Prison Rape Elimination Act (PREA) Audit Report
Adult Prisons & Jails

☐

☒

Interim

Final

☐ N/A

Date of Interim Audit Report: June 3, 2021
If no Interim Audit Report, select N/A

Date of Final Audit Report:

October 27, 2021

Auditor Information
Name:

Amanda van Arcken

Email:

Company Name:

Oregon Department of Corrections

Mailing Address:

2575 Center Street NE

Telephone:

amanda.vanarcken@doc.state.or.us

City, State, Zip:

(503) 569-8578

Salem, Oregon 97301

Date of Facility Visit:

April 18-20, 2021

Agency Information
State of Hawaii Department of Public Safety (PSD)

Name of Agency:

Governing Authority or Parent Agency (If Applicable):
Physical Address:
Mailing Address:

1177 Alakea Street
1177 Alakea Street

The Agency Is:

☐ Municipal

Click or tap here to enter text.
City, State, Zip:

Honolulu, Hawaii 96813

City, State, Zip:

Honolulu, Hawaii 96813

☐

Military

☐

Private for Profit

☐

Private not for Profit

☐

County

☒

State

☐

Federal

Agency Website with PREA Information:

https://dps.hawaii.gov/policies-and-procedures/pp-prea/
Agency Chief Executive Officer

Name:

Max N. Otani, Director

Email:

max.n.otani@hawaii.gov

Telephone:

(808) 587-1350

Agency-Wide PREA Coordinator
Name:

Cheyenne Evans

Email:

cheyenne.l.evans@hawaii.gov

PREA Coordinator Reports to:

Max N. Otani, Director
PREA Audit Report – V6.

Telephone:

(808) 587-1415

Number of Compliance Managers who report to the PREA
Coordinator:

8
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Maui Community Correctional Center

Facility Information
Name of Facility:

Maui Community Correctional Center

Physical Address: 600

Waiale Road

Mailing Address (if different from above):

Click or tap here to enter text.
The Facility Is:

☐ Municipal

City, State, Zip:

Wailuku, Hawaii 96793

City, State, Zip:

Click or tap here to enter text.

☐

Military

☐

Private for Profit

☐

Private not for Profit

☐

County

☒

State

☐

Federal

☐

Facility Type:
Facility Website with PREA Information:

Prison

☒

I

Jail

http://dps.hawaii.gov/mccc/

Has the facility been accredited within the past 3 years?

☐ Yes ☒ No

If the facility has been accredited within the past 3 years, select the accrediting organization(s) – select all that apply (N/A if
the facility has not been accredited within the past 3 years):

☐ ACA
☐ NCCHC
☐ CALEA
☐ Other (please name or describe: Click or tap here to enter text.
☒ N/A
If the facility has completed any internal or external audits other than those that resulted in accreditation, please describe:

N/A

Warden/Jail Administrator/Sheriff/Director
Name:
Email:

Deborah Taylor, Warden
deborah.m.taylor@hawaii.gov

Telephone:

(808) 243-5030

Facility PREA Compliance Manager
Name:
Email:

Gail Mirkovich, Lieutenant
gail.l.mirkovich@hawaii.gov

Telephone:

(808) 243-8684

Facility Health Service Administrator ☐ N/A
Name:
Email:

Jennifer Lopez
jennifer.d.lopez@hawaii.gov

Telephone:

(808) 243-5101

Facility Characteristics
Designated Facility Capacity:

301

Current Population of Facility:

297

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Maui Community Correctional Center

Average daily population for the past 12 months:

398

Has the facility been over capacity at any point in the past 12
months?

☒ Yes

Which population(s) does the facility hold?

☐ Females

Age range of population:

20-88 years

Average length of stay or time under supervision:

11 months

Facility security levels/inmate custody levels:

Community/Minimum/Medium

☐ No
☐ Males

☒ Both Females and Males

Number of inmates admitted to facility during the past 12 months:

2043

Number of inmates admitted to facility during the past 12 months whose length of stay
in the facility was for 72 hours or more:

781

Number of inmates admitted to facility during the past 12 months whose length of stay
in the facility was for 30 days or more:

807

☐ Yes

Does the facility hold youthful inmates?

☒ No

Number of youthful inmates held in the facility during the past 12 months: (N/A if the
facility never holds youthful inmates)
Does the audited facility hold inmates for one or more other agencies (e.g. a State
correctional agency, U.S. Marshals Service, Bureau of Prisons, U.S. Immigration and
Customs Enforcement)?

Select all other agencies for which the audited
facility holds inmates: Select all that apply (N/A if the
audited facility does not hold inmates for any other
agency or agencies):

Click or tap here to enter text.

☒ N/A
☐ Yes

☒ No

☐ Federal Bureau of Prisons
☐ U.S. Marshals Service
☐ U.S. Immigration and Customs Enforcement
☐ Bureau of Indian Affairs
☐ U.S. Military branch
☐ State or Territorial correctional agency
☐ County correctional or detention agency
☐ Judicial district correctional or detention facility
☐ City or municipal correctional or detention facility (e.g. police lockup or
city jail)

☐ Private corrections or detention provider
☐ Other - please name or describe: Click or tap here to enter text.
☒ N/A
Number of staff currently employed by the facility who may have contact with inmates:
Number of staff hired by the facility during the past 12 months who may have contact
with inmates:

191
21

Number of contracts in the past 12 months for services with contractors who may
have contact with inmates:

1

Number of individual contractors who have contact with inmates, currently authorized
to enter the facility:

1

Number of volunteers who have contact with inmates, currently authorized to enter the
facility:

175

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Physical Plant
Number of buildings:
Auditors should count all buildings that are part of the facility, whether inmates are
formally allowed to enter them or not. In situations where temporary structures have
been erected (e.g., tents) the auditor should use their discretion to determine whether
to include the structure in the overall count of buildings. As a general rule, if a
temporary structure is regularly or routinely used to hold or house inmates, or if the
temporary structure is used to house or support operational functions for more than a
short period of time (e.g., an emergency situation), it should be included in the overall
count of buildings.

7

Number of inmate housing units:
Enter 0 if the facility does not have discrete housing units. DOJ PREA Working Group
FAQ on the definition of a housing unit: How is a "housing unit" defined for the
purposes of the PREA Standards? The question has been raised in particular as it
relates to facilities that have adjacent or interconnected units. The most common
concept of a housing unit is architectural. The generally agreed-upon definition is a
space that is enclosed by physical barriers accessed through one or more doors of
various types, including commercial-grade swing doors, steel sliding doors,
interlocking sally port doors, etc. In addition to the primary entrance and exit,
additional doors are often included to meet life safety codes. The unit contains
sleeping space, sanitary facilities (including toilets, lavatories, and showers), and a
dayroom or leisure space in differing configurations. Many facilities are designed with
modules or pods clustered around a control room. This multiple-pod design provides
the facility with certain staff efficiencies and economies of scale. At the same time, the
design affords the flexibility to separately house inmates of differing security levels, or
who are grouped by some other operational or service scheme. Generally, the control
room is enclosed by security glass, and in some cases, this allows inmates to see into
neighboring pods. However, observation from one unit to another is usually limited by
angled site lines. In some cases, the facility has prevented this entirely by installing
one-way glass. Both the architectural design and functional use of these multiple pods
indicate that they are managed as distinct housing units.

14

Number of single cell housing units:

1

Number of multiple occupancy cell housing units:

6

Number of open bay/dorm housing units:

7

Number of segregation cells (for example, administrative, disciplinary, protective
custody, etc.):

12

In housing units, does the facility maintain sight and sound separation between
youthful inmates and adult inmates? (N/A if the facility never holds youthful inmates)

☐ Yes

☐ No

Does the facility have a video monitoring system, electronic surveillance system, or
other monitoring technology (e.g. cameras, etc.)?

☒ Yes

☐ No

Has the facility installed or updated a video monitoring system, electronic surveillance
system, or other monitoring technology in the past 12 months?

☒ Yes

☐ No

☒ N/A

Medical and Mental Health Services and Forensic Medical Exams
Are medical services provided on-site?

☒ Yes

☐ No

Are mental health services provided on-site?

☒ Yes

☐ No

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Where are sexual assault forensic medical exams provided?
Select all that apply.

☐ On-site
☒ Local hospital/clinic
☐ Rape Crisis Center
☐ Other (please name or describe: Click or tap here to enter
text.)

Investigations
Criminal Investigations
Number of investigators employed by the agency and/or facility who are responsible
for conducting CRIMINAL investigations into allegations of sexual abuse or sexual
harassment:

2 Agency/2 Facility

When the facility received allegations of sexual abuse or sexual harassment (whether
staff-on-inmate or inmate-on-inmate), CRIMINAL INVESTIGATIONS are conducted by:
Select all that apply.

☐ Facility investigators
☒ Agency investigators
☒ An external investigative entity

Select all external entities responsible for CRIMINAL
INVESTIGATIONS: Select all that apply (N/A if no
external entities are responsible for criminal
investigations)

☒ Local police department
☒ Local sheriff’s department
☐ State police
☐ A U.S. Department of Justice component
☐ Other (please name or describe: Click or tap here to enter text.)
☐ N/A

Administrative Investigations
Number of investigators employed by the agency and/or facility who are responsible
for conducting ADMINISTRATIVE investigations into allegations of sexual abuse or
sexual harassment?

2 Agency/2 Facility

When the facility receives allegations of sexual abuse or sexual harassment (whether
staff-on-inmate or inmate-on-inmate), ADMINISTRATIVE INVESTIGATIONS are
conducted by: Select all that apply

☒ Facility investigators
☒ Agency investigators
☐ An external investigative entity

Select all external entities responsible for
ADMINISTRATIVE INVESTIGATIONS: Select all that
apply (N/A if no external entities are responsible for
administrative investigations)

PREA Audit Report – V6.

☐ Local police department
☐ Local sheriff’s department
☐ State police
☐ A U.S. Department of Justice component
☐ Other (please name or describe: Click or tap here to enter text.)
☒ N/A

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Maui Community Correctional Center

Audit Findings
Audit Narrative (including Audit Methodology)
The auditor’s description of the audit methodology should include a detailed description of the following
processes during the pre-onsite audit, onsite audit, and post-audit phases: documents and files reviewed,
discussions and types of interviews conducted, number of days spent on-site, observations made during the
site-review, and a detailed description of any follow-up work conducted during the post-audit phase. The
narrative should describe the techniques the auditor used to sample documentation and select interviewees,
and the auditor’s process for the site review.
Amanda van Arcken, a U.S. Department of Justice (USDOJ) Certified PREA Auditor for Adult Facilities,
conducted the Prison Rape Elimination Act (PREA) on-site audit of Maui Community Correctional Center
(MCCC) in Wailuku, Hawaii from April 18-20, 2021. This audit was conducted under a contract between the
State of Hawaii Department of Public Safety (PSD) and the Oregon Department of Corrections (ODOC) in
conjunction with the Western States PREA Circular Auditing Agreement. The PSD, ODOC and nine other
agencies (California, Colorado, Los Angeles County, Nevada, New Mexico, North Dakota, Montana,
Washington and Wisconsin) are members of the Western States PREA Circular Auditing Agreement. The
audit was conducted with the assistance of one support staff – Ericka Sage. Sage is a USDOJ Certified PREA
Auditor for Adult Facilities. The audit team conducted the site review together. Amanda van Arcken conducted
the documentation review for staff and inmates; informal interviews with random staff and inmates; formal
interviews with specialized staff and targeted inmates; and, authored this report. Sage conducted informal and
formal interviews of random staff, specialized staff, random inmates, and targeted inmates.
The audit of MCCC was originally scheduled to take place in November 2020 before being delayed to March
21-27, 2021 with an auditor in the Western States PREA Circular Auditing Agreement from Nevada. Nevada
was unable to gain travel clearance, and Oregon agreed to conduct the audits needed by PSD.
The agency PREA Coordinator developed a Notification of Audit in English that was posted in the facility on
March 15, 2021. A notice was not posted in any other language, as the facility did not have any inmates with
limited-English proficiencies. The auditor verified the posting with 21 dated and time-stamped photographs.
The notification contained information about the upcoming audit and stated that any inmate or staff member
with pertinent information should send a letter containing this information to the auditor. The auditor instructed
the facility to post this notification in all housing units and throughout the facility for the six weeks prior to the
onsite review, on a brightly colored piece of paper that would stand out among other postings in these areas.
The notice contained a reminder about the confidential nature of communication with the auditor, and possible
exceptions to confidentiality. During the facility tour, the auditor observed the posting in all housing areas and
throughout the facility in inmate-accessible areas. The notice was observed to be posted in areas only
accessible to staff and areas accessible to visitors, providing them with the opportunity to contact the auditor.
Prior to the onsite review, this auditor did not receive any letters from inmates at MCCC.
The Pre-Audit Questionnaire (PAQ) was initiated by the facility and was received by this auditor from the
original Nevada auditor on February 25, 2021. The PAQ was formatted on a password-protected thumb drive
and included all relevant documentation pertaining to the audit, including, but not limited to policies,
procedures, memorandum of understanding and training documents. The auditor reviewed the questionnaire
and all documentation. The audit documentation period on the thumb drive was for September 2019 through
September 2020, to coincide with the original audit for November 2020. Updates to the PAQ and
documentation were provided to this auditor by the facility on March 25, 2021. This auditor reviewed the
Annual PREA Reports for 2011-2018, which were posted on the agency website. The 2019 Annual PREA
Report was provided to this auditor by the agency PREA Coordinator. This was the third PREA audit
conducted at MCCC. The most recent final audit report for MCCC was provided to the agency on June 1,
2018.

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News articles referencing MCCC were reviewed online. Nothing related to the sexual safety of the facility
within the last three years was located.
On March 8, 2021, this auditor sent an email to MCCC’s PREA Compliance Manager (PCM) requesting the
following documents prior to the audit team’s arrival at the facility:
• A complete inmate roster, sorted by housing unit
• A list of inmates with mobility disabilities
• A list of inmates who are hard of hearing or deaf
• A list of inmates who have vision impairment or are blind
• A list of inmates who have reported sexual abuse
The following documents were requested to be available on the first day of the onsite review:
• A complete listing of all staff, contractors, and volunteers
• Custody staff assignment rosters for all shifts of the onsite review
• Copies of any PREA-related grievances filed in the last 12 months
• A list of all inmates who have been at MCCC prior to August 2012
• A list of all inmates who identify as lesbian, gay, bisexual, transgender or intersex
• A list of all inmates who disclosed prior sexual victimization during risk screening (in community
and/or in confinement)
This auditor conducted outreach to Just Detention International (JDI), and the Maui Sexual Assault Treatment
Center (MSATC) to learn about issues of sexual safety at the facility.
• JDI is a health and human rights organization that seeks to end sexual abuse in all forms of detention
by advocating for laws and policies that make prisons and jails safe and providing incarcerated
survivors with support and resource referrals. JDI advised this auditor that they have not received any
correspondence from incarcerated survivors at MCCC within the last 12 months.
• MSATC has provided a continuum of sexual assault services to individuals and families impacted by
sexual violence for nearly thirteen years, serving the residents of Maui County. They provide support
to victims and their families through critical, acute moments of crisis and their entire process of healing.
The MSATC provides a 24-hour crisis helpline, crisis stabilization and outreach services, as well as
supportive, short-term therapy and psycho education and long-term clinical treatment. MSATC
advised this auditor they provide services to incarcerated survivors over the phone, in writing and in
person, at forensic medical exams. MSATC believed they had contact with incarcerated survivors at
MCCC over the last year and did not have any specific concerns related to the sexual safety of the
facility or the agency. Prior to the COVID-19 pandemic, a few incarcerated survivors met with an
advocate weekly. During and since the pandemic, services were restricted to phone contact.
On the morning of April 18, 2021, the audit team met with the agency PREA Coordinator and the facility PCM
for the site review. No other members of facility leadership were present, and a formal entrance meeting was
not requested.
The audit team began conducting the physical plant review of MCCC on the first day. The audit team was
provided access to all areas of the facility, including outlying buildings where inmates may be assigned for
work. This auditor observed the facility configuration, locations of cameras and security mirrors, the level of
staff supervision, the housing unit layout (including shower/toilet areas), placement of posters and other PREA
informational resources, security monitoring, and search procedures. Toilet and shower areas of the facility
allowed for inmate privacy while undressing and using facilities, except for one communal bathroom with a
shower curtain across its entrance. Once identified, the curtain was removed and replaced with one
appropriate in size to prevent cross-gender viewing. Cross-gender announcements were consistently
observed when the audit team entered housing units. The audit notice was visible in all inmate areas. Inmate
phones were tested to ensure the ability to contact the PREA Hotline. Locked boxes were in each housing
unit or common areas for inmates to deposit grievance and discrimination forms. Unit logbooks were checked
to ensure the completion of unannounced supervisory rounds.
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During the physical plant review, the audit team looked for potential blind spots in areas accessible to inmates,
and areas where cross-gender viewing may occur. The audit team did not identify any areas of concern. Each
housing unit varied in design and layout. Some units had bathrooms with separate toilet and shower stalls
with privacy curtains. Some units had common showers with either doors or curtains that allowed inmates to
shower without being viewed by staff of the opposite gender. Unit rules require that inmates close shower
curtains and toilet doors when in use, and inmates are required to be clothed upon exit.
During the physical plant review the audit team made the following recommendations –
• In Education, an inmate restroom had a locking mechanism that could permit an inmate to lock
themselves in the bathroom with another inmate or staff member. The facility PCM had the locking
mechanism removed, as verified by pictures and email to this auditor on May 21, 2021.
• In Education, the restroom for female staff members was propped open. The audit team
recommended it remain secured when not in use.
• One classroom window in Education was completely obscured with postings, which did not allow
visibility from the corridor. This auditor recommends that there always be at least one way to see into
an area for safety and security reasons.
• The door window and window to the Administrative Captain’s office was completely obscured with
postings, which did not allow visibility from the corridor. This auditor recommends that there always
be at least one way to see into an area for safety and security reasons.
• Two female inmates assigned to work in the laundry are secured in the room for the duration of their
work period by staff. This auditor recommends the facility have an odd number of inmate workers
assigned to isolated or limited view areas.
• In Module D, postings on office windows and doors obscured visibility into staff offices. This auditor
recommends that there always be at least one way to see into an area for safety and security reasons.
Cameras were not noted in areas where inmates may be using restrooms or showers. The existing camera
system consists of approximately 93 cameras that monitor the institution. Records are retained for about 30
days, depending on the amount of movement in the area under surveillance.
After the completion of the physical plant review on the first day and for the duration of the second day onsite,
the audit team conducted staff and inmate interviews. Staff were interviewed using the DOJ protocols that
question their PREA training and overall knowledge of the agency’s zero tolerance policy, reporting
mechanisms available to staff and inmates, response protocols when allegations of sexual abuse and/or
sexual harassment are made, first responder duties, data collection processes and other pertinent PREA
requirements. All interviews were conducted one at a time, in a private and confidential manner.
MCCC employs 191 staff who may have contact with inmates. Security staff are assigned daily to eight-hour
shifts. Shift hours run from 0700-1500 hours; 1500-2300 hours; 2300-0700 hours. There are approximately
35 security staff assigned to second watch; 28 assigned to third watch; and, 25 assigned to first watch.
The March 2021 edition of the PREA Auditor Handbook requires at least 12 random security staff be
interviewed. A total of 13 random interviews were conducted. Because MCCC is a small facility, many of the
staff had collateral duties. For instance, duties related to processing grievances and mail were assigned to
security staff.
A total of 24 specialized staff interviews were conducted, Interviews with the following specialized staff:
• Agency head designee
• Warden
• Agency PREA Coordinator
• Facility PREA Compliance Manager
• Agency contract administrator
• Two intermediate or higher-level facility staff
• Medical Services staff
• Mental Health Services staff
• Human Resource manager
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• Investigative staff
• SANE
• Confidential, community-based advocate
• Staff on the sexual abuse incident review team
• Designated staff member charged with monitoring retaliation
• Mailroom staff
• Grievance Coordinator
• Contractors/volunteers
The PAQ indicated the average daily population for audit period was 398 inmates. The inmate population on
the first day of the onsite review was 297. The March 2021 edition of the PREA Auditor Handbook requires at
least 13 random inmate interviews and at least 13 targeted inmate interviews for an adult prison population of
251-500 inmates. The audit team planned to interview at least one random inmate from each housing unit (13
in total), in addition to any targeted inmates. After selecting targeted inmates for interview, this auditor used
an inmate roster sorted by housing unit to select the fourth inmate of each unit. The identified inmate names
were selected for both file reviews and random interviews. A total of 15 random inmates were interviewed. No
inmates declined to be interviewed. Files were reviewed to evaluate screening and intake procedures,
documentation of inmate education and medical or mental health referrals when required.
The Maui Community Correctional Center did not have any inmates who were youthful, had limited-English
proficiencies, were placed in segregated housing for high risk of sexual victimization, or who identified as
transgender or intersex. A total of 14 targeted inmate interviews were conducted. Interviews were conducted
with the following targeted inmates:
• One inmate with a physical disability
• One inmate who was blind, deaf, or hard of hearing
• One inmate with a cognitive disability
• Seven inmates who identified as lesbian, gay, or bisexual
• One inmate who reported sexual abuse (outside of the audit documentation period)
• Three inmates who reported sexual victimization during risk screening
There were no inmates at MCCC who were admitted to the facility prior to August 20, 2012.
A review of investigative files indicated there were no allegations of sexual abuse or sexual harassment
reported to date in 2021. There was one allegation of inmate/inmate sexual abuse, three allegations of
inmate/inmate sexual harassment and one allegation of staff/inmate sexual harassment reported in 2020.
A formal exit meeting was not requested by the facility. The auditor provided a summary of the audit through
the on-site phase and provided information on what to expect during the Corrective Action Period (CAP)
directly to the agency PREA Coordinator and facility PCM.
MCCC has medical staff onsite during business hours. After hours, inmates can be transported to Maui
Memorial Medical Center. The facility has one mental health staff that is available in-person and by video from
0800-1630, depending on her schedule at other facilities.
The auditor spoke with a local Sexual Assault Nurse Examiner (SANE) at Maui Memorial Medical Center, to
discuss and confirm the agreement in place with PSD to provide SANE/SAFE services. She verified that all
SANEs receive training that meets the national training standards.
After the onsite audit, the auditor utilized the Auditor Compliance Tool for Adult Prisons and Jails as a guide
in determining compliance with each standard. To determine compliance, the auditor used the information and
documentation provided during the pre-audit, information obtained through staff and inmate interviews, and
observations during the onsite review. There were no barriers to completing the audit of MCCC.
This auditor provided the agency with an interim report on June 3, 2021, triggering the corrective action
period. This auditor communicated with the agency PREA Coordinator and/or facility PCM several times
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each month to ensure the facility was continuing to work towards compliance. The agency PREA
Coordinator and/or facility PCM provided this auditor with the required documentation in a timely manner.
After examining all evidence, this auditor found Maui Community Correctional Center in full compliance of
the PREA standards on October 19, 2021. A final audit report was provided to the agency on October 27,
2021.

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Facility Characteristics
The auditor’s description of the audited facility should include details about the facility type, demographics
and size of the inmate, resident or detainee population, numbers and type of staff positions, configuration
and layout of the facility, numbers of housing units, description of housing units including any special
housing units, a description of programs and services, including food service and recreation. The auditor
should describe how these details are relevant to PREA implementation and compliance.
The State of Hawaii Department of Public Safety (PSD) operates four jails and four prisons in the state of
Hawaii, incarcerating approximately 3500 adult offenders. Hawaii jails provide for the secure incarceration of
pretrial and short-term sentence misdemeanant populations and are situated on each major island. The jails
also provide for the transitional sentence felon population, those who have almost completed their felony
sentences and those returning to the community. Three prisons are located on the island of Oahu, and one is
located on the Big Island of Hawaii. The Saguaro Correctional Center houses Hawaii inmates on the mainland,
through a contact with CoreCivic. The mission statement of PSD is to uphold justice and public safety by
providing correctional and law enforcement services to Hawaii’s communities with professionalism, integrity,
and fairness.
Maui Community Correctional Center is a state-operated jail. MCCC houses minimum- and medium-custody
male and female inmates that have been sentenced or in pre-trial status. MCCC’s population is approximately
85% male and 15% female. Proper housing and program assignments are determined through the intake
process, available records, bail study, PREA risk screenings and classification.
On March 11, 2019, inmates at MCCC engaged in a riot that caused millions of dollars in damages. Eighteen
inmates were found guilty via an administrative process for the riot and fires. Inmates cited nonworking
telephones, overcrowding, changes to commissary and complaints about food as the catalysts to the riot. The
most significant damage had been repaired at the time of the onsite review.
The racial/ethnic composition of the inmate population is as follows –
Polynesian 37.3%
Asian 11.2%
White 29.9%
Hispanic 3.3%
African American 1.2%
Other 16.2%
MCCC is comprised of seven buildings. There are seven dormitory-style housing units, six multiple occupancy
celled housing units and one single cell housing unit.
• Intake has six beds and houses inmates with medical needs, those who may be detoxing from
substances and those under safety or suicide watches.
• Module A has pretrial and sentenced, medium-security male inmates with a capacity of 96. This
module is separated into four quadrants and was on COVID-19 quarantine status at the time of the
onsite review. Additional personal protective equipment or precautions were necessary to tour this
area.
• Module B has pretrial, medium-security male inmates with a capacity of 96. This module is separated
into four quadrants and was on COVID-19 quarantine status at the time of the onsite review. Additional
personal protective equipment or precautions were necessary to tour this area.
• Module C has 12 beds for male inmates assigned to Administrative Segregation. The inmates
assigned to this unit are considered general population status.
• Module D has 12 beds for male inmates assigned to Disciplinary Segregation. The inmates assigned
to this module are restricted in their ability to move freely about the facility due to their risk of violence
to others.
• Multi-purpose (MP)/Module III has pretrial and sentenced medium-security female inmates with a
capacity of 32. MP/Module III is separated into four separate housing areas within the one unit. This
housing unit is a gender-specific post.
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•
•
•

•

Dorms 1 and 2, with a capacity of 64, are closed. The audit team toured the vacant dorms. The facility
PCM indicated she would review the area prior to any deactivation to ensure there are no concerns
with opposite gender viewing and all postings are up to date.
Dorm 3 is normally used for pretrial and sentenced, medium-custody male inmates participating in
Drug Court. Drug Court has been postponed during COVID-19. At the time of the onsite review, the
space was being used for female inmates on quarantine status.
Dorms 4 and 5 are normally used for pretrial and sentenced, medium-custody female inmates
participating in Drug Court. Drug Court has been postponed during COVID-19. At the time of the onsite
review, both dorms were secured and unoccupied. The audit team toured the vacant dorms. The
facility PCM indicated she would review the area prior to any deactivation to ensure there are no
concerns with opposite gender viewing and all postings are up to date. This housing unit is a genderspecific post.
Dorms 6 and 7 has sentenced, minimum-security male inmates who are assigned to work lines and
on furloughs, and pretrial male inmates that are assigned to work in the facility’s kitchen. The two
dorms have the capacity for 120 beds.

Using Capital Improvement Projects (CIP) funding, MCCC has been installing video surveillance throughout
the facility to provide coverage for identified blind spots and additional security coverage after the riot.
Cameras originally installed in the hallways have been upgraded. Cameras have been installed on the facility
perimeter, in the main sallyport, Intake and the Gatehouse. The installation locations of some housing unit
cameras unintentionally created blind spots, but the facility PCM has installed security mirrors to mitigate the
lack of direct visibility. The camera project is expected to continue into 2021.
Inmate work lines, education and behavioral health programs are operated by facility staff or volunteers,
Monday through Friday between 0800 and 2100 hours. Weekend activities include visitation, recreation and
volunteer-led programs, to include Alcoholics Anonymous and Narcotics Anonymous.
Among the programs offered at MCCC are adult basic education, GED, parenting, cognitive skills, substance
abuse treatment, vocational training, and work furlough. Extended furlough is offered in conjunction with the
Maui Intake Service Center. A drug court program enables select pre-trial inmates, sentenced felons, and
parole violators to participate in in-facility treatment services, which is followed by another nine months of
treatment in the community. A review is conducted quarterly to ensure staffing is adequate for these services
and programs.

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Summary of Audit Findings
The summary should include the number and list of standards exceeded, number of standards met, and
number and list of standards not met.
Auditor Note: No standard should be found to be “Not Applicable” or “NA”. A compliance determination
must be made for each standard.

Standards Exceeded

Number of Standards Exceeded: 0
List of Standards Exceeded:
N/A

Standards Met

Number of Standards Met: 45

Standards Not Met

Number of Standards Not Met:
List of Standards Not Met:

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N/A

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PREVENTION PLANNING
Standard 115.11: Zero tolerance of sexual abuse and sexual harassment;
PREA coordinator
All Yes/No Questions Must Be Answered by The Auditor to Complete the Report
115.11 (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

115.11 (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

115.11 (c)


If this agency operates more than one facility, has each facility designated a PREA compliance
manager? (N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA



Does the PREA compliance manager have sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards? (N/A if agency operates only one facility.)
☒ Yes ☐ 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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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD Organizational chart
• Interview with the PREA Coordinator
• Interview with the PREA Compliance Manager
• Interviews with specialized and random staff
(a) The purpose of PSD Policy ADM.08.08 is to outline the Department of Public Safety's (PSD) approach
to ensure compliance with the Prison Rape Elimination Act ("PREA") of 2003, through the application of
a zero-tolerance policy toward all forms of sexual abuse, sexual harassment, and retaliation for reporting
incidents in prisons, jails, lockups, and community correctional centers. The policy has an effective date
of September 22, 2017. PSD Policy ADM.08.08 states on page 11, “PSD has a zero-tolerance policy
concerning all forms of sexual abuse, sexual harassment, and retaliation for reporting such incidents; )1)
an offender by another offender, or (2) a staff member on an offender, in a PSD prison, jail, lockup,
community correctional center, and privately contracted prison operating under the direct control of PSD
or under contract with PSD.” This policy outlines the agency’s comprehensive approach to preventing,
detecting, and responding to sexual abuse and sexual harassment, including definitions of prohibited
behaviors and consequences for those found to have participated in prohibited behaviors.
While this subsection of the standard speaks to agency level requirements, facility information reinforces
the agency policy by pointing back to the agency policy. Page 14 of the MCCC Facility Handbook states,
“The Department of Public Safety (PSD) is committed to ensuring a secure, safe, and humane
environment. The Prison Rape Elimination Act (PREA), a Federal law, was passed to address sexual
abuse and sexual harassment in correctional facilities. In support of PREA, PSD has a ‘Zero-Tolerance’
policy against any form of sexual abuse and sexual harassment towards an offender by another offender
or by a staff member at a PSD Prison, Jail, Contracted Facility, Lock Up or Community Center. All
references to staff member also include volunteers and contractors.
A ‘Zero-Tolerance’ policy means that sexual abuse and sexual harassment in any form is strictly
prohibited and all allegations of such conduct will be investigated. Any retaliation against individuals for
reporting an incident is also prohibited.”
Facility training also points back to agency policy. This auditor reviewed the MCCC lesson plan and
training curriculum for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training.
Slide 53 states, “A ‘zero-tolerance’ policy means that sexual abuse and sexual harassment is strictly
prohibited and all allegations of such conduct will be investigated…PSD has a zero-tolerance policy
concerning all forms of sexual abuse, sexual harassment, and retaliation for reporting incidents.” Slides
30, 42, 54, 55, 96, and 97 contain reminders about the zero-tolerance policy.
During interviews with specialized and random staff, all interviewees indicated they were aware of and
trained on the agency’s zero-tolerance policy.

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(b) PSD employs an upper-level, agency-wide PREA Coordinator. PSD Policy ADM.08.08 states on page
12, “PSD has designated the Litigation Coordination Office, a branch of the Director's Office, to manage
PREA. One of the Litigation Coordination Officer's functions is to fulfill the role of the upper-level staff
member designated to serve as the Department PREA Coordinator. The Department PREA Coordinator
shall have sufficient time and authority to develop, implement, and oversee PSD's efforts to comply with
the PREA standards in all PSD facilities, lockups, inclusive of monitoring at privately contracted facilities
and community correctional centers. The Department PREA Coordinator reports directly to the Director
of the Department of Public Safety.” This position is reflected in agency organizational charts. When
interviewed, the PREA Coordinator indicated that she has the time, resources and authority required to
manage her responsibilities.
(c) PSD Policy ADM.08.08 states on page 12, “Each facility shall have a designated Facility PREA
Compliance Manager with sufficient time and authority to coordinate the facility's efforts to comply with
the PREA Standards, which may be part of their other related duties. The Department PREA Coordinator
will monitor the relevant PREA duties of the Facility PREA Compliance Managers in conjunction with the
Warden or Sheriff.” MCCC has designated a lieutenant as the facility PREA Compliance Manager (PCM),
who reports directly to the warden.
When interviewed, the facility PCM indicated that she does not have the time to manage all her PREArelated responsibilities. As the Administrative Lieutenant, the PCM acts as the Court Liaison and has a
significant number of duties that prevent her from effectively coordinating the facility’s PREA compliance
efforts. Because the PCM is female, she is subject to working mandatory overtime in officer posts when
there are not enough female staff. The facility PCM shoulders most of the PREA-related duties at MCCC
and is scheduled to retire next year.
For corrective action, this auditor indicated the agency/facility would need to develop a sustainable plan
to ensure the facility PCM has enough time to complete her PREA-related duties at MCCC during her
regular workweek and provide for continuity after her retirement. On August 24, 2021, a sergeant was
promoted to lieutenant and began training to assist the facility PCM. On September 15, 2021, the facility
warden issued a written memorandum directing that two of the facility PCM’s collateral duties had been
moved to other staff, allowing her more time to oversee the facility’s compliance efforts.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the agency
and facility are in full compliance with the standard of zero-tolerance of sexual abuse and sexual
harassment, and employment of the PREA Coordinator, as it relates to PREA.

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Standard 115.12: Contracting with other entities for the confinement of
inmates
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.12 (a)


If this agency is public and it contracts for the confinement of its inmates with private agencies
or other entities including other government agencies, has the agency included the entity’s
obligation to comply with the PREA standards in any new contract or contract renewal signed on
or after August 20, 2012? (N/A if the agency does not contract with private agencies or other
entities for the confinement of inmates.) ☒ Yes ☐ No ☐ NA

115.12 (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 inmates.) ☒ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD Contract No. PSD 16-ID/MB-32
• 2014, 2017 PREA Audit reports for Saguaro Correctional Center
(a-b) PSD Policy ADM.08.08 states on page 12, “PSD mandates that any new contracts or contract
renewals with private agencies or other entities for the confinement of PSD’s offenders shall include
language that the private entity is required to adopt and comply with PREA, specifically the finalized
PREA Standards.
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The private entity shall be subject to PSD monitoring/audits as part of its contract with PSD to ensure
compliance with the PREA Standards.
The private entity is responsible with complying with the audit requirements of the PREA Standards and
any cost associated with audits as required by 115.401 to 115.404.”
PSD contracts with CoreCivic (formerly known as Corrections Corporation of America) for the
confinement of inmates. PSD Contract No. PSD 16-ID/MB-32 states on page 11, “The PROVIDER shall
be in full compliance with the Prison Rape Elimination Act (PREA). Failure to maintain full compliance
with PREA as demonstrated through facility specific PREA compliance audit shall constitute an event of
default on the part of the PROVIDER. The STATE shall provide written notice to PROVIDER of the default
and shall specify a reasonable period of time in which the PROVIDER must cure the default. The STATE
shall not specify a cure period of less than the corrective action period specified in the PREA standards,
which is currently one hundred eighty (180) days.”
PSD inmates that are medium-custody or above with more than 48 months to serve are assigned to a
CoreCivic facility in Arizona. Approximately 1074 inmates are currently housed in Arizona under this
contract. The facility underwent the onsite portion of their federal PREA Audit in March 2021. Their last
final report was provided to them in December 2017. This auditor reviewed the final reports for 2014 and
2017.
PSD Contract No. PSD 16-ID/MB-32 states on page 25, “The STATE shall have the right to inspect, at
all reasonable times, all records of, or associated with, Inmates or any charges, billings, demands, and
payments under this financial, educational, recreational, or transportation expense, timekeeping, or other
operational records.” An interview with the agency contract administrator indicated he visits the Arizona
facility every three to four months to conduct audits of their policy and procedures, with the most recent
visit occurring in March 2021.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the agency
is in full compliance with the standard of contracting with other entities for the confinement of inmates, as
it relates to PREA.

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Standard 115.13: Supervision and monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.13 (a)


Does the facility have a documented staffing plan that provides for adequate levels of staffing
and, where applicable, video monitoring, to protect inmates against sexual abuse? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Generally accepted detention and correctional practices?
☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any judicial findings of inadequacy? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any findings of inadequacy from Federal investigative
agencies? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any findings of inadequacy from internal or external
oversight bodies? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: All components of the facility’s physical plant (including
“blind-spots” or areas where staff or inmates may be isolated)? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The composition of the inmate population? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The number and placement of supervisory staff? ☒ Yes
☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The institution programs occurring on a particular shift?
☒ Yes ☐ No ☐ NA



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any applicable State or local laws, regulations, or
standards? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: The prevalence of substantiated and unsubstantiated
incidents of sexual abuse? ☒ Yes ☐ No



In calculating adequate staffing levels and determining the need for video monitoring, does the
staffing plan take into consideration: Any other relevant factors? ☒ Yes ☐ No

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115.13 (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

115.13 (c)


In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The staffing plan
established pursuant to paragraph (a) of this section? ☒ Yes ☐ No



In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The facility’s
deployment of video monitoring systems and other monitoring technologies? ☒ Yes ☐ No



In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The resources the
facility has available to commit to ensure adherence to the staffing plan? ☒ Yes ☐ No

115.13 (d)


Has the facility/agency implemented a policy and practice of having intermediate-level or higherlevel supervisors conduct and document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? ☒ Yes ☐ No



Is this policy and practice implemented for night shifts as well as day shifts? ☒ Yes ☐ No



Does the facility/agency have a policy prohibiting staff from alerting other staff members that
these supervisory rounds are occurring, unless such announcement is related to the legitimate
operational functions of the facility? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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The auditor gathered, analyzed and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• 2020 Staffing Plan for MCCC
• Interview with the warden
• Interview with the PREA Coordinator
• Interview with the PREA Compliance Manager
• Interview with intermediate or higher-level facility staff
• Housing Unit logbooks
• Staff duty rosters
• Observation of facility operations while onsite
(a, c) PSD Policy ADM.08.08 states on pages 12-13, “The Department PREA Coordinator in conjunction
with the Institutions Division Administrator (IDA) shall ensure that each facility develops, documents, and
makes its best efforts to comply on a regular basis with a written staffing plan that provides for adequate
levels of staffing, and where applicable, video monitoring, to protect inmates against sexual abuse. In
calculating adequate staffing levels and determining the need for video monitoring, each facility shall take
into consideration (115.13 a):
a. Generally accepted detention and correctional practices.
b. Any judicial findings of inadequacy.
c. Any findings of inadequacy from federal investigative agencies.
d. Any findings of inadequacy from internal or external oversight bodies.
e. All components of the facility's physical plant (including "blind-spots" or areas where staff or
inmates may be isolated).
f. The composition of the inmate population.
g. The number and placement of supervisory staff.
h. Institution programs occurring on a particular shift.
i. Any applicable State or local laws, regulations, or standards.
j. The prevalence of substantiated and unsubstantiated incidents of sexual abuse; and
k. Any other relevant factors.”
At least once per year the facility warden or designee, in collaboration with the agency PREA Coordinator,
will review the staffing plan, the deployment of monitoring technology and the allocation of PSD resources
to commit to the staffing plan to ensure compliance. Any adjustments are documented. The
documentation is compiled by the facility warden, Chief of Security and PCM and then given to the agency
PREA Coordinator, prior to the scheduling of a formal meeting. This auditor reviewed documentation
from the most recent annual staffing plan meeting, held on July 20, 2020. As a supplement to the annual
staffing plan meeting, the Chief of Security and facility warden review the existing staffing plan quarterly
and assess the number of staffing vacancies and the amount of overtime accrued by the facility, to
determine if the plan remains adequate. Interviews with the agency PREA Coordinator, facility warden
and PCM verified their participation in this process.
MCCC has not had any judicial findings of inadequacy, or findings of inadequacy from Federal
investigative agencies, internal or external oversight bodies.
(b) PSD Policy ADM.08.08 states on page 13, “In circumstances where the facility’s written staffing plan
is not complied with, the facility shall document by utilizing the PREA Mandated Reporting Form (PSD
8317) and justify all deviations from the plan. This form shall be forwarded to the Department PREA
Coordinator via email, fax, or mail within three (3) days.”
The facility PCM provided 417 pages of PREA Mandated Reporting Forms from the audit period for
review, documenting 134 times the staffing plan required deviation. Each deviation notes why a deviation
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occurred and how it was addressed. The most common reason for deviation was when there were not
enough female correctional officers to staff gender-specific posts. Each deviation is documented with the
required PSD 8371 form, a Major Incident Checklist (PSD 0155), a copy of the facility roster and a memo
to the Chief of Security.
While onsite, the audit team observed enough custody and support staff in all areas of the facility.
(d) PSD Policy ADM.08.08 states on page 14, “The Warden shall ensure that lieutenants, captains, and
correctional supervisors conduct and document unannounced walk-throughs on all watches to aid in
identifying and deterring staff sexual abuse and sexual harassment. This shall be documented in the
housing unit Informer/Logbook and/or in the Supervisor’s watch summary.
PSD staff is prohibited from alerting other staff members of the above-unannounced walk-throughs by
superiors, unless such an announcement is related to the legitimate operational functions of the facility.”
This auditor reviewed logbooks while onsite to confirm unannounced rounds were taking place and
documented as required. Unannounced rounds occurred on day, swing, and night shifts. It was not
always clear how the rounds were documented in unit logbooks. This auditor recommended the facility
PCM provide clarification to supervisory staff, including a reminder to use a red pen as required by the
facility. Interviews with intermediate or higher-level staff indicated they conduct unannounced rounds on
all shifts to detect and deter any staff misconduct, including staff sexual abuse and sexual harassment.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of supervision and monitoring, as it relates to PREA.

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Standard 115.14: Youthful inmates
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.14 (a)


Does the facility place all youthful inmates in housing units that separate them from sight,
sound, and physical contact with any adult inmates through use of a shared dayroom or other
common space, shower area, or sleeping quarters? (N/A if facility does not have youthful
inmates [inmates <18 years old].) ☐ Yes ☐ No ☒ NA

115.14 (b)


In areas outside of housing units does the agency maintain sight and sound separation between
youthful inmates and adult inmates? (N/A if facility does not have youthful inmates [inmates <18
years old].) ☐ Yes ☐ No ☒ NA



In areas outside of housing units does the agency provide direct staff supervision when youthful
inmates and adult inmates have sight, sound, or physical contact? (N/A if facility does not have
youthful inmates [inmates <18 years old].) ☐ Yes ☐ No ☒ NA

115.14 (c)


Does the agency make its best efforts to avoid placing youthful inmates in isolation to comply
with this provision? (N/A if facility does not have youthful inmates [inmates <18 years old].)
☐ Yes ☐ No ☒ NA



Does the agency, while complying with this provision, allow youthful inmates daily large-muscle
exercise and legally required special education services, except in exigent circumstances? (N/A
if facility does not have youthful inmates [inmates <18 years old].) ☐ Yes ☐ No ☒ NA



Do youthful inmates have access to other programs and work opportunities to the extent
possible? (N/A if facility does not have youthful inmates [inmates <18 years old].)
☐ 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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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Hawaii Revised Statutes 706-667
• MCCC population reports
• Interview with the PREA Compliance Manager
• Interviews with random staff and random inmates
(a-c) Hawaii Revised Statutes define a young adult defendant as a person convicted of a crime who, at
the time of the offense, is less than twenty-two years of age and who has not been previously convicted
of a felony as an adult or adjudicated as a juvenile for an offense that would have constituted a felony
had the young adult defendant been an adult. Young adult defendants sentenced to a term of
imprisonment exceeding 30 days may be committed by the court to the custody of PSD.
PSD Policy ADM.08.08 notes the difference between statute definition and the PREA standards
definition. The policy states on page 14, “If PSD does receive a youthful offender as defined by PREA,
described in paragraph (2) of this section, then the youthful offender shall not be housed in a housing
unit in which the youthful offender shall have sight, sound, and physical contact with any adult offender
through the use of a shared dayroom or other common space, shower area, or sleeping quarters. The
facility staff shall document by utilizing the PREA Mandated Reporting Form (PSD 8317) any noncompliance with the above requirement. This form shall be forwarded to the Department PREA
Coordinator via email, fax, or mail within three (3) days.
PSD staff shall maintain sight, sound, and physical separation between the youthful offenders and adult
offenders in areas outside of the housing units, or shall provide direct staff supervision, when youthful
offenders and adult offenders have sight, sound, and physical contact. (115.14 b) The facility staff shall
document by utilizing the PREA Mandated Reporting Form (PSD 8317) any non-compliance with the
above requirement. This form shall be forwarded to the Department PREA Coordinator via email, fax, or
mail within three (3) days.
PSD shall document the exigent circumstances for each instance in which a youthful offender's access
to large-muscle exercise, legally required educational services, other programs, and work opportunities
are denied in order to separate them from adult offenders by utilizing the PREA Mandated Reporting
Form (PSD 8317). This form shall be forwarded to the Department PREA Coordinator via email, fax, or
mail within three (3) days.”
This auditor reviewed MCCC population reports and did not find any inmates under the age of 18 listed.
No interviews of staff or inmates indicated a youthful inmate may have been housed at MCCC.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of youthful inmates, as it relates to PREA.
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Standard 115.15: Limits to cross-gender viewing and searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.15 (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

115.15 (b)


Does the facility always refrain from conducting cross-gender pat-down searches of female
inmates, except in exigent circumstances? (N/A if the facility does not have female inmates.)
☒ Yes ☐ No ☐ NA



Does the facility always refrain from restricting female inmates’ access to regularly available
programming or other out-of-cell opportunities in order to comply with this provision? (N/A if the
facility does not have female inmates.) ☒ Yes ☐ No ☐ NA

115.15 (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 inmates? (N/A if the
facility does not have female inmates.) ☒ Yes ☐ No ☐ NA

115.15 (d)


Does the facility have policies that enables inmates to shower, perform bodily functions, and
change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks,
or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell
checks? ☒ Yes ☐ No



Does the facility have procedures that enables inmates to shower, perform bodily functions, and
change clothing without nonmedical staff of the opposite gender viewing their breasts, buttocks,
or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell
checks? ☒ Yes ☐ No



Does the facility require staff of the opposite gender to announce their presence when entering
an inmate housing unit? ☒ Yes ☐ No

115.15 (e)


Does the facility always refrain from searching or physically examining transgender or intersex
inmates for the sole purpose of determining the inmate’s genital status? ☒ Yes ☐ No

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

If an inmate’s genital status is unknown, does the facility determine genital status during
conversations with the inmate, by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted in private by a medical
practitioner? ☒ Yes ☐ No

115.15 (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 inmates 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Interviews with random staff and random inmates
• Observation of facility operations while onsite
(a) Frequent, unannounced searches of inmates, their living quarters and other areas of the facility are
necessary to maintain the safety, security, and orderly operations of prisons. PSD Policy ADM.08.08
states on page 15, “PSD staff shall not conduct cross-gender strip searches or cross-gender visual body
cavity searches (meaning a search of the anal or genital opening), except in exigent circumstances, or
when performed by medical practitioners.” No random or targeted inmates indicated they had been
subjected to a cross-gender strip search or cross-gender visual body cavity search. In interviews, random
staff confirmed they do not conduct cross-gender searches of this nature.
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 38 defines exigent circumstances as any set of
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temporary and unforeseen circumstances that require immediate action to combat a threat to the security
or institutional order of a facility. The training provides an appropriate use of exigent circumstance and
an inappropriate use – “Example: dangerous contraband (weapons/drugs) where there is no time to call
for back-up. Not an example: Being short-staffed with no female ACOs [Adult Correctional Officers] to
perform a routine pat search is not an unforeseen circumstance. Once the ‘exigency’ is gone, cannot use
‘exigent circumstance’ to justify deviation from policy.”
(b) PSD Policy ADM.08.08 states on Page 15, “PSD staff shall not conduct cross-gender pat-down
searches of female offenders, absent exigent circumstances…Facilities shall not restrict female
offenders’ access to regularly available programming or other out-of-cell opportunities in order to comply
with this provision.” Staff who conduct any searches of this nature must document it utilizing the PREA
Mandated Reporting Form (PSD 8317).
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 65 states, “PSD staff shall not conduct cross-gender
pat-down searches of female offenders, absent exigent circumstances. PSD’s policy prohibits any crossgender pat-down searches. Facilities shall not restrict female offenders’ access to regularly available
programming or other out-of-cell opportunities in order to comply with this provision.”
No random or targeted female inmates indicated they have been searched by a male officer or have had
their access to programming or recreation restricted due to a lack of female staff. In interviews, random
male staff confirmed they do not conduct searches of female inmates. MCCC has two gender-specific
posts (MP/Module III and Dorm 4/5) and if there are not enough female staff on shift, female staff can be
mandated to work overtime. If there are no female staff, two male officers will be assigned to the post.
(c) PSD Policy ADM.08.08 states on page 15, “An incident of cross-gender strip searches and crossgender visual body cavity searches shall be documented by utilizing the PREA Mandated Reporting Form
(PSD 8317). This form shall be forwarded to the Department PREA Coordinator via email, fax, or mail
within three (3) days.” The same requirements apply to cross-gender pat-down searches of female
offenders. The facility PCM reported that no searches of this nature were conducted during the audit
period.
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 66 states, “PSD Facilities shall document all crossgender strip searches and all cross-gender visual body cavity searches. PSD Facilities shall document
all cross-gender pat-down searches of female offenders.”
Interviews with staff and inmates did not indicate that cross-gender strip searches have occurred, nor did
the audit team observe any cross-gender strip searches while onsite at MCCC.
(d) PSD Policy ADM.08.08 states on page 15, “An offender shall be allowed to shower, perform bodily
functions, and change clothing without non-medical staff of the opposite gender viewing their breasts,
buttocks, or genitalia, except in exigent circumstances, or when such viewing is incidental to routine cell
checks. The facility staff shall document any exigent circumstances by utilizing the PREA Mandated
Reporting Form (PSD 8317) any exigent incident. This form shall be forwarded to the Department PREA
Coordinator via email, fax, or mail within three (3) days.”
During the physical plant review, the audit team looked for areas where cross-gender viewing may occur.
The audit team identified one bathroom area in Dorms 6 & 7 where a shower curtain was not wide enough
to prevent cross-gender viewing. The facility PCM had the shower curtain replaced with one of an
appropriate size while the audit team was onsite. MCCC’s housing units are not uniform in nature. All
units have either individual shower/toilet doors or doors to the common area that prevent cross-gender
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viewing. Unit rules require that inmates close shower curtains and toilet doors when in use, and inmates
are required to be clothed upon exit.
PSD Policy ADM.08.08 states on page 16, “Staff of the opposite gender are required to ‘knock and
announce’ their presence when entering an offender housing unit and ensure that this notice is logged in
the Informer or Logbook. For example, a male staff member entering a female housing unit must ‘knock
and announce’ his presence via an intercom or a verbal broadcast by stating ‘male in the housing unit,
ensure that you are properly dressed.’”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 69 reinforces PSD policy by stating, “Staff of the
opposite gender are required to ‘knock and announce’ their presence when entering an offender housing
unit and ensure that this notice is logged in the Informer or Log Book.”
Permanent signs are affixed to housing unit entrances, reminding staff of the requirement to make
announcements. Cross-gender announcements were consistently observed when the audit team entered
housing units, Interviews with random staff and inmates indicated the announcements are made
consistently and as required.
(e) PSD Policy ADM.08.08 states on page 16, “PSD Non-medical staff shall not search or physically
examine a transgender or intersex offender for the sole purpose of determining the offender's genital
status. If the offender's genital status is unknown, it may be determined from conversations with the
offender, by reviewing medical records, or, if necessary, by learning this information as part of a medical
examination conducted by a medical practitioner.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 74 states, “PDS staff shall not search or physically
examine a transgender or intersex offender for the sole purpose of determining the offender’s genital
status. If the offender’s genital status is unknown, it may be determined during conversations with the
offender, by reviewing medical records, or, if necessary, by learning that information as part of a medical
examination conducted by a medical practitioner.”
Interviews with random staff indicated they are aware that searches to determine genital status are
prohibited by standard and agency policy. MCCC did not have any transgender inmates in custody at the
time of the onsite review. All staff interviewed were aware they are not permitted to conduct searched of
this nature.
(f) PSD Policy ADM.08.08 states on page 16, “PSD staff are to ensure that cross-gender pat-down
searches and searches of transgender and intersex offenders are conducted in a professional, respectful,
and in the least intrusive manner, while ensuring security operational needs for the good government and
orderly running of the facility. The professional and respectful pat-down search of a transgender and
intersex offender may be achieved by utilizing the back of your hand instead of the front of your hand.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 70 states, “PSD staff are to ensure that crossgender pat-down searches AND searches of transgender and intersex offenders are conducted in a
professional, respectful, and in the least intrusive manner, while ensuring security operational needs for
the good government and orderly running of the facility.” The training curriculum indicates “dual”
searches, where the staff of one gender searches the top half of an inmate and the staff of another gender
searches the bottom half of the inmate, are prohibited. The remainder of the training curriculum directs
how to conduct a cross-gender pat-down search using commonly accepted correctional practices.
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MCCC did not have any transgender inmates in custody at the time of the onsite review. Interviews with
random staff indicated they were knowledgeable of proper pat-down search techniques.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of limits to cross-gender viewing and searches, as it relates to
PREA.

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Standard 115.16: Inmates with disabilities and inmates who are limited
English proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.16 (a)


Does the agency take appropriate steps to ensure that inmates with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: inmates who are deaf or hard
of hearing? ☒ Yes ☐ No



Does the agency take appropriate steps to ensure that inmates with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: inmates who are blind or have
low vision? ☒ Yes ☐ No



Does the agency take appropriate steps to ensure that inmates with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: inmates who have intellectual
disabilities? ☒ Yes ☐ No



Does the agency take appropriate steps to ensure that inmates with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: inmates who have psychiatric
disabilities? ☒ Yes ☐ No



Does the agency take appropriate steps to ensure that inmates with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: inmates who have speech
disabilities? ☒ Yes ☐ No



Does the agency take appropriate steps to ensure that inmates with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Other (if "other," please explain
in overall determination notes)? ☒ Yes ☐ No



Do such steps include, when necessary, ensuring effective communication with inmates 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 inmates with disabilities including inmates 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 inmates with disabilities including inmates who: Have
limited reading skills? ☒ Yes ☐ No

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

Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with inmates with disabilities including inmates who: Are blind or
have low vision? ☒ Yes ☐ No

115.16 (b)


Does the agency take reasonable steps to ensure meaningful access to all aspects of the
agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to
inmates who are limited English proficient? ☒ Yes ☐ 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

115.16 (c)


Does the agency always refrain from relying on inmate interpreters, inmate readers, or other
types of inmate assistance except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the inmate’s safety, the performance of firstresponse duties under §115.64, or the investigation of the inmate’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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• MCCC Facility Handbook
• PSD Contract with Pacific Interpreters
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Interview with the PREA Coordinator
• Interview with the PREA Compliance Manager
• Interviews with random staff and random inmates
• Interviews with inmates with disabilities

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(a-b) PSD Policy ADM.08.08 states on page 16, “Disabled offenders and offenders with limited English
proficiency shall be provided with equal opportunity to participate in or benefit from all aspects of PSD's
efforts to prevent, detect, and respond to sexual abuse and sexual harassment.” The policy lists the
interpreter services for the deaf, blind, or hard of hearing inmates, and those with limited-English
proficiency. (This auditor has omitted the information from this report as it contains the contact information
and account number for the agency.) The agency/facility contracts with Pacific Interpreters for translation
services and has used them since at least 2013. Pacific Interpreters has more than 11,000 trained and
qualified interpreters in more than 240 languages and can be utilized by voice, video, or in-person. All
staff have access to the instructions for utilizing this service.
Written materials about PREA, to include posters in housing units, are available in English, Tagalog,
Ilocano, and Samoan. Pacific Interpreters would be used to make any other language translations
available.
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 75 states, “Disabled offenders and offenders with
limited English proficiency shall be provided with equal opportunity to participate in or benefit from all
aspects of PSD’s efforts to prevent, detect and respond to sexual abuse and sexual harassment.”
Interviews with random staff and random/targeted inmates indicated that inmates with disabilities are
afforded additional accommodation to ensure their access to all aspects of the agency’s PREA program.
Interviews were conducted with the following targeted populations:
• Two inmates with vision/hearing impairments or physical disabilities
• One inmate with cognitive impairments
The facility did not have any inmates with limited-English proficiencies. All interviews with targeted
populations indicated they were able to receive information in a format they were able to understand. No
interviews indicated another inmate had been used to assist in their comprehension. Interviews with
random staff indicated they would not use another inmate as an interpreter.
(c) PSD Policy ADM.08.08 states on page 16, “The use of offender interpreters, or other types of offender
assistance is prohibited, except in limited circumstances where an extended delay in obtaining an
effective interpreter could compromise an offenders' safety. In the limited circumstances where offender
interpreters, or other types of offender assistance are utilized, it shall be documented by utilizing the
PREA Mandated Reporting Form (PSD 8317). This form shall be forwarded to the Department PREA
Coordinator via email, fax, or mail within three (3) days.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 76 states, “The use of OFFENDER interpreters, or
other types of OFFENDER assistance is prohibited, except in limited circumstances where an extended
delay in obtaining an effective interpreter could compromise [an] offender’s safety.”
No interviews indicated another inmate had been used to assist in their comprehension. Interviews with
random staff indicated they would not use another inmate as an interpreter.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of inmates with disabilities and inmates who are limited-English
proficient, as it relates to PREA.
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Standard 115.17: Hiring and promotion decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.17 (a)


Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates
who has engaged in sexual abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No



Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates
who has been convicted of engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent
or was unable to consent or refuse? ☒ Yes ☐ No



Does the agency prohibit the hiring or promotion of anyone who may have contact with inmates
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 inmates who has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No



Does the agency prohibit the enlistment of services of any contractor who may have contact
with inmates who has been convicted of engaging or attempting to engage in sexual activity in
the community facilitated by force, overt or implied threats of force, or coercion, or if the victim
did not consent or was unable to consent or refuse? ☒ Yes ☐ No



Does the agency prohibit the enlistment of services of any contractor who may have contact
with inmates who has been civilly or administratively adjudicated to have engaged in the activity
described in the question immediately above? ☒ Yes ☐ No

115.17 (b)


Does the agency consider any incidents of sexual harassment in determining whether to hire or
promote anyone who may have contact with inmates? ☒ Yes ☐ No



Does the agency consider any incidents of sexual harassment in determining whether to enlist
the services of any contractor who may have contact with inmates? ☒ Yes ☐ No

115.17 (c)


Before hiring new employees, who may have contact with inmates, does the agency perform a
criminal background records check? ☒ Yes ☐ No



Before hiring new employees who may have contact with inmates, does the agency, consistent
with Federal, State, and local law, make its best efforts to contact all prior institutional employers
for information on substantiated allegations of sexual abuse or any resignation during a pending
investigation of an allegation of sexual abuse? ☒ Yes ☐ No

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115.17 (d)


Does the agency perform a criminal background records check before enlisting the services of
any contractor who may have contact with inmates? ☒ Yes ☐ No

115.17 (e)


Does the agency either conduct criminal background records checks at least every five years of
current employees and contractors who may have contact with inmates or have in place a
system for otherwise capturing such information for current employees? ☒ Yes ☐ No

115.17 (f)


Does the agency ask all applicants and employees who may have contact with inmates directly
about previous misconduct described in paragraph (a) of this section in written applications or
interviews for hiring or promotions? ☒ Yes ☐ No



Does the agency ask all applicants and employees who may have contact with inmates directly
about previous misconduct described in paragraph (a) of this section in any interviews or written
self-evaluations conducted as part of reviews of current employees? ☒ Yes ☐ No



Does the agency impose upon employees a continuing affirmative duty to disclose any such
misconduct? ☒ Yes ☐ No

115.17 (g)


Does the agency consider material omissions regarding such misconduct, or the provision of
materially false information, grounds for termination? ☒ Yes ☐ No

115.17 (h)


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)

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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Department of Public Safety Applicant’s Personal History Questionnaire
• Employee file reviews
• Interview with the warden
• Interview with Human Resource staff
• Interview with agency PREA Coordinator
(a) PSD Policy ADM.08.08 states on page 17, “PSD prohibits the hiring or promoting of anyone, who may
have contact with offenders, and shall not utilize the services of any contractor or volunteer, who may
have contact with offenders, if that person:
a. Has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution owned, operated, or managed by the state
as defined by 42 U.S.C. 1997, for example the Hawaii State Hospital or other state
skilled nursing, intermediate, long-term care, custodial, or residential care institution.
b. 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.
c. Has been civilly or administratively adjudicated to have engaged in the activity
described in the paragraphs above.
d. There are less stringent requirements for volunteers, who are utilized as peer
mentors, but this requires a case-by-case assessment and review with the Department PREA
Coordinator.”
(b) PSD Policy ADM.08.08 states on page 17, “PSD shall consider any incidents of sexual harassment
in determining whether to hire or promote anyone, or to utilize the services of any contractor or volunteer,
who may have contact with offenders.”
Interviews with the warden and Human Resource staff indicated the policy is implemented in practice.
The warden indicated she would likely not enlist the services of a contractor who had allegations of
sexually harassing inmates.
(c-d) PSD Policy ADM.08.08 states on page 17, “Before new employees, contractors, or volunteers, who
may have contact with offenders, are hired, PSD shall:
a. Perform a criminal background record checks, consistent with federal, state, and
local law; and
b. Utilize a ‘best effort'’ to contact all prior institutional employers for information on
substantiated allegations of sexual abuse or any resignation, due to a pending
investigation of an allegation of sexual abuse.”
Potential applicants must list all prior institutional employers in the work experience section of their
application. A signed release form and employer questionnaire is sent to all prior employers, to include
institutional employers.
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This auditor requested and reviewed 21 employee files for the required documentation. Eight of the
employees were hired prior to 2012; five of the employees were new hires; and, three of the employees
were promotional. File reviews indicated criminal record checks are completed for all new employees,
contractors, and volunteers.
(e) PSD Policy ADM.08.08 states on page 17, “PSD shall conduct criminal background record checks at
least every five years for current employees, contractors, and volunteers, who may have contact with
offenders.
a. PSD's Personnel's Office is responsible for ensuring compliance with the five year
cycle of background checks for current employees.
b. It is noted that PSD does conduct annual Lautenberg type of background checks on
those employment positions that are required to carry a firearm.”
This auditor requested and reviewed 21 employee files for the required documentation. Eight of the
employees were hired prior to 2012; five of the employees were new hires; and, three of the employees
were promotional. File reviews indicated criminal record checks are completed for all current employees,
contractors, and volunteers within the required timelines.
Interviews with Human Resource staff and the agency PREA Coordinator indicted these checks take
place as required.
(f) PSD Policy ADM.08.08 states on page 18, “PSD shall ask all applicants and employees, who may
have direct contact with offenders, about previous misconduct(s) described in paragraph (1) of this
section either on (a) a written application, (b) during an interview for hire, (c) a promotional interview, or
(d) if applicable, during any interview or written self-evaluation conducted as part of reviews of current
employees. This requirement is documented by utilizing the PREA Applicant Questionnaire (PSD 8318),
during the application process for prospective employees, employee promotions, or employee transfers.
All PSD staff has an affirmative duty to immediately disclose any such misconduct covered by sections
.1 and .2 by immediately reporting the incident through their chain of command.”
Prospective agency/facility applicants are required to submit a completed Department of Public Safety
Applicant’s Personal History Questionnaire. Section 7 of this questionnaire states, “This position may
have or involves contact with inmates in a correctional facility (prison and jail) or lockup. As required by
the Prison Rape Elimination Act of 2003 (PREA), all applicants who may have contact with an inmate in
a correctional facility (prison and jail) or lockup as described in the law must answer the four questions
below to determine their eligibility for this position.” The four questions correspond with the requirements
of (a).
PSD does not conduct self-evaluations as part of the employee review process.
(g) PSD Policy ADM.08.08 states on page 18, “Any PSD staff, who materially omits reporting such
misconduct or provides materially false information shall be subject to discipline based on the just and
proper cause standard, up to and including discharge. See Department of Human Resources Policy
702.003.” The HR policy referenced outlines the process for separating employment with PSD.
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 80 states, “All PSD Staff have an affirmative duty
to immediately disclose any such misconduct by immediately reporting through their chain of command.
Any PSD staff who materially omits reporting such misconduct OR provides materially false information
shall be subject to discipline based on the just and proper cause standard, up to and including discharge.”
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By signature on their Department of Public Safety Applicant’s Personal History Questionnaire,
prospective agency/facility applicants attest that “the information and my responses to the questions
provided in this Personal History Questionnaire are true and correct to the best of my knowledge. I agree,
understand and acknowledge that any misstatements or omissions of material facts herein may cause
disqualification from the employment process and forfeiture of all rights to any employment in the service
of the State of Hawaii &/or Dept of Public Safety.”
An interview with Human Resource staff indicated disciplinary action, including termination, is taken when
material omissions are discovered.
(h) PSD Policy ADM.08.08states on page 12, “Unless prohibited by law, the PSD shall provide information
on substantiated allegations of sexual abuse or sexual harassment involving a former employee upon
receiving a request from an institutional employer with whom the employee has applied to work.” This
auditor reviewed examples of information provided to institutional employers regarding substantiated
allegations of sexual abuse or sexual harassment involving former employees.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of hiring and promotion decisions, as it relates to PREA.

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Standard 115.18: Upgrades to facilities and technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.18 (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 inmates from sexual abuse? (N/A
if agency/facility has not acquired a new facility or made a substantial expansion to existing
facilities since August 20, 2012, or since the last PREA audit, whichever is later.)
☒ Yes ☐ No ☐ NA

115.18 (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 inmates from sexual abuse? (N/A if agency/facility has not installed or
updated a video monitoring system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit, whichever is later.)
☒ Yes ☐ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interview with agency head/designee
• Interview with agency PREA Coordinator
• Interview with the warden
• Interview with the PREA Compliance Manager
• Observation of facility operations while onsite

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(b) PSD Policy ADM.08.08 states on page 18, “When designing or acquiring any new facility, and in
planning any substantial expansion or modification of existing facilities, PSD shall consider the impact
that the design, acquisition, expansion, or modification will have on PSD’s ability to protect offenders
from sexual abuse.”
Interviews with the agency head/designee, agency PREA Coordinator, warden, and facility PREA
Compliance Manager confirmed the agency has not designed or acquired any new facilities, nor planned
a substantial expansion or modification of MCCC. During the site review, the audit team did not observe
any areas that appeared to be under construction for a substantial expansion or modification.
(b) PSD Policy ADM.08.08 states on page 18, “When installing or updating a video monitoring system,
electronic surveillance system, close circuit television (CCTV), or other monitoring technology, PSD shall
consider how such technology may enhance the agency’s ability to protect offenders from sexual abuse.”
Camera mapping was created by an architect who installed the cameras during the most recent
technological upgrade. The facility was not permitted to change the placement of the cameras when they
were installed. The facility PCM has redirected views or installed security mirrors to ensure all areas are
adequately captured.
Interviews with the warden and facility PREA Compliance Manager confirmed that the prevention of
sexual abuse and sexual harassment was a factor in determining camera placement. Because cameras
cannot be easily moved once they are installed by the contractor, the facility PCM has used security
mirrors in conjunction with camera views to see in isolated areas, such as the area behind where a
camera is located.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of upgrades to facilities and technologies, as it relates to PREA.

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RESPONSIVE PLANNING
Standard 115.21: Evidence protocol and forensic medical examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.21 (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

115.21 (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

115.21 (c)


Does the agency offer all victims of sexual abuse access to forensic medical examinations,
whether on-site or at an outside facility, without financial cost, where evidentiarily or medically
appropriate? ☒ Yes ☐ 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

115.21 (d)


Does the agency attempt to make available to the victim a victim advocate from a rape crisis
center? ☒ Yes ☐ No

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

If a rape crisis center is not available to provide victim advocate services, does the agency
make available to provide these services a qualified staff member from a community-based
organization, or a qualified agency staff member? (N/A if the agency always makes a victim
advocate from a rape crisis center available to victims.) ☐ Yes ☐ No ☒ NA



Has the agency documented its efforts to secure services from rape crisis centers?
☒ Yes ☐ No

115.21 (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

115.21 (f)


If the agency itself is not responsible for investigating allegations of sexual abuse, has the
agency requested that the investigating agency follow the requirements of paragraphs (a)
through (e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND
administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA

115.21 (g)


Auditor is not required to audit this provision.

115.21 (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? (N/A if agency always makes a victim advocate from a rape crisis center
available to victims.) ☐ 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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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• State of Hawaii Contract No. 16-HSA-01
• Interview with the PREA Compliance Manager
• Interview with SAFE/SANE
• Interview with Agency Internal Affairs Investigator
• Interviews with medical staff
• Interviews with random staff and random inmates
(a) PSD Policy ADM.08.08 states on pages 18-19, “PSD is responsible for conducting all administrative
sexual abuse investigations. All criminal sexual abuse investigations shall be referred to the county LE
agency (Honolulu Police Department, Hawaii Police Department, Maui Police Department, and Kauai
Police Department). If county LE declines to investigate the initial report related to a criminal case, then
a referral shall be made to the State of Hawaii, Department of the Attorney General (AG) to investigate
the criminal case… PSD utilizes departmental evidence protocols that maximize the potential for
obtaining usable physical evidence for administrative proceedings and preserves the crime scene for
criminal investigations and prosecution.”
(b) The National Protocol for Sexual Assault Forensic Examinations 2nd edition information from April
2013 was used when developing the program for the department as reflected in the SATC contract scope
of duties.
While the protocol is developmentally appropriate for youth, MCCC does not house youthful inmates.
Interviews with a facility investigator indicated they are knowledgeable on obtaining usable physical
evidence.
(c) PSD Policy ADM.08.08 states on page 19, “The Health Care Division staff shall determine, based on
evidentiary or medical needs, whether a victim of sexual abuse will be transported for a forensic medical
examination at the Sex Abuse Treatment Center ("SATC") or at a hospital emergency unit. This shall be
at no financial cost to the victim. In facilities without twenty-four (24) hour medical, then the on-call
physician shall be contacted. The use of Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault
Nurse Examiners (SANEs) are utilized at the SATC…If a SAFE or SANE is not available, the examination
may be performed by other qualified medical practitioners. The SATC and its contracted representative
on the outer islands have indicated that victim advocates are available during an examination.”
All forensic medical exams are provided offsite by Sexual Assault Nurse Examiners, as verified through
interview. The PAQ indicated there were no forensic medical exams provided during the audit period.
Interviews with medical staff verified inmates are not financially responsible for forensic medical exams.
(d-e) PSD Policy ADM.08.08 states on page 19, “At the request and approval of the victim, a victim
advocate from the SATC, or SATC contracted provider on the outer islands shall be provided to support
the victim through the forensic medical examination process and the investigatory interview. The purpose
of a victim advocate is to provide emotional support, crisis intervention, information, and referrals.”
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The state of Hawaii has contracted with Kapiolani Medical Center for Women and Children (KMCWC)Sex Abuse Treatment Center (SATC) to provide statewide, comprehensive victim sexual assault
treatment services. As outlined on pages two and three of the contract, “Crisis intervention services need
to be available 24 hours a day, 365 days a year. A 24-hour hotline will provide the sexual assault victim
and the community, immediate access to care both over the phone and in-person. In addition to crisis
counseling, victims often require medical-legal care and assistance with reporting options. A Sexual
Assault Response Team (SART), should be on call around the clock and staffed with personnel specially
trained to provide crisis support services to victims. Such services include crisis stabilization and
counseling, legal systems advocacy to inform the victim of legal rights and options, an acute forensic
examination to provide the victim the necessary medical assessment and treatment, and the collection
and preservation of forensic evidence if the victim decides to take criminal action.”
Interviews with a victim advocate and SANE confirmed the availability of victim advocates. Only one of
the inmates interviewed indicated they had used the advocacy services available to them.
(f) PSD Policy ADM.08.08 states on page 20, “PSD shall ensure that internal investigations comply with
the above requirements and external investigative entities (County LE) have procedures in place to
comply with the above requirement.”
Interviews with the Agency Internal Affairs Investigator, a victim advocate and a SANE confirmed that
law enforcement agencies comply with the requirements of this provision.
(g) Auditor is not required to audit this provision.
(h) This provision of the standard is not applicable to MCCC, as they make a victim advocate from a rape
crisis center available to victims, per 115.21(d).
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of evidence protocols and forensic medical examinations, as it
relates to PREA.

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Standard 115.22: Policies to ensure referrals of allegations for
investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.22 (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

115.22 (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

115.22 (c)


If a separate entity is responsible for conducting criminal investigations, does the policy describe
the responsibilities of both the agency and the investigating entity? (N/A if the agency/facility is
responsible for criminal investigations. See 115.21(a).) ☒ Yes ☐ No ☐ NA

115.22 (d)


Auditor is not required to audit this provision.

115.22 (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)

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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD Webpage
• Interview with agency head/designee
• Interviews with investigative staff
(a-c) PSD Policy ADM.08.08 states on pages 19-20, “PSD ensures that an internal administrative
investigation and an external referral for criminal investigation are completed for all allegations of sexual
abuse and sexual harassment with the limitation that any criminal referral for sexual harassment must
meet a criminal standard. All external referrals for a criminal investigation shall be processed through a
county LE [law enforcement] agency, such as Honolulu Police Department, Maui Police Department,
Kauai Police Department, and Hawaii Police Department. If an allegation of sexual abuse or sexual
harassment involves potentially criminal behavior, then the allegation shall be immediately referred to a
county LE agency. PSD Internal Affairs Office ("IA") shall be immediately notified of any allegation of
sexual abuse or potentially serious incident of sexual harassment. The administrative investigation may
be completed by IA or at the facility level pursuant to an order of the Director or his/her designee.”
The PSD PREA policy is available on the PSD website at ADM.08.08.pdf (hawaii.gov). It reiterates the
agency’s zero-tolerance policy and outlines the process for investigations and referrals. More general
information about PREA is available to the public on the PSD website at Department of Public Safety |
PREA (hawaii.gov).
Interviews with investigative staff indicated they are knowledgeable of the process for case referral. The
interview of the agency head/designee indicated the agency is committed to creating a sexually safe
environment for all inmates and has an established relationship with agency investigators to ensure
allegations are investigated and referred properly.
(d) Auditor is not required to audit this provision.
(e) Auditor is not required to audit this provision.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is in full compliance with the standard of policies to ensure referrals of allegations for investigations, as it
relates to PREA.

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TRAINING AND EDUCATION
Standard 115.31: Employee training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.31 (a)


Does the agency train all employees who may have contact with inmates on its zero-tolerance
policy for sexual abuse and sexual harassment? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on how to fulfill their
responsibilities under agency sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on inmates’ right to be
free from sexual abuse and sexual harassment ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on the right of inmates
and employees to be free from retaliation for reporting sexual abuse and sexual harassment?
☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on the dynamics of
sexual abuse and sexual harassment in confinement? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on the common
reactions of sexual abuse and sexual harassment victims? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on how to detect and
respond to signs of threatened and actual sexual abuse? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on how to avoid
inappropriate relationships with inmates? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on how to
communicate effectively and professionally with inmates, including lesbian, gay, bisexual,
transgender, intersex, or gender nonconforming inmates? ☒ Yes ☐ No



Does the agency train all employees who may have contact with inmates on how to comply with
relevant laws related to mandatory reporting of sexual abuse to outside authorities?
☒ Yes ☐ No

115.31 (b)


Is such training tailored to the gender of the inmates at the employee’s facility? ☒ Yes ☐ No



Have employees received additional training if reassigned from a facility that houses only male
inmates to a facility that houses only female inmates, or vice versa? ☒ Yes ☐ No

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115.31 (c)


Have all current employees who may have contact with inmates received such training?
☒ Yes ☐ No



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

115.31 (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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Staff training reports
• Interviews with random staff
(a) PSD Policy ADM.08.08 states on pages 20-21, “PSD provides a comprehensive training module for
all staff emphasizing PSD's zero tolerance policy and the importance of preventing sexual abuse/sexual
assault and sexual harassment toward offenders. PSD educates staff about the serious impact of
offender sexual victimization within a correctional setting.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training to ensure a comprehensive training program that provides
detailed information on all ten required elements.
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This auditor reviewed training documentation for 141 employees:
82 employees completed training as required
24 employees were away from the facility on Worker’s Compensation
28 employees resigned or retired prior to completing training
1 employee was out on extended leave
1 employee was on military deployment
5 employees did not complete PREA training as required
Four of the five employees who did not complete PREA training as required during the audit review period
also did not complete it in the year prior.
For corrective action, this auditor required the facility PREA Compliance Manager to ensure the five noted
employees take the required training. Any employees on military deployment, worker’s compensation or
other long-term leave would be required to complete training upon their return to work. Documentation of
training for the remaining employees was provided to this auditor for review and confirmation on October
19, 2021.
(b) PSD Policy ADM.08.08 states on page 22, “PSD's staff training is tailored to address all genders of
offenders in a correctional facility; therefore, additional training is not required when a staff member
transfers to a different gender facility.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training and verified the training is tailored for all genders.
(c) PSD Policy ADM.08.08 states on page 21, “The Warden, PSD Administrators, or Sheriff shall ensure
that all current staff shall have received PREA training. The Warden or Sheriff shall notify the
Department's Training and Staff Development Office (TSO) and the PREA Coordinator of any individual
who requires training.”
In the years that PREA refresher training is not provided, the agency/facility provides refresher
information on current sexual abuse and sexual harassment policies.
(d) PSD Policy ADM.08.08 states on page 21, “PSD training sign-in sheets are verification that the staff
member received and understood the PREA training. The sign-in sheet shall include the following
statement: ‘By signing this attendance sheet you acknowledge receipt of PREA Training and that you
understood the PREA Training materials.’ The sign-in sheet documentation substantiates that the staff
member has completed the required training and his/her completion shall be entered on the staff
member's training record with TSO. A copy shall also be provided to the PSD PREA Coordinator via
email, fax, or mail within three (3) days.”
Interviews with random staff indicated they received and understood training.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of employee training as it relates to PREA.

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Standard 115.32: Volunteer and contractor training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.32 (a)


Has the agency ensured that all volunteers and contractors who have contact with inmates have
been trained on their responsibilities under the agency’s sexual abuse and sexual harassment
prevention, detection, and response policies and procedures? ☒ Yes ☐ No

115.32 (b)


Have all volunteers and contractors who have contact with inmates been notified of the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and informed
how to report such incidents (the level and type of training provided to volunteers and
contractors shall be based on the services they provide and level of contact they have with
inmates)? ☒ Yes ☐ No

115.32 (c)


Does the agency maintain documentation confirming that volunteers and contractors
understand the training they have received? ☐ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• VolinCor (Volunteers in Corrections) A Handbook for Corrections Program Services Staff
• Prison Rape Elimination Act of 2003 Volunteer & Contractor Training curriculum
• Volunteer and Contractor training records
• Interview with warden
• Interviews with volunteers and contractors

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(a-b) PSD Policy ADM.08.08 states on page 22, “All volunteers and contractors, who have contact with
offenders shall be trained on PREA, PSD's policy, and their responsibilities regarding the prevention,
detection, and how to respond to a report of offender sexual abuse and sexual harassment. The level
and type of training provided to volunteers and contractors shall be tailored to the level of contact and
services provided to offenders. All current volunteers and contractors have been notified of PSD's zerotolerance policy regarding offender sexual abuse and sexual harassment, as well as how to report such
incidents.”
This auditor reviewed Prison Rape Elimination Act of 2003 Volunteer & Contractor Training curriculum.
Slide 21 states, “PSD has a zero-tolerance policy concerning all forms of sexual abuse, sexual
harassment, and retaliation for reporting incidents. This means that all sexual abuse, sexual harassment
and retaliation for reporting such incidents is strictly prohibited and all allegations will be investigated.”
This auditor reviewed VolinCor (Volunteers in Corrections) A Handbook for Corrections Program Services
Staff. The handbook relays the agency/facility expectations of contractors and volunteers when working
with inmates. Page 30 provides comprehensive information about PREA and states, “The Department
has a ZERO tolerance policy regarding the harassment, abuse, threats, etc., of inmates either by staff or
other inmates. If it mandatory that you report any PREA incident. Failure to report is a violation of Federal
and State Law, as well as Department rules. Failure to report may leave you open to administrative, civil,
and/or criminal proceedings taken against you. It may also result in suspension or termination.”
Interviews with three contractors and volunteers confirmed they had received and understood training
related to PREA and were knowledgeable of the agency’s zero-tolerance policy and their obligation to
report.
(c) PSD Policy ADM.08.08 states on page 22, “PSD maintains documentation confirming that volunteers
and contractors received an appropriate level of training and that they understood the information
provided. A copy shall be maintained with the PSD Volunteer Coordinator and is available to the PSD
PREA Coordinator upon request.”
This auditor reviewed documentation for eight volunteers to confirm all had received an appropriate level
of training. In an interview with the warden, she indicated he would immediately discontinue the services
of any volunteer that she believed violated security procedures, to include engaging in sexual abuse
and/or sexual harassment. Interviews with volunteers and contractors indicated they are aware of the
agency’s zero-tolerance policy and their reporting responsibilities.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of volunteer and contractor training as it relates to PREA.

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Standard 115.33: Inmate education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.33 (a)


During intake, do inmates receive information explaining the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment? ☒ Yes ☐ No



During intake, do inmates receive information explaining how to report incidents or suspicions of
sexual abuse or sexual harassment? ☒ Yes ☐ No

115.33 (b)


Within 30 days of intake, does the agency provide comprehensive education to inmates either in
person or through video regarding: Their rights to be free from sexual abuse and sexual
harassment? ☒ Yes ☐ No



Within 30 days of intake, does the agency provide comprehensive education to inmates either in
person or through video regarding: Their rights to be free from retaliation for reporting such
incidents? ☒ Yes ☐ No



Within 30 days of intake, does the agency provide comprehensive education to inmates either in
person or through video regarding: Agency policies and procedures for responding to such
incidents? ☒ Yes ☐ No

115.33 (c)


Have all inmates received the comprehensive education referenced in 115.33(b)? ☒ Yes ☐
No



Do inmates receive education upon transfer to a different facility to the extent that the policies
and procedures of the inmate’s new facility differ from those of the previous facility?
☒ Yes ☐ No

115.33 (d)


Does the agency provide inmate education in formats accessible to all inmates including those
who are limited English proficient? ☒ Yes ☐ No



Does the agency provide inmate education in formats accessible to all inmates including those
who are deaf? ☒ Yes ☐ No



Does the agency provide inmate education in formats accessible to all inmates including those
who are visually impaired? ☒ Yes ☐ No



Does the agency provide inmate education in formats accessible to all inmates including those
who are otherwise disabled? ☒ Yes ☐ No

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

Does the agency provide inmate education in formats accessible to all inmates including those
who have limited reading skills? ☒ Yes ☐ No

115.33 (e)


Does the agency maintain documentation of inmate participation in these education sessions?
☒ Yes ☐ No

115.33 (f)


In addition to providing such education, does the agency ensure that key information is
continuously and readily available or visible to inmates through posters, inmate handbooks, or
other written formats? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• MCCC Facility Handbook
• Inmate postings within the facility
• Inmate file reviews
• Interview with intake staff
• Interviews with inmates having limited English proficiency or disabilities
• Interviews with random inmates
(a-b) PSD Policy ADM.08.08 states on page 23, “Offenders shall receive verbal and written information
at the time of intake by Intake Service Center (ISC) staff about PSD's zero-tolerance policy and how to
report incidents or suspected incidents of sexual abuse or sexual harassment.
Within thirty (30) days of intake, PSD Facility shall provide comprehensive PREA
education via video (PRC video) or classroom instruction to offenders that addresses:
a. Prevention and intervention.
b. Self-protection.
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c. Reporting sexual abuse, sexual harassment, and protection from retaliation, including
information on the options to report the incident to a designated staff member other than an
immediate point-of-contact line officer.
d. Treatment and counseling.
e. PSD's zero-tolerance for sexual abuse/sexual assault, sexual harassment, and retaliation.”
The MCCC Facility Handbook has PREA-related information on page 14. This information includes the
agency’s zero-tolerance policy, available reporting methods (in person, in writing, anonymously, by
phone) and the numbers to contact the State Ombudsman and Sex Abuse Treatment Center.
This auditor reviewed the agency/facility Inmate PREA Training. MCCC uses a video produced by Just
Detention International to provide comprehensive information to inmates about their right to be free from
sexual abuse and sexual harassment, their right to be free form retaliation for reporting such incidents,
and agency policies and procedures for responding to such incidents. Random and targeted inmates
recalled receiving comprehensive information once they were prompted about watching a video.
This auditor reviewed the files of each inmate that was interviewed to determine if they received
comprehensive education within 30 days of their arrival at MCCC. Out of 19 files reviewed, three inmates
did not have documentation to support receiving education and ten inmates received the education more
than 30 days after their arrival.
For corrective action, the facility PCM created a report showing when an inmate was admitted and the
date they received the comprehensive education. The facility PCM provided this auditor with a copy of
the report to review during the corrective action period in June, July, and August.
An interview with a risk screener indicated the PREA information is offered to each inmate, but they do
not always opt to take the written material. Interviews with inmates indicated they were aware the zerotolerance policy and how to make a report.
(c) PSD Policy ADM.08.08 states on page 23, “Effective August 2013, all current offenders should have
received information on PREA. PSD requires that offenders who are transferred from one facility to
another be reeducated only to the extent that the policies and procedures of the new facility differ from
those of the previous facility.”
MCCC did not have any inmates at the facility who were admitted prior to August 2012.
(d) PSD Policy ADM.08.08 states on page 23, “It is PSD's policy to make appropriate provisions, as
necessary, for offenders with limited English proficiency through the CRCO's identification of authorized
interpreters. Accommodations for offenders with disabilities (including offenders who are deaf or hard of
hearing, those who are blind or have low vision, or those who have intellectual, psychiatric, or speech
disabilities) and offenders with low literacy levels shall be made at the facility level. ISC staff shall
document by utilizing the PREA Mandated Reporting Form (PSD 8317), if an inmate requires
accommodation and this form shall be forwarded to the Facility PREA Manager and Department PREA
Coordinator via email, fax, or mail within three (3) days.”
PREA posters are available throughout the facility in Samoan, Tagalog, Ilocano, Chuukese, and
Marshallese, as they are the most used languages other than English.
MCCC uses a video produced by Just Detention International to provide comprehensive information to
inmates about their right to be free from sexual abuse and sexual harassment, their right to be free form
retaliation for reporting such incidents, and agency policies and procedures for responding to such
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incidents. The video has audio, for those that are visually impaired, and subtitles are available for those
who are deaf.
There were not any inmates at MCCC during the onsite that had limited-English proficiencies. The audit
team interviewed two inmates with physical disabilities and one with cognitive impairments. All confirmed
they received PREA-related information in a format they were able to understand.
(e) PSD Policy ADM.08.08 states on page 23, “Each facility shall maintain electronic or written
documentation of an offender's participation in the educational session (video or classroom). This
documentation shall be forwarded to the Facility PREA Manager and the Department PREA Coordinator
via email, fax, or mail within three (3) days.”
During the facility intake process, inmates are provided a form to sign indicating they have received
comprehensive education, but before they watch the video. One randomly selected inmate indicated he
refused to sign it when presented to him because he did not see the video. Moving forward, the facility
PCM will have documentation signed at the time the video is shown and maintain verification of inmate
attendance in their computer database, Offender Track.
(f) PSD Policy ADM.08.08 states on page 23, “PSD shall ensure that key information on PSD's PREA
policies are continuously and readily available or visible through posters, handouts, offender handbooks,
and resources in the offender library.”
The MCCC Facility Handbook is provided to each inmate upon arrival to MCCC. Page 14 contains
information about the Prison Rape Elimination Act, reporting options, the zero-tolerance policy, and the
right to be free from retaliation for reporting sexual abuse and sexual harassment. Each inmate is offered
an additional brochure during the intake process. Key information is also continuously and readily
available on posters throughout the facility.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of inmate education as it relates to PREA.

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Standard 115.34: Specialized training: Investigations

All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.34 (a)


In addition to the general training provided to all employees pursuant to §115.31, does the
agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its
investigators receive training in conducting such investigations in confinement settings? (N/A if
the agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.21(a).) ☒ Yes ☐ No ☐ NA

115.34 (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 115.21(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 115.21(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 115.21(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 115.21(a).)
☒ Yes ☐ No ☐ NA

115.34 (c)


Does the agency maintain documentation that agency investigators have completed the
required specialized training in conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse investigations. See 115.21(a).)
☒ Yes ☐ No ☐ NA

115.34 (d)


Auditor is not required to audit this provision.

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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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD Training Curriculum on Sexual Abuse Investigations
• Investigative staff training records
• Interviews with investigative staff
(a-b) PSD Policy ADM.08.08 states on page 23, “IA, or facilities, if authorized by the Director, shall
conduct the internal administrative investigation for any allegations of sexual abuse. In addition to the
general training provided to all employees under §18.0 of this policy, PSD investigators shall receive
training on conducting sexual abuse investigations in confinement settings. PSD's specialized training
includes techniques for interviewing sexual abuse victims, proper use of Miranda (not applicable) and
Garrity warnings, preserving sexual abuse evidence for collection in confinement settings, and an
understanding of the criteria and evidence required to substantiate a case in an administrative proceeding
or for a referral by a county LE agency for criminal prosecution.”
Facility and agency investigators conduct administrative investigations. Investigations involving
potentially criminal behavior are referred to the appropriate law enforcement agency, which can be Maui
Police Department or the county Sheriff.
This auditor reviewed the curriculum utilized for investigators. The training includes instruction on
interviewing sexual abuse victims, the proper use of Miranda and Garrity warnings, evidence collection
in confinement settings, and the criteria and evidence required to substantiate a case for administrative
action or prosecution referral. Interviews with agency and facility investigative staff indicated they were
knowledgeable in each aspect of sexual abuse and sexual harassment investigations. In addition to this
training, agency and facility investigators must complete the National Institute of Corrections’ PREA:
Investigating Sexual Abuse in a Confinement Setting course. Investigators had the option to take
specialized training in Non-Confrontational Investigative Interviewing though Wicklander-Zulawski &
Associates.
Interviews with facility and agency investigators confirmed they received the training and are
knowledgeable of the required elements.
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(c) PSD Policy ADM.08.08 states on pages 23 and 24, “PSD shall maintain documentation substantiating
that investigators have completed the required training and it shall be documented on the staff member's
training record with TSO. A copy shall also be provided to the Department PREA Coordinator via email,
fax, or mail within three (3) days.”
MCCC has two facility investigators and PSD has two agency investigators. This auditor reviewed training
certificates for all four staff to ensure the required training was received.
(d) This provision is not required to be audited.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of specialized training for investigations as it relates to PREA.

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Standard 115.35: Specialized training: Medical and mental health care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.35 (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? (N/A if the agency does not have any full- or part-time medical
or mental health care practitioners who work regularly in its facilities.) ☒ Yes ☐ No ☐ NA



Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in how to preserve physical evidence of
sexual abuse? (N/A if the agency does not have any full- or part-time medical or mental health
care practitioners who work regularly in its facilities.) ☒ Yes ☐ No ☐ NA



Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in how to respond effectively and
professionally to victims of sexual abuse and sexual harassment? (N/A if the agency does not
have any full- or part-time medical or mental health care practitioners who work regularly in its
facilities.) ☒ Yes ☐ No ☐ NA



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? (N/A if the agency does not have any fullor part-time medical or mental health care practitioners who work regularly in its facilities.)
☒ Yes ☐ No ☐ NA

115.35 (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 or the agency does not employ medical staff.)
☐ Yes ☐ No ☒ NA

115.35 (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? (N/A if
the agency does not have any full- or part-time medical or mental health care practitioners who
work regularly in its facilities.) ☒ Yes ☐ No ☐ NA

115.35 (d)


Do medical and mental health care practitioners employed by the agency also receive training
mandated for employees by §115.31? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners employed by the agency.)
☒ Yes ☐ No ☐ NA

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

Do medical and mental health care practitioners contracted by or volunteering for the agency
also receive training mandated for contractors and volunteers by §115.32? (N/A if the agency
does not have any full- or part-time medical or mental health care practitioners contracted by or
volunteering for the agency.) ☒ Yes ☐ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PREA Specialized Training for Medical and Mental Health Staff
• Staff training records
• Interviews with medical and mental health staff
(a) PSD Policy ADM.08.08 states on page 24, “All full-time and part-time medical and mental health
practitioners, who work regularly in PSD facilities should be trained in:
a. How to detect and assess signs of sexual abuse and sexual harassment.
b. How to preserve physical evidence of sexual abuse.
c. How to respond effectively and professionally to victims of sexual abuse and sexual
harassment; and,
d. How and to whom to report allegations or suspicions of sexual abuse and sexual harassment.”
This auditor reviewed the curriculum to ensure a comprehensive training program that provides detailed
information on how to detect and assess signs of sexual abuse and sexual harassment; how to preserve
physical evidence of sexual abuse; how to respond effectively and professionally to victims of sexual
abuse and sexual harassment; and how and to whom to report allegations or suspicions of sexual abuse
and sexual harassment. Interviews with medical and mental health staff indicated they were
knowledgeable of the required elements.
(b) PSD Policy ADM.08.08 states on page 24, “PSD medical and mental health staff are not responsible
for conducting forensic examinations.” Interviews with medical staff confirmed they do not conduct
forensic medical exams. As the agency does not employ medical staff to conduct forensic medical
examinations, this subsection of the standard does not apply.
(c) PSD Policy ADM.08.08 states on page 24, “PSD shall maintain documentation substantiating that
medical and mental health practitioners have completed the required training and it shall be documented
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on the staff member's training record with TSO. A copy shall also be provided to the Department PREA
Coordinator via email, fax, or mail within three (3) days.”
(d) In addition to the PREA training provided to all employees, medical and mental health staff receive
additional training specific to their responsibilities with PREA. This auditor reviewed the training
curriculum to ensure it provided detailed information on how to detect and assess signs of sexual abuse
and sexual harassment; how to preserve physical evidence of sexual abuse; how to respond effectively
and professionally to victims of sexual abuse and sexual harassment; and how and to whom to report
allegations or suspicions of sexual abuse and sexual harassment. Interviews of medical and mental
health staff indicated they have received the training and are knowledgeable of the required elements.
This auditor reviewed the training certificates for all medical and mental health staff at MCCC to confirm
they completed the required specialized training. Interviews with medical and mental health staff indicated
they take the standard PREA training as well as the specialized training.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of specialized training, medical and mental health care as it relates
to PREA.

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SCREENING FOR RISK OF SEXUAL VICTIMIZATION
AND ABUSIVENESS
Standard 115.41: Screening for risk of victimization and abusiveness
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.41 (a)


Are all inmates assessed during an intake screening for their risk of being sexually abused by
other inmates or sexually abusive toward other inmates? ☒ Yes ☐ No



Are all inmates assessed upon transfer to another facility for their risk of being sexually abused
by other inmates or sexually abusive toward other inmates? ☒ Yes ☐ No

115.41 (b)


Do intake screenings ordinarily take place within 72 hours of arrival at the facility?
☒ Yes ☐ No

115.41 (c)


Are all PREA screening assessments conducted using an objective screening instrument?
☒ Yes ☐ No

115.41 (d)


Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (1) Whether the inmate has a mental, physical, or developmental
disability? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (2) The age of the inmate? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (3) The physical build of the inmate? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (4) Whether the inmate has previously been incarcerated?
☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (5) Whether the inmate’s criminal history is exclusively nonviolent?
☒ Yes ☐ No

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

Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (6) Whether the inmate has prior convictions for sex offenses
against an adult or child? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (7) Whether the inmate is or is perceived to be gay, lesbian,
bisexual, transgender, intersex, or gender nonconforming (the facility affirmatively asks the
inmate about his/her sexual orientation and gender identity AND makes a subjective
determination based on the screener’s perception whether the inmate is gender non-conforming
or otherwise may be perceived to be LGBTI)? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (8) Whether the inmate has previously experienced sexual
victimization? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (9) The inmate’s own perception of vulnerability? ☒ Yes ☐ No



Does the intake screening consider, at a minimum, the following criteria to assess inmates for
risk of sexual victimization: (10) Whether the inmate is detained solely for civil immigration
purposes? ☒ Yes ☐ No

115.41 (e)
 In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening
consider, as known to the agency, prior acts of sexual abuse? ☒ Yes ☐ No


In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening
consider, as known to the agency, prior convictions for violent offenses? ☒ Yes ☐ No



In assessing inmates for risk of being sexually abusive, does the initial PREA risk screening
consider, as known to the agency, history of prior institutional violence or sexual abuse?
☒ Yes ☐ No

115.41 (f)


Within a set time period not more than 30 days from the inmate’s arrival at the facility, does the
facility reassess the inmate’s risk of victimization or abusiveness based upon any additional,
relevant information received by the facility since the intake screening? ☒ Yes ☐ No

115.41 (g)


Does the facility reassess an inmate’s risk level when warranted due to a referral?
☒ Yes ☐ No



Does the facility reassess an inmate’s risk level when warranted due to a request?
☒ Yes ☐ No



Does the facility reassess an inmate’s risk level when warranted due to an incident of sexual
abuse? ☒ Yes ☐ No

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

Does the facility reassess an inmate’s risk level when warranted due to receipt of additional
information that bears on the inmate’s risk of sexual victimization or abusiveness?
☒ Yes ☐ No

115.41 (h)


Is it the case that inmates are not ever disciplined for refusing to answer, or for not disclosing
complete information in response to, questions asked pursuant to paragraphs (d)(1), (d)(7),
(d)(8), or (d)(9) of this section? ☒ Yes ☐ No

115.41 (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 inmate’s detriment by staff or other inmates? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD PREA Screening Tool
• Interview with PREA coordinator
• Interview with PREA compliance manager
• Interviews with staff responsible for conducting risk screening
• Interviews with randomly selected inmates
• Inmate file reviews
(a-c) PSD Policy ADM.08.08 states on pages 25 and 26, “The ISC [Intake Service Center] is required to screen
offenders at the intake screening process, which occurs upon admission to a facility, by utilizing the PREA
Screening Tool (PSD 8314) and the accompanying Instructions for the PREA Screening Tool. The intake
screening by ISC shall occur within seventy-two (72) hours of intake/arrival. The facility staff shall review the
offender's risk of sexual abuse victimization (vulnerability factors) or sexual abusiveness (predatory factors)
toward other offenders, by reviewing the ‘Intake’ PREA Screening Tool.”
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For new facility admits, this screening is conducted at the courthouse in conjunction with other screening and
assessments prior to their transport to MCCC. For transfers, this screening is conducted in the Holding area
of MCCC. During screening, the inmate sits in the hallway outside of the risk screener’s office, separated by
an iron gate. This does not provide much privacy, as holding cells are across the hall
from the office. This auditor recommends the inmate sit in the office with the screener, or another location is
utilized for the screening process.
A review of 19 inmate files indicated all 19 inmates were screened within 72-hours of transport/arrival to
MCCC.
This auditor reviewed the screening tool used by the facility. It gathers objective data and has an option for
override with approval by the agency PREA Coordinator.
(d) PSD Policy ADM.08.08 states on page 26, “ISC and facility staff shall utilize the PREA Screening Tool
(PSD 8314) to conduct PREA risk assessments. The PREA Screening Tool (PSD 8314) evaluates an
offender's vulnerability factors and predatory factors. The PREA Screening Tool considers the following criteria
to assess offenders for risk of sexual victimization:
a. Whether the offender has a mental, physical, or developmental disability.
b. The age of the offender.
c. The physical build of the offender.
d. Whether the offender has previously been incarcerated.
e. Whether the offender's criminal history is exclusively nonviolent.
f. Whether the offender has prior convictions for sex offenses against an adult or child (see predatory
factors).
g. Whether the offender is or is perceived to be gay, lesbian, bisexual, transgender, intersex, or gender
nonconforming.
h. Whether the offender has previously experienced sexual victimization, in a correctional and/or noncorrectional setting, within the last ten (10) years.
i. The offender's own perception of vulnerability (oral feedback); and,
j. Whether the offender is detained solely for civil immigration purposes, which normally does not occur
at PSD facilities.
While the screening tool considers whether an inmate has experienced sexual victimization, it limits the
information to the last ten years. The agency PREA Coordinator indicated that most screeners do not limit
information as reported by the inmate to that timeframe; however, this auditor believes the tool should reflect
the standards, and not impose a time limit. The agency PREA Coordinator indicated the system is being
updated and the time limit will not appear after the updates. In the interim, the Agency PREA Coordinator
provided written direction to all risk screeners to disregard the current tool’s limit of ten years. With the system
update in November 2021, all sexual victimization will be noted, but only victimization within the last ten years
will be used for scoring purposes.
(e) PSD Policy ADM.08.08 states on page 27, “The PREA Screening Tool considers prior predatory acts of
sexual abuse, prior convictions for violent offenses, and history of prior institutional violence or sexual
abuse, if known to the facility, in assessing offenders for risk of being sexually abusive.”
(f) PSD ADM.08.08 states on page 26, “The facility shall reassess an offender's risk of victimization or
abusiveness within thirty (30) days of intake screening, if additional relevant information is received about the
offender's victimization or abusiveness, subsequent to the intake screening, by utilizing the PREA Screening
Tool (PSD 8314). If no additional relevant information is received by the facility when reassessing the intake
screening, then check the appropriate box on the intake screening tool processed
within seventy-two (72) hours of admission.”
This auditor reviewed 19 inmate files. Five of the 19 had late 30-day screenings or no documentation showing
they received a 30-day screening. However, the 30-day screenings were all conducted without an in-person
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assessment. Interviews with targeted and random inmates indicated they did not recall being asked the risk
screening questions more than one time.
This auditor reviewed the final PREA Audit report prior to the current audit. The auditor noted only one 30-day
assessment had been completed of 16 files reviewed. She also noted, “The reports provided to the auditor
show when a 30-day reassessment is required and includes a check box showing it was completed. However,
the report form is not clear regarding which day the reassessment was actually completed, making it difficult
to determine if it was within the 30-day requirement. Another contributing factor to why reassessments may
be missed is that staff have two separate methods for documenting a completed reassessment. One involves
a quick report that brings up a list of offenders and allows the staff member to check a box stating the
reassessment was completed. The other method is to open the actual assessment form and mark a box on
the form to show reassessment was completed. Utilizing one method may make it easier to determine which
reassessments have been completed or missed.” As part of corrective action, the facility was directed to
develop a method for staff to “actively seek or receive new information” and develop a plan to ensure 30-day
screenings are completed in a manner that clearly documents their completion. The auditor noted that
corrective action was successfully completed, and the facility was compliant with the standard.
A FAQ dated August 02, 2019 states that a facility will reassess an inmate’s risk of victimization or abusiveness
no later than 30 days of intake. While the facility may generally rely on information previously gathered, it must
also capture new or additional information from a variety of sources, to include the inmate. A review of prior
information and new or additional information without consulting the inmate is not compliant with the standard.
As part of corrective action, the facility PCM provided this auditor with a list of all MCCC intakes for June, July,
and August. After the auditor randomly selected names from that list, the facility PCM provided documentation
of the 30-day risk screening for each selection. To ensure the inmate is consulted during the 30-day risk
screening, the agency PREA Coordinator has updated the agency policy and screening instructions.
(g) PSD ADM.08.08 states on page 27, “The offender's risk of victimization or abusiveness shall be
reassessed; when a referral, request, incident of sexual abuse, or receipt of additional information which may
impact the offender's risk level by utilizing the PREA Screening Tool (PSD 8314).”
Interviews with the facility PCM confirmed an additional risk screening is conducted after referral, incident of
sexual abuse or receipt of additional information which may impact the inmate’s risk level.
(h) PSD ADM.08.08 states on page 27, “An offender shall not be disciplined for refusing to answer, or for not
disclosing complete information related to, the questions asked pursuant to §24 of this policy.” Interviews with
the agency PREA Coordinator, the facility PCM and staff who conduct risk screenings confirmed they do not
discipline inmates for refusing to answer risk screening questions, and will instead complete a risk screening
based on information known to the agency/facility. No inmate indicated in an interview they had been
disciplined for refusing to disclose information.
(i) PSD ADM.08.08 states on page 27, “The information on the PREA Screening Tool (PSD 8314) is subject
to confidentiality requirements; therefore, professional and ethical rules shall be enforced to avoid any
negative impact to the offender. The information should not be exploited to the detriment of the offender.”
Interviews with screening staff indicated they are aware that information obtained during the screening process
is to remain confidential unless there is a legitimate need to know.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility is
fully compliant with this standard of screening for risk of sexual victimization and abusiveness as it relates to
PREA.
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Standard 115.42: Use of screening information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.42 (a)


Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those inmates at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Housing Assignments? ☒ Yes ☐ No



Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those inmates at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Bed assignments? ☒ Yes ☐ No



Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those inmates at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Work Assignments? ☒ Yes ☐ No



Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those inmates at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Education Assignments? ☒ Yes ☐ No



Does the agency use information from the risk screening required by § 115.41, with the goal of
keeping separate those inmates at high risk of being sexually victimized from those at high risk
of being sexually abusive, to inform: Program Assignments? ☒ Yes ☐ No

115.42 (b)


Does the agency make individualized determinations about how to ensure the safety of each
inmate? ☒ Yes ☐ No

115.42 (c)


When deciding whether to assign a transgender or intersex inmate to a facility for male or
female inmates, does the agency consider, on a case-by-case basis whether a placement
would ensure the inmate’s health and safety, and whether a placement would present
management or security problems (NOTE: if an agency by policy or practice assigns inmates to
a male or female facility on the basis of anatomy alone, that agency is not in compliance with
this standard)? ☒ Yes ☐ No



When making housing or other program assignments for transgender or intersex inmates, does
the agency consider on a case-by-case basis whether a placement would ensure the inmate’s
health and safety, and whether a placement would present management or security problems?
☒ Yes ☐ No

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115.42 (d)


Are placement and programming assignments for each transgender or intersex inmate
reassessed at least twice each year to review any threats to safety experienced by the inmate?
☒ Yes ☐ No

115.42 (e)


Are each transgender or intersex inmate’s own views with respect to his or her own safety given
serious consideration when making facility and housing placement decisions and programming
assignments? ☒ Yes ☐ No

115.42 (f)


Are transgender and intersex inmates given the opportunity to shower separately from other
inmates? ☒ Yes ☐ No

115.42 (g)


Unless placement is in a dedicated facility, unit, or wing established in connection with a
consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay,
bisexual, transgender, or intersex inmates, does the agency always refrain from placing:
lesbian, gay, and bisexual inmates in dedicated facilities, units, or wings solely on the basis of
such identification or status? (N/A if the agency has a dedicated facility, unit, or wing solely for
the placement of LGBT or I inmates pursuant to a consent decree, legal settlement, or legal
judgement.) ☒ Yes ☐ No ☐ NA



Unless placement is in a dedicated facility, unit, or wing established in connection with a
consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay,
bisexual, transgender, or intersex inmates, does the agency always refrain from placing:
transgender inmates in dedicated facilities, units, or wings solely on the basis of such
identification or status? (N/A if the agency has a dedicated facility, unit, or wing solely for the
placement of LGBT or I inmates pursuant to a consent decree, legal settlement, or legal
judgement.) ☒ Yes ☐ No ☐ NA



Unless placement is in a dedicated facility, unit, or wing established in connection with a
consent decree, legal settlement, or legal judgment for the purpose of protecting lesbian, gay,
bisexual, transgender, or intersex inmates, does the agency always refrain from placing:
intersex inmates in dedicated facilities, units, or wings solely on the basis of such identification
or status? (N/A if the agency has a dedicated facility, unit, or wing solely for the placement of
LGBT or I inmates pursuant to a consent decree, legal settlement, or legal judgement.)
☒ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interview with PREA coordinator
• Interview with PREA compliance manager
• Interview with staff responsible for risk screening
• Interview with inmates who identify as transgender, intersex, gay, bisexual
• Inmate file reviews
• Observation of facility operations while onsite
(a) PSD Policy ADM.08.08 states on page 27, “PSD shall use the information from the risk assessment
screening for housing designations, work line, program assignment, or scheduling to keep separated
those offenders at high risk of being sexually victimized from those at high risk of being sexually abusive.”
Information from the screening form is considered in the final determination of the inmate’s housing and
program assignments. Known or potential victims are not housed with known or potential aggressors.
Known and potential victims may participate in programming and work assignments with known and
potential aggressors if there is adequate staff supervision.
(b) PSD Policy ADM.08.08 states on page 27, “PSD shall use the risk screening tool information to make
an individualized assessment about how to ensure the safety of each individual offender.”
Overrides can be requested to change an inmate’s housing consideration from a lower or a higher level.
Overrides are encouraged when an inmate’s score does not seem to be an accurate reflection of their
actual risk of sexual victimization or abusiveness. When an override is requested, detailed justification
shall be provided, and it will then be submitted to the agency PREA Coordinator for consideration.
(c) PSD Policy ADM.08.08 states on pages 27 and 28, “A transgender or intersex offender will be housed
based on their legal status as a male or female. Any deviation in the housing assignment of a transgender
or intersex offender to a facility for male or female offenders will be determined by medical and mental
health practitioners with input from program and security staff initially at the intake process. In deciding
whether to assign a transgender or intersex inmate to a facility for male or female inmates, and in making
other housing and programming assignments, PSD shall consider on a case-by-case assessment of
whether a placement would ensure the offender's health and safety, and whether the placement would
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present a management or security concern. In the event that an offender's sex designation is changed
as specified under Hawaii Revised Statutes §338-17.7, "Establishment of new certificates of birth"
(effective July 1, 2015), then facility, housing, and programming assignments shall still be made as
indicated in .2, but the PREA Coordinator shall be included in the case-by-case assessment.”
When initially committing an inmate to PSD, the facility assignment is based off the inmate’s legally
recognized gender. Once received at a facility, the housing assignment is determined by medical and
mental health practitioners with input from program and security staff initially during the intake process.
In deciding whether to assign a transgender or intersex inmate to a facility for male or female inmates,
and in making other housing and programming assignments, PSD makes a case-by-case assessment of
whether the placement will ensure the inmate’s health and safety, and whether the placement could
present a management or security concern. PSD recognizes transgender, intersex and Gender X status’.
(d-e) PSD Policy ADM.08.08states on page 28, “Biannually designated facility staff identified by the
Warden shall reassess the placement and programming assignment of each transgender or intersex
offender for the purpose of assessing any threats to the safety of the offender. This biannual assessment
shall be documented by utilizing the PREA Mandated Reporting Form (PSD 8317) and/or may be
conducted as part of a classification review for the transgender or intersex offender. The completed PREA
Mandated Reporting Form shall be forwarded to the Department PREA Coordinator via email, fax, or
mail within three (3) days. A transgender or intersex offender's own view with respect to his or her own
safety shall be given serious consideration.”
At the time of the onsite review, there were not any inmates who identified as transgender.
(f) PSD Policy ADM.08.08states on page 28, “Transgender and intersex offenders shall be given the
option to shower separately from other offenders in dorm shower situations, if so requested. This
provision is applicable only when individual showers are not available at the offender's assigned housing
unit.”
MCCC has housing units with communal showers (a group of single showers put together in one room
or area) and individual showers. If a transgender inmate is assigned to a unit with a communal shower,
they are provided with a time to shower without other inmates’ present. At the time of the onsite review,
there were not any inmates who identified as transgender. Specialized and random staff confirmed this
process in interviews.
(g) PSD Policy ADM.08.08 states on page 28, “PSD Facilities shall not place LGBTI offenders in
dedicated facilities, units, or wings solely on the basis of such identification or status, unless such
placement is established in connection with a consent decree, legal settlement, or legal judgment for the
purpose of protecting such offenders.”
According to the agency PREA Coordinator, MCCC is not subject to a consent decree, legal settlement,
or legal judgment for protecting LGBTI inmates, and does not place those inmates in dedicated facilities,
units, or wings solely based on such identification. No LGB inmates indicated in their interviews that they
had been housed in such a manner. At the time of the onsite review, there were not any inmates who
identified as transgender.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of use of screening information as it relates to PREA.
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Standard 115.43: Protective Custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.43 (a)


Does the facility always refrain from placing inmates at high risk for sexual victimization in
involuntary segregated housing unless an assessment of all available alternatives has been
made, and a determination has been made that there is no available alternative means of
separation from likely abusers? ☒ Yes ☐ No



If a facility cannot conduct such an assessment immediately, does the facility hold the inmate in
involuntary segregated housing for less than 24 hours while completing the assessment?
☒ Yes ☐ No

115.43 (b)


Do inmates who are placed in segregated housing because they are at high risk of sexual
victimization have access to: Programs to the extent possible? ☒ Yes ☐ No



Do inmates who are placed in segregated housing because they are at high risk of sexual
victimization have access to: Privileges to the extent possible? ☒ Yes ☐ No



Do inmates who are placed in segregated housing because they are at high risk of sexual
victimization have access to: Education to the extent possible? ☒ Yes ☐ No



Do inmates who are placed in segregated housing because they are at high risk of sexual
victimization have access to: Work opportunities to the extent possible? ☒ Yes ☐ No



If the facility restricts any access to programs, privileges, education, or work opportunities, does
the facility document the opportunities that have been limited? (N/A if the facility never restricts
access to programs, privileges, education, or work opportunities.) ☒ Yes ☐ No ☐ NA



If the facility restricts any access to programs, privileges, education, or work opportunities, does
the facility document the duration of the limitation? (N/A if the facility never restricts access to
programs, privileges, education, or work opportunities.) ☒ Yes ☐ No ☐ NA



If the facility restricts any access to programs, privileges, education, or work opportunities, does
the facility document the reasons for such limitations? (N/A if the facility never restricts access
to programs, privileges, education, or work opportunities.) ☒ Yes ☐ No ☐ NA

115.43 (c)


Does the facility assign inmates at high risk of sexual victimization to involuntary segregated
housing only until an alternative means of separation from likely abusers can be arranged?
☒ Yes ☐ No



Does such an assignment not ordinarily exceed a period of 30 days? ☒ Yes ☐ No

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115.43 (d)


If an involuntary segregated housing assignment is made pursuant to paragraph (a) of this
section, does the facility clearly document the basis for the facility’s concern for the inmate’s
safety? ☒ Yes ☐ No



If an involuntary segregated housing assignment is made pursuant to paragraph (a) of this
section, does the facility clearly document the reason why no alternative means of separation
can be arranged? ☒ Yes ☐ No

115.43 (e)


In the case of each inmate who is placed in involuntary segregation because he/she is at high
risk of sexual victimization, does the facility afford a review to determine whether there is a
continuing need for separation from the general population EVERY 30 DAYS? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Inmate housing records
• Interview with warden
• Interview with staff who supervise segregated housing
• Interviews with random inmates
(a) PSD Policy ADM.08.08 states on page 28, “PSD discourages the placement of offenders in
involuntary administrative segregated housing solely because of their high risk of sexual victimization
status, unless an assessment of all available alternatives has been made and it is concluded that there
is no available alternative for separating the victim from a likely abuser. This shall be documented by
utilizing the PREA Mandated Reporting Form (PSD 8317), which shall be forwarded to the Department
PREA Coordinator via email, fax, or mail within three (3) days. If the PSD facility is unable to conduct the
above assessment immediately, the facility may hold the offender in involuntary administrative
segregated housing for a period of less than twenty-four (24) hours pending the completion of the
mandated assessment.”
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(b) PSD Policy ADM.08.08 states on pages 28 and 29, “Offenders placed in segregated housing for this
purpose shall have access to programs, privileges, education, and work opportunities to the extent
possible, as dictated by the facility's schedule and operational needs. If the facility restricts access to
programs, privileges, education, or work opportunities, the facility shall document this by utilizing the
PREA Mandated Reporting Form (PSD 8317). This shall be forwarded to the Department PREA
Coordinator via email, fax, or mail within three (3) days. The documentation shall include:
a. The programs, privileges, education, or work opportunities that have been limited.
b. The duration of the limitation; and,
c. The reasons for such limitations.”
(c) PSD Policy ADM.08.08 states on page 29, “If a PSD facility assigns an offender at risk of sexual
victimization to involuntary administrative segregated housing as an alternative means of separation from
the likely abuser, then such an assignment should not normally exceed a period of thirty (30) days.”
(d) PSD Policy ADM.08.08 states on page 29, “If an involuntary administrative segregated housing
assignment is made pursuant to paragraph (1) of this section, the facility shall document this by utilizing
the PREA Mandated Reporting Form (PSD 8317), which shall be forwarded to the Department PREA
Coordinator via email, fax, or mail within three (3) days.
a. The basis for the facility's concern for the offender's safety; and
b. The reason why no alternative means of separation can be arranged.
If the placement in involuntary administrative segregated housing exceeds the initial thirty (30) days, the
facility shall conduct follow-up reviews as dictated by COR.11.01: Administrative Segregation and
Disciplinary Segregation, but no less than every thirty (30) days to assess the offender's continued
separation from the general population.”
Interviews with the warden, facility PCM, and staff who supervise segregated housing confirmed MCCC
has not used involuntary segregation as a means of separation or protection for inmates at high risk for
sexual victimization.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of screening for risk of protective custody as it relates to PREA.

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REPORTING
Standard 115.51: Inmate reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.51 (a)


Does the agency provide multiple internal ways for inmates to privately report sexual abuse and
sexual harassment? ☒ Yes ☐ No



Does the agency provide multiple internal ways for inmates to privately report retaliation by
other inmates or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No



Does the agency provide multiple internal ways for inmates to privately report staff neglect or
violation of responsibilities that may have contributed to such incidents? ☒ Yes ☐ No

115.51 (b)


Does the agency also provide at least one way for inmates to report sexual abuse or sexual
harassment to a public or private entity or office that is not part of the agency? ☒ Yes ☐ No



Is that private entity or office able to receive and immediately forward inmate reports of sexual
abuse and sexual harassment to agency officials? ☒ Yes ☐ No



Does that private entity or office allow the inmate to remain anonymous upon request?
☒ Yes ☐ No



Are inmates detained solely for civil immigration purposes provided information on how to
contact relevant consular officials and relevant officials at the Department of Homeland
Security? (N/A if the facility never houses inmates detained solely for civil immigration purposes)
☐ Yes ☐ No ☒ NA

115.51 (c)


Does staff accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties? ☒ Yes ☐ No



Does staff promptly document any verbal reports of sexual abuse and sexual harassment?
☒ Yes ☐ No

115.51 (d)


Does the agency provide a method for staff to privately report sexual abuse and sexual
harassment of inmates? ☒ Yes ☐ No

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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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• PSD inmate postings/paintings within the facility
• MCCC Facility Handbook
• Interview with PREA Compliance Manager
• Interviews with random staff
• Interviews with random contractors and volunteers
• Interviews with random inmates
(a) PSD Policy ADM.08.08 states on page 29, “PSD provides multiple internal and external ways for
offenders to privately report sexual abuse and sexual harassment; retaliation by other offenders or staff
for reporting sexual abuse and sexual harassment; and staff neglect or violation of responsibilities that
may have contributed to such incidents. Offenders may report non-consensual sexual acts, abusive
sexual contacts, staff sexual misconduct, or staff sexual harassment to any PSD employee, contract
employee or volunteer by using available methods of communication, including but not limited to verbal
or written reports.”
Internal and external reporting options are readily available to inmates on the permanent PREA signs
posted throughout the facility. All inmates interviewed indicated they were aware of the available reporting
mechanisms.
(b) PSD Policy ADM.08.08 states on page 30, “PSD provides notification to offenders on how to report
abuse or harassment to a public entity, private entity, or an external agency, who is able to receive and
immediately forward offender reports of sexual abuse and sexual harassment to agency officials, such
as the Department PREA Coordinator and may allow the offender to remain anonymous upon request.
Offenders, staff, and others may report incidents of sexual abuse, sexual harassment, and retaliation for
reporting by:
a. Contacting the Ombudsman at 808-587-0770 or at 465 South King Street 4th Floor,
Honolulu, HI 96813; a Legislative or Political Representative (at their office address),
or the Department of the Attorney General at 808-586-1500 or at 425 Queen Street,
Honolulu, HI 96813.
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b. Contacting the Sex Abuse Treatment Center at 808-524-7273 or at 55 Merchant
Street, 22nd Floor, Honolulu, HI 96813.
c. Contacting the Department PREA Coordinator at 808-587-1329 or at 919 Ala Moana
Boulevard, Suite 400, Honolulu, HI 96814.
d. Contacting the Director or the relevant Deputy Director at 808-587-1288 or at 919
Ala Moana Boulevard, Suite 400, Honolulu, HI 96814; Internal Affairs at 919 Ala
Moana Boulevard, Suite 400, Honolulu, HI 96814; or the Facility Warden or
Investigator at the relevant facility.
e. Notifying a family member, who can initiate a telephone call or a letter to the Key
Staff identified above; or
f. Filing an Emergency Offender Grievance Compliant.
g. Contacting the relevant County LE agency.
If an offender is detained solely for civil immigration purposes, the offender shall be provided information
on how to contact the relevant consular officials and relevant Department of Homeland Security officials.
It should be noted that PSD does not normally house offenders solely for civil immigration purposes.”
PSD utilizes the State Ombudsman as an external reporting option. Internal and external reporting
options are readily available to inmates on the permanent PREA signs posted throughout the facility, as
well as in the MCCC Facility Handbook. Interviews with random inmates indicated they are aware of
available reporting mechanisms.
MCCC does not normally house inmates detained solely for civil immigration purposes and did not have
any at the facility during the onsite review.
(c) PSD Policy ADM.08.08 states on page 30, “PSD mandates that staff accept reports of sexual abuse,
sexual harassment, or retaliation made verbally, in writing, anonymously, and from third parties. Staff
shall immediately document all verbal reports of sexual abuse, sexual harassment, or retaliation by
immediately notifying superiors through the chain of command.”
Staff are trained on the expectation to immediately report during PREA-related trainings, as verified by
curriculum review and through interviews with random staff. Slide 86 of the Lesson Plan for Prison Rape
Elimination Act of 2003 Corrections & Law Enforcement Training states, “PSD staff are required to
complete PSD PREA Response Incident Checklist (PSD 8313) for all allegations of sexual abuse and
sexual harassment.”
(d) PSD Policy ADM.08.08 states on page 30, “A staff member may privately report incidents of offender
sexual abuse, offender sexual harassment, or retaliation as indicated in paragraph (4) [115.51(b)] of this
section.
MCCC staff, volunteers and contractors can report sexual abuse and sexual harassment privately to any
supervisor. Interviews with staff and contractors did not indicate that any person had concerns with
regards to private reporting mechanisms and all stated that they felt comfortable reporting.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of screening for inmate reporting as it relates to PREA.

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Standard 115.52: Exhaustion of administrative remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.52 (a)


Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not
have administrative procedures to address inmate grievances regarding sexual abuse. This
does not mean the agency is exempt simply because an inmate does not have to or is not
ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of
explicit policy, the agency does not have an administrative remedies process to address sexual
abuse. ☒ Yes ☐ No

115.52 (b)


Does the agency permit inmates to submit a grievance regarding an allegation of sexual abuse
without any type of time limits? (The agency may apply otherwise-applicable time limits to any
portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is
exempt from this standard.) ☒ Yes ☐ No ☐ NA



Does the agency always refrain from requiring an inmate to use any informal grievance process,
or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency
is exempt from this standard.) ☒ Yes ☐ No ☐ NA

115.52 (c)


Does the agency ensure that: An inmate who alleges sexual abuse may submit a grievance
without submitting it to a staff member who is the subject of the complaint? (N/A if agency is
exempt from 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

115.52 (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 inmates in preparing any administrative
appeal.) (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA



If the agency claims the maximum allowable extension of time to respond of up to 70 days per
115.52(d)(3) when the normal time period for response is insufficient to make an appropriate
decision, does the agency notify the inmate in writing of any such extension and provide a date
by which a decision will be made? (N/A if agency is exempt from this standard.)
☒ Yes ☐ No ☐ NA



At any level of the administrative process, including the final level, if the inmate does not receive
a response within the time allotted for reply, including any properly noticed extension, may an
inmate consider the absence of a response to be a denial at that level? (N/A if agency is exempt
from this standard.) ☒ Yes ☐ No ☐ NA

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115.52 (e)


Are third parties, including fellow inmates, staff members, family members, attorneys, and
outside advocates, permitted to assist inmates in filing requests for administrative remedies
relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.)
☒ Yes ☐ No ☐ NA



Are those third parties also permitted to file such requests on behalf of inmates? (If a third-party
files such a request on behalf of an inmate, the facility may require as a condition of processing
the request that the alleged victim agree to have the request filed on his or her behalf, and may
also require the alleged victim to personally pursue any subsequent steps in the administrative
remedy process.) (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA



If the inmate declines to have the request processed on his or her behalf, does the agency
document the inmate’s decision? (N/A if agency is exempt from this standard.)
☒ Yes ☐ No ☐ NA

115.52 (f)


Has the agency established procedures for the filing of an emergency grievance alleging that an
inmate is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from
this standard.) ☒ Yes ☐ No ☐ NA



After receiving an emergency grievance alleging an inmate is subject to a substantial risk of
imminent sexual abuse, does the agency immediately forward the grievance (or any portion
thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which
immediate corrective action may be taken? (N/A if agency is exempt from this standard.).
☒ Yes ☐ 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 inmate 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
115.52 (g)




If the agency disciplines an inmate for filing a grievance related to alleged sexual abuse, does it
do so ONLY where the agency demonstrates that the inmate filed the grievance in bad faith?
(N/A if agency is exempt from this standard.) ☒ Yes ☐ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD Policy COR.12.03
• Interview with the agency PREA Coordinator
• Interview with security staff member who processes grievances
(a) PSD Policy ADM.08.08 states on page 31, “PSD's policy COR.12.03: Inmate Grievance Program
outlines the administrative procedures available to offenders for reporting incidents of sexual abuse,
sexual harassment, or retaliation.” The agency is not exempt from this standard, as they do have
procedures to address inmate grievances pertaining to sexual abuse.
(b) PSD Policy ADM.08.08 states on page 31, “This section is an addendum to COR.12.03: Inmate
Grievance Program as it relates to PREA incidents. PREA mandates that there shall be ‘no time limits or
deadlines’ for filing a grievance that is reporting an alleged incident of sexual abuse.
a. PSD shall not restrict the processing of an offender grievance regarding an allegation of sexual
abuse.
b. The filing period set forth in COR.12.03: Inmate Grievance Program is still applicable to any
portion of the grievance that does not allege an incident of sexual abuse. The offender must still
comply with appeal filing requirements as set forth in COR.12.03.
c. PSD shall not require an offender to utilize the informal grievance process for grievances
alleging incidents of sexual abuse.
d. The statutory or legal provisions germane to the statute of limitations are applicable to any civil
action in a court proceeding.”
(c) PSD Policy ADM.08.08 states on page 31, “An offender may submit an offender grievance alleging
sexual abuse without submitting it to the staff member, who is the subject of the complaint. This grievance
shall not be referred to the staff member, who is the subject of the grievance complaint.”
The audit team noted locked grievance boxes throughout the facility. The security staff member
responsible for processing grievances indicated he consults with the facility PCM for any grievances
related to sexual abuse or sexual harassment. The facility PCM reported there were no grievances related
to sexual abuse or sexual harassment filed during the audit period.
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(d) PSD Policy ADM.08.08 states on page 31, “PSD's grievance policy and timelines may differ from the
PREA requirement that a decision on the merits of any grievance or portion of a grievance alleging sexual
abuse be made within ninety (90) days of the filing of the grievance.
a. Computation of the PREA 90-day time period does not include time consumed by offenders in
preparing any administrative appeal.
b. PSD may claim an extension of time to respond, of up to seventy (70) days, if the normal time
period for response is insufficient to make an appropriate decision. PSD shall notify the offender
in writing of any such extension and provide a date by which a decision will be made.
c. At any level of the administrative process, including the final level, if the offender does not
receive a response within the time allotted for reply, including any properly noticed extension, the
offender may consider the absence of a response to be a denial at that level.”
(e) PSD Policy ADM.08.08 states on page 32, “PSD permits third parties, including fellow offenders, staff
members, family members, attorneys, and outside advocates, to assist offenders in filing requests for
administrative remedies relating to allegations of sexual abuse and they may file such requests on behalf
of offenders.
a. If a third-party files such a request on behalf of an offender, 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.
b. If the offender declines to have the request processed on his or her behalf, PSD shall document
the offender's decision on the PREA Mandated Reporting Form (PSD 8317), which shall be
forwarded to the Department PREA Coordinator via email, fax, or mail within three (3) days.”
(f) PSD Policy ADM.08.08 states on page 32, “PSD's current Grievance policy establishes procedures
for filing an emergency grievance alleging that an offender is subject to a substantial risk of imminent
sexual abuse. This section is intended to supplement the Grievance policy by requiring that:
a. An initial response is provided within forty-eight (48) hours.
b. After receiving an emergency grievance alleging an offender is subject to a substantial risk of
imminent sexual abuse, the PSD staff member shall immediately forward the grievance or any
portion thereof that alleges the substantial risk of imminent sexual abuse to a level of review where
immediate corrective action may be initiated.
c. PSD shall issue a final agency decision within five (5) calendar days. The decision shall include
a determination as to whether the offender is at substantial risk of imminent sexual abuse and it
shall describe the action taken in response to the emergency grievance.”
(g) PSD Policy ADM.08.08 states on page 32, “PSD may initiate a misconduct violation against an
offender for filing a grievance or reporting related to alleged sexual abuse or sexual harassment, when
PSD demonstrates that the offender filed the grievance or report in bad faith.”
An interview with the security staff member assigned to process grievances confirmed that no inmate
had been disciplined for filing a sexual abuse or sexual harassment grievance.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of screening for exhaustion of administrative remedies as it relates to
PREA.

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Standard 115.53: Inmate access to outside confidential support services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.53 (a)


Does the facility provide inmates with access to outside victim advocates for emotional support
services related to sexual abuse by giving inmates mailing addresses and telephone numbers,
including toll-free hotline numbers where available, of local, State, or national victim advocacy or
rape crisis organizations? ☒ Yes ☐ No



Does the facility provide persons detained solely for civil immigration purposes mailing
addresses and telephone numbers, including toll-free hotline numbers where available of local,
State, or national immigrant services agencies? (N/A if the facility never has persons detained
solely for civil immigration purposes.) ☐ Yes ☐ No ☒ NA



Does the facility enable reasonable communication between inmates and these organizations
and agencies, in as confidential a manner as possible? ☒ Yes ☐ No

115.53 (b)


Does the facility inform inmates, prior to giving them access, of the extent to which such
communications will be monitored and the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws? ☒ Yes ☐ No

115.53 (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 inmates 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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The auditor gathered, analyzed and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• State of Hawaii Contract No. 16-HSA-01
• MCCC Facility Handbook
• Intake Brochure – An Informational Guide for Offenders
• Interview with confidential community-based advocate
• Interview with PREA Compliance Manager
• Interviews with random inmates
(a) PSD Policy ADM.08.08 states on pages 32 and 33, “PSD shall provide offenders with access to
outside victim advocates for emotional support services related to sexual abuse by doing the following:
a. Providing offenders with the mailing addresses and telephone numbers (including toll-free
hotline numbers where available) for local, state, or national victim advocacy or rape crisis
organizations. PSD's service provider is the SATC and its relevant outer island providers.
b. Providing offenders with mailing addresses and telephone numbers (including tollfree hotline
numbers where available) for immigrant services agencies for persons detained solely for civil
immigration purposes.
c. Enabling reasonable communication between offenders and these organizations in as
confidential a manner as possible, while balancing the good government and orderly running of
the facility.”
The permanent inmate PREA postings throughout the facility list the phone numbers for the Maui Sex
Abuse Treatment Center and the Ombudsman, and indicates they are confidential in nature. Most
inmates interviewed were unaware of advocacy services, despite the availability of information. Only one
inmate interviewed indicated they had personally used advocacy services.
(b) PSD Policy ADM.08.08 states on page 33, “PSD medical and mental health staff shall inform
offenders, prior to giving them access to outside support services, of the extent to which such
communications will be monitored.
a. PSD shall inform offenders of the mandatory reporting rules governing privacy, confidentiality,
and/or privilege that apply for disclosures of sexual abuse made to outside victim advocates,
including any limits to confidentiality under relevant federal, state, or local law.”
PSD has developed a posting specifically for use in medical or mental health offices. It indicates medical
and mental health staff are required to report incidents of sexual abuse and sexual harassment, and limits
to confidentiality.
(c) PSD Policy ADM.08.08 states on page 33, “PSD maintains agreements with community service
providers through SATC based on the awarded contract by the Executive Branch. The SATC provides
offenders with emotional support services related to sexual abuse. PSD maintains a copy of the grant
awarded to SATC to document the relationship and obligations for SATC and PSD.”
The state of Hawaii has contracted with Kapiolani Medical Center for Women and Children (KMCWC)Sex Abuse Treatment Center (SATC) to provide statewide, comprehensive victim sexual assault
treatment services. The supplemental contract for SATC expires on June 30, 2021 but can be extended
three times.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of inmate access to outside confidential support services as it relates
to PREA.
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Standard 115.54: Third-party reporting

All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.54 (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 an inmate? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD inmate postings/paintings within the facility
• MCCC Facility Handbook
• PSD website
(a) PSD Policy ADM.08.08 states on page 33, “PSD provides the public notice via PSD's website of the
methods for third-party reports of offender sexual abuse or sexual harassment. PSD publicly distributes
information on how to report offender sexual abuse or sexual harassment on behalf of offenders by
posting on PSD's website the Departmental PREA Policy, PREA Handout, PREA poster etc.”
The PSD website lists the contact information for the agency PREA Coordinator, PSD Internal Affairs,
the Office of the Ombudsman, the PSD Director, and the Sex Abuse Treatment Center. This information
is available to the public at How-to-report-PREA-Incident-2-3-15.jpg (1800×1200) (hawaii.gov).
Page 14 of the MCCC Facility Handbook states, “PSD provides several ways to report sexual abuse
whether you are the victim, a witness, staff member, or a concerned individual…”. Inmates are permitted
to make third-party reports on behalf of other inmates at MCCC.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined the facility is in
full compliance with this standard as it relates to PREA.
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OFFICIAL RESPONSE FOLLOWING AN INMATE REPORT
Standard 115.61: Staff and agency reporting duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.61 (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



Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding retaliation against inmates or staff who reported
an incident of sexual abuse or sexual harassment? ☒ Yes ☐ 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

115.61 (b)


Apart from reporting to designated supervisors or officials, does staff always refrain from
revealing any information related to a sexual abuse report to anyone other than to the extent
necessary, as specified in agency policy, to make treatment, investigation, and other security
and management decisions? ☒ Yes ☐ No

115.61 (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 inmates of the practitioner’s duty
to report, and the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No

115.61 (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

115.61 (e)


Does the facility report all allegations of sexual abuse and sexual harassment, including thirdparty and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ No

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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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• HRS §346 Part X, Vulnerable Adult Protective Services
• PSD Policy ADM .08.08
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Interview with warden
• Interview with PREA coordinator
• Interviews with random staff
• Interviews with medical and mental health staff
(a) PSD Policy ADM.08.08 states on page 33, “PSD requires that all staff immediately report any
knowledge, suspicion, or information, they receive regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, or a non PSD facility. PSD requires that all staff immediately report,
any knowledge, suspicion, or information, they receive regarding retaliation against offenders or staff,
who reported such an incident. PSD requires that all staff immediately report any knowledge, suspicion,
or information, they receive regarding staff neglect or violation of responsibilities that may have
contributed to a PREA incident or retaliation.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 145 states, “PSD requires all staff to report: Any
knowledge, suspicion or information regarding an incident of sexual abuse or sexual harassment that
occurred in a facility; retaliation against inmates or staff who reported such an incident; and any staff
neglect or violation of responsibilities that may have contributed to an incident or retaliation.”
Interviews with random staff indicated they are aware of their responsibility to immediately report, as
required by agency policy, staff training, and the standard.
(b) PSD Policy ADM.08.08 states on page 34, “PSD prohibits staff from revealing any information related
to a sexual abuse report to anyone other than and to the extent necessary to manage treatment,
investigation, and other security decisions, inclusive of reporting to the designated supervisors or officials
and designated State or local service agencies.”
MCCC staff training directs on slide 85, “All information related to a victim of sexual assault is
CONFIDENTIAL and should only be released to those who need this information to perform their duties.
Staff who receive any information concerning a sexual assault, shall: IMMEDIATELY (NOW) report the
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information to their superior. The Superior will then comply with the list and the Priority Reporting
Directive. PREA Check All staff involved must complete a detailed incident report prior to the end of their
shift.”
Interviews with random staff indicated they are aware of their responsibility to keep information related to
sexual abuse confidential, as required by agency policy, staff training and the standard.
(c) PSD Policy ADM.08.08 states on page 34, “Unless otherwise precluded by federal, State, or local law,
medical and mental health practitioners shall be required to report sexual abuse pursuant to paragraphs
(1-3) of this section and to inform offenders of the practitioner's duty to report, and the limitations of
confidentiality, at the initiation of services.”
PSD medical and mental health staff are required to report information regarding sexual abuse and
sexual harassment. Interviews with those staff indicated they are aware of their responsibility. PSD
inmates sign an informed consent form prior to receiving services that states medical and mental health
staff will report if inmates disclose that they have been sexually assaulted or harassed by other inmates
or staff.
(d) PSD Policy ADM.08.08 states on page 34, “HRS §346, Part X: Adult Protective Services, defines a
'vulnerable adult’ as a person eighteen (18) years of age or older who because of mental, developmental,
or physical impairment, is unable to:
a. Communicate or make responsible decisions to manage his/her own resources.
b. Carry out or arrange for essential activities of daily living; or
c. Protect oneself from abuse, including physical abuse, psychological abuse, sexual abuse,
financial exploitation, caregiver neglect, or self-neglect.
HRS §346, Part X: Adult Protective Services, mandates that personnel employed in health care, social
services, LE, and financial assistance are required to report suspected abuse or neglect of a vulnerable
adult. The law mandates reporting when there is reason to believe abuse has occurred or the vulnerable
adult is in danger of abuse, if immediate action is not taken.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 51 states, “HRS §346 Part X explicitly names
correctional staff as mandated reporters of abuse and neglect. Who are Mandated Reporters?
Employees or officers of any law enforcement agency including, the courts, police departments,
correctional institutions, and parole or probation offices. The law mandates reporting when there is reason
to believe abuse has occurred or the vulnerable adult is in danger of abuse if immediate action is not
taken.”
Interviews with the agency PREA Coordinator, warden, facility PCM, and medical/mental health staff
indicated MCCC had not housed any inmates under the age of 18 or otherwise qualified as a vulnerable
adult.
(e) PSD Policy ADM.08.08 states on page 34, “PSD [staff] shall report all allegations of sexual abuse and
sexual harassment, including third party and anonymous reports, through the chain of command and a
copy shall be forwarded to the Department PREA Coordinator via email, fax, or mail within three (3)
days.”
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of staff and agency reporting duties as it relates to PREA.
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Standard 115.62: Agency protection duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.62 (a)


When the agency learns that an inmate is subject to a substantial risk of imminent sexual
abuse, does it take immediate action to protect the inmate? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interviews with random staff
(a) PSD Policy ADM.08.08 stets on page 34, “When a Facility or PSD staff learns that an offender is
subject to a substantial risk of imminent sexual abuse, the party shall take immediate action to protect
the offender. Immediate action means to assess appropriate protective measures without unreasonable
delay. The procedures are dictated by this policy and other relevant departmental policies.”
Interviews with all staff interviewed indicated they are aware of their responsibility to take immediate
action if they learn an inmate is subject to substantial risk of imminent sexual abuse.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of agency protection duties as it relates to PREA.

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Standard 115.63: Reporting to other confinement facilities
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.63 (a)


Upon receiving an allegation that an inmate was sexually abused while confined at another
facility, does the head of the facility that received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse occurred? ☒ Yes ☐ No

115.63 (b)


Is such notification provided as soon as possible, but no later than 72 hours after receiving the
allegation? ☒ Yes ☐ No

115.63 (c)


Does the agency document that it has provided such notification? ☒ Yes ☐ No

115.63 (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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Examples of prior confinement facility notifications from 2019 and 2020
• Interview with warden
• Interview with facility PCM
• Interviews with investigative staff
(a-d) PSD Policy ADM.08.08 states on page 35, “Upon receiving an allegation that an offender was
sexually abused while confined at a non-PSD facility, the receiving Facility Head or Warden shall
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immediately notify the non-PSD facility Head or Warden of the PREA sexual abuse allegation. The Facility
Head or Warden shall include the department PREA Coordinator in the formal notification to the nonPSD facility, via ‘Carbon Copy’ for email notifications, or by emailing the fax transmittal to the head of the
facility for fax notifications. Upon receiving an allegation that an offender was sexually abused while
confined at a PSD facility, the receiving Facility Head or Warden shall immediately notify the alleged PSD
Facility Head or Warden of the PREA sexual abuse allegation. The Facility Head or Warden at the
receiving facility shall include the department PREA Coordinator in the formal notification to the PSD
facility, via ‘Carbon Copy’ for email notifications, or by emailing the fax transmittal to the head of the
facility for fax notifications. The Facility Head or Warden shall provide such notifications as soon as
possible, but no later than seventy-two (72) hours after receiving the allegation. The Facility Head or
Warden shall document that he/she has provided such notifications within seventy-two (72) hours of
receiving the allegation. The Facility Head or Warden shall require and advise the non-PSD or PSD
facility that the allegation must be investigated as required by the PREA Standards.”
An interview with the warden, facility PCM and investigative staff confirmed notifications are taking place
as required. The facility had not received any allegations or referred any allegations during the audit
period.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of reporting to other confinement facilities as it relates to PREA.

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Standard 115.64: Staff first responder duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.64 (a)


Upon learning of an allegation that an inmate was sexually abused, is the first security staff
member to respond to the report required to: Separate the alleged victim and abuser?
☒ Yes ☐ No



Upon learning of an allegation that an inmate was sexually abused, is the first security staff
member to respond to the report required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence? ☒ Yes ☐ No



Upon learning of an allegation that an inmate was sexually abused, is the first security staff
member to respond to the report required to: Request that the alleged victim not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No



Upon learning of an allegation that an inmate was sexually abused, is the first security staff
member to respond to the report required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No

115.64 (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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

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The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD PREA Response Incident Checklist PSD 8313
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Interviews with random staff
(a-b) PSD Policy ADM.08.08 states on pages 35 and 36, “PSD's first responder policy for allegations of
sexual abuse dictates that, upon learning of an allegation that an offender was sexually abused, the first
staff member, who ideally would be a security staff member, to respond to the reported incident is
required to:
a. Separate the alleged victim and abuser.
b. Preserve and protect any crime scene until appropriate steps can be taken to collect any
evidence by county LE and IA.
c. If the abuse occurred within a time period (PSD Health Care Division's standard is seventy-two
(72) hours that still allows for the collection of physical evidence, then request that the alleged
victim not take any actions that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating;
and,
d. If the abuse occurred within a time period (PSD Health Care Division's standard is seventy-two
(72) hours that still allows for the collection of physical evidence, then staff shall 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.
PSD requires that if the first staff responder is not a security staff member, the staff responder will be
required to separate the victim and abuser, if feasible, request that the alleged victim not take any actions
that could destroy physical evidence, and then immediately notify security staff.”
PSD PREA Response Incident Checklist PSD 8313 includes space on page 1 to delineate first responder
actions that were taken.
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 88 directs, “Upon learning of an allegation that an
offender was sexually abused, the first staff member to respond is required to: Separate the alleged victim
and abuser; preserve and protect any crime scene. If the abuse occurred within 72 hours, request that
the alleged victim not take any actions that could destroy physical evidence (washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating).”
The facility reported there were no allegations made to date of the onsite review for 2021. There was one
allegation of inmate/inmate sexual abuse, three allegations of inmate/inmate sexual harassment and one
allegation of staff/inmate sexual harassment reported in 2020.
Interviews with random staff indicated they understood the distinction between first responder duties with
a victim and with an alleged perpetrator.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the agency
is fully compliant with this standard of staff first responder duties as it relates to PREA.

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Standard 115.65: Coordinated response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.65 (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

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD PREA Response Incident Checklist PSD 8313
• MCCC Coordinated Facility Response Plan
(a) PSD Policy ADM.08.08 states on page 36, “Each PSD facility must develop a facility specific written
institutional plan to coordinate actions taken in response to an incident of sexual abuse, among staff first
responders, medical and mental health practitioners, investigators, and facility leadership. Each facility's
written institutional plan shall incorporate the PREA Incident Checklist (PSD 8313) and other PREA
forms. If a facility has developed a Facility PREA Coordinated Response Incident Checklist, then it must
incorporate at a minimum all variables included on the Department's PREA Response Incident Checklist
(PSD 8313). Following a PREA incident, a copy of the PREA Incident Checklist (PSD 8313) shall be
forwarded to the Department PREA Coordinator via email, fax, or mail within three (3)
days.”
PSD PREA Response Incident Checklist PSD 8313 ensures no steps are missed when responding to an
allegation.
MCCC’s Coordinated Facility Response Plan outlines the actions taken by facility staff in response to an
incident of sexual/physical abuse, harassment, and misconduct allegations. The response includes when
the initial disclosure is within 72 hours of a sexual assault incident, investigative actions, the forensic
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examination, after action and follow-up care, court referral/presentation and the after-action review. The
policy was most recently revised and signed by the warden on July 20, 2020.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of coordinated response as it relates to PREA.

Standard 115.66: Preservation of ability to protect inmates from contact
with abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.66 (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 inmates pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted? ☒ Yes ☐ No

115.66 (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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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The auditor gathered, analyzed, and retained the following evidence related to this standard:
• PSD Policy ADM.08.08
• United Public Workers Unit 10 Agreement
• Interview with agency head/designee
• Interview with warden
(a) PSD Policy ADM.08.08 states on page 37, “PSD or any other governmental entity responsible for
collective bargaining on PSD's behalf shall not enter into or renew any collective bargaining agreement
(CBA) or other similar agreement that limits PSD's ability to:
a. Remove alleged staff sexual abusers from contact with any offender pending the outcome of
an investigation; or
b. In a determination of whether and to what extent discipline is warranted.
Nothing in the PREA standards shall restrict the entering into or renewal of a CBA or similar agreement
related to:
a. The conduct of the disciplinary process as long as said CBA or similar agreement is not
inconsistent with PREA standard §115.72 (evidentiary standard) and §115.76 (disciplinary
action); or
b. Whether a non-contact assignment that is imposed pending the outcome of an investigation
shall be expunged from or retained in the staff member's personnel file following a determination
that the allegation of sexual abuse is not substantiated.”
This auditor reviewed the United Public Workers Unit 10 Agreement, effective July 1, 2017 to June 30,
2021. There are no provisions of the agreement that would limit the agency’s ability remove an alleged
staff sexual misconduct abuser from contact with inmate pending the outcome of an investigation, or
upon determining whether discipline is warranted. To the contrary, page 11 of the agreement shows the
Employer may opt to retain the Employee at work; place the Employee on leave of absence with pay;
return the Employee to work from the leave without pay pending investigation; or, reassign the employee
to a temporary workplace in the same or different position.
(b) Auditor is not required to audit this provision.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of coordinated response as it relates to PREA.

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Standard 115.67: Agency protection against retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.67 (a)


Has the agency established a policy to protect all inmates and staff who report sexual abuse or
sexual harassment or cooperate with sexual abuse or sexual harassment investigations from
retaliation by other inmates or staff? ☒ Yes ☐ No



Has the agency designated which staff members or departments are charged with monitoring
retaliation? ☒ Yes ☐ No

115.67 (b)


Does the agency employ multiple protection measures, such as housing changes or transfers
for inmate victims or abusers, removal of alleged staff or inmate abusers from contact with
victims, and emotional support services, for inmates or staff who fear retaliation for reporting
sexual abuse or sexual harassment or for cooperating with investigations? ☒ Yes ☐ No

115.67 (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 inmates or staff who reported the sexual abuse to see if there are changes that
may suggest possible retaliation by inmates 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 inmates who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by inmates or staff? ☒ Yes ☐ 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 inmate
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 inmate 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 inmate
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

115.67 (d)


In the case of inmates, does such monitoring also include periodic status checks?
☒ Yes ☐ No

115.67 (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

115.67 (f)


Auditor is not required to audit this provision.

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interview with PREA Compliance Manager
• Review of investigative files
(a-e) PSD Policy ADM.08.08 states on page 37 and 38, “PSD's policy protects all offenders and staff who
report sexual abuse or sexual harassment or cooperates with a sexual abuse or sexual harassment
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investigation, from retaliation by other offenders, staff, or others. The designated Facility PREA
Compliance Manager in conjunction with the Warden or the Sheriff is charged with monitoring any issues
related to retaliation. PSD utilizes multiple protection measures, such as housing changes or transfers
for offender victims or abusers, removal of alleged staff or offender abusers from contact with victims,
and emotional support services for offenders or staff; when the individual fears or experiences retaliation
for reporting sexual abuse or sexual harassment or for cooperating with a PREA investigation. For a
period of not less than ninety (90) days following a report of sexual abuse, the Facility PREA Compliance
Manager in conjunction with the Warden and other staff shall monitor the conduct and treatment of
offenders or staff, who reported the sexual abuse. During this minimum ninety (90) day period following
a report of sexual abuse, the Facility PREA Compliance Manager in conjunction with the Warden and
other staff shall monitor offenders, who were reported to have suffered sexual abuse, to see if there are
any changes that may suggest possible retaliation by other offenders or staff. If it has been determined
that the offender has suffered retaliation, then staff shall initiate proactive measures to promptly remedy
any retaliation. The Facility PREA Compliance Manager and the Warden shall:
a. Act promptly to remedy any such retaliation and report their actions through the chain of
command.
b. Monitor any offender disciplinary reports, housing, or program changes, or negative
performance reviews or reassignments of staff.
c. Continue such monitoring beyond ninety (90) days, if the initial monitoring indicates a continuing
need.
d. In the case of offenders, monitoring by the Facility PREA Compliance Manager shall also
include periodic status checks, preferably conducted weekly, at a minimum.
If any other individual, who cooperates with an investigation expresses a fear of retaliation, then PSD
shall take appropriate measures to protect that individual against retaliation. The facility or PSD staff shall
document all incidents of retaliation and the minimum ninety (90) day monitoring requirement described
under this section on the PREA Mandated Reporting Form (PSD 8317). A copy of this form shall be
forwarded to the Department PREA Coordinator via email, fax, or mail within three (3) days. The
obligation of the Facility PREA Compliance Manager, Warden, and/or Sheriff to monitor shall terminate,
if the investigation concludes that the allegation is unfounded.”
The PSD Facility Handbook states on page 14, “Any retaliation against individuals for reporting an
incident is also prohibited.”
The facility PCM indicated that MCCC did not receive any allegations of retaliation during the audit period.
Documents in investigative files did not reveal any allegations of retaliation. An interview with the facility
PCM indicated they are knowledgeable of the requirements associated with retaliation monitoring.
While this auditor found the facility was compliant with the subsections of this standard, a review of
investigative files indicated that some cases were determined to be unfounded when they should have
been unsubstantiated. As part of corrective action, this auditor required the facility PCM to review
investigational outcomes, make necessary changes and check in with victims and/or informants who
have had a change in outcome in order to determine if they have been retaliated against. Only one
investigational change required a check in of this nature; that inmate was no longer in PSD’s custody.
(f) Auditor is not required to audit this provision.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of agency protection against retaliation as it relates to PREA.
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Standard 115.68: Post-allegation protective custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.68 (a)


Is any and all use of segregated housing to protect an inmate who is alleged to have suffered
sexual abuse subject to the requirements of § 115.43? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interview with the warden
• Interview with PREA Compliance Manager
• Interviews with staff who supervise segregated housing
(a) PSD Policy ADM.08.08 states on page 38, “Any use of involuntary segregated housing to protect an
offender post allegation, who is alleged to have suffered sexual abuse, is subject to the requirements of
§27.0 of this policy.” Section §27.0 of the policy is outlined in the compliance determination narrative for
115.43.
The facility reported they did not use segregated housing as a means of separation or protection for any
inmates’ post allegation. Interviews with the warden, facility PCM, and staff who supervise segregated
housing confirmed MCCC has not used involuntary segregation as a means of separation or protection
for inmates’ post allegation.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of post-allegation protective custody as it relates to PREA.

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INVESTIGATIONS
Standard 115.71: Criminal and administrative agency investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.71 (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 115.21(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 115.21(a).] ☒ Yes ☐ No ☐ NA

115.71 (b)


Where sexual abuse is alleged, does the agency use investigators who have received
specialized training in sexual abuse investigations as required by 115.34? ☒ Yes ☐ No

115.71 (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

115.71 (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

115.71 (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 inmate or staff? ☒ Yes ☐ No



Does the agency investigate allegations of sexual abuse without requiring an inmate who
alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding? ☒ Yes ☐ No

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115.71 (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

115.71 (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

115.71 (h)


Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?
☒ Yes ☐ No

115.71 (i)


Does the agency retain all written reports referenced in 115.71(f) and (g) for as long as the
alleged abuser is incarcerated or employed by the agency, plus five years? ☒ Yes ☐ No

115.71 (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

115.71 (k)


Auditor is not required to audit this provision.

115.71 (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
115.21(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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD Training Curriculum on Sexual Abuse Investigations
• Interview with PREA Compliance Manager
• Interviews with investigative staff
• Review of administrative and criminal investigations
(a) PSD Policy ADM.08.08 states on page 38, “When PSD conducts an administrative investigation into
an allegation of sexual abuse and/or sexual harassment, it shall do so promptly, thoroughly, and
objectively for all allegations, including third-party and anonymous reports.”
While this auditor found the facility was compliant with the subsections of this standard, a review of
investigative files indicated that some cases were determined to be unfounded when they should have
been unsubstantiated. For corrective action, the facility conducted a review of their investigational
outcomes to determine which ones should be changed. Documentation of changes to investigational
outcomes was provided to this auditor for review.
• Two inmate-on-inmate sexual harassment outcomes were changed from unfounded to
unsubstantiated.
• One inmate-on-inmate sexual abuse outcome was changed from unfounded to unsubstantiated.
• One staff-on-inmate sexual harassment outcome was changed from unfounded to
unsubstantiated.
(b) PSD Policy ADM.08.08 states on page 39, “If sexual abuse is alleged, a PSD IA investigator, who has
received specialized training in sexual abuse investigations pursuant to §21.0 of this policy will conduct
the administrative investigation, unless the Director has authorized the Facility to conduct the
administrative investigation. The Facility Investigator must have received the specialized training in
sexual abuse investigations pursuant to §21.0.”
This auditor reviewed the curriculum utilized for PSD’s Training Curriculum on Sexual Abuse
Investigations. The training includes instruction on interviewing sexual abuse victims, the proper use of
Miranda and Garrity warnings, evidence collection in confinement settings, and the criteria and evidence
required to substantiate a case for administrative action or prosecution referral. Interviews with
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investigative staff indicated they were knowledgeable in each aspect of sexual abuse and sexual
harassment investigations.
MCCC has one facility investigator and PSD has two agency investigators. This auditor reviewed training
certificates for all staff to ensure the required training was received.
(c) PSD Policy ADM.08.08 states on page 39 that agency investigators shall “Gather and preserve direct
and circumstantial evidence, including any available physical and DNA evidence and any available
electronic monitoring data. Interview alleged victims, suspected perpetrators, and witnesses, unless a
delay of an interview of a victim is requested by county LE. Review prior complaints and reports of sexual
abuse involving the suspected perpetrator.”
An interview with investigative staff indicated they are knowledgeable on evidence collection, interviewing
and interrogation techniques and the requirement to review prior reports of sexual abuse involving the
alleged perpetrator.
(d) PSD Policy ADM.08.08 states on page 39, “When the quality of evidence appears to support criminal
prosecution, PSD shall conduct compelled interviews of staff by affording the staff member Garrity
Warnings. PSD Investigators should consult with county LE or prosecutors as to whether a compelled
interview may be an obstacle for subsequent criminal prosecution.”
An interview with investigative staff indicated they do not conduct compelled interviews; such interviews
may be conducted by the appropriate local law enforcement agency.
(e) PSD Policy ADM.08.08states on page 39, “The credibility of an alleged victim, suspect, or witness
shall be assessed on an individual basis and shall not be determined merely by the person's status as
an offender or staff member. PSD staff does not require an offender, who alleges sexual abuse, to submit
to a polygraph examination, computer voice stress analysis (CVSA) or other truth-telling device as a
condition for proceeding with the investigation. PSD staff may offer the victim or non-staff witnesses the
option to participate in this type of technological process (polygraph, CVSA or other truth-telling device).”
An interview with investigative staff indicated they are conducting credibility assessments properly, and
do not require incarcerated survivors to submit to a polygraph or other truth-telling device as a condition
for investigation. A victim may request to participate in CVSA but cannot be forced to participate.
(f-g) PSD Policy ADM.08.08 states on page 40, “Administrative investigations shall include:
a. An effort to determine whether staff actions or failures to act contributed to the abuse; and,
b. Written reports shall include a description of the physical and testimonial evidence, the
reasoning behind credibility assessments, and investigative findings of facts.
The procedures for criminal investigations conducted by county LE shall be dictated by their policies. In
practice, the county LE's procedures do require a written report that contains a thorough description of
the physical, testimonial, and documentary evidence.”
Agency and facility investigators confirmed they immediately notify county LE if their administrative
investigation reveals any criminal conduct.
(h) PSD Policy ADM.08.08 outlines that the county LE agency is charged with the responsibility to make
the required referrals for criminal prosecution. The county LE refers substantiated allegations of criminal
conduct for prosecution.
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(i) PSD Policy ADM.08.08 states on page 40, “PSD shall retain all written reports referenced in paragraph
8b) of this section for as long as the alleged abuser is incarcerated or employed by PSD, plus an
additional five (5) years.”
(j) PSD Policy ADM.08.08 states on page 40, “The departure of the alleged abuser or victim from the
employment or custody of the facility or PSD shall not provide a basis for terminating an investigation.
The investigator shall complete the investigation by formulizing a conclusion that the allegation is
substantiated, unsubstantiated, or unfounded.”
Interviews with agency and facility investigators confirmed they will continue an investigation until there
is an outcome, independent of resignations or releases.
(k) Auditor is not required to audit this provision.
(l) PSD Policy ADM.08.08 states on page 40, “When an external agency is charged with investigating an
incident of sexual abuse, the facility staff shall cooperate with the outside investigators and shall endeavor
to remain informed about the progress of the outside agency investigation.”
Interviews with the warden and facility PCM indicated they have a positive relationship with external law
enforcement, and do not experience obstacles when seeking information.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of criminal and administrative agency investigations as it relates to
PREA.

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Standard 115.72: Evidentiary standard for administrative investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.72 (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)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interview with the warden
• Interview with investigative staff
• Review of administrative and criminal investigations
(a) PSD Policy ADM.08.08 states on page 40, “PSD shall not impose an evidentiary standard higher than
a preponderance of the evidence in determining whether allegations of sexual abuse or sexual
harassment are substantiated.”
A review of investigational files indicated the agency/facility is not requiring a burden of proof higher than
a preponderance of the evidence. Interviews with the warden and agency/facility investigative staff
indicated they are aware of this standard in determining if allegations of sexual abuse or sexual
harassment are substantiated.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of evidentiary standard for administrative investigations as it relates
to PREA.
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Standard 115.73: Reporting to inmates
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.73 (a)


Following an investigation into an inmate’s allegation that he or she suffered sexual abuse in an
agency facility, does the agency inform the inmate as to whether the allegation has been
determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No

115.73 (b)


If the agency did not conduct the investigation into an inmate’s allegation of sexual abuse in an
agency facility, does the agency request the relevant information from the investigative agency
in order to inform the inmate? (N/A if the agency/facility is responsible for conducting
administrative and criminal investigations.) ☒ Yes ☐ No ☐ NA

115.73 (c)


Following an inmate’s allegation that a staff member has committed sexual abuse against the
inmate, unless the agency has determined that the allegation is unfounded, or unless the inmate
has been released from custody, does the agency subsequently inform the inmate whenever:
The staff member is no longer posted within the inmate’s unit? ☒ Yes ☐ No



Following an inmate’s allegation that a staff member has committed sexual abuse against the
inmate, unless the agency has determined that the allegation is unfounded, or unless the inmate
has been released from custody, does the agency subsequently inform the inmate whenever:
The staff member is no longer employed at the facility? ☒ Yes ☐ No



Following an inmate’s allegation that a staff member has committed sexual abuse against the
inmate, unless the agency has determined that the allegation is unfounded, or unless the inmate
has been released from custody, does the agency subsequently inform the inmate whenever:
The agency learns that the staff member has been indicted on a charge related to sexual abuse
in the facility? ☒ Yes ☐ No



Following an inmate’s allegation that a staff member has committed sexual abuse against the
inmate, unless the agency has determined that the allegation is unfounded, or unless the inmate
has been released from custody, does the agency subsequently inform the inmate whenever:
The agency learns that the staff member has been convicted on a charge related to sexual
abuse within the facility? ☒ Yes ☐ No

115.73 (d)


Following an inmate’s allegation that he or she has been sexually abused by another inmate,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been indicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No

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

Following an inmate’s allegation that he or she has been sexually abused by another inmate,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been convicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No

115.73 (e)


Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No

115.73 (f)


Auditor is not required to audit this provision.

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD PREA Mandated Reporting Form (PSD 8317)
• Review of administrative and criminal investigations
• Interview with PREA Compliance Manager
• Interview with investigative staff
(a-b) PSD Policy ADM.08.08 states on page 41, “Upon completion of an investigation (administrative or
criminal) into an offender's allegation that he/she suffered sexual abuse in a PSD facility, facility staff
shall inform the offender as to whether the allegation has been determined to be substantiated,
unsubstantiated, or unfounded. If the facility or PSD did not conduct the investigation, the facility, or PSD
shall request the relevant information from the external investigative agency in order to inform the
offender of the results.”
PSD and MCCC utilize form 8317 to make notifications to inmates. The notification is made verbally and
documented in writing. Interviews with the agency PREA Coordinator, facility PCM and investigative staff
indicated they obtain the appropriate information from investigative agencies to inform inmates.

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While this auditor found the facility was compliant with the subsections of this standard, a review of
investigative files indicated that some cases were determined to be unfounded when they should have
been unsubstantiated. For corrective action, the facility conducted a review of their investigational
outcomes to determine which ones should be changed.
• Two inmate-on-inmate sexual harassment outcomes were changed from unfounded to
unsubstantiated.
• One inmate-on-inmate sexual abuse outcome was changed from unfounded to unsubstantiated.
• One staff-on-inmate sexual harassment outcome was changed from unfounded to
unsubstantiated.
The facility PCM provided this auditor with documentation of updated notifications to the affected inmates
for review.
(c) PSD Policy ADM.08.08 states on pages 40-41, “Following an offender's allegation that a staff member
has committed sexual abuse against the offender, the facility or PSD shall subsequently inform the
offender (unless PSD has determined that the allegation is unfounded) whenever: The staff member is
no longer posted within the offender's unit; the staff member is no longer employed at the facility; the
facility or PSD learns that the staff member has been indicted on a charge related to sexual abuse within
the facility; or the facility or PSD learns that the staff member has been convicted on a charge related to
sexual abuse within the facility.”
PSD and MCCC utilize form 8317 to make notifications to inmates. The notification is made verbally and
documented in writing. Interviews with the agency PREA Coordinator, facility PCM and investigative staff
indicated they obtain the appropriate information from investigative agencies to inform inmates.
(d) PSD Policy ADM.08.08 states on page 41, “Following an offender's allegation that he/she has been
sexually abused by another offender in a PSD facility, the facility or PSD shall subsequently inform the
alleged victim whenever: the facility or PSD learns that the alleged abuser has been indicted on a charge
related to sexual abuse within the facility; or the facility or PSD learns that the alleged abuser has been
convicted on a charge related to sexual abuse within the facility.”
PSD and MCCC utilize form 8317 to make notifications to inmates. The notification is made verbally and
documented in writing. Interviews with the agency PREA Coordinator, facility PCM and investigative staff
indicated they obtain the appropriate information from investigative agencies to inform inmates.
(e) PSD Policy ADM.08.08 states on page 41, “The facility or PSD shall document all notifications to
offenders described under this section on the PREA Mandated Reporting Form (PSD 8317). A copy of
this form shall be forwarded to the Department PREA Coordinator via email, fax, or mail within three (3)
days.”
(f) Auditor is not required to audit this provision.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of reporting to inmates as it relates to PREA.

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DISCIPLINE
Standard 115.76: Disciplinary sanctions for staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.76 (a)


Are staff subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies? ☒ Yes ☐ No

115.76 (b)


Is termination the presumptive disciplinary sanction for staff who have engaged in sexual
abuse? ☒ Yes ☐ No

115.76 (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

115.76 (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)

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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• MCCC Investigative Reports
(a) PSD Policy ADM.08.08 states on page 42, “Staff are subject to disciplinary sanctions up to and
including termination for PREA sexual abuse or sexual harassment policy violations.”
The facility PCM reported that MCCC had one instance of staff sexual harassment during the audit period.
As it was unfounded, there was no discipline.
(b) PSD Policy ADM.08.08 states on page 41, “Termination shall be the presumptive disciplinary sanction
for all staff, who, after an investigation and a pre-disciplinary due process hearing, have been found to
have engaged in sexual abuse.”
(c) PSD Policy ADM.08.08 states on page 41, “Disciplinary sanctions for violations of PSD policies
relating to sexual abuse or sexual harassment (other than actually engaging in sexual abuse) must be
commensurate with the nature and circumstances of the acts committed, the staff member’s disciplinary
history, and the sanctions imposed for comparable offenses by other staff with similar histories.”
(d) PSD Policy ADM.08.08 states on page 42, “All terminations for violations of PREA sexual abuse or
sexual harassment policies, or resignations by staff, who would have been terminated, if not for their
resignation, shall be reported to LE agencies, unless the activity was clearly not criminal. PSD shall also
report the incident to any relevant licensing body applicable to the staff member, such as but not limited
to social work, educational, physician or nursing licensing bodies.”
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of disciplinary sanctions for staff as it relates to PREA.

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Standard 115.77: Corrective action for contractors and volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.77 (a)


Is any contractor or volunteer who engages in sexual abuse prohibited from contact with
inmates? ☒ 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

115.77 (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 inmates? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interview with the warden
• Interview with Agency PREA Coordinator
• Interview with PREA Compliance Manager
• Interviews with contractors and volunteers
(a) PSD Policy ADM.08.08 states on page 42, “PSD requires that any contractor or volunteer, who
engages in sexual abuse is prohibited from contact with inmates and shall be reported to county LE,
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unless the activity was clearly not criminal. PSD shall also report the incident to any relevant licensing
body applicable to the contractor or volunteer.”
The facility PCM indicated that MCCC did not have any contractors or volunteers who engaged in the
sexual abuse of an inmate during the audit period.
(b) PSD Policy ADM.08.08 states on page 42, “PSD shall take appropriate remedial measures and
consider whether to prohibit further contact with offenders in the case of any other violations not covered
by the paragraph (1) of this section, such as sexual harassment by a contractor or volunteer.”
The facility PCM indicated that MCCC did not have any instances of remedial measures with contractors
or volunteers during the audit period.
Interviews with the warden, Agency PREA Coordinator, and facility PCM indicated that any contractor
suspected of engaging in any prohibited activity is immediately removed from the facility and prohibited
from contact with inmates. Interviews with contractors and volunteers indicated they are aware of the
agency’s zero-tolerance policy and action the agency will take if they engage in prohibited conduct.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of corrective action for contractors and volunteers as it relates to
PREA.

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Standard 115.78: Disciplinary sanctions for inmates
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.78 (a)


Following an administrative finding that an inmate engaged in inmate-on-inmate sexual abuse,
or following a criminal finding of guilt for inmate-on-inmate sexual abuse, are inmates subject to
disciplinary sanctions pursuant to a formal disciplinary process? ☒ Yes ☐ No

115.78 (b)


Are sanctions commensurate with the nature and circumstances of the abuse committed, the
inmate’s disciplinary history, and the sanctions imposed for comparable offenses by other
inmates with similar histories? ☒ Yes ☐ No

115.78 (c)


When determining what types of sanction, if any, should be imposed, does the disciplinary
process consider whether an inmate’s mental disabilities or mental illness contributed to his or
her behavior? ☒ Yes ☐ No

115.78 (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 inmate to participate in such interventions as a condition of access to
programming and other benefits? ☒ Yes ☐ No

115.78 (e)


Does the agency discipline an inmate for sexual contact with staff only upon a finding that the
staff member did not consent to such contact? ☒ Yes ☐ No

115.78 (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

115.78 (g)


If the agency prohibits all sexual activity between inmates, does the agency always refrain from
considering non-coercive sexual activity between inmates to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between inmates.) ☒ Yes ☐ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• MCCC Facility Handbook
• Interview with warden
• Interviews with medical and mental health staff
• Inmate misconduct reports/adjustments
(a) PSD Policy ADM.08.08 states on page 42, “Offenders are subject to disciplinary sanctions pursuant
to a formal disciplinary process following an administrative finding that the offender engaged in offenderon-offender sexual abuse or sexual harassment.”
Inmates are held accountable through an internal disciplinary process, called “adjustments”. Adjustments
are adjudicated by lieutenants.
(b) PSD Policy ADM.08.08 states on page 42, “Sanctions shall commensurate with the nature and
circumstances of the abuse committed, the offender's disciplinary history, and the sanctions imposed for
comparable offenses by other offenders.”
Adjustments are reviewed and signed by the Chief of Security (COS). The COS may approve the
sanction, modify the sanction, dismiss the report, or order a new hearing.
(c) PSD Policy ADM.08.08 states on page 42, “The disciplinary process shall consider whether an
offender's mental disability or mental illness contributed to his/her behavior when determining what type
of sanction, if any, should be imposed. PSD medical and mental health staff shall provide therapy,
counseling, or other interventions designed to address and correct underlying reasons or motivations for
abuse.”
If there are concerns about the inmate’s mental health, the adjudicating officer will request information
from the mental health provider. The mental health provider indicates if the inmate is currently in
treatment, the date of their last encounter with mental health and if the misconduct could be due to
symptoms of the inmate’s mental illness.
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(d) PSD Policy ADM.08.08 states on page 42, “The medical, mental health, and facility staff shall consider
whether to require the offending offender to participate in such interventions as a condition of access to
programming, privileges, or other benefits.”
There are no sexual offender treatment programs at MCCC.
(e) PSD Policy ADM.08.08 states on page 43, “The PSD may discipline an adult in custody for sexual
contact with staff only upon a finding the staff member did not consent to the contact.”
The facility PCM indicated that no instances of sexual contact with a staff member occurred during the
audit period. MCCC inmates who are victim of staff sexual misconduct are not disciplined.
(f) PSD Policy ADM.08.08 states on page 43, “PSD shall not discipline an offender for reporting sexual
abuse made in good faith and based upon a reasonable belief that the alleged conduct occurred. This is
applicable, if an investigation does not establish evidence sufficient to substantiate the allegation.”
MCCC did not discipline any inmates for a report of sexual abuse made in good faith during the audit
period. Interviews with the agency PREA Coordinator and facility PCM indicated allegations are
determined to be in bad faith only when there is conclusive evidence the allegation did not occur, such
as through video surveillance records.
(g) Sexual contact is prohibited between inmates, but it is not considered to be sexual abuse. PSD Policy
ADM.08.08 states on page 43, “PSD prohibits all sexual activity or sexual contact between offenders and
shall discipline offenders for such activity or contact. PSD shall not deem such activity to constitute sexual
abuse, if it determines that the activity is consensual or not coerced.”
The MCCC Facility Handbook states on page 14, “Although not a PREA incident, it is prohibited and a
misconduct, for offenders to engage in consensual sexual acts with another offender.”
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of disciplinary sanctions for inmates as it relates to PREA.

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MEDICAL AND MENTAL CARE

Standard 115.81: Medical and mental health screenings; history of sexual
abuse
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.81 (a)


If the screening pursuant to § 115.41 indicates that a prison inmate has experienced prior
sexual victimization, whether it occurred in an institutional setting or in the community, do staff
ensure that the inmate is offered a follow-up meeting with a medical or mental health
practitioner within 14 days of the intake screening? (N/A if the facility is not a prison.)
☐ Yes ☐ No ☒ NA

115.81 (b)


If the screening pursuant to § 115.41 indicates that a prison inmate has previously perpetrated
sexual abuse, whether it occurred in an institutional setting or in the community, do staff ensure
that the inmate is offered a follow-up meeting with a mental health practitioner within 14 days of
the intake screening? (N/A if the facility is not a prison.) ☐ Yes ☐ No ☒ NA

115.81 (c)


If the screening pursuant to § 115.41 indicates that a jail inmate has experienced prior sexual
victimization, whether it occurred in an institutional setting or in the community, do staff ensure
that the inmate is offered a follow-up meeting with a medical or mental health practitioner within
14 days of the intake screening? ☒ Yes ☐ No

115.81 (d)


Is any information related to sexual victimization or abusiveness that occurred in an institutional
setting strictly limited to medical and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law?
☒ Yes ☐ No

115.81 (e)


Do medical and mental health practitioners obtain informed consent from inmates before
reporting information about prior sexual victimization that did not occur in an institutional setting,
unless the inmate is under the age of 18? ☒ 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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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Interviews with staff responsible for risk screening
• Interviews with medical and mental health staff
• Interviews with inmates who disclosed sexual victimization at risk screening
• Review of inmate files
(a) This subsection of the standard does not apply as MCCC is not a prison.
(b) This subsection of the standard does not apply as MCCC is not a prison.
(c) PSD Policy ADM.08.08 states that any offender who has disclosed a prior sexual victimization or
previous perpetration of sexual abuse shall be offered a follow-up meeting with a medical or mental health
practitioner within 14 days of the intake screening.
All inmates interviewed because they disclosed sexual victimization at risk screening indicated they were
offered follow up meetings with mental health providers.
(d) PSD Policy ADM.08.08 states on page 43, “Any information related to sexual victimization or
abusiveness that occurred in an institutional setting is strictly limited to medical and mental health
practitioners and other staff, as necessary, to formulate treatment plans and/or security management
decisions, including housing, bed, work, education, and program assignments, or as otherwise
required by federal, State, or local law.”
Interviews with staff indicated they are aware of and adhere to the requirements around confidentiality.
(e) PSD Policy ADM.08.08 states on page 43, “Medical and mental health staff shall obtain informed
consent from offenders before reporting information about prior sexual victimization that did not occur in
an institutional setting, unless the offender is under the age of eighteen (18).”
PSD medical and mental health staff indicated they utilize form DOC0404A Authorization to Release
Medical Information to obtain informed consent from inmates. Interviews with medical and mental health
staff confirmed they obtain informed consent prior to reporting prior sexual victimization that occurred
outside of an institutional setting.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of medical and mental care as it relates to PREA.

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Standard 115.82: Access to emergency medical and mental health services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.82 (a)


Do inmate victims of sexual abuse receive timely, unimpeded access to emergency medical
treatment and crisis intervention services, the nature and scope of which are determined by
medical and mental health practitioners according to their professional judgment?
☒ Yes ☐ No

115.82 (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 § 115.62? ☒ Yes ☐ No



Do security staff first responders immediately notify the appropriate medical and mental health
practitioners? ☒ Yes ☐ No

115.82 (c)


Are inmate victims of sexual abuse offered timely information about and timely access to
emergency contraception and sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate? ☒ Yes ☐ No

115.82 (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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Interviews with medical and mental health staff
(a-c) PSD Policy ADM.08.08 states on page 44, “Offender victims of sexual abuse shall receive timely,
unimpeded access to emergency medical treatment and crisis intervention services, the nature and
scope of which will be determined by medical and mental health staff according to their professional
judgment. If qualified medical or mental health staff are not on duty at the time of the report of a recent
sexual abuse, the security staff or first responder shall take preliminary steps to protect the victim as
dictated by §32.0 and §35.0. If qualified medical and mental health staff are not on duty at the time of the
report of a recent sexual abuse, they shall be immediately notified either by telephone contact to the oncall physician or when reporting for duty. Offender victims of sexual abuse, while incarcerated shall be
offered timely information about and provided timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with the professionally accepted community standards
of care, where medically appropriate.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 120 states, “Offender victims of sexual abuse will
receive timely, unimpeded access to emergency medical treatment and crisis intervention services
(determined by medical and mental health practitioners). IF no qualified medical or mental health
practitioners are on duty, security staff first responders will take preliminary steps to protect the victim
and will immediately notify the appropriate medical and mental health practitioners.”
There were no incarcerated survivors at MCCC who had received forensic medical exams within the
audit period to be interviewed by the audit team. Interviews with medical staff indicated incarcerated
survivors are offered sexually transmitted infection prophylaxis medication and treatment during the
forensic medical exam and upon their return to the facility. There were no staff who had acted as a first
responder during the audit period to be interviewed by the audit team.
(d) PSD Policy ADM.08.08 states on page 44, “Treatment services are provided to every victim without
financial cost and regardless of whether the victim names the abuser or cooperates with any investigation
arising out of the incident.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 89 states, “The Health Care Division staff shall
determine whether a victim of sexual abuse will be transported for a forensic medical examination at the
Sex Abuse Treatment Center…or at a hospital emergency unit. This will be at no financial cost to the
victim.” This is mentioned again on slides 91 and 120, and additionally notes services are “provided
without financial cost regardless of whether the offender victim names the abuser or cooperates with the
investigation”.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of access to emergency medical and mental health services as it
relates to PREA.

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Standard 115.83: 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
115.83 (a)


Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all
inmates who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility? ☒ Yes ☐ No

115.83 (b)


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

115.83 (c)


Does the facility provide such victims with medical and mental health services consistent with
the community level of care? ☒ Yes ☐ No

115.83 (d)


Are inmate victims of sexually abusive vaginal penetration while incarcerated offered pregnancy
tests? (N/A if “all-male” facility. Note: in “all-male” facilities, there may be inmates who identify
as transgender men who may have female genitalia. Auditors should be sure to know whether
such individuals may be in the population and whether this provision may apply in specific
circumstances.) ☒ Yes ☐ No ☐ NA

115.83 (e)


If pregnancy results from the conduct described in paragraph § 115.83(d), do such victims
receive timely and comprehensive information about and timely access to all lawful pregnancyrelated medical services? (N/A if “all-male” facility. Note: in “all-male” facilities, there may be
inmates who identify as transgender men who may have female genitalia. Auditors should be
sure to know whether such individuals may be in the population and whether this provision may
apply in specific circumstances.) ☒ Yes ☐ No ☐ NA

115.83 (f)


Are inmate victims of sexual abuse while incarcerated offered tests for sexually transmitted
infections as medically appropriate? ☒ Yes ☐ No

115.83 (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

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115.83 (h)


If the facility is a prison, does it attempt to conduct a mental health evaluation of all known
inmate-on-inmate abusers within 60 days of learning of such abuse history and offer treatment
when deemed appropriate by mental health practitioners? (NA if the facility is a jail.)
☒ 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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• Lesson Plan for Prison Rape Elimination Act of 2003 Corrections & Law Enforcement Training
• Review of inmate files
• Interviews with medical and mental health staff
(a-c, f) PSD Policy ADM.08.08 states on page 44, “PSD shall offer medical and mental health evaluations
and, as appropriate, treatment to all offenders (including external referrals), who have been victimized by
sexual abuse in any prison, jail, lockup, or juvenile facility. The evaluation and treatment of such victims
includes, 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. PSD shall
provide offender victims of sexual abuse with medical and mental health services consistent with the
community standard level of care. Offender victims of sexual abuse, while incarcerated shall be offered
tests for sexually transmitted infections as medically appropriate.”
Files for each inmate selected for a targeted or random interview were reviewed. Referrals to mental
health were completed as required. Interviews with inmates who reported previously perpetrating sexual
abuse or prior victimization of sexual abuse indicated they had been offered the opportunity to meet with
mental health providers.
Interviews with medical and mental health services staff members indicated ongoing treatment is
provided to victims of sexual abuse, as well as to known inmate-on-inmate abusers. When asked about
the comparison with a community-level of care, they indicated they believed the facility’s standard of care
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to be higher, as inmates are scheduled for appointments and do not have to seek these services out on
their own.
Interviews with medical staff indicated initial testing for sexually transmitted infections would occur at the
hospital during the forensic medical examination, but any follow up testing would occur at the facility.
Incarcerated survivors who declined to receive a forensic medical examination would have any testing
conducted at the facility, upon their request.
(d-e) PSD Policy ADM.08.08 states on page 44, “Offender victims of sexually abusive vaginal penetration,
while incarcerated shall be offered pregnancy tests. If pregnancy results from the sexual abuse while
incarcerated, offender victims shall receive timely and comprehensive information about and timely
access to all lawful pregnancy-related medical services.”
Interviews with medical staff confirmed this testing is available for female inmates.
(g) PSD Policy ADM.08.08 states on page 44, “Treatment services shall be provided to the offender victim
without financial cost and regardless of whether the offender victim names the abuser or cooperates with
any investigation arising out of the incident.”
This auditor reviewed the MCCC lesson plan and training curriculum for Prison Rape Elimination Act of
2003 Corrections & Law Enforcement Training. Slide 89 states, “The Health Care Division staff shall
determine whether a victim of sexual abuse will be transported for a forensic medical examination at the
Sex Abuse Treatment Center…or at a hospital emergency unit. This will be at no financial cost to the
victim.” This is mentioned again on slides 91 and 120, and additionally notes services are “provided
without financial cost regardless of whether the offender victim names the abuser or cooperates with the
investigation”.
There were no incarcerated survivors at MCCC who had received forensic medical exams within the
audit period to be interviewed by the audit team, to determine if they had been held financially responsible
for any charges related to a forensic medical exam or STI prophylaxis or treatment.
(h) This subsection of the standard does not apply as MCCC is a jail.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of ongoing medical and mental health care for sexual abuse victims
and abusers as it relates to PREA.

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DATA COLLECTION AND REVIEW
Standard 115.86: Sexual abuse incident reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.86 (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

115.86 (b)


Does such review ordinarily occur within 30 days of the conclusion of the investigation?
☒ Yes ☐ No

115.86 (c)


Does the review team include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No

115.86 (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



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 §§ 115.86(d)(1) - (d)(5), and any recommendations for
improvement and submit such report to the facility head and PREA compliance manager?
☒ Yes ☐ No

115.86 (e)


Does the facility implement the recommendations for improvement, or document its reasons for
not doing so? ☒ Yes ☐ No

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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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy & Procedures 3C-4
• Interview with the warden
• Interview with the PREA Compliance Manager
• Interview with an incident review team member
(a-c) PSD Policy ADM.08.08 states on page 45, “The Warden in conjunction with the Facility PREA
Compliance Manager shall schedule a Sexual Abuse Incident Review (SAR) at the conclusion of every
sexual abuse investigation that renders a finding that the allegation was substantiated or unsubstantiated,
unless the allegation has been determined to be unfounded. SAR shall ordinarily occur within thirty (30)
days of the when the Warden has been informed of the conclusion of the investigation and its findings,
excluding allegations determined to be unfounded. SAR Team shall include upper-level management
officials, with input from line supervisors, investigators, and medical or mental health staff. One individual
should be identified as the Recorder or Reporting Staff Member.”
(d-e) PSD Policy ADM.08.08 states on page 45, “The SAR Team shall document the following information
on the Sexual Abuse Incident Review Report form (PSD 8319):
a. Consider whether the allegation or investigation indicates a need to change policy or practice
to better prevent, detect, or respond to sexual abuse.
b. Consider whether the incident or allegation was motivated by race; ethnicity; gender identity;
lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; or gang
affiliation; or was motivated or otherwise caused by other group dynamics at the facility;
c. Examine the area in the facility, where the incident allegedly occurred to assess whether
physical barriers in the area may enable abuse.
d. Assess the adequacy of staffing levels in that area during different shifts.
e. Assess whether monitoring technology should be deployed or augmented to supplement
supervision by staff; and
The Recorder or Reporting Team Member shall prepare a report by utilizing the Sexual Abuse Incident
Review Report form (PSD 8319) to document the SAR Team's findings, including but not limited to a
determination made pursuant to paragraphs (4a-4e) of this section, and any recommendations for
improvement. The SAR Team's report shall be forwarded to the Warden to review and complete the
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Warden's Response Section. The Warden shall decide as to whether the recommendations of the SAR
Team will be implemented or document the reasons for not implementing the recommendations of the
SAR Team.”
There were no sexual abuse incident reviews conducted by the facility during the audit review period.
The investigational outcomes that were updated during this audit did not necessitate new sexual abuse
incident reviews. Interviews with the warden, facility PCM and other potential members of the incident
review team indicated they were aware of the required considerations.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with and exceeds this standard of sexual abuse incident reviews as it relates to PREA.

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Standard 115.87: Data collection
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.87 (a)


Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities
under its direct control using a standardized instrument and set of definitions? ☒ Yes ☐ No

115.87 (b)


Does the agency aggregate the incident-based sexual abuse data at least annually?
☒ Yes ☐ No

115.87 (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

115.87 (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

115.87 (e)


Does the agency also obtain incident-based and aggregated data from every private facility with
which it contracts for the confinement of its inmates? (N/A if agency does not contract for the
confinement of its inmates.) ☒ Yes ☐ No ☐ NA

115.87 (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)

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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD website
• 2017, 2018 and 2019 PREA Annual Reports
• Interview with agency PREA Coordinator
(a-f) PSD Policy ADM.08.08 states on page 46, “The Department PREA Coordinator shall collect
accurate, uniform data for every allegation of sexual abuse at facilities under its direct control by utilizing
a standardized format based on PREA definitions. The standardized format includes, 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. The Department PREA Coordinator shall aggregate the incident
based sexual abuse data at least annually. The Department PREA Coordinator shall maintain, review,
and collect data as needed from all available incident-based documents, including reports, investigation
files, and SARs. At least once a year, the Mainland Branch Unit shall report to the Department PREA
Coordinator all incident-based and aggregated data from any private facility with whom it contracts for
the confinement of PSD offenders. PSD shall provide all such data from the previous calendar year to
the Department of Justice's Survey of Sexual Violence, no later than June 30th of each year.”
When interviewed, the agency PREA Coordinator confirmed that she sends the required information to
the Department of Justice. This auditor reviewed the agency’s annual reports for 2017, 2018 and 2019.
The annual reports for 2011-2018 are available on the agency website at Department of Public Safety |
PREA (hawaii.gov).
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of data collection as it relates to PREA.

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Standard 115.88: Data review for corrective action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.88 (a)


Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess
and improve the effectiveness of its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No



Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess
and improve the effectiveness of its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Taking corrective action on an ongoing basis?
☒ Yes ☐ No



Does the agency review data collected and aggregated pursuant to § 115.87 in order to assess
and improve the effectiveness of its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Preparing an annual report of its findings and corrective
actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No

115.88 (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

115.88 (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

115.88 (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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Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD website
• 2017, 2018 and 2019 PREA Annual Reports
• Interview with agency head
• Interview with agency PREA Coordinator
(a-d) PSD Policy ADM.08.08 states on pages 46 and 47, “The Department PREA Coordinator shall review
data collected and aggregated pursuant to §50.0 of this policy in order to assess and improve the
effectiveness of its sexual abuse prevention, detection, response policies, and training, including:
a. Identifying problem areas; and
b. Taking corrective actions on an ongoing basis.
The Department PREA Coordinator shall prepare an annual report of PSD's findings and any corrective
actions for each facility, as well as the agency as a whole and as dictated by HRS §353-C8. This report
shall include a comparison of the current year's data and corrective actions with those from prior years.
The annual report shall provide an assessment of PSD's progress in addressing sexual abuse. This report
shall be approved by the Director and be made readily available to the public through PSD's departmental
website. PSD may redact specific material when publication would present a clear and specific threat to
the safety and security of a facility. A notation should be made to indicate the nature of the material
redacted.”
PSD collects and reviews data to access and improve the effectiveness of its sexual abuse prevention,
detection and response polices, practices and training in order to identify problem areas, take corrective
action on an ongoing basis, compare the current year’s data/corrective action with data/corrective action
from previous years, and assess the agency’s progress in addressing sexual abuse within its facilities.
The report is prepared by the agency PREA Coordinator and signed by the PSD Director, as confirmed
in interviews.
This auditor reviewed the agency’s annual reports for 2017, 2018 and 2019. The annual reports for 20112018 are available on the agency website at Department of Public Safety | PREA (hawaii.gov).
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard of data review for corrective action as it relates to PREA.

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Standard 115.89: Data storage, publication, and destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.89 (a)


Does the agency ensure that data collected pursuant to § 115.87 are securely retained?
☒ Yes ☐ No

115.89 (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

115.89 (c)


Does the agency remove all personal identifiers before making aggregated sexual abuse data
publicly available? ☒ Yes ☐ No

115.89 (d)


Does the agency maintain sexual abuse data collected pursuant to § 115.87 for at least 10
years after the date of the initial collection, unless Federal, State, or local law requires
otherwise? ☒ Yes ☐ No

Auditor Overall Compliance Determination

☐

Exceeds Standard (Substantially exceeds requirement of standards)

☒

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

☐

Does Not Meet Standard (Requires Corrective Action)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed, and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD Policy ADM.08.08
• PSD website
• 2017, 2018 and 2019 PSD PREA Annual Reports
• Interview with Agency PREA Coordinator
• Interview with facility PREA Compliance Manager
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(a) PSD Policy ADM.08.08 states on page 47, “The Department PREA Coordinator shall ensure that the
incident-based and aggregated data are securely retained.” The agency and facility utilize an electronic
database to collect and secure data, and includes all available incident-based documents, including
reports, investigation files, and sexual abuse incident reviews. Access to the database is granted for
employees with a legitimate need to know.
(b) PSD Policy ADM.08.08 states on page 47, “The Department PREA Coordinator shall 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 PSD's departmental website.” Data is
maintained in an electronic database. The annual reports for 2011-2018 are available on the agency
website at Department of Public Safety | PREA (hawaii.gov).
(c) PSD Policy ADM.08.08 states on page 47, “The Department PREA Coordinator shall remove all
personal identifiers and comply with federal and state statutes, HRS §92(F), Uniform Information
Practices Act, prior to publishing the data.” The reports on the website do not contain any personal
identifiers.
(d) PSD Policy ADM.08.08 states on page 47, “The Department PREA Coordinator shall maintain the
sexual abuse data collected based on §50.0 for at least ten (10) years after the date of the initial
collection, unless federal, state, or local law requires otherwise.”
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard.

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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)


Was the auditor permitted to conduct private interviews with inmates, residents, and detainees?
☒ Yes ☐ No

115.401 (n)


Were inmates permitted to send confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel? ☒ Yes ☐ No

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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)

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD website
• Interview with Agency PREA Coordinator
(a) PSD directly operates four jails (to include MCCC) and four prisons and houses additional inmates on
the mainland in a privately-operated facility. The agency began receiving audits in the first year of the
first cycle. All audits were completed by DOJ-certified auditors, and all final audit reports have been
posted on PSD’s website, available to the public at Department of Public Safety | PREA (hawaii.gov).
During the prior three-year audit period, Cycle Two, the agency ensured that each facility under their
control was audited at least once.
(b) This is the first year of Cycle Three.
(h, I, m, n) While onsite at MCCC, the audit team was provided with access to, and the ability to observe,
all areas of the facility. The auditor received copies of all requested documents and the team was
permitted to conduct private interviews with staff and inmates. Inmates were permitted to send
confidential correspondence to the auditor, prior to the onsite review. There were no barriers to
conducting the audit.
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard.

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

Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.

The auditor gathered, analyzed and retained the following evidence related to this standard:
• MCCC Pre-Audit Questionnaire (PAQ) responses
• PSD website
• Interview with Agency PREA Coordinator
(f) PSD directly operates four jails (to include MCCC) and four prisons and houses additional inmates on
the mainland in a privately-operated facility. The agency began receiving audit in the first year of the first
cycle. All audits were completed by DOJ-certified auditors, and all final audit reports have been posted
on PSD’s website, available to the public at Department of Public Safety | PREA (hawaii.gov).
Conclusion:
Based upon the review and analysis of all available evidence, the auditor has determined that the facility
is fully compliant with this standard.

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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 inmate or staff member, except where the names of administrative
personnel are specifically requested in the report template.

Auditor Instructions:
Type your full name in the text box below for Auditor Signature. This will function as your official
electronic signature. Auditors must deliver their final report to the PREA Resource Center as a
searchable PDF format to ensure accessibility to people with disabilities. Save this report document
into a PDF format prior to submission. 1 Auditors are not permitted to submit audit reports that have
been scanned. 2 See the PREA Auditor Handbook for a full discussion of audit report formatting
requirements.

Amanda van Arcken

October 27, 2021

Auditor Signature

Date

1

See additional instructions here: https://support.office.com/en-us/article/Save-or-convert-to-PDF-d85416c5-7d77-4fd6a216-6f4bf7c7c110 .
2 See PREA Auditor Handbook, Version 1.0, August 2017; Pages 68-69.
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