Audit of institutional supervision framework, 2010

• EXECUTIVE SUMMARY
• STATEMENT OF ASSURANCE
• 1.0 INTRODUCTION
• 2.0 AUDIT OBJECTIVES AND SCOPE
  • 2.1 Audit Objectives
  • 2.2 Audit Scope
• 3.0 AUDIT APPROACH AND METHODOLOGY
• 4.0 AUDIT FINDINGS AND RECOMMENDATIONS
  • 4.1 Management Framework for Institutional Supervision
    • 4.1.1 Policies and Programs
    • 4.1.2 Staffing of CSC Personnel
    • 4.1.3 Roles and Responsibilities of CSC Personnel
    • 4.1.4 Training for CSC Personnel
    • 4.1.5 Reporting and Monitoring Processes
  • 4.2 Compliance with Relevant Legislation and Policy Directives
    • 4.2.1 Compliance with Timeline Requirements
    • 4.2.2 Offender Contact with Case Management Team
    • 4.2.3 Compliance with Programming Requirements
• 5.0 OVERALL CONCLUSION

• Annex A
• Annex B
• Annex C
• Annex D
• Annex E
• Annex F

Executive Summary

As part of its mandate, The Correctional Service of Canada (CSC) is to provide correctional interventions that allow offenders to learn behaviours and skills that will facilitate their safe return to Canadian communities as law-abiding citizens. With this in mind, CSC policy requires that the supervision of an offender while in an institution includes monitoring of an offender’s changing behaviour, an ongoing review of the risk and the application of appropriate correctional interventions leading to the protection of society at the time of release. The process begins upon admission of an offender into federal custody and continues throughout the period of incarceration.

The institutional supervision framework is part of CSC’s case management activities, and represents approximately 25% of the total financial resources spent within the department ($519.3 million).¹ CSC employs approximately 16,500 staff across the country; sixteen percent of this number is comprised of employees dedicated to correctional interventions within the Welfare Programs category, and includes parole and program officers working in the institutions and in the community². The objectives of the audit of the institutional supervision framework were:

• to assess the adequacy of the management framework as it relates to the institutional supervision process, and
• to determine the extent to which CSC’s sites are complying with relevant institutional supervision legislation and policy directives.

In order to conclude on these objectives the audit included an examination of reports used as part of monitoring and assessing of offender behaviour, interviews with CSC staff and site visits to a sample of institutions across Canada.

The results of the audit indicate that key elements of a management framework are in place and that legislative requirements are being met. We found a high level of support and awareness of the policies relevant to the institutional supervision framework, and guidelines in place which assisted case management staff in preparing reports. While there is room for improvement in some areas, policies exist and roles and responsibilities are generally understood.

Highlights of opportunities for improvement include:

• Policies and Programs: Clarification of some elements of the policies;
• Resource Allocation: A formal process to address high turnover of case management positions such as Parole Officers and consideration of the current ratio of offenders to Parole Officers;
• Training: A review of the contents of the current Parole Officer training programs to consider both supervision framework and aboriginal requirements;
• Reporting and Monitoring: Implementation of performance reporting at a senior level. Currently, reporting is limited to operational purposes at an institutional level;
• Quality Control: Establishment of formal quality control methods for the institutional casework function to help ensure the consistency of quality of case management documents;
• Offender contact with the case management team: Review the tools used in the role of the Correctional Officer II in the casework management framework;
• Compliance with legislation and policy: Consider corrective measures to rectify areas of non-compliance with CSC policy, specifically:
  • Timeliness of Admission Interviews and Correctional Plan Progress Reports; and,
  • Adherence to policy guidelines on the Immediate Needs Interview, Offender Security Classification Review and transfer processes.

However, the audit team noted that there is an absence of a national monitoring system that considers or measures the quality of the information contained in the reports. Accordingly, CSC cannot fully assess the adequacy and effectiveness of its supervision framework.

Recommendations have been made in the report to address these areas for improvement. Management has reviewed and agrees with the findings contained in this report and a Management Action Plan has been developed to address the recommendations (see Annex F).

STATEMENT OF ASSURANCE

This audit engagement was conducted with an audit level of assurance.

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The findings and conclusions are based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were shared with management. The findings are applicable only to the entity examined.

_ Date:
Sylvie Soucy, CIA
A/Chief Audit Executive

1.0 Introduction

In accordance with Correctional Service of Canada (CSC)’s 2007-08 Internal Audit Plan, the Internal Audit Branch conducted a preliminary survey of the entire offender institutional case management system. Based on its findings, the team developed a three-phased audit plan. Each phase was designed to consider one of the three major components of institutional case management:

1. Intake Assessment - primary and supplementary assessments within the intake assessment process;
2. Institutional Supervision Framework - monitoring and assessments within the institutional supervision framework; and
3. Case Preparation and Release Planning Framework - pre-release decision making within the case preparation and release planning framework.

The first audit, Offender Intake Assessment was completed in April 2009. This, the second audit, focused on the second component, the institutional supervision framework.

CSC encourages and motivates offenders to change their behaviours and attitudes with a view to becoming law-abiding citizens. With this in mind, CSC policy requires that institutional supervision involves monitoring of an offender’s changing behaviour, an ongoing review of risk management and the application of appropriate correctional interventions leading to the protection of society. The process begins upon admission of an offender into federal custody and continues throughout the period of incarceration.

The institutional supervision framework is part of CSC’s case management activities, and represents approximately 25% of the total financial actual resources spent within the department ($519.3 million).³ CSC employs approximately 16,500 staff across the country; sixteen percent of this number is comprised of employees dedicated to correctional interventions within the Welfare Programs category, and includes Parole and Program Officers working in the institutions and in the community ⁴.

As such, it is a key element of CSC business and is reflected in the various corporate reports that highlight CSC strategic priorities.

As outlined in CSC’s 2010-2011 Report on Plans and Priorities, one of the five key priorities of the CSC is “Safe transition of eligible offenders into the community”. The strategic outcome linked to this operational priority is that “the custody, correctional interventions and supervision of offenders, in communities and institutions contributes to public safety.” Two of the program activities of this operational priority are custody and correctional interventions which both fall within the scope of this audit.

Another key priority is the “Enhanced capacities to provide effective interventions for First Nations, Métis and Inuit offenders”. CSC is required by policy to advise the aboriginal offenders at intake of their option to follow a healing path. If they so choose, the decision must be reflected in the correctional plan to ensure that the appropriate cultural needs are identified. CSC committed to support aboriginal offenders to succeed at rates comparable to non-aboriginal offenders by enhancing capacity and training for CSC staff amongst other initiatives

CSC’s 2007-10 Strategic Plan for Human Resources focuses on four priorities; one of which is to provide learning, training and development to employees. It was identified through preliminary interviews that a lack of training and mentoring may be a contributing factor to issues identified in the management of casework records and risk assessment. The audit will assist in this priority by bringing forward up-to-date information on this issue.

In the December 2009 CSC Report on Transformation Priorities, key legislative and regulatory proposals were discussed. These proposals refer to Bill C-43, which proposes reforms in four main areas:

1. Enhancing the sharing of information with victims;
2. Enhancing offender responsibility and accountability;
3. Strengthening the management of offenders and their reintegration; and,
4. Modernizing disciplinary actions.

At the time of the writing of this report, Bill C-43 was no longer under consideration, however the initiatives remain part of the Transformation.

This audit relates primarily to the third initiative, and references to the transformation are made where applicable throughout this report.

Annex A of this report provides a full presentation of the processes of the institutional supervision framework.

All offenders sentenced to federal institutions are subject to ongoing review of risk, which normally begins following the initial intake assessment process. CSC contends with a considerable flow through of offenders. In 2009, for offenders serving at least 2 years plus a day, which then fall under federal responsibility, a total of 8,226 offenders were admitted to CSC’s institutions for a total number of incarcerated offenders of 13,286. This number included 4,825 new admissions on Warrant of Committal⁵-⁶.

Correctional interventions first are planned during the intake assessment. They must be: 1) designed to support safe custody and facilitate the rehabilitation and reintegration of offenders and 2) be in keeping with the principle of least restrictive measure. They are based on the use of professional judgment and objective tools to justify, support and explain decisions or recommendations. Continuity in monitoring of the interventions, as part of the institutional supervision framework, is essential to effective correctional practice and public safety, which is the paramount consideration in all case management decisions.

As part of the institutional supervision framework, a number of documents are prepared to monitor and document offender progress. These reports provide information on changes to an offender’s case, information on activities related to an offender’s program needs, changes to an offender’s key ratings and an analysis of an offender’s behaviour, attitude and motivation.

The main progress monitoring reports are:

• Structured Casework Records;
• Correctional Plan Progress Reports ⁷, and,
• Assessments for Decision.

These reports support conclusions that provide an offender the opportunity to demonstrate progress over a set period of time.

The Structured Casework Record (SCWR) begins the monitoring process and identifies activities related to the offender’s program needs, including employment. These activities provide the offender the opportunity to demonstrate progress. The SCWR is completed once every 30 days by the Correctional Officer II (CXII) assigned to the offender.

The Correctional Plan Progress Report (CPPR) is the main report utilized to capture the offender’s progress; it is a critical management tool for successful reintegration and offender population management. This report provides a regular review of the offender’s Correctional Plan and it must be up-to-date prior to any requests for a Community Strategy or Community Assessment related to an upcoming decision (except for Private Family Visits decisions). This information is further described in Annex B. The CPPR is also completed in order to justify the addition or deletion of any program from an offender’s Correctional Plan and is completed annually for all offenders serving a life or an indeterminate sentence. The purpose is to assess the offender’s progress against the Correctional Plan when progress is not assessed using other reports, such as an Assessment for Decision for transfer or conditional release.

The Assessment for Decision (AFD) must be prepared prior to any upcoming decision concerning the offender’s case. It provides information on the offender’s progress and an analysis of the risk the offender poses, particularly related to the decision at hand. The two types of AFDs completed by the offender’s Parole Officer and considered in scope for this audit were: Institutional Transfers (Voluntary and Involuntary) and Offender Security Level.

The figure below represents the organizational structure of institutional case management staff.

[D]

Annex B provides descriptions of the roles and responsibilities of key institutional staff pertinent to this audit report.

2.0 Audit Objectives and Scope

2.1 Audit Objectives

The objectives of the audit of the institutional supervision framework were:

• to assess the adequacy of the management framework as it relates to the institutional supervision process, and
• to determine the extent to which CSC’s sites are complying with relevant institutional supervision legislation and policy directives.

Specific criteria related to each of the objectives are included in Annex C.

2.2 Audit Scope

The audit focused on the main objective of the institutional supervision process, which is to monitor an offender’s changing behaviour and to apply appropriate correctional interventions, ultimately contributing to the successful reintegration of the offender into the community and the protection of society.

The audit was national in scope. It included an examination of the reports produced as part of monitoring and assessing of offender behaviour. Within this scope were institutional transfers including security reclassifications, program assignments and completions, case preparation including timelines, case analysis and training. Annex A provides a visual representation of the institutional supervision framework process with the reports integrated in the process.

As was the case with the offender intake assessment audit (OIA), the focus of the audit was to assess compliance with policy of the case management function. The quality of the information and decisions made within the institutional supervision framework were not within the scope of the audit as was the case with the first audit.

Any types of detention referrals were determined to be out of scope for this audit due to the close relationship with the pre-release decision making process. These activities and processes will be reviewed as part of the next audit.

Temporary Absences, Work Releases, Perimeter Work Clearances and Judicial Reviews were identified as potential future stand alone audits and were not included in the scope of this audit. As with the audit of the offender intake assessment process, it was determined that case management of women offenders would be audited separately to best reflect the integrated nature of the case management process.

3.0 Audit Approach and methodology

The audit included the following methodologies:

• Review of relevant Commissioners’ Directives (CDs) and other governing documentation, set out in Annex D;
• Structured interviews with CSC staff;
• Field visits to all regions to tour facilities, interview and examine case management files. A list is found in Annex E;
• Offender Management System (OMS) file reviews against specific audit criteria and content guidelines, selected using a risk-based approach;
• Analysis based on information received by the Performance Measurement Group; and,
• Review of other relevant documentation including a review of files at the selected institutions.

For the OMS file review, the audit team used a representative sample and included both aboriginal and non-aboriginal offenders. This sample was derived from the population of active files at the time of the audit. The sample incorporated files from maximum, medium, and minimum institutions from each of the five regions. The following table summarizes the number of files reviewed from each facility level within each region.

The sample contained a proportional number of aboriginal offender files. The total representative aboriginal sample for our OMS file review was 23 files.

The following information was examined for each OMS file:

• The most recent Correctional Plan Progress Report (CPPR);
• The three most recent Structured Casework Records (SCWR) leading up to the most recent CPPR; and
• The most recent Assessment for Decision (AFD) made as a result of the CPPR. Preference was given to AFDs related to transfers, since the support for the transfer decision was within the scope of the audit.

These reports were examined within each OMS file to assess their completeness, consistency, and timeliness and the extent to which content guidelines were followed in the preparation of the report.

4.0 AUDIT FINDINGS AND RECOMMENDATIONS

4.1 Management Framework for Institutional Supervision

We assessed the extent to which the management framework for an institutional supervision framework is in place. This included a review of directives and guidelines, organizational structure, roles and responsibilities and training standards. We also reviewed the reporting and monitoring mechanisms in place for the program.

4.1.1 Policies and Programs

We expected to find that policies and procedures are clear, consistent, and understood by those who need to apply them.

Policies and procedures are generally clear and understood by those who need to apply them, however some elements require clarification.

On-site interviews indicated that the 700 series CDs which provide direction for case management are generally clear, consistent, and understood by case management staff. Also, policies and procedures are readily available to those who need to apply them and staff indicated they knew how to access them. Policies, procedures, and content guidelines were often referenced on a daily to weekly basis. Documentation pertinent to the audit is listed in Annex D.

Although policies were reported to generally be clear, results of interviews found some elements of the 700 series CDs require clarification, a finding consistent with the Offender Intake Assessment (OIA) audit. These elements include:

• Policies related to visitors and correspondence;
• Revisions for the new format of CPPRs;
• Private family visits, in particular the definition of family; and,
• Policies related to lifers at medium facilities.

This audit did not address these areas of concern, as this level of investigation was beyond the scope of the audit.

CSC has a service-wide review of CDs currently underway as part of the 2008 Policy Review Task Force. A report from this task force, entitled Staying on Track’ contains a recommendation (number 6) that states: “review and amend all existing CDs in order to establish consistency of format, clarity and level of detail”. This initiative may serve to rectify these outstanding issues.

Content guidelines assist the case management team in preparing reports.

Approximately 80% of interviewees indicated that content guidelines and templates, as they currently appear within the 700 series CDs, are useful to case management staff when completing reports.

The use of content guidelines in creating a report is mandatory; however noting which guidelines were considered, yet determined to be not applicable (e.g. by use of an “n/a”), is not. The actual indication of usage of content guidelines in case management reports ranged between 7% and 38%. While this may appear to contradict the interview results indicating that the content guidelines are useful, the low inclusion rate may be a result of any of the following:

• No mandatory requirement to note non-applicable guidelines;
• A function of the breadth of the guidelines; and,
• Case workers’ attempts to address many different scenarios.

This issue is discussed further in section 4.2.1 of this report.

4.1.2 Staffing of CSC Personnel

We expected to find that staffing levels related to the institutional supervision framework were determined using a systematic approach, and staffing levels were maintained at these planned levels.

Staffing resources are determined using a systematic approach; however issues were raised over the present ratio of offenders to Parole Officers.

A systematic approach to staffing resources is based on a workload formula that determines the appropriate ratio of offenders to POs at 25:1 as reported by interviewees. However, this formula does not take into consideration different variables, identified in on-site interviews, which included:

• Varying workloads between institutions of different security levels resulting from the number of reports required, the amount of administrative responsibilities, number of work releases, security requirements etc;
• Certain POs reported they had more demanding case loads than others due to the nature and complexity of the offender’s circumstances (life sentences versus short term sentences, multiple needs, mental health issues, etc); and,
• The offender population was reported to have changed to become increasingly diverse and challenging to manage.

Consistent with the OIA audit, these factors created issues with the application of a “one size fits all” staffing approach to case management. As set out in the OIA audit Management Action Plan, studies, working groups, and consultations to review the ratio of POs to offenders are underway with unions, Deputy Commissioners, and Assistant Deputy Commissioner Institutional Operations. A presentation to the Executive Committee (EXCOM) is expected in June 2010, which will seek approval for the implementation of the new ratio for intake units anticipated for April 2011.

A high turnover within case management positions was noted by CSC staff at the institutional level.

Information obtained through interviews revealed there was a significant amount of turnover within the CXII and PO positions. While the Offender Management System (OMS) itself is designed to minimize the impact of turnover by ensuring that all relevant documents are available to any case management staff assigned to a file, it does not address some of the qualitative factors that can impact the case management process. A formal process to manage turnover does not yet exist, interviewees indicated that caseloads are often re-distributed among remaining POs and CXIIs, representing additional workload beyond the 25:1 ratio. Alternatively, acting positions were reported to be utilized for an extended period of time. The increased workload and the prevalence of acting positions were reported to impact casework in the following manner:

• POs spent time familiarizing themselves with new cases prior to making case management decisions;
• Report quality was reported to suffer due to timeframe constraints;
• CSC staff in acting positions may not have a robust understanding of their roles and responsibilities; and,
• Offender engagement may suffer as relationships must be frequently re-built.

Good Practice

In the absence of a national strategy, there have been some regional initiatives reported to address these issues. The Prairie region has implemented a policy to cross train CXIIs and POs in order to make them readily available should a position need to be filled, and the Atlantic region has implemented a process to report on staffing levels to the RHQ, which are then incorporated into regional human resource plans.

The audit noted that although turnover was identified as a concern in interviews, data available did not provide a clear picture of the number of positions filled with actors. However, CSC has made significant efforts to fill vacant positions. From April 1, 2008 to March 1, 2009, CSC hired 1,584 new correctional officers.

4.1.3 Roles and Responsibilities of CSC Personnel

We expected to find that roles and responsibilities are defined, understood and documented with respect to the institution supervision framework.

Roles and responsibilities are generally clear, defined and understood, with the exception of some individuals in acting positions.

Interviews with POs confirmed that staff in substantive positions had a clear understanding of their roles and responsibilities. However, this was not always the case for those in acting positions. This has proven to be problematic as it was reported that there were numerous acting positions within case management ranks. Although those in acting positions did receive formal training for their substantive positions, 111 of the 138 interviewees stated that actors relied significantly on informal training approaches such as “learn as you go”, on the job training, peer mentoring, and job shadowing to obtain the skills and knowledge required to perform their acting jobs. While job descriptions could provide additional information on roles and responsibilities and were signed off by staff, they were rarely used as a point of reference.

4.1.4 Training for CSC Personnel

We expected to find that appropriate training relating to the institutional supervision framework process is provided to staff at all levels.

Audit testing of a sample of 30 acting and substantive POs found that 23 received the mandatory PO Orientation Course (CMO2), as defined by National Training Standards.

As formally defined by the National Training Standards, both acting and substantive POs must complete the PO Orientation Course (CMO2) prior to starting in the position. A random sample of training records for 30 substantive and acting POs was reviewed and indicated that 77% of these POs received the mandatory CMO2 Orientation Course.

Annual mandatory training is often high level and does not specifically address the institutional supervision framework.

Interviews with case management staff revealed that the annual mandatory training, as outlined by the National Training Standards, provided a high-level overview of topics for CSC staff and may not necessarily meet the specific needs of the region or institution. In particular, CXIIs and CMs received limited training specific to case management. This finding is consistent with the OIA audit.

Training related to the administration of Aboriginal requirements is limited.

There are specific aboriginal requirements which must be completed for aboriginal offenders as part of the institutional supervision framework. Interviewees suggested that additional training on how to implement these aboriginal requirements at a practical level, specific to the supervision framework, would be beneficial.

The need for additional training on aboriginal requirements and on specific case management processes is consistent with the results of the OIA audit.

4.1.5 Monitoring and Reporting Processes

We expected to find that a process existed to track and report performance at national, regional, and institution levels regarding the institutional supervision framework, which included performance metrics, issue resolution, monitoring and compliance, and continuous improvement assessments.

Performance metrics are reported and used at the local and regional levels for operational purposes; there was no evidence of national reporting.

The audit found that work performance and timelines were tracked using a variety of corporate reporting tools, including RADAR, Corporate Managing System (CMS) and OMS. These corporate reporting tools were generally accepted and found useful for CSC staff, particularly for monitoring timelines and activity rates and reporting at the OMS and casework levels.

The audit found that performance metrics and timelines were tracked at the local level, but not routinely monitored nationally. Records such as Admissions Interviews, CPPRs, and SCWRs, among others, are consulted by NHQ when case management activities such as detention referrals, are undertaken. If anomalies were found, staff at the institutional level was contacted directly.

Interview participants went on to suggest that improvements could be made to the quality of corporate reports. Although a significant amount of raw data was received, the data focused primarily on quantitative performance data with limited qualitative analysis or recommendations that would assist in improving the process. Moreover, qualitative information was developed regionally, but each region only had one resource dedicated to performance measurement, limiting their ability to analyze the performance of CSC staff on supervision framework requirements. Additionally, the audit did not find any evidence of monitoring on the quality of the reports through any corporate reporting tools thus making it challenging to assess how reliable the information was for management purposes.

Outside of the Officer Statement and Observation Reports (OSOR) which are used in institutions to document significant events mostly relating to security issues, no formal mechanisms were reported to exist to inform senior management of issues and trends related to offenders or a population within the institution. As a result, regular informal verbal briefings with institutional senior management were customary within institutions to provide updates on offender issues, trends or progress. These briefings were considered to be helpful and an effective means of communication.

There is no formal Quality Control process to assist in the reporting and monitoring process.

Guideline 005-1 Institutional Management Structure: Roles and Responsibilities, states that the Managers, Assessment and Intervention (MAIs) are responsible for supervising the POs and performing the quality control function on case management reports completed. However, there was no formal, standardized quality control process to assist them in doing so.

This guideline also states that Correctional Managers (CMs) are responsible for performing the quality control function on Structured Casework Records (SCWRs) completed by the Correctional Officers II (CXIIs). As with the MAIs, the CMs did not have a formal, standardized quality control process nor was there evidence of any training programs to teach them how to do so. As stated in section 4.2.1, our audit found that some of the key reports that assist in case management did not meet requirements. For others, even though reports were prepared in a timely fashion, the information was often copied without new information being added.

The OIA audit also identified quality control as an area of improvement. Its Action Plan states the development and introduction of a quality control process is underway, along with associated performance measurement index and indicators.

The case management areas which would benefit from formal quality control prior to being locked in OMS include CPPRs, SCWRs, and AFDs. The results of our file review, discussed in Section 4.2.1 Summary of File Review, support the need for formal quality control on reports.

CSC staff involved with institutional supervision reported they understood policy well, with a few areas of clarification required. However, they did report challenges with staffing levels and reported a need for more training specific to institutional supervision. With regard to reporting and monitoring functions, local monitoring was considered to be satisfactory but there is a lack of national reporting and monitoring. Finally it was noted that there was no training and no formal standards established for the quality control processes required by various CD’s.

In addition to these observations, the audit team noted that CSC does not have the means to measure the quality of the information in the casework records at both national and institutional levels other than timeline compliance. With a lack of comprehensive measurement tools, it is difficult to determine how well the system in place to support the case management efforts contributes to CSC objectives in this area.

CSC would benefit from clearer standards for information quality, performance indicators and reports on results.

Recommendation 1

Policies and Programs
The Assistant Commissioner, Correctional Operations and Programs should:
clarify policies where needed, strengthen processes to notify staff of relevant policy updates, implement a consistent approach to responding to policy clarification requests and update the “National Correctional Program Guidelines”. Work undertaken as a result of recommendations in the Offender Intake Assessment Audit and actions taken through the Policy Review Task Force may assist in the implementation of this recommendation.

Recommendation 2

Resource Allocation
The Assistant Commissioner, Correctional Operations and Programs (ACCOP), in collaboration with the Assistant Commissioner Corporate Services, should broaden the review of the current workload formula for Parole Officers to include institutional supervision duties.

Recommendation 3

Training
The Assistant Commissioner, Correctional Operations and Programs (ACCOP), in collaboration with the Assistant Commissioner, Human Resources Management Sector (ACHRMS), should review current training specific to the Institutional Supervision Framework for case management staff and implement improvements as required.

Recommendation 4

Monitoring and Reporting
The Assistant Commissioner, Correctional Operations and Programs (ACCOP) should undertake a review of CSC’s case management reports for continued relevance and alignment with corporate objectives. Then, the ACCOP should identify and implement relevant performance tracking measures related to the preparation of those reports still deemed appropriate to assist with ongoing improvements and CSC initiatives. Performance measures should include indicators for the quality of file contents at the institutional level. As a means to ensure compliance any identified performance gaps should be reported and addressed as part of this process.

4.2 Compliance with Relevant Legislation and Policy Directives

The audit team assessed offender files along the following three lines:

1. Compliance with mandatory timelines;
2. Compliance with mandatory policies; and
3. Usage of the content guidelines.

As noted in section 2.2 on Audit Scope, the audit procedures did not include an assessment of the quality of the case decisions, but did attempt to assess the extent of analysis in the case documents by looking for evidence in the file of "cut and paste" and noting the percentage of content guidelines that were considered in the analysis in the 30-day Structured Casework Records (SCWR).

It is important to note that while the use of content guidelines is mandatory, case management staff is not required to document whether a particular content guideline was considered but not included. Therefore the task of making a definitive assessment was impossible for the audit team.

4.2.1 Compliance with Timeline Requirements

We expected to find that Structured Casework Records (SCWR), Correctional Plan Progress Reports (CPPR), High Profile Offender Memos, and Assessments for Decisions (AFD) were completed in compliance with relevant CD policies, including timeline requirements, and that content guidelines were used and documented. The following section of this report highlights an analysis of key elements of the documents and procedures of the institutional supervision framework.

For Admissions Interviews, some of the files reviewed were in compliance with timeline requirement.

An Admissions Interview, once completed, is input as a Casework Record. Policy dictates that each offender is to receive a conference within 5 days of the offender’s penitentiary placement or transfer to another institution, regardless of security level. The responsible case management team holds a case conference to review the file and interview the offender. As per CD 705-3, the focus of the conference is to:

• confirm the language used in the file;
• introduce the case management team to the offender;
• supplement and verify information already gathered and identify areas of need that require immediate attention;
• make necessary referrals if required;
• provide expectations of the case management team;
• discuss private family visits and eligibility dates, and
• share the preliminary report if not already done.

Our audit indicated that not all offenders received an Admissions Interview, and of those that did, not all fell within the timeline. As depicted in the table below, compliance with this requirement was lower for medium facilities than for maximum and minimum facilities and lower in the Prairies and Pacific regions.

There were 122 files reviewed; 83 (or 68%) had Admissions Interviews on file. Of those 83, 68 (or 82%) were completed on time.

Further analysis of the 39 files lacking evidence of an Admissions Interview indicated the following:

• 67% (26/39) of files lacking evidence of an Admissions Interview within the 5-day timeframe did eventually hold a conference. These Admissions Interviews were on average 13 days late, and
• 33% (13/39) of offender files did not show evidence of an Admissions Interview ever being held.

Therefore, of the 122 files reviewed, 89% or 109 had an Admissions Interview completed at some point in time.

One possible explanation for going beyond the required timeframe may be due to CXIIs assigned to a case not being available to attend the case conference or not on shift within the 5 days of the offender’s transfer to an institution.

The tables below provide further detail by security level and regions.

It should be noted that of the files reviewed, 6 were not applicable for a variety of administrative reasons, such as the offender not having been placed at a parent institution.

For Correctional Plan Progress Reports files reviewed, we found varying levels of timeline compliance for the program completion requirement.

Regular reviews of the Correctional Plan are done in the form of a CPPR. CD 710-2, Progress against the Correctional Plan identifies situations where the completion of a CPPR is mandatory in order to record changes to the Correctional Plan and progress against the Correctional Plan objectives. Two events that require the completion of mandated reviews of the Correctional Plan by way of the CPPR are first, when an offender completes a core program and second, the annual review when an offender is serving a life sentence. Documenting progress is essential for making informed release and transfer decisions.

As per policy 710-1, when an offender completes a core program that has been outlined in the Correctional Plan, a Parole Officer as part of the Case Management Team (CMT) must complete, within 30 days, an analytical review to determine if an adjustment to any of the key ratings (an explanation is included in Annex B) is warranted. If an adjustment to a key rating is warranted, a CPPR must be completed within 30 days from the date the Program Performance Report is reviewed and locked in OMS. If no adjustments are warranted, then a Casework Record must be completed by the Parole Officer and entered into OMS using the coding entitled "CP Update".

Our audit found that of the 128 files reviewed, only 34 files included a core program. For these 34 files, the overall rate of completion was 68%. However, in regard to the timeframe compliance, the overall CSC rate was 91% within the required 30 day timeframe. When late, the average delay was 8 days.

We also noted that in the files where there was a Casework Record on file, the document was not coded as "CP Update" but rather coded as either "offender" or "other".

As depicted in the tables below, the compliance rate remained fairly consistent across the institutional levels with the exception of the maximum level institutions at 75%. Rates, however, varied across regions going from 60% to 100% depending on the regions.

For Correctional Plan Progress Reports for Lifers, there was also a difference in the level of compliance with policy.

Effective September 18, 2007, a CPPR must be completed by POs on an annual basis for all offenders serving life or indeterminate sentences. Overall, our audit found POs completed 55% of the required CPPRs on an annual basis.

For Offender Security Reclassification Review, 100% of files reviewed were in compliance with timeline requirement.

Review of Offender Security Reclassification (OSL) is important for the protection of public safety because it ensures offenders are continuously placed to an institution at the appropriate level of security throughout their sentence. Furthermore, it ensures that CSC is following the Corrections and Conditional Release Act which requires that the protection of society be the paramount consideration and that CSC uses the least restrictive measures consistent with this protection. Each offender is assigned a minimum, medium, or maximum security classification based on the application of the Custody Rating Scale (CRS) at intake and then the Security Reclassification Scale (SRS) thereafter along with an assessment of other relevant factors. Security Reclassification Reviews must be completed by POs within timeframes determined by the offender’s sentence.

The audit found POs met the Security Reclassification Review timeframes 100% of the time.

For Transfer Processes, 100% of the files reviewed were in compliance with timeline requirements.

The transfer process ensures that offenders are transferred to an institutional level that meets individual security requirements and program needs, while ensuring public safety. Transfers can be voluntary or involuntary, as well as inter- or intra- regional.

Regardless of the type of transfer, every offender movement between institutions requires a transfer warrant or a letter of withdrawal for Aboriginal offenders moving to a Healing Lodge. However, depending on the transfer type, delegated authority to render a decision, as well as timeframes to make a decision can change. These details are found in CD 710-2 Annex A Transfer of Offender – Delegation of Authority.

Overall, our audit indicated 100% of transfer decisions were made within mandated timeframes presented in CD 710-2 Annex A.

CD 710-2 states that a High Profile offender is one “whose offence involved the death of or serious harm to other person(s) and received significant public attention or offenders whose offence was non-violent but generated significant media attention and/or a significant number of victims”.

High Profile Offender policy dictates that if a proposed transfer is likely to generate significant public interest, then the PO will complete a Memo entitled “High Prof” at least two weeks prior to the offender’s transfer.

Our audit examined 29 files that were flagged as High Profile. Sixteen of these files were applicable in that they included a transfer that occurred during the period of incarceration. Of the 16 files, 6 had High Profile memos completed and on file prior to the transfer. For the remaining 10 files, no memo was completed. In these cases, it is possible that the PO determined that the transfer was not likely to generate significant public interest and as such determined that no memo was required.

Given the sensitivity of this area to CSC and the risk associated with offenders flagged as high profile, it would have been useful to have had some form of documentation that would have explained why a memo was not deemed appropriate for a particular transfer. However, it should be noted that policy does not indicate that this must be done.

It is important that compliance with mandatory policies, as directed by the CDs, is reflected in the offender’s case management records. This section of the audit examined compliance with the following specific policy areas:

• Immediate Needs Assessment
• Offender Security Reclassification Review
• Transfer Processes
• Aboriginal Offenders Transfer Process
• High Profile Memos

For Immediate Needs Assessment, the majority of offenders received an assessment.

As per CD 705-3, an immediate needs assessment, once completed, is documented in a casework record by the Correctional Manager (CM) or the Correctional Officer II (CXII). Policy dictates that as part of the preliminary assessment, every offender must receive an immediate needs assessment upon transferring to a new institution.

Our audit found that the majority of offenders (79%) received an immediate needs assessment upon their arrival at an institution. As depicted in the tables below, this rate remained fairly consistent across regional levels; with one exception in the Prairie region where 64% of offenders received an assessment upon their arrival at a new institution.

For the Offender Security Reclassification Review, 100% of files reviewed were authorized by the appropriate personnel.

Institutional heads, or the delegated authority, are responsible for the authorization of an offender’s security classification. This is achieved through a CSC Board Review Offender Security Level (OSL) report which must include the institutional head or delegated authority’s specific ratings in relation to three categories: institutional adjustment, escape risk, and public safety. All details pertaining to this topic are found in CD 710-6.

Overall, our audit indicated 100% of CSC Board Reviews were authorized by the appropriate personnel.

Further, our audit also indicated that over 80% of CSC Board Reviews included the mandatory specific ratings as per the three categories at the institutional level.

Each offender security classification review includes the application of the Security Reclassification Scale (SRS). This requires the SRS numerical assessment be explicitly documented in the security reclassification review. As depicted in the tables, compliance with this policy remained consistent across institutional levels, while at the regional level, the Atlantic and Quebec regions were significantly lower than the other regions.

With respect to Aboriginal offenders, there are specific factors that must be taken into consideration when completing a security classification review. They, as well as findings related to this topic, are discussed in detail in the Aboriginal Policy Compliance Section of this report.

For Transfer Processes, we found that the appropriate decision maker rendered the decision 100% of the time.

CD 710-2 Transfer of Offenders, Annex A identifies who the appropriate decision maker is to render a transfer decision. This is not only a policy requirement, but a legal requirement set out in the Corrections and Conditional Release Act as well. Audit testing indicated the appropriate decision maker rendered the transfer decision 100% of the time.

The detailed policies pertinent to voluntary inter and intra regional transfers are defined in CD 710-2. Overall, compliance with the voluntary inter and intra regional transfer processes varied depending on the region and on institutional levels.

CD 710-2 states that an offender serving a life sentence for first or second degree murder being transferred from a maximum to a medium facility must have a full psychological assessment on file that was completed within the past two years. Our audit identified five relevant files, at the medium institutional level, which met this criterion. As noted in the table, of the five files, three had a full psychological assessment on file completed within the past two years.

For Transfer of Aboriginal Offenders, 100% complied with policy.

In order for an Aboriginal offender to be transferred, a letter of withdrawal or a transfer warrant must be on file. Overall, there was 100% compliance with this part of the policy.

When determining the security classification of Aboriginal offenders, case management staff must take into consideration specific factors which are described in detail in CD 710-6 paragraph 24. However, there is no requirement to document the decision process around the consideration of the specific elements.

For High Profile Memos, there was compliance with policy.

For High Profile Offender files with a memo on file, specific elements must be addressed to ensure a memo is complete. These elements include:

• Public interest in the case from the time of arrest to present;
• A short assessment of the offender’s classification history; and,
• Concerns of probable interested parties and stakeholders and actions taken to prepare the community.

CD 710-2 paragraph 93b outlines these elements in detail. Overall, the review of the 6 memos on file indicated POs incorporated 100% of required elements on 5 files and 93% on the 6^th file.

Content guidelines were included in the 700 series CDs to assist case management staff develop pertinent and consistent reports by providing guidance towards an effective and comprehensive risk assessment. The use of content guidelines in creating a report is mandatory; however the process of noting which guidelines were considered, yet determined to be not applicable (e.g. by use of an “n/a”), is not. For this reason the audit results, which can only identify the content guidelines included in the report, may reflect a lower compliance rate than warranted. Although it is difficult to assess the exact use of content guidelines, interviews indicated that approximately 80% of case management staff made use of content guidelines to assist them in completing case management reports. In contrast, the information documented in OMS indicated the overall content guideline usage rate was considerably lower.

The following table identifies the usage rates for the content guidelines outlined in the CDs.

However this usage information is included in this audit report as it provides useful context when examining the issue of the extent of analysis included in the case management reports, particularly in conjunction with the results of the “cut and paste” testing.

4.2.2 Offender Contact with Case Management Team

We expected to find that case materials reflect one-on-one contact and knowledge of the offenders.

Most institutional staff interviewed indicated that they would need more contact with offenders to provide meaningful context for reporting purposes.

In order to develop comprehensive and up to date case management documents, Parole Officers and Correctional Officers IIs meet in person with offenders to discuss progress and issues. Particularly in minimum security level institutions, Parole Officers indicated their caseload ratio (25:1), presented challenges in preparing case management reports within timeframes. They cited a large amount of administrative work, while those in maximum institutions cited population management security issues as a key contributor to their workload. Consequently, POs reported they had limited opportunities for face-to-face offender contact.

Interviews with CXIIs indicated they had sufficient time to meet with offenders, with face time increasing slightly as the security level decreased. Despite this, interviewees went on to suggest the frequency of meetings had declined due to the rostering changes to CXII schedules where it had been some time before a CXII rotated back to the area of the institution where his or her caseload was located.

CXIIs are required to update SCWRs which in turn are intended to identify activities related to the offender’s program needs, including employment, and provide insight or analysis on the offender’s behaviour, attitude, motivation, and progress achieved in the previous 30 days. Also, the SCWR plans activities for the next 30-days with the intention of providing the offender with the opportunity to demonstrate progress.

Although our OMS file review found SCWRs were usually updated within the 30-day timeline, we found evidence of cut and paste from one record to the next where new or different material may have been more appropriate. Results of the testing for cut and paste is presented in the following compliance table:

Overall, 58% of the Structured Casework Record showed evidence of cut and paste. Minimum facilities presented the highest amount of cut and paste activity, which was of interest because offenders incarcerated in minimum institutions have the most opportunity to participate in programs, activities, interventions, private family visits, etc. thereby providing an abundance of new monthly information to incorporate into SCWRs.

There are a number of additional factors which could have influenced the amount of cut and paste in the SCWRs:

• A common theme in the interviews with all levels of the organization was a criticism of the SCWR; commonly referred to as a cyclical problem. The SCWR was not completed in a comprehensive manner because it was not used, the SCWR was not used because of the poor quality of information or a lack of new analysis it contained; and,
• Situations where there was no new information to report in the SCWR from one month to the next. For example, if an offender was wait-listed for a program and had not changed employment or incurred institutional charges, the SCWR did not require new or updated information and analysis from the previous month.

4.2.3 Compliance with Programming Requirements

We expected to find that the programs specified in offenders’ Correctional Plans are provided to offenders in a timely fashion and in accordance with the Correctional Plan. Testing in this audit was limited to the rate of completion of a program during the period of incarceration since a comprehensive evaluation was recently completed.

A measurement of program completion revealed that 67% of non-aboriginal and 64% of aboriginal inmates completed a program prior to full parole eligibility date.

Due to the small sample size of the original file review in this area, the audit team elected to perform further testing to more appropriately capture the numbers of offenders, both aboriginal and non-aboriginal.

The audit team performed substantive testing of 465 offender files to assess whether programs were provided in a timely manner. Of this total sample, 24 offenders were not referred to any core programming as a result of behavioural factors. Consequently, the sample used for analytical purposes totaled 441 offenders.

Non-Aboriginal Offenders:

Of the total sample of 441 offenders, 338 were non-Aboriginal offenders. The findings were:

Of the 112 offenders (33%) who did not successfully complete their programming before FPED there were a variety of reasons, including suspension, not meeting program targets, transfer, and withdrawal.

Aboriginal Offenders:

Of the total sample of 441 offenders, 103 were Aboriginal offenders. The findings were:

These results did not vary significantly from those of the non-Aboriginal offenders. Of the 37 Aboriginal offenders (36%) who did not successfully complete their programming prior to FPED, reasons included: wait-listing, suspension, transfer, refusal and withdrawal.

Interview results revealed that 44% of staff believed the program needs of offenders were being met which was consistent with the file review results.

There were many comments provided to the audit team regarding the challenges in meeting program requirements including:

• Population management concerns in physical transfer of offenders to programs, which caused shorter program days resulting in longer program length;
• Limited space within facilities to hold programs;
• Shorter sentences creating program capacity pressures;
• The limited number of programs available leading to increasingly strict or exclusive program criteria for qualification for a specific program; and
• The need for bilingual programming and specific, additional vocational programs.

CSC has taken steps to improve program delivery along the following lines:

• The Report on Transformation Priorities indicated that CSC will improve program delivery through the implementation of the Integrated Correction Program Model;
• The Report on Transformation Priorities indicated there would be revision to institutional and community case management policy and processes in 2010 to ensure offenders have access to programs as directed by their Correctional Plans.
• The Report on Plans and Priorities outlined a program initiative focusing on increasing program availability.

The audit work found that there was some room for improvement on the level of compliance with timeline requirements, in particular Admission Interviews and CPPRs for programs and for lifers. Timelines should be respected because they ensure the supervision of offenders in the institutions meet offender’s rights. Specifically, offenders have a pre-determined period of incarceration and CSC’s obligations under the law are governed by these timelines. Further, ensuring that the appropriate timelines are respected may also be considered as a matter of importance in protecting the security of the Canadian public.

During interviews conducted across the regions, CSC staff were asked about their ability to meet these timeline requirements and many staff indicated that they encounter some difficulty. They reported that they are burdened with a large case load and administrative tasks and only meet compliance at present levels because they forego face to face contact with inmates. This concern may be addressed in part with the recommendations raised in the previous section of this audit.

The audit team found that overall, there is compliance with relevant legislation and policy direction, with some exceptions noted. Some areas of compliance for both timelines and policy were very high, but for other policy requirements, compliance varied broadly both within regions and between institutional levels. This inconsistency raises questions as to the why this may be the case.

This answer may be related to the adequacy of the management framework of the institution supervision process. A gap was identified when the audit team examined the monitoring and reporting processes and found that there is a lack of tools in place to measure and report on the quality of the information and its qualitative adherence to the policies. While CDs set out certain required actions and content requirements for documents and although our audit work indicated that this information is documented and reported to be understood by CSC staff, further monitoring and reporting beyond timeliness is absent. Without a tool to measure this activity, the adequacy and effectiveness of the framework is difficult to assess.

Accordingly, the audit results are limited to a measurement of the timeliness of the documents and the presence of key documents. Given the discretionary and professional nature of the work performed by POs and CX IIs and in the absence of definitive standards on what is considered to be appropriate levels of quality information, the audit group cannot comment on this critical area of CSC service.

We expect that the recommendations made in the previous section related to policy clarifications, training, performance monitoring and quality assurance will assist CSC in achieving improved policy compliance in the institutional supervision framework process.

Recommendation 5

Policies and Programs
As part of Recommendation 1, the Assistant Commissioner, Correctional Operations and Programs (ACCOP) should review :

• the decision process policy for preparation of High Profile memos;
• the timeliness of Admission Interviews, Correctional Plan Progress Reports, Immediate Needs Interview, Offender Security Classification Review and transfer processes and
• the use of content guidelines as an effective tool in the monitoring of adherence to policy.

5.0 Overall Conclusion

The results of the audit indicate that key elements of a management framework are in place and that legislative requirements are being met. We found a high level of support and awareness of the policies relevant to the institutional supervision framework, and guidelines in place which assisted case management staff in preparing reports. While there is room for improvement in some areas, policies exist and roles and responsibilities are generally understood.

However, the audit team noted that there is an absence of a national monitoring and reporting system that addresses the quality of the information contained in the reports and the qualitative adherence to policies. In the absence of such a tool, CSC is not in a position to fully assess the adequacy of its supervision framework.

Annex A

Process diagram of the administrative process for inmate supervision during incarceration.

[D]

Annex B

Annex C

The preliminary survey of this audit included an exercise to map the risks identified with the TBS Management Accountability Framework (MAF) and the corresponding Core Management Controls via CSC’s risk taxonomy.

The MAF areas affected by this audit include: Policy and Programs, People, Results and Performance Accountability

Annex D

There are four pertinent Commissioner’s Directives (CDs) related to offender case management which describe in detail both the mandatory policies case management staff must follow and the suggested content guidelines case management staff can reference. Pertinent CDs and documentation relevant to this audit and the institutional supervision framework are:

• CD 710: Institutional Supervision Framework;
• CD 710-1: Progress against the Correctional Plan;
• CD 710-2: Transfer of Offenders;
• CD 710-6: Review of Offender Security Classification;
• The Corrections and Conditional Release Act (CCRA); and,
• The Corrections and Conditional Release Regulations (CCRR).

Annex E

Interviews of CSC staff included Institutional Parole Officers, Correctional Officers, Assistant Wardens-Intervention, Correctional Managers, Program Managers, Managers-Assessment and Intervention, Assistant Wardens-Operations, Regional Deputy Commissioners and other CSC stakeholders.

Annex F

¹ CSC Departmental Performance Report 2008-09

² Ibid

³ CSC Departmental Performance Report 2008-09

⁴ Ibid

⁵ Public Safety Canada , Corrections and Conditional Release Statistical Overview Annual Report 2009

⁶ Warrant of Committal Upon Conviction is a document issued by a judicial authority outlining criminal act(s) committed, penalty imposed and ordering confinement in a correctional facility. The Warrant of Committal Upon Conviction is issued under the authority of subsection 570(5) of the Criminal Code of Canada (CCC).

⁷ At the time of the field work conducted for this audit, CSC progress reports were entitled Correctional Plan Progress Reports (CPPR). However, at the time that this report was written, the form had been renamed to Correctional Plan Update (CP Update). These report names refer to the same type of document.

⁸ N = Total Sample reviewed per test area (Not Applicable files were excluded from the sample as appropriate)

⁹ Comp. with Policy = Compliance with Policy (This has been carried through the remainder of the report)