COLORADO DEPARTMENT
OF
PUBLIC SAFETY

Colorado Department of Public Safety
Division of Criminal Justice

Report of Intensive Residential Treatment
Audit Findings & Recommendations
for
San Luis Valley Community Corrections – Intensive Residential Treatment Program
(SLVCC-IRT)

Prepared by:
The Division of Criminal Justice
Office of Community Corrections
October 2016

 Jeanne M. Smith
Director
Colorado Department of Public Safety
Division of Criminal Justice
Glenn Tapia
Program Director
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
Valarie Schamper
Quality Assurance and Evaluation Supervisor
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
Cynthia Lockwood
Program Auditor and Quality Assurance Specialist
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
Jim Pyle
Program Auditor and Quality Assurance Specialist
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
Mindy Miklos
Community Corrections Specialist
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
Courtney Kramer
Implementation and Fidelity Specialist
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
Chrystal Owin
Interagency Criminal Justice Specialist
Colorado Department of Public Safety
Division of Criminal Justice
Office of Community Corrections
1

 AUTHORITY
The Division of Criminal Justice (DCJ) is mandated to conduct performance audits through the
following:
•

Statutory authority pursuant to C.R.S. §17-27-108 (2)(b);

•

Section T in the contract established between the Twelfth Judicial District Community
Corrections Board (Board) and the State of Colorado, with subcontractor responsibilities
incorporated in the contract between the Board and its local program(s).

REPORT DISTRIBUTION
Pursuant to C.R.S. §17-27-108 (2)(b), copies of this report have been distributed to San Luis
Valley Community Corrections (SLVCC) management, the Department of Corrections, Division
of Adult Parole, Community Corrections and Youthful Offender System, the Twelfth Judicial
District Community Corrections Board, and the Twelfth Judicial District Probation Department.
PURPOSE, METHODOLOGY & SCOPE
The Colorado Department of Public Safety's Division of Criminal Justice/Office of Community
Corrections (DCJ/OCC) initiated this limited scope audit of the SLVCC Intensive Residential
Treatment program in an effort to determine the facility's compliance with the Intensive
Residential Treatment (IRT) Scope of Work (SOW) as well as the Colorado Community
Corrections Standards (C.C.C.S.), as revised in August 2010. When appropriate, required
changes and recommendations regarding compliance with the SOW and Standards are provided.
Audit procedures include tests of documentary evidence, data analysis, observations and internal
control review, as well as interviews and discussions with program management, program staff
and offenders.

Dates of on-site visit

7/18/2016-7/21/2016

Date Scope

1/01/2015-7/21/2016

Number of case files requested

21

Number of case files provided

21

Number of case files removed

0

The results of the auditor’s findings are outlined in the following document. Data has been
accumulated through a collection of quantitative and qualitative observations.

2

 MEASUREMENT
Compliance with the Standards and the IRT Scope of Work (SOW) is described at three levels:
•
•
•

Compliant
Partially Compliant
Noncompliant

(85% - 100%)
(70% - 84%)
(69% or below)

Standards and SOW compliance ratings of 85% or above will not be addressed in the report.
Compliance with other Standards and elements of the SOW is addressed more extensively
within the body of the report. Some Standards and/or SOW elements may not have been
sufficiently reviewed to determine compliance or non-compliance, in such cases, an “NR” will
be noted on the chart. Some Standards may not apply to the program, in such cases, an “NA”
will be noted on the chart. In some cases, there may be brief observations noted within the text
of the audit report.
The Compliance Summary table provides an overall summary of the program’s compliance with
the SOW elements and Standards that were reviewed in this audit. The column titled Score
Band Rating refers to the formal results of the 2011 ratings of the Colorado Community
Corrections Standards. In this process, each Standard was rated by subject matter experts
(SME) on its expected impact on public safety, offender management, and offender treatment.
Standards rated in Bands A and B are among the Standards that the SME panel believed to be
the most important across the three dimensions.
PROGRAM AND AUDIT OVERVIEW
SLVCC is a privately owned community corrections facility in the twelfth Judicial District. The
Intensive Residential Treatment Program houses male Transition, Diversion and Condition of
Probation clients. At the time of our audit, SLVCC was providing Intensive Residential services
to 35 male offenders.
A full audit of the SLVCC-IRT program was published in December 2015. That audit
demonstrated deficiencies in many critical areas related to treatment quality and dosage.
Additionally, during that audit, auditors had concerns regarding the accuracy and validity of
some of the documentation which was provided for review. Subsequent to the completed audit, a
series of anonymous complaints and documented concerns regarding the SLVCC-IRT program
were brought to the attention of the DCJ/OCC. This follow-up limited scope audit was
undertaken for two primary purposes: 1) to determine the extent to which corrective actions had
been taken to remedy previous audit findings; 2) to determine whether information provided to
the audit team during the initial full audit conducted in October 2015 was in any way falsified.
In order to accomplish the goals established above, auditors reviewed three distinct sets of files.
The seven case files reviewed in the initial audit were reviewed again. An additional seven files
were selected which represented clients who participated in the IRT program at the same time as
those clients within the original sample. This allowed auditors to determine what, if any,
differences might exist within the original sample and a comparison group. Finally, seven more
recent files were selected to determine current program compliance and quality with regard to the
Scope of Work. It should be noted that a new Intensive Residential Treatment Scope of Work
3

 became effective on July 1, 2016, just prior to audit fieldwork. However, due the recency of the
SOW revisions and the period reviewed, findings within this audit report reflect compliance
issues relevant to the previous SOW. Accordingly, it is likely that there are additional changes
and program enhancements that will need to be made at the SLVCC-IRT program which are
driven by the revised SOW and therefore outside the scope of the current audit.
As indicated in the Compliance Summary below, overall the IRT program at SLVCC rated
Compliant in 0% of the Scope of Work elements tested; 15% of the Scope of Work elements were
rated as Partially Compliant; and 85% of the Scope of Work elements were rated as
Noncompliant.

SLVCC-IRT STANDARDS COMPLIANCE SUMMARY
SOW
Section
1C
3A
3B
3G
3H
3I
3L
4A
6D
7B
8A
8B
CCCS
6-080

Scope of Work/Standards Element

%
Compliance

Compliant
(85-100%)

Acceptance
Clinical Assessment (Differential)
Clinical Assessment (Individual
Treatment Planning)
Treatment Services
Direct Therapeutic Contact
Curricula
Clinical Staff Credentials and
Qualifications
Program Specific Training
Family Support Services
Quality Assurance
Treatment Plan Reviews and Updates
Daily Treatment Notes
Chronological or Progress Notes
13

Partially
Compliant
(70-84%)
 

Noncompliant
(69% or
below)
 
 

7
8
8

 
 
 
 

9
9
10
10

 
 
 
 
 

11
12
13
14
14
15

 

0

0%

2

15%

11

Report
Page #

85%

4

 Findings Related to Records Falsification
During the previous audit of the SLVCC-IRT program conducted in October 2015, auditors had
concerns regarding the accuracy of documentation provided by the program. As a part of
standard audit protocols, the DCJ/OCC provided SLVCC-IRT administration notice of the audit
two weeks in advance of fieldwork. Fieldwork was to commence on Monday, October 19, 2015.
On Friday, October 16, 2015 the case file sample list was sent to the Program Director so that the
program could ensure files were ready for auditor review the following Monday. Upon the
team’s arrival, auditors discovered that the majority of digital treatment records had modification
dates of October 17th and 18th. However, given that the treatment activities had occurred
sometime prior to those dates, the auditors were concerned as to why the records would have
been modified. There was no way at that time for the auditors to determine specifically what had
been modified. When asked directly, program administration assured auditors that the only
modifications made were simple matters such as grammar and spelling for quality assurance
purposes.
Subsequent to the publication of the audit report, the DCJ/OCC received several anonymous
emails, letters and phone calls indicating that program records had in fact been falsified in order
to show that clients had received more treatment hours than had actually occurred.
Auditors reviewed documentation provided anonymously, interviewed staff and clients and
reviewed client case files. Ultimately the allegations of clinical records falsification were found
to be true.
The initial investigation was driven by an email provided anonymously which was sent to
SLVCC-IRT staff by the then clinical director. This email, sent on October 16, 2016, included
the case file sample list provided to the program by the DCJ/OCC and said, in part:
We MUST also tweak the therapeutic Recreation note to read as a therapy note. It
must be different each day, focusing on a therapeutic issue in order to count as a
therapy group. Without this, we will not make our required number of therapy
hours.
During fieldwork for this subsequent audit, SLVCC-IRT staff and the Program Director were
asked about this email. Several staff, and ultimately the Program Director herself admitted that
the email was sent. Discussions with staff and administration revealed that several staff members
were required to come in over the weekend prior to the October 2015 audit in order to make
modifications to the clinical notes. These modifications were meant to help the program have
greater compliance on the upcoming audit and both staff and administration knew these changes
to be false representations of the treatment actually provided to clients.
In addition to staff and client interviews, auditors selected several clients who had attended
treatment concurrently with those reviewed during the October 2015 audit in order to cross
reference treatment files between the two groups. Three main differences were identified
between the files of the initial audit group and the newly identified comparison group. First,
auditors found that therapeutic recreation clinical notes had been altered in the October 2015
sample group as discussed in the above email language. The group note had been changed in the
original sample files to indicate that the group was centered on treatment related activities as
5

 opposed to recreation. Second, the comparison group revealed that the original sample files had
been modified in some instances to show that a qualified clinician had run the treatment group as
opposed to the unqualified case manager who had actually facilitated the group. Finally, in some
instances, group duration had been modified in the original sample files showing more hours of
treatment than the comparison clients who had attended the same treatment sessions on the same
days.
While ultimately the October 2015 identified several deficiencies with regard to the quantity and
quality of treatment being provided at the SLVCC-IRT program, the above identified
modifications to the treatment records call into question the validity of the October 2015 audit
findings. Accordingly, the most critical areas of treatment quantity and quality were reviewed
again during the July 2016 audit. When appropriate, findings below will distinguish between
those relevant to the October 2015 comparison group and those relevant to the more current July
2016 sample.

6

 IRT Scope of Work
Section 1
Risk/Needs Assessment
• 1C Acceptance – Partially Compliant
Of the seven current files reviewed, six (86%) clients were clinically appropriate for IRT
placement. Additionally, two of the seven files (71% compliance) had assessment scoring
errors.
Of the seven comparison files reviewed, three (43%) were clinically appropriate for IRT
placement. One of the inappropriate placements was a condition of probation client who was
sent to IRT by court order and one client’s last use was in 2011 with only two months of
previous outpatient treatment. Additionally, five of the seven files (29% compliance) had
assessment scoring errors.

7

 IRT Scope of Work
Section 3
Program Dose and Duration

• 3A Clinical Assessment (Differential Assessment) – Noncompliant
The SLVCC-IRT program uses the SOA-RS supplemental as their substance use differential
assessment. The Scope of Work (SOW) requires that a differential assessment be completed
within five days of intake into the IRT program.
In the seven current files reviewed, three (43%) contained a differential assessment (SOA-RS)
completed within five days of intake. One file was missing the differential altogether and three
others were incomplete.
In the seven comparison files reviewed, three (43%) contained a differential assessment (SOARS) completed within five days of intake. One file was missing the differential altogether and
three others were incomplete.
In both the current and comparison files reviewed, several differential assessments appeared to
be filled out by the client. This practice is allowed by the Office of Behavioral Health (OBH) if
there is evidence that the clinician has reviewed the responses with the clients and made notes
to clarify or follow up on information provided. There was not any evidence of clinician
notations found on any of the supplemental assessments reviewed. It should be noted that the
December 2015 audit report recommended that this specific assessment should be clinician
driven and done in an interview setting.
• 3B Clinical Assessment (Individualized Treatment Planning) – Noncompliant
The SOW requires initial treatment plans be completed within five business days of entry.
In the seven current files reviewed, one file (14%) included an initial treatment plan completed
within five days of intake.
In the seven comparison files reviewed, two files (29%) included an initial treatment plan
completed within five days of intake.
In addition to being completed late, treatment plans within both the current and comparison
files were found to be deficient. Plans did not address immediate needs, substance abuse,
treatment objectives, and were not specific, measurable, achievable, realistic, and time-focused
(SMART). Generally, treatment plans should be designed in collaboration with the client in
order to address their immediate needs, identify treatment objectives, and provide direction on
how clients can accomplish the goals of their individual program. However, what was seen
more often at SLVCC-IRT was that treatment plans were not created in collaboration but rather
by the client themselves with little to no input from the clinician. Overall, treatment plans
failed to address not only the criminogenic needs of client’s but also often failed even to
address substance abuse, the primary issue for which they were being treated.
8

 • 3G Treatment Services – Noncompliant
None (0%) of the weeks reviewed in either current (14 weeks) or comparison (14 weeks) files
demonstrated that clients received 40 hours of treatment services per week.
In the current files reviewed, clients received anywhere between 20.5 and 31 total treatment
service hours in a week, averaging just over 27 total hours per week.
In the comparison files reviewed, clients received anywhere between 19 and 31 total treatment
service hours in a week, averaging 24.5 total hours per week.
Treatment services are defined as individual and group therapeutic sessions, didactic or
educational services, self-help groups, vocational counseling, and life skills. In addition to
reviewing client files for actual attendance, the audit team reviewed the treatment services
schedule for the week audit work was conducted in July 2016. This schedule did not reflect a
sufficient amount of scheduled hours, meaning that even if clients attended all scheduled
treatment for the week, they would not have received the required number of treatment hours.
• 3H Direct Therapeutic Contact – Noncompliant
The SOW requires that an individual therapy session be completed within the first week of
admission into IRT and then every other week for the duration of the program.
In the seven current files reviewed, only one (14%) client received an individual session within
the first week. Additionally, four of the seven (57%) had documented individual therapy
sessions every other week thereafter.
In the seven comparison files reviewed, four (57%) clients received an individual session
within the first week. Additionally, four of the seven (57%) had documented individual therapy
sessions every other week thereafter.
The SOW also requires a minimum of 20 hours of direct therapeutic contact each week for the
duration of the IRT program. None (0%) of the 14 weeks reviewed in either the current or the
comparison files indicated sufficient direct therapeutic treatment contact hours.
In the current files reviewed, clients received anywhere between 5.5 and 16.75 Direct
Therapeutic Contact hours in a week, averaging 12.25 direct therapeutic hours per week.
In the comparison files reviewed, clients received anywhere between 5.5 and 16 Direct
Therapeutic Contact hours in a week, averaging 12.35 direct therapeutic hours per week.
In both current and comparison files, any hours facilitated by unqualified clinicians were not
counted toward Direct Therapeutic contact hours. However, it should be noted that even if
these hours had been counted, none of the total 28 weeks reviewed would have met the 20 hour
requirement.

9

 • 3I Curricula – Noncompliant
SLVCC-IRT lacked variety in their curricula, both in the current and comparison groups. The
Office of Behavioral Health does not recommend that Strategies for Self Improvement and
Change (SSIC) be used more than twice a week and diversification of evidence-based,
manualized curricula is recommended for this population. File reviews indicated that the
program provided SSIC five days a week. The treatment schedule also placed too much
emphasis on psycho-educational classes which were client led rather than staff facilitated (7.5
of the 13.5 psycho-educational hours scheduled). At the time of the audit, SLVCC was not
offering trauma informed care, a requirement in the new IRT Scope of Work which was
effective July 1, 2016.
SSIC group sessions observed by the audit team veered from the intentions of the curriculum,
lacking quality control and fidelity. It appeared that the manual was utilized for topical areas;
however, staff did not strictly adhere to the content and skill building elements of the
curriculum. There was room for growth in the quality of group facilitation by the counselors
observed. This was likely due to insufficient clinical observation and supervision (this issue is
discussed further later in the report). Interviews with staff and clients also indicated that staff
struggled to redirect the groups to the curriculum and those groups observed by the audit team
were much more structured than typical groups conducted within the SLVCC-IRT program.
File reviews also indicated that clinical staff showed a full length movie during group
treatment sessions on more than one occasion. Per OBH, movies shown in full, while
convenient at times, do not count towards direct therapeutic contact hours even if a CACII or
higher is present. Short clips of movies may be shown in an effort to stimulate conversation;
however, the majority of the group should be focused on processing. The audit team also
discovered that therapeutic recreation was actually free time for clients with no staff oversight
or facilitation. This was confirmed through staff and client interviews as well as direct
observation by auditors. Such self-directed recreation cannot be counted toward treatment
hours.
• 3L Clinical Staff Credentials and Qualifications – Noncompliant
The clinical supervisor at SLVCC-IRT during the time of the current audit had a Master’s
degree and was a registered psychotherapist. While she was working on her CACIII, without it,
she was not qualified to provide clinical supervision. Additionally, one of the three primary
clinicians at SLVCC-IRT was providing direct therapeutic and one-on-one treatment, but was
not qualified to do so. He had a Master’s degree with no certification or licensure, and was not
registered with the Department of Regulatory Agencies (DORA).

10

 IRT Scope of Work
Section 4
Skill Training

• 4A Program Specific Training – Partially Compliant
The SOW requires staff to be formally trained in program curricula and the structured
interventions used. There was evidence that some, but not all program staff were trained in
SSIC and Motivational Interviewing. Specifically the Program Director, who was the Clinical
Director during the October 2015 audit, had yet to attend SOA-R and motivational
interviewing training. Additionally, the newly hired Clinical Director had also not attended
any motivational interviewing training or training in the core programmatic curriculum, SSIC.

11

 IRT Scope of Work
Section 6
Continuing Care

• 6D Family Support Services – Noncompliant
None (0) of the files reviewed in either the current or comparison sample contained any
documented family support services. It appears that the SLVCC-IRT program still does not
incorporate any forum for family support services into their programming (e.g. work on
dysfunctional interactions, safety planning in the home, relapse prevention, and support for
ongoing treatment and risk reduction).

12

 IRT Scope of Work
Section 7
Program Quality Assurance
• 7B Quality Assurance – Noncompliant
Quality assurance can be measured through multiple methods including sitting in on treatment
sessions, providing coaching, and discussing techniques while in supervision. This is vital for
a program to thrive and meet the requirements of a treatment program. While the last DCJ
audit in October 2015 indicated that clinical supervision was inadequate, the audit team found
no evidence that any group or individual clinical supervision had taken place since that time.
Insufficient emphasis was placed on the importance and necessity of clinical supervision
within the SLVCC-IRT program, which is evident in the treatment quality issues detailed
within this report.
Additionally, as some clinicians were not yet certified and working toward a CAC, DORA
sets minimum supervision requirements at 3 hours per month. Counselors were presumably
obtaining hours toward certification, though the supervision requirement was not being met.
This raises ethical concerns around the possibility of falsified applications to DORA for
subsequent certification.

13

 IRT Scope of Work
Section 8
Program Feedback
• 8A Treatment Plan Reviews and Updates – Noncompliant
In the seven current files reviewed, four (57%) contained at least one updated treatment plan
within the first month. Updates beyond that were sporadic.
In the seven comparison files reviewed, four (57%) contained at least one updated treatment
plan within the first month. Updates beyond that were sporadic.
In both the current and comparison samples, treatment plan update practices varied greatly
when completed. During interviews, clinical staff indicated that a new procedure had been
initiated since the October 2015 audit. However, this new procedure was unclear and not
implemented consistently. In some cases updates were simply a cut and paste of the individual
treatment session notes. In others, new objectives would be added so that objectives became
cumulative over the course of treatment. However, these new objectives were similar to those
in initial treatment plans. Objectives failed to address identified criminogenic needs including
substance abuse, and were not specific, measurable, achievable, realistic, and time-focused
(SMART). There was little evidence of adjusting or enhancing client treatment goals or action
steps as they progressed through treatment.
• 8B Daily Treatment Notes – Noncompliant
Overall, daily treatment notes reviewed in both current and comparison files were significantly
lacking in quality. Auditors were told during staff interviews that treatment notes were started
by case managers who put together a template prior to the start of the week for each client with
all scheduled sessions entered. This template would include the session name, duration and a
brief note regarding the general topic meant to be covered. Clinicians were then intended to
utilize this template to enter individualized notes for each client and each session. While
reviewing the seven current and seven comparison files, auditors found several alarming
practices occurring regarding the completion of treatment notes. Most notes were not
individualized as the “progress” section frequently read the exact same for all clients. There
was a clear pattern of copying and pasting as it was not unusual to see other client names
appearing within a specific client’s notes, sometimes multiple clients in a single note. Often
times only the basic description of the curriculum session or even just a definition of the type
of treatment was in the daily clinical note. Start and end times did not match the documented
duration and facilitator names and signature lines did not always match.
Additionally, while individual treatment session notes appeared at first glance to be more
comprehensive, auditors quickly discovered that the first individual session note was often cut
and pasted into all subsequent individual session notes. Additionally, these notes looked
similar across client case files. Overall, the quality of individual treatment session notes
depended greatly on the clinician completing the treatment note.

14

 Colorado Community Corrections Standards
While the focus of this audit was compliance with the IRT Scope of Work, several concerning
issues were came to the auditors’ attention with regard to the Colorado Community Corrections
Standards both within the IRT program and within the regular residential community corrections
program at SLVCC.

SLVCC-IRT Specific Issues
• 6-080 Chronological or Progress Notes – Noncompliant
Chronological notes are meant to address criminogenic needs, document any interactions, or
progress that happens with the client from a case management perspective. This should include
what happens outside of group or weekly individual treatment sessions. The quality of
chronological entries reviewed was deficient. Chronological entries were brief and focused
primarily on terms and conditions instead of criminogenic needs and treatment goals. The
client’s progress, attitudes, and motivation were rarely documented as having been addressed
or discussed. Based on the chronological notes reviewed, it was difficult to determine what
types and to what extent interventions and/or services were being provided to SLVCC-IRT
clients by case managers.

SLVCC Regular Residential Specific Issues
• 6-120 Movement of Offenders
Information obtained through staff and client interviews indicated there was a significant delay,
ranging from three to four months, for some clients progressing to the non-residential program
after they had successfully completed all the requirements in the residential program. This
information was confirmed reviewing the client’s files. Both staff and clients interviewed
indicated that program administration was unresponsive to inquiries from either staff or client
(i.e. email, grievance, letter, etc.) regarding the delay in progression. While never specifically
stated by administration, the implication from staff was that in other contexts administration
had alluded to the need to keep bed counts up. This was generally seen as the primary reason
for failing to progress clients despite their having completed all of the requirements of the
residential program.
• 4-181 On-Grounds Surveillance & 4-200 Random Headcounts
Interviews with clients and staff as well as case file reviews demonstrated a significant drug
problem within the residential facility. The above listed Standards are but two that have a likely
impact on this issue, though further investigation is necessary to determine whether compliance
with other Standards is also problematic.
Prior to the audit, the DCJ/OCC received several telephone calls from clients and family
members stating drugs were rampant at SLVCC. Through interviews conducted during
fieldwork with both clients and staff, auditors were told that there had been an unprecedented
15

 number of “hot” UAs in the residential program. IRT clients reported being afraid to progress
to the residential side due to the abundance of drugs making it rather difficult to stay clean and
work their program. When asked why they believed drugs were so easily hidden within the
program, clients who were interviewed stated that headcounts were not randomized. They
stated that clients all know when and what route staff takes when conducting headcounts
making it rather predictable and allowing clients to prepare for the headcount by hiding any
contraband in advance.
The severity of this issue was punctuated by a review of one of the IRT client assessments.
While the client was found to be clinically appropriate for IRT placement, he was in fact
initially placed within the residential program. At the time of entry into the residential program
the client did not have a drug problem significant enough to be placed in IRT. However,
throughout the course of his stay in the SLVCC residential program, his substance abuse habit
became so severe that he subsequently required placement in the IRT program.

General SLVCC Issues
• 3-170 Incident Notification
During this audit, several incidents were reported to us by staff and clients that were never
reported to the DCJ/OCC. Auditors were told about a client slitting his wrists in an attempted
suicide in September 2015, after which clients were required to clean up blood. It was also
reported that sometime in September or October a client went into a coma due to spice use.
This incident actually occurred in December, and while notice was sent to the DCJ/OCC, it
was sent to an outdated email address and therefore was never received by the DCJ/OCC.
Finally, while reviewing employee personnel files, auditors discovered that two clinical staff
had been accused of inappropriate relationships with clients. There was sufficient evidence to
support these claims; however, neither of them was reported to DCJ, DORA, or the authorities.

16