PREA AUDIT: AUDITOR’S SUMMARY REPORT 1

Name of Facility: Mathom House

Physical Address: 1740 S Easton Rd., Doylestown, PA 18901

Date report submitted April 13, 2014

Auditor information Dan McGehee

Address PO Box 595 White Rock, SC 29177

Email: mc72fsud@aol.com

Telephone number: 803-331-0264

Date of facility visit March 12-13, 2014

Facility Information

Facility Mailing Address: same as above

(if different from above)

Telephone Number: 215-345-8638 ext 412

The Facility is: Military County Federal

Private for profit Municipal State

XXXPrivate not for profit

Facility Type: Detention Correction Other:

Name of PREA Compliance Manager: Judy Holden Title:Dep. Dir. Regulatory Compliance

Email Address: judyholden@edisoncourt.com Telephone Number:215-343-7720

Agency Information Edison Court

Name of Agency:

Governing Authority or

Parent Agency: (if applicable)

Address:43 S Main St. Doylestown, PA Mailing Address: D o y l e s t o w n P A 1 8 9 0 1

Phone: 215-345-8638

Agency Chief Executive Officer

Name:Jay Deppeler Title:President/CEO

Email Address: jdeppeler@edisoncourt.com Telephone 215.345.8638 ex.401

Agency Wide PREA Coordinator

Name: Kristin DeForest, MA, LPC Title: Dir of Prg Svcs & Compliance

Email Address: kdeforest@edisoncourt.com Telephone 215.345.8638 ex.412

PREA AUDIT: AUDITOR’S SUMMARY REPORT

JUVENILE FACILITIES

mailto:mc72fsud@aol.commailto:judyholden@edisoncourt.com

PREA AUDIT: AUDITOR’S SUMMARY REPORT 2

PREA AUDIT: AUDITOR’S SUMMARY REPORT 3

AUDIT FINDINGS

NARRATIVE:

Mathom House is utilized as an intervention for youth who have been unsuccessful in less restrictive

settings and require intensive clinical, recreational, and educational services and supervision. Residents at

Mathom House are usually between the ages of 13 to 20 years of age and length of stay has historically

ranged from 12 to 24 months as treatment length is based on goal completion and progression. Utilizing

best practices in the areas of assessment, evaluation, and treatment, Mathom House aims to maximize the

internal reliability and validity of their approaches with a challenging population of adolescents who have

committed sexual offenses, including the application of a cognitive-behavioral, dialectical (DBT), and

trauma-focused cognitive-behavioral therapy curriculum, and subterranean investigative assessments to

identify hard-to-find clinical concerns within the context of a trauma-informed milieu that rewards self-

expression, conflict resolution, and personal responsibility.

Upon entering the program, residents are typically involved in an individualized introductory level

treatment curriculum comprised of individual (at least 1x weekly), group (at least 4x weekly), and family

therapies (at least 1x monthly), and reside on the secure unit. Upon progression within the therapeutic and

residential milieus as reflected by motivation and stage of change philosophies, individuals transition to a

more advanced individualized treatment curriculum exploring related cognitive distortions, precipitating

factors, cyclic patterns of offense dynamics, empathy focus, relapse prevention planning, and the

development of healthy ways to meet personal needs. Similarly, residents become eligible for transition to

the non-secure unit of the facility following the demonstrated progression of treatment internalization,

where focus expands further toward practicing life skills and increasing supervised community

engagement. Family involvement is encouraged throughout the course of treatment for the purpose of

building and strengthening a supportive network that aids in the transition of community re-integration and

ultimate discharge planning following the successful completion of the collaboratively developed and

individualized treatment plan.

PREA upgrades

After evaluating the facility against PREA standards, staff have made numerous changes to the physical

environment. Six (6) doors which were previously made of solid construction have been equipped with a

window for easier monitoring. Security mirrors have been hung in various blind spots throughout the

facility to allow for improved monitoring and observation. Window blinds were also removed from the

resident library to allow for unimpeded visual observation. Two phones (one on each residential wing) are

preprogrammed with the following phone numbers as well as noted in the resident phone book (maintained

next to each phone):

1. Network of Victim Assistance (NOVA)-our local victim advocate agency with which the facility has a Memorandum of Understanding (MOU) in place. Their crisis hotline is available

24/7 to receive calls concerning any type of abuse or victimization.

2. ChildLine-Pennsylvania’s centralized child abuse hotline, also available 24/7.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 4

DESCRIPTION OF FACILITY CHARACTERISTICS:

Located on Bucks County property in Doylestown, Pennsylvania, the Mathom House facility is a two story

red brick building with a slate roof, formerly the Bucks County Youth Center. The building houses two

residential wings, a cafeteria, gymnasium, staff offices, and many multipurpose meeting areas. Maximum

capacity of the program is 32 beds. All but one bedroom is single occupancy. The East Side is licensed

through Pennsylvania’s Department of Public Welfare (DPW) as a 16 bed secure care unit. The West Side

is licensed as a 16 bed residential unit. Mathom House is licensed as a Residential Treatment Facility

(RTF) through DPW’s Office of Mental Health and Substance Abuse Services (OMHSAS) and is

accredited by the Council on Accreditation (COA).

The East Side’s security system includes magnetic locks on each bedroom and exterior unit doors which

are tied into the fire alarm system and disengage automatically in an emergency situation. All staff are

assigned a fob to open the doors with their use being tracked electronically. Bedroom windows are

protected by a locked screen which can only be opened by staff. The West Side’s security system includes

sensors on each bedroom door which alert staff whenever a door is opened. Bedroom windows are also

equipped with sensors which alert staff whenever a window is opened beyond the permitted height. A fire

sprinkler system spans the entire facility.

SUMMARY OF AUDIT FINDINGS: The audit was conducted on Wednesday and Thursday, March 12-13, 2014. The audit began with an

entrance interview with the auditor and facility staff. Introductions were made and the auditor went over a

proposed time line for the audit schedule for two days.

Following the entrance interview, a tour of the facility was conducted for the auditor by Mathom Staff.

The facility was orderly, clean, and well maintained. The auditor observed residents interacting with other

residents, residents interacting with staff, and staff interacting with staff. It appeared that all got along well

with each other and there was very little tension observed in the facility. With the exception of one room,

all residents are in single rooms. The one room with two beds is constantly visible by staff when occupied

by residents. Showers are single-stall with privacy curtains. There is staff supervision of residents at all

times. Staff can respond immediately to any resident needs. At the conclusion of the tour, the auditor

returned to the conference room for document review.

In the course of the two day on-site review, several residents were interviewed. All residents felt safe in

the facility and confirmed that they were under constant staff supervision. They were all thoroughly

familiar with PREA and all knew how to report abuse.

Staff were also interviewed in the course of the audit. Staff were well trained in PREA and knew how to

report abuse. Staff seemed to be helpful in their role at Mathom and determined to ensure the safety of the

residents whom they supervised.

The auditor checked the phone line to report abuse and found that it was working. Additionally he spoke

with the investigator from Doylestown who would respond in the event that he was needed for sexual

abuse investigations.

At the conclusion of the two days, an exit briefing was conducted by the auditor with facility staff. Since

the auditor had continuing dialogue with the PREA coordinator during the two days, the nine non-

compliant standards were reviewed in brief detail at the exit briefing. The auditor commended the staff for

all of the work that had been accomplished prior to the on-site review. He further advised the minor

changes which needed to be made in preparing the documentation for the nine standards in non-

compliance.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 5

Number of standards exceeded:

Number of standards met: 42

Number of standards not met: 0

Standard 115.311 Zero tolerance of sexual abuse and sexual harassment.

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

This standard was found in compliance at the time of the on-site audit on March 13, 2014 Standard 115.313 Supervision and Monitoring

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.314 Youthful residents

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

PREA AUDIT: AUDITOR’S SUMMARY REPORT 6

Standard 115.315 Limits to cross gender viewing and searches

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 7

Standard 115.316 Residents with disabilities and residents who are limited English proficient

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.317 Hiring and promotion decisions

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.318 Upgrades to facilities and technology

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.321 Evidence protocol and forensic medical examinations

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

This standard was found in compliance at the time of the on-site audit on March 13, 2014

PREA AUDIT: AUDITOR’S SUMMARY REPORT 8

Standard 115. 322 Policies to ensure referrals of allegations for investigations

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.331 Employee training

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 9

Standard 115. 332 Volunteer and contractor training

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.333 Resident education

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.334 Specialized training: Investigations

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 10

Standard 115.335 Specialized training: Medical and mental health care

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.341 Screening for risk of victimization and abusiveness

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 11

Standard 115. 342 Use of screening information

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.343 Protective custody

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115. 351 Resident Reporting

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.352 Exhaustion of administrative remedies

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

PREA AUDIT: AUDITOR’S SUMMARY REPORT 12

Standard 115.353 Resident access to outside confidential support services

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.354 Third-party reporting

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.361 Staff and agency reporting duties

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.362 Agency protection duties

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

This standard was found in compliance at the time of the on-site audit on March 13, 2014

PREA AUDIT: AUDITOR’S SUMMARY REPORT 13

Standard 115.363 Reporting to other confinement facilities

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.364 Staff first responder duties

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.365 Coordinated response

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 14

Standard 115.366 Preservation of ability to protect residents from contact with abusers.

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.367 Agency protection against retaliation

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.368 Post allegation protective custody

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.371 Criminal and administrative agency investigations

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 15

Standard 115.372 Evidentiary standards for administrative investigations

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.373 Reporting to residents

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.376 Disciplinary sanctions for staff

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014 Standard 115.377 Corrective action for contractors and volunteers

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

PREA AUDIT: AUDITOR’S SUMMARY REPORT 16

Standard 115.378 Disciplinary sanctions for residents

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.381 Medical and mental health screenings: history of sexual abuse

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 17

Standard 115.382 Access to emergency medical and mental health services

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 18

Standard 115.383 Ongoing medical and mental health care for sexual abuse victims and abusers

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

Standard initially found “does not meet” during on-site audit on March 12-13, 2014. Plan of action submitted and approved on April 4, 2014. Documentation of completion of the plan of action was approved on April 13, 2014. This standard is now met.

PREA AUDIT: AUDITOR’S SUMMARY REPORT 19

Standard 115.386 Sexual abuse incident reviews

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.387 Data collection

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.388 Data review for corrective action

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action)

This standard was found in compliance at the time of the on-site audit on March 13, 2014

Standard 115.389 Data storage, publication and destruction

Exceeds Standard (substantially exceeds requirement of standard)

XXX Meets Standard (substantial compliance; complies in all material ways with the

standard for the relevant review period)

Does Not Meet Standard (requires corrective action) This standard was found in compliance at the time of the on-site audit on March 13, 2014

PREA AUDIT: AUDITOR’S SUMMARY REPORT 20

AUDITOR CERTIFICATION:

The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and

no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under

review.

April 13, 2014

Auditor Signature Date