Department of Public Safety Division of Criminal Justice Office of Community Corrections Report of Audit Findings ComCor, Inc. January 2017 PURPOSE In October 2016, two client deaths occurred on-grounds at ComCor, Inc., both suspected as being due to drug overdose. Additionally, during this time both the Department of Corrections (DOC) and the El Paso County Community Corrections Board (Board) received one or more citizen complaints about security concerns at the facility. As a result of these occurrences and other concerns from the DOC, the Board and the Division of Criminal Justice (DCJ), these three agencies conducted a joint site visit and audit of the ComCor, Inc. residential program in November 2016. This multiagency performance audit focused generally on security and case management related activities within the ComCor, Inc. program. The DCJ focused specifically on observing security related activities and reviewing program documentation related to client disciplinary actions and critical incidents including anything related to the Prison Rape Elimination Act (PREA). Due to some additional concerns identified during the initial site visit, the DCJ also made a subsequent visit to ComCor, Inc. in January 2017 to review assessments and the appropriateness of placements in the newly funded ComCor, Inc. Intensive Residential Treatment (IRT) program. PROCESS A site visit was conducted between the dates of November 28-30, 2016 at ComCor, Inc. in order to collect information regarding program operations. The onsite audit team consisted of the following members: • • • • • • • • • • Joe Thome, Division of Criminal Justice Valarie Schamper, Division of Criminal Justice Jim Pyle, Division of Criminal Justice Cynthia Lockwood, Division of Criminal Justice Tahnee Santambrogio, Division of Criminal Justice Shawna Nichols, Division of Criminal Justice Gerald McCormac, El Paso County Community Corrections Board Maurice Motley, El Paso County Community Corrections Board Connie Vaughan, Department of Corrections Lesley Smith, Department of Corrections Program policies and procedures, client case records and program logs were all reviewed during the course of this audit. However, the DCJ audit team prioritized observing staff and clients within each of the three ComCor, Inc. buildings, speaking with a variety of staff and clients across shifts and reviewing camera footage when possible. A second site visit was conducted on January 6, 2017. The onsite audit team consisted of the following members: • • • • Valarie Schamper, Division of Criminal Justice Tahnee Santambrogio, Division of Criminal Justice Courtney Kramer, Division of Criminal Justice Chrystal Owin, Division of Criminal Justice The focus of this site visit was the review of client case records regarding assessments and treatment placement. SECURITY FUNCTIONS Overall, the audit team found that the staff practices in all three buildings were inadequate to effectively monitor the facility, client movement and general activities. This was evident in several ways: • On-Grounds Surveillance – ComCor, Inc. consists of three buildings. Two of these buildings (3808 and 3950) are former motels with a security office near the front of the grounds and rooms spread out behind the office. The third building (Roberts Road) is more contained with two security offices, one at the entrance to the residential area and one further to the rear of the client residential area. The physical layout of these buildings is such that proper surveillance of the grounds can be challenging and requires greater diligence to effectively comply with Standards. During the three day site visit, several gaps in surveillance were identified. In the Roberts Road facility, the audit team noted that the front security office was not staffed, leaving all security in the office to the rear. This staffing pattern allowed anyone coming into the residential area access to the first pod of client rooms before reaching security. This area cannot be seen from the rear security office and in fact, one member of the DCJ team was able to enter the facility and spend several minutes conversing with clients before being approached by staff and asked for credentials. In the motel style facilities (3808 and 3950), clients and others have unrestricted access to their rooms which cannot be observed from the security office other than by camera. However, during the three day site visit no security staff, in any of the buildings, were observed attending to camera monitors. In most cases, camera monitors were set off to the side and impossible for staff to view while also attending to the security office window. Accordingly, with only two staff per facility in most cases, camera monitors remained unviewed. Security staff safety was also of concern as headcounts were conducted by a single staff member. In all of the headcounts observed, the second staff member, preoccupied with other duties, was unable to monitor cameras and was therefore unaware of their fellow staff member’s movements during the headcount. Staff conducting counts were not provided with any means of easy communication in case of an emergency and were instead expected to use their cell phones should an issue arise. • Client Confidentiality – At the 3808 and 3950 buildings, residents are searched in the control rooms or must pass through to provide a sample for a drug screen. In each facility, the control rooms have computers on which client information was visible and paperwork was left on desks with client information also visible. Additionally, clients were brought into the control room to take medications. During this process clients stood within arm’s reach of the open medicine cabinets, and at various times throughout, staff had their backs to clients while entering information into the program’s data system. The potential for residents to see confidential information of others is significant. Although this audit did not review ComCor, Inc. procedures for compliance with the Health Insurance Portability and Accountability Act (HIPAA) laws and standards, the concerns were obvious to the audit team, and potentially expose ComCor, Inc. to significant and repeated violations of the mandates in HIPAA. • Headcounts – Several headcounts were observed and several staff were interviewed regarding headcount practices. Observations and interviews consistently revealed that staff do not verify the client’s physical presence in accordance with the Standards and best practice. Rather than confirming the identity of each client marked as present, staff merely need to observe “skin or hair.” When asked what this typically means, several staff indicated that it could be something as simple as a foot or ankle. However, even this minimal means of verifying the identity of an individual was not evident in practice at all times. For instance, during one headcount observed, the staff member was told by a client that another client was in the shower. The staff member then marked the second client as present without any further confirmation. • Contraband Control – The audit team identified significant issues with the quality of pat searches at ComCor, Inc. leading to insufficient contraband control. None of the pat searches observed in person or via camera footage were completed in a manner compliant with Standards. Each search fell short of being a complete pat search. In some cases bags and purses were left unsearched, in others clients were not required to turn out pockets, take off shoes and/or take off outerwear. In all cases, staff failed to effectively pat the client’s body from head to toe, often skipping areas such as the chest (for male clients) and ankles. Additionally, review of client files and interviews with staff and clients revealed an overemphasis on nuisance contraband rather than dangerous and/or illegal contraband. Staff repeatedly told auditors their focus during searches was cell phones, which are against the rules at ComCor, Inc. Clients reported a similar focus, suggesting that drugs were much easier to bring into the facility. • Disciplinary Processes and Due Process Considerations – ComCor, Inc. is a participant in the Behavioral Shaping Model and Reinforcement Tool (BSMART) project, which is a structured process for sanctioning and incentivizing community corrections clients. However, the audit team found that ComCor, Inc’s disciplinary practices did not align with the BSMART model as intended. The BSMART model was developed with evidence-based and best practices in mind, including the principles of swift, certain, consistent, fair and transparent. Overall, practices at ComCor, Inc. failed to adhere to many of these principles, most notably that of fairness and due process requirements. Many of the files reviewed demonstrated a clear pattern of inappropriate application of serious sanctions to minor behavioral violations, especially those related to financial matters. Additionally, any violation which may result in the termination of a client requires appropriate due process, which should include either a plea of guilty or a hearing and subsequent guilty finding. After the client has been determined to be guilty, the program should have a structured process for determining whether or not to terminate the client. However, program documentation rarely included information regarding client pleas, whether hearings had been conducted, and ultimate findings of guilt or innocence. Observation of program reviews for termination clearly indicated that these discussions were happening prior to a finding of guilt and lacked consistency and structure. Overall, the program’s processes for sanctioning and terminating clients were inconsistent and poorly documented. These practices also have implications related to placements within the IRT program as discussed below. STAFF TURNOVER AND TRAINING Reviews of the ComCor, Inc. personnel roster and recent employee terminations demonstrated an alarming rate of employee turnover. This was especially true for security staff who are responsible for monitoring clients 24/7 and ensuring the safety of the facility. Security staff also has the most frequent direct contact with clients of any other staff. The relative inexperience of the security staff at ComCor, Inc. was best demonstrated during the audit team’s observation of a graveyard shift in all three buildings. In the two motel style buildings, the most senior graveyard staff member on duty had been employed less than four months and the other only two months. The Roberts Road facility had more senior staff on duty with one being employed for approximately 18 months and the other 3 months. While turnover in community corrections is common, the significant turnover at ComCor, Inc. was compounded by inadequate training practices. During interviews with a variety of staff, training was described as primarily "on the job." For example, during an interview with a security technician, he described that he was trained to conduct room searches by accompanying a veteran staffer and simply mimicking their actions. There was no preservice training to prepare for room checks/contraband searches. The tech also shared that he had not received a written document describing the protocol for room checks nor been observed for fidelity to a procedure. This report was common among the staff interviewed. Most discussed a two day shadowing period, after which they were required to perform duties unsupervised. Some staff members also described a training checklist, wherein they would need to find a lead staffer to observe and check off activities over the remaining “orientation” period. However, staff were performing duties unsupervised prior to this checklist being completed. Generally, this resulted in new staff learning inadequate basic security procedures from more experienced staff, without knowledge of proper procedures to comply with Standards. Overall, the staff turnover and inadequate training likely had a significant role in the insufficient security related practices observed by the audit team. ASSESSEMENTS AND TREATMENT REFERRALS The audit team identified several issues with the accuracy of Standardized Offender Assessments – Revised (SOA-R) and subsequent placement into the ComCor, Inc. IRT program as well as treatment referrals generally. • Assessment Accuracy/Fidelity – Eleven files were reviewed comprehensively for the accuracy of assessments and none (0%) of the 11 assessments were completed accurately. Many of the assessment scoring errors were consistent across files, suggesting a need for additional training and coaching. • IRT Placement Practices and Appropriateness of Clients1 – Of the 11 files reviewed, only 2 (18%) of the clients appeared appropriate for IRT at the time of the referral. During the period of July 1, 2016 through December 31, 2016, 10% of program terminations from ComCor, Inc.’s residential program were a result of transfers into the IRT program. During this same time period, after conducting a statutory Administrative Review, ComCor, Inc. returned nearly 44% of Diversion clients terminated for a technical violation, with return to the program conditioned upon the completion of IRT. Program staff indicated that these types of terminations were purposeful. Clients were terminated and returned to jail with the intention of utilizing the Administrative Review process to bring the client back and into the IRT program after they spent some time in jail. This is inappropriate for several reasons. At its most basic this is an abuse of the Administrative Review process which unnecessarily takes up limited jail space. Additionally, IRT (and substance abuse treatment generally) should not be used as a sanction and is fundamentally not always appropriate for a client simply by virtue of having engaged in program infraction(s). However, discussions with program staff and administration revealed that program philosophy is to approach IRT as an interim sanction. Finally, in the case of those clients who are truly in need of IRT, the practice of regressing clients to jail prior to IRT placement serves to further destabilize those clients by extending their overall programming and delaying their participation in much needed treatment. Six of the 11 files reviewed were clients who had been terminated from residential programming and brought back into IRT after an Administrative Review. In most cases these clients had reached level 3 or level 4 within the residential program prior to being regressed and returned. This was problematic for several reasons. First, in three cases, the clients’ initial assessment indicated that they would have been appropriate for IRT; however, they were not initially placed 1 In March 2016, ComCor, Inc. was awarded an Intensive Residential Treatment (IRT) contract with the DCJ for services to begin July 1, 2016. in IRT as the program did not have an in-house IRT at the time and would not refer clients to other IRT providers. This failure to refer clients to IRT was identified during a previous site visit and brought to the attention of ComCor, Inc. and the El Paso County Community Corrections Board in April 2016. In the period between March 1, 2016 and June 30, 2016, only 1 of 195 terminations from ComCor, Inc. was as a result of a transfer to an IRT program. Accordingly, those clients in the sample who were assessed as needing IRT prior to the start of ComCor, Inc’s IRT contract, were required to attend weekly outpatient (level 3) treatment rather than the assessed IRT (level 4c) treatment. However, once these clients began to progress through the program and still struggle with substance abuse problems, no attempt was made to increase outpatient treatment to address these needs. Instead, clients progressed to higher levels of the program, developed strong recovery environments through work and community support, and then were completely destabilized by being regressed to jail and placed in inpatient treatment. Generally, IRT is not an appropriate placement for individuals who have strong recovery environments and by the time these clients were finally placed in IRT, they were no longer clinically appropriate for IRT placement. It is plausible that some program infractions could have been abated by placing clients in the appropriate level of treatment initially, upon intake assessment, rather than waiting to use IRT placement as a punitive measure. • General Treatment Referrals – Treatment requirements in several other files were reviewed and the audit team discovered that ComCor, Inc. was overriding TxRW treatment outcomes to target specifically only level 3 (WOP) treatment or level 4c (IRT). No intermediate substance use treatment levels were identified. While resources for intermediate treatment levels 4a and 4b can be challenging to identify, Colorado Springs is a large enough community to accommodate these needs. Additionally, the audit team discovered that ComCor, Inc. did not make treatment referrals in accordance with Standard. Instead, case managers would tell clients what treatment level they were required to attend and then leave it to the client to identify a provider and schedule an intake. As a result, many clients were not getting into treatment for months. PREA COMPLIANCE While ComCor, Inc. did pass their independent PREA audits finalized in May 2016, a review of program grievances and PREA related documentation revealed several concerns about ComCor, Inc.’s handling of issues related to the Prison Rape Elimination Act. • ComCor, Inc. did not appear to have investigated all potential PREA incidents sufficiently and in a manner adherent to the PREA Standards. In at least one instance there was information found in incident reports and/or grievances from clients reporting that a staff person was receiving sexual favors from a client. In this specific matter, the program did not refer this for criminal investigation although the alleged behavior was a violation of C.R.S. 18-7-701 “Sexual conduct in a correctional facility”. In another matter alleging staff sexual contact with a client during a search, the video recording (electronic monitoring data) was not preserved for investigative use. Another PREA incident involved a client reporting being sexually assaulted by another client. In this incidence, an investigation was initiated. However, there was no documentation found regarding investigation into the whereabouts or collection of electronic monitoring data of the client alleged to be the victimizer, nor was there any incident reports or chronological recording related to that individual. In contrast to PREA Standards another investigation was discontinued due to the client no longer being a resident in the facility and first responders in this case also failed to secure the reporting party and any evidence. Finally, some investigations were noted as being substantiated as “non-consensual sex” when the actual findings of the investigations substantiated consensual sex, which is not a PREA violation. • Sexual abuse incident reviews did not occur in all instances that should have been reviewed. Other incidents were reviewed past the required 30 day period and the form that ComCor, Inc. utilized did not address all of the areas identified by PREA Standard for sexual abuse incident reviews making such reviews incomplete. • Multiple PREA incidents investigated by ComCor, Inc. were not reported to the DCJ. • Other PREA related issues were identified related to staff training, program policies including their response plan, program staffing plans, reporting options for clients and PREA assessments not completed or completed late. • It should also be noted that during our review of client grievances, it became clear that such grievances, whether PREA related or not, were not consistently maintained, reviewed or responded to. Clients reported that grievances were not taken seriously by program administration and felt many simply wound up in the trash.