John W. Hickenlooper GOVERNOR Kathy E. Sasak INTERIM EXECUTIVE DIRECTOR Colorado State Patrol Colorado Bureau, of Investigation Division of Criminal Justice Division of Fire Prevention and Controi Division of Homeland Security and Emergency Management Division of Criminal Justice Jeanne M. Smith, Director 700 Kipling Street Suite 3000 RDO Denver, CO 80215-5865 (303) 239?4442 DEPARTMENT FAX (303) 2394491 OF PUBLIC SAFETY June 12, 2014 Leroy Lucero Crossroads Turning Point - Therapeutic Community 509 East 13th Street Pueblo, CO 81001 Terry Hart, Chair, Pueblo County Commissioner Liane McFadyen, Pueblo County Commissioner Sal Pace, Pueblo County Commissioner 215 W. 10th Street Pueblo, CO 81003 Dear Commissioners and Mr. Lucero: The Division of Criminal Justice (DCJ) and the local oversight agencies in the 10th Judicial District have reviewed program operations within the Crossroads Turning Point Therapeutic Community/Therapeutic Community of Southern Colorado (TCSC) for the last few consecutive years. These reviews, taken as a whole, have produced concerning information and ?ndings regarding the ability of the program to reach and sustain compliance with the Colorado Community Corrections Standards as well as the basic contractual requirements with the Pueblo Board of County Commissioners under Request for Proposal 11? 25. In general, it is our position that the TCSC program has failed to make substantial improvements in compliance despite sustained efforts by state and local of?cials to provide training, technical assistance, and professional consultation. The State of Colorado and local oversight/referral agencies have invested a substantial amount of human resources into assisting the TCSC with program improvement. Despite many formal and informal efforts at auditing, training, technical assistance, professional consultation, and contract actions, the TCSC program continues to use practices and policies that compromise the overall compliance With state Standards and adherence to the statement of work in the contract with Pueblo County. The most recent audit findings are also attached in a more detailed report (See Exhibit 1). Home Page: E-Mail: Jeanne.smith@cdps.state.co.us The overall concerns, ?ndings, and observations are listed generally below: 1) The program demonstrates a pattern of pervasive inadequacies in reaching and I sustaining basic compliance levels with the Standards and contract requirements. 2) The State of Colorado has invested a large and disproportionate amount of staff and ?scal resources in audits, formal training, and technical assistance into the TCSC program over time- 3) The local oversight agency (Pueblo County Correctional Services) has also invested local resources in formal on?site technical assistance and ?le reviews for the TCSC program. 4) Compliance issues still exist despite the TCSC program investing its own ?scal resources into professional consultation and technical assistance. 5) Since 2011, the State of Colorado has developed and has applied several forms of intermediate measures for corrective action to encourage the TCSC program to reach basic levels of compliance. 6) The TCSC program has experienced a signi?cant reduction of offender placements in the program since 2011. 7) The program continues to provide inadequate amounts of direct therapeutic services to offenders despite being funded at an intensive treatment level. 8) Offender outcomes are below what is expected based on results in similar programs. The TCSC opened in 2009 and was ?rst designated a new program in 2010 under the Community Corrections Risk Factor Analysis (RFA). After an initial compliance audit in 2011, the TCSC program was rated a Level 1 due to compliance issues with an overall score of 53.3%. Under the RFA, a higher score relates to lower levels of compliance with Standards while lower scores relate to higher levels of compliance. The RFA establishes a cut off score of 50 percentage points or above for the Level 1 category. In 2012 the TCSC program was rated at Level 2 with a score of 44.4%. In 2013 the program returned to Level 1 status with a score of 53.0% (See Exhibit 2). The RFA score for 2014 will approach or exceed 50 percentage points and may very likely result in a Level 1 status again. Over the course of the last 3 years of the RFA, the TCSC program has scored an average of 50 points showing no overall net improvement in compliance with the totality of the RFA measures. The statewide RFA is not compiled until August so it will be some time before the precise and ?nal score is available. However, the concerns raised in the most recent audit do not support any level of con?dence that signi?cant improvements have been made. The RF A was instituted in 2003. While it expected that a new program has some challenges in the ?rst year, it has never been the case that a new provider remained in Level 1 or 2 status for 3 or more consecutive years. In fact, the statewide average RFA score for the last 5 years for all programs was 20.5% (2009), 18.1% (2010), 18.1% (2011), 15.5% (2012), and 15.1% (2013). The average score for the TCSC program of 50 points over the last 3 years far exceeds the statewide average every year. The TCSC program was the only Level 1 program in the State of Colorado in the years of 2013 and 2011 and has been the only program rated as Level 1 due to compliance issues since 2008. Figure A shows the RFA score for the TCSC program since 2011 as well as the statewide average for all other funded community corrections programs in the RFA report. Figure A Risk Factor Analysis (RFA) Scores Compared to Statewide Average Scores 2011-2013 50 50 RFA Overall Score tatewide Ave rage While the statewide average score for all programs is trending downward showing overall improvement, the trend in RFA scores for the TCSC program show no net improvement over the last 3 years. 2011 Audits, Technical Assistance and Training The DCJ published the ?rst audit report for the TCSC program in May 2011. Three staff members from the DCJ Of?ce of Community Corrections (OCC) as well as one from the Of?ce of Behavioral Health (OBH) were present during the audit ?eld work. In follow up, in August 2011 the Office of Behavioral Health along with the staff and staff from the Colorado Department of Corrections conducted an informal site visit to provide technical assistance to the program to reach compliance. For two days in September 2011, 2 staff members from the conducted a specialized classroom training to all community corrections programs in Pueblo, including TCSC, regarding Procedural Justice and Case Planning. Later in September 2011, DCJ staff members spent 2 additional days conducting an on-site technical assistance visit to TCSC to address issues of assessment, case planning, treatment planning, and other critical community corrections functions. 2012 Audits, Technical Assistance and Training In January 2012, two staff members from the DCJ and 2 staff members from Addiction Research and Treatment Services (ARTS) organization provided formal on?site technical assistance to TCSC staff and management over a 2-day period. The following month, in February 2012 the Division of Criminal Justice issued a letter to CTP Management Staff (Charles Davis and Terry Krow). The letter provided written feedback from the onsite technical assistance visit in January 2012, by OCC staff. The feedback letter informed TCSC that areas previously identi?ed as non?compliant still remained as non-compliant and of poor quality. The letter also identi?ed problems with role confusion among staff that contribute to the overall compliance issues for such things as assessments, supervision plans, treatment plans, and chronological notes. It is important to note that these same issues persisted in the May 2014 audit of the TCSC program despite formal technical assistance feedback from the OCC staff two years prior. The 2012 letter also stated it is imperative that these issues be corrected immediately in order for the to see the positive changes upon return in the new ?scal year. The letter further communicated the DCJ recommendation that CSC take full advantage of the support provided by Ken Gaipa and Larry Terrell as you work to improve these issues before the next audit. (See Exhibit 3). In May 2012, OCC staff met with TCSC management (Mary Joy Kogovsek) to provide technical assistance and to discuss previous audit ?ndings. Later, in September 2012, staff conducted a formal classroom training regarding Structured Progress Feedback (SPF) for TCSC staff. This training included dissemination of a written Coaching Packet designed to give providers a sustainable resource to achieve and maintain compliance with the SPF standard an ongoing compliance area for TCSC even as recently as the May 2014 audit. 2013 Audits, Technical Assistance and Training In January 2013, ?ve staff members from the and two from the OBH conducted a formal . follow-up audit of the program and provided on?site technical assistance and ?le reviews. In June 2013, Division Director Jeanne Smith, OCC Director Glenn Tapia, and Pueblo County staff Brian Gomez met with Leroy Lucero to address continued compliance and contractual issues. Later that year, in August 2013 a formal audit report was provided to TCSC which included a cover letter notifying the program of its provisional contract status and 5 priority areas for immediate improvement. In September 2013, staff provided another formal classroom training regarding assessment and case planning for TCSC staff. Due to continued compliance issues and the contractual status of the program, DCJ staff conducted a 90-day review of the TCSC program in November 2013 to provide feedback to the program regarding the 5 priority issues identi?ed in the letter dated August 1, 2013. A letter was issued in December 2013 to communicate the feedback on the 90?day ?le review. While acknowledging some early progress in some priority areas, the letter informed the TCSC program that within the ?ve areas reviewed during the limited site visit ?om November 2013, substantial improvements must still be made in the following areas: 1) Compliance with weekly and pass site monitor requirements must increase 2) Job search accountability policies and procedures must be implemented completely and sustained with ?delity 3) Supervision/case planning processes and content must be improved and implemented consistently 4) Treatment of clients with co-occuring mental health diagnosis must be in full compliance with all aspects of the TCSC proposal. (See Exhibit 5). 2014 Audit In May 2014, the staff conducted a formal audit of the TCSC program prioritizing the most critical Standards and contract requirements. The attached report (Exhibit 1) provides continued findings and concerns in the audit, despite several years of formal interventions on the part of the DCJ. Also, between the time periods of October 2012 and May 2014, the Pueblo County Correctional Services provided over 20 instances of direct technical assistance contact with the TCSC staff and administration. During this timeframe, the staff provided formal consultation visits, reviews of program practices and contract requirements, and meetings with program management to address compliance issues. These were not routine visits, but were visits speci?cally intended to help the program reach compliance. To their credit, the TCSC program made its own investment in professional consultation and technical assistance. In 2011 the TCSC entered into agreement with the Addiction Research and Treatment Services (ARTS) organization to provide formal professional consultation and technical assistance from a well-established and reputable TC program in Colorado. It is understood that ARTS provided several on?site technical assistance visits to the TCSC program with very experienced management staff from their TC program in Denver. Further, in August 2012 at the recommendation of the DCJ, the TCSC program entered into contract with Esther Smith; a respected, knowledgeable and experienced community corrections professional; to provide ongoing auditing and technical assistance directly to the program. This decision was requested by the to assist the TCSC in having an accessible and knowledgeable resource, other than the DCJ and local government, to assist them with writing formal policy, procedure, and with developing formal practices to meet and sustain compliance with the Standards and contractual requirements. Despite these investments the program continues to fall well below statewide levels of basic compliance. On June 1, 2011, the issued a letter to TCSC Management (Terry Krow) and Pueblo County staff Millie Carlo to address compliance issues from the 2011 audit fieldwork. The letter stated some findings within this report have required immediate action on the part of the provider. The letter further stated the ?ndings herein related to both the Colorado Community Corrections Standards and the contractual requirements of the therapeutic community clearly indicate a need for increased education among program management and sta?? regarding relevant regulations and requirements and the application thereof. (See Exhibit 6) I On October 1, 2011, the Division of Criminal Justice issued a letter to TCSC Executive Staff (Leroy Lucero and Charles Davis). The letter brought attention to the provider Level 1 Status on the RFA, in part, due to performance issues outlined in the May 2011 audit report. The letter stated Crossroads is still not compliant with many standards and is therefore at continued risk of losing funding. The letter added The O??ice of Community Corrections strongly recommends that Crossroads hire additional sta?r to meet the requirements set forth in their Scope of Work. In addition, it is recommended that Crossroads invest in an electronic data management program to help with information management and documentation. (See Exhibit 7). - On November 3, 2011 the Director of the Of?ce of Community Corrections met with Pueblo Board of County Commissioners (BOCC) to notify them of compliance and performance issues with the community corrections programs in Pueblo including concerns with the TCSC program. During the time period between May 2011 and January 2013 the DCJ intentionally postponed the planned follow?up audit schedule so that TCSC had more time to come into compliance. This decision was reached after the provider requested additional time to reach compliance before the next publication of the RFA report. On August 1, 2013, the Division of Criminal Justice issued a letter to TCSC Executive Staff (Leroy Lucero and Charles Davis) expressing continued concern about program non? compliance issues that became evident during the follow up audit. The letter identi?ed five (5) priority areas to be targeted for immediate improvement. Speci?cally, the 5 areas targeted were random off site monitoring, job search accountability, assessment/acceptance criteria, supervision/treatment planning, and mental health services. The DCJ expressed our intention to conduct a 90-day review of the 5 priority areas as well as a formal audit in 2014 for inclusion into the 2014 Risk Factor Analysis. The letter also stated in addition to becoming compliant with the above-referenced Standards, CSC should take prompt, responsible, and diligent action to come into compliance with the remaining Standards and Scope of Work provisions identified in the audit reports. (See Exhibit 4) . On December 2, 2013, the Division of Criminal Justice issued a letter to TCSC Executive and Management Staff (Leroy Lucero, Charles Davis, Steven Hartley) observing some initial progress made by the provider in reaching beginning compliance with the Standards. The letter also stated It is also important to note that the areas reviewed during the limited site visit in November 2013 are just five (5) issues within a larger constellation of concerns identified in the most recent formal performace (sic) audit of TCSC. The letter also stated the program still must develop, execute, and sustain many changes in order to be in an acceptable performance category with the State of Colorado. (See Exhibit 5). As evidenced by the June 2014 audit report, most areas that showed early progress in 2013 currently remain as problem areas for the TCSC program. The Division of Criminal Justice is concerned that early progress was observable 6 months ago yet the June 2014 ?ndings indicate that the initial progress has not been sustained over time in order to reach compliance. Since 2011, the number of offender placements in the TCSC program have shown a net decline. Figure below shows the change in offender placements at the TCSC program over time. The data suggest a decreased demand for TC placements, decreased con?dence by local referral agencies in the TCSC program; or perhaps a combination thereof. Figure - Average Daily Population (ADP) TCSC Residential Placements FY11 through May 2014 80 70 60 50 :3 .. no? \x2011 FY 2012 FY 2013 FYTD 2014 May {2014) IWADP 54.99 41.24 55.71 . 45.53 32.55 It is important to consider that the RFA metrics do not capture audit ?ndings related to the minimum number of therapeutic hours required in the contract and OBH licensure requirements. The current requirement are that the TCSC provide at least 5 hours weekly of direct therapeutic contact. The June 2014 audit report illustrates that no clients are receiving the minimum of 5 hours which replicate ?ndings from the May 2011 audit report. The RFA data also does not take into account the contract requirement for structured mental health services. The DCJ remains convinced and concerned that the intensity and dosage of treatment being delivered at the TCSC program continue to fall below the funded and contractually minimum requirements. The TCSC program is funded at a substantially higher rate than regular community corrections programs and it is expressly expected that they meet at least the minimum hours of direct therapeutic contact required by the OBH, the contract with Pueblo County, and the general expectations of a TC provider. The current practice at TCSC results in offenders receiving the dosage of treatment they would get at a basic and lower cost outpatient level of treatment (weekly outpatient therapy to enhanced outpatient therapy). These levels are inappropriate for high risk and high need clients such as those targeted for a TC setting. In 2012, the DCJ Of?ce of Research and Statistics published a recidivism study for all community corrections programs and provided program?level data to the Of?ce of Community Corrections. The data show evidence of substandard programmatic and therapeutic operations at the TCSC pregram. Despite having accepted lower risk offenders, the TCSC 1-Year Recidivism Rate at 16.3% is 60% higher than the Peer I recidivism rate of 10.0%. The TCSC 1?Year recidivism rate is over 4 times higher than the Haven TC recidivism rate of The intention of the enhanced funding used at the TC program is, at least in part, to replicate outcomes as those measured in the TC programs in Denver. The Statement of Work (Exhibit A) to the contract between the Division of Criminal Justice and the 10th Judicial District Community Corrections Board (Pueblo County Correctional Services) provides the following language in Section I 9) Notwithstanding any other provision of this contract, the State may on an emergent basis and a?er appropriate inquiry designate any program or provider receiving funds pursuant to this contract as ineligible to continue to receive such funds when it is demonstrated either: that the current operation of the program or provider constitutes an imminent and significant threat to public safety; OR that the program or provider has demonstrated neglect, reckless disregard, or inability to sustain compliance with the Colorado Community Corrections Standards. The Statement of Work (Exhibit A) to the contract between the Division of Criminal Justice and the 10th Judicial District Community Corrections Board (Pueblo County Correctional Services) provides the following language in Section I (C): C. Standards. The Contractor shall ensure that its subcontractors meet, maintainand comply with all applicable guidelines or standards as provided in Title 1 7, Article 2 7, and Section 18?1360], C.R.S., as amended, and the ?Colorado Community Corrections Standards ?,as revised or amended, attached, marked as Exhibit and incorporated herein by reference. Non~compliance with Standards may result in: 1) Reduction of compensation as speci?ed in the Allocation Letter, sample form attached, marked as Exhibit and incorporated herein by reference; 2) Implementation of a corrective action plan developed in conjunction with a professional consultant with subject matter expertise in calorado community corrections. The consultant must be approved by the Contractor and the State. . The consultant services shall be at the expense of the program or provider. 3) Implementation of an increased sta?ing pattern that ensures adequate o?ender supervision and provision of services. 4) Cessation of of?ender placements in the program; 5) Execution of a competitive bid process, coordinated with the local community corrections board, to consider alternate program providers; 6) Cancellation of the contract; 7) Cancellation of the subcontract. Since 2011, the State of Colorado, the local government in Pueblo County, and local referral agencies have intervened using subsections and from the above referenced contract provisions. Those four options have not proven successful. The Division of Criminal Justice has provided multiple levels of assistance to TCSC to support program improvement including formal audits, on?site technical assistance, classroom training, off?site technical assistance, informal compliance reviews, placing the contractual agreement with the provider on provisional status, requiring professional consultation, and recommending increased staf?ng patterns. Further, the local agencies in the 10th judicial district have provided on-site technical assistance, local level ?le reviews and audits, county contract actions, and have ceased offender placements into the TCSC program. These remedies have all been made with the interest of facilitating operational improvements to the program. Community corrections contracts require that funding be withheld from a program that remains in the Level 1 RFA category for two consecutive years. Whether or not the August 2014 RFA report score results in Level 1, or reaches the low Level 2 range for TCSC, the Division of Criminal Justice remains highly concerned about the delivery of treatment, the offender outcomes, and the general lack of improvement in compliance. Because the timing of the new board contracts is upon us, the Division must take some action very Considering the totality of the circumstances at hand, this letter Serves as noti?cation that the Division of Criminal Justice intends to fund the TCSC program at an average daily population not to exceed 35 offenders only through the ?rst 60 days of State Fiscal Year 2014?15. At this point in time, the DCJ will not guarantee an allocation of funding to pay for services at TCSC after the date of September 1, 2014, by and through its contract with Pueblo County. Respectfully, Mafia?. I ?effi?Z?i?y - 4 .1 Jeanne M. Smith, Director Division of Criminal Justice cc: Brian Gomez Pueblo County Corrections Services Walter Pester?eld Colorado Department of Corrections Kelly Messamore Colorado Department of Corrections David Simental - 10th Judicial District Probation Amanda McGowan 10th Judicial District Probation Glenn A. Tapia - Colorado Division of Criminal Justice Attachments: Exhibit 1: Audit Report (June 2014) Exhibit 2: Letter Risk Factor Analysis (Year 9) Results (October 2013) Exhibit 3: Letter to TCSC (February 2012) Exhibit 4: Letter to TCSC (August 2013) Exhibit 5: Letter to TCSC (December 2013) Exhibit 6: Letter to TCSC and Millie Carlo (June 2011) Exhibit7: Letter to TCSC (October 2011)