Review of Audits of the Cdcr

ACCOUNTABILITY AUDIT REVIEW OF AUDITS OF THE CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION 2000–2007 OFFICE OF THE INSPECTOR GENERAL DAVID R. SHAW INSPECTOR GENERAL STATE OF CALIFORNIA MARCH 2009 ACCOUNTABILITY AUDIT REVIEW OF AUDITS OF THE CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION 2000–2007 OFFICE OF THE INSPECTOR GENERAL DAVID R. SHAW INSPECTOR GENERAL STATE OF CALIFORNIA MARCH 2009 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....................................................................................................................................7 Background.........................................................................................................................7 Objectives, Scope, and Methodology.................................................................................9 Chapter 1: Initial Follow-up Results for Four Reports Issued in 2007.............................................................12 Special Review into In-Prison Substance Abuse Programs Managed by the California Department of Corrections and Rehabilitation................15 Special Review of High-Risk Issues at the Heman G. Stark Youth Correctional Facility..........................................................................................42 Special Review into the California Department of Corrections and Rehabilitation’s Release of Inmate Scott Thomas..............................................66 The California Institution for Women Quadrennial and Warden Audit..............................78 Chapter 2: Follow-up Results for Six Reports Issued Between 2000 and 2006..............................................96 23-and-1 Program Review..............................................................................................100 California State Prison, Solano, Management Review Audit..........................................106 Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005, at Wasco State Prison...........................................................108 Special Review into Improper Housing of Maximum Custody Inmates at California State Prison Reception Centers...........................................................111 Special Review into Management of Union Leave Time by the California Department of Corrections and Rehabilitation..............................113 Special Review into Concerns Related to Substance Abuse Treatment Contractors..............................................................................................116 Response from the California Department of Corrections and Rehabilitation..........................................................................Attachment 2009 Accountability Audit Executive Summary Executive Summary This comprehensive accountability audit presents the results of the Office of the Inspector General’s (OIG) annual follow-up review of previous recommendations issued to the California Department of Corrections and Rehabilitation (CDCR). In this accountability audit, the OIG assesses the department’s progress in implementing past recommendations from ten audits and special reviews affecting the CDCR. Overall, we found that the CDCR implemented roughly 60 percent of 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 114 unresolved recommendations. Chapter 1 presents the results from our first follow-up audit of 94 recommendations made in three special reviews and one audit completed in 2007. Chapter 2 presents the results from our follow- up review of 20 recommendations made in six audits and special reviews issued from 2000 through 2006. The difference between the audits and reviews in Chapter 1 compared with 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 website. This public posting is critical because prisons are, by their very nature, places where most events occur outside the public view. Publication 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 2009 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, the department reported success in reconciling some of the reimbursable union leave time owed to it by a labor union. In response to our July 2006 review into the department’s management of union leave time (see Chapter 2), and our 2008 Accountability Audit, the department has generated several invoices from May through September 2008, billing the California Correctional Peace Officers Association a total of $2.2 million for union representatives on union paid leave. In addition, living conditions for Division of Juvenile Justice wards housed in restricted program housing has been a chronic issue since our December 2000 report on the division’s “23-and-1 Program.” The department reported in this year’s accountability audit, however, that staff are being held accountable through clear management directives, additional training, continued oversight and progressive discipline for failure to maintain living and working conditions that comply with safety and security standards. During our November 2008 site visits to Heman G. Stark, N.A. Chaderjian, and Preston Youth Correctional Facilities, we observed no noticeable safety or security concerns in the occupied rooms of these facilities’ special management housing units. 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 four 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. 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 59 of the total 94 recommendations from these four reports; two recommendations are not applicable. Thus, the department successfully addressed 64 percent of the original recommendations still applicable. • We found in the review of our February 2007 special review of in-prison substance abuse programs managed by the CDCR that the department has substantially implemented all prior recommendations of external evaluators, and the department reported that it collaborates with experts for input regarding program operations. The department also reported that it identified substance abuse treatment contractors who were providing fewer than the required number of program hours and that those contractors have adjusted their schedules to comply with contract terms. In addition, we found that the department has Office of the Inspector General Page 2 2009 Accountability Audit Executive Summary enhanced its ability to foster competition and ensure that the state receives the best value for the price by improving its bidding process for selecting program providers. Our review found that the department fully or substantially implemented 62 percent of the 29 recommendations still applicable from our February 2007 special review. Recommendations that have yet to be fully implemented, however, include issuing annual reports on recidivism for all in-prison substance abuse programs, conducting biannual program reviews, and implementing a continuous quality improvement process. • In assessing our February 2007 special review of the Heman G. Stark Youth Correctional Facility, we found that the facility implemented recommendations to hold staff members accountable for conducting daily inspections of rooms that house wards on restricted programs, and the facility improved its methods of addressing wards’ sexual misconduct toward staff. Our review determined that 63 percent of the 19 recommendations still applicable were fully or substantially implemented. Nevertheless, we found that the Division of Juvenile Justice has yet to define in its policies and procedures a minimum acceptable duration for which restricted program wards are to be allowed out of their rooms. We also found that wards housed in the facility’s “high-risk core treatment units” continue to live under more restrictive conditions than general population wards, but without the specific written protections afforded to wards in special management programs. We visited the facility’s “high-risk core treatment units” in November 2008 and found, just as we reported in February 2007, that wards assigned to these living units typically eat meals in their rooms, are not allowed to attend school in a classroom environment away from the unit, and are released from their rooms for just over two hours daily for recreation and programming time. Thus, these “high-risk core treatment units” do not accomplish the department’s goals for ward services as described by former CDCR Secretary James Tilton when he informed the OIG via letter dated April 24, 2008 that “every ward within the juvenile justice system must be provided a minimum of three hours of ‘out-of-room’ services each day.” • The department and San Quentin State Prison addressed most of the concerns we raised regarding the timely identification of certain inmates, which was the focus of our special review into the department’s release of inmate Scott Thomas from San Quentin. The institution has developed policy and procedure reforms to identify and process inmates with existing warrants, holds, or detainers, and to process the release or parole of high-control inmates. Of the 21 recommendations from our October 2007 report, 67 percent were fully or substantially implemented. • We found in reviewing our December 2007 audit of the California Institution for Women that the institution has fully implemented almost two-thirds of our Office of the Inspector General Page 3 2009 Accountability Audit Executive Summary recommendations, addressing many of the concerns we raised regarding access to and delivery of education services to inmates, processing of use-of-force incident packages, and qualifications of custody staff assigned to armed posts. We found that 65 percent of the 23 recommendations were fully or substantially implemented. In our review of these four audits, we made 31 follow-up recommendations to the CDCR and 2 follow-up recommendations to the California Prison Health Care Receivership Corporation. We expect to review these follow-up recommendations in our 2010 accountability audit. Previous Follow-up Audits Chapter 2 of this report presents the status of recommendations for six reports included in past accountability audits. The department posted an overall implementation rate of 50 percent in carrying out our recommendations remaining from previous years. We found that the department fully or substantially implemented ten recommendations; one is no longer applicable. Notable examples of recommendations implemented since our last accountability audit include the following: • The Division of Juvenile Justice reported that staff members are held accountable for failure to maintain conditions that comply with safety and security standards. According to the division, this is being accomplished through management directives, training, continued oversight and progressive discipline. During our field visits to three youth correctional facilities, we observed no noticeable safety or security concerns in the occupied rooms of these facilities’ special management program units. • The department reports success in reconciling some of the reimbursable union leave time owed by the union representing correctional officers. In addition, since May 2008, the department has billed the California Correctional Peace Officers Association over $2.2 million for union representatives on union paid leave. • Inmates at California State Prison, Solano, with seizure-related conditions are now housed in lower bunks to protect them from fall-related injuries, according to the department. • The California Prison Health Care Receivership Corporation reports that California State Prison, Solano, now has a patient-specific process for pharmacy- filled prescriptions that nearly eliminates stock medications and results in a more controlled inventory. Among the unimplemented recommendations, however, was our recommendation that the department ensure that every officer assigned to an armed post as part of his or her regular or special assignment complete a quarterly weapons proficiency course. In its March 11, 2009 response to the Office of the Inspector General, the department cited its Office of the Inspector General Page 4 2009 Accountability Audit Executive Summary reason for not implementing this recommendation as “difficult operational issues,” such as verifying quarterly compliance before it deploys officers on emergency transports or escape details. We stand behind our recommendation that officers assigned to armed posts complete quarterly firearms qualifications—except for extreme emergencies that warrant the immediate use of force to stop or control a situation. The operational issues cited by the department should not be barriers to a long-term solution that protects the department from potential legal liability should deadly force be required by officers not subjected to quarterly firearms qualifications. The following table summarizes the implementation status of the 114 outstanding recommendations we made to the department in reports issued between 2000 and 2007, 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. Table 1 Results of the 2009 Follow-up Audit Recommendations Assessed in 2009 Follow-up Audit Implementation Results Chapter 1 Total ylluF detnemelpmI yllaitnatsbuS detnemelpmI yllaitraP detnemelpmI toN detnemelpmI elbacilppA toN In-Prison Substance Abuse Programs (2007) 30 9 9 11 1 Heman G. Stark Youth Correctional Facility (2007) 20 5 7 2 5 1 Release of Inmate Scott Thomas (2007) 21 14 4 3 California Institution for Women Quadrennial Audit (2007) 23 15 8 Total 94 43 16 25 8 2 46% 17% 26% 9% 2% Chapter 2 23-and-1 Program Review (2000) 4 2 2 CSP Solano MRA (2003) 2 2 Shooting of Inmate Daniel Provencio (2005) 3 3 Improper Housing of Maximum Custody Inmates (2006) 3 2 1 Management of Union Leave Time (2006) 4 2 1 1 Substance Abuse Treatment Contractors (2006) 4 1 2 1 Total 20 5 5 5 4 1 25% 25% 25% 20% 5% Grand Totals 114 48 21 30 12 3 42% 18% 26% 11% 3% 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 eight 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 Office of the Inspector General Page 5 2009 Accountability Audit Executive Summary 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 in Chapter 2. Nevertheless, we must pursue a few critical recommendations among these unimplemented 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. • 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 department must develop a comprehensive training component that includes training on effectively and safely employing the 40 mm launcher against a moving target and from an elevated position. In addition, the department must ensure that every officer assigned to an armed post as part of his or her regular or special assignment completes a quarterly weapons proficiency course. Office of the Inspector General Page 6 2009 Accountability Audit Introduction Introduction This report presents the results of the OIG’s follow-up audit of ten previous audits and reviews of the CDCR and its subdivisions conducted between 2000 and 2007. 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 three special reviews and one audit completed in 2007. Chapter 2 presents the results from our subsequent follow-up review of recommendations made in six audits and special reviews issued from 2000 through 2006, which we are still tracking. 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 2009–10 estimated the CDCR’s budget for fiscal year 2008–09 to be $10.4 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 40 conservation camps. The Office of the Inspector General Page 7 2009 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 2009–10, the CDCR’s Adult Operations and Adult Education, Vocation, and Offender Programs have an estimated operating budget for fiscal year 2008–09 of $6.2 billion, with 44,003 positions, an average daily population of 156,807 inmates, and a per capita cost of $48,536 a year. The Adult Parole Operations program has an estimated operating budget of $838 million, with 4,387 positions, an average daily population of 125,266 parolees, and a per capita cost of $4,531 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 2008–09 of $544 million with 4,041 positions, and it provides housing and services to an average daily population of 1,717 youths in juvenile facilities and 2,096 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 $232,575 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 8 2009 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 1,734 on December 31, 2008. The dramatic decrease is due in part to legislation that keeps youthful offenders convicted of less serious crimes in their county of commitment while only those committing more serious crimes are remanded to Division of Juvenile Justice facilities. The Governor’s Budget for 2009–10 estimates that the ward population will decline to 1,551 wards by the end of that fiscal year. 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 Chapter 2, we are making this the last accountability audit for those recommendations made in past reports that have previously undergone follow-up work. Chapter 1 of this 2009 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 In-Prison Substance Abuse Programs Managed by the California Department of Corrections and Rehabilitation (February 2007) • Special Review of High-Risk Issues at the Heman G. Stark Youth Correctional Facility (February 2007) • Special Review into the California Department of Corrections and Rehabilitation’s Release of Inmate Scott Thomas (October 2007) Office of the Inspector General Page 9 2009 Accountability Audit Introduction • The California Institution for Women Quadrennial and Warden Audit (December 2007) 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. In Chapter 2 of this report, recommendations related to the remaining six audits have been included in previous accountability audits. The six audit reports were originally published between 2000 and 2006. Audit Procedures To conduct this follow-up audit, we performed the following procedures: • Reviewed ten audits and reviews of the CDCR’s facilities and programs conducted by the OIG between 2000 and 2007. • 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 114 recommendations from the previous ten 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 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. Office of the Inspector General Page 10 2009 Accountability Audit Introduction 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. The original ten reports covered in this follow-up accountability audit had issue dates ranging from December 2000 through December 2007. 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 October 29, 2008. One response due from the medical receiver’s office (not a CDCR entity) was not received until December 23, 2008. In total, the department and the receiver’s office responded on the status of 114 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. 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. Audit fieldwork was performed from November 2008 through December 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 18, 2008. In such cases, the corrective action would not be reflected in this report. Office of the Inspector General Page 11 2009 Accountability Audit Chapter 1 Chapter 1: Initial Follow-up Results for Four Reports Issued in 2007 This chapter presents the status of our initial recommendations for the following four reports: • Special Review into In-Prison Substance Abuse Programs Managed by the California Department of Corrections and Rehabilitation (February 2007) • Special Review of High-Risk Issues at the Heman G. Stark Youth Correctional Facility (February 2007) • Special Review into the California Department of Corrections and Rehabilitation’s Release of Inmate Scott Thomas (October 2007) • The California Institution for Women Quadrennial and Warden Audit (December 2007) Summary of Results Within these four reports, we provided the CDCR with 94 recommendations. Key recommendations included holding staff accountable for inspecting rooms housing wards on restricted programs and for administering appropriate sanctions against wards who violate contraband rules, providing timely identification of dangerous inmates, and offering more consistent education opportunities to inmates. Overall, we found that the department has fully or substantially implemented 59 of the 94 recommendations, with two recommendations not applicable. The remaining recommendations were either partially implemented or not implemented. In this report, we made 33 follow-up recommendations that we anticipate reviewing in our 2010 accountability audit. Table 2 summarizes the results of our audit of the 94 recommendations; a brief description of each report’s findings follows the table. Table 2 Summary of Initial Follow-up Results Fully Substantially Partially Not Success Report N/A Total Implemented Implemented Implemented Implemented Rate* In-Prison Substance Abuse 9 9 11 1 30 62% Programs Heman G. Stark Youth Correctional 5 7 2 5 1 20 63% Facility Release of Inmate Scott Thomas 14 4 3 21 67% California Institution for Women 15 8 23 65% Quadrennial Audit Total 43 16 25 8 2 94 64% *Success rate is the percentage of recommendations fully or substantially implemented compared to the total recommendations still applicable. Office of the Inspector General Page 12 2009 Accountability Audit Chapter 1 In-Prison Substance Abuse Programs Besides placing the in-prison substance abuse programs under a new Undersecretary of Programs and Chief Deputy Secretary of Programs, the department has taken several steps to improve management of in-prison substance abuse programs. We found that the department has substantially implemented all prior recommendations of external evaluators. The department reported that it collaborates with expert-member groups for input regarding program operations, and it plans to launch a pilot project at California State Prison, Solano, which will allow the department to assess the effectiveness of its expanded treatment model. The department also reported that it identified programs in which program hours fall short of contract requirements; the department required those contractors to adjust their schedules to meet those requirements. In addition, we found that the department has enhanced its ability to foster competition and ensure that the state receives the best value for the price by improving the department’s bidding process for selecting program providers. Other recommendations have yet to be fully implemented. These include defining successful completion of an in-prison substance abuse program to determine aftercare eligibility, issuing annual reports on recidivism outcomes for all in- prison substance abuse programs, conducting biannual program reviews, and implementing a continuous quality improvement process. Heman G. Stark Youth Correctional Facility The facility implemented recommendations we made concerning staff accountability for daily inspections of rooms housing wards on restricted programs and for administering appropriate sanctions against wards who violate rules regarding contraband, room condition, and destruction of state property. The facility also improved its methods for addressing sexual misconduct by wards toward staff. Despite these significant improvements, we found that both the Division of Juvenile Justice and the facility have yet to fully implement other important recommendations. For example, the division has not yet defined in its policies and procedures a minimum acceptable duration for which restricted program wards are to be allowed out of their rooms. In addition, instead of refining its policies and procedures to clearly define uniform minimum standards for safe living quarters for wards in restricted programs, the division allowed each facility to develop local policies and procedures. Finally, neither the division nor the facility acknowledges that restrictions placed on certain wards are tantamount to an extension of the special management program. Therefore, they chose not to implement our recommendations to include those wards within the same policy protections accorded to wards in the special management program. Release of Inmate Scott Thomas The department and San Quentin State Prison have addressed most of the concerns we raised [confidential text removed]. The department further reported that it assembled a team from department headquarters to conduct a compliance review of specific areas in the case records office of San Quentin’s reception center. We confirmed the institution’s Office of the Inspector General Page 13 2009 Accountability Audit Chapter 1 report that it took appropriate action against specific individuals involved in the early release of inmate Thomas. Further, San Quentin added procedures to its parole and checkout process for high-control inmates. California Institution for Women Quadrennial Audit CIW reported substantial progress in addressing the weaknesses related to its inmate education program. It reported that it had reorganized education staff to provide more consistent classroom opportunities to inmates. The institution also reported that it has established a new tracking system to monitor the timeliness of reports on incidents involving the use of force, thus addressing concerns we raised about such reports being submitted late. Finally, we confirmed that corrective actions have been effective in resolving the issue of officers who work in armed posts but fail to receive required weapons qualifications. Follow-up Recommendations In our review of the four audits, we made 33 follow-up recommendations to the CDCR. We will review these follow-up recommendations in our 2010 accountability audit. The following table presents the page numbers for the four sections in which we present a complete discussion of each report, including the findings, recommendations, and results of our follow-up audit: Report Title Number of Follow-Up Page Number Recommendations In-Prison Substance Abuse Programs (2007) 11 15 Heman G. Stark Youth Correctional Facility (2007) 7 42 Release of Inmate Scott Thomas (2007) 7 66 California Institution for Women Quadrennial Audit 8 78 (2007) Office of the Inspector General Page 14 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Special Review into In-Prison Substance Abuse Programs Managed by the California Department of Corrections and Rehabilitation We found that the department has begun remaking its substance Implementation abuse treatment programs for inmates and parolees, while Report Card considering recommendations of experts and external evaluators. The department has improved its ability to foster 2007 Recommendations: 30 competition for in-prison substance abuse programs by improving its contracting process. The department reported that it identified contractors who were providing fewer than the Fully Implemented: 9 (30%) required number of program hours and that those contractors have adjusted their schedules to comply with contract terms. Substantially Implemented: However, the department has only partially implemented all of 9 (30%) our recommendations for monitoring contractors and measuring Partially Implemented: the performance of substance abuse programs. 11 (37%) Not Implemented: 0 (0%) Summary Not Applicable: 1 (3%) In February 2007, we issued a special review1 into the in-prison substance abuse programs managed by the California Department of Corrections and Rehabilitation. The review assessed whether the department adequately manages its in-prison substance abuse programs and obtains the best value from the contractors who provide program services on its behalf. The review focused on whether program participants receive contracted services; whether the Office of Substance Abuse Programs2 adequately monitors contractor performance; and whether it uses a competitive bidding process to select contractors. The review found that the department has spent more than $1 billion to provide substance abuse treatment services to California inmates and parolees since 1989, but the programs have been ineffective at reducing the recidivism rates of participants. In reaching this conclusion, we found that poor program management has contributed to the substance abuse treatment program’s failure. A key shortcoming is the inability to achieve a “therapeutic community” within the in- prison treatment programs even though the department requires its contractors to use the therapeutic community model. Further, the department has placed many of the programs in facilities ill-suited to the therapeutic community model, and it has failed to hold contractors accountable for delivering the essential components of the therapeutic community model. The review also found that the process used to select contractors restricts bidders to minimum and maximum amounts differing by only 5 percent—a flaw that can eliminate the best-qualified 1 “Special Review into In-Prison Substance Abuse Programs Managed by the California Department of Corrections and Rehabilitation” may be found on the OIG’s Web site: http://www.oig.ca.gov/media/reports/BAI/reviews/Review_2007-02%20In- Prison%20Substance%20Abuse%20Programs%20Managed%20by%20the%20Department%20of%20Corrections% 20and%20Rehabilitation,%20Special%20Review%20Into.pdf 2 The former Office of Substance Abuse Programs is now known as the Division of Addiction and Recovery Services. Office of the Inspector General Page 15 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs candidates. In addition, the review found that contractors were allowed to shift funds from personnel budgets to operating budgets even though most of the contractors lacked the required number of counselors. Finally, the review found that many of the substance abuse treatment program’s problems had been identified before, either by external university researchers or by the Office of the Inspector General. Background Established in 1989 to develop and manage alcohol and drug programs for inmates as a means of reducing recidivism, the Office of Substance Abuse Programs so far has spent more than $1 billion to provide substance abuse treatment services to California inmates and parolees. More than $278 million of the total has been devoted to in-prison treatment. The Office of Substance Abuse Programs budgets $143 million a year for substance abuse treatment services, including in-prison treatment for state prison inmates and community-based aftercare for inmates who have paroled. The in-prison treatment services, which account for about 25 percent of the $143 million annual budget—$36 million a year—are provided through 38 programs at 22 correctional institutions statewide. The programs have the capacity to provide services to about 9,200 inmates and are operated by private providers under contracts managed by the Office of Substance Abuse Programs. An estimated 78,000 California inmates received in-prison treatment services from the program’s inception in 1989 through fiscal year 2005-06. Previous Findings and Recommendations We made 30 recommendations to the department. Among these, we recommended that it address recommendations identified by external evaluators, issue annual public reports of recidivism outcomes for all in-prison substance abuse programs, and address the high turnover in the leadership of the Office of Substance Abuse Programs. We also recommended that the department require the Office of Substance Abuse Programs to ensure that contractors for in- prison treatment programs provide the required hours of program activities and minimize disruptions to the delivery of program services by isolating program participants from general population inmates. In addition, we recommended that the department reevaluate the substance abuse program contracting process, increase competition for in-prison substance abuse program contracts, improve monitoring and spending control over substance abuse program contracts, clearly describe the specific participant data elements needed for program evaluation, and implement a continuous quality improvement process for in-prison treatment programs. Office of the Inspector General Page 16 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs 2009 Follow-up Results The department has taken several steps to improve its management of in-prison substance abuse programs. Besides elevating the program’s placement in the department and appointing new management, we found that the department has considered all the prior recommendations of the external evaluators and has obtained a legal opinion to clarify the number of drug treatment beds that the department must maintain. The department also reported that it collaborates with expert groups regarding program design, operations, assessments, and pilot programs, as well as how to ensure effective delivery of services. The department indicated that it plans to launch a pilot project in December 2008 at California State Prison, Solano, which will allow the Division of Addiction and Rehabilitation Services (DARS) to implement and assess the effectiveness of the expanded treatment model. While these changes represent significant steps toward improvement, the department should continue to remake its substance abuse programs for inmates and parolees with the recommendations of experts. Other recommendations have yet to be fully implemented, including defining successful completion of an in-prison substance abuse program to determine aftercare eligibility, and issuing annual reports on recidivism outcomes for all in-prison substance abuse programs. The department also reported that it identified programs where the program hours fell short of the contract requirements, and the department required those contractors to adjust their schedules to meet contract requirements. However, the department has only partially implemented a system to monitor contractor compliance. In addition, we found that the department has increased its ability to foster competition and ensure that the state receives the best possible value for the lowest price by improving the bidding process that it uses to select providers for in-prison substance abuse programs. Specifically, the department has followed state contracting rules regarding required documentation when fewer than three bids are received, and it has changed its requests for proposals to eliminate the minimum and maximum bid amounts. The department has also revised its bid scoring process by giving the bid price a weighting of 30 percent of the maximum points possible in scoring competitors’ bids. The department continues to evaluate the process for substance abuse program contracting. We also found that the department ensured that appropriate checks and balances exist in the process contractors use to request transfers of funds among budget categories. The department has reinforced its policies and procedures in this area by training managers and analysts who review contractors’ requests to transfer funds. The department has also clarified in its line-item budget guide that contractors must maintain a list of equipment purchased with state funds and leave all equipment and supplies on termination of their contract. Finally, the department has clarified the specific participant data that program contractors must maintain and report, but has only partially implement several of our recommendations on holding the contractors accountable for compliance with contract terms. These recommendations include conducting biannual reviews of programs, implementing a continuous quality improvement Office of the Inspector General Page 17 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs process, and including provisions in its contracts that allow the department to obtain intermediate remedies for non-compliance. Follow-up Recommendations While the department has made progress, some recommendations were not fully or substantially implemented as a result of our 2009 follow-up audit. Accordingly, the OIG recommends that the California Department of Corrections and Rehabilitation: • Continue designing and implementing substance abuse treatment programs for inmates and parolees based on input and recommendations of substance abuse treatment experts and other expert-member groups. (February 2007) • Define successful completion of an in-prison substance abuse program, such as number of hours or required participation or other specific achievements participants must attain for purposes of determining aftercare eligibility. (February 2007) • Issue annual public reports that identify both short-term and long-term recidivism outcomes for all in-prison substance abuse programs. (February 2007) • Ensure that the Division of Addiction and Recovery Services specifies in contracts with program providers the minimum number of encounter group hours that each contractor must provide each week or month and institute a system to monitor contractor compliance. (February 2007) • Cease operating the substance abuse program at locations where security or custody reasons prevent the department from completely isolating participating inmates, or if lockdowns continue to have a significant impact on a program even when its participants are isolated, and redirect its funding for use in other programs. (February 2007) • Reevaluate the substance abuse program contracting process. If the department elects to use a different contracting method to correct the deficiencies noted in this finding, the Office of the Inspector General recommends that the department establish a cross- functional team consisting of the Department of General Services, the Division of Addiction and Recovery Services, the department’s contracting unit, and other contracting experts to consider the invitation for bid, primary request for proposal, or other alternative contracting methods. (February 2007) • Ensure that the Division of Addiction and Recovery Services follow its policy requiring it to conduct biannual compliance reviews of its in-prison substance abuse programs and consider the results of those reviews in future contracting decisions. (February 2007) • Include intermediate remedies that would allow it to enforce contractor compliance in future contracts. (February 2007) Office of the Inspector General Page 18 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Implement a continuous quality improvement process that includes the following steps: • Identify the best and worst practices among the in-prison substance abuse program providers and ensure that poor-performing providers take corrective action to change their programs and adopt applicable, successful practices of the top-performing providers. (February 2007) • Identify pertinent measures of performance and methods of capturing and analyzing key information. (February 2007) • Conduct regular meetings with program providers to share best practices and pertinent performance measures. (February 2007) The matrixes on the following pages summarize the results of the 2009 follow-up audit. Office of the Inspector General Page 19 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Special Review into In-Prison Substance Abuse Programs Managed by the California Department of Corrections and Rehabilitation Finding 1 Numerous studies show that despite an annual cost of $36 million, the Department of Corrections and Rehabilitation’s in-prison substance abuse treatment programs have little or no impact on recidivism. Moreover, the department has had this information for years, but has failed to correct deficiencies identified by the studies and instead continues to open new programs. (February 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Due to the enormity of these problems, the Office of the Partially California Department of Corrections and Rehabilitation’s response: Inspector General recommends that the administration Implemented Partially Implemented. The Division of Addiction and Recovery Services convene a broad-based task force of substance abuse (DARS) has been engaged in CDCR’s system-wide shift of prioritizing and treatment experts, lawmakers, policy analysts, corrections improving rehabilitation services for offenders and parolees. DARS has officials, and stakeholders from across the political worked to remake substance abuse treatment programs within the context of spectrum to remake California’s substance abuse treatment these Department-wide changes. DARS did not convene a task force, but programs for inmates and parolees from the ground up. instead has received recommendations, input, and strategies to improve (February 2007) substance abuse treatment from several expert-member groups. These groups include the CDCR Expert Panel on Adult Offender and Recidivism Reduction Programming, and the Governor’s Rehabilitation Strike Team. DARS is actively engaged in modifying programs to incorporate the framework outlined in the California Logic Model for the future of substance abuse treatment services. DARS is developing a five-year plan based on the recommendations of these expert groups to address CDCR’s need for various levels of substance use disorder treatment to inmates and parolees. Service delivery will take a science-based, collaborative and integrated approach with other treatment areas including education, vocation, mental health, etc. DARS will launch a pilot project at California State Prison, Solano in December 2008. The Solano Project will allow the Division to implement and assess the effectiveness of its expanded treatment model, which includes strategies such as risk-needs assessments, risk-needs responsive treatment services, and integrated treatment Office of the Inspector General Page 20 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments services. DARS also collaborates with other expert member groups including the Treatment Advisory Committee (TAC) and the Policy Advisory Committee (PAC). DARS assembled the TAC, a group of substance-abuse treatment experts for day-to-day input regarding program design, program operations, pilot programs, and program assessments. The Policy Advisory Committee (PAC) includes senior officers from contracted service providers. Meetings of the PAC are convened by the DARS Director on a quarterly basis or as needed. PAC and DARS collaborate to ensure effective delivery of treatment services and to share best practices. These expert groups have provided significant feedback to DARS, such as recommendations for appropriate primary and secondary risk-needs assessments and modifications to the therapeutic community (TC) model for the in-prison setting. In addition, recommendations from these groups have informed the Division’s approach to providing Gender-Responsive and Trauma Informed Treatment for female offenders. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Immediately implement corrective actions to change the Substantially California Department of Corrections and Rehabilitation’s response: in-prison substance abuse programs and address Implemented Substantially Implemented. Attachment B in the Proof of Practice (POP) recommendations identified by external evaluators. The responds to all recommendations made by prior evaluators. Major actions should include the following: recommendations are as follows: • Develop a response and corrective action plan to Reduce program size: While DARS has reduced the size of treatment groups, address past recommendations identified by external the primary focus remains treatment quality. New modulars will increase evaluators. The plan should address every programming space and allow for treatment staff to provide one-on-one recommendation and, when necessary, include an counseling services in addition to group programs. DARS will continue to use explanation why a recommendation cannot be the Treatment Advisory Committee (TAC) to consider alternatives and address implemented. (February 2007) needed program improvements. Factors such as frequency of lockdowns, site location, and staff availability will be considered. Staff retention: In-prison Substance Abuse Program (SAP) contract renewals Office of the Inspector General Page 21 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments and AB 900 expansion contracts include salary increases. This is meant to improve staff retention. DARS has also challenged providers by adding performance measures that include staff retention. Participant recruitment: DARS actively solicits eligible inmates to volunteer for SAP programs. DARS also recognizes the importance of engaging non- voluntary participants in treatment. Inmates who do not volunteer for programs can still benefit from substance abuse treatment. Several incentive based programs have also increased participation in the continuum of in- prison to community based treatment services. Mandate Aftercare: Aftercare was mandated for two programs: Mandatory Conditions of Parole (MCOP), a pilot project for qualifying SAP parolees and SB 1453. Aftercare is also mandated for Civil Narcotic Addicts. In addition, there have been significant increases in voluntary aftercare participation. In fiscal year 2007-2008, the need for aftercare treatment exceeded the allocated funding. DARS is only budgeted to fund 50% of SAP participants in continuing care programs. Needs-assessment: The COMPAS will be used as an initial screening tool. The Addiction Severity Index (ASI) and the Texas Christian University, Clinical Evaluation of Self and Treatment (TCU-CEST) have been identified as potential secondary substance abuse disorder assessment tools. Secondary assessments will be used to establish case management and individual treatment plans for participants. Progress assessment: DARS’ expanded treatment model calls for individualized treatment plans for all SAP participants. Progress assessments will be administered regularly (as specified by the contract) and as needs arise to modify participants’ treatment plans. Therapeutic community: DARS operates a modified therapeutic community (TC) structure, recognizing that there are many barriers to operating a true TC model in correctional settings. Furthermore, aspects of the TC model did not follow best practices for Trauma Informed and Gender Responsive treatment practices for female offenders, such as the use of encounter groups. DARS is exploring other models of treatment that would be based on the severity of Office of the Inspector General Page 22 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments addiction and treatment needs of offenders. Office of the Inspector General’s comments: We reviewed the department’s response to prior evaluations and found that the response substantially addresses all the issues identified. The response also describes related corrective actions that the department has either implemented or plans to implement, or it explains why the department has not taken corrective action. • Identify the appropriate internal and external parties Fully California Department of Corrections and Rehabilitation’s response: that should receive the external evaluators’ reports, Implemented Fully Implemented. All evaluation reports are reviewed by the CDCR’s the responses to the reports, and the corrective action Secretary. Most reports are also distributed to the Legislature and the plans. (Internal parties should be of a sufficient level Governor’s office. TAC and the center for Criminal Justice Research at the within the department to ensure corrective action is University of California, Irvine (UCI) will also be included in the review of completed. External parties should include relevant future evaluation reports. legislative oversight and budget committees.) (February 2007) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Prepare a timely response and corrective action plan Substantially California Department of Corrections and Rehabilitation’s response: and submit those documents to the parties identified Implemented Substantially Implemented. DARS will prepare corrective action plans in above for all future evaluations of the in-prison response to all future evaluations. These reports will be disseminated to the substance abuse programs. (February 2007) appropriate parties in a timely manner. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • For purposes of determining aftercare eligibility, Partially California Department of Corrections and Rehabilitation’s response: define successful completion of an in-prison substance Implemented Partially Implemented. A definition of “successful completion” of an in-prison abuse program, such as number of hours or required substance abuse program was proposed to assess non-serious, non-violent, participation or other specific achievements non-sex offenders under SB 1453. This definition is currently under review by participants must attain. (February 2007) the Office of Administrative Law (OAL). The proposed definition requires that the Successful Completion Assessment Team (SCAT) determine completion based on several guidelines: time in program, participation in program, performance in program and accomplishment of treatment plan objectives. The Office of the Inspector General Page 23 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments SCAT includes members from the DARS CCIII, the SAP PAII and the SAP treatment staff. While these indicators help assess eligibility for aftercare, DARS recognizes that substance abuse addiction is a chronic condition and requires ongoing treatment. Participants never fully “complete” treatment, as recovery is a continuous process. Research demonstrates reductions in recidivism when participants receive 90 days of continuing care services following successful participation in an in-prison substance abuse treatment program. The goal of the Division is to enroll as many of its eligible SAP participants into continuing care services as possible. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Issue annual public reports that identify both short-term Partially California Department of Corrections and Rehabilitation’s response: and long-term recidivism outcomes for all in-prison Implemented Partially Implemented. DARS will coordinate with the Department’s Office of substance abuse programs. (February 2007) Research to prepare and distribute annual program performance reports that include return to custody rates at 12 and 24 months. In April 2008, DARS worked with the Department’s Office of Audits and Compliance (OAC) to develop a reporting tool on DARS’ program performance and return to custody rates. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Review the Office of Substance Abuse Programs’ Fully California Department of Corrections and Rehabilitation’s response: placement within the department’s organizational structure Implemented Fully Implemented. CDCR has modified its organizational structure. The to ensure that the placement is consistent with the scrutiny Office of Substance Abuse Programs (OSAP) was renamed to the Division of and attention needed to effectively manage and oversee the Addiction and Recovery Services (DARS) and was given elevated status within department’s substance abuse treatment programs. the Corrections Agency. (February 2007) Office of the Inspector General’s comments: In 2007, the department elevated addiction and recovery services to division level within the department. Office of the Inspector General Page 24 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments Appoint a qualified, results-oriented manager to head the Fully California Department of Corrections and Rehabilitation’s response: Office of Substance Abuse Programs and provide the Implemented Fully Implemented. A former director of the California Department of Alcohol support and resources the manager requires to carry out and Drug Programs has been appointed as Undersecretary of Programs, who necessary program changes. (February 2007) directly oversees DARS and other divisions operating adult offender programs. A Chief Deputy Secretary of Adult Programs with extensive health and welfare agency experience including substance abuse and mental health treatment services was also appointed to coordinate and oversee all rehabilitative programming including education, vocation, substance abuse treatment, anger management, and criminal thinking and life skills. DARS is now a full division rather than an office and is led by a Director, who brings substantial experience in the field of substance abuse treatment. Office of the Inspector General’s comments: In February 2007, the Governor appointed a new director of the Division of Addiction and Recovery Services, formerly known as the Office of Substance Abuse Programs. The Office of Substance Abuse Programs should: Obtain a legal opinion from the department’s general Fully California Department of Corrections and Rehabilitation’s response: counsel or the Attorney General to clarify whether the Implemented Fully Implemented. Prior to the passage of AB 900, CDCR legal opinion was department must maintain at least 9,000 in-prison drug that the Department is not bound to maintain a minimum of 9,000 beds, treatment beds as provided in Government Code section assuming that CDCR assess the, “demand, necessity, effectiveness and priority 15819.295(c). (February 2007) of having therapeutic drug bed slots and then determine how many beds are necessary.” After the passage of AB 900, DARS obtained a legal opinion from the Office of Legal Affairs recommending that, “CDCR maintain a minimum of approximately 13,000 substance abuse treatment beds even after AB 900 is fully implemented.” This position is based on the fact that the 4,000 new beds mandated in AB 900 are in addition to the 9,000 beds in existence prior to AB 900. Office of the Inspector General’s comments: We reviewed the July 20, 2007, legal opinion prepared by the department’s Office of Legal Affairs. Office of the Inspector General Page 25 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Follow-up Recommendations The California Department of Corrections and Rehabilitation should take the following actions: • Continue designing and implementing substance abuse treatment programs for inmates and parolees based on input and recommendations of substance abuse treatment experts and other expert-member groups. (February 2007) • For purposes of determining aftercare eligibility, define successful completion of an in-prison substance abuse program, such as number of hours or required participation or other specific achievements participants must attain. (February 2007) • Issue annual public reports that identify both short-term and long-term recidivism outcomes for all in-prison substance abuse programs. (February 2007) Office of the Inspector General Page 26 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Finding 2 Responsibility for the failure of the state’s $36 million in-prison substance abuse treatment programs rests with the Department of Corrections and Rehabilitation because it fails to hold providers accountable for meeting contract terms and places the programs in prison settings that undermine the treatment model. (February 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Require the Office of Substance Abuse Programs to ensure Substantially California Department of Corrections and Rehabilitation’s response: that in-prison substance abuse program contractors provide Implemented Substantially Implemented. A survey was conducted of all program activity in the required 20 hours of weekly group and individual July 2008. Eight programs were found to be out of compliance with contracted activities and access to six additional hours of activities six hours. All eight programs have adjusted their schedules to meet the contracted days per week by taking the following actions: requirements. No exceptions were granted. • Identify each program location where the program Office of the Inspector General’s comments: hours fall short of the contract requirements. Once The OIG performed no audit procedures to validate the eight contractors’ identified, either require the contractors to comply efforts to adjust their schedules to meet contract requirements. with the contract requirements or consider granting the contractor a written exception. (February 2007) • Before granting a written exception to any identified Substantially California Department of Corrections and Rehabilitation’s response: program, assess whether the program can successfully Implemented Substantially Implemented. DARS conducted assessments of programs in July operate with fewer hours at that location. If necessary, 2008. No exceptions were granted. Contracts will be reviewed as they become redirect the program funds to a more amenable eligible for renewal to determine appropriate adjustments in funding or location. (February 2007) possible relocation. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Ensure that the Office of Substance Abuse Programs Partially California Department of Corrections and Rehabilitation’s response: specifies in contracts with program providers the minimum Implemented Partially Implemented. The goal of DARS is to implement a science-based, number of encounter group hours that each contractor must collaborative and integrated approach to service delivery. Such services provide each week or month and institute a system to include but are not limited to: TC, Cognitive Behavioral Therapy (CBT), monitor contractor compliance. (February 2007) Psycho-Educational Treatment and Interventions, Trauma Informed and Office of the Inspector General Page 27 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments Gender Responsive Treatment strategies, 12 step programs, relapse prevention, and self-help groups. These models seek to build social support networks as opposed to “encounter group sessions”, which can employ a confrontational approach to treatment. Research shows that confrontational groups are not effective with many populations, including females and young adults, whereas treatment environments based on safety, respect, and dignity are fundamental to motivating behavioral change. RFPs for new contracts and contract renewals, beginning for contracts awarded in June 2008, require treatment providers to provide a minimum of 20 hours of group or face-to-face treatment per week. In addition, treatment providers must offer 6 hours of optional individual or group activity. DARS has implemented several contract monitoring systems to assure compliance. A monthly Contractor Report is sent to DARS from each program each month. Also, a monthly Site Visit Report has been implemented for reporting on contract compliance in each location (this report is completed by a headquarters-based analyst after visiting each site). A more in-depth review (Program Design and Assessment Team, PDAT concept) was implemented in January, 2007. The PDAT and monthly Site Visit Report were replaced in October 2008 by an improved compliance measurement tool – the Program Accountability Review (PAR). Contract compliance and performance will be measured by the PAR and exceptions will be considered on a case-by-case basis. Programs will be adjusted or terminated if contract non-compliance or failure to meet performance expectations persists. In addition to internal DARS monitoring tools, DARS will enforce contract compliance using CDCR tools. The Performance Accountability and Improvement Process (PAIP) is a performance-based budget allocation and accountability process for all in-prison rehabilitative programming. The PAIP aims to create statewide standards for the approach, structure, and process of rehabilitative programming. It also establishes equitable and accountable performance targets and allows CDCR to monitor achievement of these defined outcomes. The PAIP process was developed by Adult Programs, in collaboration with the Division of Adult Institutions (DAI) and Financial Services and became effective FY2008-09. Office of the Inspector General Page 28 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments CDCR’s Office of Program Policy Development and Fidelity will also conduct periodic evaluations of all CDCR Divisions. The Correctional Program Checklist (CPC) will be administered to assure compliance with the Department’s rehabilitation strategies outlined in the California Logic Model. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Minimize disruptions to the delivery of services provided Not California Department of Corrections and Rehabilitation’s response: by in-prison substance abuse programs caused by Applicable Not Applicable. DARS began tracking lockdown data on a weekly basis at lockdowns and the contaminating influence of the prison correctional facilities where contractors administer programs in June 2007 and culture on inmates participating in the eight programs released official reports beginning in August 2007. These reports are shared described in this finding by taking the following actions: with appropriate staff at DARS. DARS also worked with Wardens to implement alternatives to lockdowns and avoid barriers to programming. For example, • Completely isolate inmates participating in the lockdowns are isolated to applicable populations when feasible, allowing substance abuse programs from general prison participants engaged in treatment to continue receiving services. population inmates. (February 2007) Currently, only program participants at Substance Abuse Treatment Facility (SATF) and at Folsom Transitional Treatment Facility (FTTF) are completely isolated from the general population inmates. The current direction of the Department is to create integrated treatment yards. DARS is working in collaboration with the Division of Education, Vocations and Offender Programs (DEVOP), Division of Community Partnerships (DCP), and CDCR leadership to provide integrated treatment programs. The future treatment model will utilize risk and needs assessments and assign inmates to yards based on their programming needs. The new treatment delivery model will be implemented at California State Prison Solano. The Level II yard will be restructured so that all 1200 inmates will receive integrated rehabilitative services including vocational training, education, mental health, anger management, criminal thinking, life skills and/or substance abuse treatment based on each inmate’s risks and needs. A portion of inmates will participate in substance abuse treatment programs. The Solano project is scheduled to begin in December 2008. Office of the Inspector General Page 29 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • In locations where security or custody reasons prevent Partially California Department of Corrections and Rehabilitation’s response: the department from completely isolating participating Implemented Partially Implemented. DARS sent teams to conduct site visits and assessments inmates, or if lockdowns continue to have a significant at all seven institutions identified by the OIG. DARS administration has impact on a program even when its participants are relocated or modified programs at several sites, while several institutions are isolated, the department should cease operating the under continued monitoring. Attachment J shows the specific actions that have substance abuse program at that location and redirect been taken and the current status at each of these sites. [The referenced its funding for use in other programs. (February 2007) attachment is not included as a part of this accountability audit report.] 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: • Ensure that the Division of Addiction and Recovery Services specifies in contracts with program providers the minimum number of encounter group hours that each contractor must provide each week or month and institute a system to monitor contractor compliance. (February 2007) • In locations where security or custody reasons prevent the department from completely isolating participating inmates, or if lockdowns continue to have a significant impact on a program even when its participants are isolated, the department should cease operating the substance abuse program at that location and redirect its funding for use in other programs. (February 2007) Office of the Inspector General Page 30 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Finding 3 The bidding process used by the Office of Substance Abuse Programs to select in-prison substance abuse program providers neither fosters competition nor ensures that the state receives the highest quality services for the lowest possible price—or the best value for the $144 million represented in the current multiple-year contracts. Elements of the process also violate state contracting law. (February 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Completely reevaluate the substance abuse program Partially California Department of Corrections and Rehabilitation’s response: contracting process. If the department elects to use a Implemented Partially Implemented. The current RFP process is being used to correct and different contracting method to correct the deficiencies update future contracts with more clarity about deliverables and performance noted in this finding, the Office of the Inspector General measures which will be evaluated and tracked regularly. In an effort to explore recommends that the department establish a cross- other changes in the process, DARS sent a letter to the Chief of Contract functional team consisting of the Department of General Services requesting establishment of a team for the following purposes: Services, the Office of Substance Abuse Programs, the department’s contracting unit, and other contracting a) Review DARS current bidding process experts to consider the invitation for bid, primary request b) Solicit more bidders for proposal, or other alternative contracting methods. c) Establish effective rating/review committee (February 2007) d) Better handling of protest issues e) Minimize any ability contractors may have to manipulate scoring f) Expedite entire bidding process In Spring 2008, DARS renewed contracts for 10 of its existing in-prison SAPS. DARS also began developing 8 new contracts to establish the 2,000 beds in AB 900. Changes will continue as future progress is made with these issues. DARS staff met with Contract Management Branch Services staff on September 3rd, 2008 to discuss the above issues. DARS is exploring the Invitation For Bid (IFB) process as one alternative to the RFP process. The IFB would eliminate the need for review teams and would also eliminate the possibility of protests. DARS is also exploring alternative procurement processes such as master services agreements and solicitations to public entities. Office of the Inspector General Page 31 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments DARS is meeting regularly with the Department of General Services (DGS). In May and June 2008, DARS met with the Legal and Procurement offices and discussed the unique nature of DARS contracts. DGS legal said that DARS should enter into multi-year contracts with options to continue based on performance. DARS should require multiple bids for contracts to anticipate growth during term of the contract. DARS will continue to work with DGS to adopt appropriate contracting strategies. DARS will also be involved in a State-wide CDCR Community Rehabilitation Service Provider Forum. The forum will allow community providers to offer feedback on how to improve current contracting procedures including the expansion of a regional approach. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Increase competition for its in-prison substance abuse Fully California Department of Corrections and Rehabilitation’s response: program contracts, and ensure that the state receives the Implemented Fully Implemented. The minimum and maximum bid amounts were removed best value for those services by taking the following from the July 2007 RFP for the Leo Chesney Substance Abuse Program. In actions: addition, DARS eliminated minimum and maximum bid amounts for RFPs released in March 2007 for community based treatment services. • Eliminate the minimum and maximum bid amounts from future requests for proposal for in-prison After taking these immediate actions, DARS conducted a detailed revision of all substance abuse programs. (February 2007) in-prison SAP RFPs. The revised RFPs were released in March 2008 for the in-prison program contract renewals (male and female programs) and were awarded in June 2008. These revised RFPs will also be used for new contracts. The minimum and maximum bid amounts were removed. Instead, DARS solely specifies the annual budget for each contract. Office of the Inspector General’s comments: We reviewed the March 2008 revised request for proposal (RFP) for in-prison substance abuse program contracts and found that the department has eliminated the minimum and maximum bid amounts. • Assign enough weight to bid prices when evaluating Fully California Department of Corrections and Rehabilitation’s response: bids so that at least 30 percent of the score is based Implemented Fully Implemented. As a result of the revised RFPs, bid prices now represent at on price and consider past performance when least 30% of the rating score for all contract renewals and new contracts. In appropriate. (February 2007) addition, bidders are rated on their demonstrated qualifications of developing, Office of the Inspector General Page 32 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments implementing, and operating programs in a correctional environment. Office of the Inspector General’s comments: We reviewed the scoring criteria in the department’s RFP for in-prison substance abuse treatment program contracts and determined that bid price represents 30 percent of the maximum available points. In addition, bidders are required to provide two letters of recommendation from the warden, chief executive officer, senior director, or head administrator from an institution for which the bidder is currently providing substance abuse program services or has provided services in the past five years. • Ensure that when fewer than three bids are received, Fully California Department of Corrections and Rehabilitation’s response: the Office of Substance Abuse Programs prepares Implemented Fully Implemented. DARS uses STD 215 Agreement Summary form for all an explanation and a justification of the contracts. CDCR Contracts Services confirmed that if there are less than three reasonableness of the contract price. These bidders, Section 15 of this form must include a justification of why the Division documents should be retained in the department’s did not submit the RFP for rebid. contract file. (February 2007) Office of the Inspector General’s comments: We interviewed department contract staff and Department of General Services’ legal counsel, and we reviewed the STD 215 for the five June 2008 contracts for in-prison substance abuse treatment services for which the department received fewer than three bids. We found that for each contract, the STD 215 indicated that the department justified the reasonableness of the contract price and took reasonable efforts to inform all potential bidders of the bid opportunities. Therefore, the department did not intentionally limit the number of bids it received. Follow-up Recommendation The California Department of Corrections and Rehabilitation should continue to reevaluate the substance abuse program contracting process. If the department elects to use a different contracting method to correct the deficiencies noted in this finding, the Office of the Inspector General recommends that the department establish a cross-functional team consisting of the Department of General Services, the Division of Addiction and Recovery Services, the department’s contracting unit, and other contracting experts to consider the invitation for bid, primary request for proposal, or other alternative contracting methods. (February 2007) Office of the Inspector General Page 33 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Finding 4 Poor fiscal controls and mismanagement by the Office of Substance Abuse Programs have encouraged inappropriate spending and enabled contractors to abuse the department’s budget policies. (February 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Review the budget transfer approval process to determine Substantially California Department of Corrections and Rehabilitation’s response: whether appropriate checks and balances are in place. Implemented Substantially Implemented. The budget transfer request (BTR) process was (February 2007) reviewed to ensure that the appropriate checks and balances are in place. DARS staff follows the BTR processes in accordance with state contracting procedures and the Line Item Budget Guide (LIBG). DARS conducted training for staff and providers on the LIBG on Spring 2007. Additional changes were made to the BTR during the February 2008 training with DARS contract managers. DARS is planning to conduct additional training in February 2009, and will continue to offer training on an annual basis and/or as needed. Office of the Inspector General’s comments: The OIG acknowledges that the department’s budget transfer request process includes appropriate checks and balances. Reiterate to program staff who review budget transfer Fully California Department of Corrections and Rehabilitation’s response: requests and approve contract invoices that contract funds Implemented Fully Implemented. Program staff was informed at the LIBG training that cannot be transferred for use under other contracts. contract funds cannot be transferred for use in other contracts unless there is (February 2007) specific language in the contract allowing such transfers. DARS provides ongoing training to review the LIBG with program staff. Office of the Inspector General’s comments: We reviewed a January 2008 memorandum to Division of Addiction and Recovery Services (DARS) staff announcing scheduled training for program managers and analysts who review and process budget transfer requests (BTRs). The agenda for the training session indicated that in February 2008 DARS staff received training on how to review and process BTRs, including how to complete a checklist to ensure costs are allowable and accurate and that other applicable rules are followed. Office of the Inspector General Page 34 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments Further revise the line-item budget guide to require that Fully California Department of Corrections and Rehabilitation’s response: contractors identify and track all equipment purchased Implemented Fully Implemented. The LIBG has been changed to address the ownership of with state funds. (February 2007) equipment purchased with state funds. DARS will require that DARS Program Managers and Correctional Counselor (CC)-IIIs overseeing in-prison substance abuse programs maintain equipment inventories using the PAR tool. Office of the Inspector General’s comments: We reviewed the Line Item Budget Guide (LIBG) and found that it requires contractors to maintain a list of “theft-sensitive” equipment such as cameras, calculators, two-way radios, and computer printers. The LIBG also clarifies that upon termination of their contract, contractors are required to leave all such equipment and unused supplies. Follow-up Recommendations None Office of the Inspector General Page 35 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Finding 5 The Office of Substance Abuse Programs has failed to adequately monitor in-prison substance abuse program providers for compliance with contract terms and has not established a quality improvement process to identify improvement opportunities. (February 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Ensure that the Office of Substance Abuse Programs Partially California Department of Corrections and Rehabilitation’s response: follow its policy requiring it to conduct biannual Implemented Partially Implemented. In January 2007, DARS established the Program compliance reviews of its in-prison substance abuse Design Assessment Team (PDAT) to monitor all contracts. From February programs and consider the results of those reviews in 2007 through December 2007, PDAT conducted site visits at 15 institutions, future contracting decisions. (February 2007) many of which operate multiple programs. In April 2008, DARS initiated the development of the Program Accountability Review (PAR) tool. The PAR reflects performance measures in new RFPs and contract renewals and will ensure compliance with all contracts. It will also replace the PDAT and current DARS Program Managers site review tool. The PAR will be administered quarterly and will standardize the monitoring of contract compliance. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The Office of Substance Abuse Programs should: Clearly describe the specific participant characteristic data Substantially California Department of Corrections and Rehabilitation’s response: elements it needs for program evaluation and require its Implemented Substantially Implemented. DARS designed the Offenders Substance Abuse contractors to maintain and report it. (February 2007) Treatment (OSAT) database to enhance its capability to monitor and evaluate programs. DARS collects data on participants receiving substance abuse treatment services from contracted treatment providers and matches it with data from the Offender Information Services Branch (OISB) and the Distributed Data Processing System (DDPS) on a monthly basis. Reports of program data are shared with treatment providers, also on a monthly basis. DARS utilizes the database to monitor program successes and weaknesses based on program Office of the Inspector General Page 36 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments completion rates, length of stay in program, rates of SAP participants to aftercare, length of stay in aftercare, and return to prison rates. DARS worked with contracted treatment providers through the Management Information Systems (MIS) subcommittee to develop database elements and define data collection procedures. The MIS subcommittee continues to meet on a quarterly basis. Contracted treatment providers are required to provide monthly updates on program participant name, CDC #, program code, program admission date, program completion date, and program completion reason. Community based providers also report on facility location and facility modality. While the DARS database is now fully operational, DARS has been directed to work with OBIS on creating an integrated model of data collection for all Adult Programs. Office of the Inspector General’s comments: We reviewed the section of the department’s current RFP for in-prison substance abuse programs regarding participant data and found that that the RFP contains a list of specific data elements that contractors are required to maintain and make available to the Division of Addiction and Recovery Services (DARS) or evaluators upon request. Consider including in future contracts intermediate Partially California Department of Corrections and Rehabilitation’s response: remedies that would allow it to enforce contractor Implemented Partially Implemented. The following intermediate sanctions are available to compliance. (February 2007) DARS: mandatory technical assistance in the form of training through UCSD, in depth program assessments with action plans to remedy deficiencies, denial of BTRs to move money from salary savings to operating expenses, and contract cancellation. DARS has drafted new multi-tiered sanctions in its revised RFPs in addition to adding performance measures. DARS will also use the PAR tool to conduct regular contract compliance reviews. 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 37 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments Implement a continuous quality improvement process that Partially California Department of Corrections and Rehabilitation’s response: includes the following steps: Implemented Partially Implemented. DARS has not identified best and worst practices among treatment providers. DARS’ focus has been on improving the treatment model • Identify the best and worst practices among the in- with evidenced-based practices, identifying performance measures, and prison substance abuse program providers and maintaining accountability and contract compliance. Results of the In-Prison ensure that poor-performing providers take Program Accountability Review (PAR) tool will allow DARS to identify best corrective action to change their programs and and worst practices. adopt applicable, successful practices of the top- performing providers. (February 2007) DARS has worked with experts in the field of criminology and criminal justice studies for female addicts in the correctional system. As a result, DARS modified RFPs for female SAPs to include Trauma Informed & Gender- Responsive treatment strategies. Revised RFPs also contain performance measures which identify preferred practices. The Policy Advisory Committee (PAC) is a forum for sharing best practices with providers. Program managers will assist contractors with identified problems during the interim periods between reviews. Best practices will be included as a means of program improvement. TAC and DARS will evaluate program innovations and identify improvements to services that can contribute to program success. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Contact other government entities that use the Substantially California Department of Corrections and Rehabilitation’s response: therapeutic community model or other similar Implemented Substantially Implemented. DARS consults a broad range of research to inform substance abuse program models to identify other decision-making, including national studies of successful practices by state and entities’ current outcomes as well as their best federal agencies. In addition, UCSD has developed a set of treatment practices. (February 2007) methodologies based on national studies of best practices. One concept paper has been submitted to DARS by UCSD to-date, “Screening, Assessment, Treatment, Referral and Delivery Plan.” In April 2008, DARS sponsored a conference on Trauma-Informed and Gender Responsive Treatment (TIGR). Keynote speakers included national experts in the field of Criminology and Criminal Justice Studies for females such as Barbara E. Bloom, Ph.D., Barbara Owen, Ph.D., Stephanie S. Covington, Office of the Inspector General Page 38 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments Ph.D., and George De Leon, Ph.D. The summit served as a consensus-building forum for substance abuse treatment staff, CDCR Adult Institution staff, DARS staff, and research experts. Participants shared current research in gender- responsive treatment, evidence-based approaches, and strategies for implementing best practices. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Identify pertinent measures of performance and Partially California Department of Corrections and Rehabilitation’s response: methods of capturing and analyzing key Implemented Partially Implemented. Revised RFPs for male and female SAP contract information. (February 2007) renewals and new contracts contain performance measures. Female SAP RFPs contain an additional section on performance measures (section “Outcome Measures”), which were written by experts in the field of criminology and criminal justice studies for females. In addition, the DARS database tracks the participation rate of in-prison programs, program completion reasons, and collects program population demographics, among other information. This data is pertinent in analyzing program successes and in implementing sanctions on entities that are not complying with contract terms. DARS has also proposed a set of data elements that will be used in the Department-wide effort to centralize data collection. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Beginning in 2007, conduct regular meetings with Partially California Department of Corrections and Rehabilitation’s response: program providers to share best practices and Implemented Partially Implemented. Beginning in April 2007 and quarterly thereafter or as pertinent performance measures. (February 2007) needed, DARS meets with contractors and other stakeholders via the Policy Advisory Committee (PAC) to discuss best practices and make recommendations on how to improve service delivery. 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 39 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Recommendation Status Comments • Measure individual program performance on a Substantially California Department of Corrections and Rehabilitation’s response: regular basis and share results among all in-prison Implemented Substantially Implemented. The DARS database gathers program performance substance abuse treatment providers during the data, which is updated on a monthly basis. This database shows the regular meetings. (February 2007) enrollment, aftercare attendance, length of stay, program completion reasons, program population counts, and return to prison rates. DARS is currently distributing monthly reports to all contractors summarizing program operations and performance. Additionally, DARS reviews outcome data with the Evaluation Subcommittee on a periodic basis related to treatment discharges, length of stay, continuing care show-up rates, and return to prison rates for individual program sites. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. • Require each contractor to develop individual Substantially California Department of Corrections and Rehabilitation’s response: program goals and objectives to use as benchmarks. Implemented Substantially Implemented, DARS has prioritized creating standardized Hold contractors accountable by measuring their performance measures across all programs rather than requiring contractors to success in meeting those goals and objectives, and develop individual objectives. It is most important to standardize take the necessary action to change programs or accountability for all contractors before identifying individual program-level change providers, as warranted. (February 2007) goals. New RFPs include performance measures, which are monitored by DARS. 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: Ensure that the Division of Addiction and Recovery Services follow its policy requiring it to conduct biannual compliance reviews of its in-prison substance abuse programs and consider the results of those reviews in future contracting decisions. (February 2007) Office of the Inspector General Page 40 2009 Accountability Audit Special Review into In-Prison Substance Abuse Programs Consider including in future contracts intermediate remedies that would allow it to enforce contractor compliance. (February 2007) Implement a continuous quality improvement process that includes the following steps: • Identify the best and worst practices among the in-prison substance abuse program providers and ensure that poor- performing providers take corrective action to change their programs and adopt applicable, successful practices of the top-performing providers. (February 2007) • Identify pertinent measures of performance and methods of capturing and analyzing key information. (February 2007) • Beginning in 2007, conduct regular meetings with program providers to share best practices and pertinent performance measures. (February 2007) Office of the Inspector General Page 41 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Special Review of High-Risk Issues at the Heman G. Stark Youth Correctional Facility We found that the Division of Juvenile Justice and the Heman G. Implementation Stark Youth Correctional Facility have fully or substantially Report Card implemented about two-thirds of our recommendations. Specifically, the facility implemented recommendations we made 2007 Recommendations: 20 concerning holding staff accountable for conducting daily room inspections for restricted program wards and administering appropriate sanctions against wards who violate rules regarding Fully Implemented: 5 (25%) contraband, room condition, and destruction of state property. The facility also improved its methods of addressing sexual Substantially Implemented: misconduct by wards toward staff. Despite these significant 7 (35%) improvements, we found that both the division and the facility Partially Implemented: did not fully implement several important recommendations. 2 (10%) For example, the division has not yet defined in its policies and Not Implemented: procedures a minimum acceptable duration for which restricted 5 (25%) program wards are to be allowed out of their rooms. The division has also not refined policies and procedures to clearly Not Applicable: 1 (5%) define uniform minimum standards for wards’ living quarters and thus enhance the youth facilities’ ability to provide wards in restricted programs with safe living conditions. Instead, the division allowed each facility to develop local policies and procedures. Finally, neither the division nor the facility acknowledges that the facility operates a step-down transitional program as an extension of the special management program, and they chose not to implement our recommendations. Summary In February 2007, we issued a special review3 of high-risk issues at the Heman G. Stark Youth Correctional Facility. Our special review examined the living conditions for wards assigned to restricted programs because past reviews we conducted at the facility identified instances of unsafe or unsatisfactory living conditions for wards in these programs. We also expanded our review to include issues we uncovered during our fieldwork. These issues included problems with the facility’s transitional program for violence-prone wards and the inability of the facility to hold wards accountable for sexual misconduct directed toward staff members. The review found that the facility had not made substantial progress in improving unsafe or unsatisfactory living conditions for wards in its special management program despite being alerted to those conditions in previous OIG audits. For example, during the review our inspectors found various forms of contraband in special management program rooms and inadequate levels of education and counseling services to wards who were confined to their rooms for all but two hours a day. The review also found that the facility’s transitional program, intended to help 3 “Special Review of High-Risk Issues at the Heman G. Stark Youth Correctional Facility” may be found on the OIG’s Web site: http://www.oig.ca.gov/media/reports/BAI/reviews/Review_2007- 02%20Heman%20G.%20Stark%20Youth%20Correctional%20Facility,%20Special%20Review%20of%20High- Risk%20Issues%20at%20the.pdf Office of the Inspector General Page 42 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility wards transition from its special management program, was essentially an extension of the special management program, but without formal policies to provide the critical protections for such a restricted program. In addition, the review found that ineffective or inadequate punishment hampered the facility’s ability to hold wards accountable for sexual misconduct directed toward staff members. Background Heman G. Stark Youth Correctional Facility is located in Chino and houses its wards in programs, with each program composed of two companies identified by letters of the alphabet. The facility groups each program into one of three areas—general population, special management, and specialized program/other. Under normal circumstances, wards in the general population or in specialized programs have relatively few restrictions and are allowed to leave their rooms for several hours each day to receive various services such as academic or vocational classes, individual or group counseling, and exercise or leisure activities. In addition, such wards may also be allowed to leave their rooms to participate in work assignments; to eat meals; to obtain medical and dental care; and for telephone calls, visitations, and religious services. In contrast, the division limits the movements of certain wards, and thus the time that these wards spend outside their rooms, under what the division calls “restricted programs.” The division has three types of restricted programs. The special management program—the facility’s entire K/L living unit—is for wards who have exhibited ongoing violent and disruptive behavior. Consequently, the program segregates these wards into a structured environment to provide them education, counseling, medical care, and mental health services. Wards in the special management program spend most of their time in their rooms except for time allowed for showers and exercise. The other types of restricted programs for wards occur by temporarily restricting wards to their assigned rooms. Specifically, wards assigned to any living unit can be placed on temporary detention whereby they are isolated in their rooms for short periods, generally a day or two, if they pose a danger to themselves or others or are themselves endangered. Alternatively, an entire living unit or facility may be placed on administrative lockdown due to an operational emergency when it becomes necessary to restrict a large number of wards. Each of these conditions results in a “restricted program” for a ward. As is true with wards in general population and specialized programs, youth correctional facilities are required to provide wards in restricted programs, including the special management program, with access to certain “mandated services” unless their delivery would compromise the safety and security of the facility. These services include exercise, education, counseling, and treatment. However, because of the potentially violent or disruptive behavior exhibited by wards in special management programs, the facilities provide education and counseling services in secure program areas—typically, the wards’ rooms due to lack of other available space. Historically, the division’s practices confined restricted program wards to their rooms for 23 hours a day, allowing wards out of their rooms for one hour of exercise. The division referred to this practice as 23-and-1 confinement. However, in July 2004, the division expanded this out-of- room period to a minimum of three hours. Moreover, on April 24, 2008, former department Office of the Inspector General Page 43 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Secretary James Tilton informed our office via letter that “standards have been established by the Director of Juvenile Facilities which state that regardless of restricted status, including temporary detention, every ward within the juvenile justice system must be provided a minimum of three hours of ‘out-of-room’ services each day.” Previous Findings and Recommendations During the 2007 special review, we made the following findings: • Contraband in the form of window coverings and makeshift ropes, combined with wards’ isolation in their rooms and inadequate delivery of mandated services such as education and counseling, present an environment conducive to suicide attempts and potentially dangerous to staff. • The step-down transitional program at Heman G. Stark Youth Correctional Facility, despite its name, operates as an extension of the facility’s highly restrictive special management program, but lacks the critical protections required of such a program. • Existing methods of addressing sexual misconduct by wards at the facility are ineffective, resulting in repeated and continuing misconduct by wards and a failure to identify wards whose conduct ultimately presents a threat to public safety. • The facility’s process for performing an important mental health screening test is in disarray, potentially placing parole detainees at risk for suicide and unnecessarily delaying their assignments to treatment programs or other mental health services. • Outdated video surveillance equipment diminishes staff and ward safety. To address the findings identified in the February 2007 special review, we made 20 recommendations to the Division of Juvenile Justice and the facility. 2009 Follow-up Results The department, the Division of Juvenile Justice, and the facility reported that they had fully or substantially implemented almost two-thirds of the recommendations we made in our February 2007 report. For example, the facility reported that it: • Directs youth correctional counselors assigned to restricted programs to search and inspect rooms daily, document the results of the inspections, and forward the results to the senior youth correctional counselor for review. Counselors who fail to do so receive sanctions under progressive discipline. Office of the Inspector General Page 44 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility • Holds youths on restricted programs accountable via the Disciplinary Decision- Making System for contraband, room condition, and the destruction of state property found during daily and random room inspections. • Purchased and installed a washer and dryer for the Special Management Program. • Worked cooperatively with the department’s Selections Services Unit to recruit and fill vacant education positions. • Used space throughout the facility to provide educational services. • Reallocated teachers and teaching assistants to the living units. • Reviews cases of egregious or continuous sexual misconduct before referring the cases to the District Attorney’s Office. • Follows the Division of Juvenile Justice’s new sexual misconduct policy, which has incorporated several elements of the sexual misconduct treatment model implemented at Pelican Bay State Prison. • Assigned a full-time psychologist to the parole violator living unit. The psychologist reviews the treatment needs assessment process. • Ensures the treatment needs assessments are administered within the required time limits. • Purchased a Scantron scoring machine to reduce delays in assessing the mental health needs of wards coming into the parole violator unit. • Used existing funds to replace cameras and recording devices with digital imaging. While these changes represent significant steps toward improvement, both the Division of Juvenile Justice and the facility have not fully implemented several important recommendations. For example, the division has not yet defined in its policies and procedures a minimum acceptable duration for which restricted program wards are to be allowed out of their rooms. The division has also not refined policies and procedures to clearly define uniform minimum standards for wards’ living quarters and thus enhance the youth facilities’ ability to provide wards in restricted programs with safe living conditions. Instead, the division allowed each facility to develop local policies and procedures. Finally, neither the division nor the facility acknowledges that the facility operates a step-down transitional program as an extension of the special management program, and they chose not to implement our recommendations to do so. The division and the facility hold the position that the facility does not operate and does not intend to develop a step-down transitional program as an extension of its special management program. However, we found that wards housed in the facility’s “high-risk core treatment units” continue to live under more restrictive conditions than Office of the Inspector General Page 45 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility general population wards, but without the specific written protections afforded to wards in special management programs. We visited the facility’s “high-risk core treatment units” in November 2008. Just as we found in 2006 and reported in February 2007, wards assigned to these living units typically eat meals in their rooms, are not allowed to attend school in a classroom environment away from the unit, and are released from their rooms for just over two hours daily for recreation and programming time. Former CDCR Secretary James Tilton informed the OIG via letter dated April 24, 2008 that “every ward within the juvenile justice system must be provided a minimum of three hours of ‘out-of-room’ services each day.” Thus, irrespective of the department’s characterization of it, the program does not accomplish the department’s goals for ward services as described by former Secretary Tilton. Follow-up Recommendations While the department has made progress, some recommendations were not fully or substantially implemented as a result of our 2009 follow-up audit. Accordingly, the OIG recommends that the administration of the Division of Juvenile Justice: • Develop uniform policies and procedures to support existing directives intended to eliminate 23-and-1 confinement, including establishing a minimum acceptable duration for which restricted program wards are to be out of their rooms and for documenting daily either the means by which this was accomplished for each ward, or the reasons failing to do so. (February 2007) • Refine its policies and procedures to more clearly define the standards for wards’ living quarters and to enhance its youth facilities’ ability to provide wards in restricted programs with safe living conditions. These policies and procedures should include examples of the specific types of contraband items to be removed from restricted wards’ rooms, the frequency of staff inspections, proper documentation of those inspections, and sanctions for non-compliance. (February 2007) • Officially recognize the step-down transitional program at Heman G. Stark Youth Correctional Facility as an extension of the special management program by developing policies and procedures for the program, providing it with the resources necessary to prepare wards for a successful transition to programming units, and subjecting it to the provisions of Temporary Departmental Orders 07-82 Restricted Program, 07-83 Delivery of Mandated Services, and 07-86 Special Management Program.4 (February 2007) In addition, the OIG recommends that the Heman G. Stark Youth Correctional Facility: • Improve supervisory monitoring over staff’s delivery of mandated services to ensure that all wards assigned to restricted programs are provided with required services 4 The original recommendation referenced Institutions and Camps Branch Manual section 7200, et seq., which are no longer in effect. Office of the Inspector General Page 46 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility including three hours of time out of their rooms daily, education, and behavior counseling. (February 2007) • Until the Division of Juvenile Justice develops statewide policies and procedures for step-down transitional programs, develop local policies and procedures utilizing the guidelines of Temporary Departmental Order 07-86 Special Management Program5 for the transitional program. These policies and procedures should provide a means by which to establish individual transition plans for wards in the program and to objectively measure and monitor wards’ progress in achieving treatment goals. (February 2007) • Maintain mandated services logs for wards in the transitional program such as those used in the special management program to record the level of mandated services delivered to those wards and to ensure that they receive a minimum of three hours out of their rooms daily. (February 2007) • Conduct a progress case conference for each ward in the transitional program within 60 days of the initial conference and every 30 days thereafter to assess the ward’s readiness to be transitioned to general population housing. (February 2007) The matrixes on the following pages summarize the results of the 2009 follow-up audit. 5 The original recommendation referenced Institutions and Camps Branch Manual section 7285, which is no longer in effect. Office of the Inspector General Page 47 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Special Review of High-Risk Issues at the Heman G. Stark Youth Correctional Facility Finding 1 Contraband in the form of window coverings and makeshift ropes, combined with wards’ isolation in their rooms and inadequate delivery of mandated services such as education and counseling, present an environment conducive to suicide attempts and potentially dangerous to staff. (February 2007) Recommendation Status Comments The Administration of the Division of Juvenile Justice should: Develop uniform policies and procedures to support Partially California Department of Corrections and Rehabilitation’s response: existing directives intended to eliminate 23-and-1 Implemented Partially Implemented. The Division of Juvenile Justice (DJJ) completed a confinement, including establishing a minimum acceptable revision of the Restricted Program Policy on March 9, 2007. Training duration for which restricted program wards are to be out associated with this policy was completed and the implementation date was of their rooms and for documenting daily either the means May 1, 2008. A formal directive was given to the facilities to operate only from by which this was accomplished for each ward, or the Institutions and Camps Restricted Program Policy Manuel Section 7200-7285 reasons for failing to do so. (February 2007) dated March 9, 2007. Part of this policy training is focused on the 3-hours a day out of room mandate as well as delivery and documentation of mandated services. Particular attention is given to the documentation of the reasons a service may be refused or denied by a youth. To ensure accurate reporting, staff are documenting in the “Comment Section” of youth mandated services the reasons program was limited or not provided for that day. DJJ enhanced its ability to provide oversight and review of mandated services with the implementation of Ward Information Network Exchange (WIN Exchange). The April 30, 2008, completion of WIN Exchange provided a system wide capability, along with new functions within WIN Exchange allowing DJJ to enhance its tracking of mandated services electronically. DJJ superintendents have assigned staff to track mandated services on a daily basis. Functions in WIN Exchange allow headquarters to review individual youth records rather than a percentage of overall weekly services provided by facilities. DJJ now reports audit findings to facilities on deficiencies within specific youth records requesting facilities develop action plans to remedy the Office of the Inspector General Page 48 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments deficiency in the short and long term. The DJJ will implement Behavior Treatment Programs (BTPs) to address the needs of this population. The program service day identifies required minimum youth services throughout the day. It is the DJJ long term solution to clearly define education, counseling, recreation and access to services for youth on a daily basis. The program service day is currently being piloted at Preston Youth Correctional Facility. The continued implementation of TDOs 07-82 Restricted Program, 07-83 Delivery of Mandated Services and 07-85 Temporary Detention as well as additional training and oversight will bring this area into substantially or fully implemented over the next year. Office of the Inspector General’s comments: We reviewed the division’s response and supporting documents. Although the division introduced temporary departmental orders on March 9, 2007, revising the restricted program policy, the orders do not establish a minimum acceptable duration for which restricted program wards are to be allowed out of their rooms. The orders mention that wards should be out of their rooms to receive one hour of large muscle exercise each day, but they fail to mention that a ward should receive a minimum of three hours total time out of his or her room. On April 24, 2008, former CDCR Secretary James Tilton informed the OIG via letter that “standards have been established by the Director of Juvenile Facilities which state that regardless of restricted status, including temporary detention, every ward within the juvenile justice system must be provided a minimum of three hours of ‘out-of-room’ services each day.” The division did not provide such a standard in its response or supporting documents. Refine its policies and procedures to more clearly define Not California Department of Corrections and Rehabilitation’s response: the standards for wards’ living quarters and to enhance its Implemented Substantially Implemented. This recommendation has been addressed through youth facilities’ ability to provide wards in restricted the development and implementation of local policies and procedures. The programs with safe living conditions. These policies and Division of Juvenile Justice (DJJ) requires each program to identify all procedures should include examples of the specific types allowable property and develop procedures for room inspections. These of contraband items to be removed from restricted wards’ procedures include frequency of room searches, inspections, and subsequent rooms, the frequency of staff inspections, proper documentation. Property lists are now posted in the living units and youth are documentation of those inspections, and sanctions for non- informed about all property and canteen items allowed in their rooms on Office of the Inspector General Page 49 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments compliance. (February 2007) Special Management Program (SMPs). The DDMS system is used to hold youth accountable for property and room conditions during daily, weekly and random room searches and inspections in the living units. Placing emphasis on room conditions, room searches, inspections and consistent enforcement of each SMP property standards, will continue to improve youth safety, living conditions, and the overall climate of the facility. The Division of Juvenile Justice (DJJ) completed a revision of the Restricted Program Policy on March 9, 2007. Training associated with this policy was completed and the implementation date was May 1, 2008. A directive was given to the field to operate only from Institutions and Camps Restricted Program Policy Manuel Section 7200-7285 dated March 9, 2007. This policy clearly states youth will be afforded clean and sanitary living conditions. Further, it mandates youth rooms be cleaned on a weekly basis or as needed and that procedures are in place to clean youth rooms whether or not the youth indicates a desire to personally clean his/her room. To enhance the overall condition of the facilities, the Director mandated a graffiti abatement plan for each facility that specifically targets rooms and living unit cleanliness and appearance. This plan has a short and long term strategy to address facility conditions. The Heman G. Stark Youth Correctional Facility (HGSYCF) SMP publicly displays and disseminates to their youth through orientation an approved property list for youth assigned to the program. At HGSYCF, Youth Correctional Counselors (YCCs) are assigned specific rooms to inspect on a daily basis. The room inspection form containing the room number of each room inspected and the results of the YCC’s inspection is forwarded to the Senior Youth Correctional Counselor (SYCC). The SYCC reviews the inspection form and conducts random reviews of the rooms listed. The SYCC forwards the room inspection forms along with any youth DDMS or staff accountability actions to the Treatment Team Supervisor (TTS) each day. The TTS keeps a log on each room inspection of the contraband found and any subsequent DDMS issued to youth. A monthly report is submitted to the Program Administrator and Deputy Superintendent’s Office. Office of the Inspector General Page 50 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments The continued implementation of TDOs 07-82 Restricted Program, and 07-85 Temporary Detention as well as additional training and oversight will bring this area to fully implemented over the next year. Office of the Inspector General’s comments: We reviewed the division’s response and supporting documents and concluded that the division has not implemented the recommendation to refine its policies and procedures to more clearly define the standards for wards’ living quarters and to enhance its youth facilities’ ability to provide restricted program wards with safe living conditions. The division chose to address our recommendation through the development of local policies and procedures rather than defining minimum uniform standards at the division level. To its credit, the division issued Temporary Departmental Order #07-82 (Restricted Program); this revision to the Institutions and Camps Branch Manual became effective as of March 9, 2007. Although the order states that “[a] youth will be afforded clean and sanitary living conditions as well as access to water, at least hourly,” the order is not responsive to our recommendation. The order does not include examples of the specific types of contraband to be removed from restricted wards’ rooms, the frequency of staff inspections, the proper documentation of those inspections, and the sanctions for non-compliance. The division included various local policies and procedures in its proof of practice documents including the Heman G. Stark, Preston, and N.A. Chaderjian Allowable Property List; the Heman G. Stark, Preston, and N.A. Chaderjian Room Search Policy; and the Preston Room Clean-Up Policy. The division should review each policy, extract the best practices, and develop comprehensive and clearly defined division-level policies and procedures that follow the intent of our recommendation. The Heman G. Stark Youth Correctional Facility should: Use progressive discipline to hold staff accountable for Substantially California Department of Corrections and Rehabilitation’s response: conducting daily room inspections for wards on restricted Implemented Substantially Implemented. Youth Correctional Counselors (YCCs) assigned to programs, removing all contraband discovered, and restricted programs are directed to search and inspect identified youth rooms documenting room inspections in writing. (February 2007) daily. The room inspection form, which identifies the room number and the results of the inspection, is forwarded to the Senior Youth Correctional Counselor (SYCC) for review. The SYCC conducts random reviews to ensure a Office of the Inspector General Page 51 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments thorough search and inspection was completed by the YCC. YCC’s failing to complete room searches are addressed through progressive discipline. The SYCC forwards the room inspection form along with any youth DDMS to the Treatment Team Supervisor (TTS). The TTS maintains a log of room inspections, which identifies contraband and subsequent DDMS issued to youth. A monthly report, which contains information on room inspections and their results, is written by the SYCC and forwarded to the Program Administrator and Deputy Superintendent. The continued implementation of TDOs 07-82 Restricted Program, and 07-85 Temporary Detention as well as additional training and oversight will bring this area to fully implemented over the next year. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the Heman G. Stark Youth Correctional Facility’s representation. Administer appropriate sanctions against wards violating Substantially California Department of Corrections and Rehabilitation’s response: the rules prohibiting contraband. (February 2007) Implemented Substantially Implemented. Youth on restricted programs are held responsible through the DDMS system for contraband, room condition, and the destruction of state property during daily and random room inspections. From May 1, 2008 through September 30, 2008, 15 Behavior Reports were written holding youth responsible for destroying state property. Continued oversight and follow up will bring this area to fully implemented over the next year. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the Heman G. Stark Youth Correctional Facility’s representation. Consider installing laundry equipment in the special Fully California Department of Corrections and Rehabilitation’s response: management program unit, using existing plumbing and Implemented Fully Implemented. A washer and dryer has been purchased and installed for electrical hookups to reduce the incentive for wards to the Special Management Program. construct makeshift clotheslines. (February 2007) Office of the Inspector General’s comments: We verified that the Heman G. Stark Youth Correctional Facility received and Office of the Inspector General Page 52 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments installed the washer and dryer in the Special Management Program living unit. Improve supervisory monitoring over staff’s delivery of Partially California Department of Corrections and Rehabilitation’s response: mandated services to ensure that all wards assigned to Implemented Partially Implemented. A Senior Youth Correctional Counselor assigned to the restricted programs are provided with required services restricted program reviews all entries for mandated services each day. In including three hours of time out of their rooms daily, addition, the Heman G. Stark Youth Correctional Facility (HGSYCF) education, and behavior counseling. (February 2007) Superintendent has assigned a Treatment Team Supervisor (TTS) to review mandated services for the facility. The TTS forwards a copy of the mandated services record to the Program Administrator and Principal. With the implementation of WIN Exchange, headquarters has refined its compliance reviews and is now able to review individual youth records rather than a percentage of overall weekly mandated services. The Division of Juvenile Justice now reports deficiencies within individual youth records and directs facilities to develop action plans to remedy the deficiency in the short and long term. Continued oversight and follow up as well as the completed construction projects of group recreation areas and secure education/treatment rooms coupled with additional modulars will bring this area to substantially or fully implemented over the next year. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the Heman G. Stark Youth Correctional Facility’s representation. Facilitate compliance with educational standards by: Substantially California Department of Corrections and Rehabilitation’s response: Implemented Substantially Implemented. Lyle Egan High School (LEHS) in conjunction with • Hiring sufficient teaching staff to enable wards the department’s Selections Services Unit worked cooperatively to recruit and access to four hours of daily instruction. fill vacant education positions. Recruitment of education staff remains a (February 2007) continuous process. The closure of facilities and reduction of student population has resulted in a temporary hiring freeze. Therefore, vacant positions are covered with temporary teaching staff. On October 1, 2008, LEHS forwarded 10 new hires along with the hiring freeze exemption requests to headquarters for approval where they remain under consideration. The teaching positions being considered are: 1 Limited Term/Full Time (LT/FT) Multiple Subject Teacher; 1 LT/FT Emotional Learning Handicap Teacher; 3 LT/FT Teaching Assistants; and 5 Substitute Teachers. Office of the Inspector General Page 53 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments There are 18 vacant positions; 12 are covered by PI and TAU staff and with approval of 7 teacher freeze exemptions all vacancies will be covered with 1 added to the substitute pool. With 4 part-time Retired Annuitants working as substitutes, LEHS needs an additional 5 positions for substitute coverage to be fully implemented. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the Heman G. Stark Youth Correctional Facility’s representation. • Allocating additional dedicated space in the living Substantially California Department of Corrections and Rehabilitation’s response: units in which to provide educational programs. Implemented Substantially Implemented. Consistent with the Safety and Welfare Remedial (February 2007) Plan, Heman G. Stark Youth Correctional Facility developed plans to address space needs utilizing modulars and the renovation of existing living units. In the 2006/2007 Budget Year, $3,378,000.00 was allocated for program and recreational space to open Behavior Treatment Programs (BTPs) on Unit III. Construction is currently underway on Unit III (S&T/U&V). The Division of Juvenile Justice (DJJ) is beginning to implement BTPs to more effectively deliver treatment services to youth requiring restricted program level of care. Since February 2007, additional teaching program space has been utilized throughout the facility to provide educational services on living units (Y&Z dayrooms used for W&X students; E&F conference room utilized for F company students; and U&V dining room for Morrissey and minor students). Educational services on each of the Satellite Programs are aligned to the main school. After the completion of ongoing construction projects and the acquisition of modulars this area will be fully implemented. The Office of the Inspector General’s comments: We acknowledge that the Heman G. Stark Youth Correctional Facility allocated additional living unit space in the Y/Z and E/F living units to provide additional educational programs. However, we did not evaluate the effectiveness of the allocations. Office of the Inspector General Page 54 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments Reallocate the facility’s existing teachers among its living Substantially California Department of Corrections and Rehabilitation’s response: units in proportion to the number of non-high school Implemented Substantially Implemented. Teachers and teaching assistants have been graduate wards attending school in those living units. reallocated to the living units. They teach non-high school graduates in spaces (February 2007) allocated for education or program, when available. Teachers and teaching assistants have been assigned school days on Saturday and evening schedules on some core treatment program living units to provide further access to education services. After filling the 10 education positions currently going through the hiring process and the recruitment and hiring of five additional positions this area will be fully implemented. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the Heman G. Stark Youth Correctional Facility’s representation. Follow-up Recommendations The Administration of the Division of Juvenile Justice should take the following actions: • Develop uniform policies and procedures to support existing directives intended to eliminate 23-and-1 confinement, including establishing a minimum acceptable duration for which restricted program wards are to be out of their rooms and for documenting daily either the means by which this was accomplished for each ward, or the reasons failing to do so. (February 2007) • Refine its policies and procedures to more clearly define the standards for wards’ living quarters and to enhance its youth facilities’ ability to provide wards in restricted programs with safe living conditions. These policies and procedures should include examples of the specific types of contraband items to be removed from restricted wards’ rooms, the frequency of staff inspections, proper documentation of those inspections, and sanctions for non-compliance. (February 2007) The Heman G. Stark Youth Correctional Facility should improve supervisory monitoring over staff’s delivery of mandated services to ensure that all wards assigned to restricted programs are provided with required services including three hours of time out of their rooms daily, education, and behavior counseling. (February 2007) Office of the Inspector General Page 55 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Finding 2 The step-down transitional program at Heman G. Stark Youth Correctional Facility, despite its name, operates as an extension of the facility’s highly restrictive special management program, but lacks the critical protections required of such a program. (February 2007) Recommendation Status Comments The Administration of the Division of Juvenile Justice should: Consider officially recognizing the step-down transitional Not California Department of Corrections and Rehabilitation’s response: program at Heman G. Stark Youth Correctional Facility as Implemented Not Applicable. The Administration at Heman G. Stark Youth Correctional an extension of the special management program by Facility (HGSYCF) does not operate a step-down program. All youth are developing policies and procedures for the program, classified as high risk, medium-high risk, medium-low risk or low risk. providing it with the resources necessary to prepare wards Implementation of the Division of Juvenile Justice (DJJ) youth classification for a successful transition to programming units, and process at HGSYCF, requires youth be placed on living units in accordance subjecting it to the provisions of Institutions and Camps with their treatment needs and risk of institutional violence. Based on this Branch Manual section 7200, et seq. (February 2007) classification, Special Management Program (SMP) youth traditionally are sent to living units within the facility designated as high risk core treatment units. While there may have been some initial efforts to develop transitional processes between SMPs and the high risk program at HGSYCF, it is not the DJJ’s intent that high risk units be designed as transitional programs for SMPs. HGSYCF living units are being brought into compliance with Farrell program staffing and population levels. This modification allows for more opportunity to develop core treatment units consistent with the Safety and Welfare Remedial Plan. In addition, the living unit population is limited to 36 youth thereby increasing the staff to youth ratio and provides increased space for youth activities. All youth are assigned to the appropriate core treatment living unit based on their classification. Youth classifications are reviewed and revised consistently for risks of institutional violence changes. The Office of the Inspector General’s comments: Despite the Division of Juvenile Justice’s position that the Heman G. Stark Youth Correctional Facility does not operate a step-down transitional program as an extension of the special management program, we found that wards Office of the Inspector General Page 56 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments housed in the facility’s “high-risk core treatment units” (X and F) continue to operate under more restrictive conditions than general population wards. These wards lack the specific written protections afforded to special management program wards. We visited the facility’s “high-risk core treatment units” (X and F) during a November 2008 site visit. Just as we found in 2006 and reported in February 2007, wards assigned to these living units typically eat meals in their rooms, are not allowed to attend school in a classroom environment away from the unit, and are released from their rooms for just over two hours daily for recreation and programming time. On April 24, 2008, former CDCR Secretary James Tilton informed the OIG via letter that “every ward within the juvenile justice system must be provided a minimum of three hours of “out-of-room” services each day.” Our analysis of log entries and Daily Schedule and Team Reports for the period November 9 through November 16, 2008, revealed that X and F wards achieved three hours of out-of-room time about one-third of the time. The Heman G. Stark Youth Correctional Facility should: Until the Division of Juvenile Justice develops statewide Not California Department of Corrections and Rehabilitation’s response: policies and procedures for step-down transitional Implemented Not Applicable. The Division of Juvenile Justice does not intend to develop programs, develop local policies and procedures utilizing transitional programs at Heman G Stark Youth Correctional Facility. the guidelines of Institutions and Camps Branch Manual section 7285 for the transitional program. These policies The Office of the Inspector General’s comments: and procedures should provide a means by which to The Division of Juvenile Justice’s and the Heman G. Stark Youth Correctional establish individual transition plans for wards in the Facility’s position is that the facility does not operate and does not intend to program and to objectively measure and monitor wards’ develop a step-down transitional program as an extension of the special progress in achieving treatment goals. (February 2007) management program. However, we found that wards housed in the facility’s “high-risk core treatment units” (X and F) continue to operate under more restrictive conditions than general population wards, but without the specific written protections afforded to special management program wards. We visited the facility’s “high-risk core treatment units” (X and F) during a November 2008 site visit. Just as we found in 2006 and reported in February 2007, wards assigned to these living units typically eat meals in their rooms, are not allowed to attend school in a classroom environment away from the unit, and are released from their rooms for just over two hours daily for recreation and programming time. On April 24, 2008, former CDCR Secretary James Tilton informed the OIG via letter that “every ward within the juvenile justice system Office of the Inspector General Page 57 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments must be provided a minimum of three hours of “out-of-room” services each day.” Our analysis of log entries and Daily Schedule and Team Reports for the period November 9 through November 16, 2008, revealed that X and F wards achieved three hours of out-of-room time about one-third of the time. Maintain mandated services logs for wards in the Not California Department of Corrections and Rehabilitation’s response: transitional program such as those used in the special Implemented Not Applicable. Without the development of a transitional program, this management program to record the level of mandated recommendation is not applicable. services delivered to those wards and to ensure that they receive a minimum of three hours out of their rooms daily. The Office of the Inspector General’s comments: (February 2007) The Division of Juvenile Justice’s and the Heman G. Stark Youth Correctional Facility’s position is that the facility does not operate and does not intend to develop a step-down transitional program as an extension of the special management program. However, we found that wards housed in the facility’s “high-risk core treatment units” (X and F) continue to operate under more restrictive conditions than general population wards, but without the specific written protections afforded to special management program wards. Conduct a progress case conference for each ward in the Not California Department of Corrections and Rehabilitation’s response: transitional program within 60 days of the initial Implemented Not Applicable. Without the development of a transitional program, this conference and every 30 days thereafter to assess the recommendation is not applicable. ward’s readiness to be transitioned to general population housing. (February 2007) The Office of the Inspector General’s comments: The Division of Juvenile Justice’s and the Heman G. Stark Youth Correctional Facility’s position is that the facility does not operate and does not intend to develop a step-down transitional program as an extension of the special management program. However, we found that wards housed in the facility’s “high-risk core treatment units” (X and F) continue to operate under more restrictive conditions than general population wards, but without the specific written protections afforded to special management program wards. Follow-up Recommendations The Administration of the Division of Juvenile Justice should officially recognize the step-down transitional program at Heman G. Stark Youth Correctional Facility as an extension of the special management program by developing policies and procedures for the program, providing it with the resources necessary to prepare wards for a successful transition to programming units, and subjecting it Office of the Inspector General Page 58 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility to the provisions of Temporary Departmental Orders # 07-82 Restricted Program and # 07-83 Delivery of Mandated Services. (February 2007) The Heman G. Stark Youth Correctional Facility should take the following actions: • Until the Division of Juvenile Justice develops statewide policies and procedures for step-down transitional programs, develop local policies and procedures utilizing the guidelines of Institutions and Camps Branch Manual section 7285 for the transitional program. These policies and procedures should provide a means by which to establish individual transition plans for wards in the program and to objectively measure and monitor wards’ progress in achieving treatment goals. (February 2007) • Maintain mandated services logs for wards in the transitional program such as those used in the special management program to record the level of mandated services delivered to those wards and to ensure that they receive a minimum of three hours out of their rooms daily. (February 2007) • Conduct a progress case conference for each ward in the transitional program within 60 days of the initial conference and every 30 days thereafter to assess the ward’s readiness to be transitioned to general population housing. (February 2007) Office of the Inspector General Page 59 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Finding 3 Existing methods of addressing sexual misconduct by wards at Heman G. Stark Youth Correctional Facility are ineffective, resulting in repeated and continuing misconduct by wards and a failure to identify wards whose conduct ultimately presents a threat to public safety. (February 2007) Recommendation Status Comments The Heman G. Stark Youth Correctional Facility should: Consistently apply the directives of the superintendent’s Not California Department of Corrections and Rehabilitation’s response: July 6, 2006, memorandum in administering disciplinary Applicable Not Applicable. The memorandum written by the former Superintendent is in sanctions to wards engaging in sexual misconduct. conflict with the Welfare and Institutions Code (W&I) and Disciplinary (February 2007) Decision Making System (DDMS) Policy. Projected board extensions are not automatic. The memorandum dated 7/6/06 was not rescinded; however, Youth Sexual Misconduct TDO #07-88 dated 7/13/07 superseded the memorandum. The Youth Sexual Misconduct TDO reiterated the language from the W&I Code and DDMS policy. W&I Code 1719(d) and DDMS Policy Section 7362 indicate that the department may extend a youth’s projected board date if all other sanctioning options have been considered and determined to be unsuitable in light of the youth's previous case history and the circumstances of the misconduct. The W&I Code and DDMS Policy further state that in any case in which a projected board date has been extended, the disposition report shall clearly state the reasons for the extension. The length of the extension shall be based on the seriousness of the misconduct, the youth's prior disciplinary history, progress toward treatment objectives, earned program credits, and any extenuating or mitigating circumstances. In addition, a Temporary Departmental Order (TDO) #07-88 on ward sexual misconduct has been developed and distributed to the Division of Juvenile Justice (DJJ) facilities and staff and youth have received training. The TDO focuses on three approaches to address youth sexual misconduct. They are as follows: Office of the Inspector General Page 60 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments • Employee access to support services • Holding youth accountable through DDMS and referral to the District Attorney's Office when appropriate • Youth access to appropriate intervention and treatment Office of the Inspector General’s comments: Although the Heman G. Stark Youth Correctional Facility did not rescind the former superintendent’s July 6, 2006, memorandum, we confirmed that the facility is applying appropriate departmental and facility directives to administer disciplinary sanctions to wards engaging in sexual misconduct. We interviewed appropriate staff members and reviewed supporting documents, and we determined that the facility has developed and implemented procedures consistent with the division’s Temporary Departmental Order # 07-88 (Youth Sexual Misconduct). The facility provides access to support services, holds wards accountable through the Disciplinary Decision-Making System and district attorney referral process, and ensures wards have access to appropriate intervention and treatment. Prepare and refer all cases of egregious or continuous Substantially California Department of Corrections and Rehabilitation’s response: sexual misconduct falling under the criteria of section Implemented Substantially Implemented. Automatic referrals to the District Attorney are not 7382 of the Institutions and Camps Branch Manual and consistent with the current sexual misconduct policy. TDO 07-88 on youth Penal Code Section 314 to the District Attorney’s Office sexual misconduct mandates that if a youth has engaged in repeated sexual for criminal filing, allowing the District Attorney’s Office misconduct or a single egregious act, the Program Manager is required to meet to evaluate each case on its individual merit. (February with the Superintendent and DDMS Coordinator to determine if a referral to 2007) the District Attorney’s Office is appropriate. Since DJJ's primary mission is rehabilitation, the policy does not include an automatic referral. Each case is reviewed on an individual basis. DJJ wants to have the ability to consider all treatment interventions prior to referring the case to the DA's Office whenever possible. Office of the Inspector General’s comments: We agree with the facility’s assertion that it has substantially implemented our recommendation. We reviewed the division’s temporary departmental order for Office of the Inspector General Page 61 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments referring sexual misconduct cases to the District Attorney’s Office, and we interviewed the facility staff member responsible for preparing cases for referral to the district attorney. We also found that the facility has referred 14 sexual misconduct cases to the district attorney since February 26, 2007 (the date the OIG issued its report). To date, the district attorney has successfully prosecuted five of the 14 cases. Four wards received county jail terms ranging from 180 days to one year. The fifth ward received a one-year state prison term. Consider adopting the Pelican Bay State Prison sexual Fully California Department of Corrections and Rehabilitation’s response: misconduct treatment model, or if necessary a modified Implemented Fully Implemented. The Inmate Sexual Misconduct Reduction Policy from the version of it, at Heman G. Stark Youth Correctional Division of Adult Institutions was reviewed in developing a policy for Division Facility. (February 2007) of Juvenile Justice (DJJ). Several elements of their policy were incorporated into DJJ's policy. Some examples include the addition of a new violation code (intentionally sustained masturbation without exposure), and a modified version of the Employee Report of Sexual Misconduct and mental health referral. Office of the Inspector General’s comments: We agree with the facility’s assertion that it has fully implemented our recommendation. We reviewed the division’s temporary departmental order dealing with youth sexual misconduct and noted that it incorporates several aspects of the sexual misconduct treatment model implemented at Pelican Bay State Prison. For example, the division’s policy includes a mental health referral for the offending ward and an opportunity for the reporting staff member to request specific support services (including the Employee Assistance Program). Follow-up Recommendations None Office of the Inspector General Page 62 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Finding 4 The process for performing an important mental health screening test at Heman G. Stark is in disarray, potentially placing parole detainees at risk for suicide and unnecessarily delaying their assignments to treatment programs or other mental health services. (February 2007) Recommendation Status Comments The Heman G. Stark Youth Correctional Facility should: Designate a psychologist on the parole violator unit as the Fully California Department of Corrections and Rehabilitation’s response: individual responsible for overseeing and directing the Implemented Fully Implemented. A full time Psychologist has been assigned to the parole treatment needs assessment process at Heman G. Stark violator living unit and they are responsible for reviewing the Treatment Needs Youth Correctional Facility. (February 2007) Assessments in accordance with Institutions and Camps Branch Manual Section 6260. Office of the Inspector General’s comments: We confirmed that the Heman G. Stark Youth Correctional Facility has fully implemented this recommendation. We interviewed appropriate staff members, reviewed supporting documentation, and confirmed the assigned psychologist is monitoring the treatment needs assessment process. Through the designated psychologist, hold staff Fully California Department of Corrections and Rehabilitation’s response: accountable for administering and conducting treatment Implemented Fully Implemented. The assigned psychologist forwards a list of youth who needs assessments completely and within the time limits have been administered the Treatment Needs Assessment (TNA) test to the prescribed by policy. (February 2007) Program Administrator of the parole violator living unit. Upon review of the Program Administrator, the report is forwarded to the Deputy Superintendent. If it is determined staff were negligent in performing the TNA test within the prescribed time frames set by Institutions and Camps Branch Manual Section 6260, progressive discipline is used as appropriate. Office of the Inspector General’s comments: We confirmed that the Heman G. Stark Youth Correctional Facility has fully implemented this recommendation. We interviewed appropriate staff members, reviewed supporting documentation, and confirmed that the assessments from January 2008 through October 2008 were completed on time. Office of the Inspector General Page 63 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Recommendation Status Comments Obtain a Scantron scoring machine to allow immediate Fully California Department of Corrections and Rehabilitation’s response: scoring and evaluation of wards’ treatment needs Implemented Fully Implemented. In February 2008, a Scantron scoring machine was assessment tests at the facility to reduce delays in purchased and placed into service. The psychologist assigned to the parole assessing the mental health needs of wards coming into the violator unit inputs the Treatment Needs Assessment tests into the Scantron and parole violator unit. (February 2007) uploads the results into a dedicated computer connected through the Large Area Network. Office of the Inspector General’s comments: We confirmed that the Heman G. Stark Youth Correctional Facility has fully implemented this recommendation. We interviewed appropriate staff members, reviewed supporting documentation, and found that the treatment needs assessment tests of wards coming into the parole violator unit occurred within 21 days of wards’ arrival to the unit. Follow-up Recommendations None Office of the Inspector General Page 64 2009 Accountability Audit High-Risk Issues at the Heman G. Stark Youth Correctional Facility Finding 5 Outdated video surveillance equipment diminishes staff and ward safety. (February 2007) Recommendation Status Comments The Heman G. Stark Youth Correctional Facility should: Work with the department’s Office of Facilities Substantially California Department of Corrections and Rehabilitation’s response: Management to aggressively explore alternatives to using Implemented Substantially Implemented. Heman G. Stark Youth Correctional Facility has the Capital Outlay Budget Change Proposal process and begun a comprehensive project with existing funding to replace cameras and replace the facility’s video monitoring system as recording devices with digital imaging. All recording devices have been expeditiously as possible. (February 2007) replaced with a digital format recording. Most cameras have been replaced with color, low light operating cameras and the conversion of the few remaining black & white cameras is anticipated to be complete within 60-days to achieve the status of fully implemented. Office of the Inspector General’s comments: We confirmed that the Heman G. Stark Youth Correctional Facility has substantially implemented the recommendation to replace its video monitoring system. We reviewed purchase orders and stock received reports, and we physically observed a new digital camera surveillance system installed and being used by facility staff. Follow-up Recommendations None Office of the Inspector General Page 65 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Special Review into the California Department of Corrections and Rehabilitation’s Release of Inmate Scott Thomas We found that the California Department of Corrections and Implementation Rehabilitation and San Quentin State Prison have fully Report Card implemented two-thirds of our recommendations. Specifically, the department and the institution addressed most of the 2007 Recommendations: 21 concerns we raised regarding the timely identification and treatment of inmates [confidential text removed].6 The institution has also developed policies and procedures to identify and Fully Implemented: 14 (67%) process inmates with existing warrants, holds, or detainers, and to process the release or parole of high-control inmates. Substantially Implemented: However, the department is still determining how to modify its 0 (0%) existing database to alert staff [confidential text removed]. The Partially Implemented: California Health Care Receivership Corporation is 4 (19%) experiencing difficulties in implementing two of our Not Implemented: recommendations, while the department’s Division of Adult 3 (14%) Parole Operations and Office of Audits and Compliance failed to address our recommendations. Summary In October 2007, we issued a special review7 into the California Department of Corrections and Rehabilitation’s release of inmate Scott Thomas on May 18, 2007. The purpose of our special review was to assess whether San Quentin State Prison followed established policies and procedures [confidential text removed] in releasing Thomas on parole. The review found [confidential text removed] San Quentin case records and counseling staff incorrectly identified Scott Thomas as the subject of a warrant and inappropriately released him to the Alameda County Sheriff’s Office. Despite Division of Adult Parole Operations and San Quentin staff’s failure to follow department procedures, the responsible staff member at the reception center should have known state law prohibited Scott Thomas’s release on a Friday and did not follow department procedures when paroling Thomas from security housing. Background At approximately 4:00 p.m. on Saturday, May 19, 2007, Scott Chris Thomas—a parolee released from San Quentin the previous day—entered a San Francisco bakery and allegedly assaulted a 6 The Office of the Inspector General issued a confidential report and a public report related to the special review. Personal health care information protected from public disclosure by various state and federal privacy laws was redacted from the public report. 7 “Special Review into the California Department of Corrections and Rehabilitation’s Release of Inmate Scott Thomas” may be found on the OIG’s Web site: http://www.oig.ca.gov/media/reports/BAI/reviews/Review_2007- 10%20CDCR,%20Special%20Review%20into%20the%20Release%20of%20Inmate%20Scott%20Thomas.pdf Office of the Inspector General Page 66 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas 14-year-old girl, stabbing her multiple times in the throat, wrist, legs, and stomach. Thomas also allegedly stabbed a 60-year-old male bakery patron who intervened. Thomas reportedly fled the scene of the attack, and police later arrested him in the parking lot of a nearby hospital [confidential text removed]. Previous Findings and Recommendations Soon after the incident, the OIG became involved to assess whether San Quentin staff followed established policies and procedures in [confidential text removed] releasing Thomas on parole. In our review, we examined various laws, policies and procedures, inmate records, and other criteria [confidential text removed], as well as parole systems, functions, and processes. We also interviewed [confidential text removed] staff at San Quentin, at the department’s 11 other reception centers, and at headquarters; interviewed custody and administrative staff at San Quentin; reviewed institutional files, logs, records, and other relevant documents [confidential text removed]. We then analyzed the information gathered through the above procedures and formulated our conclusions. A series of mistakes, oversights, and failures to follow California Department of Corrections and Rehabilitation policy resulted in San Quentin staff [confidential text removed] improperly releasing Thomas on parole on May 18, 2007. [One paragraph of confidential text removed] San Quentin staff’s mistakes and their failure to follow policy also resulted in the improper release of Thomas. Soon after Thomas had been admitted to San Quentin for violating the terms of his parole, San Quentin staff mistakenly identified Thomas as the subject of an arrest warrant from nearby Alameda County. However, the Alameda County Sheriff’s Office determined that Scott Thomas was not the person identified in its warrant and returned him to the custody of San Quentin the same day. San Quentin then improperly released Thomas in the nearby community. Thomas’s parole agent contributed to the improper release of Thomas. Department policy requires a parole agent to inform an institution 30 days before releasing a high-control inmate of the parole division’s plans and reporting instructions for the inmate. However, Thomas’s parole agent from the Los Angeles area did not complete this notification. Had the parole agent notified San Quentin of the inmate’s high-control status as required, San Quentin staff might have released Thomas appropriately. Nevertheless, the staff member who authorized the release of Thomas failed to identify notices in Thomas’s file clearly indicating his high-control status, as well as other information that should have prohibited his decision to release Thomas on May 18 to the nearby community. To address the issues identified in the October 2007 special review, we made a total of 21 recommendations—ten recommendations to San Quentin State Prison; eight recommendations to department headquarters; and one recommendation each to the Division of Adult Parole Office of the Inspector General Page 67 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Operations, the Office of Audits and Compliance, and the California Prison Health Care Receivership Corporation. 2009 Follow-up Results We found that the California Department of Corrections and Rehabilitation and San Quentin State Prison have fully implemented two-thirds of our recommendations. The department and the institution have addressed most of the concerns we raised regarding the timely identification and treatment of inmates [confidential text removed]. In an October 5, 2007, memorandum, the department directed all reception centers to follow existing [confidential text removed] policies and procedures and provide training to receiving and release personnel [confidential text removed] within 30 days. That memorandum further directed that local operating procedures be updated to ensure that receiving and release personnel [confidential text removed] use the Distributed Data Processing System (DDPS) [confidential text removed]. Soon after the directive, San Quentin updated its local operating procedure [confidential text removed] and included the use of DDPS [confidential text removed] in the screening of arriving inmates [confidential text removed]. [One paragraph of confidential text removed]. In December 2007, the department reported that it assembled a team of three case records managers to conduct a compliance review of specific areas within the San Quentin reception center case records office. The compliance review team reviewed the central file request process from San Quentin’s Case Records North and South; the processing of holds, warrants, and detainers by case records staff; and the preparation and approval of the warden’s checkout order. As reported by the institution, we confirmed that appropriate action was taken against staff members involved in the Thomas incident. Case records staff, correctional counselor IIIs, and classification and parole representatives at all institutions were directed by the department to attend training on the department’s policy over the proper notifications to be made of an inmate hold, warrant, or detainer. Finally, San Quentin added additional procedures in its parole and checkout process for high-control inmates that should prevent a similar incident from occurring. Despite the above actions, other recommendations we made are only partially implemented or not implemented. Those recommendations are repeated below. Follow-up Recommendations The OIG made seven follow-up recommendations. Five of these are confidential and do not appear in the public version of our report. Office of the Inspector General Page 68 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas The Division of Adult Parole should: • Monitor the work of the parole staff who did not follow policies and procedures in identifying Thomas as high-control and who failed to notify the institution of the inmate’s release plans and reporting instructions. Continue monitoring this work until those staff members are consistently complying with policies and procedures. If appropriate, provide remedial training or take disciplinary action. (October 2007) The Office of Audits and Compliance should: • Audit the Division of Adult Parole Operations’ compliance with the above policies and procedures. The division should use the findings from this audit to train and discipline staff as appropriate. (October 2007) The matrixes on the following pages summarize the results of the 2009 follow-up audit. Office of the Inspector General Page 69 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Special Review into the California Department of Corrections and Rehabilitation’s Release of Inmate Scott Thomas Finding 1 The contents of this finding are redacted because of their confidential nature. This finding is based on specific health care information for Thomas. The OIG removed the text of this finding to comply with state and federal privacy laws. We made ten recommendations related to this finding. Of these recommendations, the department has fully implemented five and partially implemented four. One recommendation has not been implemented. Office of the Inspector General Page 70 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Finding 2 The contents of this finding are redacted because of their confidential nature. This finding is based on specific health care information for Thomas. The OIG removed the text of this finding to comply with state and federal privacy laws. We made ten recommendations related to this finding. Of these recommendations, the department has fully implemented five and partially implemented four. One recommendation has not been implemented. Office of the Inspector General Page 71 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Finding 3 San Quentin case records and counseling staff incorrectly identified inmate Scott Thomas as the subject of a warrant and inappropriately released him to the custody of the Alameda County Sheriff’s Office. (October 2007) Recommendation Status Comments The warden of San Quentin should: Monitor the work of the staff who did not follow policies Fully California Department of Corrections and Rehabilitation’s response: and procedures in processing the warrant notification and Implemented Fully Implemented. An investigation has been conducted and appropriate in validating inmate holds, wants, or detainers prior to adverse action against the [staff members] is complete. releasing Scott Thomas to Alameda County. Continue monitoring this work until those staff members are Office of the Inspector General’s comments: consistently complying with policies and procedures. If Based on OIG site visits to San Quentin in March and November 2008, the appropriate, provide remedial training or take disciplinary institution implemented procedural changes in the case records area that should action. (October 2007) prevent case records staff from improperly processing the release or parole of a high-control inmate, and prevent mistakes in the processing of warrant notifications and validating inmate holds, wants, or detainers. We also confirmed during the November site visit that disciplinary action was taken against the appropriate staff members. Ensure that appropriate staff notify inmates who are the Fully California Department of Corrections and Rehabilitation’s response: subjects of a warrant notification and that staff document Implemented Fully Implemented. A memorandum directing the institutions to train staff on the notification in the inmates’ central files. their responsibility in the warrant procedures regarding the notification to (October 2007) inmates and documentation of warrants was issued with training completed in December 2007. Office of the Inspector General’s comments: The written direction referenced in the department’s response was a January 2, 2008, memorandum from the director of the Division of Adult Institutions to all wardens, classification and parole representatives, correctional counselor IIIs, and case records managers. The memorandum reemphasized the existing department policy for the inmate notification of a hold, warrant, or detainer. The memorandum directed that training on the policy be completed by January 18, 2008. San Quentin’s associate warden over the institution’s reception center operations issued a subsequent memorandum on March 7, 2008, to the institution’s correctional counselor IIs and IIIs and Office of the Inspector General Page 72 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Recommendation Status Comments correctional case records managers and supervisors. An attachment to the memorandum clarified staff responsibilities and duties for inmate holds, warrants, and detainers. The attachment addressed how staff members are to notify an inmate who is the subject of a warrant notification, and how staff members must document the notification in the inmate’s central file. In-service training records indicate that San Quentin gave training on holds and warrants to its case records staff 12 days after the Scott Thomas incident. The staff members who did not follow policies and procedures in processing the warrant notification and in validating inmate holds, warrants, or detainers before releasing Scott Thomas to Alameda County were both present for that training. With the assistance of the department’s Office of Audits Fully California Department of Corrections and Rehabilitation’s response: and Compliance, audit a representative sample of inmates’ Implemented Fully Implemented. The Office of Audits and Compliance has developed an records to determine the extent of non-compliance with audit tool and included the audit of Case Records into the peer review audit case records policies and procedures. If the rate of process effective January 2008. compliance is unsatisfactory, provide training or administer progressive discipline, if necessary, to staff and Office of the Inspector General’s comments: supervisors who are not performing their jobs. In December 2007, a team of three case records managers from department (October 2007) headquarters conducted a compliance review of specific areas within the San Quentin reception center case records office. They reviewed the central file request process from other regions; the processing of holds, warrants, and detainers; and the warden’s checkout order. In addition, we confirmed that the holds, warrants, and detainers section of the audit included a worksheet for use in the peer review audit of case records by the department’s Office of Audits and Compliance. Follow-up Recommendations None Office of the Inspector General Page 73 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Finding 4 Despite Division of Adult Parole Operations and San Quentin staff’s failure to follow department procedures, the prison reception center’s staff should have known state law prohibited Scott Thomas’s release on a Friday. (October 2007) Recommendation Status Comments The warden of San Quentin should: Monitor the work of those staff members who did not Fully California Department of Corrections and Rehabilitation’s response: follow policies and procedures in reviewing Thomas’s Implemented Fully Implemented. An investigation has been conducted and appropriate records before release. Continue monitoring this work until adverse action against the [subject staff members] is complete. those staff members are consistently complying with policies and procedures. If appropriate, provide remedial Office of the Inspector General’s comments: training or take disciplinary action. (October 2007) Based on OIG site visits to San Quentin in March and November 2008, San Quentin implemented procedural changes in the case records area designed to prevent case records staff from improperly processing the release or parole of a high-control inmate. The procedures are also designed to prevent mistakes in the processing of warrant notifications and in validating inmate holds, wants, or detainers. We confirmed during the November site visit that disciplinary action was taken against the subject staff members. Finding 3 of this report includes a recommendation to Fully California Department of Corrections and Rehabilitation’s response: audit a representative sample of inmates’ records to Implemented Fully Implemented. The Office of Audits and Compliance has developed an determine the extent of non-compliance with case records audit tool and included the audit of Case Records into the peer review audit policies and procedures. Include in this audit testing for process effective January 2008. compliance with the preparation and approval of inmate checkout orders, as cited in this finding. (October 2007) Office of the Inspector General’s comments: In December 2007, a team of three case records managers from department headquarters conducted a compliance review of specific areas within the San Quentin reception center case records office. They reviewed the central file request process from other regions; the processing of holds, warrants, and detainers; and the warden’s checkout order. In addition, the department developed a holds, warrants, and detainers audit worksheet to be used in the peer review audit of case records by the department’s Office of Audits and Compliance. Office of the Inspector General Page 74 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Recommendation Status Comments The Division of Adult Parole Operations should: Monitor the work of the parole staff who did not follow Not California Department of Corrections and Rehabilitation’s response: policies and procedures in identifying Thomas as high Implemented Not Applicable. The recommended action for this item is Not Applicable control and who failed to notify the institution of the because the regulations were not up to date. inmate’s release plans and reporting instructions. Continue monitoring this work until those staff members are As such, DOM Section 81010.23 is being updated to incorporate current policy consistently complying with policies and procedures. If with regard to Health Care release procedures. The DOM revisions will appropriate, provide remedial training or take disciplinary incorporate and reflect current Division of Adult Institutions (DAI) and action. (October 2007) Division of Adult Parole Operations (DAPO) policy and procedures. These revisions shall address initial releases, as well as the release of Health Care parole violators. Office of the Inspector General’s comments: The OIG disagrees that this recommendation is not applicable. The need to change or revise department regulations and policies does not alleviate responsibility to monitor and supervise work performance using current department regulations and policies. Therefore, we regard this recommendation as not implemented. The Office of Audits and Compliance should: Audit the Division of Adult Parole Operations’ compliance Not California Department of Corrections and Rehabilitation’s response: with the above policies and procedures. The division Implemented Not Applicable. According to the Division of Adult Parole Operations, this should use the findings from this audit to train and finding by the Office of the Inspector General is based on an outdated discipline staff as appropriate. (October 2007) Department Operations Manual section and has not been followed since 1992. This being the case, there is no function for the Office of Audits and Compliance to audit. As such, the need for the referenced audit is unnecessary. Office of the Inspector General’s comments: The OIG disagrees that this recommendation is not applicable. Clearly, there was a departure from policies, procedures, or standard practice that contributed to the incident. Therefore, an audit by the department’s Office of Audits and Compliance of the Division of Adult Parole Operations’ compliance with policies, procedures, or standard practice currently in effect is appropriate. We Office of the Inspector General Page 75 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Recommendation Status Comments regard this recommendation as not implemented. Follow-up Recommendations The Division of Adult Parole should: • Monitor the work of the parole staff who did not follow policies and procedures in identifying Thomas as high-control and who failed to notify the institution of the inmate’s release plans and reporting instructions. Continue monitoring this work until those staff members are consistently complying with policies and procedures. If appropriate, provide remedial training or take disciplinary action. (October 2007) The Office of Audits and Compliance should: • Audit the Division of Adult Parole Operations’ compliance with the above policies and procedures. The division should use the findings from this audit to train and discipline staff as appropriate. (October 2007) Office of the Inspector General Page 76 2009 Accountability Audit Special Review into the Release of Inmate Scott Thomas Finding 5 A staff member did not follow department procedures when he paroled Scott Thomas from security housing. (October 2007) Recommendation Status Comments The warden of San Quentin should: Require that the associate warden closely monitor the staff Fully California Department of Corrections and Rehabilitation’s response: member’s work to ensure he complies with the policies Implemented Fully Implemented. An investigation has been conducted and appropriate and procedures pertaining to his position. If necessary, adverse action against the [subject staff member] is complete. provide training or impose discipline as appropriate. (October 2007) Office of the Inspector General’s comments: Based on an OIG site visit to San Quentin in November 2008, disciplinary action was taken against the staff member in question, and the employee was reassigned. We note, however, that between the time the department became aware of the staff member’s role in releasing Scott Thomas and that employee’s reassignment, the staff member improperly released at least one other inmate. Further, two more inmates were improperly released from San Quentin before measures were put in place to minimize the probability of further such incidents. Follow-up Recommendations None Office of the Inspector General Page 77 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit The California Institution for Women Quadrennial and Warden Audit We found that the California Institution for Women had fully Implementation implemented almost two-thirds of our recommendations. Report Card Specifically, the institution has addressed many of the concerns we raised regarding the access to and delivery of education 2007 Recommendations: 23 services to inmates, the processing of use-of-force incident packages, and the qualifications of custody staff assigned to armed posts. Fully Implemented: 15 (65%) Partially Implemented: Summary 8 (35%) In December 2007, we issued an audit report8 concerning the California Institution for Women (CIW) and the performance of its warden. The purpose of the audit was to satisfy our statutory requirement to audit each warden one year after appointment and to audit each correctional institution at least once every four years. The report revealed that although Warden Dawn Davison faced numerous challenges, her supporters described her as a compassionate warden who is devoted to CIW’s mission. Her supporters also felt that she had made great strides in steering the institution in a positive direction. Davison had implemented several innovative programs, and she brought a positive energy to the staff and inmates. Overall, we found that Davison is a hard worker and generally performs her duties well, but she could improve by requiring a greater degree of compliance with department policy by her staff. Nevertheless, we found that Davison was steadily improving the prison, and we concluded that she should continue serving as warden at CIW. Background of Warden The Governor appointed Dawn S. Davison as the warden of CIW in November 2004. Davison began her career with the State of California in January 1980 as a graduate student assistant at Lanterman Developmental Center. In 1986, Davison transferred to the department as a personnel supervisor at CIW. Over the next eight years, she advanced through various administrative classifications, which provided her with extensive personnel experience. In January 1994, Davison was promoted to business manager at Calipatria State Prison. In October 1997, Davison received a promotion to correctional administrator at California State Prison, Los Angeles County. In May 2000, she transferred to the California Rehabilitation Center in Norco, where she planned and directed the overall housing operations for approximately 4,000 Level II inmates. Davison then served as the chief deputy warden at CIW from 2002 until she became warden in 2004. We evaluated Davison in October 2005 following the enactment of Penal Code section 6126(a)(2). 8 “The California Institution for Women Quadrennial and Warden Audit” may be found on the OIG’s Web site: http://www.oig.ca.gov/media/reports/BAI/audits/Quadrennial%20and%20Warden%20Audit_2007- 12%20California%20Institution%20for%20Women.pdf Office of the Inspector General Page 78 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Institution Overview Established in 1952, CIW’s primary mission is to provide a safe and secure environment while providing quality health care and institution programs geared to meet the special needs of female offenders. CIW also houses inmates with special needs, including maternity care, psychiatric care, methadone treatment, and medical problems such as HIV infection. Located in Corona in Riverside County, the institution accommodates all custody levels of female inmates and functions as a reception center for incoming female inmates. As of September 30, 2007, the department reported that CIW housed 2,511 inmates. CIW offers various educational, vocational, and rehabilitative programs designed to increase inmates’ social awareness and personal responsibility. For example, the institution provides substance abuse treatment programs, firefighting training, and several self-help groups and community improvement projects. In partnership with the Center for Children of Incarcerated Parents, one of the institution’s notable programs is the Family Reunification Program, which helps incarcerated mothers maintain or regain contact with their children. Previous Findings and Recommendations During our 2007 audit, we made the following findings: • The aging and overcrowded institution had fallen into disrepair, and many buildings had become inadequate; nevertheless, the institution still waited for overdue repair funds from department headquarters. • Inmate attendance rates were poor in education classes because of frequent cancellations and other factors. • The institution did not always assign inmates with low reading abilities to adult basic education classes. • Inmates sent to off-site medical specialists did not always receive prompt follow-up medical care. • The institution did not complete its use-of-force incident packages within the required timelines. • The visiting center staff did not consistently adhere to visiting policies and regulations, increasing the risk of visitors bringing banned materials into the institution. • The institution failed to ensure that staff members assigned to armed posts always met their quarterly weapons qualifications requirements. Office of the Inspector General Page 79 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit To address the findings identified in the December 2007 audit, we made 23 recommendations to the department and CIW. 2009 Follow-up Results The department and CIW reported that they had fully implemented almost two-thirds of the recommendations we made in our December 2007 report. CIW reported substantial progress in addressing the weaknesses related to its inmate education program, and the institution reorganized education staff to provide more consistent classroom opportunities to inmates. CIW also reported that it had issued policies and trained correctional counselors and inmate assignment staff to ensure that they consistently assign inmates with low reading scores to education programs. In addition, CIW reported that it had fully addressed the concerns we raised related to the late submittal of use-of-force incident packages. The institution reported that it had established and implemented a new tracking system to monitor the timeliness of incident reports that include use of force. Finally, CIW reported that it had resolved the weakness related to officers who work in armed posts failing to receive proper weapons qualifications. We reviewed weapons qualification records for custody staff assigned to armed posts in July 2008 and found that CIW’s corrective actions have been effective. Follow-up Recommendations To address the recommendations that the department or CIW has not yet fully or substantially implemented, the OIG recommends that the California Department of Corrections and Rehabilitation: • Identify all maintenance and safety problems and generate a corrective action plan. (December 2007) • Identify staffing requirements and resources necessary to complete repairs and maintain the institution’s infrastructure based on the corrective action plan developed. (December 2007) • Compare the inmate literacy requirements contained in its Operations Manual section 101010.1 with those of Penal Code section 2053.1 and change the department Operations Manual as necessary. (December 2007) • Assess whether legislative exemptions from current state laws related to inmate literacy are needed for the inmate firefighting program, especially during dry years. (December 2007) Office of the Inspector General Page 80 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit • Perform an analysis of the visiting center staffing levels at the three adult women’s correctional facilities to determine whether appropriate staffing exists at each facility based on the average number of visitors each institution processes daily and the physical layout of each visiting facility. (December 2007) In addition, we recommend that: • The California Department of Corrections and Rehabilitation’s Division of Health Care Services and the California Health Care Receivership should assess the possible causes for the delays in providing inmates with prompt follow-up care, including the timely scheduling of appointments and whether there are too few doctors available to meet the 14-day requirement, and take appropriate corrective action. (December 2007) • The California Institution for Women and the management of the El Prado Adult School should ensure that the classrooms have adequate air conditioning by obtaining sufficient capital outlay funding to purchase and install appropriate air conditioning units. (December 2007). • The California Institution for Women should implement measures to address the high turnover of custody staff assigned to the visiting area. (December 2007) The matrixes on the following pages summarize the results of the 2009 follow-up audit. Office of the Inspector General Page 81 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit The California Institution for Women Quadrennial and Warden Audit Finding 1 The aging and overcrowded institution has fallen into disrepair, and many buildings have become inadequate, yet the institution still waits for overdue repair funds from department headquarters. (December 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Assemble an experienced team and conduct a thorough Fully California Department of Corrections and Rehabilitation’s response: physical plant inspection of the California Institution for Implemented Fully Implemented. Assessment completed and sent to Facility Planning, Women. (December 2007) Construction & Management on May 12, 2008. Office of the Inspector General’s comments: We reviewed the facilities condition assessment that a department consultant completed for the buildings located at CIW. The department contracted with VFA Inc. to conduct the assessment. Using the results of the inspection, identify all Partially California Department of Corrections and Rehabilitation’s response: maintenance and safety problems and generate a corrective Implemented Partially Implemented. Facilities Management met with staff members from action plan. (December 2007) CIW on June 13, 2008 to review and discuss their facility assessment documents. Facilities Management provided a requirement list report to CIW listing any time-sensitive priorities. The requirement list is being used by CIW to develop their long-term plan of action for maintenance projects/issues at CIW. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Using the corrective action plan, identify staffing Partially California Department of Corrections and Rehabilitation’s response: requirements and resources necessary to complete repairs Implemented Partially Implemented. Facilities Management is currently in the process of and maintain the institution’s infrastructure. preparing a Statewide Budget Change Proposal for special repair projects, (December 2007) deferred maintenance projects and additional plant operation staffing. Office of the Inspector General Page 82 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Recommendation Status Comments 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: • Using the results of the inspection, identify all maintenance and safety problems and generate a corrective action plan. (December 2007) • Using the corrective action plan, identify staffing requirements and resources necessary to complete repairs and maintain the institution’s infrastructure. (December 2007) Office of the Inspector General Page 83 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Finding 2 The attendance rate is poor in education classes because of frequent cancellations and other factors. (December 2007) Recommendation Status Comments The California Institution for Women and the management of the El Prado Adult School should: Ensure that they effectively utilize all available teaching Fully California Department of Corrections and Rehabilitation’s response: staff and redirect teachers as necessary. (December 2007) Implemented Fully Implemented. Education proposal approved by the Office of Correctional Education on 1/30/08. Office of the Inspector General’s comments: We reviewed the proposal that CIW submitted to the Office of Correctional Education to better utilize available teaching staff and redirect teachers as necessary. The proposal contained the appropriate approvals and included provisions for better utilizing instructors from the bridging program. Ensure that the classrooms have adequate air conditioning Partially California Department of Corrections and Rehabilitation’s response: by obtaining sufficient capital outlay funding to purchase Implemented Partially Implemented. Concept Paper has been received from the institution and install appropriate air conditioning units. and is under consideration for development as a Capitol Outlay Budget (December 2007). Concept Proposal (COBCP) for Fiscal Year 2010-2011. This COBCP funding to purchase and install appropriate air conditioning units. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. As part of the performance appraisal process, periodically Fully California Department of Corrections and Rehabilitation’s response: review teacher files to ensure that teachers initiate Implemented Fully Implemented. Tracking log established and maintained in the main disciplinary actions in accordance with the policies Education Office. In addition, copies of progressive discipline are placed in established in the Education Staff Handbook. the Education file and provided for the teacher’s class file. (December 2007) Office of the Inspector General’s comments: We reviewed an August 30, 2007, memorandum that the acting principal of the El Prado Adult School sent to CIW education staff. The memorandum reemphasized the methods for disciplining inmates who do not attend Office of the Inspector General Page 84 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Recommendation Status Comments education programming. The memorandum also established a tracking system for monitoring disciplinary actions. CIW provided evidence of a training class it provided to CIW education staff on the disciplinary process. CIW also provided an example of a log it has created to track inmates who have received discipline for missing education classes. Follow-up Recommendation The California Institution for Women and the management of the El Prado Adult School should ensure that the classrooms have adequate air conditioning by obtaining sufficient capital outlay funding to purchase and install appropriate air conditioning units. (December 2007). Office of the Inspector General Page 85 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Finding 3 The California Institution for Women does not always assign inmates with low reading abilities to adult basic education classes. (December 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation should: Compare the inmate literacy requirements contained in its Partially California Department of Corrections and Rehabilitation’s response: Operations Manual section 101010.1 with those of Penal Implemented Partially Implemented. Determined revisions necessary for entire Education Code section 2053.1 and change the department section of the DOM. Team established in July 2008 to develop issue paper Operations Manual as necessary. (December 2007) addressing recommendations for each revision. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. For the inmate firefighting program, assess whether Partially California Department of Corrections and Rehabilitation’s response: legislative exemptions are needed from current state laws Implemented Partially Implemented. Due to complexities of providing educational services related to inmate literacy, especially during dry years. in a camp environment, the Principal and Distance Learning Teacher at CIW (December 2007) are drafting an issue paper for discussion purposes. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. The California Institution for Women should: Assign all inmates with reading scores below the ninth Fully California Department of Corrections and Rehabilitation’s response: grade level to formal education programs regardless of Implemented Fully Implemented. Classification committees are assigning inmates with a their educational attainment. (December 2007) 9.0 or below to Education or placing them on a Waiting List for Educational Services. Appropriate training is being conducted, as well as monthly reports generated. Office of the Inspector General’s comments: We reviewed a January 16, 2008, memorandum from CIW’s warden that Office of the Inspector General Page 86 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Recommendation Status Comments requires all inmates appearing before unit classification committees with a reading score below the ninth grade level to be assigned to a formal education program or placed on the education waiting list. CIW also provided documentation of training it provided to correctional counselors on the new requirements. We reviewed reports showing the results of unit classification committee hearings, which included evidence that the counselors are reviewing inmates’ reading levels when making assignments. Develop written procedures that align with the Fully California Department of Corrections and Rehabilitation’s response: department’s current education policies. (December 2007) Implemented Fully Implemented. Updated Departmental Operations Manual Supplement #155 established. This supplement includes written procedures that align with the departments current education policies. Office of the Inspector General’s comments: We reviewed the supplement #155 and found that it included requirements that align with the department’s current education policies. Provide training to members of the Unit Classification Fully California Department of Corrections and Rehabilitation’s response: Committee and the Inmate Assignment Office staff on the Implemented Fully Implemented. Appropriate training was conducted with all Correctional proper way to assess test scores before assigning inmates Counselors I (CCI) and Correctional Counselors II (CCII) in January 2008. to education, forestry, and other programs at the institution. If exceptions to the written policies and Office of the Inspector General’s comments: procedures are necessary, written approval from an We reviewed a January 24, 2008, memorandum from the principal of the El associate warden or higher should be placed in the Prado Adult School that requires all correctional counselors and the inmate inmate’s case file. (December 2007) assignment lieutenant to attend the training program. Monitor the work of the Unit Classification Committee Fully California Department of Corrections and Rehabilitation’s response: and the Inmate Assignment Office until the staff Implemented Fully Implemented. Appropriate training was conducted with all CCI’s and demonstrate that they consistently comply with the written CCII’s in January 2008. policies and procedures. (December 2007) Office of the Inspector General’s comments: According to the correctional counselor III who oversees CIW’s classification functions, a correctional counselor II reviews each inmate assignment to ensure that an inmate’s reading assessment score was properly considered by counselors and inmate assignment staff. Office of the Inspector General Page 87 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Follow-up Recommendations The California Department of Corrections and Rehabilitation should: • Compare the inmate literacy requirements contained in its Operations Manual section 101010.1 with those of Penal Code section 2053.1 and change the department Operations Manual as necessary. (December 2007) • Assess whether legislative exemptions from current state laws related to inmate literacy are needed for the inmate firefighting program, especially during dry years. (December 2007) Office of the Inspector General Page 88 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Finding 4 Inmates sent to off-site medical specialists do not always receive prompt follow-up medical care. (December 2007) Recommendation Status Comments The California Department of Corrections and Rehabilitation’s Division of Health Care Services and the California Health Care Receivership should: Assess the possible causes for the delays in providing Partially California Department of Corrections and Rehabilitation’s response: inmates with prompt follow-up care, including the timely Implemented Partially Implemented. Pending Independent Review. scheduling of appointments and whether there are too few doctors available to meet the 14-day requirement, and take Office of the Inspector General’s comments: appropriate corrective action. (December 2007) The OIG performed no audit procedures to verify the department’s representation. Follow-up Recommendation The California Department of Corrections and Rehabilitation’s Division of Health Care Services and the California Health Care Receivership should assess the possible causes for the delays in providing inmates with prompt follow-up care, including the timely scheduling of appointments and whether there are too few doctors available to meet the 14-day requirement, and take appropriate corrective action. (December 2007) Office of the Inspector General Page 89 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Finding 5 The California Institution for Women does not complete its use-of-force incident packages within the required timelines. (December 2007) Recommendation Status Comments The California Institution for Women should: Use the current electronic use-of-force log as a tracking Fully California Department of Corrections and Rehabilitation’s response: system to ensure the prompt follow-up on use-of-force Implemented Fully Implemented. The Use of Force Coordinator and the District Attorney incident packages submitted late. (December 2007) Liaison Officer have established a new tracking system identifying all incident reports and timeframes to include Use of Force incidents. Office of the Inspector General’s comments: We reviewed the tracking system that CIW uses to ensure prompt follow-up on late use-of-force incident packages, and we agree that––if used as designed––the system would be effective in tracking the receipt of reports. Immediately enforce its policy that all staff members are to Fully California Department of Corrections and Rehabilitation’s response: forward their use-of-force incident packages to the use-of- Implemented Fully Implemented. The Use of Force Coordinator prepares a weekly force coordinator within stated timeframes. The institution memorandum to the Chief Deputy Warden identifying all late or outstanding should use performance appraisals and progressive incident reports to include Use of Force incidents. discipline to hold staff members and the use-of-force coordinator accountable for their adherence to the policy. Office of the Inspector General’s comments: (December 2007) We reviewed periodic reports that the use-of-force coordinator prepared for the chief deputy warden to identify overdue incident reports. The reports included the incident log number, the date of the incident, the incident commander, and the current status of the report. Follow-up Recommendations None Office of the Inspector General Page 90 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Finding 6 The visiting center staff does not consistently adhere to visiting policies and regulations, increasing the risk of visitors bringing banned materials into the institution. (December 2007) Recommendation Status Comments The California Institution for Women should: Immediately provide training to all visiting center staff Fully California Department of Corrections and Rehabilitation’s response: members regarding their responsibilities for enforcing the Implemented Fully Implemented. Appropriate training was conducted with all Visiting visiting rules and regulations. (December 2007) Center Staff in January 2008 and ongoing as necessary. In addition, the Visiting Brochure was revised in April 2008. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Provide adequate oversight of the visiting function to Fully California Department of Corrections and Rehabilitation’s response: ensure the visiting center staff is enforcing all inmate Implemented Fully Implemented. Staffing patterns were reviewed by CIW to determine if visiting policies and regulations, terminating visiting for more staff could be added without depleting other areas. In May 2008, a non-compliance with visiting regulations, and roaming the Correctional Lieutenant was added to Visiting Room staffing. visiting areas. (December 2007) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Use the sound option on the metal detector to prevent Fully California Department of Corrections and Rehabilitation’s response: misinterpretation of the metal detector’s readings. Implemented Fully Implemented. A new metal detector was purchased and installed on (December 2007) January 15, 2008. Office of the Inspector General’s comments: We reviewed the purchase order that CIW created to obtain its new metal detector. We also observed the new metal detector and confirmed that CIW is using the sound option. Office of the Inspector General Page 91 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Recommendation Status Comments Consider installing security cameras to provide an Fully California Department of Corrections and Rehabilitation’s response: additional deterrent to the introduction of contraband. Implemented Fully Implemented. A camera system was purchased and installed on March (December 2007) 1, 2008. Office of the Inspector General’s comments: We reviewed the purchase order that CIW created to obtain its new camera system. Implement measures to address the high turnover of Partially California Department of Corrections and Rehabilitation’s response: custody staff assigned to the visiting area. Implemented Partially Implemented. In May 2008, CIW contacted the Prison Industry (December 2007) Authority regarding the status of the new Visiting Processing Center being built. In September 2008, the new Visiting Processing Center was completed and is being utilized. The processing center and visitor center was too small confined quarters for staff to work. These changes make it a more desirable area to work. 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: Perform an analysis of the visiting center staffing levels at Partially California Department of Corrections and Rehabilitation’s response: the three adult women’s correctional facilities to determine Implemented Partially Implemented. A staffing analysis was completed in August 2008. It whether appropriate staffing exists at each facility based was determined that additional staff was needed and a request for 3.0 on the average number of visitors each institution personnel year positions for visitor center staffing is being prepared in fiscal processes daily and the physical layout of each visiting year 2010. facility. (December 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 92 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Follow-up Recommendations The California Institution for Women should implement measures to address the high turnover of custody staff assigned to the visiting area. (December 2007) The California Department of Corrections and Rehabilitation should perform an analysis of the visiting center staffing levels at the three adult women’s correctional facilities to determine whether appropriate staffing exists at each facility based on the average number of visitors each institution processes daily and the physical layout of each visiting facility. (December 2007) Office of the Inspector General Page 93 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Finding 7 The California Institution for Women fails to ensure that staff members assigned to armed posts always meet their quarterly weapons qualifications requirements. (December 2007) Recommendation Status Comments The California Institution for Women should: Ensure all staff members who are issued a department Fully California Department of Corrections and Rehabilitation’s response: firearm as part of their regular or special assignment, such Implemented Fully Implemented. Memorandums were issued to staff on October 1, 2007 as armed posts, complete a quarterly proficiency course and again on January 4, 2008 addressing quarterly proficiency requirement. before and after assuming the assignment. (December 2007) Office of the Inspector General’s comments: Although its January 4, 2008, memorandum does not specifically address firearms qualification requirements, the October 1, 2007, memorandum does address the requirements. This memorandum restates the department Operations Manual requirement that “all departmental peace officers who are issued a departmental weapon as part of their regular or special assignment…shall complete a proficiency course on a quarterly basis prior to assuming the post.” The October 1, 2007, memorandum identifies specific CIW post assignments covered by the requirement and states that an employee must complete the training before he or she can assume the post. We reviewed the weapons qualification records of officers assigned to armed posts as of July 2008. Each officer who worked in an armed post had either qualified or received counseling for failing to complete qualification. Set up a process to track adherence to the quarterly Fully California Department of Corrections and Rehabilitation’s response: weapons requirement for peace officers who are issued a Implemented Fully Implemented. A memorandum was issued on December 1, 2007 department firearm as part of their regular or special addressing and ensuring bi-weekly reviews are being conducted. assignment. (December 2007) Additionally, there is now a Quarterly Qualification Listing published in the In-Service Training Bulletins. Office of the Inspector General’s comments: We reviewed the December 1, 2007, memorandum requiring armory staff to complete biweekly reviews of staff members requiring quarterly weapons qualification. We also reviewed a July 2008 quarterly qualifications listing, Office of the Inspector General Page 94 The California Institution for Women 2009 Accountability Audit Quadrennial and Warden Audit Recommendation Status Comments which identified the dates that range qualifications would occur and the post positions that require quarterly qualification. The listing also included a notice that failure to qualify would result in staff members being redirected from their posts. We reviewed the weapons qualification records of officers assigned to armed posts as of July 2008. Each officer who worked in an armed post had either qualified or received counseling for failing to complete qualification. Follow-up Recommendations None Office of the Inspector General Page 95 2009 Accountability Audit Chapter 2 Chapter 2: Follow-up Results for Six Reports Issued Between 2000 and 2006 This chapter provides the follow-up results of six audits and reviews originally issued between 2000 and 2006. 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 53 percent (10 of 19) of our past recommendations. Nine recommendations remain unimplemented or only partially implemented, and one recommendation is 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.15 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. Summary of Results During our follow-up for this accountability audit, we found that the department has satisfactorily implemented (either fully or substantially implemented) ten of the 19 recommendations that were remaining at the start of this audit—a completion rate of 53 percent, as shown in Table 3. We also found that one recommendation was no longer applicable, thus leaving nine recommendations still unimplemented or only partially implemented. Table 3 Overall Implementation Rates at the Start of the 2009 Accountability Audit Status of Implementation Number of Unimplemented Satisfactory Unsatisfactory Recommendations Prior to 2009 Name Implementation Implementation Accountability Audit Adult Operations and Programs 16* 8 53% 7 47% Division of Juvenile Justice 4 2 50% 2 50% Totals 20* 10 53% 9 47% * Includes one recommendation found to be no longer applicable during the current 2009 accountability audit. 15 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 96 2009 Accountability Audit Chapter 2 Notable examples of implemented recommendations from this year’s accountability audit include the following: • The Division of Juvenile Justice reported that staff members are held accountable for failure to maintain living and working conditions that comply with safety and security standards. According to the division, this effort is being accomplished through clear management directives, additional training, continued oversight, and progressive discipline. During field visits to three youth correctional facilities, including Heman G. Stark Youth Correctional Facility, we observed no noticeable safety or security concerns in the occupied rooms of these facilities’ special management program units. • The CDCR reports success in reconciling some of the reimbursable union leave time owed to the department. Since May 2008, the CDCR has generated several invoices, billing the California Correctional Peace Officers Association a total of $2.2 million for union representatives on union paid leave. • Inmates at California State Prison, Solano, who suffer from seizure-related conditions are now housed in lower bunks to protect them from fall-related injuries, according to the department. The department reports that the institution’s pharmacy sends a weekly listing of all inmates prescribed seizure medications to the associate warden of health care services who reviews the list to ensure all inmates are appropriately housed. • The California Prison Health Care Receivership Corporation reports that California State Prison, Solano, now has a process of patient-specific, pharmacy- filled prescriptions that nearly eliminates stock medications and results in a more controlled inventory. Remaining Unimplemented Recommendations Even though only nine 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 some 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 nine 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. Office of the Inspector General Page 97 2009 Accountability Audit Chapter 2 Adult Operations and Programs The department has seven remaining recommendations for its adult operations and programs. The areas affected by the unimplemented recommendations include officer training in the use of impact munitions, quarterly weapons qualifications for officers assigned to armed posts, and recovery of overpayments to substance abuse treatment contractors. For example, the department reported that the basic correctional officer academy has constructed a platform and moving targets in response to our recommendation that training on impact munitions such as the 40 mm launcher include firing from an elevated position and at moving targets. Although the department reports that it is revising the Impact Munitions Instructor’s Guide, the department will not mandate firing the 40 mm launcher from an elevated post or at a moving target. In addition, the department reported that it has not implemented our recommendation to ensure that all officers assigned to armed posts—including relief officers, permanent intermittent officers, and those working armed posts through voluntary overtime and shift swaps—must complete a weapons proficiency course each quarter. The department said that it “does not agree that quarterly training of all custody staff is reasonable or fiscally responsible with the current state financial crisis.” However, our recommendation does not require the department to train all custody staff. Rather, our recommendation is that all officers assigned to armed posts complete quarterly firearms qualifications. While the department’s response implies that our recommendation is unreasonable or fiscally irresponsible, the costs of limiting armed post assignments to only officers who have qualified quarterly are likely to be much less than the potential legal costs associated with the use of deadly force by officers not subject to quarterly firearms qualifications. Finally, the department reported that it has completed reconciliations for three substance abuse services coordination agencies that it believes have received revenues in excess of expenditures. The department reported that its own reconciliation quantifies these overpayments at over $5 million and that all three contractors have hired attorneys and will contest the reconciliation in court. Division of Juvenile Justice The Division of Juvenile Justice still has two unimplemented recommendations for improving the operations of its juvenile facilities. The division reports that it has only partially implemented our recommendation to review its methods for tracking mandated services to wards and implement procedures to ensure that such services are provided and accurately documented. However, according to the division, it has made progress with the implementation of the Ward Information Network Exchange, which enables headquarters personnel to review individual youth records in real time. Similarly, the division reports only partial implementation of our recommendation to include in its Institutions and Camps Branch Manual its policy of allowing wards in restricted programs at least three hours outside their rooms every day. 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. Office of the Inspector General Page 98 2009 Accountability Audit Chapter 2 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. 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. • The Division of Juvenile Justice needs to ensure that youthful offenders receive mandated services, especially when the offenders 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 department must develop a comprehensive training component that includes training on effectively and safely employing the 40 mm launcher against a moving target and from an elevated position. In addition, the department must ensure that every officer assigned to an armed post as part of his or her regular or special assignment completes a quarterly weapons proficiency course. The following matrixes present the findings, recommendations, and results of our follow- up review of the six reports. Office of the Inspector General Page 99 Division of Juvenile Justice 2009 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’s response: wards and implement procedures to ensure that weekly Implemented Partially Implemented. The Division of Juvenile Justice (DJJ) completed a and monthly, as well as daily, services are provided and revision of the Restricted Program Policy on March 9, 2007. Training accurately documented. (December 2000) associated with this policy was completed on May 1, 2008. A formal directive was issued to all facilities mandating compliance with Institutions and Camps Restricted Program Policy, Manuel Section 7200-7285 dated March 9, 2007. A large component of this policies training was focused on youth assigned to restricted programs receiving 3-hours a day out of their rooms as well as mandated services delivery and documentation. Particular attention was given to documentation of the reasons a service is refused or declined by a youth. To ensure accurate reporting, staff document in the comment section of the youth mandated service log the reason services are not be provided for the day. The DJJ facility superintendents have assigned staff to track mandated services on a daily basis. Each facility has developed a local process to review mandated services daily to ensure services are provided. With the implementation of the Ward Information Network Exchange (WIN Exchange) headquarters personnel are now able to review individual youth records in real time opposed to a percentage of overall weekly mandated services. The DJJ now reports deficiencies within specific youth records requiring facilities to develop action plans to remedy the deficiency in the short and long term. The continued implementation of TDOs 07-82 Restricted Program, 07-83 Delivery of Mandated Services and 07-85 Temporary Detention as well as additional training and oversight will bring this area into substantially or fully Office of the Inspector General Page 100 Division of Juvenile Justice 2009 Accountability Audit 23-and-1 Program Review Recommendation Status Comments implemented over the next 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 101 Division of Juvenile Justice 2009 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 Substantially California Department of Corrections and Rehabilitation’s response: provide clear justification for isolating wards in restricted Implemented Substantially Implemented. The Division of Juvenile Justice (DJJ) completed a programs. (December 2000) revision of the Restricted Program Policy on March 8, 2007. Training associated with this policy was completed on May 1, 2008. A formal directive was issued to all facilities mandating compliance with Institutions and Camps Restricted Program Policy, Manuel Section 7200-7285 dated March 8, 2007. As DJJ evaluated the delivery of services and long term needs of this population, we have focused on the immediate conditions of confinement to mitigate the negative impact on youth. The DJJ continues to focus on the long term needs of this population and is the process of developing Behavior Treatment Program (BTPs). In addition, the space needs of these programs are currently being addressed statewide. Three policy revisions over the last eight years have helped establish clear due processes for youth in Temporary Detention (TD), Special Management Programs (SMPs) and Administrative Lock-Down. These policy revisions have further defined the population placed in restricted programs. The DJJ has focused on the removal and redirection of mental health, suicidal, and endangered youth from restricted programs. The recent policy change eliminates the ability of staff to place endangered and suicidal youth in restricted programs requiring instead that they develop treatment intervention plans for youth meeting this criteria. The DJJ policy now requires supervisors to review and approve all youth placed on TD within the first hour of confinement. Supervisors must now endorse all placements of youth in TD effectively providing immediate oversight into how, when and why a youth is placed in temporary detention. Restricted program policy revisions mandate youth participation in SMP referrals and extensions. The policy now states that youth shall not be placed on TD for punishment and more clearly defines consideration for identified Office of the Inspector General Page 102 Division of Juvenile Justice 2009 Accountability Audit 23-and-1 Program Review Recommendation Status Comments Americans with Disabilities Act accommodations. The DJJ has enhanced the Program Change Protocol (PCP) associated with Administrative Lockdown process. The revised PCP further defines the purpose, standards, notification and reporting processes associated with this administrative action. During limited program status, facility programs and activities are clearly defined within the PCP documentation and it has enhanced the level of review and oversight by management. The DJJ has made notable progress in reducing its reliance on TD, SMPs, and Administrative Lockdown. The average length of stay in an SMP has dropped from over 6 months in 2000 to 38 days as of July 2008. TDs have dropped from an average of over 14 days in 2000, to an average of 53.4 hours as of July 2008 (PbS Statistics and COMPSTAT Data Collection July 2008). The continued implementation of TDOs 07-82 Restricted Program, 07-85 Temporary Detention as well as additional training and oversight will bring this area to fully implemented over the next year. Office of the Inspector General’s comments: We reviewed the division’s revised policy and found that it remains a temporary departmental order that has yet to be finalized into the division’s Institutions and Camps Branch Manual. 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. Programming expectations currently in policy for youth programs––including wards assigned to temporary in restricted programs in the areas of education, recreation and counseling detention––at least three hours outside their rooms every exceed the minimum 3-hours out of room requirement for youth each day. day in its Division of Juvenile Justice Institutions and When these services are impacted due to safety concerns, DJJ mandates every Camps Branch Manual. (December 2000) youth receive a minimum of 3-hours per day of outside the room activity. The Division of Juvenile Justice (DJJ) completed a revision of the Restricted Program Policy on March 8, 2007. Training associated with this policy was completed on May 1, 2008. A formal directive was issued to all facilities mandating compliance with Institutions and Camps Restricted Program Policy, Manuel Section 7200-7285 dated March 8, 2007. A memorandum was Office of the Inspector General Page 103 Division of Juvenile Justice 2009 Accountability Audit 23-and-1 Program Review Recommendation Status Comments forwarded from the Director of Facilities in August 2007, reestablishing 3- hours minimum out of room time per day for youth and the expectation requiring superintendents to assign a staff to monitor this service daily. In December 2007 and January 2008, headquarters’ staff met with each facility’s restricted program management team to reinforce the requirement of 3-hours of out of room time for all youth. Staff also reviewed the implementation of the August 2007 Director’s memorandum and discussed functions of the soon to be activated Ward Information Network Exchange (WIN Exchange). In April 2008, as a result of the new functions of WIN Exchange, the DJJ began to monitor individual youth mandated service records including temporary detention providing feedback to the facility on unclear or incomplete mandated service records. The DJJ will implement Behavior Treatment Programs (BTPs) and program service days to address the needs of this population. The program service day will establish service levels above DJJ’s current minimum standards. The program service day is currently piloted at Preston Youth Correctional Facility and is expected to be implemented with all DJJ programs. Through clear management directives, continued implementation of TDOs 07- 82 Restricted Program, 07-83 Delivery of Mandated Services and 07-85 Temporary Detention as well as additional training will bring this area to substantially or fully implemented over the next 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 104 Division of Juvenile Justice 2009 Accountability Audit 23-and-1 Program Review 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 Substantially California Department of Corrections and Rehabilitation’s response: related to wards’ living conditions, particularly conditions Implemented Substantially Implemented. Staff are being held accountable for failure to that threaten safety and security. (December 2000) maintain living and working conditions that comply with Division of Juvenile Justice (DJJ) safety and security standards. In March 2008, facilities reported during the preceding six months 365 examples of their efforts towards staff accountability including, but not limited to; log notations, memorandums, training, read and initial memos, written notices of deficiencies, work improvement discussions and adverse actions. Through the implementation of TDO 07-82 Restricted Program, clear management directives, additional training, continued oversight and progressive discipline, DJJ has ensured restricted program staff are held accountable for adhering to policies and procedures. It is anticipated this area will be fully implemented over the next year. Office of the Inspector General’s comments: In November 2008, we conducted site visits at Heman G. Stark, N.A. Chaderjian, and Preston youth correctional facilities. We did not observe any noticeable safety or security concerns in the occupied rooms of each facility’s special management program. Office of the Inspector General Page 105 California State Prison, Solano 2009 Accountability Audit Management Review Audit California State Prison, Solano Management Review Audit Finding 4 The Office of the Inspector General found that a significant number of inmates taking psychotropic medications were inappropriately housed in buildings lacking air conditioning and that 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 The Office of the Inspector General recommends Fully California Department of Corrections and Rehabilitation’s response: that the institution conduct periodic evaluations of Implemented Fully Implemented. Each Monday, the CSP-Solano Pharmacy sends a listing of all the housing assignments of inmates who have been inmates prescribed seizure medications to the Associate Warden Health Care prescribed seizure medications to ensure that these Services. The Associate Warden reviews this list that same day to ensure all inmates inmates are housed appropriately. (March 2003) are appropriately housed. In the event of a discrepancy, the appropriate Facility Captain is immediately notified and ensures the inmate is correctly housed. Office of the Inspector General’s comments: We did not verify whether the procedure the department described is in effect. However, we reviewed pharmacy records as of November 6, 2008, and identified 108 inmates who were prescribed phenytoin, a drug commonly used for epilepsy seizures. Of these 108 inmates, 107 were housed in a lower bunk and one was housed in a middle bunk. Based on our limited review, it appears that the institution is ensuring that inmates who have been prescribed seizure medication are housed appropriately. Office of the Inspector General Page 106 California State Prison, Solano 2009 Accountability Audit Management Review Audit Finding 9 The Office of the Inspector General found that 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 The Office of the Inspector General recommends that Fully California Prison Health Care Receivership Corporation’s response: the California State Prison, Solano, develop a method Implemented Fully Implemented. Since the pharmacy reform project began in January 2007, a to reconcile the types and quantities of complete revision of pharmacy policies, procedures and practices has been pharmaceuticals shipped from its pharmacy to its initiated statewide, with a goal of timely, standardized and accountable clinics and the correctional treatment center with the pharmacy services. Specifically, CSP-Solano has converted to a process of types and quantities of medications prescribed to patient-specific pharmacy-filled prescriptions, and there is no longer nurse inmates. (March 2003) administered bulk stock for medication prescribed on an ongoing basis. The adoption of the patient-specific prescription process nearly eliminates stock medications and assures only medications actively ordered by prescribers are dispensed. Since each medication is filled in a patient-specific prescription, inventory is very controlled. Furthermore, stock medication is limited to an authorized list and is available only for after-hours and emergent use. The current process requires each dose of stock medication to be signed out by a nurse for a specific inmate assuring that it can be tracked. The authorized stock inventory levels are preset based on appropriate need and monitored during monthly inspections to assure the processes are followed. These changes, along with the overall pharmacy policy and practice standardization efforts, have improved both inventory control and record- keeping relating to CSP-Solano’s pharmacy program. As the reform initiatives continue to be rolled out, we expect additional improvements in accountability and efficiency while maintaining appropriate levels of service. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the receiver’s representation. Office of the Inspector General Page 107 Special Review into the Shooting of Inmate Daniel Provencio 2009 Accountability Audit on January 16, 2005, at Wasco State Prison 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 covering Not California Department of Corrections and Rehabilitation’s response: the use of direct-impact weapons from an elevated post. Implemented Not Implemented. Currently, not all of the Department’s institutions have (June 2005) elevated platforms at the range for qualification. However, the Basic Correctional Officer Academy (BCOA) and Office of Correctional Safety are currently revising the Impact Munitions Instructor’s Guide to address the use of a direct impact weapon from an elevated post and at moving targets. The BCOA has constructed a platform and have purchased moving targets that the cadets are currently being trained to discharge a weapon from an elevated post at moving targets. Although the Department is revising the Impact Munitions Instructor’s Guide, the Department will not mandate the firing of the 40MM from an elevated post and/or at a moving target. 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 Special Review into the Shooting of Inmate Daniel Provencio 2009 Accountability Audit on January 16, 2005, at Wasco State Prison 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. Currently, not all of the Department’s institutions have launcher against a moving target. (June 2005) elevated platforms at the range for qualification. However, the Basic Correctional Officer Academy (BCOA) and Office of Correctional Safety are currently revising the Impact Munitions Instructor’s Guide to address the use of a direct impact weapon from an elevated post and at moving targets. The BCOA has constructed a platform and have purchased moving targets that the cadets are currently being trained to discharge a weapon from an elevated post at moving targets. Although the Department is revising the Impact Munitions Instructor’s Guide, the Department will not mandate the firing of the 40MM from an elevated post and/or 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 assigned to an armed post as part of Not California Department of Corrections and Rehabilitation’s response: his or her regular or special assignment (which includes Implemented Not Implemented. The California Department of Corrections and relief, voluntary overtime and trades/swaps, permanent Rehabilitation does not agree that quarterly training of all custody staff is intermittent, etc.) must complete a weapons proficiency reasonable or fiscally responsible with the current state financial crisis. course on a quarterly basis. (June 2005) Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. However, we must note that our recommendation does not require the department to train all custody staff. Rather, our recommendation is that officers assigned to armed posts complete quarterly firearms qualifications. Thus, only staff who wish to be eligible for such assignments would have to undergo quarterly firearms qualifications. While we recognize that the department needs some flexibility to address emergency situations, shift swaps for employees’ convenience are not emergencies. The department’s response implies that the recommendation is unreasonable or fiscally irresponsible, but the costs of limiting armed post assignments to only officers who have qualified Office of the Inspector General Page 109 Special Review into the Shooting of Inmate Daniel Provencio 2009 Accountability Audit on January 16, 2005, at Wasco State Prison Recommendation Status Comments quarterly are likely to be much less than the potential legal costs associated with the use of deadly force by officers not subject to quarterly firearms qualifications. Office of the Inspector General Page 110 Special Review into Improper Housing of Maximum Custody Inmates 2009 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: Ensure that California Code of Regulations, Title 15, section Substantially California Department of Corrections and Rehabilitation’s response: 3341.5(b) and California Department of Corrections and Implemented Substantially Implemented. The revisions have been made and submitted Rehabilitation Operations Manual section 62050.12 are to Regulations and Policy Management Branch for the regulatory amended to replace references to the psychiatric process. 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. Modify the coding in the Offender Based Information Fully California Department of Corrections and Rehabilitation’s response: System or adopt some other methodology to clearly identify Implemented Fully Implemented. Effective 6/10/08, the Offender Based Information segregated housing. For example, replace “Palm Hall” with System was modified to read AdSeg replacing Palm. “ASU.” (March 2006) Office of the Inspector General’s comments: We reviewed the Offender Based Information System (OBIS) entries for three randomly selected inmates currently in segregated housing at the California Institution for Men. For each inmate, OBIS correctly designated the inmate as being housed in ADSEG rather than PALM. Designate and train appropriate staff members to Fully California Department of Corrections and Rehabilitation’s response: immediately notify facility staff when they identify inmates Implemented Fully Implemented. An instructional memo from the Director was sent to during subsequent processing who should be placed in the institutions for staff to complete the housing of Max Custody Inmates administrative segregation. (March 2006) training by 8/31/08. All 33 institutions have submitted a memorandum Office of the Inspector General Page 111 Special Review into Improper Housing of Maximum Custody Inmates 2009 Accountability Audit at California State Prison Reception Centers Recommendation Status Comments stating the housing of Max Custody inmates training has been completed. Office of the Inspector General’s comments: We reviewed the department’s instructional memorandum outlining the training requirements related to the housing of maximum custody inmates. We also reviewed the memorandums from each of the 33 institutions indicating their level of compliance with the training directive. Based on our review, we agree with the department’s assertion that each institution has provided the required training, and it appears that the vast majority of staff members have received the training. Office of the Inspector General Page 112 Special Review into Management of Union Leave Time 2009 Accountability Audit by the 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: Continue its efforts to fully implement a system to Substantially California Department of Corrections and Rehabilitation’s response: internally reconcile union leave time on a monthly basis. Implemented Substantially Implemented. (July 2006) Update September 2008 The CDCR has been successful in reconciling some of the reimbursable union leave time owed to the Department. Since May 2008, the CDCR has generated a number of invoices, billing the California Correctional Peace Officers Association (CCPOA) a total of $2,229,275.37 for union representatives on Union Paid Leave (UPL). This amount includes two invoices for a total of $827,786.06 mailed to the CCPOA September 29, 2008 for long-term UPL October 2007 thru August 2008. See attached spreadsheet showing a summary of all invoices billed to the CCPOA. The CDCR is currently working in conjunction with the Department of Personnel Administration (DPA) to implement streamlined measures to comply with recommendations made to the CDCR by the Office of Inspector General and Bureau of State Audits. The DPA has Governor’s Office- assigned oversight over the State’s Implemented Terms governing all Bargaining Unit (BU) 6 labor matters. Next Steps: October 2008 Finalize billing for CCPOA representatives on short-term UPL, pursuant to the governing October 1, 2007 UPL Agreement (attached). Finalize streamlined procedures for the reconciliation of union leave time and billing on a monthly basis effective with the finalized September 2008 billing; Office of the Inspector General Page 113 Special Review into Management of Union Leave Time 2009 Accountability Audit by the California Department of Corrections and Rehabilitation Recommendation Status Comments invoice the CCPOA on an ongoing monthly basis capturing prior month UPL. Develop comprehensive action plan for prior year CCPOA RTB/UPL reconciliation and billing. Continue work-in-progress efforts towards automation of UPL processing and tracking internally. Continue to work with the Department’s Business Information System (BIS) project team for inclusion of the UPL processing and billing within BIS (projected implementation February 2009). Take more active efforts in collection of payment for invoices billed to the CCPOA that are past due totaling $1,401,489.31. Office of the Inspector General’s comments: We contacted a representative from the Department of Personnel Administration (DPA) and verified that the DPA is taking an active role in developing new policies and procedures for handling union paid leave matters. In conjunction with the California Correctional Peace Substantially California Department of Corrections and Rehabilitation’s response: Officers Association, develop uniform policies and Implemented Substantially Implemented. Reconciliation of the Release Time Bank (RTB) for procedures that facilitate reconciling the release time bank the time period of July 2005 thru June 2008 (RTB termination date per balance each quarter with the union’s records. (July 2006) Stipulated Agreement) is a work-in-progress. The CDCR and CCPOA had agreed upon a July 1, 2005 RTB starting balance of 17,254 hours; however, a full reconciliation of time bank donations and usage from July 2005 forward remains incomplete due to inconsistencies in data reported by both the CDCR and CCPOA. Next Steps: October 2008 The DPA will assist the CDCR in developing a comprehensive action plan for streamlined reconciliation of the RTB. Office of the Inspector General’s comments: We contacted a representative from the department’s Office of Labor Relations to follow up on this issue. Based on meeting dates provided by this representative, it appears representatives from the department and the California Correctional Peace Officers Association met to reconcile hours in the release time bank on 16 separate occasions between February 8, 2008, and Office of the Inspector General Page 114 Special Review into Management of Union Leave Time 2009 Accountability Audit by the California Department of Corrections and Rehabilitation Recommendation Status Comments November 14, 2008. In addition, we contacted a DPA representative and verified that the DPA has taken an active role in overseeing the reconciliation process. 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 monthly reconciliation process is reliant upon (July 2006) accurate reporting of union leave time by the field. The CDCR, in conjunction with the DPA, is in the process of streamlining procedures for the reconciliation/audit of union leave time and billing on a monthly basis. Field training needs are currently being identified; training via conference call will be conducted Mid-October 2008 to address field UPL process and accurate keying of leave codes. Office of the Inspector General’s comments: The OIG performed no audit procedures to verify the department’s representation. Once a new contract is negotiated for Bargaining Unit 6, Not California Department of Corrections and Rehabilitation’s response: reconsider the need for requesting legislative funding for Implemented Not Implemented. The State's Implemented Terms for BU 6 have no set term union issues addressed in labor contracts, such as and remain in effect until such time as the State and the CCPOA reach a new compensation for Bargaining Unit 6 executive vice Memorandum of Understanding bargaining contract. presidents and chapter presidents. (July 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 115 Special Review into Concerns Related to 2009 Accountability Audit 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: Collect all refunds owed to the state by the three substance Partially California Department of Corrections and Rehabilitation’s response: abuse services coordination agencies related to excess Implemented Partially Implemented. CDCR’s Office of Audits and Compliance (OAC) revenue the agencies received for services provided during completed reconciliations for the following three Substance Abuse Services their contract period December 1, 1998, to December 31, Coordination Agencies (SASCAs). In parenthesis is the dollar amounts in 2003. (October 2006) which CDCR believes the revenues have exceeded the expenditures. 1.Westcare : 1/1/2000 to 11/30/2000; 1/1/2002 to 12/31/2003 (2.6 million dollars) 2.Walden House: 6/30/1999 to 6/30/2004 (1.84 million dollars) 3.Mental Health Systems (MHS): 6/30/1999 to 6/30/2004 ($580,000) All three contractors have hired attorneys and will pursue this reconciliation in court. CDCR will hold Administrative Review Committee (ARC) hearings before scheduled court dates to allow contractors the opportunity to appeal the reconciliation findings and provide documentation to dispute the figures. 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 116 Special Review into Concerns Related to 2009 Accountability Audit Substance Abuse Treatment Contractors 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. MHS contends the 22 vehicles purchased over the accordance with generally accepted accounting principles. contract period were the property of the State and therefore, MHS should not (October 2006) be required to capitalize and depreciate the vehicles in their accounting records. CDCR’s OAC believes there is no documentation authorizing MHS to purchase any vehicles. Furthermore, MHS’s proposed budgets for the contract period did not include any amounts for the vehicle purchases. Therefore, OAC concluded the vehicles are the property of MHS and only annual depreciation may be charged under the contract. The amount MHS owes to CDCR for the vehicles, as estimated by OAC, is included in the $580,000 recovery amount indicated in item 1.1. 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 Fully California Department of Corrections and Rehabilitation’s response: costs of providing services during these periods when Implemented Fully Implemented. On October 31, 2006, a letter was sent to Mental Health reconciling its revenues to actual costs. (October 2006) Services, WestCare, and Walden House on behalf of DARS requiring revenues be reconciled to actual costs and 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 completed. All future contracts will adhere to the Line Item Budget Guide (LIBG) in which all non-expendable equipment will be included in bid documents and will be depreciated over time. Office of the Inspector General Page 117 Special Review into Concerns Related to 2009 Accountability Audit Substance Abuse Treatment Contractors Recommendation Status Comments 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 118 Special Review into Concerns Related to 2009 Accountability Audit 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: Fully cooperate with the Office of the Attorney General Not California Department of Corrections and Rehabilitation’s response: regarding the recovery of equipment the department Applicable Not Applicable. The OIG did not refer this recommendation to the Office of the improperly gifted to contractors. (October 2006) Attorney General (AG). Should any such referral be made, DARS will fully cooperate with any investigation by the AG. Office of the Inspector General’s comments: We referred this issue to the Office of the Attorney General (AG) in a March 24, 2008, letter. However, the AG’s office, in a letter dated May 19, 2008, declined to pursue the matter further. According to the letter, several concerns would impede the successful recovery of property and equipment improperly gifted to contractors. These concerns include uncertainties about the identity of the vendors and property, whether sufficient consideration was given in exchange for the property, and whether statutes of limitation apply. The letter states that because of these concerns and because the AG’s office lacks resources to make the recovery of this property a priority, the AG’s further involvement is not warranted. Because of the AG’s response, we agree with the department’s assertion that this recommendation is no longer applicable. Office of the Inspector General Page 119 Attachment Response from the California Department of Corrections and Rehabilitation