HomeMy WebLinkAbout20081256.tiff Page I1of14
To:Weld County Community Corrections Board
Division of Criminal Justice/Office of Community Corrections (CDPS)
From: Michael Riede, Contract Monitor for WCCCB
Re: Report of Monitoring/Review at the Villa Community Corrections Facility(Weld County)
Date:April 1, 2008
This report will represent a 60-day review of monitoring activities at the Villa Community Corrections
Facility(Avalon Correctional Services) located In Greeley, Colorado from approximately January 22, 2008
through March 26, 2008.The report is an independent response through a contract with the Weld
County Community Corrections Board regarding the Limited Scope Audit performed at the Villa
Community Corrections facility on October 25, & 26, 2007 by the Division of Criminal Justice/Office of
Community Corrections in cooperation with the Alcohol and Drug Abuse Division of the Colorado
Department of Human Services(ADAD), Colorado Department of Corrections, Colorado Judicial
Department, and the Weld County Community Corrections Board.The date scope of this audit was
March 1, 2007 through October 24, 2007.
The critical findings and conclusions of this scope audit report to the WCCCB and the Villa dated January
29, 2008 indicated programmatic deficiencies in three general areas: public safety, offender
management, and offender treatment. A quote from the report letter described it best and outlined the
task at hand for the monitor: "While the various findings described in this report are individually
significant,we are most concerned that a total of 79%of the areas surveyed were rated as either
"Needs Improvement" or"Unsatisfactory."
The body of this report will address five of the six sections outlined and cited in the scope audit report of
October, 2007.These five sections will relate to Colorado Community Corrections Standards (C.C.C.S.)
sections 2-000,3-000,4-000, 5-000, and 6-000 as outlined in the scope report from DCJ/OCC.The last
section, "IRT Contract and RFP" (Treatment-Related Requirements)will not be addressed for two
reasons:on March 19, 2008 DCJ/OCC notified The Villa that they would not renew the program's
contract for IRT services for FY 09,the contract will be terminated the end of May, 2008 and ADAD has - -
continued responsibility for auditing and reviewing the"Treatment-Related Requirements" per that
agencies standards, although it should be noted that this writer did audit two cases from the RTC/IRT
population; interviewed the three RTC counselors individually;and attended one of their unit meetings.
The final section of this report will include this writer's conclusions with recommendations to the Weld
County Community Corrections Board and the administration at the Villa.
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Page I2of14
C.C.C.S. Section 2-000
Personnel Standards
Regarding the"findings"from the scope audit(October, 2007) all 8 standards cited were addressed by
the Villa management team and brought into compliance with C.C.C.S. standards.
➢ Ten personnel files were reviewed by this writer reflecting background and fingerprint checks
were completed on all files. In several of the files there was not official documentation
proving graduation from college or high school, although some of the newer case managers
had just graduated from the University of Northern Colorado in December, 2007.
Y During the monitoring period there was staff turnover and promotions creating Case
Manager and Security Staff vacancies.Two Security Staff personnel were promoted without
a BA degree, but seemed to meet the minimum qualifications according to C.C.C.S. section 2-
140: "related education or experience may be substituted on a year for year basis."Also
found were two other case manager positions, Placement Coordinator and another
residential Case Manager where the years of experience were substituted in lieu of a BA
degree.
i It should be noted that the current Operations Manager who is responsible for the security
of the facility does not have a BA degree and because of the importance of this position, this
writer feels there needs to be clarification regarding C.C.C.S. section 2-150 and this position
should require a BA degree.
Based on the results of the past DCJ/OCC audit of February, 2007 and the current scope audit
of October, 2007, both reports related deficiencies in staff training. During the monitoring
period,the Villa developed and implemented a 40-hour new employee orientation training
for all new hires for both security staff and case managers.The curriculum for the new case
manager's training includes a mentorship with the case manager supervisor or an
experienced case manager.Also added to case manager training are non-DVD(DVD trainings - --
on disc from Avalon Corrections are a prevalent practice in the program)trainings on
Motivational Interviewing (MI), Relapse Prevention, Sex Offender Notification, Games
Criminals Play, etc.
It is this writer's opinion that the Villa's management team is currently making an effort to enhance
training throughout all the programs in the facility, hopefully it will be maintained and continue to
improve.
Page I3of14
MONITOR'S REPONSE TO CORRECTIVE ACTION No 1:
A. Regarding personnel files audited all basic pre-employment and employment requirements
were met.
B. No incidents of unethical staff/offender relationships occurred during the monitoring period,
although all employees now must review and sign-off that they understand the corporation's
Staff Conduct and Ethics policy.
C. As stated,the Villa administration has developed and implemented a new employee orientation
for new hires, plus enhanced the quality and availability of more advanced training.The training
records of all employees are being tracked and updated on a monthly basis by the program's
Administrative Officer.This system is a good checks and balances to remind staff and their
supervisors of their responsibility to receive and complete 40 hours of annual training.
Page 14of14
C.C.C.S. Section 3-000
Management Control Standards
There were seven standards cited in this section,five of the standards were brought into compliance
during the monitoring period.
During the monitoring period,the Villa Management Team continued to update and revise
the facilities policies and procedures in preparation for their response to the current limited
scope audit. Because of this ongoing work,this writer did not review or audit the facilities
policies and procedures.
All facility staff meetings are scheduled monthly on the last Monday of the month. This
writer attended one of these meetings, a review of the attendance sheet indicated that most
of the facility staff attended,including all case managers. The agenda for this meeting was
operational and focused on several major changes (i.e.:change in drug testing companies
and protocol, new orientation process, etc.). It should be noted that the case managers
meet weekly to staff cases and supervision plans. These meetings are co-facilitated by the
Assistant Director and the Case Manager Supervisor. Also,the treatment counselors meet
weekly with the Assistant Director. Shift supervisors and assistant shift supervisors from the
security staff meet with the Operations Manager once per month to discuss operational
issues with an emphasis on facility coverage and off-site verifications.
➢ The facilities centralized grievance file was reviewed on several occasions, copies of
grievances filed by the offenders were verified in their case file. Currently,the Villa seems to
be in compliance with the review and response to offender grievances. The centralized
grievance file still reflects a gap from September, 2007 through the first week of October,
2007, reflecting no offender grievances being filed or documented.
➢ Throughout the monitoring period,this writer focused and discussed management the
importance of internal case file audits for the purpose of quality assurance but just as
important for the training of case managers and counselors. Internal auditing of case
manager files is the responsibility of the Case Manager Supervisor. Due to staff turnover
(one case manager on FMLA),training new staff,caseload coverage issues, and the additional
duty of completing the SOA-R assessments on new offenders whose case managers have not
been trained, it is literally impossible for this position to devote the time needed to complete
quality internal audits. Management at the Villa is well aware of this problem and hopefully
it will be addressed and resolved in the near future.
Page ISof14
MONITORS RESPONSE TO CORRECTIVE ACTION No. 2:
Currently,the program's policies and procedures are being updated and revised for response to the
scope audit.
A. The program is attempting to address the lack of consistent internal auditing, but during the
monitoring period, this had not been accomplished.
B. The grievance/appeal procedure seems to be in compliance with State standards.
C. All critical incidents were reported to referral and oversight agencies as required during the
monitoring period.
Page I6of14
C.C.C.S. Section 4-000
Security Standards
ENTRY PAPERWORK STANDARDS:
All offender files reviewed after an entry date of November 1, 2007, and through the
monitoring period, reflected completion of all offender advisement forms and an intake
interview signed and date recorded by the offender and security staff. It was observed
though that an intake interview could take from 30-60 minutes and the"date/time"for each
form reviewed indicated the same repetitive time of day on each form.
The Villa has completely re-organized the property room in the basement of the facility and
implemented a more accountable system to inventory and secure incoming offender
property within 12 hours of admission.
MONITORS RESPONSE TO CORRECTIVE ACTION No.3:
A. Since November 1, 2007, intake interviews, advisements and paperwork have been
improved, plus there is now regular review/audit by the Operations Manager and the
Assistant Director.
B. Advisement materials are reviewed by the Operations Manager and Assistant Director.
DRUG AND ALCOHOL TESTING STANDARDS:
On approximately February 1, 2008,the Villa eliminated their in-house drug screening process and
switched to Norchem (a reputable drug testing company in Arizona)for lab verification. This change in
substance abuse testing has enhanced the programs accuracy in testing and eliminated the possibility of
falsifying UA results.
MONITORS RESPONSE TO CORRECTIVE ACTION No.4:
A. All TRC and RTC files reviewed during the monitoring period indicated that these offenders
were tested on a monthly basis for drugs and alcohol per standard. _
B. All security staff has been re-trained by a representative from Norchem. Policy and
procedure has been implemented to address training for new staff in drug collection
protocol.
C. The possibility of falsified UA's has been reduced by contracting with Norchem for testing
and lab verification.
D. Norchem provides aggregate UA documentation on all tests.
Page I7of14
WHEREABOUTS MONITORING STANDARDS:
One of the conclusions/findings of the scope audit was that random off-site monitoring and verifications
were only 21%compliant and unsatisfactory. Because public safety and offender accountability are
paramount in community supervision,this writer reviewed and audited one of the sex offenders in the
facility. After completion of standard case review protocol,focus was narrowed to the offender's off-
site monitoring by comparing the offender's daily sign-out sheet to the offender's weekly level sheet,
which has a section for off-site verification per C.C.C.S.4-160. After reviewing three months of sign-out
sheets for December, 2007,January and February, 2008, it was found that five dates were falsely
verified by a security staff supervisor. Ironically,two of the false verifications were documented on
February 11, 2008, and February 19, 2008, stating that the offender was at work, when in fact, he had
been terminated from his job on February 8, 2008. On these two falsely documented dates and times,
the offender was in the facility.
This information of false verification was presented to the Director and Assistant Director.This writer
was informed at a later date that the employee received a disciplinary action in the form of a letter of
reprimand placed in their personnel file.
It is this writer's opinion that the Villa has made an effort to increase off-site whereabouts through
phone contacts and actual face-to-face contact in the community. This incident of false off-site
verifications is very serious and concerning. Even though this incident involves a shift supervisor, it
could have been a lack of understanding on the employee's part about the importance of off-site
verifications and how it relates to community safety,thus mandating re-training? Or it could have been
that the facility promotes a monthly contest with the security staff, awarding the employee with the
most monthly verifications a gift certificate to Starbucks? The person disciplined for the false
verifications has been a consistent monthly winner of the gift card.
MONITORS RESPONSE TO CORRECTIVE ACTION No 5:
A. As stated, through file audits,the program on the surface is improving in monitoring
activities. It is highly recommended that the Operations Manager create an internal
auditing process to review the verifications of his supervisors and staff.
B. The importance of off-site monitoring needs to be re-enforced by the facility management
through new employee orientation, re-training,discussions at unit meetings and competent
oversight/internal auditing.
FACILITY SECURITY STANDARDS:
➢ During the monitoring period,there was at least one medical emergency when an offender
had an early morning allergic type seizure. The shift supervisor assessed the situation and
arranged immediately to have the offender transported by ambulance service to the nearest
hospital.
Page Ili of14
As stated in the limited scope audit of October, 2007,there is a new layout system on all
floors of the facility with improved lines of site from the security offices on the second and
third floors. Also, on the second and third floors there is one security staff on these floors for
each shift(24/7). All rooms in the basement of the facility are padlocked. The basement
area is not accessible by the offenders without a staff member present as an escort. In
March, 2008,surveillance cameras were installed throughout the facility enhancing security
standards.
➢ During the monitoring period, regular head counts were observed by this writer. The head
counts are performed randomly and documented by the security staff assigned to that floor.
This procedure seems to be in compliance with State standards.
➢ Also throughout the monitoring period, this writer observed pat searches and bag searches
at the front desk area. These type searches were random and not documented. Room
searches are conducted by security staff assigned to their floor. These searches are
documented in the Operations Manager's office.
➢ Currently the Villa employs 22 personnel as security staff including the Operations Manager.
The program does have an on-call system to cover staff absences due to sick or annual leave.
This back-up system is mainly supported by shift and assistant shift supervisors with
overtime compensation.
MONITORS RESPONSE TO CORRECTIVE ACTION No. 6:
A. Facility layout changes have continued to improve especially with the installation of security
cameras internally and externally throughout the facility.
B. One medical situation occurred and the offender was transported to a hospital by
ambulance.
C. Random pat down and bag searches are completed on a regular basis. Searches of visitors,
rooms, and grounds surrounding the facility were not observed.
D. The Operations Manager has implemented several new trainings related to security duties _ ,
(i.e.:specific pat down, bag, and room searches).
Page 19of14
C.C.C.S. Section 5-000
Facilities Standards
Regarding the findings of the four standards addressed in the scope audit, this writer and the liaison
from the WCCCB found that three out of the four standards improved and have come into compliance.
At question is standard 5-020, "compliance with fire authority?"
➢ On file in the facility is documentation from the Union Colony Fire and Rescue Authority
dating the last building fire inspection was completed June 28, 2007. The scope audit cited
and recommended that since the Villa re-organized the facility there are now a number of
locked doors making it unclear whether the new layout meets fire code requirements? On
January 22, 2008, the Union Colony Fire and Rescue completed an inspection with the
maintenance supervisor of the Villa on the main door to the basement of the facility that
now has a "panic bar" on the stair (basement) side with keyed lock from the lobby side that
met requirement. A letter dated February 21, 2008, from the Union Colony Fire and Rescue
documents with satisfaction this inspection.
➢ To date, all showers, basins, and toilets are in working order. During the monitoring period,
these facilities were checked on a routine basis by the liaison from the WCCCB and this
writer.
The issue of cigarette smoking within the facility has been corrected. Staff retraining and
awareness plus immediate consequences if a violation occurs have controlled the problem.
Smoking is allowed only in a designated fenced area in the middle of the complex.
During the monitoring period, there were routine spot checks of all dormitory areas. These
checks were conducted by the WCCCB liaison, this writer, and other unannounced official
visitors. The individual dorm rooms, halls, and bathroom areas were satisfactorily clean and
maintained on an ongoing basis.
MONITORS RESPONSE TO CORRECTIVE ACTION No.7:
A. There is a letter from the Union Colony Fire and Rescue passing inspection of a locked door
from the main facility lobby to the basement. There has not been a fire inspection of the
entire facility completed since June 28, 2007.
B. There has been a successful systematic plan implemented to eliminate unlawful tobacco use
within the facility.
C. During the monitoring period, all identified maintenance issues have been addressed and
improved. Through staff awareness and electronic surveillance, all dorm areas are now
cleaned and maintained daily plus these areas seem to be safer.
cage I10of14
C.C.C.S. Section 6-000
Case Management Standards
Nine standards in this section were cited by the scope audit of October, 2007. During the monitoring
period,this writer spent at least 50%of his time conducting case audits/reviews; meeting with case
managers and supervisors discussing assessments and case management; and meeting/discussions with
management about this writer's findings.
There was marked improvement regarding the completion of the SOA-R assessments and case
management continuity on offenders who entered the TRC Program after November 1, 2007 through
the end of the monitoring period. Although it is this writer's impression that the Villa's Director and
Assistant Director are attempting to improve case management standards in the program,the issues of
staff turn-over and too much responsibility placed on the Case Manager Supervisor are barriers that
may prevent this goal from being accomplished.
As stated, an emphasis has been placed on training new hires in all levels of the program. Part of on-
going training though, is commitment to quality internal case audits, a valuable training tool that has not
been enforced or strategized by the Director,this concern was expressed and the response has been
viewed as an empty commitment.
Y Without going into the detailed depth of the scope audit(October, 2007), the TRC case
reviews completed during the monitoring period on offenders entering the program after
November 1, 2007, were in compliance with standards relating to weekly meetings(6-070),
updated chronological/progress notes(6-080), monthly review of offender progress (6-110),
and referrals to qualified treatment providers (6-6160).
➢ Regarding the review of assessments (SOA-R), on the TRC offenders entering the program
after November 1, 2007,they were completed within 10 working days of the offender's
admission. During the monitoring period,there was case manager turnover and extended
FMLA leave. This of course creates an ongoing SOA-R training issue and the responsibility for
the completion of assessments falls on the case manager supervisor,the placement
coordinator(SOA-R trained February, 2008),and a non-residential case manager. Prior to
November 1, 2007, it was found that part of the SOA-R assessments on the RTC/IRT offender
population were being assessed and completed by the security staff.Then the LSI on
occasion was completed by a certified counselor in the IRT program. There was no evidence
of six month or qualifying event re-scoring of the LSI in any of the case files reviewed.
Page Ill of 14
➢ The program changed the supervision plan format during the monitoring period. This new
format is more detailed and seems to have offender and case manager buy-in. There was
just one case reviewed that did not have a supervision plan;this offender had been in the
program since June, 2007. Administration could not provide justification for this oversight.
There were no supervision plan revisions in the files reviewed, but the monthly offender
progress reports did indicate positive/negative change, and through these reports, the case
managers were working the original supervision plan.
Regarding the standards addressing offender budget and financial transactions, this writer
only reviewed the monthly financial statements in the case files and they seem to be in
compliance with state standards.
➢ The limited Power of Attorney documents that offender's sign at intake have been changed
since the scope audit to require upon escape, offender funds maintained by the program are
distributed by law toward Court ordered fines and fees.
MONITORS RESPONSE TO CORRECTIVE ACTION No.8:
A. Currently, there is an emphasis on case manager training and retraining. At the weekly case
manager meetings, the Assistant Director highlights and discusses on-going case
management duties. There has been improvement in training case managers,the problem
is staff retention and too much responsibility placed on the Case Manager Supervisor.
B. The language in the Terms and Conditions document has been modified and is compliant
with Colorado law.
C. As stated, there is not a strong commitment to a good and consistent internal auditing
process. Because this process is not engrained in the management of the program, it has
brought the Villa demonstrated problems around public safety and offender rehabilitation.
Page 112of14
CONCLUSIONS:
Overall, during the monitoring period there has been demonstrated improvement by the Villa in all
sections and standards of the Colorado Community Corrections Standards cited in the scope audit of
October, 2007.
The Villa was a broken program and over the past five months, management has been putting the pieces
back together. The facility safety, offender management, and offender treatment have all been
enhanced. The question today is"sustainability," can the Villa program continue to improve? To
partially answer this question,this writer has often wondered, "Why did it come to this?" My opinion
after spending over two months monitoring the program has to do with the "culture" that has existed
since Avalon Corrections purchased and took control of the Villa facility. A"culture" that promoted or
tolerated cutting corners and withholding relevant facility or offender information from the WCCCB and
the Division of Criminal Justice.
Trying to further answer the question of"Why did it come to this?"the current Director of the Villa,who
also held this position during the scope audit period, may demonstrate potential and has a strong
background in security, but lacks the sufficient knowledge and skills regarding the treatment component
of a large community corrections program. It is this writer's perception that due to poor mentoring and
oversight, his ability to lead a facility without a strong treatment background, is questionable. Part of the
question of sustainability might best be answered if the Director be considered for re-assignment within
the organization with an emphasis on security.
Finally,"Why did it come to this?" is reflected in the results of the scope audit exposing the Villa's
culture of cutting corners in case management, assessments, and offender/employee program
accountability. More than enough reasons to implement a quality internal audit process to sustain
program integrity.
Page I13of14
RECOMMENDATIONS:
> Weld County Commissioners authorize the creation of a Department/Division for the
administration of community corrections services for the county. Examples of successful
Departments/Divisions that have this responsibility under their authority are:Arapahoe,
Boulder, El Paso,Jefferson, Larimer,and Mesa Counties. Weld County is a burgeoning
county. Having only one FTE dedicated to this work function is unrealistic. The board
receives 4%administrative funds that can probably support expansion to include a director's
position with experience in Criminal Justice and Community Corrections. Other correctional
services and revenue could then be added in time and/or as needed to offset general fund
dollars.
• For ease of administration, most of the aforementioned county divisions are lodged in a
larger county department but none are under a Sheriff. Reasons for not lodging a Division
(administrative work function) under a Sheriff are because of the universally viewed
perception of impartiality or neutrality. Outright operating the community corrections
program is not the political position most Sheriffs take. That is putting people in jail/prison,
is more of their focus (public safety), not taking them out of incarceration. This also could
put the sheriff or his staff at a higher level of decision making than the community
corrections board members. A Division (or staff to the board) should function as an
independent entity in providing information to the board, DCJ, Court, etc., and in monitoring
the compliance of the vendor's contract. The County must recognize and support the unique
mission and role of such a Division in regards to its relationship with the community
corrections board, which may not be congruent with the mission of for example, a Sheriffs
Department.
• The Weld County Community Corrections Board develop a small committee representative
of the local criminal justice community to meet regularly with key Avalon/Villa personnel to
identify and discuss operational concerns, develop an improvement plan,set short and long-
term goals with outcomes. Schedule a performance audit with DCJ, DOC, WCCCB and ADAD
by years-end based on this improvement plan.
> Continue the role of a monitor, especially if the Weld County Commissioners cannot approve - -
the creation of a Justice Department/Division.
▪ Continue the standing weekly face-to-face meetings with the Villa Director and the liaison
from the WCCCB board.
> Avalon recruits for a new on-site Director for the Villa. Someone with a balanced background
in treatment and security.
Page 114of14
➢ That the current Treatment Coordinator at the Villa be retained and remain in that position
with less overall facility administrative responsibility. This will give the person the ability to
focus on enhancing case management, quality treatment of offenders,and have the time to
oversee a good internal audit process.
Y Avalon be a member(and active participant) of the Colorado Community Corrections
Coalition (vender association). Apparently,when Avalon purchased the Villa program,they
stopped membership.
r Incrementally lift the DOC moratorium to allow Avalon to sufficiently staff operations. This
will give them a fair opportunity to rebuild the program and dispel the old "culture" in ways
that are consistent with "an improvement plan."
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