides for information to be provided if necessary. d. Clients sign receipt and understanding of the training the document becomes part of the client record. e. Information on the zero tolerance policy and how to report is on posters throughout the facility and is included in the Client Handbook. Interviews with clients show that they were aware of the information in various locations.
Standard 115.234: Specialized training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.234 (a)
 In addition to the general training provided to all employees pursuant to §115.231, does the agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its investigators have received training in conducting such investigations in confinement settings? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
115.234 (b)
 Does this specialized training include: Techniques for interviewing sexual abuse victims? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
 Does this specialized training include: Proper use of Miranda and Garrity warnings? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
 Does this specialized training include: Sexual abuse evidence collection in confinement settings? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
 Does this specialized training include: The criteria and evidence required to substantiate a case for administrative action or prosecution referral? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
115.234 (c)

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 Does the agency maintain documentation that agency investigators have completed the required specialized training in conducting sexual abuse investigations? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA 115.234 (d)
 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)
a. The agency has 3 Administrative Investigators. Criminal investigations are referred to the Minneapolis Police Department. The Administrative Investigations are used to determine causes and remedies to incidents. The Administrative Investigators have received training on investigations in confinement setting through “Educorr”. b. The Minneapolis Police Department uses highly trained and experienced detectives that are licensed Peace Officers through the State of Minnesota. c. The specialized training completed by the Administrative Investigators is documented and I received copies of this documentation.
Standard 115.235: Specialized training: Medical and mental health care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.235 (a)
 Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in: How to detect and assess signs of sexual abuse and sexual harassment? ☒ Yes ☐ No
 Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in: How to preserve physical evidence of sexual abuse? ☒ Yes ☐ No
 Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in: How to respond effectively and professionally to victims of sexual abuse and sexual harassment? ☒ Yes ☐ No

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 Does the agency ensure that all full- and part-time medical and mental health care practitioners who work regularly in its facilities have been trained in: How and to whom to report allegations or suspicions of sexual abuse and sexual harassment? ☒ Yes ☐ No
115.235 (b)
 If medical staff employed by the agency conduct forensic examinations, do such medical staff receive appropriate training to conduct such examinations? N/A if agency medical staff at the facility do not conduct forensic exams.) ☐ Yes ☐ No ☒ NA 115.235 (c)
 Does the agency maintain documentation that medical and mental health practitioners have received the training referenced in this standard either from the agency or elsewhere? ☒ Yes ☐ No 115.235 (d)
 Do medical and mental health care practitioners employed by the agency also receive training mandated for employees by §115.231? ☒ Yes ☐ No
 Do medical and mental health care practitioners contracted by and volunteering for the agency also receive training mandated for contractors and volunteers by §115.232? [N/A for circumstances in which a particular status (employee or contractor/volunteer) does not apply.] ☐ Yes ☐ No ☒ NA
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)
Alpha Human Services does not have Medical Staff employed. Medical services would be proved by community clinics. Forensic exams would be completed at Hennepin County Medical Center Minneapolis Minnesota.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION AND ABUSIVENESS
Standard 115.241: Screening for risk of victimization and abusiveness

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All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.241 (a)
 Are all residents assessed during an intake screening for their risk of being sexually abused by other residents or sexually abusive toward other residents? ☒ Yes ☐ No
 Are all residents assessed upon transfer to another facility for their risk of being sexually abused by other residents or sexually abusive toward other residents? ☒ Yes ☐ No
115.241 (b)
 Do intake screenings ordinarily take place within 72 hours of arrival at the facility? ☒ Yes ☐ No
115.241 (c)
 Are all PREA screening assessments conducted using an objective screening instrument? ☒ Yes ☐ No
115.241 (d)
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: Whether the resident has a mental, physical, or developmental disability? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: The age of the resident? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: The physical build of the resident? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: Whether the resident has previously been incarcerated? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: Whether the resident’s criminal history is exclusively nonviolent? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: Whether the resident has prior convictions for sex offenses against an adult or child? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: Whether the resident is or is perceived to be gay, lesbian, bisexual, transgender, intersex, or gender nonconforming (the facility affirmatively asks the resident about his/her sexual orientation and gender identity AND makes a subjective determination based on

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the screener’s perception whether the resident is gender non-conforming or otherwise may be perceived to be LGBTI)? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: Whether the resident has previously experienced sexual victimization? ☒ Yes ☐ No
 Does the intake screening consider, at a minimum, the following criteria to assess residents for risk of sexual victimization: The resident’s own perception of vulnerability? ☒ Yes ☐ No
115.241 (e)
 In assessing residents for risk of being sexually abusive, does the initial PREA risk screening consider, when known to the agency: prior acts of sexual abuse? ☒ Yes ☐ No
 In assessing residents for risk of being sexually abusive, does the initial PREA risk screening consider, when known to the agency: prior convictions for violent offenses? ☒ Yes ☐ No
 In assessing residents for risk of being sexually abusive, does the initial PREA risk screening consider, when known to the agency: history of prior institutional violence or sexual abuse? ☒ Yes ☐ No
115.241 (f)
 Within a set time period not more than 30 days from the resident’s arrival at the facility, does the facility reassess the resident’s risk of victimization or abusiveness based upon any additional, relevant information received by the facility since the intake screening? ☒ Yes ☐ No
115.241 (g)
 Does the facility reassess a resident’s risk level when warranted due to a: Referral? ☒ Yes ☐ No
 Does the facility reassess a resident’s risk level when warranted due to a: Request? ☒ Yes ☐ No
 Does the facility reassess a resident’s risk level when warranted due to a: Incident of sexual abuse? ☒ Yes ☐ No
 Does the facility reassess a resident’s risk level when warranted due to a: Receipt of additional information that bears on the resident’s risk of sexual victimization or abusiveness? ☒ Yes ☐ No
115.241 (h)
 Is it the case that residents are not ever disciplined for refusing to answer, or for not disclosing complete information in response to, questions asked pursuant to paragraphs (d)(1), (d)(7), (d)(8), or (d)(9) of this section? ☒ Yes ☐ No

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115.241 (i)
 Has the agency implemented appropriate controls on the dissemination within the facility of responses to questions asked pursuant to this standard in order to ensure that sensitive information is not exploited to the resident’s detriment by staff or other residents? ☒ 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)
a. All clients have a history of sexual deviant behavior and most have been convicted of criminal sexual conduct. Clients are screened prior to acceptance into the program following strict guidelines from MN Rule 2965.01000. The screening is a Psycho-Sexual Evaluation. Clients that are determined to be aggressively violent or exceptionally vulnerable are not accepted into the program. An interview with the Intake Director indicated that screening includes intense interviews and history checks of the clients including institutional reports. I was provided with a copy of this assessment which includes; Criminal History, Institutional History, Mental Health History, Psychological History, Psychosexual History, Medical and Physical Issues and Personality Testing. b. Clients are also screened with a facility PREA Risk Assessment. This assessment is completed when the client first arrives at the facility. c. The PREA Risk Assessment is a comprehensive tool and is used as a secondary assessment more specific to the standard. d. Between the initial pre-acceptance screening and the PREA Risk Assessment tool, all aspects of this standard are met. e. All prior incidents of aggressive behavior, past sexual victimization and past sexual violent incidents are considered. f. Clients meet with their specific therapist at least weekly and sexual aggressiveness and or vulnerability is assessed at these meetings. g. Interviews with the supervisors and the therapists all indicated that risk assessment is an on-going procedure within the facility for all clients. h. Clients are not punished for not answering sensitive questions in the facility screening. i. Policy and the Employee Handbook spell out privacy of client information. Only therapists and supervisors have access to screening information.
Standard 115.242: Use of screening information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report

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115.242 (a)
 Does the agency use information from the risk screening required by § 115.241, with the goal of keeping separate those residents at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Housing Assignments? ☒ Yes ☐ No
 Does the agency use information from the risk screening required by § 115.241, with the goal of keeping separate those residents at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Bed assignments? ☒ Yes ☐ No
 Does the agency use information from the risk screening required by § 115.241, with the goal of keeping separate those residents at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Work Assignments? ☒ Yes ☐ No
 Does the agency use information from the risk screening required by § 115.241, with the goal of keeping separate those residents at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Education Assignments? ☒ Yes ☐ No
 Does the agency use information from the risk screening required by § 115.241, with the goal of keeping separate those residents at high risk of being sexually victimized from those at high risk of being sexually abusive, to inform: Program Assignments? ☒ Yes ☐ No
115.242 (b)
 Does the agency make individualized determinations about how to ensure the safety of each resident? ☒ Yes ☐ No
115.242 (c)
 When deciding whether to assign a transgender or intersex resident to a facility for male or female residents, does the agency consider on a case-by-case basis whether a placement would ensure the resident’s health and safety, and whether a placement would present management or security problems (NOTE: if an agency by policy or practice assigns residents to a male or female facility on the basis of anatomy alone, that agency is not in compliance with this standard)? ☒ Yes ☐ No
 When making housing or other program assignments for transgender or intersex residents, does the agency consider on a case-by-case basis whether a placement would ensure the resident’s health and safety, and whether a placement would present management or security problems? ☒ Yes ☐ No
115.242 (d)
 Are each transgender or intersex resident’s own views with respect to his or her own safety given serious consideration when making facility and housing placement decisions and programming assignments? ☒ Yes ☐ No
115.242 (e)

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 Are transgender and intersex residents given the opportunity to shower separately from other residents? ☒ Yes ☐ No
115.242 (f)
 Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex residents, does the agency always refrain from placing: lesbian, gay, and bisexual residents in dedicated facilities, units, or wings solely on the basis of such identification or status? ☒ Yes ☐ No
 Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex residents, does the agency always refrain from placing: transgender residents in dedicated facilities, units, or wings solely on the basis of such identification or status? ☒ Yes ☐ No
 Unless placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay, bisexual, transgender, or intersex residents, does the agency always refrain from placing: intersex residents in dedicated facilities, units, or wings solely on the basis of such identification or status? ☒ 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)
a. The screening information is used in housing assignments. New clients are housed at the Freemont House which has more intense supervision. If a client is deemed to be potentially aggressive or potentially extremely vulnerable they would most likely not be allowed into the program. b. Each client is assigned a therapist and receives treatment on an individual basis as well as group programing. c. Transgender or Intersex clients would have to identify as male to become part of the treatment program. There have been no Transgender or Intersex clients in the program since the last audit. d. The facility takes each client’s views of safety into consideration when making housing assignments. e. All the shower areas of both buildings are private and all clients are able to shower privately. f. The facility does not have any special housing units and would place any client from the LGBTI definition into regular housing.

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REPORTING
Standard 115.251: Resident reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.251 (a)
 Does the agency provide multiple internal ways for residents to privately report: Sexual abuse and sexual harassment? ☒ Yes ☐ No
 Does the agency provide multiple internal ways for residents to privately report: Retaliation by other residents or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
 Does the agency provide multiple internal ways for residents to privately report: Staff neglect or violation of responsibilities that may have contributed to such incidents? ☒ Yes ☐ No
115.251 (b)
 Does the agency also provide at least one way for residents to report sexual abuse or sexual harassment to a public or private entity or office that is not part of the agency? ☒ Yes ☐ No
 Is that private entity or office able to receive and immediately forward resident reports of sexual abuse and sexual harassment to agency officials? ☒ Yes ☐ No
 Does that private entity or office allow the resident to remain anonymous upon request? ☒ Yes ☐ No
115.251 (c)
 Do staff members accept reports of sexual abuse and sexual harassment made verbally, in writing, anonymously, and from third parties? ☒ Yes ☐ No
 Do staff members promptly document any verbal reports of sexual abuse and sexual harassment? ☒ Yes ☐ No
115.251 (d)
 Does the agency provide a method for staff to privately report sexual abuse and sexual harassment of residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐ Exceeds Standard (Substantially exceeds requirement of standards)

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☒ Meets Standard (Substantial compliance; complies in all material ways with the standard for the relevant review period)
☐ Does Not Meet Standard (Requires Corrective Action)
a. The facility has a policy allowing clients to make reports to staff members and provides means for clients to report privately. Staff members and clients have face to face contact with each other during the majority of the day and interviews with clients showed that they had knowledge on how to make a report and that they could do it privately if they wished to. b. The facility has toll free outside agency phone numbers posted throughout the facility and in the Client Handbook and also in the PREA Client Information Packet. The agencies include local police departments, the MN DOC Sexual Assault Helpline and the Minneapolis Sexual Violence Center. c. Interviews with staff members indicated that they would accept reports from clients and third party persons and act upon the reports immediately. I was provided with a copy of a client making a report to a therapist on behalf of another client. The report was acted upon immediately. d. Staff Members indicated that they could make reports privately to supervisors by various means including e-mail, phone or face to face.
Standard 115.252: Exhaustion of administrative remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.252 (a)
 Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not have administrative procedures to address resident grievances regarding sexual abuse. This does not mean the agency is exempt simply because a resident does not have to or is not ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of explicit policy, the agency does not have an administrative remedies process to address sexual abuse. ☒ Yes ☐ No ☐ NA 115.252 (b)
 Does the agency permit residents to submit a grievance regarding an allegation of sexual abuse without any type of time limits? (The agency may apply otherwise-applicable time limits to any portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 Does the agency always refrain from requiring a resident to use any informal grievance process, or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.252 (c)

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 Does the agency ensure that: A resident who alleges sexual abuse may submit a grievance without submitting it to a staff member who is the subject of the complaint? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 Does the agency ensure that: Such grievance is not referred to a staff member who is the subject of the complaint? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.252 (d)
 Does the agency issue a final agency decision on the merits of any portion of a grievance alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the 90-day time period does not include time consumed by residents in preparing any administrative appeal.) (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 If the agency determines that the 90-day timeframe is insufficient to make an appropriate decision and claims an extension of time [the maximum allowable extension of time to respond is 70 days per 115.252(d)(3)] , does the agency notify the resident in writing of any such extension and provide a date by which a decision will be made? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 At any level of the administrative process, including the final level, if the resident does not receive a response within the time allotted for reply, including any properly noticed extension, may a resident consider the absence of a response to be a denial at that level? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.252 (e)
 Are third parties, including fellow residents, staff members, family members, attorneys, and outside advocates, permitted to assist residents in filing requests for administrative remedies relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 Are those third parties also permitted to file such requests on behalf of residents? (If a third-party files such a request on behalf of a resident, the facility may require as a condition of processing the request that the alleged victim agree to have the request filed on his or her behalf, and may also require the alleged victim to personally pursue any subsequent steps in the administrative remedy process.) (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 If the resident declines to have the request processed on his or her behalf, does the agency document the resident’s decision? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.252 (f)
 Has the agency established procedures for the filing of an emergency grievance alleging that a resident is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA

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 After receiving an emergency grievance alleging a resident is subject to a substantial risk of imminent sexual abuse, does the agency immediately forward the grievance (or any portion thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which immediate corrective action may be taken? (N/A if agency is exempt from this standard.). ☒ Yes ☐ No ☐ NA
 After receiving an emergency grievance described above, does the agency provide an initial response within 48 hours? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 After receiving an emergency grievance described above, does the agency issue a final agency decision within 5 calendar days? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 Does the initial response and final agency decision document the agency’s determination whether the resident is in substantial risk of imminent sexual abuse? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 Does the initial response document the agency’s action(s) taken in response to the emergency grievance? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
 Does the agency’s final decision document the agency’s action(s) taken in response to the emergency grievance? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.252 (g)
 If the agency disciplines a resident for filing a grievance related to alleged sexual abuse, does it do so ONLY where the agency demonstrates that the resident filed the grievance in bad faith? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
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)
Alpha Human Services has a grievance policy and procedure for clients to file grievances. However the grievance policy treats any grievance pertaining to sexual abuse or sexual harassment as an emergency grievance and will act upon the grievance immediately.
Standard 115.253: Resident access to outside confidential support services

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All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.253 (a)
 Does the facility provide residents with access to outside victim advocates for emotional support services related to sexual abuse by giving residents mailing addresses and telephone numbers, including toll-free hotline numbers where available, of local, State, or national victim advocacy or rape crisis organizations? ☒ Yes ☐ No
 Does the facility enable reasonable communication between residents and these organizations and agencies, in as confidential a manner as possible? ☒ Yes ☐ No
115.253 (b)
 Does the facility inform residents, prior to giving them access, of the extent to which such communications will be monitored and the extent to which reports of abuse will be forwarded to authorities in accordance with mandatory reporting laws? ☒ Yes ☐ No
115.253 (c)
 Does the agency maintain or attempt to enter into memoranda of understanding or other agreements with community service providers that are able to provide residents with confidential emotional support services related to sexual abuse? ☒ Yes ☐ No
 Does the agency maintain copies of agreements or documentation showing attempts to enter into such agreements? ☒ 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)
a. The facility would utilize “Sexual Violence Center” Minneapolis https://www.sexualviolencecenter.org/ for advocacy and support services for clients. The toll free phone number for this crisis center is readily available to clients along with the phone number for the MN DOC Sexual Assault Helpline. Clients would be allowed to use an office phone if necessary for privacy. b. The crisis center informs any caller about disclosure protocols. c. Alpha Human Services has a signed MOU with the Sexual Violence Center. A conversation with the Executive Director of the center affirmed that they have a current MOU with the facility

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and would provide services to clients as consistent with community care. I was provided with a copy of the MOU.
Standard 115.254: Third-party reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.254 (a)
 Has the agency established a method to receive third-party reports of sexual abuse and sexual harassment? ☒ Yes ☐ No
 Has the agency distributed publicly information on how to report sexual abuse and sexual harassment on behalf of a resident? ☒ 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)
Policy provides for means for third-party reporting. Interviews with clients indicated that they knew third persons could make reports for them and interviews with staff members indicated that they would accept these reports and act upon them immediately. Phone numbers for making third-party reports are posted on the agency web-site.
OFFICIAL RESPONSE FOLLOWING A RESIDENT REPORT
Standard 115.261: Staff and agency reporting duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.261 (a)
 Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding an incident of sexual abuse or sexual harassment that occurred in a facility, whether or not it is part of the agency? ☒ Yes ☐ No

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 Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding retaliation against residents or staff who reported an incident of sexual abuse or sexual harassment? ☒ Yes ☐ No
 Does the agency require all staff to report immediately and according to agency policy any knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities that may have contributed to an incident of sexual abuse or sexual harassment or retaliation? ☒ Yes ☐ No 115.261 (b)
 Apart from reporting to designated supervisors or officials, do staff always refrain from revealing any information related to a sexual abuse report to anyone other than to the extent necessary, as specified in agency policy, to make treatment, investigation, and other security and management decisions? ☒ Yes ☐ No
115.261 (c)
 Unless otherwise precluded by Federal, State, or local law, are medical and mental health practitioners required to report sexual abuse pursuant to paragraph (a) of this section? ☒ Yes ☐ No
 Are medical and mental health practitioners required to inform residents of the practitioner’s duty to report, and the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No
115.261 (d)
 If the alleged victim is under the age of 18 or considered a vulnerable adult under a State or local vulnerable persons statute, does the agency report the allegation to the designated State or local services agency under applicable mandatory reporting laws? ☒ Yes ☐ No
115.261 (e)
 Does the facility report all allegations of sexual abuse and sexual harassment, including third-party and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ 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)

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a. All and any allegations or incidents of sexual abuse, sexual harassment and or retaliation are reported to supervisors as soon as possible following policy. Staff members stated during interviews that they were aware of their duty to report. In review of one incident, the staff member that was informed of an incident reported to supervisors immediately. b. Staff members are obligated to keep information about clients private and because the facility is also a treatment program, staff must abide by Federal Healthcare HIPPA regulations. c. The facility does not employ medical staff. d. Facility staff members are mandatory reporters following Minnesota State Statute 626.556. e. All reports or suspicions of sexual misconduct are reported to facility supervisors immediately.
Standard 115.262: Agency protection duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.262 (a)
 When the agency learns that a resident is subject to a substantial risk of imminent sexual abuse, does it take immediate action to protect the resident? ☒ 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)
Policy requires immediate safety measures for victims. Interviews with all employees assured that a client’s safety is of upmost importance.
Standard 115.263: Reporting to other confinement facilities
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.263 (a)
 Upon receiving an allegation that a resident was sexually abused while confined at another facility, does the head of the facility that received the allegation notify the head of the facility or appropriate office of the agency where the alleged abuse occurred? ☒ Yes ☐ No
115.263 (b)

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 Is such notification provided as soon as possible, but no later than 72 hours after receiving the allegation? ☒ Yes ☐ No 115.263 (c)
 Does the agency document that it has provided such notification? ☒ Yes ☐ No 115.263 (d)
 Does the facility head or agency office that receives such notification ensure that the allegation is investigated in accordance with these standards? ☒ 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)
a. Policy requires notification to another facility of any reports of incidents that occurred at that facility. There have been no reports of this nature at least since the last audit. b. The supervisors indicated through interviews that notification to the other facility would happen as soon as possible and certainly within 72 hours. c. The information would be included in a facility incident report. d. The Executive Director assured that such notifications would take place and would investigate any allegation receive from another facility.
Standard 115.264: Staff first responder duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.264 (a)
 Upon learning of an allegation that a resident was sexually abused, is the first security staff member to respond to the report required to: Separate the alleged victim and abuser? ☒ Yes ☐ No
 Upon learning of an allegation that a resident was sexually abused, is the first security staff member to respond to the report required to: Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence? ☒ Yes ☐ No
 Upon learning of an allegation that a resident was sexually abused, is the first security staff member to respond to the report required to: Request that the alleged victim not take any

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actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
 Upon learning of an allegation that a resident was sexually abused, is the first security staff member to respond to the report required to: Ensure that the alleged abuser does not take any actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
115.264 (b)
 If the first staff responder is not a security staff member, is the responder required to request that the alleged victim not take any actions that could destroy physical evidence, and then notify security staff? ☒ Yes ☐ 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)
a. Policy VIII defines responsibilities for staff members as first responders to an incident of sexual abuse within the facility. Interviews with staff members proved that they were aware of their duties and responsibilities as first responders to ensure the safety of clients and maintain a crime scene while conserving evidence. Staff members also have a “First Responder Sexual Assault Checklist” to follow to assist them in following correct protocols. b. All employees indicated through interviews that they knew the importance and procedures to follow to preserve any potential evidence.
Standard 115.265: Coordinated response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.265 (a)
 Has the facility developed a written institutional plan to coordinate actions among staff first responders, medical and mental health practitioners, investigators, and facility leadership taken in response to an incident of sexual abuse? ☒ Yes ☐ No
Auditor Overall Compliance Determination

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☐ 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)
a. Policy VIII and the “First Responder Sexual Assault Checklist” both detail protocols and procedures to follow in the event of a sexual abuse incident. The protocols include requesting emergency medical aid and law enforcement investigators along with notifying supervisors.
Standard 115.266: Preservation of ability to protect residents from contact with abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.266 (a)
 Are both the agency and any other governmental entities responsible for collective bargaining on the agency’s behalf prohibited from entering into or renewing any collective bargaining agreement or other agreement that limits the agency’s ability to remove alleged staff sexual abusers from contact with any residents pending the outcome of an investigation or of a determination of whether and to what extent discipline is warranted? ☒ Yes ☐ No 115.266 (b)
 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)
a. Staff Members of Alpha Human Services are “At Will” employees and not covered by any collective bargaining agreement. Both policy and the Employee Handbook spell out up to termination sanctions for employees involved in any misconduct. The Executive Director assured me that alleged abusive employees would be removed from and forbidden access to the facility.

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Standard 115.267: Agency protection against retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.267 (a)
 Has the agency established a policy to protect all residents and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other residents or staff? ☒ Yes ☐ No
 Has the agency designated which staff members or departments are charged with monitoring retaliation? ☒ Yes ☐ No 115.267 (b)
 Does the agency employ multiple protection measures, such as housing changes or transfers for resident victims or abusers, removal of alleged staff or resident abusers from contact with victims, and emotional support services for residents or staff who fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with investigations? ☒ Yes ☐ No
115.267 (c)
 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 or staff who reported the 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: 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

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 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)
a. Policy and the Employee Handbook forbid retaliation by staff members. The PREA Compliance Manager is tasked with monitoring retaliation. b. The facility has limited housing choices and therefore any staff involved in retaliation would be removed from the facility and any clients involved in retaliation would be removed from the treatment program. c. Supervisors stated that monitoring for retaliation would occur during the entire stay of the client. d. Clients meet with therapists weekly and are given the opportunity to express concerns at such meetings. e. The facility would protect any individual from retaliation in any instance.

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INVESTIGATIONS
Standard 115.271: Criminal and administrative agency investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.271 (a)
 When the agency conducts its own investigations into allegations of sexual abuse and sexual harassment, does it do so promptly, thoroughly, and objectively? [N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
 Does the agency conduct such investigations for all allegations, including third party and anonymous reports? [N/A if the agency/facility is not responsible for conducting any form of criminal OR administrative sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA
115.271 (b)
 Where sexual abuse is alleged, does the agency use investigators who have received specialized training in sexual abuse investigations as required by 115.234? ☒ Yes ☐ No
115.271 (c)
 Do investigators gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data? ☒ Yes ☐ No
 Do investigators interview alleged victims, suspected perpetrators, and witnesses? ☒ Yes ☐ No
 Do investigators review prior reports and complaints of sexual abuse involving the suspected perpetrator? ☒ Yes ☐ No
115.271 (d)
 When the quality of evidence appears to support criminal prosecution, does the agency conduct compelled interviews only after consulting with prosecutors as to whether compelled interviews may be an obstacle for subsequent criminal prosecution? ☒ Yes ☐ No
115.271 (e)
 Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an individual basis and not on the basis of that individual’s status as resident or staff? ☒ Yes ☐ No

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 Does the agency investigate allegations of sexual abuse without requiring a resident who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a condition for proceeding? ☒ Yes ☐ No
115.271 (f)
 Do administrative investigations include an effort to determine whether staff actions or failures to act contributed to the abuse? ☒ Yes ☐ No
 Are administrative investigations documented in written reports that include a description of the physical evidence and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings? ☒ Yes ☐ No
115.271 (g)
 Are criminal investigations documented in a written report that contains a thorough description of the physical, testimonial, and documentary evidence and attaches copies of all documentary evidence where feasible? ☒ Yes ☐ No
115.271 (h)
 Are all substantiated allegations of conduct that appears to be criminal referred for prosecution? ☒ Yes ☐ No
115.271 (i)
 Does the agency retain all written reports referenced in 115.271(f) and (g) for as long as the alleged abuser is incarcerated or employed by the agency, plus five years? ☒ Yes ☐ No
115.271 (j)
 Does the agency ensure that the departure of an alleged abuser or victim from the employment or control of the agency does not provide a basis for terminating an investigation? ☒ Yes ☐ No
115.271 (k)
 Auditor is not required to audit this provision.
115.271 (l)
 When an outside entity investigates sexual abuse, does the facility cooperate with outside investigators and endeavor to remain informed about the progress of the investigation? [N/A if an outside agency does not conduct administrative or criminal sexual abuse investigations. See 115.221(a).] ☒ Yes ☐ No ☐ NA

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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)
a. All and any allegations or incidents of sexual abuse are reported to the Minneapolis Police Department http://www.minneapolismn.gov/police/WCMSP-211690 the facility would only perform Administrative Investigations. b. The Administrative Investigators have received specialized training for investigations in a confinement setting. c. Investigators collect all and any available evidence and are highly experienced in interview techniques. d. Minneapolis Police Department would work in coordination with the Hennepin County Attorney’s Office https://www.hennepinattorney.org/about/divisions/divisions#adult-prosecution during a sexual abuse investigation. e. All client statements are taken serious and a polygraph would not be used to determine credibility of clients. f. Administrative Investigations are used to improve sexual safety in the facility and are documented. g. Criminal Investigations are documented including all evidence and contained in a Criminal Complaint written by the Hennepin County Attorney’s Office. h. Criminal allegations or incidents are referred for prosecution by the Hennepin County Attorney’s Office. i. All records are retained for at least 10 years. j. The Executive Director and the Detective from the Minneapolis Police Department assured that a criminal investigation would continue even if a staff member left employment k. N/A l. The Executive Director and the PREA Compliance Manager are kept appraised of an investigation by the Minneapolis Police Department.
Standard 115.272: Evidentiary standard for administrative investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report 115.272 (a)
 Is it true that the agency does not impose a standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐ Exceeds Standard (Substantially exceeds requirement of standards)

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☒ Meets Standard (Substantial compliance; complies in all material ways with the standard for the relevant review period)
☐ Does Not Meet Standard (Requires Corrective Action)
a. The facility would investigate any and all allegations and or incidents of sexual abuse based on any evidence available.
Standard 115.273: Reporting to residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.273 (a)
 Following an investigation into a resident’s allegation that he or she suffered sexual abuse in an agency facility, does the agency inform the resident as to whether the allegation has been determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No
115.273 (b)
 If the agency did not conduct the investigation into a resident’s allegation of sexual abuse in an agency facility, does the agency request the relevant information from the investigative agency in order to inform the resident? (N/A if the agency/facility is responsible for conducting administrative and criminal investigations.) ☒ Yes ☐ No ☐ NA
115.273 (c)
 Following a resident’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The staff member is no longer posted within the resident’s unit? ☒ Yes ☐ No
 Following a resident’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The staff member is no longer employed at the facility? ☒ Yes ☐ No
 Following a resident’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The agency learns that the staff member has been indicted on a charge related to sexual abuse in the facility? ☒ Yes ☐ No

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 Following a resident’s allegation that a staff member has committed sexual abuse against the resident, unless the agency has determined that the allegation is unfounded, or unless the resident has been released from custody, does the agency subsequently inform the resident whenever: The agency learns that the staff member has been convicted on a charge related to sexual abuse within the facility? ☒ Yes ☐ No
115.273 (d)
 Following a resident’s allegation that he or she has been sexually abused by another resident, does the agency subsequently inform the alleged victim whenever: The agency learns that the alleged abuser has been indicted on a charge related to sexual abuse within the facility? ☒ Yes ☐ No
 Following a resident’s allegation that he or she has been sexually abused by another resident, does the agency subsequently inform the alleged victim whenever: The agency learns that the alleged abuser has been convicted on a charge related to sexual abuse within the facility? ☒ Yes ☐ No
115.273 (e)
 Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No
115.273 (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)
a. Policy IX C. outlines responsibilities to notify clients of the results or the conditions of an on-going investigation. Supervisors all stated that they would keep a client informed of the outcome of an investigation. b. The facility supervisors would be kept informed by Minneapolis Police Department of the results of an investigation. c. Clients would be kept informed of the status of an offending staff member. Because of the small nature of the facility, the staff member would be removed from the facility. d. The victim would be informed of any investigation and or conviction of an abusive client. e. Notifications would be documented in the clients file.

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DISCIPLINE
Standard 115.276: Disciplinary sanctions for staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.276 (a)
 Are staff subject to disciplinary sanctions up to and including termination for violating agency sexual abuse or sexual harassment policies? ☒ Yes ☐ No 115.276 (b)
 Is termination the presumptive disciplinary sanction for staff who have engaged in sexual abuse? ☒ Yes ☐ No 115.276 (c)
 Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) commensurate with the nature and circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories? ☒ Yes ☐ No 115.276 (d)
 Are all terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, reported to: Law enforcement agencies unless the activity was clearly not criminal? ☒ Yes ☐ No
 Are all terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, reported to: Relevant licensing bodies? ☒ Yes ☐ 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)
a. All staff members are subject up to termination for violations of code of conduct spelled out in Policy X and the Employee Handbook.

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b. The Executive Director stated that termination would be presumptive for a sexual abuse incident. c. Past history of the employee would be considered in sanctions imposed. d. Terminations for sexual abuse violations would certainly be reported to the Minneapolis Police Department. The facility is also required to report such staff misconduct to the MNDOC.
Standard 115.277: Corrective action for contractors and volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.277 (a)
 Is any contractor or volunteer who engages in sexual abuse prohibited from contact with residents? ☒ Yes ☐ No
 Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement agencies unless the activity was clearly not criminal? ☒ Yes ☐ No
 Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing bodies? ☒ Yes ☐ No
115.277 (b)
 In the case of any other violation of agency sexual abuse or sexual harassment policies by a contractor or volunteer, does the facility take appropriate remedial measures, and consider whether to prohibit further contact with residents? ☒ 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)
a. Policy X also spells out sanctions for contractors and volunteers. Such offenders would be removed from the facility and reported to local police. b. The facility does not have any volunteers, but would treat them the same as contractors and forbid them to have entrance to the facility or contact with any client.
Standard 115.278: Interventions and disciplinary sanctions for residents

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All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.278 (a)
 Following an administrative finding that a resident engaged in resident-on-resident sexual abuse, or following a criminal finding of guilt for resident-on-resident sexual abuse, are residents subject to disciplinary sanctions pursuant to a formal disciplinary process? ☒ Yes ☐ No
115.278 (b)
 Are sanctions commensurate with the nature and circumstances of the abuse committed, the resident’s disciplinary history, and the sanctions imposed for comparable offenses by other residents with similar histories? ☒ Yes ☐ No
115.278 (c)
 When determining what types of sanction, if any, should be imposed, does the disciplinary process consider whether a resident’s mental disabilities or mental illness contributed to his or her behavior? ☒ Yes ☐ No
115.278 (d)
 If the facility offers therapy, counseling, or other interventions designed to address and correct underlying reasons or motivations for the abuse, does the facility consider whether to require the offending resident to participate in such interventions as a condition of access to programming and other benefits? ☒ Yes ☐ No
115.278 (e)
 Does the agency discipline a resident for sexual contact with staff only upon a finding that the staff member did not consent to such contact? ☒ Yes ☐ No
115.278 (f)
 For the purpose of disciplinary action does a report of sexual abuse made in good faith based upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an incident or lying, even if an investigation does not establish evidence sufficient to substantiate the allegation? ☒ Yes ☐ No
115.278 (g)
 Does the agency always refrain from considering non-coercive sexual activity between residents to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between residents.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐ Exceeds Standard (Substantially exceeds requirement of standards)

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☒ Meets Standard (Substantial compliance; complies in all material ways with the standard for the relevant review period)
☐ Does Not Meet Standard (Requires Corrective Action)
a. The facility does not have any means to keep an offending client in segregation. Clients that are abusive are both arrested and transported to the Hennepin County Jail to await prosecution or a remanded to their Probation Officer and the governing agency that has jurisdiction over them. b. Sanctions are spelled out in the Client Handbook and offenders would be removed from the treatment program. c. Mental disabilities would be considered in sanctions. d. The facility is a treatment facility and a minimum security level confinement facility and would not be able to accommodate offending clients. e. Sexual contact with any person is grounds for removal from the program and would be dealt with on a case by case basis. f. The facility would accept all reports and not discipline clients for reports that end up unfounded. g. Mutual sexual activity between clients is not considered criminal but is a violation of client conduct and facility rules.
MEDICAL AND MENTAL CARE
Standard 115.282: Access to emergency medical and mental health services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.282 (a)
 Do resident victims of sexual abuse receive timely, unimpeded access to emergency medical treatment and crisis intervention services, the nature and scope of which are determined by medical and mental health practitioners according to their professional judgment? ☒ Yes ☐ No
115.282 (b)
 If no qualified medical or mental health practitioners are on duty at the time a report of recent sexual abuse is made, do security staff first responders take preliminary steps to protect the victim pursuant to § 115.262? ☒ Yes ☐ No
 Do security staff first responders immediately notify the appropriate medical and mental health practitioners? ☒ Yes ☐ No

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115.282 (c)
 Are resident victims of sexual abuse offered timely information about and timely access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with professionally accepted standards of care, where medically appropriate? ☒ Yes ☐ No
115.282 (d)
 Are treatment services provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident? ☒ Yes ☐ 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)
a. Policy outlines duties of responding staff members to render first aid to victims and immediately request emergency medical responders if necessary. Victims would be transported to a local hospital emergency department. b. The facility does not have medical staff employed. First responders would provide immediate medical care and would follow first responder protocols and request emergency aid. c. Victims would receive access to emergency infections prophylaxis. d. The PREA Coordinator and the Executive Director both assured that no costs would be charged to victims.
Standard 115.283: Ongoing medical and mental health care for sexual abuse victims and abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.283 (a)
 Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility? ☒ Yes ☐ No
115.283 (b)

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 Does the evaluation and treatment of such victims include, as appropriate, follow-up services, treatment plans, and, when necessary, referrals for continued care following their transfer to, or placement in, other facilities, or their release from custody? ☒ Yes ☐ No
115.283 (c)
 Does the facility provide such victims with medical and mental health services consistent with the community level of care? ☒ Yes ☐ No
115.283 (d)
 Are resident victims of sexually abusive vaginal penetration while incarcerated offered pregnancy tests? (N/A if all-male facility.) ☐ Yes ☐ No ☒ NA
115.283 (e)
 If pregnancy results from the conduct described in paragraph § 115.283(d), do such victims receive timely and comprehensive information about and timely access to all lawful pregnancy-related medical services? (N/A if all-male facility.) ☐ Yes ☐ No ☒ NA
115.283 (f)
 Are resident victims of sexual abuse while incarcerated offered tests for sexually transmitted infections as medically appropriate? ☒ Yes ☐ No
115.283 (g)
 Are treatment services provided to the victim without financial cost and regardless of whether the victim names the abuser or cooperates with any investigation arising out of the incident? ☒ Yes ☐ No
115.283 (h)
 Does the facility attempt to conduct a mental health evaluation of all known resident-on-resident abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate by mental health practitioners? ☒ 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)

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a. Medical and or Mental Health Treatment would be provided through community health care clinics. b. The Executive Director stated that on-going treatments would be monitored and coordinated by the facility as needed. c. The treatment would be at the community level of care. d. N/A all male facility. e. N/A all male facility. f. Resident victims would receive treatment options for sexual transmitted diseases. g. The Executive Director assured that medical services would be provided free of charge. h. The facility has licensed mental health evaluators as therapists and would provide such services.
DATA COLLECTION AND REVIEW
Standard 115.286: Sexual abuse incident reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.286 (a)
 Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse investigation, including where the allegation has not been substantiated, unless the allegation has been determined to be unfounded? ☒ Yes ☐ No
115.286 (b)
 Does such review ordinarily occur within 30 days of the conclusion of the investigation? ☒ Yes ☐ No
115.286 (c)
 Does the review team include upper-level management officials, with input from line supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No
115.286 (d)
 Does the review team: Consider whether the allegation or investigation indicates a need to change policy or practice to better prevent, detect, or respond to sexual abuse? ☒ Yes ☐ No
 Does the review team: Consider whether the incident or allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; gang affiliation; or other group dynamics at the facility? ☒ Yes ☐ No
 Does the review team: Examine the area in the facility where the incident allegedly occurred to assess whether physical barriers in the area may enable abuse? ☒ Yes ☐ No

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 Does the review team: Assess the adequacy of staffing levels in that area during different shifts? ☒ Yes ☐ No
 Does the review team: Assess whether monitoring technology should be deployed or augmented to supplement supervision by staff? ☒ Yes ☐ No
 Does the review team: Prepare a report of its findings, including but not necessarily limited to determinations made pursuant to §§ 115.286(d)(1) - (d)(5), and any recommendations for improvement and submit such report to the facility head and PREA compliance manager? ☒ Yes ☐ No
115.286 (e)
 Does the facility implement the recommendations for improvement, or document its reasons for not doing so? ☒ 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)
a. Policy requires an incident review and I was given an example of an incident review. Interviews with supervisors showed that all incidents in the facility receive some type of review. b. Policy requires reviews within 30 days. The review I was given a copy of was completed within 8 days of the incident. c. The review team consists of the Executive Director, the PREA Coordinator and the PREA Compliance Manager. d. Interviews with team members indicated that staff actions, training, physical layout, client level and staffing levels would all be considered during a review. e. The Executive Director stated that he would consider all and any recommendations presented to him to deter further incidents.
Standard 115.287: Data collection
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.287 (a)

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 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 115.287 (f)
 Does the agency, upon request, provide all such data from the previous calendar year to the Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.) ☐ Yes ☐ No ☒ NA
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)
a. The facility maintains incident based statistics following policy. b. Incident based data is contained in annual reports. c. The information is adequate to be provided to the US Dept of Justice Survey of Sexual Violence. d. All files and reports are kept for data review. e. N/A f. N/A

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Standard 115.288: Data review for corrective action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.288 (a)
 Does the agency review data collected and aggregated pursuant to § 115.287 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No
 Does the agency review data collected and aggregated pursuant to § 115.287 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Taking corrective action on an ongoing basis? ☒ Yes ☐ No
 Does the agency review data collected and aggregated pursuant to § 115.287 in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies, practices, and training, including by: Preparing an annual report of its findings and corrective actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No
115.288 (b)
 Does the agency’s annual report include a comparison of the current year’s data and corrective actions with those from prior years and provide an assessment of the agency’s progress in addressing sexual abuse ☒ Yes ☐ No
115.288 (c)
 Is the agency’s annual report approved by the agency head and made readily available to the public through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.288 (d)
 Does the agency indicate the nature of the material redacted where it redacts specific material from the reports when publication would present a clear and specific threat to the safety and security of a facility? ☒ Yes ☐ 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)

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a. The agency follows policy and records incident based data and posts that data in its annual report. The facility uses the data to deter and also maintain its zero tolerance policy. b. The annual report contains statistics from current and previous years. c. The report is posted on the agency web-site http://alphaservices.org/index.php/prea-policy/annual-report/ d. The report does not contain any redacted material.
Standard 115.289: Data storage, publication, and destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.289 (a)
 Does the agency ensure that data collected pursuant to § 115.287 are securely retained? ☒ Yes ☐ No
115.289 (b)
 Does the agency make all aggregated sexual abuse data, from facilities under its direct control and private facilities with which it contracts, readily available to the public at least annually through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.289 (c)
 Does the agency remove all personal identifiers before making aggregated sexual abuse data publicly available? ☒ Yes ☐ No
115.289 (d)
 Does the agency maintain sexual abuse data collected pursuant to § 115.287 for at least 10 years after the date of the initial collection, unless Federal, State, or local law requires otherwise? ☒ 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)

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a. The facility follows policy, the Employee Handbook, MN Rule 2920.4900 and Minnesota State Statute 609.344 in reference to data privacy and data retention. b. The data is posted on the agency web-site. c. There are no personal identifiers on the annual report or statistics. d. Data is retained for at least 10 years.
AUDITING AND CORRECTIVE ACTION
Standard 115.401: Frequency and scope of audits
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.401 (a)
 During the prior three-year audit period, did the agency ensure that each facility operated by the agency, or by a private organization on behalf of the agency, was audited at least once? (Note: The response here is purely informational. A "no" response does not impact overall compliance with this standard.) ☐ Yes ☒ No
115.401 (b)
 Is this the first year of the current audit cycle? (Note: a “no” response does not impact overall compliance with this standard.) ☐ Yes ☒ No
 If this is the second year of the current audit cycle, did the agency ensure that at least one-third of each facility type operated by the agency, or by a private organization on behalf of the agency, was audited during the first year of the current audit cycle? (N/A if this is not the second year of the current audit cycle.) ☒ Yes ☐ No ☐ NA
 If this is the third year of the current audit cycle, did the agency ensure that at least two-thirds of each facility type operated by the agency, or by a private organization on behalf of the agency, were audited during the first two years of the current audit cycle? (N/A if this is not the third year of the current audit cycle.) ☐ Yes ☐ No ☒ NA
115.401 (h)
 Did the auditor have access to, and the ability to observe, all areas of the audited facility? ☒ Yes ☐ No
115.401 (i)
 Was the auditor permitted to request and receive copies of any relevant documents (including electronically stored information)? ☒ Yes ☐ No
115.401 (m)

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 Was the auditor permitted to conduct private interviews with inmates, residents, and detainees? ☒ Yes ☐ No
115.401 (n)
 Were residents permitted to send confidential information or correspondence to the auditor in the same manner as if they were communicating with legal counsel? ☒ 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)
a. This is the second audit for the facility. The previous audit was completed June 22, 2015. b. This is the second year of the audit cycle. H. I had access to all areas of both building of the facility. I also had access to client records. I. I requested and promptly received copies of numerous documents to verify compliance with the standards. m. I was given a private office to conduct interviews with clients and staff members. n. Clients and staff were given the opportunity to contact me. My contact information was posted in conspicuous areas throughout both buildings. I received no correspondence from clients or staff members.
Standard 115.403: Audit contents and findings
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.403 (f)
 The agency has published on its agency website, if it has one, or has otherwise made publicly available, all Final Audit Reports within 90 days of issuance by auditor. The review period is for prior audits completed during the past three years PRECEDING THIS AGENCY AUDIT. In the case of single facility agencies, the auditor shall ensure that the facility’s last audit report was published. The pendency of any agency appeal pursuant to 28 C.F.R. § 115.405 does not excuse noncompliance with this provision. (N/A if there have been no Final Audit Reports issued in the past three years, or in the case of single facility agencies that there has never been a Final Audit Report issued.) ☒ Yes ☐ No ☐ NA

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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)
The agency has the final report for the audit posted on its web-site from June 22, 2015 and is obligated under contract to post this final report within 90 days of receipt of the report.
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AUDITOR CERTIFICATION
I certify that:
☒ The contents of this report are accurate to the best of my knowledge.
☒ No conflict of interest exists with respect to my ability to conduct an audit of the agency under review, and
☒ I have not included in the final report any personally identifiable information (PII) about any resident or staff member, except where the names of administrative personnel are specifically requested in the report template.
Timothy Pippo July 17, 2019
Auditor Signature Date