OIG

Review of Audits of the Cdcr

Office of the Inspector General · 2000-2006-review-of-audits-of-the-cdcr · Special review · 2008-04-01 · CDCR

ACCOUNTABILITY AUDIT REVIEW OF AUDITS OF THE CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION 2000–2006 OFFICE OF THE INSPECTOR GENERAL MATTHEW L. CATE INSPECTOR GENERAL STATE OF CALIFORNIA APRIL 2008 ACCOUNTABILITY AUDIT REVIEW OF AUDITS OF THE CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION 2000–2006 OFFICE OF THE INSPECTOR GENERAL MATTHEW L. CATE INSPECTOR GENERAL STATE OF CALIFORNIA APRIL 2008 P.O. Box 348780, Sacramento, CA 95834-8780 (cid:131) (916) 830-3600 (cid:131) fax: (916) 928-5974 (cid:131) inquire@oig.ca.gov Copies of this publication may be downloaded from the Office of the Inspector General’s Web site: www.oig.ca.gov Contents Executive Summary.......................................................................................................................1 Introduction....................................................................................................................................8 Background.........................................................................................................................8 Objectives, Scope, and Methodology...............................................................................10 Chapter 1: Initial Follow-up Results for Four Reports Issued in 2005 and 2006.............................................14 Special Review into the Shooting of Inmate Daniel Provencio.........................................18 Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers...........................................................................................30 Management of Union Leave Time by the California Department of Corrections and Rehabilitation...............................................................................41 Concerns Related to Substance Abuse Treatment Contractors.......................................55 Chapter 2: Follow-up Results for 33 Reports Issued Between 2000 and 2005...............................................69 Adult Operations and Programs Salinas Valley State Prison Inmate Appeal and Inmate Disciplinary Processes..............75 California Rehabilitation Center Review of the Inmate Appeal Process...........................77 California State Prison, Sacramento Management Review Audit....................................78 Valley State Prison for Women Management Review Audit.............................................83 Inmate Appeals Branch.....................................................................................................87 Sierra Conservation Center Management Review Audit..................................................88 Leo Chesney Community Correctional Facility Management Review Audit.....................91 Office of Internal Affairs....................................................................................................94 High Desert State Prison Management Review Audit....................................................103 Local Assistance Program..............................................................................................108 Correctional Facility Mail Processing..............................................................................109 Office of Audits and Compliance.....................................................................................113 Medical Contracting Process..........................................................................................116 California Substance Abuse Treatment Facility and State Prison, Corcoran Management Review Audit.......................................................................................118 California State Prison, Solano Management Review Audit...........................................131 Pharmaceutical Expenditures.........................................................................................134 Education Programs at Level IV Institutions...................................................................136 Commission on Correctional Peace Officer Standards and Training.............................138 Special Review into the Death of Correctional Officer Manuel A. Gonzalez Jr..............141 Division of Juvenile Justice Heman G. Stark Youth Correctional Facility Management Review Audit.......................148 23-and-1 Program Review..............................................................................................156 Ventura Youth Correctional Facility Management Review Audit....................................160 Intensive Treatment Program.........................................................................................165 Juvenile Parole Board.....................................................................................................169 Southern Youth Correctional Reception Center and Clinic Management Review Audit.......................................................................................171 Office of Audits and Compliance.....................................................................................175 N.A. Chaderjian Youth Correctional Facility Management Review Audit.......................177 Special Review into the Death of a Ward at N.A. Chaderjian Youth Correctional Facility........................................................................................192 Board of Parole Hearings Indeterminate Sentence Hearings and Appeals.............................................................201 Review of Board of Parole Hearings Decisions..............................................................207 Hearings for Mentally Disordered Offenders..................................................................208 Supervision of Deputy Commissioners...........................................................................209 Interpretation Services Procedures.................................................................................213 Response from the California Department of Corrections and Rehabilitation.......................................................................Attachment 1 The Office of the Inspector General’s Comments on the Department’s Response..........................................................................Attachment 2 2008 Accountability Audit Executive Summary Executive Summary This comprehensive accountability audit presents the results of the Office of the Inspector General’s annual follow-up review of previous recommendations issued to the California Department of Corrections and Rehabilitation (CDCR). In this accountability audit, the Office of the Inspector General (OIG) assesses the department’s progress in implementing past recommendations from 37 audits and special reviews affecting the CDCR’s Adult Operations and Programs, Division of Juvenile Justice, and Board of Parole Hearings. Overall, we found that the CDCR has improved its record for implementing our recommendations, but our audit also revealed that some critical recommendations remain unaddressed. This year’s accountability audit is divided into two chapters that analyze the department’s efforts to take corrective action on 212 unresolved recommendations. Chapter 1 presents the results from our first follow-up audit of 41 recommendations made in four special reviews completed in 2005 and 2006. Chapter 2 presents the results from our follow-up review of 171 recommendations made in 33 audits and special reviews issued from 2000 through 2005. The difference between the audits and reviews in Chapter 1 compared to Chapter 2 is that the recommendations reviewed in Chapter 2 already have been subject to at least one follow-up accountability audit. In addition, some recommendations in Chapter 2 have been subject to several accountability audits. Therefore, for many of these recommendations, this will be our last review. The Reason for Performing Accountability Audits Our mission is to safeguard the integrity of California’s correctional system, and one way we carry out this mission is to audit the CDCR to uncover criminal conduct, administrative wrongdoing, poor management practices, waste, fraud, and other abuses by staff, supervisors, and management. To bring public transparency to the state’s correctional system, in 2004 we began publishing our audit reports on our Web site. This public posting is critical because prisons are, by their very nature, places where most events occur outside the public view. The public airing of our audit reports provides a powerful incentive to the department to remedy problems afflicting its divisions and institutions. We discovered, however, that while our audits publicly identified hundreds of problems, the department was still not taking timely or effective action to address many of the issues. Therefore, in 2005 we began conducting the comprehensive “accountability audit.” The accountability audit provides periodic follow-up results on previous audits and special reviews and assesses whether the department has implemented each of our recommendations. This unified audit allows us to efficiently track the department’s progress and keep important issues in the public eye. Office of the Inspector General Page 1 2008 Accountability Audit Executive Summary Accountability Has Made a Difference Our public accountability audits have spurred the department to take corrective action and improve operations in areas ranging from safety and security to fiscal management and mandated services. For example, in 2005, the Board of Parole Hearings started with a dismal 41 percent success rate; the board now has a 68 percent success rate. Similarly, the Division of Juvenile Justice started with a 62 percent success rate in 2005. The division now boasts an 86 percent success rate—an increase of 24 percentage points. Thus, through our continued follow-up and the department’s diligence in addressing recommendations, the department has progressed steadily since we performed our first accountability audit three years ago—but many issues remain unresolved. We will continue to do our part by following up on specific problems and recommending workable solutions, but it is up to the CDCR to implement positive change and become the model correctional agency that California deserves. Table 1 presents a comparison of the department’s initial and current success rates in addressing our recommendations. (We consider full or substantial implementation as “successfully implemented.”) Table 1 Comparison of Initial Implementation Rates to 2008 Rates Percentage of Recommendations Successfully Implemented Initial Success 2008 Accountability Change in Report Rate Audit Success Rate Success Rate Division of Juvenile Justice 2005 Accountability Audit 62% 86% 24 Points Board of Parole Hearings 2005 Accountability Audit 41% 68% 27 Points Adult Operations and Programs 2006 Accountability Audit 75% 88% 13 Points Departmental Total 69% 86% 17 Points First-time Follow-up Audits Our assessment of the four audits undergoing a first-time follow-up review, presented in Chapter 1 of this report, revealed the following: • Overall, we found that the department has fully or substantially implemented 24 of the total 41 recommendations from these four more-recent reports; four recommendations are not applicable. Thus, the department successfully addressed 65 percent of the original recommendations still applicable. • Our review of the June 2005 report on the shooting of inmate Daniel Provencio found that the department has improved weapons training for the firing of the 40 mm direct-impact projectile. Nevertheless, officers still do not practice shooting at moving targets, and at four of the five institutions we visited, officers are not required to practice shooting from an elevated position. These two factors may have contributed to the inaccurate placement of the 40 mm projectile that led to inmate Provencio’s death. Further, our current review found that the department does not ensure that officers placed in an armed post fulfill the Office of the Inspector General Page 2 2008 Accountability Audit Executive Summary department’s quarterly weapons qualification. We found that only 57 percent of the report’s seven recommendations were fully or substantially implemented. • In our review of the March 2006 report on improper housing of maximum custody inmates, we found that prison reception centers have improved their process for identifying potentially dangerous maximum custody inmates to separate them from the general population. The department’s progress shows a major improvement over the unsafe conditions cited in our March 2005 report on the fatal stabbing of Correctional Officer Manuel A. Gonzalez Jr. We found that 75 percent of the 13 recommendations were fully or substantially implemented. • We noted some improvements in the department’s management over union leave time, which was the focus of our July 2006 report. However, the department failed to carry out our most crucial recommendation—the development of a reconciliation process to properly record and account for union leave time. Without this reconciliation process, the department could be wasting state funds. Our current review found that 56 percent of the report’s nine recommendations were fully or substantially implemented. • We found that the department implemented a number of recommendations from our October 2006 report on substance abuse treatment contractors. But, as with the report on union leave time, the department failed to carry out our most crucial recommendation—collecting overpayments of nearly $5.6 million. Our review determined that 67 percent of the report’s 12 recommendations were fully or substantially implemented. In our review of these four audits, we made 14 follow-up recommendations to the CDCR. We expect to review these follow-up recommendations in our 2009 accountability audit. Previous Follow-up Audits Chapter 2 of this report presents the status of recommendations for 33 reports included in past accountability audits. Besides the praiseworthy overall implementation rate of 86 percent, during this year’s accountability audit we noted that, since the 2007 accountability audit, the department’s success rate in carrying out our recommendations has steadily improved. Of the 171 recommendations remaining from previous years, we found that the department fully or substantially implemented 69 recommendations; two are no longer applicable. Notable examples of recommendations implemented since our last accountability audit include the following: • Our recent review of the California Institution for Men’s tool control policies and oversight activities found that the institution successfully implemented our recommendation that all tools within the secured perimeter be under the supervision of the tool control team. Office of the Inspector General Page 3 2008 Accountability Audit Executive Summary • The California Institution for Men and Wasco State Prison have procedures to minimize the access to evidence collected during an incident. Valley State Prison for Women reported that it also limits staff members’ access to its evidence room, which now provides for better control over the storage of confiscated drugs. • The California Substance Abuse Treatment Facility and State Prison, Corcoran, purchased a time clock for contracted physicians to clock in and out when reporting for or departing work. Moreover, the medical administrative staff conducts reconciliations of the physician time cards and the monthly registry billings. These measures greatly improve staff accountability and protect state resources. However, despite the department’s progress in implementing numerous recommendations from the 33 reports, we are troubled by the nature and scope of the 100 recommendations that the department has still only partially implemented or not implemented. Several of these unimplemented recommendations represent ongoing problems that place staff members and inmates in danger or potentially waste millions of dollars in state funds. Among the unimplemented recommendations are the following: • The CDCR’s Adult Operations and Programs still have 47 recommendations to implement in various areas, including inmate safety, dental care, and pharmacy operations. o At California State Prison, Solano, inmates suffering from seizure-related conditions continue to be housed in upper bunks, putting them at risk for injury and subjecting the state to possible litigation. o Inmates at California State Prison, Sacramento, are still not receiving dental exams within 90 days of their arrival, as required by a federal court order. And California Substance Abuse Treatment Facility and State Prison, Corcoran, still has a backlog of inmates awaiting dental services. o The department’s pharmacy tracking and inventory system is still deficient and is likely wasting state funds. The department, however, reported that the court-appointed receiver is implementing a computerized distribution system to replace the outdated, inefficient system. o High Desert State Prison’s main yards still lack video cameras because of funding issues. These cameras are a necessity during incidents because video can help identify involved inmates or be used as evidence in disciplinary actions. • The Division of Juvenile Justice has 45 unaddressed recommendations, including 23 recommendations that resulted from two audits of the N.A. Chaderjian Youth Correctional Facility. One critical recommendation that the division indicated it had only partially implemented is ending the practice of isolating youths in their Office of the Inspector General Page 4 2008 Accountability Audit Executive Summary rooms for long periods. Other unimplemented recommendations include providing mental health services during lockdowns, offering training to counseling and treatment staff, and correcting building deficiencies. • The Board of Parole Hearings has eight recommendations that remain unaddressed. Moreover, the board has only partially implemented several of our recommendations made in 2005 to safeguard the funds it spends on interpretation services and to collect past overpayments made to interpreters. It should be noted that some of the 100 recommendations might remain unimplemented for reasons beyond the department’s control. For example, the department may have been denied funding, a federal court may have intervened and taken over this responsibility, or the department may have disagreed with our initial recommendation. The following table summarizes the implementation status of the 212 outstanding recommendations we made to the department in reports issued between 2000 and 2006, which were included in the scope of our audit. The matrixes in the body of this report detail the department’s response and our assessment of each recommendation’s progress. Office of the Inspector General Page 5 2008 Accountability Audit Executive Summary Table 2 Results of the 2008 Follow-up Audit Recommendations Assessed in 2008 Follow-up Audit Implementation Results Chapter 1 Total Office of the Inspector General Page 6 ylluF detnemelpmI yllaitnatsbuS detnemelpmI yllaitraP detnemelpmI toN detnemelpmI elbacilppA toN Review into the Shooting of Inmate Daniel Provencio (2005) 7 4 2 1 Improper Housing of Maximum Custody Inmates (2006) 13 8 1 2 1 1 Management of Union Leave Time (2006) 9 4 1 2 2 Substance Abuse Treatment Contractors (2006) 12 6 3 3 41 22 2 9 4 4 53% 5% 22% 10% 10% Chapter 2 Adult Operations & Programs SVSP Inmate Appeal & Disciplinary Process (2000) 3 3 CRC Inmate Appeals (2000) 1 1 CSP Sacramento MRA (2000) 4 2 1 1 Valley State Prison for Women MRA (2001) 4 3 1 Inmate Appeals Branch (2001) 1 1 Sierra Conservation Center MRA (2001) 5 4 1 Leo Chesney CCF MRA (2001) 3 2 1 Office of Internal Affairs* (2001) 11 4 2 1 2 2 High Desert State Prison MRA (2001) 6 1 1 4 Local Assistance Program (2002) 1 1 Correctional Facility Mail Processing (2002) 8 6 1 1 Office of Audits and Compliance** (2002) 2 1 1 Medical Contracting Process (2002) 1 1 SATF MRA (2003) 23 6 4 9 4 CSP Solano MRA (2003) 3 1 2 Pharmaceutical Expenditures (2003) 2 1 1 Education Programs at Level IV Institutions (2003) 2 1 1 Commission on CPOST (2005) 6 1 3 2 Review into the Death of Officer Gonzalez (2005) 11 7 3 1 Total Adult Operations & Programs 97 39 9 31 16 2 40% 9% 32% 17% 2% Division of Juvenile Justice Heman G. Stark YCF MRA (2000) 7 2 1 4 23-and-1 Program Review (2000) 4 4 Ventura YCF MRA (2002) 6 2 1 2 1 Intensive Treatment Program (2002) 4 1 3 Juvenile Parole Board (2002) 1 1 Southern Youth CRCC MRA (2003) 5 5 Office of Audits and Compliance*** (2003) 3 1 1 1 N.A. Chaderjian YCF MRA (2005) 19 1 1 11 6 Death of a Ward at N.A. Chaderjian YCF (2005) 8 1 1 5 1 Total Division of Juvenile Justice 57 7 5 36 9 0 12% 9% 63% 16% 0% Board of Parole Hearings Indeterminate Sentence Hearings & Appeals (2000) 5 1 3 1 Review of BPH Decisions (2003) 1 1 Hearings for Mentally Disordered Offenders (2003) 1 1 Supervision of Deputy Commissioners (2003) 2 2 Interpretation Services Procedures (2005) 8 2 6 Total Board of Parole Hearings 17 5 4 8 0 0 29% 24% 47% 0% 0% Grand Totals 212 73 20 84 29 6 * Formerly Office of Investigative Services 34% 9% 40% 14% 3% ** Formerly CDC Internal Audits *** Formerly CYA Internal Audits 2008 Accountability Audit Executive Summary We Will No Longer Follow Up On Certain Recommendations Although we strongly believe in the benefits of accountability, follow-up audits come at a cost. The department has had up to seven years to carry out many of the outstanding recommendations detailed in Chapter 2 of this report. Further, we have reminded the department to address these recommendations through previous accountability audits, and over the years, the department has had opportunities to correct these deficiencies. We do not believe it is in the state’s interest to continue expending our limited resources to pursue lingering recommendations that the department has demonstrated it cannot or will not address. At this point, therefore, this assessment will be our last for most of the unimplemented recommendations. We hope policy makers and the public take note of the CDCR’s inability to successfully implement these 100 recommendations (out of 734 recommendations) left over from 33 past audits. Nevertheless, we must pursue a few critical recommendations among these 100 recommendations because—in keeping with our mission to safeguard California’s correctional system—some issues are too serious to ignore. Therefore, we will continue to track and report on the following specific issues until they are resolved. • California State Prison, Solano, must ensure that inmates who suffer from seizure- related conditions are housed in lower bunks to protect them from fall-related injuries in the event of a seizure. • The department needs to establish efficient pharmacy tracking and inventory procedures to minimize the waste of state funds. • The Division of Juvenile Justice needs to ensure that youthful offenders receive mandated services, especially when they are isolated in their rooms for long periods. This is important because extended confinement combined with lack of exercise or recreation may aggravate mental health problems and increase the risk of suicide. Office of the Inspector General Page 7 2008 Accountability Audit Introduction Introduction This report presents the results of the OIG’s follow-up audit of 37 previous audits and reviews of the CDCR and its subdivisions conducted between 2000 and 2006. The purpose of the follow-up audit was to assess and report on the CDCR’s progress in implementing our previous recommendations. We performed the accountability audit under California Penal Code section 6126, which assigns the OIG responsibility for oversight of the CDCR. This year’s accountability audit is divided into two chapters. Chapter 1 presents the results from our first follow-up audit of recommendations made in four special reviews completed in 2005 and 2006. Chapter 2 presents the results from our subsequent follow- up review of recommendations made in 33 audits and special reviews issued from 2000 through 2005. Background Effective July 1, 2005, the Youth and Adult Correctional Agency was dissolved and its former entities were reorganized as the California Department of Corrections and Rehabilitation (CDCR). The department now includes the following major entities: • The Division of Adult Operations and the Division of Adult Programs (formerly the California Department of Corrections) • The Division of Juvenile Justice (formerly the California Youth Authority) • The Corrections Standards Authority (formerly the Board of Corrections and the Commission on Correctional Peace Officer Standards and Training) • The Board of Parole Hearings (formerly the Board of Prison Terms and the Narcotic Addict Evaluation Authority) • The Juvenile Parole Board (formerly the Youthful Offender Parole Board) The Governor’s Budget for fiscal year 2008–09 estimated the CDCR’s budget for fiscal year 2007–08 to be $10.1 billion. THE DIVISIONS OF ADULT OPERATIONS AND ADULT PROGRAMS Adult Operations and Adult Programs comprise three main programs: Adult Operations; Adult Education, Vocation, and Offender Programs; and Adult Parole Operations. The Adult Operations program consists of 33 institutions, which includes 12 reception centers. The Adult Operations program also consists of 13 community correctional facilities, five out-of-state correctional facilities, and 47 conservation camps. The Office of the Inspector General Page 8 2008 Accountability Audit Introduction program’s objective is to provide safe and secure detention facilities to protect society from further criminal activities and to provide necessary services, such as feeding, clothing, record keeping, inmate classification assessments, and employee training. The objective of Adult Education, Vocation, and Offender Programs is to contribute to public safety by designing and operating programs that enable offenders to successfully reenter society. The education and vocational programs provide inmates with an opportunity for self-improvement through life skills and career training. The substance abuse programs plan, develop, implement, and monitor addiction and recovery services within the department to reduce recidivism and relapse and promote pro-social behavior for the successful reintegration of offenders. Adult Parole Operations’ primary objective, consistent with the need for public safety, is to increase the rate and degree of successful release and reintegration into society for offenders paroled from state prison. The program is responsible for providing direct supervision, surveillance, and necessary capture of the state’s parolee population. It also works, in conjunction with Adult Education, Vocation, and Offender Programs, to provide offenders with direct support services, such as job placement, education, housing, and substance abuse treatment. According to the Governor’s Budget for fiscal year 2008–09, the CDCR’s Adult Operations and Adult Education, Vocation, and Offender Programs have an estimated operating budget for fiscal year 2007–08 of $5.8 billion, with 44,407 positions, an average daily population of 163,269 inmates, and a per capita cost of $44,339 a year. The Adult Parole Operations program has an estimated operating budget of $863 million, with 4,282 positions, an average daily population of 136,870 parolees, and a per capita cost of $4,554 a year. THE DIVISION OF JUVENILE JUSTICE The Division of Juvenile Justice operates youth correctional facilities and conservation camps throughout the state. Ninety-five percent of youthful offenders in Division of Juvenile Justice custody are male. According to the Governor’s Budget, the division has an estimated operating budget for fiscal year 2007–08 of $580 million with 4,638 positions, and it provides housing and services to an average daily population of 2,294 youths in juvenile facilities and 2,415 youths on parole. The Governor’s Budget also reports that the per capita cost to house and treat a youth in a juvenile facility is $224,842 a year. The Division of Juvenile Justice defines its mission as follows: To protect the public from criminal activity by providing education, training, and treatment services for youthful offenders committed by the courts; assisting local justice agencies with their efforts to control crime and delinquency, and encouraging the development of state and local programs to prevent crime and delinquency. Office of the Inspector General Page 9 2008 Accountability Audit Introduction The division provides youths committed to its custody—who are called wards—with education services, medical care, counseling, and mental health treatment and is mandated to provide wards with constitutionally adequate conditions of confinement. California Welfare and Institutions Code section 1120 requires the division to operate a statewide education program of academic and vocational classes to enable wards to attain a high school diploma or equivalent (GED). Over the past 12 years, the number of youthful offenders committed to the Division of Juvenile Justice has declined from 10,122 in June 1996 to 2,212 on January 31, 2008. The Governor’s Budget for 2008–09 estimates that the ward population will decline to 1,786 wards by the end of the fiscal year. THE BOARD OF PAROLE HEARINGS The Board of Parole Hearings conducts hearings to grant, deny, revoke, or suspend the parole of adult inmates, and it makes decisions on parole consideration hearings for adult inmates sentenced under indeterminate sentencing laws. Indeterminate sentencing applies to a prison term that, instead of being fixed in advance by the court, is set by the court for an “indeterminate period” such as 25 years to life. Offenders are eligible for parole consideration after they serve the minimum prison term specified by state law for the particular crime committed. In addition, the board advises the Governor on applications for clemency and helps screen inmates scheduled for parole to determine whether they should be classified as mentally disordered offenders to be confined to state hospitals for treatment, or classified as sexually violent predators subject to civil confinement.1 To perform these duties, according to the Governor’s Budget, the board has an estimated operating budget for fiscal year 2007–08 of $111 million with 537 positions. Objectives, Scope, and Methodology In 2005, we began conducting the comprehensive “accountability audit,” which publicly identifies the recommendations from past reports that the department has not taken timely or effective action to address. The accountability audit provides periodic follow-up results on previous audits and special reviews and assesses whether the department has implemented each of our recommendations. This unified audit allows us to efficiently track the department’s progress and keep important issues in the public eye. Historically, recommendations identified as “partially implemented” or “not implemented” are carried forward to the next accountability audit. Through this process of follow-up audits, we ensure meaningful reform in the state correctional system. However, we are limited in our ability to continually allocate resources to report on recommendations that, even after many years, the department has made little or no progress to implement. Therefore, with the exception of a few critical issues discussed in 1 A civil confinement commits the inmate to a psychiatric facility for counseling and treatment after the inmate has served his or her criminal sentence. Office of the Inspector General Page 10 2008 Accountability Audit Introduction Chapter 2, we are making this the last accountability audit for those recommendations made in past reports that have previously undergone follow-up work. In Chapter 2 of this report, recommendations related to 33 of the 37 total audits have been included in previous accountability audits. For the Board of Parole Hearings’ Indeterminate Sentence Hearings and Appeals audit, this represents the fourth accountability audit. The 33 audit reports were originally published between 2000 and 2005. Chapter 1 of this 2008 accountability audit presents the first follow-up review for the following four reports issued by the OIG. Their issue dates are in parentheses. • Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005, at Wasco State Prison (June 2005) • Special Review into Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers (March 2006) • Special Review into Management of Union Leave Time by the California Department of Corrections and Rehabilitation (July 2006) • Special Review into Concerns Related to Substance Abuse Treatment Contractors (October 2006) Because this is the first accountability audit for the recommendations from these four reports, the recommendations that have not yet reached the level of “substantially implemented” or “fully implemented” will be considered follow-up recommendations and subject to future accountability audits. AUDIT PROCEDURES To conduct this follow-up audit, we performed the following procedures: • Reviewed 37 audits and reviews of the CDCR’s facilities and programs conducted by the OIG between 2000 and 2006. • Reviewed statutes, regulations, lawsuits, and other documents pertinent to the CDCR’s current operating environment. • Contacted the CDCR and requested an implementation status and supporting documentation on its progress in implementing each of our 212 recommendations from the previous 37 audits. The department’s unedited responses are included in each matrix section of this report. • Based on our risk assessment of the recommendations and the CDCR’s responses, we conducted interviews, made observations, reviewed records, and performed Office of the Inspector General Page 11 2008 Accountability Audit Introduction tests, or we relied on the department’s statements. The extent of audit procedures performed for each recommendation is described in our comments in each matrix section of this report. • Evaluated the information developed from the audit procedures and classified the department’s progress in implementing each recommendation into one of the following five categories: o Fully implemented: The recommendation has been implemented and no further corrective action is necessary. o Substantially implemented: More than half the corrective actions necessary to fulfill the recommendation have been implemented. o Partially implemented: Half or less than half of the corrective actions necessary to fulfill the recommendation have been implemented. o Not implemented: The recommendation has not been implemented. o Not applicable: The recommendation is no longer applicable. In some instances, the department has successfully addressed the problems targeted by the recommendations by implementing alternative solutions; wherever this has occurred, we acknowledge those achievements in the report. The original 37 reports covered in this follow-up accountability audit had issue dates ranging from March 2000 through October 2006. Therefore, in most cases, the CDCR had a significant amount of time to implement the recommendations before we conducted the follow-up audit. Because the scope of the audits and reviews included in this follow-up was extensive, we granted the department three months to prepare its implementation statuses. The department largely met the goal and submitted its implementation statuses to us on December 14, 2007. Several responses due from the medical receiver’s office (not a CDCR entity) were not received until January 30, 2008. In total, the department and the receiver’s office responded on the status of 212 outstanding recommendations. We tested only a sample of the department’s responses because of the large number of recommendations. The sample was selected based on our judgment after considering primary risk factors, such as safety, security, and fiscal materiality. Other risk factors considered included legal issues, government affairs, and public interest. The selection methods allowed for the efficient review of the more serious recommendations while limiting testing to about 19 percent of the 212 total recommendations (a target sample of 40 recommendations). Office of the Inspector General Page 12 2008 Accountability Audit Introduction We also performed a cursory review of the responses in which we did no audit testing. This review consisted of assessing the response, including supporting documents if provided, for reasonableness and applicability to the recommendations. As a result, several responses that did not meet our risk threshold for sample testing were returned for clarification. This occurred when we observed status levels that did not seemingly agree with the implementation level that the department presented in the narrative. In other cases, the department’s narrative did not adequately address the recommendation. Because of this dialog, the department changed some of its initially reported implementation levels and response narratives. This process allowed for a more accurate representation of a recommendation status without significantly adding to the audit resources required for this report. Audit fieldwork was performed from January 2008 through February 2008. Therefore, for items included in our sample, it is possible that the department took action to address some of the recommendations after we completed the follow-up fieldwork. Similarly, for items not included in our sample, it is possible that the department took corrective action after December 14, 2007. In such cases, the corrective action would not be reflected in this report. Office of the Inspector General Page 13 2008 Accountability Audit Chapter 1 Chapter 1: Initial Follow-Up Results for Four Reports Issued in 2005 and 2006 This chapter presents the status of our initial recommendations for the following four reports: • Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005, at Wasco State Prison (June 2005) • Special Review into Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers (March 2006) • Special Review into Management of Union Leave Time by the California Department of Corrections and Rehabilitation (July 2006) • Special Review into Concerns Related to Substance Abuse Treatment Contractors (October 2006) Summary of Results Within these four reports, we provided the CDCR with 41 recommendations. Key recommendations included improving weapons training for armed custody officers, enhancing the capability for identifying and isolating dangerous inmates, improving management over union leave time, and recovering overpayments to contractors that coordinate substance abuse services. Overall, we found that the department has fully or substantially implemented 24 of the 41 recommendations, with four recommendations not applicable. The remaining recommendations were either partially implemented or not implemented. In this report, we made 14 follow-up recommendations that we anticipate reviewing in our 2009 accountability audit. Table 3 summarizes the results of our audit of the 41 recommendations; a brief description of each report’s findings follows the table. Table 3 Summary of Initial Follow-up Results Fully Substantially Partially Not Success Report N/A Total Implemented Implemented Implemented Implemented Rate* Shooting of Inmate Provencio 4 2 1 7 57% Improper Housing of Maximum 8 1 2 1 1 13 75% Custody Inmates Management of Union Leave Time 4 1 2 2 9 56% Concerns Related to Substance 6 3 3 12 67% Abuse Treatment Contractors Total 22 2 9 4 4 41 65% *Success rate is the percentage of recommendations fully or substantially implemented compared to the total recommendations still applicable. Office of the Inspector General Page 14 2008 Accountability Audit Chapter 1 SHOOTING OF INMATE PROVENCIO We found that the department has improved its weapons training to include the firing of the 40 mm direct-impact projectile. However, the department reports that at no time does it practice shooting at moving targets, and at four of the five institutions we visited, officers do not practice shooting from an elevated position during quarterly weapons qualification. In our June 2005 report, we found that both of these factors may have contributed to the inaccurate placement of the 40 mm projectile that led to inmate Provencio’s death. Moreover, in this current follow-up audit, we found that the department does not ensure that each officer placed in an armed post fulfills the department’s quarterly weapons qualification, potentially endangering the lives of staff members and inmates. IMPROPER HOUSING OF MAXIMUM CUSTODY INMATES The department has made notable progress in properly housing maximum custody inmates in its reception centers. We found that prison reception centers have improved their process for identifying potentially dangerous maximum custody inmates and segregating them from general population inmates. This progress shows a significant improvement over the conditions we found during our March 2005 review of the circumstances surrounding the fatal stabbing of Correctional Officer Manuel A. Gonzalez Jr. In that review, we learned that the accused assailant was a maximum custody inmate who, despite a long history of in-prison violence, had been placed in a general population cell instead of segregated housing. Because of that review, the CDCR implemented new procedures to identify and house violent inmates to prevent this situation from happening in the future. However, our March 2006 review of maximum custody inmates housed in reception centers found that despite new procedures, large numbers of potentially dangerous maximum custody inmates were still slipping through the screening process and ending up in the general population. Therefore, the department’s reception centers were not taking all the steps necessary to identify and isolate dangerous inmates. MANAGEMENT OF UNION LEAVE TIME The department reported it has made numerous improvements in its recordkeeping over union leave time, but the department also conceded it has only partially developed a reconciliation process. As reported in our July 2006 review into the department’s management of union leave time, the department failed to provide adequate oversight of union leave time and potentially wasted millions of dollars in public resources. To provide adequate oversight, we recommended that the department perform regular reconciliations of union leave time. Until this recommendation is implemented, the department cannot assure itself that union leave time is recorded and accounted for properly, and therefore, it cannot adequately protect public resources. Office of the Inspector General Page 15 2008 Accountability Audit Chapter 1 CONCERNS RELATED TO SUBSTANCE ABUSE TREATMENT CONTRACTORS The department has implemented several recommendations from our 2006 review, but the most important recommendation remains unresolved—collecting overpayments of almost $5.6 million to contractors that coordinate substance abuse services. The department has not yet collected the overpayments because it took almost 14 months to determine the amounts the contractors owed the state. The contractors have disputed the amounts, and the department’s Administrative Review Committee is considering the matter. Follow-up Recommendations In our review of the four audits, we made 14 follow-up recommendations to the CDCR. We expect to review these follow-up recommendations in our 2009 accountability audit. • Develop a more comprehensive training component covering the use of direct- impact weapons from an elevated post. • Develop a comprehensive training component that includes training on how to effectively and safely employ the 40 mm launcher against a moving target. • Ensure that every officer assigned to an armed post as part of his or her regular or special assignment (which includes relief, voluntary overtime and trades/swaps, permanent intermittent, etc.) completes a weapons proficiency course on a quarterly basis. • Ensure that California Code of Regulations, Title 15, section 3341.5(b) and California Department of Corrections and Rehabilitation Operations Manual section 62050.12 are amended to replace references to the psychiatric management unit with references to the psychiatric services unit. • Modify the coding in the Offender Based Information System or adopt some other methodology to clearly identify segregated housing. For example, replace “Palm Hall” with “ASU.” • Designate and train appropriate staff members to immediately notify facility staff when they identify inmates during subsequent processing who should be placed in administrative segregation. • Continue its efforts to fully implement a system to internally reconcile union leave time on a monthly basis. • In conjunction with the California Correctional Peace Officers Association, develop uniform policies and procedures that facilitate reconciling the release time bank balance each quarter with the union’s records. Office of the Inspector General Page 16 2008 Accountability Audit Chapter 1 • Conduct periodic audits to ensure that time is recorded accurately and union leave time is reconciled monthly. • Once a new contract is negotiated for Bargaining Unit 6, reconsider the need for requesting legislative funding for union issues addressed in labor contracts, such as compensation for Bargaining Unit 6 executive vice presidents and chapter presidents. • Collect all refunds owed to the state by the three substance abuse services coordination agencies related to excess revenue the agencies received for services provided during their contract period December 1, 1998, to December 31, 2003. • Require Mental Health Systems, Inc. to restate its expenses to record the costs of its purchases of automobiles in accordance with generally accepted accounting principles. • Ensure that Mental Health Systems, Inc. uses its adjusted actual costs of providing services during these periods when reconciling its revenues to actual costs. • Fully cooperate with the Office of the Attorney General regarding the recovery of equipment the department improperly gifted to contractors. The following four sections present a complete discussion of each report, including the findings, recommendations, and results of our follow-up audit. Office of the Inspector General Page 17 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005, at Wasco State Prison The OIG found that the department has improved its weapons Implementation training to include the firing of the 40 mm direct-impact Report Card projectile, but the department does not ensure that all peace officers in armed posts satisfactorily complete the quarterly 2005 Recommendations: 7 weapons qualification. Moreover, the department does not include in its quarterly weapons qualification the firing from an Fully Implemented: elevated position at four of the five institutions we visited, and at 4 (57%) no time does it include shooting at moving targets. Both of these Partially Implemented: elements may have accounted for the inaccurate placement of 2 (29%) the 40 mm projectile that led to inmate Provencio’s death. On a positive note, the department reported that it has developed or Not Implemented: 1 (14%) revised procedures for housing unit security checks and cell searches, evidence handling, and emergency response. Summary In June 2005, we issued a special review2 into the January 16, 2005, shooting of Daniel Provencio, an inmate at Wasco State Prison. The purpose of our special review was to ensure the timeliness, thoroughness, and objectivity of the investigations and to identify any systemic policy or training deficiencies, procedural violations, or other factors that may have contributed to the incident or had an impact on the effectiveness of the investigations that followed. The review also considered whether the incident revealed the need for statutory or regulatory changes, as well as changes to staff training requirements. The review found that the investigations of the incident were thorough, objective, and timely. Furthermore, the investigative entities’ conclusions—namely, that the actions of the officer did not involve criminal misconduct, that he acted reasonably, and that he had complied with department policy in firing the 40 mm direct-impact projectile at Provencio—were supported by the weight of the evidence. However, the special review identified other issues of concern. These issues included deficiencies in the following areas: staff training in the use of direct-impact weapons; housing unit security checks and cell searches; emergency response procedures; evidence handling; and identification of responsibility for conducting administrative investigations. Background On January 16, 2005, at Wasco State Prison, a fight broke out between two inmates who were finishing their evening meal. As officers attempted to control the situation, inmate Daniel 2 “Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005, at Wasco State Prison” may be found on the OIG’s Web site: http://www.oig.ca.gov/reports/pdf/spc_review/01-16-05_Provencio.pdf. Office of the Inspector General Page 18 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Provencio inserted himself into the incident and was struck once in the head by a 40 mm direct- impact “sponge,” or rubber-like projectile. The resulting head wound to Provencio caused him to lapse into a coma approximately 45 minutes later and caused his eventual death on March 4, 2005. The CDCR’s Office of Internal Affairs conducted a criminal investigation into the incident and found no criminal misconduct by Wasco employees. The department’s Law Enforcement and Investigations Unit also conducted a use-of-force investigation into the incident and later determined that the actions of the correctional officer who fired the direct-impact round at Provencio complied with department policy. The findings of the Law Enforcement and Investigations Unit were also presented to an independent Deadly Force Review Board comprising executive-level law enforcement officers from outside the department. The members of the Deadly Force Review Board determined that the officer’s shooting of Provencio was reasonable under the circumstances and complied with the department’s policy governing the use of less-than-lethal direct-impact weapons. Previous Findings and Recommendations Immediately following the incident, the OIG became involved to ensure the timeliness, thoroughness, and objectivity of the investigations by the various entities and to identify any systemic policy or training deficiencies, procedural violations, or other factors that may have contributed to Provencio’s death. In our review, we examined the Wasco incident reports and related documents; the criminal investigative report by the Office of Internal Affairs; the use-of- force investigative report by the Law Enforcement and Investigations Unit; the Deadly Force Review Board findings; and the Wasco Use-of-Force Committee findings. We also examined the department’s relevant policies and procedures concerning safety and security, weapons deployment, emergency incident response, medical response, and crime scene management. As a result of the June 2005 special review, we found that the investigations into the death of inmate Provencio were thorough and objective and were completed in a reasonably timely manner. We also found that the investigative entities’ conclusions—specifically, that the control booth officer’s discharge of the 40 mm launcher complied with department policy—were supported by the weight of the evidence. However, the review did identify other issues of concern. These issues included deficiencies in the following areas: • Peace officers were inadequately trained on the 40 mm projectile weapon, and Wasco lacked a consistent policy for qualification with the 40 mm launcher. • Wasco staff members failed to conduct timely cell searches of the housing unit after the incident and failed to properly maintain the housing unit’s logbooks. In addition, Wasco staff members may not have regularly performed thorough security checks of the housing units during shift changes. • Wasco had insufficient emergency notification procedures for use-of-force incidents. Office of the Inspector General Page 19 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio • Some of the evidence in the case was handled improperly, but this deficiency did not affect the investigation. • None of the CDCR entities investigating the incident was required to conduct an administrative investigation beyond the use-of-force review to determine whether corrective or disciplinary action of all staff members involved was appropriate. To address the issues identified during the June 2005 special review, we made four recommendations to the CDCR and three recommendations to Wasco State Prison. The recommendations to the department focused on the scope of investigative activities, the development of a comprehensive training component covering the use of direct-impact weapons from an elevated post, and the effective and safe firing of the 40 mm launcher against a moving target. We also recommended that the CDCR ensure that every officer armed with a department- issued weapon is regularly qualified with that weapon, including firing live rounds or using a realistic simulator. The recommendations addressed to Wasco focused on developing and revising procedures related to housing unit security checks and post-incident cell searches, use- of-force emergency notification, and evidence handling. 2008 Follow-up Results The CDCR reported that it has made the following improvements since the June 2005 special review: • Revised the annual and quarterly weapons qualification to include firing live rounds using the 40 mm direct impact launcher. • Revised local procedures and post orders at Wasco to require the staff to conduct security checks at shift change and maintain cell search logbooks. • Included language in post orders stating that staff members are not to leave their posts without permission from a supervisor. • Received evidence-handling training from the California District Attorney’s Association. The training was videotaped and distributed to staff members at other institutions. • Created a new Deadly Force Investigative Team and identified the Office of Investigative Services to have full responsibility for conducting investigations depending on the memorandum of understanding established with local authorities for criminal investigations. Even with these improvements, the department still has not taken all the available steps to reduce the likelihood of a future occurrence similar to the circumstances surrounding Provencio’s death. Office of the Inspector General Page 20 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio The control booth officer who shot Provencio fired the 40 mm direct-impact weapon from the second-tier control booth, which sat about 12 ½ feet above the dayroom floor where the inmate was standing. Our 2005 review of the shooting indicated that firing from an elevated position contributed to the inaccurate placement of the 40 mm projectile. The authorized target area when shooting the 40 mm direct-impact weapon is Zone 1, which is below the waist. Moreover, the CDCR Emergency Operations Unit conceded that the target area is reduced geometrically when sighted through a weapon from an elevated position at a downward angle. Further, even though department policy does not require firing from an elevated position during weapons training, it is recommended by the CDCR Emergency Operations Unit. Nevertheless, in January 2008, we visited five adult institutions (Sierra Conservation Center; California Substance Abuse Treatment Facility and State Prison, Corcoran; Deuel Vocational Institution; California Institution for Men; and Wasco State Prison) and found that four out of the five institutions did not include firing from an elevated position during weapons qualification, including Wasco, where Provencio was shot. In addition, the department reported that it does not practice shooting at moving targets at any of its institutions. Instead, the department explained that staff members are trained to use sound judgment when deploying munitions at a moving target. Our special review noted that Provencio was moving toward the floor officer at the time the control booth officer fired the weapon. Provencio’s forward movement both created a moving target and increased the likelihood that the projectile would strike him in the upper body as he moved into its flight path. Also, during site visits, we asked staff members from the five institutions to describe the process used to ensure that officers assigned to armed posts have completed their quarterly qualification. Based on their responses, we found that the institutions are usually in compliance. The exceptions are when an institution exhausts its list of qualified personnel and when officers who are not qualified volunteer for overtime or when qualified officers trade shifts (swaps) with an unqualified officer. These exceptions could cause a potentially dangerous situation. According to Title 15 of the California Code of Regulations, section 3276(a), “Only peace officers who have satisfactorily completed firearms training and who are currently qualified in the firing of departmental firearms shall be assigned to armed posts or otherwise be authorized to possess, carry or use a departmental firearm. Exceptions are only authorized in extreme emergencies when peace officers are not available in sufficient numbers or in time to stop or control a situation which warrants the immediate use of force.” The department’s Operations Manual section 32010.19.7 further stipulates “all department peace officers who are issued a department weapon as part of their regular or special assignment such as armed posts, transportation, SERT, Special Housing Unit, Special Agents, etc.…shall complete a proficiency course on a quarterly basis prior to assuming the post.” Based on the regulation and Operations Manual section mentioned above, it would appear that the department’s intent is to have only qualified personnel in armed posts unless there is an extreme emergency, and that qualified personnel are those peace officers who have completed a proficiency course on a quarterly basis before assuming the post. The institutions, however, operate differently. The current operating procedures, consistent with a November 2004 Office of the Inspector General Page 21 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio memorandum from the deputy director of the Institutions Division (renamed the Division of Adult Institutions), allows peace officers to swap or trade work assignments without regard to each other’s qualifications or training. The memorandum states that an employee who “works an armed position because of a swap or overtime is not doing so as part of their regular assignment. This is a voluntary, emergency/temporary assignment. Therefore, these employees will not be required to be quarterly qualified prior to working an armed post.” Understandably, there are sometimes unusual circumstances when staff members must be assigned to tasks for which they might not be prepared, but to allow personnel to trade assignments without regard to qualifications endangers the lives of staff and inmates. The department should ensure that at all times qualified personnel are in armed posts unless there is an extreme emergency as defined in Title 15. Follow-up Recommendations As a result of the 2008 follow-up audit, the OIG recommends that the California Department of Corrections and Rehabilitation: • Develop a more comprehensive training component covering the use of direct- impact weapons from an elevated post. (June 2005) • Develop a comprehensive training component that includes training on how to effectively and safely employ the 40 mm launcher against a moving target. (June 2005) • Ensure that every officer assigned to an armed post as part of his or her regular or special assignment (which includes relief, voluntary overtime and trades/swaps, permanent intermittent, etc.) must complete a weapons proficiency course on a quarterly basis. (June 2005) The matrixes on the following pages summarize the results of the 2008 follow-up audit. Office of the Inspector General Page 22 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005, at Wasco State Prison Finding 2 A number of contributing factors may have accounted for the control booth officer’s inaccurate placement of the 40 mm projectile, including inadequate training on the weapon and the lack of a consistent policy at Wasco for qualification with the 40 mm launcher. (June 2005) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Develop a more comprehensive training component Partially California Department of Corrections and Rehabilitation’s response: covering the use of direct-impact weapons from an elevated Implemented Partially Implemented. The Basic Correctional Officer Academy direct impact position. (June 2005) weapons training has been changed to include firing from an elevated post. All Institutions that have elevated posts have also been trained for the use of direct impact weapons from an elevated post. Office of the Inspector General’s comments: In January 2008, we conducted site visits at the California Institution for Men; Deuel Vocational Institution; Sierra Conservation Center; California Substance Abuse Treatment Facility and State Prison, Corcoran; and Wasco State Prison. We found that four out of the five institutions did not include firing from an elevated position during weapons qualification, including Wasco, where Provencio was shot. In addition, the department informed us that not all the institutions include firing from an elevated position in their weapons training. Thus, the department assessed the recommendation as partially implemented. Office of the Inspector General Page 23 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Recommendation Status Comments Develop a comprehensive training component that includes Not California Department of Corrections and Rehabilitation’s response: training on how to effectively and safely employ the 40 mm Implemented Not Implemented. At no time does the California Department of Corrections launcher against a moving target. Absent adequate training, and Rehabilitation (CDCR) practice with moving targets. Staff are trained to the use of this weapon should be discontinued. (June 2005) use sound judgment when deploying munitions at a moving target. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that every officer armed with a department-issued Partially California Department of Corrections and Rehabilitation’s response: weapon is regularly qualified with that weapon, including Implemented Fully Implemented. The Basic Correctional Officer Academy and staff at the firing live rounds or using a realistic simulator. (June 2005) institutions are trained to fire live rounds from all departmental issued weapons. Office of the Inspector General’s comments: In January 2008, we conducted site visits at the California Institution for Men; Deuel Vocational Institution; Sierra Conservation Center; California Substance Abuse Treatment Facility and State Prison, Corcoran; and Wasco State Prison. We found that each institution revised the course qualification for the 40 mm direct-impact launcher to include the firing of live rounds. In addition, we asked staff members from the five institutions to describe the process used to ensure that officers assigned to armed posts have completed their quarterly qualification. Based on their responses, we determined the following: • The institution’s in-service training office or armory sergeant develops the list of officers who did not complete their required weapons qualification. • The weapons qualification frequency is based on the requirements of each officer’s regularly assigned post, which is quarterly for officers assigned to armed posts and annually for other officers. • If an officer assigned to an armed post has not met the firearm proficiency requirements, the officer is redirected to a non-armed post until the officer completes the required weapons qualification. Office of the Inspector General Page 24 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Recommendation Status Comments • Although there is not a required policy, staff members at some institutions believe that officers are responsible for rescheduling and completing their qualification requirements. While at other institutions, staff members have implemented a monitoring process to follow up on officers who failed to qualify. • To backfill vacant armed posts, institutions usually use their pool list of relief or permanent intermittent officers who are also required to qualify quarterly. • Sometimes the officer who backfills an armed post is not regularly assigned to an armed post and is therefore only completing an annual, rather than a quarterly, firearm proficiency qualification. For example, this happens when an institution exhausts the available resources identified on its pool list or when officers volunteer for overtime or trade shifts or assignments with another officer. According to Title 15 of the California Code of Regulations, section 3276(a), “Only peace officers who have satisfactorily completed firearms training and who are currently qualified in the firing of departmental firearms shall be assigned to armed posts or otherwise be authorized to possess, carry or use a departmental firearm. Exceptions are only authorized in extreme emergencies when peace officers are not available in sufficient numbers or in time to stop or control a situation which warrants the immediate use of force.” The department’s Operations Manual section 32010.19.7 further stipulates “all department peace officers who are issued a department weapon as part of their regular or special assignment such as armed posts, transportation, SERT, Special Housing Unit, Special Agents, etc.…shall complete a proficiency course on a quarterly basis prior to assuming the post.” Based on the regulation and Operations Manual section mentioned above, it would appear that the department’s intent is to have only qualified personnel in armed posts unless there is an extreme emergency, and that qualified personnel are those peace officers who have completed a proficiency course on a quarterly basis before assuming the post. The institutions, however, operate differently. The current operating procedures, consistent with a Office of the Inspector General Page 25 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Recommendation Status Comments November 2004 memorandum from the deputy director of the Institutions Division (renamed the Division of Adult Institutions), allows peace officers to swap or trade work assignments without regard to each other’s qualifications or training. The memorandum states that an employee who “works an armed position because of a swap or overtime is not doing so as part of their regular assignment. This is a voluntary, emergency/temporary assignment. Therefore, these employees will not be required to be quarterly qualified prior to working an armed post.” Understandably, there are sometimes unusual circumstances when staff members must be assigned to tasks for which they might not be prepared, but to allow personnel to trade assignments without regard to qualifications endangers the lives of staff and inmates. The department should ensure that at all times qualified personnel are in armed posts unless there is an extreme emergency as defined in Title 15. Based on the results of our audit, the CDCR has not fully implemented our recommendation to ensure that every officer armed with a department-issued weapon is regularly qualified with that weapon. Therefore, we modified the status to partially implemented. Follow-up Recommendations The California Department of Corrections and Rehabilitation should take the following actions: • Develop a more comprehensive training component covering the use of direct-impact weapons from an elevated post. (June 2005) • Develop a comprehensive training component that includes training on how to effectively and safely employ the 40 mm launcher against a moving target. (June 2005) • Ensure that every officer assigned to an armed post as part of his or her regular or special assignment (which includes relief, voluntary overtime and trades/swaps, permanent intermittent, etc.) must complete a weapons proficiency course on a quarterly basis. (June 2005) Office of the Inspector General Page 26 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Finding 3 Wasco staff may not have regularly performed thorough security checks of the housing unit during shift changes, failed to conduct timely cell searches of the housing unit after the incident, and failed to properly maintain the housing unit’s logbooks. (June 2005) Recommendation Status Comments Wasco State Prison should: Develop clear written requirements governing security Fully California Department of Corrections and Rehabilitation’s response: checks of housing units during shift changes, maintenance Implemented Fully Implemented. Current procedures and post orders require staff to of housing unit logbooks, and timely cell searches conduct security checks at shift change and to maintain cell search and log following any significant incident at the institution. books. (June 2005) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Follow-up Recommendation None Finding 4 Emergency notification procedures for use-of-force incidents at Wasco State Prison were deficient. (June 2005) Recommendation Status Comments Wasco State Prison should: Revise its emergency notification procedures to clarify Fully California Department of Corrections and Rehabilitation’s response: responsibility for ordering employees to remain at their Implemented Fully Implemented. Post Orders include the verbiage for staff to not leave their posts following significant incidents at the institution. post without permission from their supervisor. Staff receive on going training. (June 2005) Office of the Inspector General Page 27 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Follow-up Recommendation None Finding 5 Members of the Wasco staff improperly handled some of the evidence in the case, but this deficiency did not affect the investigation. (June 2005) Recommendation Status Comments Wasco State Prison should: Institute policies and procedures and training to ensure that Fully California Department of Corrections and Rehabilitation’s response: all evidence related to incidents resulting in injury to staff Implemented Fully Implemented. The California District Attorney’s Association provided or inmates is preserved pending instructions from training to CDCR staff that was videotaped and distributed statewide. investigating officials. (June 2005) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Follow-up Recommendation None Office of the Inspector General Page 28 Special Review into the Shooting 2008 Accountability Audit of Inmate Daniel Provencio Finding 6 None of the Department of Corrections and Rehabilitation entities investigating the incident was required to conduct an administrative investigation beyond the use-of-force review to determine whether corrective or disciplinary action of all staff involved was appropriate. (June 2005) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Reassess the scope of work of each of its investigative Fully California Department of Corrections and Rehabilitation’s response: entities to avoid unnecessary duplication and to ensure that Implemented Fully Implemented. A new Deadly Force Investigative Team was approved administrative investigations are conducted in use-of-force and the Office of Investigative Services now has full responsibility for incidents involving the death or serious injury of an inmate conducting the investigations depending on the Memorandum of to identify potential staff misconduct. (June 2005) Understanding established with the Local Authorities for the criminal investigation. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Follow-up Recommendation None Office of the Inspector General Page 29 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Special Review into Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers The OIG found that state prison reception centers have Implementation significantly improved their processes to ensure potentially Report Card dangerous maximum custody inmates are segregated from the 2006 Recommendations: 13 general population. Improvements to the Distributed Data Currently Applicable: 12 Processing System are complete; department operating procedures, receiving and release post orders, and the Fully Implemented: screening review form are revised and updated; and institution 8 (67%) classification committee decisions are reflected in the Distributed Data Processing System. Substantially Implemented: 1 (8%) Partially Implemented: Summary 2 (17%) Not Implemented: In March 2006, we issued a special review3 on the improper 1 (8%) placement of maximum custody inmates into general population Not Applicable: housing at state prison reception centers. The special review grew 1 out of an earlier OIG review on the circumstances surrounding the January 10, 2005, fatal stabbing of Correctional Officer Manuel A. Gonzalez Jr. by an inmate at the California Institution for Men reception center. That review, issued in March 2005, determined that the accused assailant was a maximum custody inmate who, despite a long history of in-prison violence, had been placed in a general population cell instead of in segregated housing. As a result of the March 2005 review, we recommended that inmates who return to prison after paroling from a security housing unit—and who are therefore designated “maximum custody” inmates—be placed in administrative segregation pending review by an institutional classification committee. The CDCR issued a memorandum on August 1, 2005, implementing that recommendation and directing reception centers to use the statewide Offender Based Information System (OBIS) to identify inmates who paroled from security housing units or other segregated housing when they return to prison. The March 2006 special review covered six of the state’s reception centers, which together served 52 of the state’s 58 counties and in 2004 received 79 percent of the state’s incoming male inmate population. The review determined that despite the new procedures, large numbers of potentially dangerous maximum custody inmates were still slipping through the screening process and ending up in the general population. We identified 66 maximum custody inmates at five reception centers who should have been in administrative segregation but instead were housed with general population inmates. In addition, we found that the new procedures might cause inmates who could be safely placed in the general population to be assigned to administrative segregation unnecessarily. The inmates affected are those who were placed in administrative segregation at a paroling institution for their own protection or for other reasons not attributable to misconduct. 3 “Special Review into Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers” may be found on the OIG’s Web site: http://www.oig.ca.gov/reports/pdf/improper_housing.pdf. Office of the Inspector General Page 30 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Background The CDCR operates 11 reception centers for adult male and female felons at prisons throughout the state. The reception centers serve as entry points into the state prison system for offenders newly sentenced to prison and for parolees and former inmates returning to prison after violating parole or committing new crimes. The reception centers also serve as transfer centers for inmates being moved from one institution to another. As such, the central function of the reception centers is to receive, hold, process, and transfer inmates to other facilities. Each year, thousands of inmates pass through the state’s reception centers—and a large percentage of these inmates are parolees returning to prison after either violating parole or committing new crimes. On March 10, 2006, the CDCR issued a memorandum to address our recommendations identified in the March 2006 special review. The CDCR distributed the memorandum to all associate directors, wardens, classification and parole representatives, and reception center correctional counselors. The memorandum required each reception center warden to ensure the following: • All inmates returning to the department with prior segregation or protective housing designation must be placed directly in the administrative segregation unit. • A formal institution classification committee action, to include a thorough review of the central file and current case factors, must be documented per policy before these inmates can be released from administrative segregation. • Operating procedures and post orders must be reviewed and updated. • Staff members responsible for housing inmates processed through the reception center receiving and release office must be trained. Previous Findings and Recommendations As a result of the March 2006 special review, we found that numerous potentially dangerous maximum custody inmates were still being assigned to general population housing at prison reception centers throughout the state. At the same time, the procedures instituted on August 1, 2005, may have caused inmates who could be safely assigned to the general population to be unnecessarily placed in administrative segregation. To address this finding, we made 13 recommendations to the CDCR that focused on training staff and enhancing OBIS and the Distributed Data Processing System (DDPS). The key recommendations were to modify the DDPS to: • Differentiate returning maximum custody inmates who should be retained in administrative segregation from returning inmates who can be safely assigned to the general population. Office of the Inspector General Page 31 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers • Prevent maximum custody inmates designated as needing administrative segregation from being inadvertently placed in general population housing. • Generate a standardized report to identify all maximum custody inmates and their current housing location at each reception center. In addition, the OIG also recommended that the department address the following: • Update receiving and release post orders and local operating procedures to be consistent with the department’s new screening methods. • Designate and train appropriate staff members to immediately notify the facility staff when they identify inmates during processing who should be placed in administrative segregation. 2008 Follow-up Results In January 2008, we visited three reception centers (Deuel Vocational Institution, California Institution for Men, and Wasco State Prison) to determine whether reception center staff members were following the procedures identified in the March 2006 memorandum. At each institution, we interviewed staff members in receiving and release, central control, watch office, and classification services and found that they understand their role in identifying maximum custody inmates and the importance of housing them in administrative segregation. The follow- up review also found that operating procedures and receiving and release post orders had been updated to reflect the screening methods identified in the March 2006 memorandum. In addition, we found that the CDCR implemented several improvements to the DDPS to address our previous recommendations. A new data field—the Parole Transfer Custody Level—was created in the DDPS. The field allows counselors, prior to the inmate’s release from administrative segregation to parole or transfer, to designate a lower custody level if the inmate is returned to prison. This change allows the system to differentiate maximum custody inmates who should be retained in administrative segregation if they return to custody from inmates who can be safely assigned to the general population. Also, a lockout feature was added to the DDPS. If central control staff members try to assign a maximum custody inmate to a general population housing unit, they will receive an error message that prevents them from completing the housing assignment. Furthermore, to ensure that all maximum custody inmates are housed appropriately, the central control staff members now have the ability to generate a report that identifies all inmates designated as maximum custody and their current housing location. The institution is required to generate the report daily, but we found that some institutions generate the report during each shift. However, contrary to the department’s representations, we found that the institutions had not provided block training to all employees in the recognition of reception center inmates requiring maximum custody housing. All employees coming in contact with inmates should be familiar Office of the Inspector General Page 32 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers with the procedures so they can immediately alert facility staff if an inmate should be placed in administrative segregation in accordance with the March 2006 memorandum. This would provide the institution a back-up process in the event the receiving and release, central control, watch office, and classification services staff make a critical error in assigning a dangerous inmate to less than safe housing conditions. The follow-up review also noted that the counselors at the institutions are promptly removing the maximum custody designation in the DDPS when inmates are released from administrative segregation because of an institution classification committee decision. This helps prevent general population inmates from being housed in the more expensive maximum custody beds. The department reported that changes to the California Code of Regulations and the California Department of Corrections and Rehabilitation Operations Manual were not necessary to implement the OIG’s recommendations. However, specific changes related to the psychiatric management unit are pending department review. The department did not implement our recommendation to modify OBIS to clearly identify segregated housing. The department performed an evaluation and determined that the modification was not feasible. Lastly, the department states that the CDC-1882 Initial Housing Review form has been modified to include fields showing previous segregated housing, as well as the date the form was completed. Follow-up Recommendations As a result of the 2008 follow-up audit, the OIG recommends that the California Department of Corrections and Rehabilitation take the following actions: • Ensure that California Code of Regulations, Title 15, section 3341.5(b) and California Department of Corrections and Rehabilitation Operations Manual section 62050.12 are amended to replace references to the psychiatric management unit with references to the psychiatric services unit. (March 2006) • Modify the coding in the Offender Based Information System or adopt some other methodology to clearly identify segregated housing. For example, replace “Palm Hall” with “ASU.” (March 2006) • Designate and train appropriate staff members to immediately notify facility staff when they identify inmates during subsequent processing who should be placed in administrative segregation. (March 2006) The matrixes on the following pages summarize the results of the 2008 follow-up audit. Office of the Inspector General Page 33 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Special Review into Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers Finding 1 Numerous potentially dangerous maximum custody inmates are still assigned to general population housing at prison reception centers throughout the state. At the same time, the newly instituted procedures may cause inmates who could be safely assigned to the general population to be unnecessarily placed in administrative segregation. (March 2006) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Modify existing custody designations in the Distributed Substantially California Department of Corrections and Rehabilitation’s response: Data Processing System to differentiate maximum custody Implemented Fully Implemented. The Max Custody Program has been released and inmates who should be retained in administrative implemented. segregation if they return to custody from those who can be safely assigned to the general population. The Office of the Inspector General’s comments: institutional classification committee should assign the We interviewed staff members responsible for the Max Custody Enhancement designations as part of the initial hearing already required Project. The staff members told us that a new data field—the Parole Transfer at the paroling institution at the time an inmate is placed in Custody Level (PTCL)—was created in the Distributed Data Processing System segregated housing. The committee should change the (DDPS) to address our recommendation. The PTCL field allows counselors, designation when appropriate at subsequent classification prior to the inmate’s release from administrative segregation to parole or hearings. (March 2006) transfer, to designate in the DDPS a lower custody level if the inmate is returned to prison. This feature may be appropriately used when identifying inmates formerly assigned to administrative segregation for reasons other than their own misconduct, such as protection from enemies or to preserve the integrity of an investigation. In addition, in January 2008, we contacted institutional counselors at Deuel Vocational Institution, California Institution for Men, and Wasco State Prison to determine their familiarity with the PTCL field. The counselors at Deuel Vocational Institution and Wasco State Prison were familiar with the PTCL field and described specific scenarios when they would use the field. However, the counselors at the California Institution for Men told us they had just recently received the DDPS training manual, which included information related to the Office of the Inspector General Page 34 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Recommendation Status Comments PTCL field. The counselors at the California Institution for Men told us they plan to conduct training in the near future. Also, counselors at each institution told us that during the institution classification committee hearings they occasionally come across situations where an inmate is housed in administrative segregation inappropriately. For example, one inmate was designated as maximum custody upon arrival. However, based on the counselor’s review of the inmate’s case file, he determined that the inmate’s custody level was incorrect. Therefore, the inmate was transferred from administrative segregation to the general population. Although the DDPS has been modified to differentiate maximum custody inmates who should be retained in administrative segregation if they return to custody from those who can be safely assigned to the general population, the institutions do not always use this feature correctly. As a result, inmates are still occasionally housed inappropriately, so we changed the status of this recommendation to substantially implemented. Subsequent to implementation of the first Fully California Department of Corrections and Rehabilitation’s response: recommendation, the department should consider Implemented Fully Implemented. The Max Custody Program has been released and enhancing the process by adding a lockout feature and implemented. using the name verify database file to make the information available immediately upon the inmate’s Office of the Inspector General’s comments: arrival at the reception center. The lockout feature would During January 2008 site visits at Deuel Vocational Institution, California prevent maximum custody inmates designated as needing Institution for Men, and Wasco State Prison, we interviewed central control administrative segregation from being inadvertently placed staff members and observed the process used within the DDPS to assign an in general population housing. The new system would be inmate to a housing unit. We observed that if central control staff members tried similar to the one used for inmates needing single-cell to assign a maximum custody inmate to a general population housing unit, they housing and would make the information available at the received an error message. Authorization from management staff is required to time the inmate arrives at the reception center instead of 24 override the error message. Department directives state that maximum custody hours later. (March 2006) inmates should not be housed in general population housing. Amend California Code of Regulations, Title 15, and the Not California Department of Corrections and Rehabilitation’s response: California Department of Corrections and Rehabilitation Applicable Not Applicable. Changes to the California Code of Regulations (CCR) and the Operations Manual as needed to implement the California Department of Corrections and Rehabilitation Operations Manual recommendations provided in this report. (March 2006) (DOM) determined to be unnecessary. Office of the Inspector General Page 35 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Amend California Code of Regulations, Title 15, section Partially California Department of Corrections and Rehabilitation’s response: 3341.5(b) and California Department of Corrections and Implemented Partially Implemented. Corrections to CCR and DOM sections to reflect policy Rehabilitation Operations Manual section 62050.12 to and procedure of Psychiatric Services Unit are pending review. replace references to the psychiatric management unit with references to the psychiatric services unit. (March 2006) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Revise department procedures to require that inmates Fully California Department of Corrections and Rehabilitation’s response: returning to custody who paroled from a protective Implemented Fully Implemented. Provided written instruction to staff. housing unit be automatically placed in administrative segregation pending review by an institutional Office of the Inspector General’s comments: classification committee. (March 2006) We reviewed the CDCR directive dated March 10, 2006, and found that the language adequately addresses the recommendation. The directive requires inmates returning to custody who paroled from a protective housing unit be placed in an administrative segregation unit upon return to prison. It further states that if an inmate was in a protective housing unit at the time of parole, the inmate’s custody designation will be maximum custody. To help ensure that the Distributed Data Processing Fully California Department of Corrections and Rehabilitation’s response: System reflects up-to-date information, require reception Implemented Fully Implemented. Direction given during Warden’s meeting. centers to promptly remove maximum custody designations in the Distributed Data Processing System Office of the Inspector General’s comments: when they release inmates from administrative We conducted site visits at Deuel Vocational Institution, California Institution segregation. (March 2006) for Men, and Wasco State Prison during the week of January 15, 2008. We reviewed documents related to decisions made at the institution committee meetings for administrative segregation classification, and we specifically focused on decisions related to the release of inmates from administrative segregation. In addition, we reviewed inmate housing information in the DDPS. Based on our review, we found that the counselors at the institutions are promptly removing the maximum custody designation in the DDPS when inmates are released from administrative segregation. Office of the Inspector General Page 36 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Recommendation Status Comments Provide training to staff members responsible for entering Fully California Department of Corrections and Rehabilitation’s response: data into the Offender Based Information System to ensure Implemented Fully Implemented. Provided written instructions to the staff on the need for that information for inmates placed in administrative training. segregation or segregated housing is accurate. (March 2006) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Provide training to staff members responsible for Fully California Department of Corrections and Rehabilitation’s response: reviewing Offender Based Information System housing Implemented Fully Implemented. Institutional Service Training completed. information to ensure that enough of the inmates’ history is reviewed to make an accurate evaluation. The review Office of the Inspector General’s comments: must be thorough enough to accurately identify high- The OIG performed no audit procedures to verify the department’s control maximum custody inmates who were transferred representation. immediately before parole and should include printing and reviewing enough pages of the housing history to make a thorough evaluation. (March 2006) Modify the coding in the Offender Based Information Not California Department of Corrections and Rehabilitation’s response: System to clearly identify segregated housing. For Implemented Not Implemented. This recommendation was evaluated and determined not to example, replace “Palm Hall” with “ASU.” (March 2006) be feasible. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Modify the CDC-1882 Initial Housing Review form to Fully California Department of Corrections and Rehabilitation’s response: include fields showing previous segregated housing and Implemented Fully Implemented. The CDC-1882 Initial Housing Review form has been the date the form is completed. (March 2006) modified. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Update receiving and release post orders and local Fully California Department of Corrections and Rehabilitation’s response: operating procedures to be consistent with screening Implemented Fully Implemented. A directive was issued to institutional staff to update Post methods required by the August 1, 2005, directive or new Orders and local Operational Procedures. Office of the Inspector General Page 37 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Recommendation Status Comments screening methods subsequently developed. (March 2006) Office of the Inspector General’s comments: During site visits at Deuel Vocational Institution, California Institution for Men, and Wasco State Prison, we reviewed local operating procedures and staff post orders. Based on our review, we found that the screening methods required by the department directives are reflected in either the institutions’ local operating procedures or receiving and release staff members’ post orders. Designate and train appropriate staff members to Partially California Department of Corrections and Rehabilitation’s response: immediately notify facility staff when they identify Implemented Fully Implemented. Much of this training is now being given through block inmates during subsequent processing who should be training. Research to ensure standardization at all institutions and the placed in administrative segregation. (March 2006) academy has been completed. Office of the Inspector General’s comments: During site visits at Deuel Vocational Institution, California Institution for Men, and Wasco State Prison, we interviewed staff members in receiving and release, central control, watch office, and classification services. Based on our discussions with them, it appears they understand their role in identifying maximum custody inmates. In addition, staff members in receiving and release and the watch office told us they receive on-the-job training related to housing maximum custody inmates appropriately. However, contrary to the department’s representation, the institutions did not provide block training to ensure that all employees who encounter inmates are familiar with the procedures for housing dangerous inmates in reception centers. We reviewed the agendas used for the annual block training at Deuel Vocational Institution, California Institution for Men, and Wasco State Prison. Based on our review, we found no specific training identified. In addition, we specifically asked the in-service training staff members at the three institutions whether there was a section during block training that discussed the importance in identifying maximum custody inmates housed with the general population who should be in administrative segregation. They were unaware of a block training section specific to that subject. Training all staff members is essential in the event that staff members working in receiving and release, central control, watch office, and classification services inadvertently or unknowingly place in the general population an inmate Office of the Inspector General Page 38 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Recommendation Status Comments who should have been a maximum custody inmate. If they are aware of the proper procedures, staff members (such as correctional officers and medical personnel not directly involved in inmate housing assignments) may bring the inmate housing error to the attention of the appropriate personnel for remediation. We also asked staff members at CDCR headquarters about the type of research conducted to ensure standardized training at all institutions and the academy. However, the department was unable to provide us with supporting documentation for its research. Therefore, there was no evidence to support the department’s representation that it had established a systematic process to train staff members through annual block training. However, to the extent that staff members understood their role in identifying maximum custody inmates from on-the-job training, we believe the department has partially implemented the recommendation. Develop a standardized report in the Distributed Data Fully California Department of Corrections and Rehabilitation’s response: Processing System to identify all maximum custody Implemented Fully Implemented. Institutions are able to produce Max-Custody reports in inmates at each reception center and ensure that each their Control Room on a daily basis. reception center uses the report every day to screen for maximum custody inmates improperly assigned to general Office of the Inspector General’s comments: population housing. (March 2006) During January 2008 site visits at Deuel Vocational Institution, California Institution for Men, and Wasco State Prison, we interviewed central control staff members and reviewed the Max Custody report generated at each institution. Deuel Vocational Institution generates the report daily, while the California Institution for Men and Wasco State Prison generate the report during each shift. We found that the reports identified all inmates designated as maximum custody and their current housing location, and we noted that all maximum custody inmates identified on the reports were housed appropriately. Office of the Inspector General Page 39 Improper Housing of Maximum Custody Inmates 2008 Accountability Audit at California State Prison Reception Centers Follow-up Recommendations The California Department of Corrections and Rehabilitation should: • Ensure that California Code of Regulations, Title 15, section 3341.5(b) and California Department of Corrections and Rehabilitation Operations Manual section 62050.12 are amended to replace references to the psychiatric management unit with references to the psychiatric services unit. (March 2006) • Modify the coding in the Offender Based Information System or adopt some other methodology to clearly identify segregated housing. For example, replace “Palm Hall” with “ASU.” (March 2006) • Designate and train appropriate staff members to immediately notify facility staff when they identify inmates during subsequent processing who should be placed in administrative segregation. (March 2006) Office of the Inspector General Page 40 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Special Review into Management of Union Leave Time by the California Department of Corrections and Rehabilitation The CDCR reported that it has developed a standardized process Implementation for approving, documenting, reporting, and recording union Report Card leave and release time bank usage information. Also, the department reports that it has developed a billing system to help 2006 Recommendations: 9 recapture costs associated with staff members on union-paid leave. According to the department, the state has entered into Fully Implemented: two agreements with union management—one related to a limit 4 (45%) on the number of time bank hours used and the other related to Substantially Implemented: the union reimbursing the department for staff members on 1 (11%) union-paid leave. But despite these efforts, the department still does not have assurances that union leave time is recorded and Partially Implemented: 2 (22%) accounted for properly. The department reports that it has only partially implemented a reconciliation process, which the OIG Not Implemented: made as its first recommendation for providing adequate 2 (22%) oversight of union leave time. Summary In July 2006, the OIG issued a report titled “Special Review into Management of Union Leave Time by the California Department of Corrections and Rehabilitation.”4 The review found that the department failed to provide adequate oversight of union leave time and potentially wasted millions of dollars in public resources and created an operational burden on state correctional institutions. From January 2000 through December 2005, CDCR employees used 318,317 hours of union leave time, equating to about $12 million5 in staff resources. The most significant of the union leave categories for the department is the Bargaining Unit 6 release time bank for rank- and-file members of the California Correctional Peace Officers Association (CCPOA), which accounted for 197,802 hours of union leave time between 2000 and 2005. Ultimately, we were unable to quantify the fiscal impact of the department’s mismanagement of union leave time because the department did not maintain accurate and reliable records on union leave. Background California Government Code sections 3512 through 3524 (the Ralph C. Dills Act) require state agencies to allow a reasonable number of union representatives a reasonable amount of time off without loss of compensation to meet and confer with state representatives on matters within the 4 The entire report may be found on the OIG’s Web site: http://www.oig.ca.gov/pdf/071406_unionleave.pdf. 5 The $12 million figure is based on a rate of $37.66 per hour, which averages the salary and associated employee benefits for a mid-step correctional officer for fiscal years 1999–2000 and 2005–2006. Office of the Inspector General Page 41 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation scope of union representation. The amount and type of union leave time is subject to negotiation between the state and its 21 recognized bargaining units. The CDCR’s rank-and-file employees are affiliated with 19 of the state’s bargaining units. Consistent with the Ralph C. Dills Act, contracts between the state and the department’s 19 bargaining units include provisions that establish various types of union leave time. In general, these union leave arrangements fall into five main categories: release time bank, official business (informal), official business (union), union-paid leave, and union activist release time. Some union leave categories require the state to absorb the cost of the employee’s absence from the job, while others call for the union to compensate the agency for the lost time, either monetarily or through hours donated by union members. Previous Findings and Recommendations Our 2006 report identified weaknesses that prohibited the CDCR from adequately managing union leave time and associated costs. The review found that the department did not establish sound accounting practices for the release time bank; coding errors and ineffective tracking of leave donations and usage made it impossible to tell whether the release time bank was overdrawn. In addition, the department was unable to reconcile its time bank records with those of the union, and the department did not enforce the release time bank cap of 10,000 hours. Further, nobody was managing the release time banks for supervisors. Because of the department’s overall poor controls in tracking leave donations and usage, we ultimately found it impossible to determine the total true loss in staff resources caused by poor accounting practices. We also noted other weaknesses, such as employees being released to union business without verifying that the employees were authorized to conduct union business. Moreover, the department was not consistently charging time to the release time bank and had not controlled the individual usage of union release time or required time sheets for employees on union leave. The department also under-billed the CCPOA for reimbursable union leave time and failed to request funding to offset the costs of providing relief coverage for union officials who work full time on union business. Finally, we found that the department exceeded the legislative funding provided to cover the cost of releasing CCPOA delegates to attend the union’s annual conference. The lack of an effective system for union leave management has caused the department to lose many opportunities to control costs and seek reimbursement for a significant amount of staff time lost because of union-related activities. While we are unable to determine the actual cost to the state, we estimate the figure could be in the millions of dollars. In addition, when legislative funding did occur for union activities, such as the annual CCPOA delegates conference, we found that the CDCR spent $400,000 more than was legally funded for the 2002–05 fiscal years. In our 2006 report, we recommended that the department reconcile union leave internally to time authorized, used, and billed. In addition, we recommended that the department reconcile its release time balance each quarter to the union’s records. We also recommended that the department collect full reimbursement when union employees are released from work to perform Office of the Inspector General Page 42 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation union activities unless the release is specifically addressed in the labor contracts. In total, we prescribed nine recommendations to the department. 2008 Follow-up Results We found that the department has taken several positive steps to negotiate resolutions to union leave issues during a period when no Bargaining Unit 6 memorandum of understanding (MOU) exists between the CDCR and the CCPOA. In April 2007, an agreement between the department and the CCPOA established a larger maximum cap of 35,000 hours a year for the donation and use of leave credits that pertain to the release time bank. Moreover, in November 2007, a second agreement was reached with the CCPOA regarding cost reimbursement for staff members on short- and long-term union-paid leave. This new agreement calls for the CCPOA to reimburse the department for total compensation costs of staff members who take union-paid leave. We previously recommended that the department request funding from the Legislature for union issues addressed in labor contracts, such as compensation for Bargaining Unit 6 executive vice presidents and chapter presidents. However, because its MOU with the CCPOA expired in July 2006, the department has been unable to implement the recommendation. While the CDCR has made substantial progress developing policies and procedures to improve its ability to effectively manage union leave, several OIG recommendations have yet to be fully implemented: • Complete monthly internal reconciliations of union leave time. • Regularly reconcile the release time bank balance with the union’s records. • Conduct periodic audits to ensure that time is recorded accurately and union leave time is periodically reconciled. Specifically, the CDCR indicated that it has made several unsuccessful attempts with the CCPOA to develop a uniform system of periodically reconciling the release time bank. According to the department, negotiations with the CCPOA were hindered by the expiration of the MOU with the CCPOA, but recently, as a condition of the November 2007 agreement, both parties agreed to immediately meet and begin a reconciliation of the release time bank balance. The department did not provide us with any further information in its response on the status of efforts to reconcile its records for release time bank balance with those of the CCPOA. In addition, the CDCR also reported that it has made only a partial effort to develop a system to internally track and reconcile union leave time monthly to help capture data on time authorized, used, and billed. As a result, the CDCR has not yet implemented a system to conduct audits to ensure that union leave time is recorded accurately and reconciled periodically. Follow-up Recommendations As a result of its 2008 review, the OIG recommends that the California Department of Corrections and Rehabilitation take the following actions: Office of the Inspector General Page 43 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation • Continue its efforts to fully implement a system to internally reconcile union leave time on a monthly basis. (July 2006) • In conjunction with the California Correctional Peace Officers Association, develop uniform policies and procedures that facilitate reconciling the release time bank balance each quarter with the union’s records. (July 2006) • Conduct periodic audits to ensure that time is recorded accurately and union leave time is reconciled monthly. (July 2006) • Once a new contract is negotiated for Bargaining Unit 6, reconsider the need for requesting legislative funding for union issues addressed in labor contracts, such as compensation for Bargaining Unit 6 executive vice presidents and chapter presidents. (July 2006) The matrixes on the following pages summarize the results of the 2008 follow-up audit. Office of the Inspector General Page 44 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Special Review into Management of Union Leave Time by the California Department of Corrections and Rehabilitation Finding The California Department of Corrections and Rehabilitation has mismanaged millions of dollars in public resources and created an operational burden on itself and the institutions by failing to accurately control and account for union leave time. (July 2006) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Reconcile union leave time internally on a monthly basis. Partially California Department of Corrections and Rehabilitation’s response: Include in the reconciliation the authorization of release Implemented Partially Implemented. The California Department of Corrections and time for union business and any other documentation that Rehabilitation (CDCR) Office of Labor Relations developed a monthly would capture the time authorized, used, and billed. reconciliation process beginning with the July 2005 pay period. Ongoing (July 2006) evaluation and assessment of the reconciliation process resulted in the department enhancing the monthly reconciliation beginning with the July 2007 pay period. Upon further identified assessments, an additional enhancement was established in November 2007 for implementation in December 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. In conjunction with the California Correctional Peace Not California Department of Corrections and Rehabilitation’s response: Officers Association, develop uniform policies and Implemented Not Implemented. Starting point reconciliation, initially agreed upon by both procedures that facilitate reconciling the release time bank the California Correctional Peace Officers Association and the CDCR, netted balance each quarter with the union’s records. (July 2006) a balance of 17,254 Release Time Bank hours available as of July 1, 2005. During the year 2006 and 2007 to date, the CDCR has made subsequent requests to the California Correctional Peace Officers Association for additional reconciliations; however, the California Correctional Peace Officers Association has failed to respond or cooperate, as outlined below, with applicable copies of the documents enclosed in this mailing: 10/23/2006: Letter to the California Correctional Peace Officers Association Office of the Inspector General Page 45 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments advising them the CDCR records indicated their RTB usage had exceeded their donation level by 2,055 hours. A request to meet with California Correctional Peace Officers Association to reconcile the RTB in accordance with Article 10.13 of the Bargaining Unit 6 Memorandum of Understanding was included in the letter. 10/30/2006: Response letter received from the California Correctional Peace Officers Association objecting to the 10/23/2006 letter. 11/03/2006: CDCR again demanded to meet with California Correctional Peace Officers Association to reconcile the Release Time Bank. A meeting was scheduled for November 7, 2006, with an invitation to meet for the reconciliation on that date contained within the letter. 01/12/2007: The California Correctional Peace Officers Association did not respond to the 11/03/2006 letter, nor did they show for the scheduled 11/07/2006 scheduled reconciliation. The CDCR Office of Labor Relations discussed the matter with the Department of Personnel Administration, who sent a letter to the law firm representing California Correctional Peace Officers Association, seeking their assistance for a meeting to attempt reconciliation of the RTB. The California Correctional Peace Officers Association made contact with CDCR Office of Labor Relations and agreed to a meeting on February 21, 2007. 02/21/2007: California Correctional Peace Officers Association representatives went to the CDCR Office of Labor Relations for a meeting, which was scheduled in hopes of the Release Time Bank reconciliation. The California Correctional Peace Officers Association staff person made a statement that the 17,254 hours initially thought to be an agreed upon figure in July 2005, was potentially higher than actually was available due to confusion with the merger of the two department Release Time Banks. (The California Department of Corrections and California Youth Authority merged into one department on 07/01/2005.) During the delivery of that statement, California Correctional Peace Officers Association stopped the meeting and the California Correctional Peace Officers Association representatives left without reconciliation. Office of the Inspector General Page 46 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments 03/06/2007: Letter sent to CCPOA from CDCR Office of Labor Relations summarizing the 02/21/2007 meeting and asking to reschedule the meeting to attempt reconciliation of the Release Time Bank. The California Correctional Peace Officers Association was advised that should they not wish to meet for the purpose of reconciliation of the Release Time Bank, it would be assumed the California Correctional Peace Officers Association accepted our record numbers and would move forward accordingly. No response was received from the California Correctional Peace Officers Association. 05/10/2007: Letter sent to California Correctional Peace Officers Association from CDCR Office of Labor Relations, again summarizing the 02/21/2007 meeting, as well as the 03/06/2007 letter sent to him with no response received. Reference was made to the March/April 2007 Release Time Bank stipulated settlement agreement between the State of California and California Correctional Peace Officers Association, and a request to meet to reconcile was extended. (Explained on Page 6 below.) No response was received from the California Correctional Peace Officers Association. 06/13/2007: The CDCR Office of Labor Relations received a telephone call from the law firm representing the California Correctional Peace Officers Association, seeking a meeting to discuss Release Time Bank reconciliation. Meeting was scheduled for 06/18/2007. 06/18/2007: CDCR Office of Labor Relations and California Correctional Peace Officers Association attorney met to discuss the need and mechanism to reconcile the RTB between the two parties. The California Correctional Peace Officers Association attorney stated he would be involved in mediation of the Bargaining Unit 6 Memorandum of Understanding, however, after that process concluded, he would be in touch with the CDCR Office of Labor Relations to attempt a reconciliation meeting. 08/24/2007: California Correctional Peace Officers Association attorney forwarded to the CDCR Office of Labor Relations a letter stating he would be in touch after his return to work in mid-September 2007 to try to set up a follow-up meeting for the Release Time Bank reconciliation. 09/17/2007: CDCR Office of Labor Relations sent reply letter to the Office of the Inspector General Page 47 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments California Correctional Peace Officers Association attorney 08/24/2007 letter, acknowledging his contact and stated we would look forward to hearing from him for a meeting. No response has been received as of 10/03/2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Standardize the policies and procedures used for approving Fully California Department of Corrections and Rehabilitation’s response: union leave time and processing transactions, and Implemented Fully Implemented. On 02/03/2006, the CDCR distributed a statewide policy distribute those policies and procedures throughout the entitled “Required Documentation of Various Types of Approved Leaves”. department. (July 2006) Contained within that document is the appropriate process for reporting and documenting union leave, official business and Release Time Bank usage. Uniformity was established with absence codes and personnel reporting procedures. On 01/19/2007, another copy of the 02/03/2006 statewide policy was distributed to the CDCR Wardens. On 02/26/2007, a memorandum was prepared to Mr. Matthew Cate, Inspector General, summarizing the leave process overview the CDCR implemented, in an effort to ascertain a review by the Office of the Inspector General as to whether the processes put in place would fulfill the objectives outlined in their report. No known response was received. On 03/29/2007, a statewide telephone training conference was held to review the union leave procedures. Invited attendees include the Wardens, Superintendents, Parole Regional Administrators, Labor Relations Advocates, Institutional Personnel Officers, Accounting Offices, and other applicable departmental personnel responsible for union leave reporting in one form or another. Presentations were provided by the CDCR Office of Labor Relations, Office of Personnel Services and the Accounting Office. Prior to the training, each site was provided a copy of the “Union Leave Presentation” handbook, as well as an instructional compact disc developed by the CDCR Office of Labor Relations. The compact disc provided a systematic review of the approval and routing process for union leave. Office of the Inspector General Page 48 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments Office of the Inspector General’s comments: Although we performed no audit procedures to verify the department’s response, the Inspector General responded to the department’s February 26, 2007, memorandum. On March 28, 2007, the Inspector General issued a letter to the department’s secretary thanking him for sharing the department’s progress in developing policies and procedures to account for union leave time. The Inspector General also emphasized the importance of the department regularly reconciling with the State Controller’s leave and usage records and labor organization records. However, based on the department’s response to the first and second recommendations, it appears the department is having difficulty achieving this task. Establish policies and procedures for accurately recording Fully California Department of Corrections and Rehabilitation’s response: union leave time throughout the department. Provide Implemented Fully Implemented. On 02/03/2006, the CDCR distributed a statewide policy training throughout the department on the use of entitled “Required Documentation of Various Types of Approved Leaves”. timekeeping codes. (July 2006) Contained within that document is the appropriate process for reporting and documenting union leave, official business and Release Time Bank usage. Uniformity was established with absence codes and personnel reporting procedures. On 01/19/2007, another copy of the 02/03/2006 statewide policy was distributed to the CDCR Wardens. On 02/26/2007, a memorandum was prepared to Mr. Matthew Cate, Inspector General, summarizing the leave process overview the CDCR in an effort to ascertain a review by the Office of the Inspector General as to whether the processes put in place would fulfill the objectives outlined in their report. No known response was received. On 03/29/2007, a statewide telephone training conference was held to review the union leave procedures. Invited attendees include the Wardens, Superintendents, Parole Regional Administrators, Labor Relations Advocates, Institutional Personnel Officers, Accounting Offices, and other applicable departmental personnel responsible for union leave reporting in one form or another. Presentations were provided by the CDCR Office of Labor Relations, Office of Personnel Services and the Accounting Office. Prior to the training, each site was provided a copy of the “Union Leave Presentation” handbook, Office of the Inspector General Page 49 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments as well as an instructional compact disc developed by the CDCR Office of Labor Relations. The compact disc provided a systematic review of the approval and routing process for union leave. Office of the Inspector General’s comments: Although we performed no audit procedures to verify the department’s representation, the Inspector General responded to the department’s February 26, 2007, memorandum on March 28, 2007. (Refer to the OIG’s comments to the preceding recommendation.) Conduct periodic audits to ensure that time is recorded Partially California Department of Corrections and Rehabilitation’s response: accurately and union leave time is reconciled monthly. Implemented Partially Implemented. The CDCR Office of Labor Relations enhanced the (July 2006) monthly union leave reconciliation process beginning with the July 2007 pay period, which encompasses the records of the originating source document for union leave, the CDCR Office of Labor Relations records, the work site reporting structure inclusive of the Labor Relations Advocate or applicable entity, through the Personnel record keeping and key data entry process. Upon further identified assessments, an additional enhancement was established in November 2007 for implementation in December 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. To minimize fiscal and operational impacts, negotiate and Fully California Department of Corrections and Rehabilitation’s response: enforce a reasonable annual cap on release time bank Implemented Fully Implemented. March/April 2007: a “Stipulated Settlement Agreement” usage with the California Correctional Peace Officers was reached with the California Correctional Peace Officers Association Association. (July 2006) relative to the Release Time Bank cap and usage provisions. The agreement includes: o A 35,000-hour annual cap on donations and use of leave pertaining to the Release Time Bank. o With the exception of fiscal year 2006-2007, California Correctional Peace Officers Association shall not accumulate more than 35,000 hours in the Release Time Bank. o For fiscal year 2006-2007, the California Correctional Peace Office of the Inspector General Page 50 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments Officers Association was allowed to accumulate donations in excess of the 35,000-hour cap, but not exceeding 2,500 hours, to cover any deficit that exists to the bank before June 30, 2007. o In the event the balance of hours in the Release Time Bank is greater than 35,000 on July 1, 2007 (although equal or less than 37,500), the surplus hours will remain in the bank and may be used, however California Correctional Peace Officers Association will not be entitled to accumulate additional Release Time Bank hours until the balance goes below 35,000 hours. o California Correctional Peace Officers Association’s usage will be calculated upon a fiscal year basis. o The institution of the 35,000-hour cap shall be retroactive to July 1, 2006. o Should Release Time Bank leave in excess of the hours currently in the bank, then for the current fiscal year only (i.e., July 1, 2006 to June 30, 2007), California Correctional Peace Officers Association will be allowed to repay the deficit out of future donations on or before June 30, 2007. However, if a deficit exists at the end of the 2006-2007 fiscal year, then the deficit will be converted to union paid leave and California Correctional Peace Officers Association will be billed accordingly. Any future use (after fiscal year 2006- 2007) in excess of hours available in the RTB will be processed as union paid leave pursuant to section 10.14 of the 2001/2006 Memorandum of Understanding. (Note: California Correctional Peace Officers Association did not receive sufficient donations as of June 30, 2007.) o The parties agreed that California Correctional Peace Officers Association’s use in fiscal year 2006-2007 of Release Time Bank leave in excess of donations to the bank shall not establish a “past practice” or right of California Correctional Peace Officers Association to use Release Time Bank leave in excess of the donation balance in any subsequent fiscal year. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 51 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments Enforce the requirement that all employees, unless Fully California Department of Corrections and Rehabilitation’s response: specifically exempted under labor contracts, submit Implemented Partially Implemented. On 05/05/2005, then-Youth Adult and Correctional monthly attendance sheets to account for any absences and Agency provided an official notice to the California Correctional Peace time worked. In the alternative, obviate the need for Officers Association stating the intent to implement an updated process for monthly time reporting by negotiating a new leave system documenting and tracking approved absences granted to employees to wherein state employees working full time on union perform union related activities. A packet outlining the codes and processes business neither accrue nor use sick leave and vacation was provided at that time to the California Correctional Peace Officers time, with the understanding that the state may need to Association. Ensuing correspondence/discussion with California Correctional compensate the employees for the loss of those benefits. Peace Officers Association resulted in California Correctional Peace Officers As a third alternative, work with the unions to develop Association stating they were not interested in opening a “zippered” 1993 another solution that provides the necessary accountability. agreement in regard to leave reporting. (July 2006) On 02/03/2006, the CDCR distributed a statewide policy entitled “Required Documentation of Various Types of Approved Leaves”. Contained within that document is the appropriate process for reporting and documenting union leave, official business and Release Time Bank usage. Uniformity was established with absence codes and personnel reporting procedures. The CDCR put into place a process where the union officials would submit an attendance sheet when they utilized personal leave credits. Absence of submitting such would be a self-certification of no personal leave credits used. In July 2007, a process was initiated by the CDCR wherein an “administratively generated 998” would be completed by the Office of Personnel Services, with an attached source document from the California Correctional Peace Officers Association, showing the individual on union leave for the requested dates. This mechanism then captures the union leave for accountability purposes, and thus increases the integrity of the State Controller’s Office official records. In regard to the Office of Inspector General’s third recommended alternative, the Department of Personnel Administration in late September 2007 and to date, is in the process of establishing another solution for union officials to report their absences. An option the Office of Inspector General did not recommend which would obviate the need for monthly time reporting for the long-term and continuous off-work union officials, is to negotiate a union leave policy in which the union pays the total compensation to include the cost of all benefits and leave accruals. Office of the Inspector General Page 52 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed a limited review of the department’s implementation of the recommendation. We found that after the department’s initial response, it entered into an agreement in November 2007 with the CCPOA regarding union-paid leave. Under the stipulation, the union may designate up to 13 union individuals to work full time on union business. Further, none of the individuals is required to submit an attendance form regarding their union-paid leave. In addition, instead of submitting attendance forms, the CCPOA has agreed to reimburse the state for the total compensation costs for anyone taking union-paid leave. This compensation includes wages, payroll-related costs and contributions, payroll taxes, employer-paid contributions to retirement, health benefits, and the value of leave accruals each pay period. Based on the agreement between the CDCR and the CCPOA on the reporting of union-paid leave and the accountability for the payroll costs associated with the use of union-paid leave, we consider the recommendation to be fully implemented. Collect full reimbursement, including benefits where Substantially California Department of Corrections and Rehabilitation’s response: applicable, when union employees are released from work Implemented Partially Implemented .The document for billing the California Correctional to perform union activities unless the release is specifically Peace Officers Association is ready for approval to be forwarded to the CDCR addressed in labor contracts or requested by the state. Accounting Office, however, due to the status of litigation involving the (July 2006) Release Time Bank coupled with the uncertain and highly sensitive status of negotiations on a successor Memorandum of Understanding with the California Correctional Peace Officers Association, the Department of Personnel Administration advised CDCR to hold in abeyance invoicing California Correctional Peace Officers Association for amounts due and owing. Office of the Inspector General’s comments: We performed no audit procedures to verify the department’s representation. However, in November 2007, the CDCR and the CCPOA reached an agreement that provides the CDCR with the mechanism to begin billing for total compensation costs of staff members on union-paid leave until the Legislature approves a new MOU. Therefore, we consider the recommendation substantially implemented. Office of the Inspector General Page 53 Management of Union Leave Time by the 2008 Accountability Audit California Department of Corrections and Rehabilitation Recommendation Status Comments Request funding from the Legislature for union issues Not California Department of Corrections and Rehabilitation’s response: addressed in labor contracts, such as compensation for Implemented Not Implemented. The State of California and the California Correctional Bargaining Unit 6 executive vice presidents and chapter Peace Officers Association failed to reach a successor agreement to the 2001- presidents. (July 2006) 2006 Bargaining Unit 6 Memorandum of Understanding. Consequently, there is no mechanism for the funding request at this time. Office of the Inspector General’s comments: Because of the lack of a current MOU, we acknowledge that the department is unable to implement this recommendation. Once a new contract is negotiated, the department should reconsider the need for legislative funding. Follow-up Recommendations The California Department of Corrections and Rehabilitation should: • Continue its efforts to fully implement a system to internally reconcile union leave time on a monthly basis. (July 2006) • In conjunction with the California Correctional Peace Officers Association, develop uniform policies and procedures that facilitate reconciling the release time bank balance each quarter with the union’s records. (July 2006) • Conduct periodic audits to ensure that time is recorded accurately and union leave time is reconciled monthly. (July 2006) • Once a new contract is negotiated for Bargaining Unit 6, reconsider the need for requesting legislative funding for union issues addressed in labor contracts, such as compensation for Bargaining Unit 6 executive vice presidents and chapter presidents. (July 2006) Office of the Inspector General Page 54 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Special Review into Concerns Related to Substance Abuse Treatment Contractors While the CDCR has implemented several recommendations Implementation from the OIG’s October 2006 review, the most important issue Report Card remains unresolved—collecting overpayments of almost $5.6 million to agencies that coordinate substance abuse services. 2006 Recommendations: 12 The department failed to remedy this issue because it did not Currently Applicable: 9 notify the agencies of the overpayments until it reconciled contractors’ expenses and payments in December 2007. This Fully Implemented: reconciliation occurred almost 14 months after we issued our 6 (67%) report and only days before the department would have missed Partially Implemented: the opportunity to recover the overpayments at all. In response, 3 (33%) the agencies involved are disputing the amounts that the Not Applicable: department identified as overpayments. 3 Summary In October 2006, we issued a special review6 into the department’s oversight of its contractors for substance abuse treatment programs. The review revealed that the department’s Division of Addiction and Recovery Services (DARS), formerly named the Office of Substance Abuse Programs, failed to properly oversee its substance abuse treatment service contractors. Specifically, DARS neglected to enforce its contractual requirement that three regional treatment service coordinators reconcile their revenues and expenses related to the services they provided during their contract periods. As a result, the department ultimately paid the contractors amounts that exceeded the actual costs of providing the services. In addition, one contractor overstated its expenses for providing services by more than $250,000 over a four-year period because it had not appropriately accounted for the purchase of 22 vehicles. Furthermore, the department violated the California Constitution and state policy when it allowed contractors to retain ownership of potentially millions of dollars of equipment purchased with state funds. Finally, the review revealed that the department did not thoroughly investigate an incident regarding one contractor that disposed of confidential inmate information by placing it in the dumpster of a nearby private business. Background In response to a dramatic increase in the number of offenders committed to the state’s prisons and returning to custody because of drug-related offenses, the CDCR established the Office of Substance Abuse Programs in 1989. As indicated above, the department subsequently renamed the office the Division of Addiction and Recovery Services (DARS). DARS is responsible for designing, developing, and implementing effective alcohol and drug treatment programs for 6 “Special Review into Concerns Related to Substance Abuse Treatment Contractors” may be found on the OIG’s Web site: http://www.oig.ca.gov/reports/pdf/finalrptmasterdoc103106.pdf. Office of the Inspector General Page 55 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors inmates and parolees. To accomplish this, DARS contracts with organizations that provide in- prison substance abuse treatment for inmates in custody and community-based treatment services for inmates on parole. At the time of the review, the in-prison providers operated 38 therapeutic community programs at 22 institutions statewide. DARS also contracts with organizations that serve as substance abuse services coordination agencies in each of the state’s four parole regions. These agencies help inmates transition from the in-prison programs to community-based services. Between 1998 and 2003, three agencies— Mental Health Systems, Inc., Walden House, Inc., and WestCare—provided these services, with Walden House, Inc. serving two of the four parole regions. Previous Findings and Recommendations We identified the following four findings as a result of the October 2006 review. • The department overpaid three contractors nearly $5 million from fiscal year 2000–01 through 2003–047 because it neglected to enforce a contractual requirement that its three substance abuse services coordination agencies—Mental Health Systems, Inc., Walden House, Inc., and WestCare—periodically reconcile revenues with actual costs. The contracts called for the department to compensate the service coordinators for the lesser of the contractors’ actual costs of providing services or an amount determined by using the rates established in the contract. When we reconciled the contractors’ revenues and expenses, we found that the department overpaid the three contractors $4,991,147. • Mental Health Systems, Inc. inappropriately expensed the entire value of 22 vehicles it purchased with state funds from fiscal year 2000–01 through 2003–04. As a result, it overstated its expenses by more than $250,000. Although Mental Health Systems, Inc. was justified in acquiring the vehicles to meet its contractual responsibilities as a regional substance abuse services coordinator, it should have capitalized and depreciated the vehicles over their useful lives. Instead, it recorded the related costs as expenses at the time of purchase. • The department violated state law and policy by allowing contractors to retain ownership of potentially millions of dollars of property purchased with state funds. In its budget guide for contractors to follow in determining allowable costs, the department included a provision that allowed contractors to retain ownership of equipment they purchased with state funds if the equipment cost less than $5,000. As a result, the department gave away state equipment costing potentially millions of dollars. That budget guide provision was contrary to the State Contracting Manual. Furthermore, the California Constitution, Section 6, Article XVI, prohibits gifting public money or anything of value to any individual for a private purpose. 7 During our October 2006 audit, we only reviewed and reconciled up to four years of financial information for the substance abuse services coordination agencies. The agencies’ contracts, however, covered a 61-month period from December 1, 1998, to December 31, 2003. Office of the Inspector General Page 56 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors • The department may have failed to hold a contractor accountable for mishandling confidential inmate information. Phoenix Houses of California, Inc. operated a substance abuse treatment program at the California Substance Abuse Treatment Facility and State Prison, Corcoran, under a contract with DARS that ended in June 2006. On June 23, 2006, the manager of a nearby business reported that multiple items had been placed in that business’s dumpster. The items included documents that contained confidential inmate information, and mishandling this information may have violated state and federal law. Because the investigative unit at the institution was deficient in investigating the incident, the department did not hold the contractor accountable for its actions. We made 12 recommendations to address the identified findings. For example, we recommended that the department require the three agencies to reconcile their revenues and expenses and refund the department excess revenue they received during their 61-month contract period. We also recommended that Mental Health Systems, Inc. restate its expenses to record the costs of vehicles it purchased with state funds in accordance with generally accepted accounting principles. To ensure contractors do not retain ownership of equipment costing less than $5,000, we recommended that the department immediately revise its budget guide and all current cost reimbursement contracts to clarify ownership rights and responsibilities of contractors when they purchase such equipment with state funds. We also recommended that the department fully cooperate with the Office of the Attorney General regarding any investigation or inquiries related to this matter. Finally, we recommended that the investigative services unit at the California Substance Abuse Treatment Facility and State Prison, Corcoran, reconsider its decision to close its investigation of the incident related to one contractor’s improper disposal of confidential documents—and that the department take corrective action to ensure the contractor is held accountable for its actions. 2008 Follow-up Results We found the following results regarding the department’s corrective action taken to address the four findings identified in the October 2006 review. • The department did not complete its final reconciliations of the contractors’ revenues and expenses until December 2007, which was almost 14 months after we addressed the issue in our October 2006 report and only days before the statute of limitations for taking legal action under the contracts was due to lapse. To conduct its reconciliations, the department mainly relied on reconciliation data submitted by the contractors and audit work performed by the OIG during the October 2006 review. Although the methods used by the department to conduct its reconciliations were not consistent, the department concluded that it overpaid the contractors approximately $4.8 million. The department notified the contractors about its reconciliation results on December 19, 2007, and requested that they submit any written comments to the Office of the Inspector General Page 57 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors department’s Administrative Review Committee. As a result, the committee planned to meet with the contractors in March 2008 to review their issues and determine the amount of overpayments that the contractors owe to the state. When we reviewed the department’s reconciliations, however, we concluded that two of the contractors were overpaid an additional $800,000 because the department’s reconciliation allowed these two contractors to retain a 5 percent profit fee that was not authorized under the terms of the contract. Therefore, the contractors owe the state approximately $5.6 million. • Mental Health Systems, Inc. disagrees that it inappropriately expensed the 22 vehicles and believes that its purchase was appropriate under the terms of its contract with DARS. However, the contractor has released the title to the state for five of the vehicles it purchased with state funds. DARS requested a legal opinion regarding the contractors’ purchase of the vehicles. • In March 2007, DARS revised its budget guide to clarify the guidelines on contractors’ use of state funds to purchase equipment and supplies and to clarify that ownership of all expendable supplies and equipment costing less than $5,000 vests with the state. DARS notified both its own staff and the contract providers of the budget guide revisions. We confirmed that the department appropriately revised its budget guide and that the contracts allowed the department to revise the guide for clarity purposes. In March 2008, we referred the matter to the California Attorney General for review regarding recovering equipment the department improperly gifted to contractors. • The investigative services unit at the California Substance Abuse Treatment Facility and State Prison, Corcoran, determined that Phoenix Houses of California, Inc. did not violate regulatory requirements when it disposed of documents containing inmate information. The department’s Office of Internal Affairs considered the issue and decided not to investigate further. However, the department issued a letter to admonish the contractor for its failure to safeguard confidential information; the contractor later submitted a comprehensive corrective action plan to address the incident. We reviewed the plan and confirmed that it addressed the contractor’s implementation of new safety and security reviews and procedures for storing confidential information. Follow-up Recommendations As a result of the 2008 follow-up review, the OIG recommends that the California Department of Corrections and Rehabilitation take the following actions: • Collect all refunds owed to the state by the three substance abuse services coordination agencies related to excess revenue the agencies received for services provided during their contract period December 1, 1998, to December 31, 2003. (October 2006) Office of the Inspector General Page 58 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors • Require Mental Health Systems, Inc. to restate its expenses to record the costs of its purchases of automobiles in accordance with generally accepted accounting principles. (October 2006) • Ensure that Mental Health Systems, Inc. uses its adjusted actual costs of providing services during these periods when reconciling its revenues to actual costs. (October 2006) • Fully cooperate with the Office of the Attorney General regarding the recovery of equipment the department improperly gifted to contractors. (October 2006) The matrixes on the following pages summarize the results of the 2008 follow-up audit. Office of the Inspector General Page 59 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Special Review into Concerns Related to Substance Abuse Treatment Contractors Finding 1 The department overpaid three contractors nearly $5 million from fiscal year 2000–01 through 2003–04 because it did not require the contractors to reconcile revenues to their actual costs, as required under the contracts. (October 2006) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Require the substance abuse services coordination agencies Partially California Department of Corrections and Rehabilitation’s response: to reconcile revenues received during the contracts covering Implemented Partially Implemented. California Department of Corrections and the period December 1, 1998, to December 31, 2003, with Rehabilitation (CDCR) and Office of Audits and Compliance (OAC) will the actual costs of providing the services and refund any complete reconciliations by March 1, 2008. excess revenue received during that period. (October 2006) Notes from April 07 CAP: In Oct. 2006 CDCR notified Walden House, West Care, and Mental Health Systems to reconcile revenues received during the contract period 12/1/03 and repay any excess revenue by 12/29/07. Although the providers did not entirely agree with the OIG’s findings, Mental Health Systems conducted the reconciliation and provided CDCR a check for $63,578.01 dated 12/22/06 for revenues received. WestCare disagrees with the finding however, in an Aug 31, 07 letter to Kathy Jett has offered to settle any dispute with CDCR over amounts paid on the 1999-2003 SASCA contract for $350,000. Walden House conducted a reconciliation and provided CDCR a check for $7870.77 in April 2007. Office of the Inspector General’s comments: We contacted the department’s Division of Addiction and Recovery Services (DARS) and determined that the Office of Audits and Compliance had completed the reconciliations of the service coordinator agencies’ accounts in December 2007. DARS submitted key correspondence and financial documents to us in support of its corrective action regarding the reconciliations. We performed a cursory review of those documents, and our conclusions are summarized below. Office of the Inspector General Page 60 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Recommendation Status Comments DARS has been slow to address this recommendation. In fact, the department almost missed the opportunity to collect any overpayments from the service agencies at all. As stated in our October 2006 audit report, the statute of limitations for legal action under the service coordinator contracts was due to lapse on December 31, 2007, or shortly thereafter. Although DARS first requested that the service coordinator agencies reconcile their accounts in October 2006, DARS did not formally follow up with the agencies and did not request the OAC to conduct an independent reconciliation of the agencies’ accounts until October 2007. Consequently, the OAC did not complete its reconciliations and report the overpaid amounts to the agencies until December 19, 2007. To conduct its reconciliations, the OAC primarily relied on reconciliation data submitted by the service coordinator agencies and audit work performed by the OIG during the October 2006 audit. In completing its work, the OAC used inconsistent review periods and methodologies when it conducted the three reconciliations. For example, based on OAC documents we reviewed, it appears that the OAC based one service agency’s reconciliation on data from 72 months of operations, one from 60 months of operations, and one from only 35 months of operations. Yet the contract period for all three contracts was 61 months. In addition, the OAC allowed two of the agencies to deduct a 5 percent profit fee from their net revenues, equal to 5 percent of their adjusted direct expenses, but the OAC did not allow such a deduction for the third agency. Because the third agency could not provide 26 months worth of financial records, the OAC simply relied on our October 2006 report to determine the amount of that agency’s excess revenue. However, we had concluded during our audit that the contracts were cost reimbursement contracts and not fee-for-service contracts. Therefore, we excluded such fees when determining the agencies’ net revenues. Based on the OAC’s December 2007 reconciliation letters, the department needs to collect approximately $4.8 million that it overpaid to three service coordinator agencies for services provided from December 1, 1998, to December 31, 2003. The OAC requested that the contractors submit any written comments to the department’s Administrative Review Committee within 30 days of receiving the OAC’s December 19, 2007, letters. As a result, the committee planned to meet with the contractors in March 2008 to review Office of the Inspector General Page 61 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Recommendation Status Comments their issues and determine the amount of overpayments that the contractors owe to the state. As previously addressed, however, in its reconciliation for two of the agencies, the OAC may have understated the owed amount by $795,954 because it incorrectly allowed the agencies to keep a 5 percent profit fee. Based on the OAC’s reconciliation data, we believe that the service coordinator agencies owe the state nearly $5.6 million. Follow-up Recommendation The California Department of Corrections and Rehabilitation should collect all refunds owed to the state by the three substance abuse services coordination agencies related to excess revenue the agencies received for services provided during their contract period December 1, 1998, to December 31, 2003. (October 2006) Finding 2 Mental Health Systems, Inc. inappropriately expensed the entire value of 22 automobiles purchased with state funds for fiscal years 2000–01 through 2003–04, overstating its expenses by more than $250,000. (October 2006) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Require Mental Health Systems to restate its expenses to Partially California Department of Corrections and Rehabilitation’s response: record the costs of its purchases of automobiles in Implemented Partially Implemented. Mental Health Services (MHS) sent a response to the accordance with generally accepted accounting principles. Division of Addiction and Recovery Services (DARS) re-calculating their (October 2006) response to the OIG report, which is different than the amount the OIG report states. Therefore, DARS is requesting DARS/OAC to verify contractors opinion. In addition CDCR/DARS has requested a legal opinion regarding the purchasing of vehicles by contractors. MHS disagrees with this OIG’s finding and believes the purchase was made on an oral approval from CDCR staff, the use of the vehicles was appropriate, and although the vehicles were registered to MHS, they were the Office of the Inspector General Page 62 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Recommendation Status Comments property of CDCR. Through a painstaking process, MHS has released the titles for 5 vehicles to CDCR. MHS’s refund check was for overstating revenues received and had nothing to do with this automobile issue. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that Mental Health Systems uses its adjusted actual Partially California Department of Corrections and Rehabilitation’s response: costs of providing services during these periods when Implemented Partially Implemented. On October 31, 2006 Joseph D. Ossmann sent a reconciling its revenues to actual costs. (October 2006) letter to Mental Health Services, WestCare, and Walden House, in behalf of DARS, requiring that revenues be reconciled to actual costs, and that any revenues in excess of the actual cost of providing the services be repaid. DARS is following up with audits to ensure that this is done. All future contracts will adhere to the LIBG whereas all non-expendable equipment will be included in bid documents and depreciate over time. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Follow-up Recommendations The California Department of Corrections and Rehabilitation should take the following actions: • Require Mental Health Systems to restate its expenses to record the costs of its purchases of automobiles in accordance with generally accepted accounting principles. (October 2006) • Ensure that Mental Health Systems uses its adjusted actual costs of providing services during these periods when reconciling its revenues to actual costs. (October 2006) Office of the Inspector General Page 63 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Finding 3 The Department of Corrections and Rehabilitation has violated state law and policy by allowing contractors to retain ownership of potentially millions of dollars of property purchased with state funds. (October 2006) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Immediately revise its budget guide and all current cost reimbursement contracts to: • Ensure that ownership of all property purchased by Fully California Department of Corrections and Rehabilitation’s response: contractors with state funds vests with the state. Implemented Fully Implemented. DARS staff and contract providers were notified of the policy clarification/change regarding utilizing state funds for equipment and supplies. This was provided to the contractor via letter from DARS as well as reiterated in the LIBG. • Require contractors to leave all equipment purchased Fully California Department of Corrections and Rehabilitation’s response: with state funds as part of a cost reimbursement Implemented Fully Implemented. The LIBG was revised on March 2007 incorporating contract for use by subsequent contractors or for the language that ensures that ownership of all expendable supplies and/or department to otherwise utilize according to its equipment having an acquisition of less than $5,000, that is purchased by needs. (October 2006) contractors with state funds, will vest with the state. State contractors are not allowed to purchase non-expendable equipment with a unit acquisition cost of $5,000 or more. Office of the Inspector General’s comments: We reviewed letters that DARS sent to its program section managers and its substance abuse program directors clarifying the supplies/expendable equipment policy. We also reviewed the department’s March 28, 2007, Line Item Budget Guide (LIBG) for Cost Reimbursement Budgets and confirmed that it clarifies the proper treatment of equipment purchased with state funds. In addition, we reviewed a section of the contract language for one of the current providers. It stated that “the Contractor agrees that revisions to the LIBG which do not alter or change the intent of the program can be made without amending Office of the Inspector General Page 64 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Recommendation Status Comments the Agreement and will become effective on the date stipulated in the transmittal letter.” We agree with the department that the clarification in the LIBG regarding the treatment of equipment does not change the intent of the program. Therefore, it is reasonable for the department to conclude that it does not need to amend existing contracts to address this issue. Furthermore, DARS indicated in its response to the second recommendation in Finding 2 above that language in future contracts will adhere to the revised LIBG. Revise its budget guide to require future contractors to leave Fully California Department of Corrections and Rehabilitation’s response: all unused supplies purchased with state funds as part of a Implemented Fully Implemented. Contract providers have been advised to return all cost reimbursement contract for use by subsequent equipment purchased with state fund to DARS upon termination of services or contractors or for the department to dispose of according to redirect equipment to different contract providers per DARS instruction. Thus, its needs. (October 2006) DARS has revised the Line Item Budget Guide (LIBG). Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The OIG is referring the matter relating to the department’s Not California Department of Corrections and Rehabilitation’s response: gift of public funds to contractors to the Attorney General’s Applicable Not Implemented. The Office of the Inspector General is referring this to the Office for its consideration in recovering equipment the Attorney General’s Office. All DARS staff will fully cooperate with all law department improperly gifted to contractors. The OIG enforcement personnel during the course of any investigation. recommends that the department cooperate fully with the Attorney General in this matter. (October 2006) Office of the Inspector General’s comments: We changed the department’s designated status of corrective action for this recommendation from not implemented to not applicable for the following reasons: • We did not refer this matter to the Office of the Attorney General until March 2008. • The department indicated above that it has been standing by and is ready to cooperate with the Office of the Attorney General if it decides to pursue the matter. Follow-up Recommendation Fully cooperate with the Office of the Attorney General regarding the recovery of equipment the department improperly gifted to contractors. (October 2006) Office of the Inspector General Page 65 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Finding 4 The Department of Corrections and Rehabilitation may have failed to hold a contractor accountable for mishandling confidential inmate information. (October 2006) Recommendation Status Comments The California Substance Abuse Treatment Facility and State Prison, Corcoran, should: Reconsider its decision to close its investigation related to Fully California Department of Corrections and Rehabilitation’s response: the improper disposition of confidential inmate information. Implemented Not Applicable. This matter was initially referred to the investigation unit at In reconsidering its decision, the investigative services unit the Substance Abuse Treatment Facility (SATF) for review. Upon conclusion should consider the pertinent federal, state, and contractual of the fact finding inquiry, SATF investigations unit determined that no criteria that require Phoenix Houses of California, Inc. to regulatory violation occurred. CDCR Internal Affair Unit arrived at the same ensure that confidential information is properly conclusion. safeguarded. (October 2006) Office of the Inspector General’s comments: While we performed no audit procedures to verify the department’s representation, based on the department’s response and its November 2007 letter to the Inspector General informing him that the Office of Internal Affairs had considered the issue and decided not to investigate further, we have determined the recommendation to be fully implemented rather than not applicable. If the investigative services unit concludes that Phoenix Houses of California, Inc. did not properly safeguard confidential inmate information, the California Department of Corrections and Rehabilitation should: Pursue any available legal remedies for violations of federal Not California Department of Corrections and Rehabilitation’s response: and state laws. (October 2006) Applicable Not Applicable. This matter was initially referred to the investigation unit at the Substance Abuse Treatment Facility (SATF) for review. Upon conclusion of the fact finding inquiry, SATF investigations unit determined that no regulatory violation occurred. CDCR Internal Affair Unit arrived at the same conclusion. The records found were not confidential inmate information, they were the Office of the Inspector General Page 66 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Recommendation Status Comments same information that a person could obtain via the Public Information Act. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Officially admonish Phoenix Houses of California, Inc. for Fully California Department of Corrections and Rehabilitation’s response: its failure to safeguard confidential inmate information so Implemented Fully Implemented. On October 31, 2006, by Joseph D. Ossmann Deputy that the department can consider the actions of Phoenix Director (A), DARS management issued a letter admonishing Phoenix House. Houses of California, Inc. in future contracting considerations. (October 2006) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The Division of Addiction and Recovery Services should: Make certain that Phoenix Houses of California, Inc. takes Fully California Department of Corrections and Rehabilitation’s response: corrective action to ensure that confidential inmate Implemented Fully Implemented. DARS requested corrective action from Phoenix House. information it possesses as part of its current or future The corrective action was received. substance abuse treatment contracts is adequately safeguarded. (October 2006) DARS issued a letter on October 19, 2006, to all of the Substance Abuse Program (SAP) Program Managers outlining the policy on safeguarding confidential inmate information. Office of the Inspector General’s comments: We reviewed the November 2006 corrective action plan submitted by the regional director of Phoenix Houses of California, Inc. The plan was comprehensive and addressed the contractor’s implementation of new safety and security reviews as well as its newly developed procedures on the storage of confidential information. If the Office of Substance Abuse Programs determines that Phoenix Houses of California, Inc. has not taken appropriate corrective actions, and therefore cannot properly safeguard confidential inmate information, the California Department of Corrections and Rehabilitation should: Office of the Inspector General Page 67 2008 Accountability Audit Concerns Related to Substance Abuse Treatment Contractors Recommendation Status Comments Cancel its substance abuse treatment contracts with Phoenix Not California Department of Corrections and Rehabilitation’s response: Houses of California, Inc. for cause. (October 2006) Applicable Not Implemented. DARS is satisfied with Phoenix Houses of California, Inc. corrective action plan submitted on November 13, 2006. Office of the Inspector General’s comments: As previously addressed, we reviewed the November 2006 corrective action plan and found that it was comprehensive and addressed the contractor’s implementation of new safety and security reviews and new procedures on the storage of confidential information. Because the contractor implemented appropriate corrective actions to ensure that confidential inmate information is properly safeguarded, DARS did not need to cancel its substance abuse treatment contracts with the contractor. Therefore, we changed the department’s designated status of this recommendation to not applicable. Follow-up Recommendation None Office of the Inspector General Page 68 2008 Accountability Audit Chapter 2 Chapter 2: Follow-Up Results for 33 Reports Issued Between 2000 and 2005 This chapter provides the follow-up results of 33 audits and reviews originally issued between 2000 and 2005. All of these audits have been subject to at least one previous accountability audit; for most of these audits, this accountability audit presents our final assessment of the CDCR’s implementation of past recommendations. At the conclusion of our audit fieldwork, the department had either fully or substantially implemented 86 percent (632 of 734) of our past recommendations. This high rate of implementation—an increase of 17 percentage points since our first accountability audit—demonstrates that our original audits and follow-up accountability audits have driven change at the department. At the start of this follow-up audit, 171 of the 734 recommendations remained unimplemented. In performing the audit, we found that the CDCR has satisfactorily implemented 69 of the 171 unresolved recommendations. However, 100 recommendations remain unimplemented or only partially implemented, and two recommendations are no longer applicable. History of Past Audits and Reviews Starting in 2005, we began conducting reviews of past audit recommendations and issued public reports detailing the corrective action taken by the department.8 These reports, called accountability audits, provide the public and policy makers with objective information on the status of our past recommendations and, ultimately, serve as a tool to hold the department accountable. As shown in Table 4, there were 734 recommendations covered by our previous accountability audits of the 33 reports issued between 2000 and 2005. Of those 734 recommendations, 171 remained unimplemented at the start of this 2008 accountability audit. 8 Between 2002 and 2004, the OIG completed four follow-up audits of past recommendations; however, we did not issue public reports. Office of the Inspector General Page 69 2008 Accountability Audit Chapter 2 Table 4 History of Past OIG Accountability Audits Follow-up Audits Total Recommendations 2002 Recommendations Since Original to Assessed in 2008 Report (Year Issued) Audit 2004 2005 2006 2007 Follow-up Audit Adult Operations & Programs SVSP Inmate Appeal & Disciplinary Process (2000) 7 X X 3 CRC Inmate Appeals (2000) 5 X 1 CSP Sacramento MRA (2000) 18 X 4 Valley State Prison for Women MRA (2001) 30 X 4 Inmate Appeals Branch (2001) 4 X X 1 Sierra Conservation Center MRA (2001) 54 X 5 Leo Chesney CCF MRA (2001) 19 X 3 Office of Internal Affairs* (2001) 32 X 11 High Desert State Prison MRA (2001) 28 X 6 Local Assistance Program (2002) 5 X 1 Correctional Facility Mail Processing (2002) 32 X 8 Office of Audits and Compliance** (2002) 4 X 2 Medical Contracting Process (2002) 7 X 1 SATF MRA (2003) 72 X 23 CSP Solano MRA (2003) 24 X 3 Pharmaceutical Expenditures (2003) 3 X 2 Education Programs at Level IV Institutions (2003) 5 X 2 Commission on CPOST (2005) 7 X 6 Review into the Death of Officer Gonzalez (2005) 34 X 11 Subtotal for Adult Operations & Programs 390 97 Division of Juvenile Justice Heman G. Stark YCF MRA (2000) 51 X X X 7 23-and-1 Program Review (2000) 6 X X 4 Ventura YCF MRA (2002) 101 X X 6 Intensive Treatment Program (2002) 9 X X 4 Juvenile Parole Board (2002) 8 X X 1 Southern Youth CRCC MRA (2003) 68 X X 5 Office of Audits and Compliance*** (2003) 8 X X 3 N.A. Chaderjian YCF MRA (2005) 52 X 19 Death of a Ward at N.A. Chaderjian YCF (2005) 16 X 8 Subtotal for Division of Juvenile Justice 319 57 Board of Parole Hearings Indeterminate Sentence Hearings & Appeals (2000) 8 X X X 5 Review of BPH Decisions (2003) 2 X X 1 Hearings for Mentally Disordered Offenders (2003) 2 X X 1 Supervision of Deputy Commissioners (2003) 5 X X 2 Interpretation Services Procedures (2005) 8 X 8 Subtotal for Board of Parole Hearings 25 17 Totals 734 171 * Formerly Office of Investigative Services ** Formerly CDC Internal Audits *** Formerly CYA Internal Audits Office of the Inspector General Page 70 2008 Accountability Audit Chapter 2 Summary of Results During our follow-up for this accountability audit, we found that the department has satisfactorily implemented (in other words, either fully or substantially implemented) 69 of the 171 recommendations that were remaining at the start of this audit—a completion rate of 41 percent, as shown in Table 5. We also found that two recommendations were no longer applicable, thus leaving 100 of the 734 recommendations still unimplemented or only partially implemented. Table 5 Overall Implementation Rates at the Start of the 2008 Accountability Audit Status of Implementation Number of Unimplemented Satisfactory Unsatisfactory Recommendations Prior to 2008 Name Implementation Implementation Accountability Audit Adult Operations and Programs 97* 48 51% 47 49% Division of Juvenile Justice 57 12 21% 45 79% Board of Parole Hearings 17 9 53% 8 47% Totals 171* 69 41% 100 59% * Includes two recommendations found to be no longer applicable during the current 2008 accountability audit. Notable examples of implemented recommendations from this year’s accountability audit include the following: • Our recent review of the California Institution for Men’s tool control policies and oversight activities found that the institution successfully implemented our recommendation that all tools within the secured perimeter be under the supervision of the tool control team. • The California Institution for Men and Wasco State Prison have procedures to minimize the access to evidence collected during an incident. Valley State Prison for Women reported that it also limits staff members’ access to its evidence room, which now provides for better control over the storage of confiscated drugs. • The California Substance Abuse Treatment Facility and State Prison, Corcoran, purchased a time clock for contracted physicians to clock in and out when reporting for or departing work. Moreover, the medical administrative staff conducts reconciliations of the physician time cards and the monthly registry billings. These measures greatly improve staff accountability and protect state resources. Although the results of our 2008 accountability audit indicate that 100 previous recommendations remain unimplemented, Table 6 provides additional perspective by showing the total number of recommendations made since the original reports were issued and the overall implementation status from that point. Office of the Inspector General Page 71 2008 Accountability Audit Chapter 2 Table 6 Implementation Rates Since the Original Reports Were Issued, 2000–2005 Status of Implementation Number of Recommendations Satisfactory Unsatisfactory Name Made, 2000–2005 Implementation Implementation Adult Operations and Programs 390* 341 88% 47 12% Division of Juvenile Justice 319 274 86% 45 14% Board of Parole Hearings 25 17 68% 8 32% Totals 734* 632 86% 100 14% * Includes two recommendations found to be no longer applicable during the current 2008 accountability audit. Remaining Unimplemented Recommendations Even though only 100 recommendations remain unresolved, some of these recommendations represent problems that continue to jeopardize the safety of staff and inmates, waste public funds, or increase the risk of legal action against the state. Of equal concern is that, in many instances, the department has had several years to implement these remaining recommendations, and we have reminded the department to address them in previous accountability audits. However, it should also be noted that some of the 100 recommendations might remain unimplemented for reasons beyond the department’s control. For example, the department may have been denied funding, a federal court may have intervened and taken over this responsibility, or the department may have disagreed with our initial recommendation. ADULT OPERATIONS AND PROGRAMS The department has 47 remaining recommendations for its adult operations and programs. The areas affected by the unimplemented recommendations include inmate safety, dental care, and pharmacy operations. For example, at California State Prison, Solano, we found that some inmates with seizure-related issues were housed in upper bunks despite medical recommendations to house the inmates in lower bunks. As a result, inmates may be at risk of serious injury, thus exposing the department to possible litigation. In addition, the department reported that inmates at California State Prison, Sacramento, are still not receiving dental exams within 90 days of their arrival, as required by a federal court order. Moreover, California Substance Abuse Treatment Facility and State Prison, Corcoran, continues to have a backlog of inmates awaiting dental services. By failing to implement these recommendations, the department may come under further scrutiny by the courts. Further, the department reported that its pharmacy tracking and inventory system is still deficient at three prisons: High Desert State Prison; California Substance Abuse Treatment Facility and State Prison, Corcoran; and California State Prison, Solano. The Office of the Inspector General Page 72 2008 Accountability Audit Chapter 2 department indicated that these deficiencies will be fixed through a contract that the medical receiver signed with Maxor National Pharmacy Services Corporation. The contractor is developing a computerized distribution system for prescriptions; however, the system has not been implemented at these three institutions. Thus, the potential for wasting state funds from pharmacy operations will continue until implementation is completed. Lastly, the department noted that the main yards at High Desert State Prison still lack video cameras because of funding issues. During incidents, the video could help identify the inmates involved, serve as documentation for disciplinary actions, and be used to evaluate the staff’s response to the incident. The video also could be useful in training sessions. DIVISION OF JUVENILE JUSTICE The Division of Juvenile Justice still has 45 unimplemented recommendations for improving the operations of its juvenile facilities, including 23 recommendations stemming from two audits of the N.A. Chaderjian Youth Correctional Facility. According to the division, partially implemented recommendations at N.A. Chaderjian that effect staff and inmate safety include ending the practice of isolating wards in their rooms for long periods, providing mental health services during lockdowns, providing training to the counseling and treatment staff, correcting building deficiencies, and conducting a security audit of the facility. By not fully implementing these recommendations, the Division of Juvenile Justice risks not complying with the requirements identified in the Farrell v. Tilton Consent Decree. BOARD OF PAROLE HEARINGS We found that the Board of Parole Hearings has implemented 17 of 25 past recommendations, but eight recommendations remain uncorrected. Notably, the Board of Parole Hearings informed us that it only partially implemented several of our 2005 recommendations designed to safeguard the funds it spends on interpretation services, including collecting past overpayments made to interpreters. Final Assessment for All But a Few Recommendations For most of the outstanding recommendations discussed in Chapter 2, this will be our final follow-up. We have made our best effort to pursue these recommendations, but we cannot continue to expend state resources to follow up on recommendations that the department will not or cannot address. Further, we hope that our accountability audit prompts policy makers and the public to hold the department responsible for implementing the remaining recommendations. Office of the Inspector General Page 73 2008 Accountability Audit Chapter 2 However, there are a few critical recommendations that are too serious to ignore. While we continue to review the CDCR’s operations through our audits and special reviews, we will track and report on the following specific issues until they are resolved. • California State Prison, Solano, must ensure that inmates who suffer from seizure- related conditions are housed in lower bunks to protect them from fall-related injuries in the event of a seizure. • The department needs to establish efficient pharmacy tracking and inventory procedures to minimize the waste of state funds. • The Division of Juvenile Justice needs to ensure that youthful offenders receive mandated services, especially when they are isolated in their rooms for long periods. This is important because extended confinement combined with lack of exercise or recreation may aggravate mental health problems and increase the risk of suicide. The following matrixes present the findings, recommendations, and results of our follow- up review of the 33 reports. Office of the Inspector General Page 74 Salinas Valley State Prison 2008 Accountability Audit Inmate Appeal and Inmate Disciplinary Processes Salinas Valley State Prison Inmate Appeal and Inmate Disciplinary Processes Finding 2 The Salinas Valley State Prison had made little progress in improving its inmate disciplinary process. (September 2003) Recommendation Status Comments Salinas Valley State Prison should: Develop an alternative method of tracking informal inmate Fully California Department of Corrections and Rehabilitation’s response: appeals instead of logging each informal appeal in the Implemented Fully Implemented. SVSP has eliminated the formal tracking and logging of appeals tracking system. (April 2006) informal inmate appeals in the appeals tracking system. SVSP has developed and implemented the logging and tracking of informal inmate appeals by each respective department head. Informal inmate appeals are collected, reviewed, logged and assigned to the appropriate reviewer on a daily basis. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Provide for staff accountability in the inmate disciplinary Fully California Department of Corrections and Rehabilitation’s response: system procedures. (September 2003) Implemented Fully Implemented. SVSP has continued with implemented corrective action relevant to the following identified areas: • Individual Chief Disciplinary Officer Registries are maintained with weekly requests for updates generated. • Registry logs are audited monthly by the Chief Disciplinary Officer and are in compliance with PC 2081, DOM and the CCR. • Periodic training is provided to all staff, including Chief Disciplinary Officers relevant to the inmate disciplinary process. SVSP has identified and implemented the following new processes to monitor staff accountability in the inmate disciplinary process. • Review and monitoring of quarterly Comp stat data reports specific Office of the Inspector General Page 75 Salinas Valley State Prison 2008 Accountability Audit Inmate Appeal and Inmate Disciplinary Processes Recommendation Status Comments to the inmate disciplinary process. • Staff accountability is maintained through Senior Hearing Officer assignment and tracking by the respective Facility/Correctional Captain. This computerized tracking system is utilized by the respective Facility/Correctional Captain in preparation of the weekly status report. • Weekly facility status reports are prepared through review and audit of the SHO assignment tracking and CDCR 1154 Disciplinary Action logs by the respective Facility/Correctional Captains to report current inmate disciplinary process status. This weekly status report is reviewed by the Associate Warden, Chief Deputy Warden and Warden. • Weekly Chief Disciplinary Officer, Facility/Correctional Captain participation with Classification Services Representative exit reviews with specific review of inmate discipline. • Progressive discipline is provided as deemed necessary. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Prepare and execute a corrective action plan to address Fully California Department of Corrections and Rehabilitation’s response: deficiencies in the inmate disciplinary process. (April 2006) Implemented Fully Implemented. SVSP has identified and corrected all areas described within the 2006 Office of the Inspector General follow up accountability audit report. See above. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 76 California Rehabilitation Center 2008 Accountability Audit Review of the Inmate Appeal Process California Rehabilitation Center Review of the Inmate Appeal Process Finding 3 A high percentage of the inmate appeals at the California Rehabilitation Center concerned the forwarding of inmate property and trust funds to other institutions. (August 2000) Recommendation Status Comments The California Rehabilitation Center should: Consider initiating procedures to transfer inmate property at Not California Department of Corrections and Rehabilitation’s response: the time of the inmate’s relocation rather than waiting for Implemented Not Implemented. CRC has implemented the practice of the property officer the inmate to return a form once inmate is permanently checking OBIS each week for CRC inmates who have been permanently housed at another institution. (August 2000) transferred from CIM to another institution. This process was established in lieu of the recommendation of the OIG. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 77 California State Prison, Sacramento 2008 Accountability Audit Management Review Audit California State Prison, Sacramento Management Review Audit Finding 5 The Identix Touchlock II System did not work properly and, apparently, some of the institution staff members did not use it. (September 2000) Recommendation Status Comments California State Prison, Sacramento, should: Explore options for a cost-effective electronic system that Not California Department of Corrections and Rehabilitation’s response: effectively tracks the entry and departure of staff and Implemented Not Implemented. The California Department of Corrections and visitors at the institution. (April 2006) Rehabilitations Emergency Operations Unit has been contacted in order to determine if a cost-effective system that effectively tracks the entry and departure of staff and visitors is available. According to the Emergency Operations Unit, no other prison is utilizing such a system, and the Emergency Operations Unit is not currently exploring options for such a system. The Warden is committed to the safety and security of the prison and continually improving safety and security. If a system is discovered that can meet the needs and is cost-effective, he will consider purchasing it. Currently, manual systems are being used for accountability in lieu of electronic systems. Each institution has developed staff accountability procedures. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 78 California State Prison, Sacramento 2008 Accountability Audit Management Review Audit Finding 7 The institution was not in compliance with the regulatory requirement for providing dental examinations to inmates. (September 2000) Recommendation Status Comments California State Prison, Sacramento, should: Barring a change in Title 15, California Code of Partially California Department of Corrections and Rehabilitation’s response: Regulations, comply with the requirement to provide dental Implemented Partially Implemented. The requirement to examine inmates within 14 days examinations to inmates within 14 days of their arrival at the of arrival from reception centers has been superseded by the Federal Court institution. (September 2000) ordered Perez v. Tilton Stipulated Agreement. Dental Staff at general population institutions are now required to provide a dental examination within 90 days of arrival to inmates who come directly from a reception center. California State Prison, Sacramento is not yet in full compliance with this requirement; however we are working towards attaining compliance. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 9 Employee probation and performance reports were not completed in a timely manner. (September 2000) Recommendation Status Comments The warden of California State Prison, Sacramento, should: Take steps to ensure that performance and probationary Substantially California Department of Corrections and Rehabilitation’s response: reports are completed in a timely manner. (September 2000) Implemented Substantially Implemented. On June 1, 2007, California State Prison, Sacramento’s Personnel Office implemented an electronic tracking and notification system for all employee performance and probationary Office of the Inspector General Page 79 California State Prison, Sacramento 2008 Accountability Audit Management Review Audit Recommendation Status Comments reports. This includes the ability to initiate overdue reports. The system has improved the distribution and tracking of Performance Evaluations and has decreased the number of overdue evaluations. However, the current status of evaluations is below our objective of 100% completion rate. A continued monitoring and evaluation of this system, and implementing necessary changes will continue to improve the system and the percentage of overdue reports will decrease. California State Prison, Sacramento’s goal is to complete all evaluations on a month-to- month basis. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 12 The California State Prison, Sacramento, incurred high costs in workers’ compensation expenditures and related service fees paid to the State Compensation Insurance Fund. (September 2000) Recommendation Status Comments The California Department of Corrections and Rehabilitation and the warden of California State Prison, Sacramento, should: Implement measures to lower workers’ compensation costs Substantially California Department of Corrections and Rehabilitation’s response: through enhanced case monitoring, thereby minimizing Implemented Substantially Implemented. Caseload management is a crucial component service fees paid to the State Compensation Insurance Fund. of our plan to reduce Workers’ Compensation costs. The addition of the (April 2006) second Return to Work Coordinator position at SAC in March 2006 continues to allow more efficient tracking of Workers’ Compensation cases. Per figures published on the Department of Personnel Office of the Inspector General Page 80 California State Prison, Sacramento 2008 Accountability Audit Management Review Audit Recommendation Status Comments Administration (DPA) website, although our service fees have increased in the past three fiscal years, there is still an overall reduction in these costs for 06/07 FY of 5.46% when compared with service fees paid in 01/02 FY. In addition, it should be noted that SAC has considerably increased our total number of staff resulting in an increase of total payroll from just over $76 million in 01/02 FY to nearly $128 million in 06/07 FY. Even with this significant increase (approximately 68%) in total payroll, SAC has managed to continue a steady decline in cost expenditures as a percentage of payroll from 8.71% in 01/02 FY to a low of just 4.29% in 06/07 FY. As an additional component of our efforts to reduce service fees, SAC is working with staff from the Office of Risk Management (ORM) who recently conducted a case review of over 100 SAC claims considered “low-activity claims” (no activity for the past six months). The ORM staff has prepared a report to SCIF identifying 43 current cases that can be closed and an additional 31 cases that appear ready for settlement. This should further reduce service fees as these cases settle and close. Office of the Inspector General’s comments: To verify the prison’s response, we reviewed statistical data from the Department of Personnel Administration’s (DPA) Web site related to workers’ compensation program costs. We also interviewed prison administrative staff members and obtained supporting documentation related to the workers’ compensation program. We corroborated the workers’ compensation program cost statistics that California State Prison, Sacramento, claimed in its response against information available on the DPA’s Web site. In addition, we found that the total percentage of the prison’s payroll costs spent to manage and pay out compensation claims dropped by 4.42 percent from fiscal year 2001–02 through fiscal year 2006–07. California State Prison, Sacramento, reported that it has taken several steps to help lower the overall costs related to the workers’ compensation program. Specifically, besides hiring a second return-to-work coordinator, the prison indicated that it now conducts bi-weekly meetings with institution management regarding the status of cases, holds quarterly meetings with the State Compensation Insurance Fund (SCIF), initiates Office of the Inspector General Page 81 California State Prison, Sacramento 2008 Accountability Audit Management Review Audit Recommendation Status Comments frequent communications with SCIF adjusters, and maintains communications with ill or injured employees, their supervisors, and their treating physicians. Prison managers also stated that they identify and arrange for light- or modified-duty assignments when applicable and conduct ongoing staff training on workplace safety. Overall, while we found that California State Prison, Sacramento, successfully lowered its percentage of total payroll costs paid annually for service fees for the workers’ compensation program in recent years, room for improvement still exists. According to the DPA’s Web site, two-thirds of all other adult institutions statewide had a lower percentage of workers’ compensation costs relative to the percentage of payroll costs during the 2006–07 fiscal year. Therefore, we concur that the recommendation is substantially implemented. Office of the Inspector General Page 82 Valley State Prison for Women 2008 Accountability Audit Management Review Audit Valley State Prison for Women Management Review Audit Finding 6 Employee probation and performance reports were not completed in a timely manner. (January 2001) Recommendation Status Comments Valley State Prison for Women should: Hold staff members with responsibility for preparing Fully California Department of Corrections and Rehabilitation’s response: performance and probation reports accountable for Implemented Fully Implemented. When a new employee begins their assignment at Valley completing and submitting the reports on the required date State Prison for Women, the Personnel Specialist prepares a Performance and use progressive discipline to ensure compliance. Evaluation Tracking card. This card details the due dates of all required (April 2006) Performance Reports, probationary as well as annual. The tracking cards are sorted numerically by the month they are due. Each month, the tracking cards for the proceeding month’s performance reports are pulled. The performance reports are prepared by Personnel Staff and distributed to the applicable Division Head for appropriate disposition. On the 6th day of each month, a Past Due Performance Report is processed by Personnel and forwarded to the Warden. The Warden uses this report to address delinquent performance reports in the executive staffing meetings and issue direct assignments to complete the Performance Report(s). For the current year (2007), 98% of the total performances due have been processed on time. The remaining 2% past due are primarily staff that are on vacation, official business, extended sick or otherwise absent from the institution. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 83 Valley State Prison for Women 2008 Accountability Audit Management Review Audit Finding 7 Control over the storage and disposal of drugs at Valley State Prison for Women was inadequate. (January 2001) Recommendation Status Comments Valley State Prison for Women should: Follow its updated evidence control procedure Fully California Department of Corrections and Rehabilitation’s response: (operational procedure 83090.04) for the destruction of Implemented Fully Implemented. ISU follows the guidelines as required by the Department drugs. (April 2006) Operations Manual regarding the destruction of drugs. Valley State Prison for Women and Central California Women’s Facility share the expense of the costs for the destruction of the drugs. The ISU Evidence Officer always signs an acknowledgment verifying the counts. ISU has one Correctional Officer who is designated as the Evidence Officer. This officer is supervised by a sergeant and these 2 individuals are the only staff that have access to the evidence room, where the confiscated drugs are stored. The supervisor(s) conduct unannounced inventories of the evidence room monthly and enter their names in the log book. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 84 Valley State Prison for Women 2008 Accountability Audit Management Review Audit Finding 13 A number of deficiencies in institutional security at Valley State Prison for Women were found. (January 2001) Recommendation Status Comments Valley State Prison for Women should: Take the following additional actions with respect to Fully California Department of Corrections and Rehabilitation’s response: weapons qualifications: Implemented Fully Implemented. As of October 2007, Valley State Prison for Women • Conduct a quarterly audit of staff members continues to provide Quarterly Qualifications for specific staff in designated assigned to armed posts to ensure compliance positions. Quarterly audits are also completed for staff in designated positions with the quarterly range qualifications. to ensure quarterly qualifications requirements are met. All posts requiring • Instruct armed post supervisors to ensure that monthly weapons qualification are noted in the IST Bulletin, which is issued their subordinates fulfill their quarterly range monthly to all staff. requirements. • Pursue progressive discipline against staff Supervisors continuously inspect CDC 861 Weapons Qualification Cards (Gold members and supervisors who are non- Cards) of staff in designated posts to ensure compliance with the quarterly compliant with range qualification requirements. requirements. (April 2006) Names of staff who fail to comply with the quarterly compliance are forwarded to the Correctional Captain for appropriate action. Progressive Discipline is taken if the circumstances warrant. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 85 Valley State Prison for Women 2008 Accountability Audit Management Review Audit Finding 14 The Valley State Prison for Women warden failed to purchase drug interdiction equipment mandated by the Department of Corrections. (January 2001) Recommendation Status Comments Valley State Prison for Women should: Ensure that all employees receive drug interdiction Partially California Department of Corrections and Rehabilitation’s response: training. (January 2001) Implemented Partially Implemented. Throughout the last year, Valley State Prison for Women has provided Crime Scene and Evidence Training during the weekly Block Training classes. The IST Lesson Plan for Crime Scene and Evidence Preservation specifically refers to drugs or drug paraphernalia as possible evidence at a crime scene. During the training, information relating to the identification of various types of drugs and the manner the drugs are packaged within an institution is provided. This training also provides specific information regarding the appropriate manner of searching in an effort to train staff to be more successful in locating drugs and other types of contraband. Valley State Prison for Women provides monthly training to ISU staff to enhance its drug interdiction efforts. Additionally, Drug Interdiction training was added to the curriculum of the weekly Block Training Classes as of November 2007. This training will provide detailed information relevant to the signs and symptoms of being under the influence of drugs. Subject matter experts assigned to the ISU instruct these classes. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 86 2008 Accountability Audit Inmate Appeals Branch Review of the Inmate Appeals Branch California Department of Corrections and Rehabilitation, Office of Compliance Finding 1 Integration of the inmate appeals tracking system with third-level appeals was still in the planning stage. (February 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Require the Information Systems Division to either Partially California Department of Corrections and Rehabilitation’s response: integrate the inmate appeals tracking system with the Implemented Partially Implemented. Since the 2006 Accountability Audit, the Inmate third-level appeals or contract with a private firm to do Appeals Branch (IAB) has worked continuously with Enterprise Information so. (February 2001) Systems (EIS) to design and develop an enhanced Inmate Appeals Tracking System (IATS) for use by the Third Level. EIS was also tasked with building a program to replace antiquated and unsupported software used by IAB appeal examiners. The completed applications for this were tested in April 2007, with full implementation taking place in July 2007. These improvements complete the technological “platform” from which an integrated statewide appeal database application can now be launched, and represent the second of a three phase process to achieve departmental connectivity. Discussion with EIS regarding Phase III is underway to determine the project’s current feasibility and how resources will be allocated, if approved. With the recent program improvements: a sequel server database and Windows environment with linkage to the Offender Based Information System and Distributed Data Processing System, completing the final phase of the project would likely take approximately three to six months. Prioritization of the project, whether contracted or not, rests with EIS and Headquarters. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 87 Sierra Conservation Center 2008 Accountability Audit Management Review Audit Sierra Conservation Center Management Review Audit Finding 1 The administration failed to follow up on a mandated policy directive, an inmate was victimized, and staff was placed at risk as a result. No manager or supervisor was held accountable for failing to implement the required changes. (May 2001) Recommendation Status Comments The warden of Sierra Conservation Center should: Hold managers and supervisors accountable for failure to Fully California Department of Corrections and Rehabilitation’s response: follow through with their responsibilities. (May 2001) Implemented Fully Implemented. 5 of the 47 Letters of Instruction issued from April 2006- April 2007 were issued to Custody and Non-Custody managers and supervisors. Letters of Instruction are issued to managers and supervisors when merited. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that letters of instruction are issued when merited. Fully California Department of Corrections and Rehabilitation’s response: (April 2006) Implemented Fully Implemented. Total number of Letters of Instruction issued from April 2006 - April 2007: 47 (Custody: 26 of 47 Letters of Instruction issued to custody staff; 5 of the 26 to custody supervisors and managers); (Non- Custody: 16 of the 47 Letters of Instruction issued to non-custody staff. [Note: No Letters of Instruction were issued to a non-custody manager or supervisor.] Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Maintain a tracking log with complete and up-to-date Fully California Department of Corrections and Rehabilitation’s response: information on the disposition of letters of instruction. Implemented Fully Implemented. The institution’s Employee Relations Officer maintains a (April 2006) written log for Letters of Instruction. The Employee Relations Officer reviews each Letter of Instruction for format and content (in accordance with institution’s Operational Procedure), issues it a log/tracking number, and routes the Letters of Instruction to the Warden for approval and signature, Office of the Inspector General Page 88 Sierra Conservation Center 2008 Accountability Audit Management Review Audit Recommendation Status Comments prior to forwarding the Letters of Instruction to the Institutional Personnel Officer. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 2 Inmate and staff safety was jeopardized and illegal inmate activities may have gone unnoticed because inmates were allowed to erect unauthorized privacy curtains within the housing units. (May 2001) Recommendation Status Comments The warden of Sierra Conservation Center should: Continue to enforce the order that the staff remove all Partially California Department of Corrections and Rehabilitation’s response: sheets and makeshift privacy curtains in housing units that Implemented Fully Implemented. Supervisory staff have provided training regarding would obstruct the view of officers. (May 2001) curtains (i.e., visual obstructions). Written directives have been distributed to staff and inmates by managerial staff regarding visual obstructions, modesty screens, etc. Custodial staff post orders contain verbiage informing staff of their duties and responsibilities as it relates to the removal of shower curtains, visual obstructions in the dorms. Additionally, inmates found in violation have been subjected to progressive disciplinary action. This is an on-going process. Office of the Inspector General’s comments: On January 9, 2008, we conducted an unannounced site visit of the housing units at Sierra Conservation Center. We observed no less than 20 different instances of inmates using makeshift privacy curtains in their bunk areas. We also noticed at least eight instances where inmates had rigged cloth curtains out of bed sheets to use as shower privacy screens. While most of the privacy curtains were observed in the Mariposa and Calaveras housing units, we found that the Office of the State Fire Marshal had made similar observations in two of the five housing units on the Tuolumne yard during the fire marshal’s annual fire and life safety inspection in August 2007. Although Sierra Office of the Inspector General Page 89 Sierra Conservation Center 2008 Accountability Audit Management Review Audit Recommendation Status Comments Conservation Center has made efforts to implement the recommendation, our observations indicate that it is not yet fully implemented. Therefore, we modified the status to partially implemented. Sierra Conservation Center could do more to hold officers and supervisors accountable for removing makeshift privacy screens. Finding 7 In some instances, the inmate disciplinary system at Sierra Conservation Center was not regularly meeting statutory, constitutional, or procedural mandates. (May 2001) Recommendation Status Comments Sierra Conservation Center should ensure that: The form used for the administrative officer of the day Fully California Department of Corrections and Rehabilitation’s response: inspection sheets be revised to include a review of the Implemented Fully Implemented. Effective Nov. 2007 Department Administrative Officers of disciplinary logbooks. (April 2006) the Day are assigned specific areas of the institution to inspect during their weekly AOD duties. Audit instruments have been created for these specific areas. In regards to disciplinary logbook reviews the audit instrument has been revised to include specific information contained in disciplinary logbooks. This information is in the audit tool specific to housing units where disciplinary logbooks are maintained. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 90 Leo Chesney Community Correctional Facility 2008 Accountability Audit Management Review Audit Leo Chesney Community Correctional Facility Management Review Audit Finding 1 Allegations of misconduct by staff and inmates at the Leo Chesney Center were not adequately investigated. (October 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Develop and implement clear policies to guide Partially California Department of Corrections and Rehabilitation’s response: investigations into alleged misconduct by individuals at Implemented Substantially Implemented. On 12/15/05 a new Leo Chesney CCF contract was community correctional facilities who are not employed by approved that incorporated clear “Contractor Employee Misconduct” the Department of Corrections and Rehabilitation. procedural requirements. Similar language was incorporated into eleven of (April 2006) the other M/CCFs. One facility (Delano CCF) was adamantly opposed and CCFA is attempting to re-visit this matter with the facility's new administration in the coming weeks. Office of the Inspector General’s comments: We reviewed the amended contract language that the department submitted as proof of practice. We then verified that most community correctional facilities (CCFs) statewide have contractually agreed to notify the CDCR whenever there is an allegation of employee misconduct at a CCF. The CCFs have also agreed to allow the CDCR to conduct its own investigation once an allegation is reported. Although these contract amendments address part of our original recommendation by giving the department the authority to investigate misconduct at the CCFs, misconduct allegations originating at the CCFs are not investigated properly because the headquarters-based unit responsible for managing the CCFs does not follow the most current department policies on employee misconduct. As a result, we consider this recommendation only partially implemented. Specifically, according to a facility captain from the headquarters-based Community Correctional Facilities Administration (CCFA), the CCFA uses an outdated version of the department Operations Manual policies related to investigation of employee misconduct. The outdated policy only required that Office of the Inspector General Page 91 Leo Chesney Community Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments the most serious types of misconduct be referred to the Office of Internal Affairs for investigation and allowed less serious misconduct to be self- investigated by the CCFA. This policy hindered the department’s ability to objectively review employee misconduct allegations and ensure fair and thorough investigations. As a result, the department established new employee misconduct policies in mid-January 2007. The new policies require that employee misconduct allegations that could lead to adverse action must be referred immediately to the Office of Internal Affairs for investigation. Moreover, if the subjects, allegations, or both are not clearly defined or more information is needed to determine whether misconduct occurred, the CCFA must request an allegation inquiry to be promptly performed by a locally designated investigator approved by the Office of Internal Affairs. However, according to a senior special agent at the Office of Internal Affairs, the CCFA does not have such designated investigators, and therefore, is not following current department policy. Finding 3 The Leo Chesney Center was using revenues generated from inmate telephone calls to make capital improvements. (October 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Continue to use the new statewide Inmate Telephone Fully California Department of Corrections and Rehabilitation’s response: System agreement to provide inmate telephone services for Implemented Fully Implemented. On 12/15/05 a new Leo Chesney CCF contract was all future community correctional facility contracts. approved that incorporated the Inmate/Ward Telephone System as a contract (April 2006) requirement. As a result, the Inmate Telephone Revenue Fund (ITRF) no longer exists. CCFA requested DOF complete a fiscal close out audit of the previous contract to ensure all State funds were appropriately accounted for. An audit finding determined that the CCF still had some residual ITRF monies that should be remitted to the State. The CCFA is currently working with the CCF and their corporate office to finalize the audit. Office of the Inspector General Page 92 Leo Chesney Community Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 5 A California Department of Corrections and Rehabilitation staff member assigned to the Leo Chesney Center had a practice of cashing inmate trust account checks and release checks for inmates paroling from the institution. (October 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Continue its efforts to implement a program that provides Fully California Department of Corrections and Rehabilitation’s response: inmates with release monies at the time of parole, but Implemented Fully Implemented. On 12/15/05 a new Leo Chesney CCF contract was eliminates the need for department employees to cash approved that requires the CCF contractor to directly provide inmates with inmate checks. (October 2001) release funds (either a check or cash) upon their parole/discharge from the CCF (Financial Management Requirements). Departmental staff are no longer required to issue and/or cash release checks on behalf of inmates. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 93 2008 Accountability Audit Office of Internal Affairs Special Review of the Office of Investigative Services California Department of Corrections and Rehabilitation Finding 1 The Office of Investigative Services9 could not effectively manage its caseload with its existing staffing levels without significant changes in its management practices. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Develop policies and procedures for prioritizing Fully California Department of Corrections and Rehabilitation’s response: investigative cases. (October 2001) Implemented Fully Implemented. In recent years, Office of Internal Affairs has developed and organized a comprehensive case prioritization scheme around a recognized “Madrid Criteria.” The Madrid criteria is a topology of case types that receive priority. These cases are codified in Department Operations Manual Article 22 as cases to be “designated” by Vertical Advocates and in the Bureau of Independent Review Protocols as cases to be “monitored” by Special Assistant Inspectors Generals. By policy and court order, Office of Internal Affairs, Employment Advocacy and Prosecution Team and Bureau of Independent Review essentially by consensus set an initial priority for a case during the Central Intake decision making process. Operationally and procedurally, Office of Internal Affairs staff are then guided by the Investigators Field Guide and the Case Management System. The Case Management System enables Office of Internal Affairs staff to manage the priority of cases with data fields for “date of discovery,” “date of incident” and features like “case reminder.” Evidence of the effectiveness of this comprehensive scheme of organization, policy and procedure is the reduction of cases lost to statute of limitation violations. In 2003, the Office of Inspector General reported that approximately 43% of the cases at California Department of Corrections and Rehabilitation were lost to time constraints. In 2004, the Bureau of State 9 The department’s Office of Investigative Services is now called the Office of Internal Affairs. Office of the Inspector General Page 94 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments Audits reported that number had been reduced to 21% and in 2006, the OIG reported that number had been reduced to 2%. Recent reports in 2007 by the Bureau of Independent Review indicate that number is now less than 2%. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 3 The Office of Investigative Services lacked adequate controls to prevent overtime abuse. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Assign each region a monthly allocation of budgeted Substantially California Department of Corrections and Rehabilitation’s response: overtime and prepare a monthly log for each regional Implemented Substantially Implemented. Overtime for the Office of Internal Affairs special office that begins with monthly allotted hours and is agents is managed by headquarters, based upon a set California Department adjusted for each usage. When overtime is granted, the of Corrections and Rehabilitation budget allocation. Paid overtime and supervisor should immediately e-mail the agent and the compensatory time off are monitored at the regional level. Paid overtime is overtime timekeeper for the purpose of adjusting monthly routinely approved ahead of time for special operations, or other special case balances and providing evidence of previous overtime priority issues. Each agent completes a form entitled STD 682 – Authorization approval. In order to provide regional supervisors for Extra Hours form documenting the overtime or compensatory time off, flexibility in managing cases, the Office of Internal Affairs which is approved by the supervisor. Monthly overtime reports are generated should consider rolling over unused office balances from and reviewed by Office of Internal Affairs management in headquarters. one month to the next. (April 2006) Central office management control and a set allotment for dollars have rectified the previous condition of occasional individual abuses and a $1.2 million overtime expenditure in 2001. Moreover, a regional allotment of overtime would prohibit the Office of Internal Affairs as a whole from properly managing its priorities. Cases requiring overtime are not evenly distributed by region. The need for overtime may be more specific to one region based upon caseload and prioritization. Office of the Inspector General Page 95 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments Because this need can shift, central management of overtime dollars permits greater control. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 4 The background checks of Office of Investigative Services agents were inadequate because of a departmentally imposed 11-hour limit on conducting background investigations. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Reevaluate whether the proposed budget increase to 40 Not California Department of Corrections and Rehabilitation’s response: hours per background investigation for potential Implemented Not Implemented. It should be noted that controls over the policies, procedures employees of the Office of Internal Affairs is justified, or process of the Background Investigations Unit are not managed by Office of given that investigators are obtaining 75 percent of the Internal Affairs. required information using only 11 hours per investigation. (April 2006) The request for a 40 hour allotment to conduct a complete and thorough background investigations of all peace officer candidates is still being considered by the Department. The request from Office of Internal Affairs is that background investigators be allotted as many hours as needed to conduct a complete and thorough investigation; not to exceed 40 hours. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that background investigation files contain Fully California Department of Corrections and Rehabilitation’s response: evidence that potential employees of the Office of Internal Implemented Fully Implemented. It should be noted that controls over the policies, Office of the Inspector General Page 96 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments Affairs have not been the subject of past or pending procedures or process of the Background Investigations Unit are not managed adverse actions, as mandated by California Penal Code by Office of Internal Affairs. sections 6065(b)(1) and 6126.2. (October 2001) Previous and current practice by the California Department of Corrections and Rehabilitation’s Background Investigations Unit is to determine whether Office of Internal Affairs candidates have been subject to past or pending adverse actions. Pursuant to Penal Code Section 6065(b)(1) the department performs a thorough background check on any peace officer selected to conduct internal affairs investigations in addition to the background screening conducted when the person was initially hired as a peace officer. The practice is strictly followed by California Department of Corrections and Rehabilitation’s BIU for special agent candidates. Background investigators track this process to ensure the process is thoroughly completed using a “Roadmap Worksheet.” During this process, letters are sent to each Investigative Services Unit, Employee Relations Officer (or equivalent) and the personnel operations section of the prospective candidate’s employer. Letters are also sent to the Office of Internal Affairs unit (for current California Department of Corrections and Rehabilitation employees, the Office of Civil Rights is sent a letter asking about past or present investigations). Additionally, past and present supervisors are also contacted for knowledge of the candidate’s status and past performance. Further, the background investigator must conduct a personnel file review of current or former California Department of Corrections and Rehabilitation employees, which includes a face-to-face with the Employee Relations Officer and Investigative Services Unit. If no adverse personnel action is noted in the case file, they will indicate they conducted the file review, and are required to specifically note whether any previous disciplinary action occurred. The Official Personnel File Review Worksheet is included in the background investigation file as documentation of this contact including notes of any information obtained. In the event that written correspondence is not received, the investigators make telephone contact and verbal responses are noted on the appropriate forms as documentation that the information was received. Background investigation cases cannot be closed until this information is verified and becomes part of the file. Office of the Inspector General Page 97 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 5 The Office of Investigative Services did not conduct background checks of staff borrowed to conduct internal affairs investigations. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Refrain from using investigative services unit investigators Not California Department of Corrections and Rehabilitation’s response: until their supplemental background investigations are Applicable Not Applicable. Office of Internal Affairs no longer uses investigative staff at complete. (April 2006) the institutions to conduct internal affairs investigations. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 7 The internal affairs case tracking system did not have adequate controls to prevent unauthorized access. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Formalize the process for verifying that case management Fully California Department of Corrections and Rehabilitation’s response: information system access is limited to only authorized Implemented Fully Implemented. August 4, 2006, the Case Management System security users. The process should define the frequency of reviews, agreement was modified to include the hiring authorities’ name, signature, and require a reconciliation of beginning and ending date for authorization of the employee requesting access to the Case Office of the Inspector General Page 98 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments authorized users for the period, and specify the date when Management System. The Case Management System security agreement is users are added or deleted. Included in this process should then faxed to the Case Management System database administrator to be a requirement that an exit document be prepared by the complete the approval process. The Case Management System database departing staff’s supervisor that instructs the information administrator time stamps and reviews the documents for the required technology staff to remove the user’s access. (April 2006) information and then files it in the Case Management System information bank. Case Management System user’s status is reviewed every 30 days for authorized access and level of access. The Case Management System database administrator submits a monthly executive access report to the Office of Internal Affairs Chief of Operations for a review process. The Case Management System database administrator has implemented several logs/files that capture each Case Management System user’s detailed logon information. These logs capture the date the Case Management System user’s account was created and the date the account was deactivated. The Case Management System security agreement section # 5 states “To notify Office of Internal Affairs Case Management System Support staff if my duties change so as to eliminate my need to access Case Management System or any portions of Case Management System data not pertinent to my duties.” Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 8 A significant number of investigation files lack sufficient documentation to show that the investigation was conducted in accordance with established guidelines. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Office of the Inspector General Page 99 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments Prepare a supervisory quality control review sheet that Not California Department of Corrections and Rehabilitation’s response: ensures that the investigative package is complete, the Implemented Not Implemented. In general, the Office of Internal Affairs has increased the investigative plan was followed, all witnesses were quality of its investigative product by emphasizing a more contemporaneous interviewed, required notices were performed, and the and active supervisory approach to case progression. final report represents a clear, fair, and unbiased representation of the facts. (April 2006) The condition of inadequate documentation of supervisory review of cases has been resolved by the development and use of Case Management System’s, case activity log, BIR investigation assessment tools (derivative of Article 14, Article 22 and the Investigators Field Guide), and the hiring authority assessment utilizing Form 402. It should be noted that the Office of Internal Affairs-South “quality control checklist” OIG recommended be used statewide is not used in Office of Internal Affairs-South and is not considered a quality control tool. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 9 The Office of Investigative Services did not have procedures in place to ensure that the regional offices process Category II case rejections consistently and properly. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Establish procedures to ensure that case rejection letters Not California Department of Corrections and Rehabilitation’s response: are issued within the prescribed ten-day time frame. Applicable Not Applicable. No longer applicable as the prescribed 10 day time frame no (October 2001) longer exists. Office of the Inspector General’s comments: We confirmed that the requirement to issue case rejection letters within a ten- day time frame is no longer applicable. Because of a class action order, the Office of the Inspector General Page 100 2008 Accountability Audit Office of Internal Affairs Recommendation Status Comments department rewrote and reissued Chapter 3, Article 14 of the department Operations Manual, which, in part, resulted in the elimination of the ten-day requirement. Finding 10 The Office of Investigative Services was not adequately fulfilling its responsibility for overseeing Category I investigations. (October 2001) Recommendation Status Comments The Office of Internal Affairs should: Use the Department of Corrections and Rehabilitation Partially California Department of Corrections and Rehabilitation’s response: internal audit staff to perform field audits to identify trends Implemented Partially Implemented. Office of Internal Affairs agrees on the importance of in complaints against staff so that resources can be focused identifying trends in complaints against California Department of Corrections on the most pervasive problems. (October 2001) and Rehabilitation staff. Office of Internal Affairs has established a Management and Analysis Unit that produces allegation trend data that is shared with hiring authorities. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 101 2008 Accountability Audit Office of Internal Affairs Finding 11 The procedures used by the Office of Investigative Services for handling evidence did not comply with regulatory requirements or the agency’s own guidelines. (October 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Standardize evidence policy and procedures throughout Fully California Department of Corrections and Rehabilitation’s response: the department and include the standards in the Office of Implemented Fully Implemented. The Office of Internal Affairs agrees with the Office of Internal Affairs’ Investigation Policy and Procedures Inspector General’s recommendation regarding standardized evidence Manual, and train staff to ensure that the policies and procedures. The Investigator’s Field Guide devotes considerable attention to procedures are properly implemented and followed. evidence handling, processing, and retention. All Office of Internal Affairs (April 2006) agents have a copy of the Investigator’s Field Guide (Vol 1) and the updates to the anticipated Vol 2 do not affect this section. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The Office of Internal Affairs should: Install a dedicated alarm system for the southern regional Substantially California Department of Corrections and Rehabilitation’s response: office evidence room. (April 2006) Implemented Substantially Implemented. The southern region office is presently under renovation and the new evidence room will be alarmed and secure, in line with the other regional offices. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 102 High Desert State Prison 2008 Accountability Audit Management Review Audit High Desert State Prison Management Review Audit Institution Programs Finding 6 Design of the cells in the administrative segregation unit did not allow the custody staff to control the lights inside the cells. (November 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: In future construction projects, design buildings to provide Fully California Department of Corrections and Rehabilitation’s response: the custody staff with the ability to control cell lights from Implemented Fully Implemented. This change has been implemented in the current design the outside. (November 2001) criteria for Administrative Segregation Units. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 7 Security cameras were not available to monitor activity on the main yards. (November 2001) Recommendation Status Comments High Desert State Prison should: Continue to pursue resources to install video cameras on Partially California Department of Corrections and Rehabilitation’s response: the main yards in order to enhance security. Implemented Partially Implemented. In 2006 a Budget Change Proposal for the video (November 2001) surveillance system was completed for fiscal year 2007/08. The cost is estimated at $3.5 million. The Budget Change Proposal was removed from the Office of the Inspector General Page 103 High Desert State Prison 2008 Accountability Audit Management Review Audit Recommendation Status Comments Governor’s Budget for fiscal year 2007/08. The video surveillance system is now part of a $70 million Budget Change Proposal for fiscal year 2008/09. High Desert State Prison is still actively attempting to get approval for the funding of the video surveillance system. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 11 Performance and probation reports for employees at High Desert State Prison were not being completed in a timely manner. (November 2001) Recommendation Status Comments The warden of High Desert State Prison should: Hold managers and supervisors in the administrative area Substantially California Department of Corrections and Rehabilitation’s response: accountable for completing annual performance Implemented Substantially Implemented. Performance, probationary, COPAS and NON- evaluations and probation reports. (November 2001) COPAS route slips are currently being generated by the Personnel office on a monthly basis, but will now be completed on a weekly basis (per the direction of the Chief Deputy Warden). Each route slip notes the employee’s name, position number, classification, due date, critical dates of the review period and report date. Route slips will be forwarded to the appropriate Associate Wardens or Correctional Captain per High Desert State Prison Department Operations Manual Supplement 32010.6. An original copy will also be forwarded to the Chief Deputy Warden for follow up and review of any outstanding and or pending performance/probationary reports. Supervisory staff are being held accountable for failure to complete required reports. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 104 High Desert State Prison 2008 Accountability Audit Management Review Audit Health Care Program Finding 3 Thirteen inmates on psychotropic medication were not included in the mental health delivery system. (November 2001) Recommendation Status Comments The High Desert State Prison medical department should: Develop a system to ensure that inmates requiring Partially California Department of Corrections and Rehabilitation’s response: psychotropic medications are included in the mental health Implemented Partially Implemented. High Desert State Prison continues Psychotropic drugs delivery system before they receive the medications. for newly arrived inmates who have been mental health patients (30-day (November 2001) supply) until they can be evaluated during Reception Center processing. All general population inmates receiving psychotropic medications are reviewed weekly and are interviewed by yard case managers. If medications were prescribed for a psychotropic reason, the inmates are seen by an IDTT and placed in a mental health program. Inmates receiving psych meds for medical reasons are not placed in the program. High Desert State Prison is developing audits as part of the QMAT that will ensure all appropriate inmates are included in the MHSDS. Initial draft of audit tool is scheduled for implementation effective November 15, 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 105 High Desert State Prison 2008 Accountability Audit Management Review Audit Finding 4 High Desert State Prison was not providing inmates with dental services required under state regulations. (November 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Eliminate inconsistencies between California Code of Partially California Department of Corrections and Rehabilitation’s response: Regulations, Title 15 and the Department of Corrections Implemented Partially Implemented. Regarding the non-compliance of High Desert State and Rehabilitation Operations Manual concerning inmate Prison to provide dental services as required under state regulations, the dental care. (November 2001) Office of Inspector General comments that this is a discrepancy between the Department Operations Manual and Title 15 and that it is the California Department of Corrections and Rehabilitation that must correct this discrepancy. It should be noted, however, that on April 28, 2006, the Honorable Jeffrey S. White of the United States District Court, signed the Stipulation and Order for the Perez class action lawsuit on this very issue. The agreement includes a phased rollout of the state’s 33 adult institutions in bringing California Department of Corrections and Rehabilitation into compliance through the Dental Program’s newly developed Policies and Procedures manual. Judge White has agreed to this plan. Reconciliation of the Department Operations Manual and Title 15 is now progressing, but will likely be some years before completion. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 106 High Desert State Prison 2008 Accountability Audit Management Review Audit Finding 6 Controls over the tracking of prescription drugs were grossly inadequate. (November 2001) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Implement an automated inventory system to track and Partially California Department of Corrections and Rehabilitation’s response: monitor prescription drugs. (April 2006) Implemented Partially Implemented. This institution maintains various inventories, but still operates with a 20-year-old computer program that does not allow us to have a completely automated inventory system. High Desert State Prison monitors all controlled drugs and have an ongoing daily count implemented. This is new since HDSP last responded. High Desert State Prison’s wholesaler does have ongoing records of all purchases. The Maxor Corporation will put in a new automated inventory system in the near future. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 107 2008 Accountability Audit Local Assistance Program Special Review of the Local Assistance Program Parole and Community Services Division California Department of Corrections and Rehabilitation Finding 4 The Department of Corrections and Rehabilitation had not established an information system adequate to verify information reported on invoices submitted by local jurisdictions. (January 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Continue to pursue developing an information system to Not California Department of Corrections and Rehabilitation’s response: assist with the Local Assistance Program invoice Implemented Not Implemented. All the positions have been filled and staff are reviewing verification process. (January 2002) invoices from the counties. A savings has already been identified from the review to date. On-site visits are being performed to monitor the implementation of this program. Once the visits are completed an assessment will be prepared. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 108 2008 Accountability Audit Correctional Facility Mail Processing Review of Correctional Facility Mail Processing California Department of Corrections and Rehabilitation Finding 3 The institutions were often inefficient in conducting the initial search of incoming mail. (July 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Ensure that the California State Prison, Sacramento, has Fully California Department of Corrections and Rehabilitation’s response: implemented the recommendation to use automatic letter Implemented Fully Implemented. California State Prison, Sacramento has begun using the openers. (July 2002) automated letter opener. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that the California Institution for Men and Salinas Not California Department of Corrections and Rehabilitation’s response: Valley State Prison have implemented the recommendation Implemented Not Implemented. Institutions have identified some magazines that are to develop a list of acceptable publications that employees completely banned, but that list is not all inclusive. Institutions have can immediately place in housing unit mailbags. (July 2002) implemented a process where magazines are screened on an issue by issue basis. For example, Lowrider magazine may be approved one month, but the following month may contain a drawing depicting frontal nudity. It is for this reason that an approved publications list is not feasible. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that the California Institution for Men eliminates the Fully California Department of Corrections and Rehabilitation’s response: practice of verifying all inmate addresses. (July 2002) Implemented Fully Implemented. The California Institution for Men has developed a system utilizing Post Office boxes for each facility to eliminate the need to verify each inmate’s housing. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 109 2008 Accountability Audit Correctional Facility Mail Processing Finding 5 Procedures for handling cash found in inmate mail differed at each facility and the mailroom process for handling checks and money orders was inefficient. (July 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Ensure that Salinas Valley State Prison fully implements the Fully California Department of Corrections and Rehabilitation’s response: recommendation to standardize the process for handling cash Implemented Fully Implemented. Procedure for handling and processing cash that is to conform to the process for handling other contraband. found in incoming mail is in operational procedure #2. (July 2002) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 6 Some of the selected institutions had inefficient processes for handling unstamped mail. (July 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Ensure that the California Correctional Institution fully Fully California Department of Corrections and Rehabilitation’s response: implement the recommendation to rely on accounting Implemented Fully Implemented. A list of inmates requesting indigent envelopes is personnel to monitor inmate trust accounts for sufficient generated from each facility at the California Correctional Institution and funds to pay postage on outgoing mail and provide pre- forwarded to the Accounting Trust Office by the fifth of each month. The Trust stamped envelopes to indigent inmates. (July 2002) Office verifies the inmate’s account to determine if the inmate has funds to pay postage and notes the list accordingly. The Trust Office then forwards the list to the Mailroom staff to supply envelopes and minimum first-class postage to the noted eligible indigent inmates. This procedure is in accordance with the Office of the Inspector General Page 110 2008 Accountability Audit Correctional Facility Mail Processing Recommendation Status Comments California Code of Regulations, Title 15, Section 3134, Indigent Inmates, and is also included in California Correctional Institution’s Operational Procedure 203, Institutional and Inmate Mail. With the above exception, inmates without funds are not allowed to mail outgoing articles except as authorized by California Code of Regulations, Title 15, Section 3165(d), Mailing Legal Documents. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 8 Some of the selected institutions did not fully comply with California Code of Regulations, Title 15 requirements. (July 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Develop the standard checklist for reviewing mail operation Partially California Department of Corrections and Rehabilitation’s response: plans submitted by the prisons. (July 2002) Implemented Partially Implemented. New mail regulations are currently being established through the Administrative Procedures Act. It is expected these should be finalized around early in 2008. All institutions will need to develop a DOM supplement once these regulations are finalized. It is expected that a checklist will be used as part of that process. A copy of these regulations is included for your information. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 111 2008 Accountability Audit Correctional Facility Mail Processing Recommendation Status Comments Provide an updated list of courts to all 33 institutions. Fully California Department of Corrections and Rehabilitation’s response: (July 2002) Implemented Fully Implemented. All institutions have complied with this expectation. Lists are provided in the Law Libraries at all adult institutions. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 9 The Office of the Inspector General was unable to determine whether the prisons reviewed complied with delivery standards for regular inmate mail. (July 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Ensure that the California Medical Facility and the Fully California Department of Corrections and Rehabilitation’s response: Correctional Training Facility fully implement the Implemented Fully Implemented. The California Medical Facility developed and recommendation to institute a modified tracking system implemented a “Mailroom Daily Evaluation Worksheet” which tracks received based on mail trays and bins rather than stamping or mail trays and bins. logging each piece of first-class mail. (July 2002) The Correctional Training Facility now utilizes a tracking system based on mail trays and bins for all outgoing first class mail, outgoing package counts, incoming first class mail, incoming bulk bins. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 112 2008 Accountability Audit Office of Audits and Compliance Office of Compliance, Management Review of the Audit Functions of the California Department of Corrections and Rehabilitation Finding 1 The Program and Fiscal Audits Branch did not adhere to professional standards for internal auditing. (October 2002) Finding 2 The Program and Fiscal Audits Branch, which performed most of the department’s audit work, was not effectively communicating with the department’s executive staff in planning annual audit activities and in reporting audit performance. (October 2002) Finding 3 The Program and Fiscal Audits Branch did not target internal audit activity toward issues posing the highest risk. (October 2002) Finding 4 The Program and Fiscal Audits Branch was not responsive to executive management requests for special audits. (October 2002) Finding 5 The Office of Compliance did not monitor the status of audit projects. (October 2002) Finding 6 The Program Compliance Unit of the Program and Fiscal Audits Branch used a highly structured auditing approach that could fail to reveal important issues relating to the entities under audit. (October 2002) Finding 7 The audit functions of the California Department of Corrections and Rehabilitation were fragmented, with a lack of coordination of audit activities and incomplete coverage of areas requiring audit, resulting in a failure to comply with state law governing financial accountability. (October 2002) Office of the Inspector General Page 113 2008 Accountability Audit Office of Audits and Compliance Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Continue its efforts to recruit a permanent assistant Fully California Department of Corrections and Rehabilitation’s response: secretary for the Office of Audits and Compliance, Implemented Fully Implemented. An Assistant Secretary for the Office of Audits and ensuring that the person selected possesses the training, Compliance was appointed by the Governor in June 2007. The incumbent has knowledge, and experience to manage an internal auditing the training, knowledge, and experience to manage an internal auditing unit. unit. (October 2002) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that the Office of Audits and Compliance continues Partially California Department of Corrections and Rehabilitation’s response: to develop operating policies and procedures that will Implemented Partially Implemented. The Office of Audits and Compliance is developing ensure that its audit activity is consistent with the standards processes to ensure audit activity is consistent with Standards for the prescribed in the Standards for the Professional Practice Professional Practice of Internal Auditing. The Office of Audits and of Internal Auditing. The policies and procedures should Compliance Audit Manual is being updated to align with the internal office include the following: restructure currently underway. • A process for effective communication with the • Communication with executive staff to plan audit activities and report department’s executive staff in planning annual audit performance is an on-going process. Audit assignments are audit activities and reporting audit performance. requested by executive staff to be included in the annual audit plan. The audit plan for fiscal year 2007/08 will be presented to executive management in December 2007. Audit activities/performance is reported weekly at administrative staff meetings. • A process by which to develop a risk-based • A comprehensive risk assessment conducted by the Office of Audits and comprehensive annual plan for identifying the Compliance on the Division of Juvenile Justice, identified areas of risk priorities of the internal audit activity. to be included in the annual audit plan. In addition, the Office of Audits and Compliance has begun conducting Peer Reviews and those areas with high deficiencies warrant additional follow up reviews. Even the less significant deficiencies are brought to executive level attention for immediate resolution, i.e., additional staff training. • A process for entering into the audit monitoring • The Office of Audits and Compliance is in the process of developing a system the data necessary to adequately monitor comprehensive database to collect, manage, and monitor various the status of audits. information relative to the life-cycle of an audit, from the planning Office of the Inspector General Page 114 2008 Accountability Audit Office of Audits and Compliance Recommendation Status Comments stage through full implementation or compliance of all recommendations. The process for entering information into the monitoring system is being established concurrently. • A system to monitor the amount of time the staff • A component of the database currently being developed is estimated spends on audits. (October 2002) and actual audit hours. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 115 2008 Accountability Audit Medical Contracting Process Special Review of the Medical Contracting Process Health Care Services Division California Department of Corrections and Rehabilitation Finding 4 The current deficiencies in the department’s contracting process may lead to problems in the quality and continuity of inmate medical care. (October 2002) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Develop a more effective and efficient system for Partially California Department of Corrections and Rehabilitation’s response: processing and monitoring medical service invoices, Implemented Partially Implemented. The Health Care Services Division, under the including validation that contractors have performed all direction of the Receiver, has implemented a detailed Plan of Action (POA) services invoiced prior to issuing payment. (April 2006) which was accepted by the Federal Court on November 15, 2007. The POA details strategic steps to be taken in the areas of contract management and invoice processing. The Health Care Document Management System (HCDMS) is scheduled to be on line at ten institutions by May of 2008. This system, combined with other steps taken in the areas of staffing, training, and management reporting, will exceed the recommendations of the “Original Finding #4.” Office of the Inspector General’s comments: We reviewed the Plan of Action section titled “Contract and Invoice Processing Initiative” and determined the following: • Under the Plan of Action, the receiver states that the department is making significant contract processing changes that should improve its management of the health care contract system. For example, the Plan of Action cites that in January 2007 the department reorganized its headquarter work units that processed health care contracts and established the new Plata Contract and Invoice Branch (PCIB). The Plan of Action also states that by establishing the PCIB, the department now has the infrastructure needed to implement further contract processing reform, which includes centralizing functions for processing medical Office of the Inspector General Page 116 2008 Accountability Audit Medical Contracting Process Recommendation Status Comments service invoices. Eventually, all invoice receipt, scanning, indexing, and review and adjudication functions will be performed centrally by the PCIB rather than at institutional or regional accounting offices throughout the state. • In addition, the Plan of Action states that the department developed its HCDMS contracts information technology system and piloted it at four institutions. The piloted system allows staff members to approve health care invoices electronically, and the pilot institutions have already achieved significant improvements in quality control, contract management, and invoice processing time. The Plan of Action further indicates that once the department completes and stabilizes the system’s implementation at the pilot institutions, it plans to roll out the HCDMS, which will include streamlined processing sub-systems for both procurement and invoice processes at all 33 adult institutions in phases over a 12-month period. Simultaneously, the department will establish an administrative support unit to develop and implement policies and procedures and training material to support the implementation of the new systems. • Finally, the Plan of Action calls for the department to establish an internal review unit to support management oversight of contract and invoice processing. The unit will conduct both random and targeted reviews of processed invoices to verify that invoiced services were provided. Office of the Inspector General Page 117 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit California Substance Abuse Treatment Facility and State Prison, Corcoran Management Review Audit Finding 1 Deficiencies in the substance abuse treatment program were preventing the institution from reducing recidivism by helping inmates overcome drug dependency. (January 2003) Recommendation Status Comments The Division of Addiction and Recovery Services should: Conduct systematic, in-depth monitoring of treatment Fully California Department of Corrections and Rehabilitation’s response: providers for compliance with contract terms. Monitoring Implemented Partially Implemented. DARS has established the Program Design and reports should reflect all substantive details of the Assessment Unit that conducts in-depth systematic reviews of in-prison provider’s records and operations. The reports should also substance abuse programs and issues corrective action plans as appropriate. include the Office of Substance Abuse Programs’ analysis The Unit will make follow up visits and annual return visits to substantiate and evaluation of the provider’s operations. (April 2006) compliance. In addition, all Substance Abuse Program (SAP) Program Managers (PM) visit each of their contract sites at least monthly and provide a written report documenting their findings. Office of the Inspector General’s comments: We interviewed staff members from the department’s Division of Addiction and Recovery Services (DARS), and we reviewed documents and reports to verify the department’s response and to determine the extent of DARS’ monitoring. According to the staff, DARS established the Program Design and Assessment Unit in January 2007. Since that time, the unit’s three-person Program Design and Assessment Team (PDAT) has conducted program assessments at 13 adult institutions and one conservation camp. The PDAT uses a best practices questionnaire to interview program participants, facility staff, and contracted program staff. The team documents the results of its interviews and observations in a report, and then it develops a draft corrective action plan to address the reported results. The facility and program staff members review the plan and submit it back to the PDAT, indicating the targeted completion date for each proposed action. Office of the Inspector General Page 118 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments We reviewed the reports and corrective action plans for two of the PDAT’s assessments. The reports were comprehensive and included background information on the programs, detailed findings, and recommendations that identified specific areas that needed improvement. The corrective action plans identified specific steps, or proposed actions that addressed the reported recommendations. Based on DARS’ success in implementing this monitoring system, we have upgraded the department’s status level for this recommendation to fully implemented. When drafting contracts for substance abuse treatment Not California Department of Corrections and Rehabilitation’s response: services, include provisions for the remedy of nonmaterial Implemented Not Implemented. Provisions for the remedy of noncompliance resulting in instances of noncompliance with contract terms that are damages to California Department of Corrections and Rehabilitation (CDCR) reasonably associated with damages actually incurred as a have been added to new RFP’s in the category of intermediate sanctions. This result of noncompliance, including provisions for language will be incorporated in all new contracts. liquidated damages related to instances of noncompliance for which the value of actual damages cannot be readily Office of the Inspector General’s comments: determined. (November 2006) The OIG performed no audit procedures to verify the department’s representation. Whether performed by UCLA or by another contractor, Not California Department of Corrections and Rehabilitation’s response: ensure that future studies of the effectiveness of the Implemented Not implemented. From 1997 to 2002, CDCR contracted with external substance abuse program at the institution include a evaluators at the University of California, Los Angeles to evaluate the comparison of the treatment group to a control group of effectiveness of in-prison substance abuse programs. These evaluations similar inmates who did not receive treatment. included the use of matched comparison groups consisting of treatment and (April 2006) non-treatment subjects. Although CDCR has continued to work with UCLA to evaluate both in-prison and community-based substance abuse programs, these later studies did not compare outcomes across treatment and non- treatment groups. In 2006, CDCR initiated an evaluation project with UCLA using randomized control groups to test the effectiveness of alternative interventions within the treatment group. CDCR is also conducting an evaluation of the new mandatory aftercare programs using a historical comparison group of SAP graduates to test the effectiveness of these new programs in increasing aftercare participation and outcomes. CDCR is currently exploring the feasibility of using historical comparison groups of treatment and non- treatment offenders to measure the effectiveness of SATF and other in-prison substance abuse programs in terms of return to prison rates. Office of the Inspector General Page 119 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Return to using smaller clusters of inmates to conform to Not California Department of Corrections and Rehabilitation’s response: the Office of National Drug Control Policy’s Implemented Not Implemented. Although the Division of Addiction and Recovery Services recommendation that therapeutic community program (DARS) programs typically average 200 treatment beds, these programs are clusters consist of no more than 50 to 75 inmates. divided into two 100 participant programs which include sub-groups of 18 (April 2006) participants. The Treatment Advisory Committee (TAC) is currently evaluating the science of program and cluster size and will provide additional recommendations regarding ideal group size. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 2 Serious deficiencies in the medical care provided to inmates at the California Substance Abuse Treatment Facility and State Prison, Corcoran, were placing the health of inmates and staff at risk and exposing the state to possible legal action. (January 2003) Recommendation Status Comments California Substance Abuse Treatment Facility and State Prison, Corcoran should: Continue to work with the Division of Correctional Health Partially California Department of Corrections and Rehabilitation’s response: Care Services’ departmentwide efforts to address the Implemented Partially Implemented. Recruitment efforts continue. Healthcare hiring shortage of medical staff as cited by a federal court workshops were conducted on the following dates: April 21, 2006, April 4, monitor. (April 2006) 2007, and August 9, 2007. Medical staffing vacancies are discussed at weekly Quality Management Committee meetings. Beginning October 15, 2007, weekly conferences will be held with the Chief Medical Officer, Health Care Manager, and the Regional Medical Director regarding Medical staffing Office of the Inspector General Page 120 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments issues. Due to the salary adjustments many medical staff vacancies have been filled. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Develop methods to reduce or eliminate inmate medical Partially California Department of Corrections and Rehabilitation’s response: appeal backlogs without placing inmates at risk. Implemented Partially Implemented. Since the last update, one additional Analyst and three (January 2003) Office Technicians have been added to the Medical Appeals staff. Currently, three Office Technician positions are vacant. Office Technician interviews were held on October 22-24, 2007. Much of the appeals backlog is due to staff vacancies. Appeals requiring physician intervention are filtered into the doctors’ lines on a weekly basis. Overtime is authorized for Medical Appeals staff. A Correctional Counselor II has been placed on special assignment, for 6 months, to assist in Medical Appeals with the Americans with Disabilities Act appeals. Current backlog of medical appeals is 92 with 33% designated Americans with Disabilities Act. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Hold medical staff responsible for completing Partially California Department of Corrections and Rehabilitation’s response: administrative activities, including responding to inmate Implemented Partially Implemented. Medical continues to have a backlog in Medical medical appeals in a timely manner. (January 2003) Appeals due to the critical shortage of physicians and the significant increase in numbers of Medical appeals. The physician shortage precludes aggressive focus on holding medical staff responsible for timely response of appeals. Additional support staff has been assigned to assist with the increased volume of medical appeals. Over the past 6 months, the average number of appeals is 623 per month, which represents a 68% increase from the past 6 month period of October 11, Office of the Inspector General Page 121 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments 2006 through April 11, 2007. Overtime for Medical appeals staff is authorized on a continuing basis. The Medical Appeals office sends out weekly notices to staff and supervisors. Medical Appeals is a standing agenda item discussed at both the Medical Program Subcommittee and the Health Care Quality Management Committee meetings. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Review all medical procedures currently referred to Partially California Department of Corrections and Rehabilitation’s response: contracted specialist clinics or outside providers to identify Implemented Partially Implemented. Effective September 28, 2006, the Utilization Nurse those that could be performed by institution doctors. has been meeting with the doctors on a monthly basis to review and approve (January 2003) “Request for Services” for outside consultant/services pursuant to the Inmate Medical Services Guidelines. Currently, the California Substance Abuse Treatment Facility, Corcoran has only 5 physicians performing primary care duties on grounds. These 5 contracted physicians are board certified in Internal Medicine and as such only perform minor procedures such as incisions and drainage and suturing of minor lacerations. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Establish procedures and systems to ensure that all inmate Substantially California Department of Corrections and Rehabilitation’s response: requests for reasonable accommodation and medical Implemented Substantially Implemented. Healthcare staff makes temporary reasonable verification of disabilities under the Americans with accommodations until such time evaluation and examination of the inmate Disabilities Act are processed in a timely manner and that occurs. The California Substance Abuse Treatment Facility, Corcoran employs all appropriate accommodations or modifications are an Americans with Disabilities Act nurse who stays abreast of health care implemented without delay. (January 2003) Americans with Disabilities Act issues involving reasonable accommodations, equipment, and appliances. The Americans with Disabilities Act Registered Nurse utilizes a tracking system for completeness of CDC 1845s and issues temporary accommodation chronos as needed. When applicable, the primary Office of the Inspector General Page 122 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments care physician completes the CDC 1845, Disability Placement Program Verification form. The Plata Office Technicians schedule evaluation of CDC 1824 appeals and CDC 1845 disability verification into the weekly physician’s lines. The Americans with Disabilities Act Registered Nurse reviews the CDC 1845’s for accuracy and completeness. In addition a Correctional Counselor II has been assigned to assist with Americans with Disabilities Act appeals. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Track pending actions on Americans with Disabilities Act Substantially California Department of Corrections and Rehabilitation’s response: requests to ensure completion within established time Implemented Substantially Implemented. While awaiting chronos, the Americans with limits and ensure that medical chronologies or Disabilities Act Nurse continues to track medical equipment, appliances, and modifications are implemented without delay. chronos. The Medical Appeals Analysts also track additional medical appeals (January 2003) modifications. If necessary, reasonable accommodations are made and temporary chronos are issued. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Systematically identify inmates with chronic medical Substantially California Department of Corrections and Rehabilitation’s response: conditions and ensure that those inmates are monitored Implemented Substantially Implemented. The institution reported that its chronic care through regular appointments with institution doctors. program was established as part of the inmate medical services program (January 2003) (known informally as the “Plata” decision) was activated in Jan. 2004. Appropriate local operating procedures have been implemented and staff training has been completed. Inmates identified with a chronic care disease are evaluated and scheduled for follow-up at regular intervals as determined by the primary care provider or mid-level practitioner. Inmates with chronic medical conditions are flagged in the Inmate Scheduling and Tracking System (IMSATS). Inmate’s designated high risk are evaluated by the PCP and scheduled for appropriate follow-up. The California Substance Abuse Treatment Facility, Corcoran continues to experience a critical shortage of physicians. Therefore, full implementation of the CCP has not occurred. Office of the Inspector General Page 123 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments The Health Records Technician-II provides a list to the Plata Office Technicians who then schedule the high-risk inmates to be seen by a physician or mid-level practitioner. High Risk lines are determined and scheduled by clinic staff according to each yards needs. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Establish policies and procedures to require periodic Substantially California Department of Corrections and Rehabilitation’s response: laboratory work and measurement of vital signs for Implemented Substantially Implemented. Chronic Care Policies and Procedures (P&P) chronic care inmates. Ensure that this information is have been established as part of the Inmate Medical Services Program. SATF available to doctors at the time of examinations so they continues to experience a critical shortage of physicians. Therefore, full may adequately assess chronic medical conditions. implementation of the CCP has not occurred. When a CCP patient is seen, the (January 2003) nurse records appropriate vital signs and diagnostic tests are ordered as appropriate. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Enforce the August 2004 memorandum from the health Fully California Department of Corrections and Rehabilitation’s response: care manager instructing medical personnel to sign in and Implemented Fully Implemented. Medical personnel continue to sign in and out at out of the institution and record actual times of arrival and designated areas within the Medical Department. In addition a time clock was departure. (April 2006) purchased, effective August 1, 2006, for contracted staff who are required to clock in and out when reporting for work. Office of the Inspector General’s comments: The August 2004 memorandum has been replaced by a July 2006 memorandum from the institution’s chief medical officer that instructs all registry physicians to clock in and out using the time clock and timecards located at the institution’s East/West entrance. In January 2008, we conducted fieldwork at the institution to determine whether the July 2006 memorandum was being enforced. We interviewed the acting chief medical officer and the medical secretary, and we reviewed documents to obtain an understanding of the current process. In addition, we confirmed the existence and use of the time Office of the Inspector General Page 124 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments clock and tested a sample of registry physicians’ records to verify that they recorded their times of arrival and departure daily. As of January 2008, the California Substance Abuse Treatment Facility and State Prison, Corcoran, employed nine physicians, all of whom were contracted registry physicians. Based on our fieldwork, we confirmed that the institution’s medical administrative staff enforced the July 2006 memorandum and that all registry physicians clock in and out daily. We also found that the medical administrative staff had implemented a detailed process to reconcile physicians’ daily timecards to the registry’s monthly billing. The California Department of Corrections and Rehabilitation should: Continue to develop an automated system combining an Partially California Department of Corrections and Rehabilitation’s response: individual patient’s medical record with pharmacy tracking Implemented Partially Implemented. The Receiver’s Information Technology staff is information. (January 2003) working on the development and implementation of an automated health information system that will include an electronic medical record that will incorporate all aspects of health care. Anticipated completion date, December 2012. Effective February 2007, Maxor Pharmaceutical Services, Incorporated was contracted by the Receiver to oversee the management of pharmaceutical services within the institutions. Maxor is currently implementing a computerized distribution system. This is a process where institutions will be rolled out during different time periods. The Pharmacist-II has not been notified as to when SATF will have the system implemented. Maxor is also in the process of starting up a central pharmaceutical packaging system that will incorporate all refills. Currently pharmacy profile records are provided for each inmate when seen by the physician or mid-level practitioner. Also, pharmacy profile records are available in the facility medical clinics and the CTC Treatment and Triage Area (TTA). Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 125 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Finding 3 Pharmacy operations at the California Substance Abuse Treatment Facility and State Prison, Corcoran, were seriously deficient. (January 2003) Recommendation Status Comments The Division of Correctional Health Care Services should: Continue to develop and implement an automated barcode Not California Department of Corrections and Rehabilitation’s response: system for tracking the inventory and movement of Implemented Not Implemented. There is no local authority to purchase and implement an pharmaceutical products within the institutions. automated system that will incorporate each patient’s medical records and (January 2003) pharmacy tracking information. Effective February 2007, Maxor Pharmaceutical Services, Incorporated was contracted by the Receiver to oversee the management of pharmaceutical services within the institutions. Maxor is currently implementing a computerized distribution system. This is a process where institutions will be rolled out during different time periods. The Pharmacist-II has not been notified as to when the California Substance Abuse Treatment Facility, Corcoran will have the system implemented. Maxor is also in the process of starting up a central pharmaceutical packaging system that will incorporate all refills. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Work with the court-appointed federal receiver to develop Fully California Department of Corrections and Rehabilitation’s response: a competitive salary structure for pharmacy professionals, Implemented Fully Implemented. Effective January 2007, salaries for pharmacists were while continuing efforts to hire full-time pharmacy staff at increased. Pharmacy is currently fully staffed by Civil Service employees. present salary levels. (April 2006) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 126 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Finding 4 The dental care program at the California Substance Abuse Treatment Facility and State Prison, Corcoran, was seriously deficient and inmates were not receiving dental services required under state regulations. (January 2003) Recommendation Status Comments California Substance Abuse Treatment Facility and State Prison, Corcoran, should: Establish procedures to comply with Title 15 of the Partially California Department of Corrections and Rehabilitation’s response: California Code of Regulations, requiring that dentists Implemented Partially Implemented. The Inmate Dental Services Program Policy & examine inmates within 14 days of the date inmates arrive Procedures (IDSP P&P) stipulated agreement supersedes the Title 15 of at the assigned institution from the reception center, and California Codes of Regulations. The IDSP P&P of August 2007 indicates all develop a reporting and monitoring system to track inmates shall receive a complete dental examination within 90 days of compliance. (January 2003) assignment to a Mainline institution. (5.15-2) Tracking of compliance will be accomplished once an IT system has been implemented which currently is under the direction of the receiver. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Review the chief dental officer’s duty statement and either Fully California Department of Corrections and Rehabilitation’s response: require the chief dental officer to devote 40 percent of his or Implemented Fully Implemented. The Chief Dentist duty statement has been revised to her time to clinic work as described in the current duty indicate that within 10% of the time they will attend quarterly Chief Dentist statement, or revise the duty statement as necessary. meetings in Sacramento and other meetings as required by the DCHCS as well (January 2003) by the CDCR. Assume the duties of Health Care Manager on an as-needed basis to include day-to-day supervision of field health care operations. Participate as a member of the executive management team in executive staff sessions. Provide direct patient care as directed by the Chief Dentist, Clinical Standards and Services, DCHCS. Additionally, statewide Chief Dentists and Supervising Dentists have received documented training from Dental Program of Headquarters in the form of quarterly Chief Dentist’s meetings. 40% clinic duty removed from duties. Office of the Inspector General’s comments: Office of the Inspector General Page 127 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments The OIG performed no audit procedures to verify the department’s representation. Provide management training to on-site dental management Fully California Department of Corrections and Rehabilitation’s response: staff, including training on planning and goal setting; Implemented Fully Implemented. CSATF performs ongoing training in order for dental staff performance measurement; interpersonal communication; to obtain inter-disciplinary knowledge such as Peer Review, Dental and principles of supervision. (January 2003) Subcommittee, and Dental Authorization Review. We have obtained training from multiple disciplines and other departments such as the Appeals Process, Effective Communication as related to the American Disabilities Act, Quality Management Assessment Team, and Investigative Services Unit, et al. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Continue efforts to reduce the dental backlog. Partially California Department of Corrections and Rehabilitation’s response: (January 2003) Implemented Partially Implemented. CSATF has made continual efforts to reduce the dental back log by increasing of staff: Office Technicians, Dental Assistants, and Dentists; alternative work schedules, and implementing a simple interim tracking system to monitor the delivery of oral health care. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Have the health care manager and the chief dental officer Partially California Department of Corrections and Rehabilitation’s response: finalize the policies and procedures for local operation of Implemented Partially Implemented. The local operation procedures of dental services dental services. (January 2003) (LOP) for our emergency dental services at the Correctional Treatment Center CTC was revised and approved on October 26, 2007. In addition, CSATF is currently updating our dental services (LOP) to reflect our individual needs as an institution. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 128 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Recommendation Status Comments The Division of Correctional Health Care Services should: Improve its support of the dental function at the institution Partially California Department of Corrections and Rehabilitation’s response: by conducting site visits, both scheduled and unannounced, Implemented Partially Implemented. The DCHCS has provided training for the current and to inspect dental operations, provide guidance, and meet new employees of the California Substance Abuse Treatment Facility, with the institution’s dental management to discuss areas of Corcoran Dental Department and will continue to provide supportive services. concern. (January 2003) In addition, DCHCS HQ Dental staff are providing inspections of dental areas around the state. Office of the Inspector General’s comments: We contacted management and staff from the department’s Division of Correctional Health Care Services (DCHCS) to obtain information about its inspections of dental functions throughout the state. Based on information and documents the DCHCS provided to us, we found that the DCHCS developed new dental care policies and procedures in coordination with the Perez v. Tilton, et al. lawsuit. In addition, the department established a rollout schedule that identifies when each institution is required to implement the new policies and procedures. The department also began conducting readiness assessments of each institution and completed its assessment of the California Substance Abuse Treatment Facility and State Prison, Corcoran, in May 2007. The readiness assessments will be used to establish a baseline measure of each institution’s level of compliance with the new dental care policies and procedures. Office of the Inspector General Page 129 California Substance Abuse Treatment Facility and State Prison, Corcoran 2008 Accountability Audit Management Review Audit Finding 8 The institution was not properly documenting inmate activity in the administrative segregation units. (January 2003) Recommendation Status Comments California Substance Abuse Treatment Facility and State Prison, Corcoran, should: Record inmate movement in the administrative segregation Fully California Department of Corrections and Rehabilitation’s response: isolation log (CDC-Form 114) as it occurs and use this Implemented Fully Implemented. Administrative Segregation Sergeants conduct weekly document to record unusual incidents and other noteworthy audits of Administrative Isolation Logs CDC 114’s as well as the unit Isolation conditions. (January 2003) Log to ensure compliance. In addition the institution had an Ad/Seg audit conducted November 4, 2006 by the Office of Audits and Compliance, which demonstrated compliance regarding CDC 114 Isolation logs as well as CDC 114 files. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 130 California State Prison, Solano 2008 Accountability Audit Management Review Audit California State Prison, Solano Management Review Audit Finding 4 A significant number of inmates taking psychotropic medications were inappropriately housed in buildings lacking air conditioning and some inmates who were taking anticonvulsant medications were not assigned to lower bunks to lessen the possibility of injury in the event of a seizure. (March 2003) Recommendation Status Comments California State Prison, Solano, should: Conduct periodic evaluations of the housing assignments Not California Department of Corrections and Rehabilitation’s response: of inmates who have been prescribed seizure medications Implemented Fully Implemented. Currently, the assigned Armstrong Correctional Counselor to ensure that these inmates are housed appropriately. II conducts a weekly audit to ensure all inmates requiring lower bunks/tiers (March 2003) due to seizure medication or other issues are appropriately housed. Office of the Inspector General’s comments: We reviewed pharmacy records as of January 11, 2008, and identified 15 inmates who were prescribed seizure medications for seizure-related issues and housed in an upper bunk. Furthermore, we found that 14 of those inmates had a current Work and Safety Chrono form issued by a physician requiring them to be housed in a lower bunk. The remaining inmate had a Work and Safety Chrono from his previous institution that required him to be housed in a lower bunk. California State Prison, Solano, medical staff later prepared a Comprehensive Accommodation Chrono form for that inmate, identifying the lower bunk requirement. The associate warden for health care and the institution’s public information officer told us that the correctional counselor II, who is responsible for handling Americans with Disabilities Act issues, does not currently conduct weekly audits to ensure that inmates prescribed seizure medications for seizure-related issues are housed appropriately. The officials also told us that they were unaware of any current policy that required the correctional counselor II to conduct those audits, but they were receptive to adding it to the counselor’s current workload. Based on our review, it appears that custody staff members are not always following the housing Recommendation made by the medical staff, and there is Office of the Inspector General Page 131 California State Prison, Solano 2008 Accountability Audit Management Review Audit Recommendation Status Comments no audit process in place to ensure compliance. Therefore, we have modified the status of this recommendation to not implemented. Finding 7 California State Prison, Solano, was not complying with state regulations governing inmate dental care and as a result may have been exposed to the risk of litigation. (March 2003) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Assess whether the increased dental staffing and Partially California Department of Corrections and Rehabilitation’s response: equipment have improved the availability of dental Implemented Partially Implemented. Currently, all institutions are under the purview of the examinations to inmates across all institutions. Perez v. Tilton, et al Stipulated Agreement as it relates to providing Dental (April 2006) Care. All issues related to program effectiveness and staffing are being addressed through the special master. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 132 California State Prison, Solano 2008 Accountability Audit Management Review Audit Finding 9 Pharmacy record keeping and physical controls over prescription medications stored in the infirmary and clinics were inadequate to prevent unauthorized access and theft. (March 2003) Recommendation Status Comments California State Prison, Solano, should: Develop a method to reconcile the types and quantities of Not California Department of Corrections and Rehabilitation’s response: pharmaceuticals shipped from its pharmacy to its clinics Implemented Not Applicable. The Receiver’s Information Technology staff is working on the and the Correctional Treatment Center with the types and development and implementation of an automated health information system quantities of medications prescribed to inmates. that will include an electronic medical record that will incorporate all aspects (March 2003) of health care. Anticipated completion date, December 2012. Effective February 2007, Maxor Pharmaceutical Services, Incorporated was contracted by the Receiver to oversee the management of pharmaceutical services within the institutions. Maxor Pharmaceutical is currently implementing a computerized distribution system. This is a process where institutions will be rolled out during different time periods. Maxor Pharmaceutical is also in the process of starting up a central pharmaceutical packaging system that will incorporate all refills. Office of the Inspector General’s comments: The OIG did not perform audit procedures to verify the department’s representation; however, we changed the status from not applicable to not implemented. Although the department’s response indicates that the receiver’s information technology staff is working on implementing our recommendation in the near future, California State Prison, Solano, did not describe what is currently being done to address the problem. Office of the Inspector General Page 133 2008 Accountability Audit Pharmaceutical Expenditures Survey of California Department of Corrections and Rehabilitation Pharmaceutical Expenditures Finding 1 The Department of Corrections and Rehabilitation has failed to implement recommendations from four recent audits and studies at a cost of millions in potential pharmaceutical expenditure savings. (July 2003) Finding 2 The Department of Corrections and Rehabilitation could reduce its annual pharmaceutical costs by an estimated minimum 20 percent—saving upwards of $26 million a year—by implementing effective management controls such as those recommended in recent audits and studies. (July 2003) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Continue the project to replace the outdated and inefficient Partially California Department of Corrections and Rehabilitation’s response: Pharmacy Prescription Tracking System with the automated Implemented Partially Implemented. The Health Care Services Division, now under the Health Care Management System and implement the new direction of the Receiver, has developed a detailed Plan of Action (POA) system statewide as soon as practicable. (April 2006) which addresses delivery of medications, tracking of prescriptions and a wide variety of other medication related issues. These steps will increase accuracy, as well as reducing expenditures and waste. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. In light of the flexible options likely to be available under Fully California Department of Corrections and Rehabilitation’s response: the February 2006 federal court order appointing a receiver Implemented Fully Implemented. The Receiver has contracted with Maxor National over the department’s medical health care delivery system, Pharmacy Services Corporation to coordinate and implement a safe, efficient reconsider the option of contracting with a private and cost-effective drug selection process and treatment approach through the pharmacy services management firm to implement the statewide Pharmacy and Therapeutics Committee. recommendations submitted in the reports and studies conducted since 2000. (April 2006) Office of the Inspector General’s comments: Office of the Inspector General Page 134 2008 Accountability Audit Pharmaceutical Expenditures Recommendation Status Comments We verified that the California Prison Health Care Receivership and the Maxor National Pharmacy Services Corporation entered into a three-year, $15.1 million agreement effective January 1, 2007, for pharmacy management consulting services. Less than one month later, the contract was amended to broaden the scope of consultant services for an additional cost to the state of $7.1 million, totaling $22.2 million over the three-year contract term. In brief, the agreement calls for the development of a pharmaceutical delivery system that provides 1. centralized oversight, control, and monitoring services; 2. clinical pharmacy management processes including formulary controls; 3. a comprehensive program to review, audit, and monitor pharmaceutical contracting and procurement processes; 4. a human resources program that effectively manages pharmacy staffing operations; 5. standardization of drug distribution operations; 6. a uniform pharmacy information management system; 7. pharmacy accreditation standards. Office of the Inspector General Page 135 2008 Accountability Audit Education Programs at Level IV Institutions Survey of Education Programs at California Department of Corrections and Rehabilitation Level IV Institutions Observation 1 Only a small percentage of inmates at Level IV institutions were enrolled in education classes and classes were closed a large percentage of the time because of lockdowns and other disruptions. (July 2003) Observation 2 The department and institutions had no means of accounting for the activities of teachers during lockdowns and labor agreements hampered the redirection of teachers to other functions during those periods. (July 2003) Observation 3 When lockdowns and other program disruptions were taken into account, the annual per-inmate cost of the education programs at Level IV institutions greatly exceeded the annual per-inmate cost budgeted. (July 2003) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Systematically evaluate the effectiveness of the new Not California Department of Corrections and Rehabilitation’s response: alternative education delivery models. The evaluation Implemented Not Implemented. The California Department of Corrections and should include inmate participation rates, progress in Rehabilitation (CDCR) will be utilizing the Correctional Program Assessment achieving educational goals, and the impact of the Process (C-PAP) to review all programs including the Alternative Education programs on recidivism. (April 2006) Delivery Models (AEDM) during 2007 and 2008. The C-PAP is designed to evaluate each program’s basic structure to see if it contains the necessary framework to successfully meet the requirements of CDCR with a likelihood of reducing recidivism. There is still not enough data from the field to determine the actual effect on recidivism that is a direct result of the AEDM being implemented. Once the Office of Correctional Education (OCE) completes their audit process, the CDCR will review the results of the C-PAP along with the audit reports to analyze the effectiveness of the AEDM. Office of the Inspector General’s comments: Office of the Inspector General Page 136 2008 Accountability Audit Education Programs at Level IV Institutions Recommendation Status Comments The OIG performed no audit procedures to verify the department’s representation. The Office of Correctional Education should: Dedicate staff to perform periodic on-site reviews to Partially California Department of Corrections and Rehabilitation’s response: ensure compliance with department policies and Implemented Partially Implemented. The OCE has provided dedicated personnel to the procedures. The on-site reviews should include, but not be Office of Audits and Compliance in order to establish the Education limited to, verification of educational representatives Compliance Branch Team (ECBT). The ECBT Coordinator works with other participating in classification committees, verification of Office of Audits and Compliance (OAC) members in planning site reviews. The class closures for teacher vacancies beyond 30 days, and education review team adheres to the combined audit schedule prepared by verification of the accuracy of timekeeping for inmate OAC in concurrence with the newly approved school calendar. However, program participation. (April 2006) education may be directed to conduct education reviews outside the scheduled dates as necessary. Requests may originate from CDCR Administration, OCE Management, or Wardens. Reviews are also scheduled in response to Office of Inspector General (OIG), Legislative and/or Governor’s Office requests. The ECBT has developed an audit tool that specifically addresses and checks for compliance in the specific areas that the OIG has recommended as well as others. The ECBT has completed audits at nine of the thirty-three prisons and plans to complete the remaining audits throughout 2007-2008. Of the original five Level IV institutions inspected by the OIG in 2003, two have been audited to date. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 137 2008 Accountability Audit Commission on Correctional Peace Officer Standards and Training Special Review of the Commission on Correctional Peace Officer Standards and Training Finding 1 The executive board of the Commission on Correctional Peace Officer Standards and Training has not met for nearly a year and the commission therefore is not performing its function of developing and monitoring training and selection standards for correctional peace officers. (May 2005) Recommendation Status Comments The Corrections Standards Authority should: Ensure that board members regularly attend board Fully California Department of Corrections and Rehabilitation’s response: meetings. (October 2006) Implemented Fully Implemented. CSA’s board is fully appointed and had an average of 15 of 19 members present at each board meeting in 2007. The 2007 meeting minutes reflect the attendance rate. (Attachment – 2007 Board Meeting Schedule) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 2 The Commission on Correctional Peace Officer Standards and Training has made minimal progress in developing training standards and has inadequately monitored compliance with the few general curriculum standards that already existed. (May 2005) Recommendation Status Comments The Corrections Standards Authority should: Continue to diligently develop job analyses to establish Partially California Department of Corrections and Rehabilitation’s response: selection and training standards for the department’s Implemented Partially Implemented. Job analyses for the Correctional Officer (CO), Youth correctional peace officer classifications while considering Correctional Officer (YCO), and Youth Correctional Counselor (YCC) alternatives to expedite the project’s December 2008 classifications will be published in December 2007. There are an additional 44 completion date. (October 2006) correctional peace officer classifications that require job analysis in order for Office of the Inspector General Page 138 2008 Accountability Audit Commission on Correctional Peace Officer Standards and Training Recommendation Status Comments CSA to develop selection and training standards. A traditional job analysis takes approximately 1 year to complete for a single classification. Given the scope of CSA’s responsibility (47 classifications), a traditional approach would be prohibitively expensive and time consuming. Therefore, CSA has designed an innovative approach of classification clustering that will reduce the time and cost of job analysis and standards development. In addition to the continued use of this innovative approach, CSA will continue to explore additional alternatives to expedite the completion of job analyses and standards development. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Continue to develop training standards based on completed Partially California Department of Corrections and Rehabilitation’s response: job analyses and monitor compliance with the standards Implemented Partially Implemented. Upon completion of the prerequisite job analyses, CSA once they are established. (May 2005) will develop selection and/or training standards for the 47 correctional peace officer classifications for which it has standard setting responsibility. A compliance program for each classification will be implemented after the job analysis is complete, standards have been set, instruction and training has been provided, and a compliance tool has been designed. The first priority for standards setting and compliance monitoring will be for the CO/YCO/YCC classifications which will have a completed job analysis in December 2007. Standards and compliance monitoring will be established for the remaining classifications upon completion of the job analysis for each classification cluster. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 3 The apprenticeship program administered by the commission is inadequately monitored and faces possible decertification because of non-compliance with federal and state apprenticeship program standards. (May 2005) Office of the Inspector General Page 139 2008 Accountability Audit Commission on Correctional Peace Officer Standards and Training Recommendation Status Comments The California Department of Corrections and Rehabilitation may want to consider: Eliminating the correctional peace officer apprenticeship program. If the program is retained, however—and unless a new Bargaining Unit 6 contract makes material changes to the meaning and application of the apprenticeship program—the Office of the Inspector General recommends that the Office of Training and Professional Development take the following actions: • Obtain the resources required to bring the Not California Department of Corrections and Rehabilitation’s response: correctional peace officer apprenticeship program Implemented Not Implemented. OTPD’s request to administratively establish 2 positions to into compliance with standards set by the process backlogged apprenticeship program applications and support the JATC Department of Industrial Relations, Division of is on hold as CDCR works with CCPOA to reconvene the Joint Apprenticeship Apprenticeship Standards. (May 2005) Training Committee. Due to budget constraints, estimated completion date is expected to be in Spring, 2008. • Ensure that an appeals and grievances committee, Partially California Department of Corrections and Rehabilitation’s response: or a comparable apprenticeship program Implemented Partially Implemented. A letter from Secretary Tilton to CCPOA to reconvene oversight body, meets as needed to address an 8-person Joint Apprenticeship Training Committee (JATC) has been signed appeals, grievances, and time credit applications. and sent to CCPOA on November 26, 2007. Initial JATC organizing meeting (May 2005) scheduled for January 16, 2008 to include reconvening the JATC Appeals and Grievances Committee. JATC Appeals and Grievances Committee’s initial meeting scheduled for April 16, 2008. • Develop an effective audit function and conduct Not California Department of Corrections and Rehabilitation’s response: field audits to ensure compliance by local Implemented Not Implemented. Awaiting reconvening of the JATC and the availability of two apprenticeship programs. (May 2005) additional staff resources to schedule and conduct local apprenticeship program field audits. Due to budget constraints, estimated start date for audit function is unknown. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representations. Office of the Inspector General Page 140 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Special Review into the Death of Correctional Officer Manuel A. Gonzalez Jr. on January 10, 2005, at the California Institution for Men Finding 4 Sycamore Hall inmates were able to obtain and hide weapons because of lax tool controls, poor building maintenance, and the consistent failure of the correctional staff to conduct required cell searches. (March 2005) Recommendation Status Comments The California Institution for Men should: Discontinue the storage of tools within the secured Fully California Department of Corrections and Rehabilitation’s response: perimeter unless they are placed under the supervision and Implemented Fully Implemented. All tools are currently under the control and oversight of control of the institution’s tool control officer and subjected the institution’s tool control team. The California Institution for Men has to standard inventory procedures. (December 2006) enhanced the tool control process by establishing a tool control team under the oversight of the institution’s Investigative Services Unit in addition with a daily inventory accountability by staff assigned to use the tools. On the Job Training has been completed. Office of the Inspector General’s comments: During a January 2008 site visit to the California Institution for Men, we reviewed the institution’s tool control policies and oversight activities and found that all tools within the secured perimeter were under the supervision and control of the tool control team. The tool control officers told us that they maintain a master list of all tools on institution grounds, and they audit the areas periodically to ensure each area conducts daily and quarterly tool inventories. In addition, the tool control team investigates any discrepancies between the master inventory list and the quarterly inventories submitted by each area. According to a tool control team officer, the tool control team also conducts random tool control inspections and provides on-the-job training to staff members on appropriate tool control procedures. In addition, we confirmed with the in-service training officer that tool control training is included as part of the training for new employees so that all employees are aware of the policy Office of the Inspector General Page 141 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Recommendation Status Comments and understand the importance of maintaining adequate control over all tools. (Note: Our December 2006 follow-up report found that the California Institution for Men had completed security audits to address building maintenance and cell search deficiencies.) Finding 6 The medical clinic at the California Institution for Men reception center—where the victim was taken after the stabbing—was poorly equipped and ill prepared to handle the emergency. (March 2005) Recommendation Status Comments The California Institution for Men should: Conduct regular monthly meetings of the emergency Fully California Department of Corrections and Rehabilitation’s response: medical response review committee in conjunction with Implemented Fully Implemented. Regular meetings are conducted and the California post-incident debriefings in which medical personnel Institution for Men is no longer backlogged on the review of medical involved in specific incidents participate. emergency responses. (December 2006) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The California Department of Corrections and Rehabilitation should: Continue its efforts to develop appropriate emergency Not California Department of Corrections and Rehabilitation’s response: medical policies and procedures and a level of Implemented Not Implemented. The Receiver concurs with the recommendation and preparedness at all of the institutions consistent with DCHCS will develop programs, protocols and training to assure compliance. community standards. (December 2006) Due to the special circumstances regarding the utter disrepair and dysfunction of CDCR/DCHCS medical programs which led to the drastic Court action creating the Receivership it is not possible, at this time, to be more specific in terms of implementation and/or completion of these recommendations. Office of the Inspector General Page 142 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 7 The management of the California Institution for Men did not set up an Emergency Operations Center or institute an Emergency Operations Plan in the wake of Officer Gonzalez’s stabbing due to ambiguous protocols. As a result, there was some confusion in the chain of command, emergency operations policies were not implemented, the crime scene was partially destroyed, and an incident log was not initiated. (March 2005) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Update section 55010 of the California Department of Partially California Department of Corrections and Rehabilitation’s response: Corrections and Rehabilitation Operations Manual so that Implemented Partially Implemented. Written direction has been provided to clarify when it (1) clarifies ambiguities such as the circumstances under institutions may be required to activate their Emergency Operation Center. which the Emergency Operations Plan should be implemented, and (2) incorporates changes in technology Additionally, each institution provides an annual Administrator Officer of the that have occurred since that section’s last revision in Day training, this training covers Emergency Response. 1989. (March 2005) The Department Operations Manual section 55000 is currently in the process of being revised to be in compliance with Federal and State mandates i.e. FEMA and the Office of Emergency Services. Office of the Inspector General’s comments: The written direction referenced in the department’s response was a June 2005 memorandum from headquarters to all wardens clarifying when an institution may be required to activate its emergency operations center. We reviewed the memorandum and confirmed that it provided guidance on when it may be necessary to activate an emergency operations center. However, we reviewed the emergency operations plans at the California Institution for Men Office of the Inspector General Page 143 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Recommendation Status Comments and Wasco State Prison in January 2008 and found neither institution’s plan contained information or guidance from the June 2005 memorandum. Since these two institutions failed to incorporate the guidance of the June 2005 memorandum into their emergency operations plans and the department Operations Manual section 55010 has not been updated, we agree that the recommendation is only partially implemented. Finding 8 The California Institution for Men did not implement important emergency procedures in response to the incident, leading to contamination of the crime scene and the loss of important evidence. (March 2005) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Evaluate the need for a memorandum of understanding or Fully California Department of Corrections and Rehabilitation’s response: protocols governing when an outside agency should take Implemented Fully Implemented. A general format for memorandum of understanding was primary responsibility for the criminal investigation of a provided to the institutions and the Office of Correctional Safety has received crime against a staff member. (March 2005) and maintains them. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Re-evaluate and assess the scope and responsibility of Partially California Department of Corrections and Rehabilitation’s response: institutions’ Investigative Services Units as the primary Implemented Partially Implemented. The Department Operations Manual section 55000 is criminal investigative entity given their manpower, currently in the process of being revised to be in compliance with Federal training, and resource limitations. (March 2005) and State mandates i.e. FEMA and the Office of Emergency Services. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 144 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Recommendation Status Comments Clearly define the role and expectations of Investigative Fully California Department of Corrections and Rehabilitation’s response: Services Units in identifying and securing potential crime Implemented Fully Implemented. The Department Operations Manual section has scenes, identifying and preserving evidence and, if they provisions for the specialized training for Investigative Services Unit staff on remain the primary investigative entity, proper processing crime scene provisions. of the crime scene and collection of evidence. (March 2005) Office of the Inspector General’s comments: We interviewed investigative services unit staff members at the California Institution for Men and Wasco State Prison to determine whether they were adhering to and enforcing the proposed department Operations Manual language related to crime scene preservation and evidence collection. Both facilities have procedures to minimize access to evidence collected, as well as evidence sent to the Department of Justice for testing. Access to the evidence rooms is limited, with only the evidence officers and watch commander having access to the rooms. Training for crime scene preservation is included in each facility’s 40-hour annual block training given to staff members. The California Institution for Men’s annual administrator of the day training also has a section dedicated to crime scene preservation. Evaluate the need for training at the correctional officer, Fully California Department of Corrections and Rehabilitation’s response: sergeant, and Investigative Services Unit levels regarding Implemented Fully Implemented. The California District Attorney’s Association has the identification and collection of physical evidence with provided training to CDCR staff. potential forensic examination in mind, including but not limited to the manner of collection, processing, and Office of the Inspector General’s comments: documentation. (March 2005) The department worked with the California District Attorneys Association (CDAA) to provide training on crime scene preservation, evidence retrieval and documentation, report writing, witness and suspect interviewing, and courtroom testimony. We reviewed the sign-in sheets and confirmed that all adult institutions sent staff members to attend the CDAA training. In addition, according to department headquarters’ staff, the CDAA training was filmed and will be sent to all institutions for ongoing training needs. Aside from the CDAA training, we obtained sample copies of the 40-hour block training agendas at the California Institution for Men and Wasco State Prison. Both facilities have incorporated crime scene preservation into their annual block training given to staff members. Office of the Inspector General Page 145 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Recommendation Status Comments Develop a “lessons learned” instructional curriculum by Fully California Department of Corrections and Rehabilitation’s response: which all institutions can learn what went right and what Implemented Fully Implemented. Training modules have been completed. went wrong in the events leading up to and following the death of Officer Gonzalez and present it as formal training Office of the Inspector General’s comments: to custody staff at all institutions. (March 2005) The department provided a copy of the “lessons learned” training module that the institutions were directed to use to train all staff members. The training module was a breakdown of the OIG’s findings and recommendations in its “Special Review into the Death of Correctional Officer Manuel A. Gonzalez Jr. on January 10, 2005, at the California Institution for Men,” issued March 16, 2005. Department documentation indicated that all institutions except for the California Institution for Men provided the “lessons learned” training curriculum to their staff members. According to the training lieutenant at the California Institution for Men, the institution was exempt from the training because the death occurred at the institution, and the executive staff felt it was inappropriate to have the staff relive the tragic event. Finding 10 Inmate Blaylock was permitted to conduct a telephone conference with an attorney before he was indicted for the murder of Officer Gonzalez even though the attorney’s request for the conference was not properly submitted in writing. (March 2005) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Evaluate and, depending upon the advice of the Partially California Department of Corrections and Rehabilitation’s response: department’s legal counsel, modify regulations governing Implemented Partially Implemented. The Regulation and Policy Management Branch has “confidential calls” between inmates and their attorneys. received the last of the stakeholder approvals for revised regulations on Such modifications may address permitting verification confidential inmate phone calls to attorneys. The proposed regulations will through independent sources that the requesting attorney is be "packaged" and forwarded to Executive Management for review and licensed to practice, balancing inmates’ right to counsel approval. with the institution’s need to validate such calls and its Office of the Inspector General Page 146 Special Review into the Death of 2008 Accountability Audit Correctional Officer Manuel A. Gonzalez Jr. Recommendation Status Comments resources available to facilitate them. (March 2005) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Develop procedures for wardens and chief deputy wardens Fully California Department of Corrections and Rehabilitation’s response: to communicate with key institutional staff members (such Implemented Fully Implemented. The Warden/Designee from the sending institution will as the litigation coordinator and the public information communicate with the Warden/Designee from the receiving institution prior officer) when inmates requiring special handling enter to the transfer of a “High Notoriety” or “Sensitive Case” inmate per a their institutions. Such communications should include Directive Memorandum. instructions to staff that all external inquiries concerning these inmates be referred to the attention of the warden or Office of the Inspector General’s comments: the warden’s designee. (March 2005) The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 147 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Heman G. Stark Youth Correctional Facility Management Review Audit Finding 1 The Heman G. Stark Youth Correctional Facility did not have a system to ensure that allegations of staff misconduct were promptly and properly investigated. Moreover, management actions relative to such investigations appeared to be questionable. (October 2000) Recommendation Status Comments The superintendent of Heman G. Stark Youth Correctional Facility should: Require the administrative assistant to enter all tracking Partially California Department of Corrections and Rehabilitation’s response: notes in the inquiry database in a timely manner and Implemented Partially Implemented. The Superintendent directly oversees the Staff periodically review the inquiry database looking for open Misconduct Database Management System at Heman G. Stark Youth complaints for which it appears a sufficient amount of time Correctional Facility to ensure any allegations of staff misconduct are properly has elapsed for the complaints to have been processed and investigated. To ensure the Heman G. Stark Staff Misconduct Database closed. (October 2000) Management System is being used effectively and consistently, whether at the level of a Staff Inquiry or referred for an Internal Affairs Investigation, every open staff misconduct complaint being tracked through the Staff Inquiry Database, including those that originated through the Youth Grievance System, are under review. The Office of Audits and Compliance, within the California Department of Corrections and Rehabilitation, is providing guidance and technical assistance to the Office of the Superintendent at Heman G. Stark Youth Correctional Facility to eliminate Office of the Inspector General concerns and reduce the number of databases used to track allegations of staff misconduct. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 148 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 2 The Heman G. Stark Youth Correctional Facility educational and vocational classes were poorly attended and wards’ academic achievement was low in comparison to other Division of Juvenile Justice facilities. (October 2000) Recommendation Status Comments The Division of Juvenile Justice Education Services Branch and Heman G. Stark Youth Correctional Facility should: Increase efforts to recruit and retain qualified education Fully California Department of Corrections and Rehabilitation’s response: staff, including full-time teachers, special education Implemented Fully Implemented. In April 2006, the new contract to remedy the compensation instructors, and substitutes. (October 2000) for teacher pay was implemented. Since April 2006, sustained efforts to secure candidates with the requisite skills and qualifications required to fill vacant teacher positions at Heman G. Stark Youth Correctional Facility have yielded positive results. Because of the aforementioned dedicated efforts, in November of 2007, Lyle Egan High School has limited teacher vacancies. To ensure that future Educational Services to wards are not interrupted due to teacher vacancies, the Education Services at headquarters has developed a partnership with the California Department of Corrections and Rehabilitation Workforce Planning Office to ensure that any new teacher vacancies throughout the youth correctional system are filled in a timely manner. Moreover, Education Services, within the Division of Juvenile Justice, currently employs two full-time Recruitment Coordinators assigned to the Northern and Southern regions, while at the site level; Lyle Egan High School has secured one full-time Recruitment Coordinator, who serves in the classification of a retired annuitant assistant principal. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The Division of Juvenile Justice Education Services Branch and the principal should: Continue their efforts to develop trade advisory Fully California Department of Corrections and Rehabilitation’s response: committees at the facility. The committees should use Implemented Fully Implemented. The Acting Superintendent of Education has appointed a meeting agendas and minutes to develop and organize Trade Advisory Committee Coordinator at headquarters. The Trade Advisory Office of the Inspector General Page 149 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments effective committee goals. (October 2000) Committee Coordinator provides leadership, guidance and technical expertise for Trade Advisory Committee meetings being conducted at sites across the State of California. The Trade Advisory Committee Coordinator ensures that at local sites, including Lyle Egan High School, Heman G. Stark Youth Correctional Facility, Trade Advisory Committee meetings are effectively facilitated by using good business practices like the preparation of agendas and the distribution of minutes. Moreover, when necessary, the Trade Advisory Committee Coordinator provides guidance to assist Trade Advisory Committees in establishing meaningful goals based upon one of the foundational principles of reform efforts being implemented, which is that successful re-entry into California communities begins at the time a youth is committed to the juvenile justice system. In order to meet with as many trade advisors from the local community as possible, and to be responsive to the Education Services Remedial Plan in the Farrell v. Tilton litigation, the principal at Heman G. Stark Youth Correctional Facility, has implemented a strategy whereby vocational instructors from Lyle Egan High School conduct industrial visitations. The purpose of industrial visitations is for vocational instructors to form partnerships with potential ward employers in the community, as well as to make provisions for ongoing opportunities to stay abreast of equipment, techniques and trends in designated vocational fields. To ensure maximum student contact time, vocational instructors, at Lyle Egan High School are required to conduct Trade Advisory Committee meetings and industrial visitations on alternate schedule days. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 150 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 3 Wards at the Heman G. Stark Youth Correctional Facility were not provided with required treatment services. (October 2000) Recommendation Status Comments The superintendent of Heman G. Stark Youth Correctional Facility and the principal should: Require teachers to participate in case conferences as Partially California Department of Corrections and Rehabilitation’s response: facilitated by the alternative education schedule. Implemented Partially Implemented. Heman G. Stark Youth Correctional Facility assigns (October 2000) teachers to attend case conferences that are scheduled on the half-day per week designated for that purpose in the Division of Juvenile Justice Academic Calendar. As part of school guidance and pupil advising responsibilities, teachers are expected to attend and be full partners in case conferences that occur during alternate school scheduling. When conducted during scheduled class periods, teachers are not available to participate in case conferences. To that end, the Superintendent and Principal at Heman G. Stark Youth Correctional Facility are working diligently to remove existing barriers to full implementation of a case conference schedule that contains provisions for both teachers and treatment team staff to attend case conferences as equal members of the interdisciplinary team. A comprehensive plan that contains an agreed upon strategy for addressing the compelling need for inclusion of teachers in the case conference process is expected to be submitted to the Director of Juvenile Facilities and the Superintendent of Education by February 1, 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Continue to take steps to ensure that wards are assigned Substantially California Department of Corrections and Rehabilitation’s response: to education and work programs within four days of Implemented Substantially Implemented. The principal for Lyle Egan High School has arrival at their permanent living units. (January 2005) identified the issues precluding adherence to the 4-day delivery of academic services standard at Heman G. Stark Youth Correctional Facility, and has implemented a strategy that will ensure that wards are enrolled in academic and vocational classes within the prescribed timeframes. Office of the Inspector General Page 151 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Because scheduling changes had occurred only once a week, the issue precluding adherence to the 4-day standard at Heman G. Stark Youth Correctional Facility was that wards were scheduled for a 5-period school day with corresponding academic and/or vocational classes within four days of arrival to a permanent living unit, but the actual first day of school attendance may not have occurred until after five working days, rather than within the four calendar days prescribed by policy. To correct the issue, the principal at Lyle Egan High School has implemented a strategy whereby enrollment changes occur twice instead of once weekly. Implementation of the aforementioned strategy will ensure adherence to the standard that wards attend school within four calendar days of arriving to a permanent living unit. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 152 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 5 All wards, including those in Phase 2 and 3, have been confined to eating in their rooms since the 1996 staff murder, hampering socialization efforts. (October 2000) Recommendation Status Comments The Division of Juvenile Justice should: Research the existence of and reasons for vacancies in Partially California Department of Corrections and Rehabilitation’s response: cook positions at the Heman G. Stark Youth Correctional Implemented Partially Implemented. In conjunction with the Office of Personnel Services, Facility that prevent serving ward meals in a cafeteria- Food Managers serving in both the adult and juvenile systems are participating style setting and, if appropriate, work with the California in a shared Food Services Task Force. On September 20, 2007, the Food Department of Corrections and Rehabilitation, the Services Task Force was convened for the first time for the purposes of Department of Finance, and the Department of Personnel discussing the reasons for vacancies, the difficulties in retaining incumbents, Administration to enhance the facility’s ability to fill the possible specification changes, testing options, and pay scales. In addition, on vacant positions. (July 2007) September 25, 2007, with a return date of October 15, 2007, food managers and administrators from both the adult and juvenile divisions were asked to distribute job audit forms to their employees. In March of 2008, the Food Services Task Force is expected to make final recommendations that may depend, in part, on assistance from control agencies like the Department of Personnel Administration and the Department of Finance. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 153 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 11 The Ward Information Network had numerous weaknesses. (October 2000) Recommendation Status Comments The Division of Juvenile Justice should: Conduct periodic audits of the Ward Information Partially California Department of Corrections and Rehabilitation’s response: Network to ensure that only properly authorized staff can Implemented Partially Implemented. In the Division of Juvenile Justice, the Ward make programming changes. (October 2000) Information Network development server located at the Enterprise Information System headquarters has a password protected design environment that is accessible to programming staff only. The Division of Juvenile Justice Internet Provider address for the Ward Information Network development server is different from any other servers in the youth correctional system. Only eight programming staff members have access to the design environment on the development server. The development server is where the coding work for feature requests and design changes occur. Once design changes are compiled and a “build” is deployed to local facilities, no one can access the design environments any longer. Even the original programmers do not have access to a “compiled” Ward Information Network structure. Resident Staff Information Systems Analysts administer the Ward Information Network servers at local youth correctional facilities. The Staff Information Systems Analysts perform their duties under the working title of Local Area Network managers. Local Area Network managers are responsible for maintaining the password system and the access rights for local staff members. Individual profiles determine who can perform discrete functions like viewing, editing, or using menu items from the selection of tasks, check fors, and reports available for each palette item. The Local Area Network manager sets the staff member profiles based upon direction from the Superintendent and in accordance with local procedures. Local Area Network managers and programmers cannot make design or coding changes to the Ward Information Network system through local servers. In 2008, to protect the integrity of the system from unauthorized staff members making programming changes and so that the aforementioned safeguards to the Ward Information Network continues to remain in effect, the Office of the Office of the Inspector General Page 154 Heman G. Stark Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Director of Juvenile Facilities will ensure that the Ward Information Network at each youth correctional facility is subject to an annual audit of the system. At the site level, superintendents and Local Area Network managers will continue to work collaboratively toward continuous improvement of the Ward Information Network for the end user by providing opportunities for both structured and on-the-job training activities. Under the guidance of local superintendents, designated program managers will monitor staff compliance with policies and procedures supported by the Ward Information Network and will take the administrative actions necessary to ensure improved performance when necessary. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 155 Division of Juvenile Justice 2008 Accountability Audit 23-and-1 Program Review Division of Juvenile Justice 23-and-1 Program Review Finding 1 A significant portion of the wards interviewed said they were deprived of their rights while housed in temporary detention units. (December 2000) Recommendation Status Comments The Division of Juvenile Justice should: Review its methods for tracking mandated services to Partially California Department of Corrections and Rehabilitation response: wards and implement procedures to ensure that weekly Implemented Partially Implemented. The Director of Juvenile Facilities has been monitoring and monthly, as well as daily, services are provided and compliance with the standards contained in both the revised Restricted accurately documented. (December 2000) Program Policy and the August 24, 2007, Wards Assigned to Restricted Programs Memorandum. To that end, on a weekly basis, a management review of the mandated services that have been provided to wards on restricted status is forwarded to youth correctional facilities with special management programs. Likewise, the Superintendent at each youth correctional facility is being required to be in 100% compliance with “out of room” service delivery, or within three days, submit an explanation of facility noncompliance with the standard to the Director of Juvenile Facilities. The aforementioned explanation is expected to include the “barriers” causing less than 100% compliance with the standard, and a description of the corrective actions proposed to mitigate identified “barriers.” Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 156 Division of Juvenile Justice 2008 Accountability Audit 23-and-1 Program Review Finding 2 The reasons for wards’ detention were not clearly documented. (December 2000) Recommendation Status Comments The Division of Juvenile Justice should: Finalize and implement policies and procedures that Partially California Department of Corrections and Rehabilitation’s response: provide clear justification for isolating wards in Implemented Partially Implemented. On March 9, 2007, the Chief Deputy Secretary signed restricted programs. (December 2000) the revised Restricted Program Policy, and in April 2007, the Policy, Procedures, Programs and Regulations Unit disseminated the newly adopted restricted program standards to internal and external juvenile justice stakeholders throughout the State of California. To refine expectations and enhance service delivery, the Restricted Program Policy has been revised three times since 2001. The automation necessary to support full implementation of the revised Restricted Program Policy in the Ward Information Network is being “Beta” tested at O. H. Close Youth Correctional Facility. If the Ward Information Network automation test is successful, the Division of Juvenile Justice is scheduled to train staff members on all aspects of the revised Restricted Program Policy in January 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. As part of the department’s efforts to finalize the above Partially California Department of Corrections and Rehabilitation’s response: policy, include its policy of allowing wards in restricted Implemented Partially Implemented. On August 24, 2007, the Director of Juvenile Facilities programs––including wards assigned to temporary issued the Wards Assigned to Restricted Programs Memorandum, clearly detention––at least three hours outside their rooms every restating the standard that regardless of restricted status, including temporary day in its Division of Juvenile Justice Institutions and detention, a ward must be provided a minimum of three hours of “out of room Camps Branch Manual. (July 2007) services” each day. The Director of Juvenile Facilities also stated that the three-hour minimum was to occur in addition to the time required for activities of daily living like showering or taking medication. Moreover, the memorandum stated that only documented safety and security concerns could countermand the minimum standard of three hours of “out of room services”. Office of the Inspector General Page 157 Division of Juvenile Justice 2008 Accountability Audit 23-and-1 Program Review Recommendation Status Comments In the memorandum, the Director of Juvenile Facilities clearly communicated an expectation of 100% compliance with the directives contained therein. In addition, the Wards Assigned to Restricted Programs Memorandum directed that each day a ward does not receive the mandatory “out of room” time that is expected by policy, the program manager is to ensure that a member of the treatment team personally interviews the ward in question. Concurrently, in the memorandum, the Director of Juvenile Facilities set the expectation that treatment team members are to counsel and encourage a ward on restricted status to participate in program activities. Should the ward be restricted from program time due to behavior, the program manager is further required to ensure that the treatment team develops goals with specific behavioral components. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 3 Living conditions in the wards’ rooms and cells were substandard. (December 2000) Recommendation Status Comments The Division of Juvenile Justice should: Hold staff accountable for failing to follow policies Partially California Department of Corrections and Rehabilitation’s response: related to wards’ living conditions, particularly Implemented Partially Implemented. Staff members are being held accountable for failure to conditions that threaten safety and security. maintain living and working conditions that comply with Division of Juvenile (December 2000) Justice safety and security standards contained in policy and/or issued through memorandums. Supervisors routinely monitor established internal tracking systems like logbooks and the Ward Information Network for compliance with local and statewide security practices. Supervisory methods used to hold staff accountable for maintaining a safe and secure correctional environment Office of the Inspector General Page 158 Division of Juvenile Justice 2008 Accountability Audit 23-and-1 Program Review Recommendation Status Comments include training, counseling, and when judged necessary, the application of employee discipline. In the last six months, management from youth correctional facilities within the Division of Juvenile Justice have reported 105 log notations, 43 all staff memorandums, 42 read and initial memorandums, 15 corrective action memorandums, 20 supervisory counseling sessions, and 5 work improvement discussions related to living conditions that threaten safety and security. Most recently to enhance living conditions, the Director of Juvenile Facilities, has directed that superintendents develop a corrective action plan to render each youth correctional community “graffiti free”. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 159 Ventura Youth Correctional Facility 2008 Accountability Audit Management Review Audit Ventura Youth Correctional Facility Management Review Audit Finding 5 The academic achievement of Ventura Youth Correctional Facility’s wards was low compared to that of other Division of Juvenile Justice facilities. (June 2002) Recommendation Status Comments Ventura Youth Correctional Facility should: Make every effort to compile a list of qualified substitute Fully California Department of Corrections and Rehabilitation’s response: instructors so that classes can continue without Implemented Fully Implemented. At Mary B. Perry High School, Ventura Youth cancellation when an instructor is sick, takes vacation, or is Correctional Facility, in response to agreements made with the Court in the otherwise absent. (June 2002) Farrell litigation, the principal has diligently pursued strategies to address the need for recruitment, selection and retention of qualified substitute teachers. To ensure that classes can continue without cancellation when the permanent teacher is not available, two permanent full-time substitute teachers have been retained as part of the faculty that serves the educational needs of students attending Mary B. Perry High School. According to standards agreed upon with the Court in the Farrell litigation, each high school within the Correctional Education Authority, including Mary B. Perry High School, is required to use a minimum 5.5% substitute teacher to permanent teacher ratio to determine the standard number of teachers that must be maintained in the substitute pool. Based upon a current faculty of 25 teachers, by implementing a strategy that retains two permanent full-time substitute teachers, the principal has ensured that Mary B. Perry High School exceeds the minimum standard set by the Court in the Farrell Education Remedial Plan for a substitute teacher pool. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 160 Ventura Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Explore ways to lessen the disruption or cancellation of Substantially California Department of Corrections and Rehabilitation’s response: classes and ensure that all class cancellations are for valid Implemented Substantially Implemented. The Acting Superintendent of Education has reasons and that all alternatives to cancellation have been explored ways to lessen academic and vocational class disruptions and explored. (June 2002) cancellations that occur in high schools throughout the Division of Juvenile Justice. The standard contained in the policy that accompanies the Division of Juvenile Justice Academic Calendar allows teachers to take vacation leave only on unassigned days. According to the policy standards, personal appointments should be scheduled during non-instructional time. According to standards agreed upon in the Farrell litigation, each high school within the Correctional Education Authority, including Mary B. Perry, is required to maintain a teacher absence rate below 7%. According to data submitted to the Secretariat within the California Department of Corrections and Rehabilitation for September 2007, Mary B. Perry High School had a teacher absence rate of 10.7%. More importantly, since September 2007, the principal reports that the teacher absence rate has been decreasing. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 161 Ventura Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 6 Certain fundraising activities conducted by staff at the Ventura Youth Correctional Facility were not properly administered. (June 2002) Recommendation Status Comments The Division of Juvenile Justice should: Provide training to administrators at the Division of Fully California Department of Corrections and Rehabilitation’s response: Juvenile Facilities in the proper use of ward benefit Implemented Fully Implemented. On November 26, 2007, to ensure adherence to standards funds. (June 2002) as prescribed by Division of Juvenile Justice policy, the Business Manager conducted training with administrators serving in the Division of Juvenile Facilities, at headquarters, on the proper use of ward benefit funds. In addition, on November 30, 2007, the Deputy Director of Juvenile Facilities conducted training with Superintendents on the same subject. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 8 The Division of Juvenile Justice and the Ventura Youth Correctional Facility failed to comply with established security requirements. (June 2002) Recommendation Status Comments Ventura Youth Correctional Facility should: Continue to pursue a mutual aid agreement with a local Partially California Department of Corrections and Rehabilitation’s response: law enforcement agency and develop procedures for Implemented Partially Implemented. The Division of Juvenile Facilities is committed to handling hostage situations, rather than waiting for the preserving public safety in the event of a hostage incident at a youth department to develop a standardized mutual aid correctional facility. To that end, the Division of Juvenile Facilities is Office of the Inspector General Page 162 Ventura Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments agreement. (June 2002) partnering with the Office of Correctional Safety, within the California Department of Corrections and Rehabilitation, to develop a Hostage Management policy and training curricula that contain provisions for responding to a hostage event. The Division of Juvenile Facilities will conduct Hostage Management and Basic Emergency Preparedness training for managers and administrators serving throughout the youth correctional system in early 2008. At the site level, the Superintendent at Ventura Youth Correctional Facility has negotiated an agreement for mutual aid with the Ventura County Sheriff and the Lancaster State Prison Warden related to hostage negotiations. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Consider relying on local law enforcement to handle Partially California Department of Corrections and Rehabilitation’s response: potential hostage situations and either amend or follow Implemented Partially Implemented. In adherence to an August 17, 2007, memorandum section 1809 of the Division of Juvenile Justice issued by the Director of Juvenile Facilities, Superintendents are to consider Institutions and Camps Branch Manual accordingly. local law enforcement agencies as primary partners for aid in the event of a (June 2002) hostage incident, and are to regard trained officers from the closest adult correctional facility, via support from the Office of Correctional Safety, available to serve as members of a secondary crisis response team. To reflect the change in operating procedures for responding to a hostage event, the Director of the Division of Juvenile Facilities has requested that the language contained in the Institutions and Camps Branch Manual, Section 1809, be revised to eliminate the standard that requires each youth correctional facility, including Ventura, to retain a trained hostage negotiator on site. The Policy, Procedures, Programs, and Regulations Unit, within the Division of Juvenile Justice, is expected to issue the revisions to section 1809 to stakeholders throughout the youth correctional system in 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 163 Ventura Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Continue efforts to obtain funds to install bulletproof Not California Department of Corrections and Rehabilitation’s response: glass to protect the youth correctional officer stationed at Implemented Not Implemented. In 2005, based upon concerns that were expressed by the the reception desk. (June 2002) Office of the Inspector General for the safety of youth correctional officers, a Budget Change Proposal was submitted to the California Department of Corrections and Rehabilitation for the purpose of obtaining funds to install bulletproof glass in the reception area at Ventura Youth Correctional Facility. Subsequently, the request for funding was denied. Section 08860.200A of the California Department of Corrections and Rehabilitation Design Criteria Guidelines does not require bulletproof glass for reception areas. The aforementioned Design Criteria Guidelines require bulletproof glass for control rooms, pharmacies and armories, but not reception areas. Although the Division of Juvenile Justice Design Criteria Guidelines have not been developed, adopting a standard more restrictive than the California Department of Corrections and Rehabilitation Design Criteria Guidelines, which requires bulletproof glass for reception areas, is not expected. Concurrently, KMD, architectural programmer, has indicated that the use of bulletproof glass in reception areas has not been established as a standard for the new Division of Juvenile Justice prototype facility. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 164 Division of Juvenile Justice 2008 Accountability Audit Intensive Treatment Program Division of Juvenile Justice Review of the Intensive Treatment Program Finding 2 The division’s process to screen wards for placement in the intensive treatment program failed to ensure that all wards needing intensive treatment were identified and received the necessary treatment. (November 2002) Recommendation Status Comments The Division of Juvenile Justice should: Ensure that all wards—parole violators, as well as newly Partially California Department of Corrections and Rehabilitation’s response: committed wards—receive a treatment needs assessment Implemented Partially Implemented. The Division of Juvenile Justice is committed to ensuring within the time limit required by division policy. that each parole violator, as well as any newly committed ward receives a (November 2002) Treatment Needs Assessment within the time limits required by Division of Juvenile Justice policy. Scantron equipment has been secured or ordered for each youth correctional facility within the Division of Juvenile Justice that admits new commitments or parole violators. Providing each site with Scantron equipment will improve the completion of Treatment Needs Assessments within the prescribed timeframes contained in the Division of Juvenile Justice Institutions and Camps Branch Manual, Section 6260. In addition, efforts are continuing to replace the current paper-based Treatment Needs Assessment with a fully automated process using the Massachusetts Youth Screening Instrument-Second Version. Much of the groundwork sufficient to support the full automation of the Massachusetts Youth Screening Instrument- Second Version scoring has been completed. Discussions have been held with the California Department of Corrections and Rehabilitation, Enterprise Information Systems, to develop a project plan for creating the infrastructure required for full automation of the Massachusetts Youth Screening Instrument- Second Version. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 165 Division of Juvenile Justice 2008 Accountability Audit Intensive Treatment Program Recommendation Status Comments Provide each youth correctional facility the appropriate Substantially California Department of Corrections and Rehabilitation’s response: equipment to allow immediate scoring and reviewing of Implemented Substantially Implemented. Equipment for scanning Treatment Needs wards’ treatment needs assessments at the facilities. Assessment protocols has been secured or ordered for each youth correctional (July 2007) facility within the Division of Juvenile Justice that admits new commitments or parole violators. To that end, Scantron scoring equipment has been installed for parole violators at N.A. Chaderjian Youth Correctional Facility. Also, Scantron scoring equipment has been installed and is operating at the three reception centers within the youth correctional system to include the Southern Youth Correctional Reception Center and Clinic, Preston Youth Correctional Facility, and Ventura Youth Correctional Facility. The Division of Juvenile Facilities anticipates that Scantron scoring equipment will be installed and operating at H. G. Stark Youth Correctional Facility by February 1, 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that scored assessments that identify a red flag Partially California Department of Corrections and Rehabilitation’s response: on the suicide, anger, or thought disorder scales are Implemented Partially Implemented. To reinforce the standards contained in the Treatment reviewed by a psychologist the same workday the Needs Assessment Policy, the Chief Psychiatrist issued a memorandum to Chief assessment is scored. (July 2007) Medical Officers, Chief Psychologists, Senior Psychologists, and Superintendents, on September 11, 2007. In part, the Treatment Needs Assessment Memorandum stated that within 24 hours of a Treatment Needs Assessment being conducted, a senior psychologist must review any scored protocol with red flag findings related to suicide, anger or thought disorders. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 166 Division of Juvenile Justice 2008 Accountability Audit Intensive Treatment Program Finding 3 Treatment services provided to wards in the intensive treatment program were limited in scope, lacking in planning, poorly documented, and generally deficient in quality. (November 2002) Recommendation Status Comments The Division of Juvenile Justice should: Continue to provide training to youth correctional Partially California Department of Corrections and Rehabilitation’s response: counselors in mental health treatment principles and Implemented Partially Implemented. In 2007, in adherence to agreements made in the Farrell methods and provide continuing education to Safety and Welfare Remedial Plan, the Division of Juvenile Justice secured psychiatrists, psychologists, and other members of the eighteen Integrated Behavioral Treatment Model trainers who are responsible mental health staff. (November 2002) for providing technical assistance, and for training, coaching, and mentoring staff members throughout the youth correctional system. As policies, procedures, and practices critical to reform efforts are approved for implementation, members of the Integrated Behavioral Treatment Model Team, as well as designated staff members from across disciplines within the Division of Juvenile Justice, are becoming certified in designated subject matter areas. Simultaneously, in 2007, the Division of Juvenile Justice is developing a Comprehensive Training Plan that is consistent with agreements made with the Court in the Farrell v. Tilton litigation. As part of the Comprehensive Training Plan, a Division of Juvenile Justice Training Calendar has been established. The Division of Juvenile Justice Training Calendar is inclusive of training mandated by policy, and provides for staff development opportunities in areas that support the statewide implementation of juvenile justice reform. In 2008, the Division of Juvenile Justice Training Calendar will be updated to reflect the certification of additional staff trainers and the subsequent approval of business contracts for specified training sessions. Training sessions will be continuous until juvenile justice reform is fully implemented and staff members, including youth correctional counselors, are equipped with sufficient knowledge and skills to perform the rehabilitative and public safety mission set by the public for the Division of Juvenile Justice. In 2008, the majority of training sessions scheduled are for staff members from across various disciplines, which include psychiatrists, psychologists, and mental health professionals. Office of the Inspector General Page 167 Division of Juvenile Justice 2008 Accountability Audit Intensive Treatment Program Recommendation Status Comments Specifically, in 2007, a Safe Crisis Management Training for Trainers was held on April 23-27 and June 18-22. Subsequently, Safe Crisis Management Training was conducted June 20-22, July 25-27, and August 29-31, for 107 staff members within the Division of Juvenile Justice. In addition, beginning in October 2007, initial Aggression Replacement, Youth with Mental Disorders, and Understanding and Preventing Suicide training sessions were conducted for designated staff members. In December of 2007, executive staff members are scheduled to attend training on Motivational Interviewing Techniques, with training to follow at the site level in January of 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 168 Division of Juvenile Justice 2008 Accountability Audit Juvenile Parole Board Review of the Process Used by the Division of Juvenile Justice and the Juvenile Parole Board to Establish Ward Program Requirements Finding 3 Despite incurring significant expense in providing a broad array of treatment programs for wards, the state had not sought to measure the effectiveness of the programs. (December 2002) Recommendation Status Comments The Division of Juvenile Justice should: Institute methods of assessing the effectiveness of Partially California Department of Corrections and Rehabilitation’s response: curriculum and treatment provided to wards. Implemented Partially Implemented. Foundational to the success of the Integrated (December 2002) Behavioral Treatment Model agreed to with the Court in the Farrell v. Tilton litigation is the establishment of a Division of Juvenile Justice Classification System that uses an evidenced-based Risk/Needs Assessment. To that end, a customized Division of Juvenile Justice Risk/Needs Assessment is under development. The Division of Juvenile Justice Risk/Needs Assessment under development is being designed to meet the specific needs of juveniles committed by the Court to the youth correctional system at the State level in California. When approved by the Chief Deputy Secretary and made operational, the Division of Juvenile Justice Risk/Needs Assessment will evaluate, using quantitative measures, the risks, needs, strengths, and skill levels of wards entering youth correctional facilities. When the Division of Juvenile Justice Risk/Needs Assessment is approved for adoption, Interdisciplinary Treatment Teams will have the information necessary to incorporate specific, evidenced-based targets for intervention into Individual Case Plans. When the Division of Juvenile Justice Classification System is approved by the Chief Deputy Secretary, every 120 days, an Interdisciplinary Treatment Team will be required to re-evaluate the results of each individual Division of Juvenile Justice Risk/Needs Assessment that has been administered. The Division of Juvenile Justice Risk/Needs Assessment will be re-evaluated every 120 days to determine whether the selected targets contained in an Individual Case Plan for a ward are addressing the factors identified for intervention. When the Integrated Behavioral Treatment Model is Office of the Inspector General Page 169 Division of Juvenile Justice 2008 Accountability Audit Juvenile Parole Board Recommendation Status Comments fully implemented as a result of current reform efforts underway, Interdisciplinary Treatment Teams across the State of California will be targeting interventions for wards that are focused upon mitigating risk factors by maximizing individual strengths and increasing specific skill levels. When adopted, the Division of Juvenile Justice Risk/Needs Assessment will be scored electronically. The fully automated Division of Juvenile Justice Classification System will allow stakeholders the ability to generate customized management reports with aggregate data that identifies changes in specific areas related to the risk of wards re-offending. Concurrently, the Division of Juvenile Justice is developing a quality assurance process to measure the effectiveness of treatment services being delivered. The Division of Juvenile Justice is committed to selecting, adopting, and/or developing programs that conform to current evidence-based principles for effective intervention. Currently, the Juvenile Research Branch is collaborating with the Integrated Behavioral Treatment Model Team to establish criteria for evaluating potential programs and to aid in the selection of services that are the most closely aligned with evidenced-based principles. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 170 Southern Youth Correctional Reception Center and Clinic 2008 Accountability Audit Management Review Audit Southern Youth Correctional Reception Center and Clinic Management Review Audit Finding 1 The 2003 audit revealed that the Southern Youth Correctional Reception Center and Clinic had failed to comply with established security requirements. (June 2003) Recommendation Status Comments The Southern Youth Correctional Reception Center and Clinic should: Continue to improve its security procedures by taking Partially California Department of Corrections and Rehabilitation’s response: the following actions: Implemented Partially Implemented. The Southern Youth Correctional Reception Center and Clinic is working with the Director of Juvenile Facilities to develop a • Continue efforts to repair holes in ward room long-term strategy for repairing the holes in walls described in the Annual walls and inventory the condition of the 1800 Safety and Security Audit that was conducted in 2006. Plans are being rooms once repairs are complete so wards can developed through established Department of Finance options for be held accountable for any damage they appropriation of funds for the major repair and/or renovation of rooms with cause. (July 2007) walls that contain holes. In November 2006, twenty-four rooms that were not suitable for housing were placed on non-use status until properly repaired. In addition, in 2007, any immediate repairs to walls that were within the scope of local responsibilities were made. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Identify available hostage negotiator training Partially California Department of Corrections and Rehabilitation’s response: courses and ensure the facility has at least one Implemented Partially Implemented. The Division of Juvenile Facilities is partnering with qualified and trained hostage negotiator on the Office of Correctional Safety, within the California Department of staff. (June 2003) Corrections and Rehabilitation, to develop a Hostage Management Policy and training curricula that contain provisions for responding to a hostage event. The intent of the Director of Juvenile Facilities is to conduct Hostage Management and Basic Emergency Preparedness training for managers and administrators serving throughout the youth correctional system in early Office of the Inspector General Page 171 Southern Youth Correctional Reception Center and Clinic 2008 Accountability Audit Management Review Audit Recommendation Status Comments 2008. In adherence to the August 17, 2007, memorandum issued by the Director of Juvenile Facilities, Superintendents are to consider local law enforcement agencies as primary partners for aid in the event of a hostage incident, and are to regard trained officers from the closest adult correctional facility, via support from the Office of Correctional Safety, available to serve as members of a secondary crisis response team. To reflect the change in operating procedures for responding to a hostage event, the Director of Juvenile Facilities has requested that the language contained in the Institutions and Camps Branch Manual, Section 1809, be revised to eliminate the standard that requires each youth correctional facility, including Southern Youth Correctional Reception Center and Clinic, to retain a trained hostage negotiator on site. In addition, the Superintendent has negotiated an agreement for mutual aid with the Los Angeles County Sheriff. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Ensure armory staff have time to accurately Partially California Department of Corrections and Rehabilitation’s response: inventory weapons and other controlled Implemented Partially Implemented. The Superintendent at the Southern Youth materials. (June 2003) Correctional Reception Center and Clinic has set the clear expectation that weapons and other controlled materials contained in the armory will be routinely inventoried. In accordance with the directive issued by the Superintendent, the Chief of Security has assigned a Lieutenant to inventory the armory on a monthly basis. In December of 2008, the Chief of Security will conduct an audit of the armory to ensure that the monthly inventory has been maintained accurately. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 172 Southern Youth Correctional Reception Center and Clinic 2008 Accountability Audit Management Review Audit Finding 4 Deficiencies were found in medical services at the Southern Youth Correctional Reception Center and Clinic. (June 2003) Recommendation Status Comments The Southern Youth Correctional Reception Center and Clinic and the Division of Juvenile Justice should: Develop policies and procedures for periodic peer reviews Partially California Department of Corrections and Rehabilitation’s response: of the medical programs at reception centers and clinics. Implemented Partially Implemented. In addition to the foundational set of 29 Farrell (June 2003) medical policies, Health Care Services in collaboration with the Court experts has developed a Peer Review Policy. On November 7, 2007, the Peer Review Policy responsive to the Farrell Medical Remedial Plan was forwarded to the Chief Deputy Secretary for review and approval. Notwithstanding efforts to develop a Peer Review Policy, in the spring of 2007, to ensure quality clinical delivery of services based upon prescribed standards of care, the Health Care Director completed peer reviews of every physician serving within the Division of Juvenile Justice, including those serving at the Southern Youth Correctional Reception Center and Clinic. On November 28, 2007, the Peer Review Policy was signed by the Chief Deputy Secretary and issued to stakeholders throughout the youth correctional system. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 173 Southern Youth Correctional Reception Center and Clinic 2008 Accountability Audit Management Review Audit Finding 11 Staff performance appraisals and probationary reports at the Southern Youth Correctional Reception Center and Clinic were not completed on time. (June 2003) Recommendation Status Comments The Southern Youth Correctional Reception Center and Clinic should: Develop a system to identify and address delinquent Partially California Department of Corrections and Rehabilitation’s response: annual employee appraisals and probation reports and hold Implemented Partially Implemented. The Southern Youth Correctional Reception Center supervisors accountable for completing the reports and and Clinic has developed a system to notify supervisors of the due dates for appraisals. (June 2003) completing annual performance appraisals and probation reports for employees within their span of control. As a result, by the 5th of each month, each supervisor receives a list of annual performance appraisals and probation reports that are due by the end of the month. As part of the newly created notification system, the Personnel Office submits a monthly Delinquent Employee Appraisals and Probation Report to the Office of the Superintendent. To ensure continuous improvement and enhanced accountability, the superintendent reviews the monthly Delinquent Employee Appraisals and Probation Report and takes appropriate action to correct deficiencies, including recommending administrative measures like training, and when judged necessary, the application of discipline. Since the implementation of a formal notification and review system, supervisors have made progress toward completing evaluations of employee performance and probation reports within the timeframes prescribed by Juvenile Justice policy. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 174 Division of Juvenile Justice 2008 Accountability Audit Office of Audits and Compliance Division of Juvenile Justice Office of Audits and Compliance Management Audit Finding 1 The Division of Juvenile Justice was not making effective use of the Office of Internal Audits10 as a tool for identifying problems needing corrective action. (July 2003) Finding 2 The Office of Internal Audits was poorly managed and inadequately supervised and was not fulfilling its audit responsibilities. (July 2003) Finding 3 The reporting structure of the Office of Internal Audits did not adequately protect the independence of the internal audit function and impeded communication between the Office of Internal Audits and the department director. (July 2003) The OIG made the following recommendations as a result of the three findings: Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Provide for the Office of Audits and Compliance to be Fully California Department of Corrections and Rehabilitation’s response: managed by an assistant secretary who can ensure that the Implemented Fully Implemented. An Assistant Secretary for the Office of Audits and office adheres to the Standards for the Professional Compliance was appointed by the Governor in June 2007. The incumbent has Practice of Internal Auditing. (July 2003) the training, knowledge, and experience to manage an internal auditing unit. Office of the Inspector General’s comments: 10 The department’s Office of Internal Audits is now called the Office of Audits and Compliance. Office of the Inspector General Page 175 Division of Juvenile Justice 2008 Accountability Audit Office of Audits and Compliance Recommendation Status Comments The OIG performed no audit procedures to verify the department’s representation. Require that the assistant secretary of the Office of Audits Partially California Department of Corrections and Rehabilitation’s response: and Compliance ensure that the department’s Implemented Partially Implemented. A comprehensive risk assessment conducted by the comprehensive risk assessment includes division Office of Audits and Compliance on the all aspects of the Division of Juvenile institutions, camps, education services, treatment Justice, identified areas of risk to be included in the annual audit plan. In programs, parole operations, and headquarters to identify addition, the Office of Audits and Compliance has begun conducting Peer areas of high risk when assigning resources and Reviews and those areas with high deficiencies warrant additional follow up developing work plans. (July 2003) reviews. Even the less significant deficiencies are brought to executive level attention for immediate resolution, i.e., additional staff training. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Arrange for external assessments of the office at least Not California Department of Corrections and Rehabilitation’s response: every five years and communicate the results of the Implemented Not Implemented. An external audit firm was contacted mid-2007 however the external assessments to the department director, in pursuit has been postponed. The Office of Audits and Compliance is not only accordance with the Standards for the Professional undergoing an internal restructure under the direction of the recently Practice of Internal Auditing. (July 2003) appointed Assistant Secretary, but a physical move is scheduled for late June 2008. Efforts will resume upon completion of the move and a contract will be executed late 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 176 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit N.A. Chaderjian Youth Correctional Facility Management Review Audit Finding 1 Wards at N.A. Chaderjian were not receiving the counseling and other treatment services they were required to receive under state law. (May 2005) Recommendation Status Comments The management of N.A. Chaderjian Youth Correctional Facility should: Assess the training needs of the facility’s counseling staff, Partially California Department of Corrections and Rehabilitation’s response: particularly those of the youth correctional counselors, and Implemented Partially Implemented. Block training modules at N. A. Chaderjian and make available the funding and time necessary to upgrade DeWitt Nelson Youth Correctional Facilities have been developed to provide their knowledge, skills, and ability through formal training. forums to discuss and opportunities to improve knowledge and skills in areas In addition, use in-house staff, such as psychologists, staff like developing Individual Change Plan goals, drafting Identified Treatment experienced in using the Ward Information Network, and Issues, updating Individual Case Conference records, writing reports, the best and most experienced treatment staff to provide reviewing journals, and conducting the large and small group counseling structured on-the-job training on counseling techniques, sessions that are critical to the rehabilitation of wards committed to the care living unit file documentation methods, and other relevant and treatment of the Division of Juvenile Justice. Four hours of block training topics. (May 2005) modules on the aforementioned subjects are scheduled to be delivered at N. A. Chaderjian and DeWitt Nelson Youth Correctional Facilities by April of 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 177 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 2 Education services provided to wards at N.A. Chaderjian were deficient. (May 2005) Recommendation Status Comments The Division of Juvenile Justice should: Expedite the appointment of a superintendent of education. Not California Department of Corrections and Rehabilitation’s response: (May 2005) Implemented Not Implemented. Recruitment efforts to secure a Superintendent of Education, who would serve in a Career Executive Assignment, which is a civil service classification, have failed to yield a viable candidate pool. To remove recruitment barriers, the Superintendent of Education position within the Division of Juvenile Justice has been converted from a civil service classification to an exempt status. The decision to change the Superintendent of Education position from a civil service position to exempt status has allowed the Division of Juvenile Justice to advertise and recruit on a nationwide basis for qualified candidates. Applications received from national recruitment efforts have been reviewed and the most qualified candidates have been interviewed. Notwithstanding aggressive recruitment efforts, the Division of Juvenile Justice has not identified a candidate with the requisite skills to serve in this important leadership role. Currently, the Superintendent of Education position is being advertised on a continuous basis. In the interim, since June 2005, the Acting Superintendent has implemented corrective action to improve the academic and cultural environment at N.A. Chaderjian High School. The improved academic and cultural environment has yielded positive results for students. According to data reported to the Secretariat within the California Department of Corrections and Rehabilitation, significant gains occurred in the number of high school eligible students receiving academic services during the third quarter of 2007. Delivery of academic services is being monitored using multiple indicators of performance. Indicators of school performance are being routinely measured and quantified. Trends indicating overall improvement in statistics are evident. For example, during the 2007 third quarter, the number of classes Office of the Inspector General Page 178 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments scheduled increased from 1,401 in July to 2,020 in September. In addition, the Average Daily Attendance indicated that 81% of eligible students were receiving 240 minutes of instruction per day. More importantly, the percentage is steadily increasing. At the same time, the absent rate decreased from a high of greater than 50% to a rate of 25%. Similarly, the number of scheduled classes that were closed due to teacher absence steadily declined. Very encouraging to overall reform efforts underway is data contained in special education reports which indicated that special education students received at least 90% of mandated services for the months of September and October 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Bargain during the next Bargaining Unit 3 negotiations for Partially California Department of Corrections and Rehabilitation’s response: removal of the exempt status of teachers, as it relates to the Implemented Partially Implemented. The Department of Personnel Administration manner in which leave credits are charged for partial day negotiated a Memorandum of Understanding that does not charge Bargaining absences. (May 2005) Unit 3 staff members for absences in less than whole day increments. To remove this provision and charge leave credits for partial day absences, the Department of Personnel Administration will need to reopen the current Memorandum of Understanding. The Division of Juvenile Justice is implementing comprehensive reform that is focused upon providing the treatment and education services necessary to restore wards to their communities as productive citizens. To that end, simultaneously with reform efforts, to ensure education services are delivered as mandated by state and federal law, the Division of Juvenile Justice has implemented a corrective action plan to ensure that teacher abuse of leave time is addressed administratively. According to data reported to the Secretariat within the California Department of Corrections and Rehabilitation, the number of scheduled classes that were closed due to teacher absence steadily declined during the third quarter of 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 179 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Bargain during the next Bargaining Unit 6 negotiations to Not California Department of Corrections and Rehabilitation’s response: eliminate the authority of counselors to keep wards from Implemented Not Implemented. After extensive negotiations, the State of California reached attending high school classes. (May 2005) impasse with Bargaining Unit 6. The State of California has implemented its last, best and final offer. This action voided the previous Memorandum of Understanding. Prior to commencing the bargaining process, the State of California identified items for change in the Unit 6 contract that were considered critical to establishing a viable employer and employee relationship. During the aforementioned process, Section 24.03 (c) that authorized youth correctional counselors to hold back wards from high school classes was not identified as requiring change. Section of 24.03 (c) was not designated as requiring change because the Division of Juvenile Justice was implementing the Integrated Behavioral Treatment Model agreed upon with the Court in the Farrell Safety and Welfare Remedial Plan. The Integrated Behavioral Treatment Model includes provisions for a Program Service Day that eliminates the need for youth correctional counselors to withhold wards from high school attendance. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The management of the Education Services Branch of the Division of Juvenile Justice and the N.A. Chaderjian Youth Correctional Facility’s education administrators should: Expedite the appointment of a permanent principal for Fully California Department of Corrections and Rehabilitation’s response: N.A. Chaderjian High School. (May 2005) Implemented Fully Implemented. A full-time, permanent Principal for N. A. Chaderjian High School was appointed on September 25, 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Use performance appraisals and progressive discipline to Partially California Department of Corrections and Rehabilitation’s response: hold teachers and administrators accountable for their Implemented Partially Implemented. The Division of Juvenile Justice, Correctional Office of the Inspector General Page 180 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments performance, including attending case conferences, Education Authority, has developed a system to notify administrators of the meeting performance objectives, and accurately reporting due dates for completing annual performance appraisals for employees within special education services and attendance. (May 2005) their span of control. Since the implementation of a formal notification system, education administrators have made progress toward completing evaluations of teacher performance. As part of the reform of the youth correctional system, and in an effort to improve teacher effectiveness, individual performance is being assessed quarterly using a Correctional Education Authority teacher observation form. The Correctional Education Authority teacher observation form contains a rubric that is aligned with the California standards for teachers. Instituting quarterly teacher observations has provided education administrators with a valuable tool for accurate assessment of teacher performance and has enhanced the effectiveness of the annual State of California performance appraisal system. At the site level, reporting of the special education services being delivered is being carefully monitored. Teachers and assistant principals are being provided with staff development opportunities designed to increase the skills required for implementation of juvenile justice reform efforts that are underway. When necessary, teachers and assistant principals are being held accountable for work improvement through counseling and progressive discipline. The Acting Superintendent of Education has been working closely with the new principal to provide support, guidance, and on-the-job training. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 181 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Finding 3 Structural defects, maintenance problems, and deficient management practices at N.A. Chaderjian jeopardized the safety of employees, wards, and visitors. (May 2005) Recommendation Status Comments N.A. Chaderjian Youth Correctional Facility’s management should: Develop and implement a comprehensive plan in Partially California Department of Corrections and Rehabilitation’s response: conjunction with the plant operations staff of the Northern Implemented Partially Implemented. Using the Kitchell Engineering Facility Final California Youth Correctional Center to identify, Assessment Report for guidance, a comprehensive N. A Chaderjian Youth prioritize, and correct all building deficiencies that create Correctional Facility Corrective Action Project Plan has been developed to security and safety risks. The plan should specifically correct structural and infrastructure building deficiencies. The address the deficiencies identified in the May 2005 report comprehensive N. A Chaderjian Youth Correctional Facility Corrective Action and should have cost estimates and a schedule with target Project Plan includes a schedule of work and corresponding cost estimates dates for completion. The Division of Juvenile Justice that systematically corrects the list of identified deficiencies in a prioritized headquarters should assist the facility with the plan. way based upon an analysis of safety and security risks to staff, wards, and the (May 2005) public. The Superintendent response to the Kitchell Facility Assessment Final Report will serve as the guide for any future funding requests related to structural deficits and maintenance problems at N. A. Chaderjian Youth Correctional Facility. The aforementioned N. A Chaderjian Youth Correctional Facility Corrective Action Project Plan will be used to establish a criterion of needs and current Department of Finance options for the appropriation of funds. The Office of Facilities Planning within the California Department of Corrections and Rehabilitation will submit a proposal to the Department of Finance to fund the projects contained in the N. A Chaderjian Youth Correctional Facility Corrective Action Project Plan in 2008. Office of the Inspector General’s comments: We reviewed the Kitchell Engineering Facility Final Assessment during the 2007 Accountability Audit and found that it addressed many of the deficiencies identified in the 2005 Management Review Audit. We also Office of the Inspector General Page 182 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments reviewed the N.A. Chaderjian Youth Correctional Facility Corrective Action Project Plan provided by the department for this current 2008 audit and found that the plan lists 97 repair and replacement projects and the cost of each project. Although the plan prioritizes the projects, it does not provide a schedule of anticipated completion dates. Take steps to secure the recreation yard fences. In so Not California Department of Corrections and Rehabilitation’s response: doing, consider “climb-resistant” fences and using wire of Implemented Not Implemented. The superintendent at N. A. Chaderjian Youth Correctional the appropriate gauge to lessen the possibility of wards Facility is committed to building a community where staff and youth can safely ripping or breaking through the fence. (May 2005) live and work. To that end, a 2007/2008 minor Capital Outlay Budget Change Proposal to secure funds for the purpose of purchasing “climb resistant” fences for recreation yards was developed. That being said, as a result of the anticipated change in ward population due to commitments made in the Farrell Mental Health Remedial Plan, the Division of Juvenile Justice is not planning to pursue the aforementioned proposal. Adherence to agreements made with the Court in the Farrell litigation will significantly change the mission of N.A. Chaderjian Youth Correctional Facility and the population served, and therefore will reduce the necessity for addressing ward behavior by purchasing “climb resistant” fences for recreation yards. On August 24, 2006, the Mental Health Remedial Plan in the Farrell litigation was filed with the Court. In the Mental Health Remedial Plan, as an interim measure, the Division of Juvenile Justice committed to consolidating most mental health programs that are operating within Northern California at N.A. Chaderjian Youth Correctional Facility. At the time of consolidation, the population served will change from high risk wards to those who require specialized mental health treatment. To serve the needs of the changed population at the N.A. Chaderjian Youth Correctional Facility, the Division of Juvenile Justice has agreed to implement comprehensive reform which includes reducing the number of wards assigned to specialized treatment programs while increasing the number of staff members providing care, services, and supervision. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 183 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Update and formalize hostage procedures and provide Partially California Department of Corrections and Rehabilitation’s response: hostage training as necessary. (May 2005) Implemented Partially Implemented. In May 2006, at the direction of the Superintendent, hostage procedures contained in the N. A. Chaderjian Youth Correctional Facility Multi-Hazard Plan were updated. In 2007, staff members at N. A. Chaderjian Youth Correctional Facility received an overview of the updated hostage procedures contained in the Multi-Hazard Plan during block training. In adherence to a August 17, 2007, memorandum issued by the Director of Juvenile Facilities, Superintendents are to consider local law enforcement agencies as primary partners for aid in the event of a hostage incident, and are to regard trained officers from the closest adult correctional facility, via support from the Office of Correctional Safety, available to serve as members of a secondary crisis response team. To reflect the change in operating procedures for responding to a hostage event, the Director of the Division of Juvenile Facilities has requested that the language contained in the Institutions and Camps Branch Manual, Section 1809, be revised to eliminate the standard that requires each youth correctional facility, including N. A. Chaderjian, to retain a trained hostage negotiator on site. The Policy, Procedures, Programs, and Regulations Unit, within the Division of Juvenile Justice, is expected to issue the revisions to section 1809 to stakeholders throughout the youth correctional system by April 1, 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Set the bottom of the perimeter fence in concrete (as Not California Department of Corrections and Rehabilitation’s response: required in section 1813 of the Division of Juvenile Justice Implemented Not Implemented. To be consistent with the California Department of Institutions and Camps Branch Manual) and, if necessary, Corrections and Rehabilitation, Division of Adult Institutions, the Division of replace fence poles with poles of a larger diameter. Juvenile Justice, Institutions and Camps Branch Manual, Section 1813, will be (May 2005) revised to eliminate the standard that the bottom of the perimeter fence must be set in concrete. Office of the Inspector General’s comments: Office of the Inspector General Page 184 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments The OIG performed no audit procedures to verify the department’s representation. Develop and implement a radio replacement schedule in Partially California Department of Corrections and Rehabilitation’s response: conjunction with Division of Juvenile Justice headquarters Implemented Partially Implemented. Since the restructuring of the California Youth and dedicate funding for that function in order to supply Authority into the California Department of Corrections and Rehabilitation, facility personnel with adequate communication devices. the Radio Communications Unit has become responsible for supporting radio (May 2005) system performance and equipment needs at youth correctional facilities within the Division of Juvenile Justice. The Radio Communications Unit has recognized that the radio equipment and system at N.A. Chaderjian Youth Correctional Facility are beyond their useful life cycle. In addition, the Radio Communications Unit has determined that the radio system at the Northern California Youth Correctional Center is one of the most urgent in need of upgrading when compared to others within the California Department of Corrections and Rehabilitation. To that end, the Radio Communications Unit has allocated funds from the radio replacement budget for the current year to pay for an upgrade to the shared radio system. Initial project planning has begun and the Radio Communications Unit will be working with the Department of General Services to design and install adequate radio system upgrades at the Northern California Youth Correctional Center, which includes N. A. Chaderjian Youth Correctional Facility. The planned upgrades to the radio system will be modeled after recent, successful upgrades at four co-located adult facilities. The tentative installation period for the improved radio system has been identified as Spring of 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Improve security related to the ward visiting area by Partially California Department of Corrections and Rehabilitation’s response: providing uninterrupted visual coverage. The facility’s Implemented Partially Implemented. As an interim measure, to ensure uninterrupted visual management should also consider adding another staff coverage, the Superintendent at N. A. Chaderjian Youth Correctional Facility person to the visiting tower so that one person can has approved the temporary placement of an additional staff member in the continually monitor the visiting area while the other can visiting hall tower, Administration Control, during ward visiting. Office of the Inspector General Page 185 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments operate the doors for wards entering and leaving. The aforementioned practice will continue until security positions are (May 2005) realigned at N. A. Chaderjian Youth Correctional Facility, and the Superintendent permanently assigns an additional youth correctional officer to the visiting hall tower, Administration Control, during ward visiting. The Superintendent expects the realignment of security positions to occur after new security schedules are approved as a result of the full implementation of the Safety and Welfare Remedial Plan at N. A. Chaderjian Youth Correctional Facility. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Augment electronic mail and the read-and-initial system Not California Department of Corrections and Rehabilitation’s response: by conducting quarterly meetings involving line staff and Implemented Not Implemented. The N. A. Chaderjian Youth Correctional Facility has not management to enhance communication and provide a implemented the specific recommendation of the Office of the Inspector forum to discuss issues affecting the work environment. General because of the required funding to support the implementation of the The facility’s management should also ensure that meeting enhancement. N. A. Chaderjian Youth Correctional Facility is committed to times are rotated so that staff from different shifts can building a strong correctional community based upon positive communication attend. (May 2005) and core values. The Superintendent continues to encourage N. A. Chaderjian Youth Correctional Facility posted staff members to share concerns with management using cost effective methods such as electronic, telephonic, and supervisory contacts, and through interactions with members of the N. A. Chaderjian Management Team during routine visits to the living units. In addition, the Office of the Superintendent at N.A. Chaderjian Youth Correctional Facility conducts weekly, monthly and quarterly meetings that include supervisors, managers, labor and posted staff member representatives. Moreover, monthly, to promote collaborative problem solving, under the direction of the Office of the Superintendent, meetings and forums are occurring among senior youth correctional counselors, parole agents, and on subjects related to education, violence reduction, staff assaults, and employee- labor relations. Also, on an as needed basis, to communicate information on matters critical to the safety and security of N. A. Chaderjian Youth Correctional Facility, the Office of the Superintendent, will direct that team meetings and critical incident debriefing sessions occur with designated staff members. Office of the Inspector General Page 186 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The Division of Juvenile Justice should: Use the results of the Kitchell Engineering visual Partially California Department of Corrections and Rehabilitation’s response: assessment of N.A. Chaderjian to recommend to the Implemented Partially Implemented. The N. A. Chaderjian Youth Correctional Facility has administration and the Legislature whether to make the drafted a response to the Kitchell Facility Assessment Final Report that repairs and keep the facility open or close it and find a identifies and prioritizes physical plant issues for repair. The Superintendent suitable alternative for housing the wards. (May 2005) response to the Kitchell Facility Assessment Final Report will serve as the guide for any future funding requests related to structural deficits and maintenance problems at N. A. Chaderjian Youth Correctional Facility. The aforementioned N. A Chaderjian Facility Corrective Action Project Plan will be used to establish a criterion of needs and current Department of Finance options for the appropriation of funds. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Require the Division of Juvenile Facilities (formerly Partially California Department of Corrections and Rehabilitation’s response: known as the Institutions and Camps Branch) to perform Implemented Partially Implemented. In an effort to streamline the security audit process the annual security audit of the N.A. Chaderjian Youth and focus on the most critical safety and security concerns facing the Division Correctional Facility and other facilities as required by of Juvenile Facilities, the language in specific areas of the Institutions and section 1800 of the Division of Juvenile Justice Institutions Camps Branch Manual, Section 1800 through 1848, are currently under and Camps Branch Manual. (May 2005) revision. Once the revision to the policy language is complete and the new 1800 Safety and Security Standards are approved by the Chief Deputy Secretary, a Juvenile Facilities Security Audit Team will be assembled to assess each youth correctional facility for compliance with the safety and security standards contained in the Institutions and Camps Branch Manual, Section 1800 through 1848. In the interim, as part of the annual Division of Juvenile Facilities Security Audit, each superintendent continues to be required to conduct an 1800 Safety and Security Self-audit for compliance with the standards currently contained Office of the Inspector General Page 187 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments in the Institutions and Camps Branch Manual, Section 1800 through 1848. In 2007, each youth correctional facility within the Division of Juvenile Justice, including N. A. Chaderjian Youth Correctional Facility, complied with the aforementioned requirement to complete an 1800 Safety and Security Self- audit. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 4 Staff at N.A. Chaderjian were not consistently complying with department policies and procedures governing the use of psychotropic medications and suicide prevention, assessment, and response. (May 2005) Recommendation Status Comments The chief medical officer at N.A. Chaderjian Youth Correctional Facility should: Continue to work with the department’s Division of Substantially California Department of Corrections and Rehabilitation’s response: Correctional Health Care Services to fill vacancies in Implemented Substantially Implemented. An aggressive recruitment, selection, and retention psychiatrist positions at the facility. (May 2005) plan has been implemented for psychiatrists at the Northern California Youth Correctional Center. A sustained effort to secure candidates with the requisite skills and qualifications has yielded positive results. Currently, the Northern California Youth Correctional Center has no psychiatrist positions that are vacant. Recently six full-time psychiatrists have been secured for the Northern California Youth Correctional Center. Three psychiatrists have begun their tenure and three are pending clearance of mandatory pre-employment screening. The newly secured psychiatrists will be allocated to serve as follows: three at N. A. Chaderjian Youth Correctional Facility, two at O.H. Office of the Inspector General Page 188 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Close Youth Correctional Facility, who will also cover DeWitt Nelson Youth Correctional Facility, and one at the Northern California Youth Correctional Center Outpatient Housing Unit. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Develop a checklist for the unified health record that Not California Department of Corrections and Rehabilitation’s response: itemizes all the requirements to be met by mental health Implemented Not Implemented. In the professional judgment of health care professionals staff before administering psychotropic medications. These within the Division of Juvenile Justice a flow-sheet checklist for the Unified requirements should include fulfilling requirements for Health Record that itemizes all of the requirements that a psychiatrist must mental health testing and psychiatric evaluations; written satisfy prior to administering psychotropic medications is inappropriate. informed consent; developing treatment plans; and However, ensuring that the requirements are satisfied is a part of the Mental statements of duration of prescription time and desired Health Peer Review process. clinical effect; and performing laboratory tests. (May 2005) That being said, designated mental health professionals in response to the Farrell Mental Health Remedial Plan are developing a comprehensive Psychotropic Drug Policy that will address all aspects of psychotropic medication usage including the Keyhea process. The Psychotropic Drug Policy will also address rules and standards related to mental health assessments, psychiatric evaluations, informed consent, individual treatment plans, prescriptions, clinical effects of medication, and protocols for ordering laboratory testing. The Psychotropic Drug Policy will be submitted to Court experts for review on or before February 1, 2008. The Psychotropic Drug Policy will eliminate the need for the recommended checklist. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that incoming parole violators receive treatment Partially California Department of Corrections and Rehabilitation’s response: needs assessments. (May 2005) Implemented Partially Implemented. With the installation of Scantron equipment at N.A. Chaderjian Youth Correctional Facility, scoring of the Treatment Needs Assessments according to standards contained in the Division of Juvenile Justice Institutions and Camps Branch Manual, Section 6260, has significantly improved. Office of the Inspector General Page 189 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments Notwithstanding, efforts are continuing to replace the current paper-based Treatment Needs Assessment with a fully automated process using the Massachusetts Youth Screening Instrument-Second Version. Much of the groundwork sufficient to support the full automation of the Massachusetts Youth Screening Instrument-Second Version scoring has been completed. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The Division of Juvenile Justice should: Expedite the development and implementation of the Partially California Department of Corrections and Rehabilitation’s response: general mental health and pharmacy services/medication Implemented Partially Implemented. Designated mental health professionals in administration policies and procedures, as called for in the collaboration with experts appointed by the Court are developing an Farrell v. Tilton Mental Health Remedial Plan. (July 2007) administrative system of mental health policies responsive to the Farrell Mental Health Remedial Plan. Part of the administrative system of mental health policies will be the Division of Juvenile Justice Psychotropic Drug Policy. The Psychotropic Drug Policy will be submitted to the Court experts for review on or before February 1, 2008. The comprehensive Psychotropic Drug Policy being drafted will address all aspects of psychotropic medication usage including the Keyhea process. Health care professionals in collaboration with experts appointed by the Court are developing an administrative system of medical policies responsive to the Farrell Medical Remedial Plan. The foundational set of 29 Farrell medical policies have been reviewed by the Court experts and approved by the Chief Deputy Secretary. Part of the administrative system of medical policies in the Division of Juvenile Justice is the Medication Administration Policy and the Pharmacy Services Policy. A Farrell Health Care Training Plan has been implemented that calls for health care as well as designated facility treatment and security staff members to be trained statewide on the rules and standards contained in the new administrative system of medical policies. The Farrell health care curriculum has been developed and senior facility staff members will receive the training Office of the Inspector General Page 190 N.A. Chaderjian Youth Correctional Facility 2008 Accountability Audit Management Review Audit Recommendation Status Comments during November and December of 2007. The Health Care Services Director appointed a statewide pharmacy manager on March 12, 2007, who is overseeing pharmacy services for the Division of Juvenile Justice. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 191 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Special Review into the Death of a Ward on August 31, 2005, at the N.A. Chaderjian Youth Correctional Facility Finding 1 Although the lockdown was justified at its inception, the extent to which the Division of Juvenile Justice deprived the ward and other Northern Hispanic wards in Pajaro Hall of services during the lockdown is inconsistent with the Division of Juvenile Justice’s mission. (December 2005) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: End immediately the practice of isolating wards in their Partially California Department of Corrections and Rehabilitation’s response: rooms over extended periods of time. (December 2005) Implemented Partially Implemented. On March 9, 2007, the Chief Deputy Secretary signed the revised Restricted Program Policy, and in April 2007, the Policy, Procedures, Programs and Regulations Unit disseminated the new restricted program standards to internal and external juvenile justice stakeholders throughout the State of California. To refine expectations and enhance service delivery, the Restricted Program Policy has been revised three times since 2001. On August 24, 2007, the Director of Juvenile Facilities issued the Wards Assigned to Restricted Programs Memorandum, clearly restating the standard that regardless of restricted status, including temporary detention, a ward must be provided a minimum of three hours of “out of room services” each day. The memorandum also stated that the three-hour minimum was to occur in addition to the time required for activities of daily living like showering or taking medication. Moreover, the memorandum stated that only documented safety and security concerns could countermand the minimum standard of three hours of “out of room services”. In the memorandum, the Director of Juvenile Facilities clearly communicated an expectation of 100% compliance with the directives contained therein. In addition, the Wards Assigned to Restricted Programs Memorandum directed that each day a ward does not receive the mandatory “out of room” Office of the Inspector General Page 192 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments time that is expected by policy, the program manager is to ensure that a member of the treatment team personally interviews the ward in question. Concurrently, in the memorandum, the Director of Juvenile Facilities set the expectation that treatment team members are to counsel and encourage a ward on restricted status to participate in program activities. Should the ward be restricted from program time due to behavior, the program manager is further required to ensure that the treatment team develops goals with specific behavioral components. The Director of Juvenile Facilities has been carefully monitoring compliance of staff members with the standards contained in both the revised Restricted Program Policy and the August 24, 2007 Wards Assigned to Restricted Programs Memorandum. To that end, on a weekly basis, a management review of mandated services provided to wards on restricted programs is forwarded to each youth correctional facility. Likewise, the Superintendent at each youth correctional facility is being required to be in 100% compliance with “out of room” service delivery, or within three days, submit an explanation of facility noncompliance with the standard to the Director of Juvenile Facilities. The aforementioned explanation is expected to include the “barriers” causing less than 100% compliance with the standard, and a description of the corrective actions proposed to mitigate identified “barriers.” The automation necessary to support full implementation of the revised Restricted Program Policy in the Ward Information Network is being “Beta” tested at O.H. Close Youth Correctional Facility. If the Ward Information Network automation test is successful, the Division of Juvenile Justice will train staff members on all aspects of the revised Restricted Program Policy in the first quarter of 2008. Office of the Inspector General’s comments: In addition to the department’s response, we requested information pertaining to the Division of Juvenile Justice’s use of administrative lockdowns, in which programming for an entire facility or living unit is halted. The data provided by the department shows that for the four institutions composed entirely of individual rooms, there were six administrative lockdowns in 2006 that Office of the Inspector General Page 193 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments averaged 5.75 days and three lockdowns in 2007 that averaged 6.3 days. The longest lockdown periods for 2006 and 2007 were 10 days and 8 days, respectively. Both occurred at Heman G. Stark Youth Correctional Facility. The duration of these lockdowns is much shorter than the eight-week lockdown that preceded the ward suicide at N.A. Chaderjian. Although we conducted no audit procedures to verify the department’s representation that it tracks wards on modified programs to ensure they receive three hours out of their rooms each day, the shorter duration of the division’s administrative lockdowns is encouraging. Ensure that wards receive assessments and counseling as Partially California Department of Corrections and Rehabilitation’s response: needed by monitoring the Division of Juvenile Justice’s Implemented Partially Implemented. The Chief Deputy Secretary approved revisions to the provision of mental health services during lockdowns and Program Change Protocol on March 9, 2007. Whenever restricted status modified programming that exceed 14 days as required in exceeds 14 days, the Program Change Protocol requires that a ward receive the policies and procedures that became operational in mental health services, including assessments and counseling. 2006. (December 2005) The Policy, Procedures, Programs, and Regulations Unit disseminated the revised Program Change Protocol to each youth correctional facility within the Division of Juvenile Justice on May 16, 2007. The Division of Juvenile Facilities plans to conduct training on the revised Program Change Protocol, including the rules that provide for the delivery of mental health services by April 1, 2008. The Division of Juvenile Programs, Mental Health Services, in collaboration with Court appointed Subject Matter Experts is drafting a Mental Health Policy Package responsive to the Court in the Farrell v. Tilton litigation. The Mental Health Policy Package will be submitted to the Court experts for review on February 1, 2008. The rules and standards contained in the Mental Health Policy Package will reinforce the requirement that a ward be provided mental health services when placed on restricted status. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 194 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments Work with the Legislature and the courts to end the Not California Department of Corrections and Rehabilitation’s response: practice of returning adult inmates to Division of Juvenile Implemented Not Implemented. According to a legal opinion issued by the California Justice facilities. (December 2005) Department of Corrections and Rehabilitation, Office of Legal Affairs, failure to allow an adult inmate to return to the Division of Juvenile Justice who has remaining confinement time under juvenile jurisdiction is unconstitutional. To alleviate safety and security concerns related to the practice of returning an adult inmate to the Division of Juvenile Justice, the department worked with the legislature to pass the McPherson Act. After the completion of an adult sentence, the McPherson Act allows an adult inmate the option of serving any remaining confinement time from a juvenile court commitment in an adult facility. A request to remain in an adult prison must be submitted in writing. The Welfare and Institutions Code section 1732.8 makes clear that consent is required, even if the Division of Juvenile Justice has some other statutory ability to place a ward in an adult prison. The words “[not] withstanding any other law” make section 1732.8 the priority over any other statute passed prior to 2001, when section 1732.8 was enacted. According to the legal opinion issued, the department may not force a ward involuntarily to serve the remainder of a juvenile court commitment in an adult facility. A ward is not sentenced as a criminal and has no right to a jury trial. Therefore, forcing a ward to be confined as a sentenced criminal appears to violate the Sixth and Fourteenth Amendments to the United States Constitution. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 195 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Finding 2 The Division of Juvenile Justice failed to assess or act on the ward’s mental health needs. (December 2005) Recommendation Status Comments N.A. Chaderjian Youth Correctional Facility should: Ensure that staff members file the suicide risk screening Partially California Department of Corrections and Rehabilitation’s response: questionnaires in the wards’ unified health records as Implemented Partially Implemented. N.A. Chaderjian Youth Correctional Facility staff required by policy. (July 2007) members are required to file Suicide Risk Screening Questionnaires in the Unified Health Record in accordance with the Suicide Prevention, Assessment and Response Policy. To ensure adherence to the Suicide Prevention, Assessment and Response Policy, the Assistant Superintendent at N.A. Chaderjian Youth Correctional Facility met with staff members responsible for processing Suicide Risk Screening Questionnaires and provided training that reinforced the standards regarding the retention of the protocols in the Unified Health Record. Subsequently, on October 12, 2007, the Assistant Superintendent at N.A. Chaderjian Youth Correctional Facility conducted an internal audit to obtain baseline data regarding staff compliance with the policy standards for distributing the Suicide Risk Screening Questionnaire. The results of the internal audit found that for a two-month period, August 1 to September 30, 2007, 127 wards had been screened using the questionnaire. The internal audit further found that of the 25 randomly selected corresponding Unified Health Records reviewed; several required additional administrative steps be taken to ensure full compliance with policy standards. Until compliance is achieved with Division of Juvenile Justice policy, the Assistant Superintendent at N.A. Chaderjian Youth Correctional Facility will conduct quarterly audits for staff compliance with the Suicide Prevention, Assessment and Response Policy and will take corrective action as appropriate to remove any barriers to full implementation of policy directives. Office of the Inspector General’s comments: Office of the Inspector General Page 196 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments The OIG performed no audit procedures to verify the department’s representation. Preston Youth Correctional Facility should: Ensure that it complies with existing treatment needs Substantially California Department of Corrections and Rehabilitation’s response: assessment policies and procedures, including those that Implemented Fully Implemented. Preston Youth Correctional Facility staff members are require specific mental health problems identified during required to identify specified “red flag” mental health issues when the assessments—suicide, anger, or thought disorder—be administering the Treatment Needs Assessment. On September 11, 2007, to given “red flags” and forwarded promptly to the senior ensure adherence to the Treatment Needs Assessment Policy, the Chief psychologist or treatment needs assessment psychologist. Psychologist issued a memorandum to Preston Youth Correctional Facility (December 2005) staff members. The memorandum reinforced the rules and standards that govern senior psychologist review of Treatment Needs Assessments with “red flag” issues. On November 21, 2007, to further ensure adherence to the Treatment Needs Assessment Policy, the Supervising Casework Specialist, at Preston Youth Correctional Facility, issued a memorandum to the Parole Agent III. The memorandum reinforced the rules and standards that govern senior psychologist review of Treatment Needs Assessments with “red flag” issues and described in detail the process for documenting services rendered as the result of a Treatment Needs Assessment in the Ward Information Network. Since hiring an additional senior psychologist, the Superintendent at Preston Youth Correctional Facility has implemented a procedure that requires the Casework Specialist to immediately hand-carry any Treatment Needs Assessment Scantron scoring document that is administered and “red- flagged” to the Senior Psychologist. Upon receipt of any Scantron scoring documents that are “red-flagged”, the Senior Psychologist is required to evaluate the findings, issue appropriate treatment orders, record the date and time, and return the Scantron document to the Casework Specialist for delivery of any recommended treatment services. Office of the Inspector General’s comments: During a site visit to Preston Youth Correctional Facility on January 10, 2008, we reviewed 32 treatment needs assessments to determine compliance with policy. We found that all 32 assessments were administered within the 21-day Office of the Inspector General Page 197 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments requirement and that three assessments with “red flags” were promptly reviewed by the senior psychologist. However, we found five assessments that were not scored within one day of the test. Although we recognize that improvements have been made and that the senior psychologist is promptly reviewing treatment needs assessments that indicate red flags, we also found that treatment needs assessments are not always scored within the required time frame. Based on our review, we disagree with the department’s assertion that the recommendation is fully implemented. Therefore, we concluded that this recommendation is substantially implemented. The Division of Juvenile Justice should: Develop and implement a custody classification system. Partially California Department of Corrections and Rehabilitation’s response: Included in this system should be an instrument designed Implemented Partially Implemented. Foundational to the success of the Integrated Behavior to assist in identifying the most appropriate placement for Treatment Model agreed to with the Court in the Farrell v. Tilton litigation is wards. The instrument should consider whether the ward the establishment of a Division of Juvenile Justice Classification System that has the sophistication and maturity level for the uses an evidenced-based Risk/Needs Assessment. recommended placement. (December 2005) As of January 2007, based upon the Risk for Facility Violence Assessment, with the exception of specific exemptions agreed to with the Farrell Safety and Welfare Remedial Plan Court Expert, the Division of Juvenile Justice has been separating wards assessed with a high risk for facility violence from those assessed with a low risk. Similarly, the Division of Juvenile Justice has been reclassifying wards using a system predicated on facility behavior. Since August of 2007, the Classification, Assessment, Placement and Intake Interdisciplinary Team, within the Division of Juvenile Justice, in collaboration with court appointed Subject Matter Experts, has been sponsoring the development of an interim Classification Policy responsive to the Farrell Safety and Welfare Remedial Plan. The interim Classification Policy being developed includes assessment and reassessment procedures, as well as electronically calculated objective scoring criteria. In 2007, the Electronic Reclassification Pilot Project was initiated at O. H. Close Youth Correctional Facility. In 2008, the Electronic Reclassification Office of the Inspector General Page 198 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments Pilot Project will be completed and the results evaluated. The Division of Juvenile Justice anticipates implementation of the interim Classification Policy throughout the youth correctional system at the State level soon thereafter. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 3 Living unit staff and communication center staff failed to follow key policies and procedures, resulting in a period of 38 minutes before staff opened the ward’s door. However, it is not possible to determine whether a faster response would have saved the ward’s life. (December 2005) Recommendation Status Comments N.A. Chaderjian Youth Correctional Facility should: Modify the existing video surveillance system so that it Fully California Department of Corrections and Rehabilitation’s response: will accurately date and time stamp all video recordings. Implemented Fully Implemented. The Superintendent at N.A. Chaderjian Youth (December 2005) Correctional Facility implemented a project plan to ensure that the capacity of the existing video surveillance system could be expanded to include accurate date and time stamping of all video recordings. In adherence to the project plan, N.A. Chaderjian Youth Correctional Facility secured an outside vendor to install new servers with the capacity to date and time stamp video recordings. The servers with expanded capacity were installed by October 31, 2007. Video cameras were aligned appropriately on November 1, 2007. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 199 Special Review into the Death of a Ward 2008 Accountability Audit at N.A. Chaderjian Youth Correctional Facility Recommendation Status Comments The Division of Juvenile Justice should: Ensure that the revised policies and procedures for Partially California Department of Corrections and Rehabilitation’s response: addressing all aspects of wards’ covering their room Implemented Partially Implemented. In March of 2006 and again in April of 2007, the windows are incorporated into the Division of Juvenile Assistant Director of Facilities issued directives setting the expectation that Justice Institutions and Camps Branch Manual and adhered staff members were to have a clear unobstructed view of wards in their to by all facilities. (July 2007) rooms. The aforementioned memorandums further stated that when wards cover their windows and obstruct staff visibility, a breach of safety and security exists, requiring immediate intervention. The Director of Juvenile Facilities has continued to emphasize the expectation for compliance with the directive contained in the memorandums at monthly superintendent meetings. The Policy, Procedures, Programs and Regulations Unit, in collaboration with Subject Matter Experts from the Division of Juvenile Facilities are currently incorporating the directive into policy for inclusion into the Institutions and Camps Branch Manual. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 200 Board of Parole Hearings 2008 Accountability Audit Indeterminate Sentence Hearings and Appeals Review of the Board of Parole Hearings Indeterminate Sentence Hearings and Appeals Finding 1 The Board of Parole Hearings’ system for identifying and scheduling indeterminate sentence hearings was inadequate to ensure that the hearings were properly managed and conducted with reasonable promptness. (March 2000) Recommendation Status Comments The Board of Parole Hearings should: Implement the Lifer Scheduling and Tracking System to Substantially California Department of Corrections and Rehabilitation’s response: enable the board to have access to the most current, Implemented Fully Implemented. LSTS was deployed on 11/1/07 statewide. Staff from all accurate, and relevant information necessary to manage its CDCR divisions worked together diligently to fully develop the LSTS lifer hearing responsibilities. (March 2000) application timely. BPH/DAI/DAPO staff have access to the application. Institutional connectivity is complete for all 33 institutions. All testing and training is complete. UPMs are working with contractors on change requests to refine the application. Training was provided to all BPH users throughout the state. The training components are: Scheduling, Commissioners, Deputy Commissioners and Retired Deputy Commissioners, Decision Review staff, Decision Processing Staff, Psychologists, Senior Psychologists, Victim Services. Customized training manuals were prepared for these various types of users. Office of the Inspector General’s comments: We verified that the Board of Parole Hearings implemented the Lifer Scheduling and Tracking System (LSTS) as of November 1, 2007. The system should provide the board with access to information necessary to manage its lifer hearing responsibilities, such as minimum eligible parole dates and LSTS- generated Hearing No Later Than Dates (which relate to legally mandated subsequent hearing dates). In addition, the LSTS reports contained fields for psychological evaluation completion dates. Both the Board of Parole Hearings and institution-based LSTS users informed us that they were satisfied with the system and had not experienced major access or operating problems. Office of the Inspector General Page 201 Board of Parole Hearings 2008 Accountability Audit Indeterminate Sentence Hearings and Appeals Recommendation Status Comments While the LSTS was too new to verify the accuracy of all its data elements, in February 2008, the Inspector General made an unannounced visit to observe the Board of Parole Hearings lifer hearings. Based on information gathered during this visit, it would appear that the board was not yet using the LSTS to its full capacity. For example, on the day of the Inspector General’s visit there were four hearings scheduled and each had a problem with the psychological evaluation – either the psychological evaluation had not been updated or it had not been distributed on time to all parties. The two hearings scheduled for the following day had similar problems. As a result, several of these hearings were rescheduled. Although this observation was anecdotal and not quantifiable proof, it points out that even though the LSTS may have the capability to provide the board with the necessary information to manage its hearings, it is not yet being fully utilized and some staff members may need more training or closer supervision. For that reason, we have determined this recommendation to be only substantially implemented. Ensure that the Lifer Scheduling and Tracking System Fully California Department of Corrections and Rehabilitation’s response: includes regular monthly reports for use in forecasting, Implemented Fully Implemented. LSTS currently has standard management and court scheduling, and managing the lifer hearing workload. reports that can be accessed by the executive management, institutional (July 2005) administrators, schedulers, department supervisors and managers, IT personnel, and the BPH decision review staff, legal staff, and BPH forensic unit. Users can utilize the reports to manage workload and identify problems. Office of the Inspector General’s comments: We verified that LSTS users can access a variety of reports to forecast, schedule, and manage the lifer hearing workload. These reports have improved the board’s ability to perform various tasks for lifer hearings, such as forecasting hearing workload. For example, before the implementation of the LSTS, the board was unable to readily forecast the number of lifer inmates who needed a hearing in a particular time period and, as a result, relied on institution-based staff members to provide information on the number of inmates who needed hearings. We verified that a LSTS report, Inmates Needing a Hearing or Review, identifies lifers who need a hearing within a specific period by corresponding institution; the report also provides a summary total for all institutions. For instance, as of January 25, 2008, the LSTS identified 54 inmates who would need an initial hearing during the period December 1 to 31, 2012. Office of the Inspector General Page 202 Board of Parole Hearings 2008 Accountability Audit Indeterminate Sentence Hearings and Appeals Recommendation Status Comments Ensure that the Lifer Scheduling and Tracking System Substantially California Department of Corrections and Rehabilitation’s response: contains quality control features so that the information Implemented Fully Implemented. LSTS includes a variety of quality control features, entered into, stored within, and produced by the system is including mandatory fields of entry and system checks that will block alpha accurate. (April 2002) and numeric entries in certain instances. LSTS contains a secondary review requirement for board and psychiatric reports that are submitted into LSTS that will ensure the quality of information entered, stored and produced. In addition, LSTS allows access to users depending upon the authority granted by management and requires authentication into the system. Office of the Inspector General’s comments: We observed that the Board of Parole Hearings staff members use the LSTS to perform various lifer hearing workload processes. In doing so, we verified that the LSTS includes mandatory fields of entry and system checks. For example, the board’s LSTS user project manager demonstrated the time control edit that does not allow a user to input a time for a hearing that has occurred in the past. The project manager also demonstrated that the LSTS allows input into data fields only from a pre-determined list. In addition, a scheduling analyst from the board’s Hearing Division demonstrated that she had access to only the LSTS menus for which she had been granted clearance. Forensic Assessment Division staff members also demonstrated the quality control edit that allows psychologists to enter information into the LSTS only for inmates assigned to their caseload. We also tested the accuracy of the LSTS-generated Hearing No Later Than Date—an important component of many LSTS reports—and found that data entry and data omission errors caused minor discrepancies in ten out of 130 (7.69 percent) sampled transactions. For instance, we found that the panel members did not enter the hearing decision into the LSTS for four of the ten transactions. We also found that data entry errors caused the remaining six discrepancies. In these cases, either the panel members or board analyst did not input the correct hearing decision or date into the LSTS, resulting in an inaccurate Hearing No Later Than Date. After we shared the discrepancies with the board’s Hearing Division chief, the chief researched the discrepancies and corrected the LSTS entries. We also learned that the merger of three stand-alone databases (which formed the LSTS database foundation before the November 1, 2007, launch date) Office of the Inspector General Page 203 Board of Parole Hearings 2008 Accountability Audit Indeterminate Sentence Hearings and Appeals Recommendation Status Comments caused minor discrepancies, as well. For example, inmates who had escaped or were out to court (in federal or state jurisdictions) and, therefore, could not have a parole hearing were included in the LSTS-generated Backlog Report. As of January 25, 2008, the Hearing Division analysts had identified about 158 “merger-related” discrepancies and, with the assistance of institution-based case records staff members, had resolved 112 of the discrepancies. The Hearing Division chief informed us that as soon as the 158 discrepancies are cleared, any future discrepancies would result only from data entry or data omission errors. To mitigate such errors, the Hearing Division plans to form a Quality Control Unit to review at least 20 percent of all lifer hearings against their corresponding entries for accuracy, thereby minimizing the effect of data entry or omission errors. Because the LSTS contains minor discrepancies and the board is still implementing its quality control processes, we determined that the recommendation was substantially implemented rather than fully implemented. Finding 3 The Board of Parole Hearings’ estimated schedule for eliminating the hearing backlog by May 2002 was unrealistic. (April 2002) Recommendation Status Comments The Board of Parole Hearings should: Ensure that the Lifer Scheduling and Tracking System Substantially California Department of Corrections and Rehabilitation’s response: reports an actual count of hearings that have passed their Implemented Substantially Implemented. CDCR staff and contractors are currently working statutory due dates. (July 2005) on a backlog report that will identify all hearings that have passed their statutory due dates. Due to data conversion issues from various IT applications that were imported into LSTS, many cases are being reviewed manually to ensure proper reporting. The Backlog report should be available by the end of November, 2007. Office of the Inspector General’s comments: We reviewed the LSTS-generated Backlog Reports for November and Office of the Inspector General Page 204 Board of Parole Hearings 2008 Accountability Audit Indeterminate Sentence Hearings and Appeals Recommendation Status Comments December 2007 and discussed the content of the reports and their preparation with the Board of Parole Hearings staff members responsible for reviewing and preparing the reports. The staff members showed us the manual adjustments they made to the reports to resolve the merger-related discrepancies (discussed in Finding 1) and other programming issues to ensure proper reporting. On February 26, 2008, the Hearing Division analyst who reviewed and manually adjusted the November and December 2007 Backlog Reports informed us that the January 2008 LSTS-generated Backlog Report required only a minimal number of manual adjustments because the LSTS programmers modified the system. Based on our review of the reports and discussions with board staff members, we acknowledge that the LSTS- generated Backlog Report identifies the hearings that have passed their statutory due dates. LSTS is capable of producing accurate reports; however, data entry and data omission errors will occur without a constant quality control review process. Ensure that the Lifer Scheduling and Tracking System Partially California Department of Corrections and Rehabilitation’s response: counts the hearing backlog based on the hearing date Implemented Partially Implemented. LSTS counts the hearing backlog based on hearing required by Penal Code section 3041(a) and request that date and is programmed to report according [to] the requirements of the the Legislature amend California Penal Code section Rutherford/Lugo court conditions and the requirements of Penal Code section 3041(d) accordingly. In addition, consider the impact of 3041(d), thereby eliminating the need to request that the Legislature amend the requirement to have hearing panels consist of at least the statute. Nevertheless, BPH and CDCR Legislative Liaison staff are two commissioners when the backlog reaches zero. considering a proposal to amend Penal Code section 3041(d) so that its (July 2005) reporting requirements are the same as the court requirements. The number of commissioners required on life parole consideration hearing panels in view of the backlog of hearings has generated several legislative changes. Senate Bill (SB) 778 (Chapter 131/2001) authorized the BPH to convene specified hearing panels composed of one Commissioner (rather than two), and one Deputy Commissioner. Prior to July 2005, the BPH was composed of 9 Governor-appointed Commissioners. The BPH typically experienced 2 to 3 Commissioner vacancies from 1992 to 2005, and simultaneously the number of indeterminately sentenced prisoners requiring parole consideration hearings increased. SB 778 was scheduled to sunset on December 31, 2005; however, the passage of SB 737 (Chapter 10/2005) extended the BPH’s ability to convene two-person panels until the hearing backlog is effectively eliminated. By recent report to the Rutherford/Lugo Office of the Inspector General Page 205 Board of Parole Hearings 2008 Accountability Audit Indeterminate Sentence Hearings and Appeals Recommendation Status Comments Court, this is now estimated to be May 2010. SB 737 also increased the number of current Commissioners to 12 that preside over adult hearing matters. Based on BPH’s internal analysis and the workload study conducted by the independent contractor, Cooperative Personnel Services (CPS), 12 Commissioners will not be sufficient to address current and projected workload demands. Per the workload study, the projected workload must include the declining level of backlogged hearings and an estimated 2% growth rate in new hearings. In 2005, the number of life parole consideration hearings scheduled increased to approximately 5,000 and in 2006/2007 it increased to 6,676 hearings. The BPH expects to schedule an estimated 7,100 hearings in 2008/2009. According to the CPS workload study, the turnover of Commissioners is also a contributing factor in the backlog of hearings. In addition to number of hearings required, the workload study developed a time-per-task calculation to determine the number of positions required to complete the organizational workload. Based on the findings in the workload study, it is estimated three to five additional Commissioners will be needed to meet current and future demands. BPH and the Administration are reviewing recommendations to add additional Commissioner positions to the parole board. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s response. Office of the Inspector General Page 206 2008 Accountability Audit Review of Board of Parole Hearings Decisions Review of Board of Parole Hearings Decisions Finding 4 The Board of Parole Hearings had not implemented a regulatory requirement to systematically review its decisions to ensure the decisions are complete, accurate, consistent, uniform, and further public safety. (January 2003) Recommendation Status Comments The Board of Parole Hearings should: Ensure that it modifies California Code of Regulations, Partially California Department of Corrections and Rehabilitation’s response: Title 15, section 2041, to allow for review of a portion of Implemented Partially Implemented. BPH voted on 8/21/07 to approve the regulation proposed decisions rather than all decisions. (January 2005) amendment and to convey it to the Office of Administration Law (OAL). On 10/12/07, BPH issued public notice to solicit public comments. The public comment period runs from 10/12-11/26/07. Since the public has requested a hearing under the Administrative Procedures Act, the hearing has been scheduled for January 17, 2008. Thereafter, the regulation amendment will be presented to the BPH at its monthly meeting for final approval. The regulation will then be filed with the OAL, which has 30 business days to review. Amendment takes effect 30 calendar days after OAL approval. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 207 Board of Parole Hearings 2008 Accountability Audit Hearings for Mentally Disordered Offenders Review of the Board of Parole Hearings Hearings for Mentally Disordered Offenders Finding 5 The Board of Parole Hearings’ practice of automatically scheduling mentally disordered offender placement hearings 60 days after the inmate’s arrival in custody was unnecessary and inefficient. (January 2003) Recommendation Status Comments The Board of Parole Hearings should: Approve and implement the planned revisions to its Substantially California Department of Corrections and Rehabilitation’s response: mentally disordered offenders hearing process and Implemented Fully Implemented. Changes have been incorporated into the Mentally discontinue the practice of automatically conducting Disordered Offender (MDO) Placement Hearing Procedures. MDO Hearing placement hearings for mentally disordered offenders Information (BPH 1420), Notice of MDO Rights and Acknowledgement (BPH 60 days after placing them into the custody of the 1410) and Placement Hearing Attorney Appointment Forms have been Department of Mental Health. Instead, the board should revised. In addition, a postcard has been developed for MDO inmates conduct mentally disordered offender placement requesting a Placement Hearing. All Deputy Commissioners and interested hearings at the request of the parolee or the Department parties were formally noticed of the changes on October 18, 2007. Policy of Mental Health. (January 2003) changes were implemented on November 5, 2007. Office of the Inspector General’s comments: The department has developed, approved, and distributed revised policies and procedures that should satisfactorily address the recommendation. However, the new policies were issued after the date of our audit engagement letter, and staff members have not yet gone through a full cycle of applying the new policies and procedures. As a result, we modified the status to substantially implemented. Office of the Inspector General Page 208 Board of Parole Hearings 2008 Accountability Audit Supervision of Deputy Commissioners Review of the Board of Parole Hearings Supervision of Deputy Commissioners Finding 1 The Board of Parole Hearings had significantly overstated the number of deputy commissioner positions it required to fulfill its responsibilities and that the actual number of deputy commissioner positions it needed was only about 39—slightly more than half its deputy commissioner staff. (January 2003) Recommendation Status Comments The Board of Parole Hearings should: Ensure completion of the workload analysis. Fully California Department of Corrections and Rehabilitation’s response: (January 2003) Implemented Fully Implemented. In August 2007 Cooperative Personnel Services (CPS), Human Resource Services, issued a draft final report representing a comprehensive time and workload analysis of Commissioner and Deputy Commissioner (DC) positions. The report provided the basis of a resource allocation and time management system for these designated positions. The study was conducted from October 11, 2006 through August 17, 2007 and focused on the 12 Commissioners who are appointed by the Governor of the State of California and the 91 established DC positions. At the start of the study there were 11 Commissioners and 81 DCs, along with 26 retired annuitants who also assisted with DC duties. A copy of the Workload Study is attached. For the DC workload study, the approach and methodology included: • Development of an “available work year” calculation to determine the number of hours actually available within a year to perform assigned work tasks after allowances for paid authorized absences and training. • The use of expert panels to review the preliminary task lists to be used during the field observations, to identify other significant tasks performed by the job classification, and to make recommendations on sites to be observed that would best reflect stratified groups. Office of the Inspector General Page 209 Board of Parole Hearings 2008 Accountability Audit Supervision of Deputy Commissioners Recommendation Status Comments • Independent field observations by CPS consultants, who conducted 36 site visits at 25 facilities. This observation sample included 680 hearings and assessments, and constituted a 0.3 percent sample of the estimated 213,235 hearings and assessments that occurred during that period. • Supplemental self-reporting survey to obtain information on non-hearing tasks, which was developed in consultation with Associate Chief Deputy Commissioners (ACDC) and DCs, from 72 DCs over a 650 DC day period. • Observation and documentation of hearing complexity factors, such as whether the hearing was scheduled, whether ADA accommodations were provided, whether there were objections made to the proceedings or evidence, whether witnesses testified and how many, and the disposition of the case. Based on the results of the Deputy Commissioner portion of the workload study and the developed time standards, it was determined that 104.07 DC Personnel Years (PYs) are needed to perform current caseloads. Office of the Inspector General’s comments: In November 2007, we reviewed the workload study prepared by Cooperative Personnel Services (CPS) and found that it used reasonable methodologies to perform the study and develop conclusions. However, because the CPS study focused on board tasks as currently performed, its value is limited to the extent that the tasks and processes studied remain unchanged. The study did not, nor was it intended to, identify and analyze inefficiencies in the process it examined. CPS did comment on certain obvious inefficiencies in the board’s processes, including the scheduling of hearings that are subsequently postponed. Despite the shortcomings, we found that the board has fully implemented the limited requirement of our recommendation to complete the workload study. Office of the Inspector General Page 210 Board of Parole Hearings 2008 Accountability Audit Supervision of Deputy Commissioners Finding 2 The deputy commissioners of the Board of Parole Hearings, who carry out most of the board’s functions, received little supervision and the board had no means of accounting for how they spent their time. (January 2003) Recommendation Status Comments The Board of Parole Hearings should: Continue its efforts to increase the number of authorized Fully California Department of Corrections and Rehabilitation’s response: associate chief deputy commissioner positions relative to Implemented Fully Implemented. Effective July 1, 2006, the Board of Parole Hearings was the number of deputy commissioners they supervise and authorized to establish two additional Associate Chief Deputy Commissioner to make the compensation of the associate chief deputy positions bringing the number of established positions from 7 to 9. The Board commissioner position commensurate with the has one additional unallocated position that is the result of population responsibility of the position for supervising deputy adjustments, bringing the total authorized Associate Chief Deputy commissioners. (January 2003) Commissioner positions to 10, and is currently working with both CDCR Office of Personnel Services and Budget Management Branch to establish this position. During this relevant time period the Board had 4 vacant Associate Chief Deputy Commissioner positions. Due to both the age of the list and limited number of candidates on the exam list, the Board initiated a new exam process. In early 2007, the Board of Parole Hearings, in conjunction with the CDCR Exams Unit, held another exam for the Associate Chief Deputy Commissioner classification and as a result of this process was able to fill all 9 allocated positions. The candidate pool remains small; however, as it increased from 5 candidates to only 19 candidates. The list of eligible candidates remains very small due to the ongoing pay and benefit compaction issue for this classification. Specifically, the Board of Parole Hearings recruits and hires vacant Associate Chief Deputy Commissioner positions primarily from its current Deputy Commissioner pool of interested candidates who have been examined for the ACDC class. Unfortunately, very few current Deputy Commissioners compete in this exam process because the pay and benefit compensation is negatively impacted. That is, rather than increasing as would be anticipated, Deputy Commissioners actually take a net loss in pay as a result of the retirement designation. Deputy Office of the Inspector General Page 211 Board of Parole Hearings 2008 Accountability Audit Supervision of Deputy Commissioners Recommendation Status Comments Commissioners are designated Safety whereas Associate Chief Deputy Commissioners are designated Miscellaneous. Previously in 2006 this issue was elevated to CDCR for review and appropriate action. In mid April 2007 the Board of Parole Hearings submitted a formal request to increase the compensation for the classification of Associate Chief Deputy Commissioner. The request was made to the Office of Personnel Services (OPS) to be considered for the OPS Classification and Pay Plan for 2007/2008. The Classification and Pay Plan will allow Human Resources to focus resources in accordance with an approved departmental plan. In mid October 2007 the board submitted additional paperwork to the OPS regarding the same issue. With regard to the Associate Chief Deputy Commissioner to Deputy Commissioner supervision ratio, the Board of Parole Hearings currently has 91 established Deputy Commissioner positions and 9 established Associate Chief Deputy Commissioner positions, although one of these positions is being utilized as the board’s Acting Chief Deputy Commissioner. The Board currently maintains an average of 6.5 to 1 staffing ratio for 4 Associate Chief Deputy Commissioners and an average of 10.5 to 1 staffing ratio for the remaining 4 Associate Chief Deputy Commissioners. This results in an overall staffing ratio of Associate Chief Deputy Commissioner positions to Deputy Commissioners of approximately 8.5 to 1. The Board anticipates adjusting the staffing ratio further once the additional Associate Chief Deputy Commissioner position is established. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 212 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Special Review of the Board of Parole Hearings Interpretation Services Procedures Finding 1 The Board of Parole Hearings did not specify in writing the terms and conditions of interpretation services to be provided. (March 2005) Recommendation Status Comments The Board of Parole Hearings should: Provide interpreters with confirmation letters specifying Partially California Department of Corrections and Rehabilitation’s response: the terms and conditions of the services to be provided for Implemented Partially Implemented. In May 2007, the Board of Parole Hearings (Board) all hearings. The letters should include at least the hired a staff member responsible for maintaining the Board’s Interpreter following information: database. The Board was successful in issuing to all its interpreters a new Application Interpreter Appointment and Letter of Agreement (Packet) • Inmate’s name and California Department of consisting of a uniform, statewide policy for hiring interpreters (attached). Corrections and Rehabilitation identification The Packet includes, but is not limited to, standard reimbursement rates, number cancellation fees, and mileage and travel time allowances for interpreters. The Board’s new policy requires all Board interpreters have a signed • Date, time, and location of the hearing agreement on file to be eligible for inmate/parolee hearing assignments. A list • Type of hearing of interpreters who completed the Packet will be distributed to Board staff on a monthly basis commencing in January 2008. The Packet is available to all • Agreed-upon reimbursement rate prospective interpreters by mail or on the Board’s website at http://www.cdcr.ca.gov/DivisionsBoards /BOPH/attorney employment.html. • Travel reimbursement policy, including mileage rate allowed All interpreters hired by the Board for lifer hearings and for those interpreters • Hearing cancellation policy in Regions 1 and 2 currently receive a written confirmation letter (attached) specifying the terms and conditions of the interpreter services to be provided. • Invoice process and time frames for invoice The confirmation letter includes all elements as bulleted in Finding Number 1, submittal and payment Recommendations. Regions 3 and 4 Board staff who are not in full • Signature block and telephone number block to compliance with the new interpreter policy were notified, trained and directed allow a Board of Parole Hearings representative to be in full compliance by January 1, 2008. At that time, one hundred percent to verify services at completion of the hearing (100%) of the interpreters will receive confirmation letters for all Board (March 2005) hearings. Office of the Inspector General Page 213 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that the confirmation letter includes the Partially California Department of Corrections and Rehabilitation’s response: reimbursement rate for each hearing when hiring one Implemented Partially Implemented. If one interpreter is hired for multiple hearings, a interpreter for multiple hearings. (July 2007) separate confirmation letter is sent to the interpreter for each hearing. As noted in Finding Number 1 above, all interpreters hired by the Board for lifer hearings and those interpreters in Regions 1 and 2 currently receive a written confirmation letter specifying the terms and conditions of the interpreter services to be provided. The confirmation letter includes all elements as bulleted in Finding Number 1, Recommendations. Regions 3 and 4 Board staff who are not in full compliance with the new interpreter policy were notified, trained and directed to be in full compliance by January 1, 2008. At that time, one hundred percent (100%) of the interpreters will receive confirmation letters for all Board hearings. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Require interpreters to bring the confirmation letter to the Partially California Department of Corrections and Rehabilitation’s response: hearing. (March 2005) Implemented Partially Implemented. As provided on Page Two of the Interpreter Letter of Agreement, the interpreter is “required to bring the confirmation letter with them to the hearing. Upon completion of services, the interpreter shall present this letter to the hearing officer … for signature as proof of attendance.” As noted in Finding Number 1 above, all interpreters hired by the Board for lifer hearings and all interpreters in Regions 1 and 2 currently receive a written confirmation letter specifying the terms and conditions of the interpreter services to be provided. The confirmation letter includes all elements as bulleted in Finding Number 1, Recommendations. Regions 3 and 4 Board staff who are not in full compliance with the new interpreter policy were notified, trained and directed to be in full compliance by January 1, 2008. At that time, one hundred percent (100%) of the interpreters will receive confirmation letters for all Board hearings. Office of the Inspector General Page 214 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 2 Invoices for services were paid without verification that the services were provided. (March 2005) Recommendation Status Comments The Board of Parole Hearings should: Require a Board of Parole Hearings representative to sign Fully California Department of Corrections and Rehabilitation’s response: and date the confirmation letter and return it to the Implemented Fully Implemented. On August 6, 2007, the Board issued a memorandum interpreter at the completion of service. (March 2005) notifying hearing panel members interpreters will be presenting original interpreter confirmation letters for their review and signature (attached). Panel members were instructed to sign and date the original confirmation letters acknowledging the interpreters’ presence at the hearing and to return the original confirmation letter to the interpreter for submission to the Board. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Require a Board of Parole Hearings representative to affix Partially California Department of Corrections and Rehabilitation’s response: the representative’s initials next to each inmate’s name, Implemented Partially Implemented. As noted in Finding Number 1, Recommendation verifying that each hearing was held, if one interpreter is Number 2, if one interpreter is hired for multiple hearings, a separate hired for multiple hearings. (July 2007) confirmation letter is sent to the interpreter for each hearing. As further noted in Finding Number 1 above, all interpreters hired by the Board for lifer hearings and interpreters for hearings in Regions 1 and 2 currently receive a written confirmation letter specifying the terms and conditions of the interpreter services to be provided. The confirmation letter includes all elements as bulleted in Finding Number 1, Recommendations. Regions 3 and 4 Board staff who are not in full compliance with the new interpreter policy Office of the Inspector General Page 215 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Recommendation Status Comments were notified, trained and directed to be in full compliance by January 1, 2008. At that time, one hundred percent (100%) of the interpreters will receive confirmation letters for all Board hearings. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 3 The Board of Parole Hearings did not use invoice records to detect fraud. (March 2005) Recommendation Status Comments The Board of Parole Hearings should: Use electronic methods to systematically record, track, and Partially California Department of Corrections and Rehabilitation’s response: monitor payments to interpreters so as to detect duplicate Implemented Partially Implemented. The Board continues to work with Information claims. (March 2005) Technology (IT) staff to enhance the current Oracle database used to interact with the Board’s lifer and Revocation Scheduling Tracking System (RSTS) revocation hearing databases. With the November 1, 2007, release of the new Lifer Scheduling Tracking System (LSTS) database, we are working with IT staff to have connectivity to the data for verification of lifer hearing action. In addition, IT staff will be implementing language modifications to include auto save and conditional verification of hearing information on our existing Oracle Invoice Tracking Database. However, it should be noted, the Board is receiving original interpreter confirmation letters which include the original signature of the hearing panel thereby verifying attendance at the hearing. In addition to the “checks and balance” and auditing processes already in place with California Department of Corrections and Rehabilitation (CDCR). Headquarters’ Accounting Office, the Unit is currently auditing monthly IT- generated reports to detect possible duplicate payment. It should be noted Office of the Inspector General Page 216 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Recommendation Status Comments during our audit research, we have learned there is an existing issue with what appears to be a duplicate entry. However, upon further research, we discovered the duplication is actually re-entry of a corrected invoice. This is a process that must be completed manually. IT staff are rewriting present logic in the database to electronically accomplish this task. Finally, the Board’s Administration Unit is currently advertising two (2) Office Technician positions which will be responsible for processing and auditing, among other things, interpreter invoices. Thus, the work currently performed by Hearings Division staff will be properly assigned and realigned with the Board’s Administration Unit, Accounting Office. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Audit interpreter payments, beginning with fiscal year Partially California Department of Corrections and Rehabilitation’s response: 2003–04, and recoup overpayments. (July 2007) Implemented Partially Implemented. The Board produced an inclusive Invoice Monitoring Report to audit and recoup possible overpayments to interpreters. During FYs 2003-2004 and 2004-2005, the Department of General Services (DGS) processed interpreter payments for the Board. DGS staff informed our office they already recouped duplicate funds for invoices during their audit review process; however, they were unable to provide us with a report verifying complete reimbursement or produce a list of those interpreters in which they received reimbursement. Therefore, on October 30, 2007, the Board provided DGS with a list of interpreters in which there appears to be a possible overpayment of funds during FYs 2003-2004 and 2004-2006. The Board received reassurance from DGS they will compare the list against the funds already recouped from the interpreters and determine if there are any outstanding interpreters with overpayment. DGS indicated this audit will be complete by December 31, 2007. In FY 2005-2006, the Board merged with CDCR. Therefore, all invoice processing documentation transitioned to the CDCR Headquarters’ Accounting Office. On December 12, 2007, a list of possible overpayment of interpreters was identified and forwarded to CDCR’s Accounting Office for FYs 2005-2006 to present. The CDCR’s Accounting Office will identify the Office of the Inspector General Page 217 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Recommendation Status Comments warrant number for each payment. Thereafter, upon receipt of the warrant list, the Board is required to submit separate requests to the State Controller’s Office for copies of the warrants to verify whether an interpreter received multiple payments. Finally, although our Accounting Office has been unable to verify whether there is a statute of limitations to collect reimbursement of funds, we have been instructed to go forward in our pursuit of reimbursement. Therefore, upon receipt of cancelled warrants/checks from the State Controller, the Board will send letters with copies of the warrants requesting funds to those interpreters who received duplicate payment. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Finding 4 Interpreters were not required to submit invoices within a prescribed time limit. (March 2005) Recommendation Status Comments The Board of Parole Hearings should: Require interpreters to submit invoices within prescribed Fully California Department of Corrections and Rehabilitation’s response: time limits specified in the hearing confirmation letter. Implemented Fully Implemented. As previously addressed in other submissions to the Office (March 2005) of the Inspector General, while the Board found no laws or regulations mandating the submission for payment within a prescribed time limit, the Board nonetheless has included language in the Interpreter’s Letter of Agreement (Page 3) and the updated interpreter confirmation letters (attached) indicating invoices shall be submitted within two months from the date of the hearing to ensure expediency of process. It is further provided in the Letter of Agreement invoices submitted after the two-month period may Office of the Inspector General Page 218 Board of Parole Hearings 2008 Accountability Audit Interpretation Services Procedures Recommendation Status Comments cause delay in payment to the interpreter/organization. All interpreters hired by the Board for lifer hearings and all interpreters in Regions 1 and 2 for hearings currently receive a written confirmation letter (attached) specifying the terms and conditions of the interpreter services to be provided. The confirmation letter includes all elements as bulleted in Finding Number 1, Recommendations, as well as the following language: “In order to avoid any delays in processing of payment, please return this signed form within 60 days of the hearing.” Board staff not in full compliance with the new interpreter policy were notified, trained and directed to be in full compliance by January 1, 2008. At that time, one hundred percent (100%) of the interpreters will receive confirmation letters for all Board hearings. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Office of the Inspector General Page 219 Attachment 1 Response from the California Department of Corrections and Rehabilitation Attachment 2 The Office of the Inspector General’s Comments on the Department’s Response The Office of the Inspector General’s Comments on the Department’s Response We are concerned that the department’s current practice produces inconsistent levels of training for armed officers and therefore potentially jeopardizes staff, inmate, and public safety by not requiring that all correctional staff assigned to armed posts receive quarterly weapons training. Furthermore, because of the inconsistency in the department’s weapons training requirements, the department could face future litigation. The department states in its response that its current policy requires correctional staff members who are regularly assigned to an armed post, or who have a high likelihood of being assigned to an armed post, and staff members on special assignments such as internal affairs or inmate transportation to complete a weapons proficiency course on a quarterly basis. Yet, as a result of shift swaps, the department allows other staff members who complete a weapons proficiency course only annually to fill the same armed posts. For example, officer A escorts inmates to the local public hospital on Monday. This is his regular assignment; therefore, he is required to qualify each quarter with his weapon. On Tuesday, officer A makes arrangements with officer B to exchange jobs and officer B transports the inmates. However, because officer B does not regularly carry a weapon while on duty, the department did not require him to complete a quarterly weapons qualification. Officer B is required to qualify only annually. As a result, the department required a higher standard of training for armed personnel on Monday than it did on Tuesday. And because weapons proficiency is a perishable skill and requires ongoing practice, Tuesday’s escort may not possess the same level of proficiency, which could present safety issues for the correctional staff, the inmate, or the public. This weapons qualification policy—which results in an inconsistency in the training of staff members at armed posts—may place the department in a difficult situation should it need to defend its current practice in the event of an officer- involved shooting.