Audit of the management of inmate transfers, 2017

The Audit of the Management of Inmate Transfers was conducted as part of the Correctional Service of Canada (CSC) Internal Audit Sector's 2015-18 Risk-Based Audit Plan (RBAP)

The objectives of this audit were to provide assurance that:

• the management framework in place supported the effective management of inmate transfers; and
• CSC was complying with relevant legislation and CSC policy directives related to the management of inmate transfers.

The audit was national in scope and included visits to all regions and National Headquarters (NHQ).

The audit examined whether CSC policies, guidelines and other documentation were clear and promoted efficiencies; whether key roles and responsibilities were defined, documented and understood, and whether CSC was achieving the best value for money when transferring inmates. Additionally, the audit looked at whether CSC was complying with various legislative and CSC policy requirements. As well, staff and inmate safety was examined.

Transfers play an important role in the Service's ability to manage the inmate population within the confines of the law, and are key to meeting the Organization's priorities. Furthermore, they allow inmates access to programs that may not be available at their current institution, and transfers also permit inmates to be closer to their home community. Between April 2014 and August 2015, CSC transferred over 8,000 inmates, accounting for a total of over $4.2 million of recorded expenditures during the 2014-2015 fiscal year. The Assistant Commissioner, Correctional Operations and Programs is responsible for overseeing the transfer process and has been identified as the Office of Primary Interest (OPI) for this audit.

Transfers relate specifically to CSC's priorities of "[s]afe management of eligible offenders during their transition from the institution to the community… and [s]afety and security of the public, victims, staff and offenders in institutions and the community."^{Footnote 1}

Transfers also link to CSC's corporate risk that the Organization will not be able to respond to the complex, diverse and evolving profile of the offender population^{Footnote 2} and that CSC will not be able to maintain required levels of operational safety and security in the Institutions and in the community.^{Footnote 3}

With respect to the first objective on effectiveness of the management framework in relation to the transfer of inmates, we found that the framework generally supported the effective management of inmate transfers. We also found that the policies in place surrounding the transfer process were generally clear as were the roles and responsibilities.

However, the audit also noted a number of areas that required further consideration by management to ensure that the transfer process is able to function with greater effectiveness:

• although policies are clear, there are several areas within the policies where efficiencies in the transfer process could be realized;
• all key positions within the transfer process would benefit from fully trained backfills; and
• a refinement of costing information for the air transfer process would be beneficial to ensure the organization is operating in an efficient and economical manner.

The second objective of this audit focused on CSC's compliance with legislation and CSC policies. The audit found that officers are briefed on the inmates they are transferring and overall, inmates are receiving continuity of care while they are being transferred. The air transfer process is in compliance with CSC policies, and transfer decisions are being made within the prescribed timeframes.

As with the first objective, there are a few areas where improvements can be made. These include:

• transfer decision documentation should be shared with inmates in a timely manner;
• information considered in the decision to transfer should be recorded within the decision documentation;
• the Threat Risk Assessment (TRA) process should be reviewed to ensure it is adding value to the transfer process; and
• more timely sharing of health care information and improved management of medication to ensure better continuity of care.

A4D - Assessment for Decision

CCRA - Corrections and Conditional Release Act

CCRR - Corrections and Conditional Release Regulations

CD - Commissioner's Directive

IRO - Institutional Reintegration Operations

MAI - Manager, Assessment and Intervention

NHQ - National Headquarters

NTC - National Transfer Coordinator

OMS - Offender Management System

OPI - Office of Primary Interest

RBAP - Risk-Based Audit Plan

RDC - Regional Deputy Commissioner

RHQ - Regional Headquarters

SIO - Security Intelligence Officer

SHU - Special Handling Unit

TRA - Threat Risk Assessment

The Audit of the Management of Inmate Transfers was conducted as part of the Correctional Service of Canada (CSC) Internal Audit Sector's 2015-2018 Risk-Based Audit Plan (RBAP).

Transfers play an important role in the Service's ability to manage the inmate population within the confines of the law, and are vital to meeting CSC's organizational priorities of "[s]afe management of eligible offenders during their transition from the institution to the community […] and [s]afety and security of members of the public, victims, staff and offenders in institutions and the community."^{Footnote 4} Transfers also link to CSC's corporate risk that "CSC will not be able to respond to the complex, diverse and evolving profile of the offender population"^{Footnote 5} and that "CSC will not be able to maintain required levels of operational safety and security in institutions and in the community."^{Footnote 6}

There are a number of reasons why a transfer would take place. They include: to house inmates in an environment that is consistent with their security level; to allow inmates to participate in correctional programs and other interventions as identified in their Correctional Plan; to provide an opportunity for inmates who have been in segregation to re-enter the general population when all other options to alleviate segregation at the current institution have been exhausted, and to allow inmates to be in closer proximity to community support. As well, inmates may be transferred to:

• a CSC Treatment Centre for treatment, programming or for assessment purposes;
• an Aboriginal correctional facility;
• the Special Handling Unit (SHU); and
• attend court proceedings.^{Footnote 7}

Between April 2014 and August 2015, CSC transferred over 8,000 inmates. There are three main types of transfers: an intra-regional transfer (within the same region), an inter-regional transfer (from one region to another) and an international transfer. For intra-regional transfers, the most commonly used method for transferring inmates is via transfer van or bus, while inter-regional transfers typically take place via chartered aircraft. International transfers normally take place between Canada and countries with which a valid transfer agreement exists.^{Footnote 8} The International Transfers of Offenders Act also includes provisions allowing Canada to enter into an administrative arrangement with a state or non-state entity for the transfer, on a case-by-case basis, of a person who has been declared unfit to stand trial, or not guilty on account of a mental disorder.

When an inter- or intra-regional transfer takes place, it can be either voluntary or involuntary. A voluntary transfer is inmate initiated, and is generally done to allow the inmate to be closer to family/community support, to access programming or to be in a less restrictive environment. Involuntary transfers may take place when an inmate's risk to staff, other inmates and/or public safety is no longer manageable within the current site. Involuntary transfers are initiated by the case management team most often due to an inmate's security requirements being reassessed; to provide the inmate being transferred a safe environment or to improve the safety of the institution from which the inmate is being transferred from.

The Corrections and Conditional Release Act (CCRA) Section 28 states that "the Service shall take all reasonable steps to ensure that the penitentiary in which [offenders] are confined is one that provides them with an environment that contains only the necessary restrictions, taking into account:

1. the degree and kind of custody and control necessary for
   1. the safety of the public,
   2. the safety of that person and other persons in the penitentiary, and
   3. the security of the penitentiary;
2. accessibility to
   1. the person's home community and family,
   2. a compatible cultural environment, and
   3. a compatible linguistic environment; and
3. the availability of appropriate programs and services and the person's willingness to participate in those programs.

As a result, it is essential that the Service provides a transfer process that is fair, efficient and effective.

There are several areas within the CCRA and the Corrections and Conditional Release Regulations (CCRR) that are applicable to transferring inmates. Under Section 29 of the CCRA, the Commissioner may authorize the transfer of a person who is sentenced, transferred or committed to a penitentiary to another penitentiary, or to a provincial correctional facility or hospital, based on previously signed agreements, and in conjunction with applicable regulations. However, prior to a transfer decision being made, Section 87 of the CCRA requires that the Service take into consideration the inmate's state of health and health care needs, as well as, "[…]the inmate's progress towards meeting the objectives set out in the inmate's correctional plan."^{Footnote 9}

Additionally, before an involuntary transfer can take place under Section 29 of the CCRA^{Footnote 10}, there are a number of requirements which must be fulfilled. An institutional head or a staff member designated by the institutional head shall:

1. give the inmate written notice of the proposed transfer, including the reasons for the proposed transfer and the proposed destination;
2. after giving the inmate a reasonable opportunity to prepare representations with respect to the proposed transfer, meet with the inmate to explain the reasons for the proposed transfer and give the inmate an opportunity to make representations with respect to the proposed transfer in person or, if the inmate prefers, in writing;
3. forward the inmate's representations to the Commissioner or to a staff member designated […]; and
4. give the inmate written notice of the final decision respecting the transfer, and the reasons for the decision,
   1. at least two days before the transfer if the final decision is to transfer the inmate, unless the inmate consents to a shorter period; and
   2. within five working days after the decision if the final decision is not to transfer the inmate.^{Footnote 11}

As with all activities, the Financial Administration Act and Treasury Board policies require sound stewardship of government resources to ensure that service delivery is efficient and economical.

There are a number of Commissioner's Directives and Guidelines related to transferring inmates, some of which include:

Commissioner's Directive 710-2 - Transfer of Inmates, which specifies the roles and responsibilities for staff, such as the Assistant Commissioner, Correctional Operations and Programs, Regional Deputy Commissioner and Institutional Head in relation to transfers.

Guidelines 710-2-3 - Inmate Transfer Process, which details the procedures that are to be followed for each type of transfer, including the documents which must be prepared, the decision maker, timeframes and the consultations that are to occur prior to a transfer taking place.

Guidelines 710-2-2 - Inter-Regional Transfers by Air, which details the procedures that are to be followed in preparation for the transfer, on the day of the transfer and throughout the duration of the flight. It also includes the security protocols that are to be followed when the aircraft arrives and when inmates are transferred to and from the aircraft.

The Institutional Reintegration Operations Division (IRO) falls under the responsibility of the Correctional Operations and Programs Sector, and is responsible for preparing and reviewing policies and procedures in relation to the transfer process. Additionally, IRO initiates and coordinates the standing offer process^{Footnote 12}, and oversees the review and payments for services rendered as part of the inter-regional flights. It is also responsible for coordinating inter-regional transfers and works with the Regional Transfer Coordinators in each region to establish a list of inmates who will be transferred on inter-regional flights.

The Regional Deputy Commissioner/Assistant Deputy Commissioner, Correctional Operations of the receiving region is responsible for approving inter-regional transfers. The Regional Transfer Coordinators act as a liaison between the regions when an inter-regional transfer is being proposed, and prepares the inter-regional transfer lists once it has been determined that an inmate will be transferred from one region to another.

Depending on the region, the Regional Transfer Coordinator also acts as the intra-regional transfer coordinator. For intra-regional transfers, the approach is not consistent amongst each region, as each one has an established process that suits their respective needs. As a result, the role of Regional Transfer Coordinator varies by region.

At the institutions, the Parole Officer, Manager of Assessment and Intervention (MAI) and Institutional Head are all involved in the preparation and approval of a transfer. Generally, for intra-regional transfers, the Institutional Head is responsible for approving the transfer of inmates out of their institution, after consulting with the proposed receiving institution.

The Audit of the Management of Inmate Transfers was identified as a high audit priority and an area of risk to CSC in the 2015-2018 RBAP. A scan was conducted of CSC policies, past audit work, legal decisions, the results of external reports, and other available information. A risk assessment of the transfer process was then completed based on the results of the scan, preliminary interviews with the Office of Primary Interest (OPI), members of CSC's senior management, and staff at the regional and institutional levels.

Overall, the assessment identified that the main risks to CSC related to the Service not providing an inmate an opportunity for procedural fairness, such as not sharing all the information that was used in the decision-making process, an inmate escaping while being transferred and CSC not providing an inmate sufficient opportunity to rebut the transfer decision. As well, a number of the risks identified during the assessment process align with recommendations made by the Coroner's Inquest Touching the Death of Ashley Smith. These identified risks have been incorporated into this audit.

The objectives of this audit were to provide assurance that:

• the management framework in place supports the effective management of inmate transfers; and
• CSC is complying with relevant legislation and policy directives related to the management of inmate transfers.

Specific criteria are included in Annex A.

The Audit of the Management of Inmate Transfers was national in scope and focused on the processes in place with respect to the transfer of male and female inmates. All security levels were included within the scope of this audit and site visits occurred in all regions and at NHQ.

The following areas were not examined as part of this audit:

• international transfers as the decision for approval is made outside of the organization and the process for undertaking such transfers varies significantly from the domestic transfer process;
• inmate movement within a clustered site as the transfer policy does not always apply to these inmates. As well, transfer warrants are not required for movements within a clustered site;
• victim notification and other broader victim considerations, as an internal audit is planned for 2017-2018 which will focus on victim services. Additionally, some of the possible risks associated with victim notification were considered as part of the Audit of the Release Process (2012);
• the appropriateness of the original decision to transfer an inmate was not evaluated; however, an assessment was completed to determine whether the identified purpose of the transfer was achieved;
• transfers outside of CSC jurisdiction, due to the low volume of such transfers; and
• any transfer where a transfer warrant was not required (such as when an escaped inmate is re-captured, and when an inmate is being escorted to court by the police and will not be incarcerated in another federal facility prior to returning).

The first objective of this audit was to provide assurance that the management framework in place supports the effective management of inmate transfers.

The management framework for the transfer of inmates was examined from three perspectives: CSC's policy framework, its roles and responsibilities, and CSC's stewardship of resources. Annex A provides high level results for all audit criteria.

The following sections highlight areas where management attention is required.

We expected to find that CSC's Commissioner's Directives and Guidelines including manuals are clear, support the transfer process, and comply with applicable legislation.

With noted exceptions, the following areas met the audit expectations for this criterion:

• Commissioner's Directives and Guidelines reviewed did not contradict either the Corrections and Conditional Release Act (CCRA) or the Corrections and Conditional Release Regulations (CCRR).

As discussed below, there is one area within the policy framework that warrants further consideration by management.

Overall, the Commissioner's Directives and Guidelines related to the transfer process are clear; however, there are some areas where streamlining of the policies would be beneficial in making the transfer process more efficient and effective.

Through interviews with CSC staff, 72% (85 out of 118) felt that the Commissioner's Directives and Guidelines related to the transfer process were clear; however, there are a number of areas identified where improvements could be made that would bring efficiencies to the transfer process. One frequently identified concern was the number of staff involved in a transfer, particularly when an inter-regional transfer is being considered.

The diagram below depicts the number of CSC staff who are involved in the transfer process. The number of staff involved in the transfer process can fluctuate depending on the type and complexity of the transfer taking place.^{Footnote 13}

CSC Staff Members Involved in the Inter-regional Inmate Transfer Process^{Footnote 14}

As discussed previously, and further in Section 3.1.2 for inter-regional transfers, there are a significant number of staff involved in preparing the paperwork to ensure it progresses from one stage to the next. Internal Audit is of the opinion, that with so many staff involved in the process, there is a risk that the process is not operating efficiently.

When staff members were asked whether there were any areas within the policies they were unable to meet, 37% (34 out of 93) stated there were. The most commonly stated reason for not being able to meet the requirements of the policy was the inability to meet the timeframes established within the transfer policies as they are often waiting for other sites to provide comments. Through a review of the Commissioner's Directives and Guidelines related to transfers, neither provided a timeframe for how long it should take to receive transfer comments. The audit team was informed that a Policy Bulletin was issued during the conduct phase of the audit which established timeframes for providing transfer comments for inter-regional transfers. The Bulletin now requires that transfer comments be sent back to the receiving region within five working days of being requested.

While interviewing sites, it was noted that each site had a different process in place for receiving requests for transfer comments. As part of a request made to each region, the audit team found that approximately half of CSC's sites are using a general email address for transfer comment requests, while the other sites have all requests go to a specific person. There is a risk that should the individual be away for an extended period of time, the request for transfer comments could sit in their personal email inbox until the person returns or until the requesting site follows up with another individual, thus delaying the transfer process. The audit was unable to assess the extent to which these concerns have occurred.

Requests for comments are often completed through emails, and the date transfer comments are requested and subsequently received is not recorded into the Assessment for Decision as only the comments that are received are added into the Assessment for Decision. As a result, it would have been extremely time consuming for both the auditee and the audit team to assess the timeliness of the receipt of transfer comments.

Through discussions with sites, regions and a review of the transfer process, there were a number of additional areas identified where improvements could be made to the transfer process to make it more efficient. These include:

• Streamlining the number of policies and guidelines that need to be consulted - depending on the type of transfer that is taking place, there could be three or more policies and guidelines that could be applicable. With multiple policy requirements contained within multiple documents, there is a risk that a step could be missed, either delaying the transfer and/or causing CSC to be in non-compliance with the law or its own policies; therefore amalgamation or streamlining of the documents could be considered.
• Maintaining up-to-date high level institutional population profiles - many staff indicated that they would like to have access to up-to-date institutional population profiles for all sites that could include information such as the security threat groups that the site is able to accommodate. Although it is recognized that it may be difficult to keep such a document up-to-date, as population profiles change frequently, this information is still important. Without it, there is a risk that the sending sites may be going through the work of proposing a transfer to a site where the inmate will not be able to integrate into the population, thus requiring the sending site to restart the process.
• Adding guidance on CSC's expectations for transfer consultation comments - as will be discussed further in section 3.2.4, consultation comments are to be sought from the receiving institution as part of the assessment and decision process. Of the CSC staff interviewed, 51% (39 out of 77) felt that the consultation process associated with transfers was useful, but noted that the type of information that was included within these comments was inconsistent. They felt that at times the comments they received were vague or did not provide any useful information, such as an explanation regarding why the receiving site was not supportive of the transfer. Another concern noted was that comments, at times, were opinions rather than fact-based. For example, comments focussed on whether the inmate should have been assessed at a specific security level instead of whether the institution was able to accommodate the inmate in terms of programming, safety, etc. The audit team reviewed the policy framework to determine the amount of direction provided with regards to consultation comments. We found that CSC's policy only required that comments be provided, but did not include any additional information on what should be included within the comments. The audit team assessed the value of the comments being recorded within the transfer documentation to determine whether they contained information of high value, and generally found this not to be the case, see section 3.2.4 for further details.

An additional area where some respondents would like to see a change in the transfer policies is related to transfer criteria. For example, as CSC's population ages, and inmates remain at the same institution for an extended period of time, many staff believed that having the ability to give an inmate a "fresh start" at a new institution could be beneficial. In many cases, these inmates do not fit into any of CSC's current transfer criteria as listed in the current policies and therefore are denied a transfer.

Additionally, the audit team identified another area where policy clarification could be beneficial. As will be discussed further in section 3.2.4, through file reviews of transfers associated with treatment centres, decision documentation often did not contain all of the consideration points required by policy.

We expected to find that roles and responsibilities were defined, formally documented, and understood.

With noted exceptions, roles and responsibilities were generally clear and defined. However, the following areas did not fully meet the audit expectations for this criterion.

Key positions within the transfer process were not consistently backfilled during absences from the office.

There are a number of individuals involved in the transfer process who hold key positions which the audit team has identified as critical to the process. These include: the National Transfer Coordinator (NTC), the Regional Transfer Coordinators and the Onboard Transfer Coordinators.

The NTC is responsible for coordinating all inter-regional transfers, and establishing a yearly flight schedule, as well as the schedule for each flight. Additionally, this position is responsible for creating the inter-regional transfer list, and assisting the Onboard Transfer Coordinator throughout the inter-regional flight. Lastly, the NTC is responsible for determining that the air carrier which meets CSC's needs is available. It is also the responsibility of the NTC to review all expenses associated with the inter-regional flight to determine whether they are reasonable and accurate.

Through discussions with the NTC, a back-up has been identified for this position; however the back-up has not been fully trained to complete all of the responsibilities of the NTC position, and therefore does not have the detailed knowledge and experience associated with the process. Other staff indicated that when the NTC is away the process does not run as smoothly.

The Regional Transfer Coordinator is also responsible for acting as a liaison between institutions when inter-regional transfers are being proposed. All consultation comments on proposed inter-regional transfers currently go through the Regional Transfer Coordinator. This position is also responsible for maintaining a regional list of inter-regional transfers which the NTC uses to create the inter-regional transfers flight list. Depending on the region, the Regional Transfer Coordinator may also be involved with the coordination of intra-regional transfers.

At the time of fieldwork, the regions were at various stages of identifying and training someone to act as a back-up for the Regional Transfer Coordinator. In one region, they were changing the organizational structure to have three individuals knowledgeable in the transfer portfolio, and would be able to cover for each other, should one be away. In two other regions, the audit team was informed that they had just recently identified a back-up for this position and training of this individual would begin shortly. In another region, the Regional Transfer Coordinator indicated that an official back-up had not been identified, however, we have subsequently been informed that someone has been identified who had previously assisted in the role of Regional Transfer Coordinator. In the last region we were told that no official permanent back-up had been identified and trained.

As the Regional Transfer Coordinators act as liaison between the regions, it is critical that someone be able to step in when required, as all inter-regional transfer consultations are dependent on the Regional Transfer Coordinators. Additionally, the Regional Transfer Coordinators are responsible for preparing the inter-regional transfer lists which is a key step in determining which inmates will be transferred on the next inter-regional flight. Through discussions with NHQ, we were informed that NHQ has the capacity to assist should a Regional Transfer Coordinator be unavailable.

The Onboard Transfer Coordinator is responsible for coordinating the activities on each inter-regional flight, and ensuring that the roles and responsibilities of the officers and correctional managers on the flight are known and completed. They are also involved in determining where the inmates sit, and are responsible for coordinating with NHQ, in the event of unforeseen delays, mechanical issues, medical emergencies, etc. occur during the flight. There are two Onboard Transfer Coordinators, one who works out of the Ontario Region and one who works out of the Quebec Region.

Both Onboard Transfer Coordinators indicated that they either have a fully trained back-up or that they are in the process of training someone should they be unable to fulfill their responsibilities.

The role of site transfer coordinator was not formally defined within the policy framework.

The roles and responsibilities of site transfer coordinators vary greatly by site. At some sites, the site transfer coordinator is a MAI or a Parole Officer while at other sites, an assistant has been designated this responsibility. For sites where the MAI or Parole Officer have been designated this responsibility, they are also often responsible for providing transfer comments when other sites are proposing a transfer to their site. The audit team also found that the delegation of responsibility for providing comments varies from site to site. At some sites, one person is generally responsible for providing all comments, while at other sites, a team approach is taken.

For sites where an assistant has been designated to be the transfer coordinator, they are often responsible for distributing the requests for comments to the appropriate person and depending on the region, may also be responsible for coordinating the actual movement of inmates between institutions.

Many of the site transfer coordinators indicated that their roles and responsibilities were not formally documented, either by way of a job description or in policy, and many learned through job shadowing. Additionally, not all individuals have a designated backup. Without having a consistent process, there is a risk that should the coordinator be away, transfer documentation or steps could be missed, thus delaying a transfer decision.

We expected to find that CSC ensures that costs associated with transfers are known and is achieving the best value for money for the organization.

With noted exceptions, the following areas met the audit expectations for this criterion:

• Institutional management strove to minimize the amount of overtime incurred when transferring inmates; and
• the reason for transferring an inmate was generally being fulfilled. Based on the file reviews, 93% (112 out of 120) were deemed to have met the intent of the transfer.

However, additional areas related to the stewardship of resources require additional attention.

Due to the way CSC's costs associated with transfers are embedded within the overall inmate population management costs at the institutions, CSC is currently unable to determine the total cost of transferring inmates, particularly for intra-regional transfers.

Between April 2014 and August 2015, CSC performed over 8,000 transfers of inmates between its institutions, of which approximately 1,500 inmates were transferred using inter-regional aircrafts. For inter-regional transfers, NHQ is responsible for paying the cost of the flight and associated costs as well as reimbursing sites for the costs incurred as a result of their participation in the process. As a result, the inter-regional flight costs are generally well tracked and can be identified.

For intra-regional transfers, we were unable to determine the total cost to the Service.

Within CSC's financial system, the costs for maintaining the transfer vehicles, shipping inmate effects, vehicle maintenance, etc. are not distinguished between transfer and non-transfer related activities as they are recorded based on expense category. As well, for fuel costs, vehicles are also used for escorting inmates to appointments, court appearances, etc. and fuel is consumed during institutional perimeter patrols therefore identifying the amount of fuel consumed within a transfer is not broken down.

Additionally, within the correctional officer scheduling system for non-overtime hours worked, a distinction is not made between time worked for inmate escorts and time worked for inmate transfers. As many officers will perform both escorts and transfers, the transfer component would be a difficult item to specifically identify, thus making it difficult to track the number of hours spent escorting inmates versus transferring inmates. As a result, the cost to the organization of trying to better identify and segregate the intra-regional transfer cost may be too high for the benefits this information would provide.

CSC completed some analysis when it revised the air transfer process; however, no subsequent or ongoing analysis has been completed to determine whether the changes made are achieving the intended goal or whether there could be more efficient ways to transfer inmates inter-regionally.

With the closure of several CSC institutions in 2013-2014, CSC was facing a number of population pressures and was required to move a significant number of inmates in a very short period of time, therefore pushing the organization to find more efficient ways to transfer inmates. CSC initiated a number of changes to the air transfer process in an attempt to make the process more efficient, both in terms of the amount of time the inter-regional flights took and through a reduction in overall costs. One of these changes included using larger, faster aircraft that allowed CSC to transfer more inmates on each flight.

The second change was to adjust the starting point for CSC staff who accompany the inmates during the flight. Prior to this second change, all flights were operated by a group of Correctional Officers from the Quebec Region.

Table 1: This Table illustrates the route the inter-regional flight takes.

An analysis was prepared by CSC indicating that over $1.8 million in hypothetical savings would be realized annually based on the changes that were to take place. In July 2014, management presented to the Departmental Audit Committee information on changes brought to the inter-regional transfer process and associated cost. At that time, management stated that over the first year, $445 thousand dollars were saved compared to what the previous process would have cost. Management also stated that they would develop "a system to automatically determine the most effective operating model based upon the transfer lists and demands." As part of this audit, the auditors inquired whether an analysis had been completed to support whether CSC is effectively obtaining good value for money. However, none could be provided at this time. Going forward, and given the fact that inter-regional transfer costs are generally well tracked, CSC could benefit from conducting an analysis of costs over time to ensure they remain efficient as indicated to the Departmental Audit Committee in July 2014.

We found that two different approaches are used for each of the transfer teams in terms of selecting officers for the flight. For the Ontario Region, there is not a set group of officers who supervise every inter-regional flight. Officers volunteer to be part of the flight and their correctional manager will determine which officers are selected based on their schedules, in order to minimize whenever possible the amount of overtime incurred. A similar process is used for some officers in the Quebec Region; however, there is a dedicated team that typically works the flight while other officers are only requested to fill out the staff complement. For the dedicated team, depending on their pre-determined work schedule, they may be required to work on a pre-scheduled rest day, which results in additional overtime being incurred by the organization, but provides continuity in the transfer team. Through discussions with NHQ, we were informed that the process used in each region for selecting the correctional officers is a regional responsibility.

In order to allow for flexibility, CSC uses the Standing Offer process to procure the aircrafts used for inter-regional flights. As part of the process, aircraft providers submit a bid to Public Services and Procurement Canada to provide aircraft services for a specific period of time at a specific price per statute mile. CSC is obligated to take the lowest bid that matches their pre-established criteria (such as aircraft size, aircraft speed, starting location, etc.). For CSC flights where the estimated cost is over $100,000, additional levels of approval are required. CSC's Contract Review Board and Public Services and Procurement Canada provide a challenge function in terms of the size of aircraft being requested and also the estimated costs.

As there are a number of variables that need to be taken into account when determining the flight route, including public safety, it is not possible to use a standardized approach for each flight. The number of inmates leaving and arriving at a particular institution varies with each flight which could result in additional or cancelled stops or a change in the route. When these changes are required, the costs and added value of a modification is considered but not regularly documented. As well, depending on the total number of inmates that require a transfer, the size of the aircraft will also be adjusted. NHQ did indicate that efficiencies are always being considered and looked for; however, documented analysis does not exist to show that the current processes lead to an efficient use of resources.

The audit team understands that there are a number of factors that need to be considered when transfers are being completed. The first of these is public safety, as well as compliance with legal requirements and meeting the needs of offenders. Over and above those considerations, processes can always be reviewed for improved efficiencies. For example, while the audit team accompanied inmates on a transfer flight, the aircraft was grounded for a period of time as the flight was unable to land at the next destination due to the condition of the runway. The distance between the institution of where the inmates were being transferred to/from, and the airport where the flight was grounded is relatively short when completed by land. As a result, instead of the flight landing at the second airport, the initial leg of the transfer may have been less costly if completed via land instead of air. We would encourage management to conduct lessons learned exercises periodically (annually or every two years) to review how well transfers went, and identify any areas that were of concern or where improvements could potentially be brought to the process.

Cost savings is not the only factor that requires consideration when determining the value for money associated with the inter-regional flights. When CSC moved to a larger aircraft, they were able to assist the Prairie Region to transfer inmates from one province to another, whereas previously, a ground transfer would be required and could take multiple days to complete. Through this change, they were able to reduce the number of staff needed to assist with the transfer as well as improve the safety related to the transfer, as CSC employees were not transporting inmates for long periods of time. It also reduces the discomfort for inmates who are being transferred over long distances. This service is also provided for inmates in the Quebec Region when space permits.

Overall, based on the transfers that are taking place, the original reason for the transfer is generally being met and the organization continues to improve the process when an opportunity is identified. However, for the changes that have been made, no subsequent or ongoing analysis has been conducted to determine whether the changes undertaken resulted in the predicted savings or if the current process/routes continue to be as efficient and cost-effective as when first introduced.

With respect to the first objective, we found that parts of the management framework in place support the effective management of inmate transfers. The CSC policies applicable to transfers are in compliance with legislative requirements; roles and responsibilities are generally defined, and the original intent behind the transfer is generally being met.

Still, the management framework requires further improvements in order to better support the management of inmate transfers. We noted a few areas that require consideration by management to ensure that the risks to the organization, both from an operational and financial perspective, are better managed:

• policies in place should be reviewed to determine whether efficiencies can be gained within the transfer process and the streamlining of these policies should also be considered;
• CSC should ensure that all key positions have identified backups and that those backfilling these key positions are fully trained; and
• NHQ should further refine its costing information of the air transfer process to be better equipped to identify emerging cost increases and ensure an efficient use of resources.

The second objective was to provide reasonable assurance that CSC is complying with relevant legislation and policy directives related to the management of inmate transfers.

The objective was examined from four perspectives: staff and public safety, inmate well-being and safety, transfers by air and transfer documentation.

Annex A provides high level results for all audit criteria.

The following sections highlight areas where management attention is required.

We expected to find that the CSC policy framework is being followed in order to ensure that staff and public safety is maintained during the transfer process.

The area below met the audit expectation for this criterion:

• Correctional officers who were responsible for transferring inmates were being provided with a briefing on the inmates they were transferring prior to a ground transfer taking place.

However, the following areas did not fully meet the audit expectations for this criterion:

Threat Risk Assessments (TRA) were not being completed for all transfers when required, and those that were done did not always have information that added value.

A Threat Risk Assessment (TRA) is defined as "an evaluation of factors that could pose a danger to the management of an offender, the safety of others, or security of an operational unit in particular circumstances."^{Footnote 15} Commissioner's Directive 566-6 - Security Escorts requires that a TRA be completed for "any maximum security inmate when the institutional head has information which could affect the conditions of the escort, all medium security inmates and all inmates who are being transferred using air transportation." As well, TRAs are required for any unplanned escorts.^{Footnote 16}

The audit team completed file reviews on a sample of transfers that took place during our review period to determine whether a TRA was present. Of the files reviewed where a TRA was required, 70% (110 out of 157) had a TRA on file. Of the 110 TRAs, the audit team determined that they contained useful information only 60% (66 out of 110) of the time. To determine the usefulness of the information, the audit team evaluated the comments included within the TRA to assess whether additional information (over and above the information that was already known) was provided that would assist the correctional officers in ensuring their safety and the safety of the public.

Interview results indicated that 75% (21 out of 28) of interviewees at the institutional level felt that the TRAs provided useful information. During these interviews, there were a number of areas where possible improvements were identified. These included requiring a TRA only if there is critical or specific information that needs to be communicated or ensuring that new and relevant information is added to the TRAs to improve their usefulness. As identified through file testing, many of the TRAs are being completed only because they are required, however, they do not contain any additional information that would be useful to the transfer team. There is a risk that if the information contained within the TRA is not generally viewed as being useful, the officers on the transfer may not always refer to it, or may overlook critical details that could impact their safety or the safety of the public for those cases where relevant information was shared.

Following the completion of the fieldwork portion of the audit, Commissioner's Directive 566-6 - Security Escorts was revised to streamline the TRA process. As part of the revision, a TRA Review Board is to be established at each institution, and is tasked with reviewing all current and new inmates admitted to the institution to determine whether a TRA is required each time the inmate in question is leaving the institution. If new information becomes available for an inmate who does not require a new TRA each time they leave the institution, there is an expectation that the existing TRA will be updated.

The inmate-to-staff ratio required when transferring inmates could be further clarified.

As per Commissioner's Directive 566-6 - Security Escorts, for ground escorts of maximum and medium security inmates, two officers are required for the first inmate and one additional officer is added for each additional inmate. However, the Commissioner's Directive goes on to state that "[t]he above-noted staff-to-inmate ratio does not apply to intra or inter-regional transfers using vehicles equipped with inserts which separate inmates from one another or when in an aircraft."^{Footnote 17} The Commissioner's Directive does not define or provide any further guidance on the ratio that is to be used when the transfer vehicle is equipped with a divider. As part of the update to Commissioner's Directive 566-6 - Security Escorts, the staff-to-inmate ratio exception related to vehicles with inserts was removed. The updated policy requires that a two-to-one ratio be in place for the first inmate and one additional officer is to be added for each additional inmate, however, the Directive does allow the Institutional Head to authorize a change to this ratio.

Through interviews with correctional officers who have completed a ground transfer with inmates, 74% (29 out of 39) felt that the staff-to-inmate ratio was adequate to meet the identified safety needs. The most common concern was related to the possibility of the correctional officers being outnumbered by inmates should a situation arise where the officers have to take all the inmates out of the transfer van at the same time. It should be noted that such events are not a common occurrence. During discussions with a number of sites, the audit team was informed that the ratio of inmate-to-staff was not consistent between regions. In some regions, they send one additional officer for each additional inmate, while in other regions one additional officer is added for every two additional inmates. We noted that in some of the TRAs reviewed, the number of officers to accompany the transfer would increase depending on the inmate being transferred, thus alerting the correctional officers to the additional risks associated with the inmate.

We expected to find that CSC is complying with the requirements for considering and maintaining an inmate's health needs throughout the transfer process, and is sharing all information required to ensure an inmate's well-being is maintained.

Overall, no concerns were expressed related to the continuity of care for inmates on methadone, and sites generally did not have significant concerns related to continuity of care for inmates being transferred. However, the audit team has identified a number of areas that did not fully meet the audit expectations for this criterion.

Inmate files and health care information were not being sent to the receiving institution in a timely manner.

Inmates have a number of files that contain critical information, such as health care, psychology, preventative security (which may include information such as gang affiliations, incompatibles, etc.) and case management information. As it stands, the information contained within the health care, psychology and preventative security files are not easily accessible through CSC's current electronic databases. Commissioner's Directive 710-2 - Transfer of Inmates requires that inmate's files be transferred with them for all non-emergency transfers.

To test whether inmates' files were being sent in a timely manner, the audit team requested, for a sample of inmate files, and the dates the files were received at the new institution. We found that not all files were being entered into the records system and/or sent with the inmates when the inmates were transferred. For many of the regions, the average number of days between when the transfer took place, and when the files were received/entered into the system was two or three days. These files contain critical information about the inmate that may not otherwise be available, and may prevent an inmate from receiving proper care. Some sites concurred with this finding, stating that inmate health care files can take days to reach the receiving institution, thus preventing a thorough review of the inmate's file and reducing the efficiency of the care the inmate receives.

File reviews were also conducted to determine whether an inmate's Health Care Transfer Summary (Form 0377-01) was included in the inmate's health care file. The Health Care Transfer Summary provides an overall summary of an inmate, such as suicide attempts and self-injury concerns, allergies, general information about the inmate, mental health concerns, physical health concerns, and the medication the inmate is currently taking.

Of the 71 files reviewed, 83% (59 out of 71) had a Health Care Transfer Summary on file. Some sites told the team that the health care staff often do not find out until the last minute that an inmate is being transferred out, and that this does not allow them sufficient time to prepare the inmate's medication and complete the Health Care Transfer Summary. Without these summaries, the receiving site may not be able to prepare appropriately for the arriving inmate and may not be able to meet the inmate's health care needs upon arrival.

As part of the instructions contained within the Health Care Transfer Summary, there is a requirement that it be sent within 48 hours before the transfer is to take place. Of the files reviewed, 69% were sent within this timeframe. There is a concern that should summaries be sent too early (more than two days before the transfer is to take place), the information may lack recent health changes that have occurred between the time the summary was prepared and the inmate was transferred. During 2015-2016, the Evaluation Branch completed an evaluation of health services and found similar concerns related to information sharing and incomplete documentation, more specifically the completion of Health Care Transfer Summaries. Health Services is currently in the process of implementing a new service platform that should help address some of these concerns.

Although the audit team could not confirm this via audit testing, sites were concerned that their site might not be the best fit for some inmates being transferred there.

As discussed in Section 3.1.3, the purpose for which an inmate was transferred was generally being achieved; however, 62% (33 out of 53) of the CSC staff we interviewed felt that at times, inmates had been transferred to their institution, which in their opinion, was not the best fit for the inmate. The most commonly noted concern was related to not being able to provide the required inmate's mental or physical health care, particularly for inmates returning from treatment centres. Some sites indicated that their layout was not suitable for those with mobility issues, and that it was difficult for those inmates to access certain locations within the institution.

As well, concerns were expressed that inmates were being sent to institutions where they did not fit the institutional profile, both in terms of the inmate population profile and the open environment. With regards to population profiles, depending on the crime an inmate has committed, or an inmate's reputation, other inmates may be less receptive and may therefore place the inmate's safety at risk.

As previously discussed, many sending sites are not aware of the population profiles of specific institutions and will propose a transfer without knowing this information as profiles are not actively shared between regions. When an inmate is transferred to a site that does not fit their needs, there is an increased possibility that the inmate may not integrate well into the general population.

Inmate medication was not always being sent with the inmate when they were being transferred.

Through interviews with nurses, 73% (11 out of 15) indicated that they had concerns with the administration of medication during transfers. One of the most common concerns was that medication was not always being sent with the inmate. For some sites, this created a great deal of concern as they may not regularly stock the medication that the inmate is taking, thus forcing them to use a local pharmacy or wait until the inmate's medication is received from the regional pharmacy.

The audit team also observed this situation during one of the inter-regional transfer flights. During that flight, it was observed that not all the inmates who required medication had their medication in the bag sent with them. The audit team also observed that the medication bags were not always properly labelled, and that in some cases the outside of the bag did not have the inmate's name on it. Through interviews with nurses who have been on inter-regional flights, they indicated that at times, inmates were supposed to be provided a specific medication, but it was not included in the medication bag, and that a sufficient amount of medication was not always included to last the duration of the flight.

One nurse that worked on an inter-regional flight indicated that these concerns had been shared with RHQ but that no indication was received as to what actions had been taken. The audit team followed-up with RHQ who provided us with email documentation that these concerns were shared with the sites where the issue originated. As well, we were informed that historically these concerns were not forwarded to NHQ, but that a new process was being initiated whereby all flight nurses would be asked to provide NHQ with any issues identified during the flight, and that this information will be discussed during the National Managers of Clinical Services monthly conference calls.

Concerns over the timeliness of inter-regional transfers still exist.

During the Audit of Offender Population Management in 2012, concerns were expressed by many sites that it was taking too long to transfer an inmate. These concerns were still present at the time of this audit as 78% (62 out of 80) of staff interviewed indicated that they had issues with the timeliness of inter-regional transfers. Through a review of files, and as expected, the audit team found, as seen in Table 2, that on average, transfers within a region take much less time to be completed. The transfer Commissioner's Directive does not indicate how long a transfer should take once a decision has been made.

Table 2: This Table illustrates the average number of days, by transfer type, it takes for an inmate to be transferred once the transfer has been approved.

As mentioned in Section 3.2.4, CSC is generally meeting the timeframe requirements for making a decision to transfer an inmate. Through interviews, we were informed that obtaining final approval can take a significant amount of time, particularly for inter-regional transfers when the sending institution is waiting to receive transfer comments back from the proposed receiving region. As discussed in Section 3.1.1, CSC recently released Policy Bulletin 513 in October 2015 which should address some of the concerns associated with sites not receiving transfer comments back within a timely manner for inter-regional transfers.

Once an inmate has been approved for an inter-regional transfer, their name is put onto the inter-regional transfer list which is sent to the NTC at NHQ. Only inmates who have a confirmed bed at the receiving institution will be considered for a seat on the inter-regional transfer plane. An informal priority list has been established, and seats are allocated based on this priority list. Once all the seats have been designated, the inmates who have not been allocated a seat will be moved onto the list for the next inter-regional flight, as there are a limited number of seats available on each inter-regional flight.

We expected to find that CSC was in compliance with the Guidelines on Inter-regional Transfers by Air.

The following areas met the audit expectations for this criterion:

• during our flight observation, ground support was present at each stop along the inter-regional transfer route;
• post-operation reports were being prepared and provided to NHQ following each flight, and the accuracy of two observation reports were tested and were consistent with the observations made by the audit team who was on the flight;
• during our flight observation, inmate restraint equipment was checked prior to each inmate boarding the plane;
• we observed that staff who were on the flight were informed of their responsibilities and of any inmate concerns; and
• a process was in place at the main institution used to house inmates overnight to ensure they did not interact with the institution's regular population.

In addition to the concerns identified below, the following area was also noted and previously discussed in Section 3.2.2:

• during our observation, not all inmate medication was sent with the inmate and some medication was not properly labelled.

Guideline requirements were not always being met with regards to the paperwork that was to be present for inmates on the inter-regional flight.

In September 2015 and March 2016, the audit team observed three days of the air transfer process, and also reviewed a number of post-operation reports to determine whether there were any ongoing concerns with inmate paperwork. During the flight observation, the audit team observed that one inmate arrived without all of his required paperwork, and the plane had to wait to depart until the paperwork was produced. That resulted in the flight being delayed. Depending on the length of the delays, CSC could incur additional costs, including overtime, meals, and flight crew costs if an inmate's paperwork is not included at the time of their transfer.

Additional paperwork concerns were also identified including TRAs not being present in the inmate files and appropriate photos not being supplied. Without a TRA, should something occur during the flight, CSC staff may not have immediate access to key information.

Based on the information in a post-operation report, a transfer warrant did not arrive with the inmate and in this case, a copy was sent to the Onboard Transfer Coordinator. The audit found, through observation and a review of the post-operation reports that the paperwork had not been placed in the required protective sleeve. Without this, paperwork may be damaged by rain or snow during the transfer or paperwork could be misplaced if they are not properly secured. Moreover, without this information, key safety information could be missed, potentially putting the safety of the public, staff and inmates involved in the transfer at risk.

The Inter-regional Transfer by Air Health Services Procedures requires that, when the health package (which contains the inmate's medication) is passed along from one person to the next, the Health Package for Transfer Tracking form is to be signed. The audit team found that this was not being done consistently on the flights it observed. Without this form, in the event of an incident, the chain of custody would not be known.

We expected to find that CSC was completing and sharing all required transfer documentation within the required timeframes.

The following areas met the audit expectations for this criterion:

• overall, CSC decisions were being made within the timelines prescribed^{Footnote 18};
• transfers to and from the Special Handling Unit (SHU) generally met the requirements of the policy framework; and
• transfer warrants and Assessments for Decision were generally on file.

However, the following areas did not fully meet the audit expectations for this criterion.

Evidence was lacking to show that decision documentation was being shared with inmates in a timely manner.

CSC has been subjected to a number of recent court rulings on the grounds of habeas corpus.^{Footnote 19} In many of the court cases, inmates challenged CSC on the grounds of procedural fairness, with respect to the reason for transfer (disclosure), the right to counsel, and having a sufficient amount of time to provide a rebuttal to the information that was being used to make the transfer decision, and also on the reasonableness of the decision. In many cases, there was also a concern that CSC was not sharing a sufficient amount of the security information used in making specific decisions.

Section 12(d) of the CCRR requires that an inmate be provided with written notification of the final decision respecting a transfer. We found that in 53% (42 out of 79) of the files reviewed, CSC provided the inmate with written notification of an approved transfer after making the final decision to transfer the inmate as required by legislation. In ten of these cases, we could not find the final decision document, and therefore were unable to assess whether the inmate was notified.

In cases of denied transfers, the audit team was able to find evidence within the inmate's case management file, that the final decision was shared with the inmate 63% (37 out of 59) of the time. Section 12(d)(ii) of the CCRR and Guidelines 710-2-3 Inmate Transfer Process, require that the inmate be notified within five working days following the final decision not to transfer. Of the files where we could find evidence that an inmate was notified of the decision, 57% (20 out of 35) of the cases had evidence that the inmate was notified within five working days. Therefore, out of all denied transfers reviewed, 34% (20 out of 59) of the files reviewed had evidence to support that the final decision to deny the transfer was shared with the inmate within five working days.

There are a number of other documents that are to be shared with the inmate during the transfer decision making process, including the Assessment for Decision (A4D), the Notice of Involuntary Recommendation for involuntary transfers and the Notice of Pen Placement Recommendation. These documents are used to notify the inmate that a transfer is being considered, and of the information that is being presented to the Institutional Head for consideration. Without these notices, an inmate may not be aware that there is a proposed transfer, and will not be able to properly provide a rebuttal within the required timeframes^{Footnote 20}. This could result in CSC facing legal repercussions if the inmate is not provided with a sufficient opportunity to rebut a proposed transfer.

Section 12(a) of the CCRR requires that when an inmate is being considered for a transfer, they be given written notice of the proposed transfer. We found that in 82% (36 out of 44) of the files reviewed where a Notice of Involuntary Transfer Recommendation/Notice of Pen Placement Recommendation was required, there was evidence in the inmate's paper file that the notice was shared with the inmate. As previously discussed, an A4D is critical in providing an inmate with information on a transfer that is being proposed, or why the inmate is being penitentiary placed to a specific institution. In files where the A4D was reviewed, 52% (16 out of 31) had evidence that the A4D was shared with the inmate. In six of these files we were unable to assess whether the A4D was shared, as in many cases, we were unable to locate it within the file.

It was also found that in a number of files, a CSC decision would indicate that an inmate had provided a rebuttal, but the audit team was unable to find a paper copy of the rebuttal or a summary of the rebuttal in the Offender Management System (OMS). Without this information, the audit team was unable to assess whether CSC was taking into account all aspects of an inmate's rebuttal. Additionally, the audit team found that in some cases a rebuttal would be on file, but CSC's written decision only indicated that the rebuttal was taken into consideration, and did not indicate the specific information that was taken into consideration. We also found this to be the case when a transfer was being denied. Further, in a few files, the specific reasons for denying the transfer were not identified. Without this information, CSC could face additional legal repercussions should an inmate feel an improper decision was made.

Overall, we were able to confirm that procedural fairness^{Footnote 21} was followed in 54% (31 out of 57)^{Footnote 22} of files reviewed. Included within this figure there were 15 cases where there was missing documentation, and we were unable to confirm that all documents had been properly shared with the inmates.

Treatment Centres were not including all required comments and areas that were considered when preparing decision documents.

As part of the transfer process, there are two key documents where CSC is required to demonstrate the factors being considered when making a final transfer decision. The first document is the A4D, which is the initial document the inmate's parole officer prepares. It is to include the results of the case conference from the receiving institution, consultation comments from the Security Intelligence Officer (SIO), and discussions on whether there are any physical or mental health concerns. There are a few situations where an A4D is not required; in these cases, the second document, the CSC decision document is to contain this information.^{Footnote 23}

Through file reviews, we found that there was a significant variation in our results, when treatment centre admissions and discharges were included. Table 3 provides a summary of our file review results.

Table 3: This Table illustrates the results of file testing related to the information contained within CSC's Decision documentation

Comments from SIOs often focus on incompatibility concerns, as well as overall security based information on the inmate. Without these comments, there could be increased security and safety risks. Further, without consulting with and obtaining feedback from health care on an inmate's physical/mental health, an inmate's needs may not be known when the decision to transfer is being made. Additionally, transfer comments assist the sending site in determining whether an inmate will be able to integrate into a particular institution. If a site was to receive consultation comments and not include them within the decision documentation, CSC could face legal challenges, and an inmate would not have access to all information used in the decision making process on whether a transfer will take place.

As discussed previously, transfer comments are not always provided in a timely manner and, at times, sites will proceed with the transfer without receiving comments from the receiving site. We were also told that when emergency transfers are required, it is often difficult to obtain the receiving site comments within the short timeframes which accompany emergency transfers.

Of the files where comments were found, 70% (53 out of 76) were deemed to provide high value information^{Footnote 24}. Without high value comments, the decisions being made may not be in the best interests of the inmates and CSC's ultimate goal of reintegration. Additionally, resources could be used to transfer an inmate, only to determine that the inmate will need to be transferred again as the receiving institution is not an appropriate environment for the inmate. In many of these cases, the information contained within the decision documents only indicated whether the site would accept the inmate or not. We saw evidence in some files to suggest that sites are at times only including a summary of the information they receive into the decision documentation, which may help to explain why some files were deemed not to contain high value comments.

As discussed in section 3.1.1, many of those interviewed would like to receive additional guidance on the expectations of CSC in relation to consultation comments. Although the transfer guidelines require that comments are to be obtained, neither the Commissioner's Directive on transfer nor the applicable guidelines indicate the depth or breadth that is expected in relation to the comments. Without meaningful and detailed consultation comments, the decision maker may not have all the critical information when deciding whether or not to transfer an inmate, thus putting the institution, staff, the public and the inmate at risk.

There is a significant discrepancy between test results which included Treatment Centres and the results where Treatment Centres were excluded. Within the Treatment Centre's decision documentation, we typically found that the decision document would only say the inmate was being admitted or discharged. Based on the requirements of the applicable legislation and CSC policies, the Treatment Centres were not compliant. When the Treatment Centres that were visited as part of the audit were asked why required information was not included, one site indicated that most of the information would be contained in the admission documentation; however, the audit team found that this information is not available in OMS and would require a review of the inmate's physical file. Sites indicated that they would take these concerns into consideration and would update their processes.

Transfers were not being entered into OMS in a consistent manner.

During our file reviews, we found that when transfer documentation was being entered into OMS, there were inconsistencies from transfer to transfer and from site to site. In one case, we saw the same type of transfer for two different inmates coded differently in OMS with one being listed as a voluntary transfer while the other was listed as an administrative transfer. While in other cases, one set of documents would list the transfer as a voluntary transfer and the transfer warrant would indicate the transfer was an emergency transfer or vice versa. The last common and least concerning error we observed concerned transfers that were recorded as intra-regional transfers when in fact they were inter-regional transfers.

For many of the transfers where inconsistencies were identified, an admission to, or discharge from, a Treatment Centre was involved. As discussed previously, there are inconsistent applications of policy requirements for treatment centre admissions and this may explain some of the inconsistencies identified above.

OMS automatically generates certain documents based on the type of transfer that has been identified. Therefore, if the transfer is not properly identified within OMS, there is a possibility that required documents may not be produced, and therefore not shared with the inmate, which could result in legal implications for CSC.

For the second audit objective, we found that correctional officers were being briefed on the inmates they were to transfer intra-regionally. Additionally, the air transfer process was generally operating in compliance with policy, and CSC was making transfer decisions within the prescribed timeframes.

There are a number of areas where CSC could improve as it relates to staff safety, inmates' well-being and safety, and transfer documentation. These include:

• transfer decisions documentation is not being shared with inmates in a timely manner;
• all information considered as part of a transfer was not consistently being documented, this was particularly the case for treatment centres;
• inmate's health care information was not consistently being sent in the 48 hours before the transfer is to take place, and a sufficient amount of medication was not always being transferred with the inmates; and
• TRAs were not consistently being completed and when they were, they were not consistently adding valuable information for the transfer officers.

With respect to the first objective on the effectiveness of the management framework in relation to the transfer of inmates, we found that the framework generally supports the effective management of inmate transfers. The audit noted a number of areas that requires further consideration by management to ensure that the transfer process is able to function more efficiently.

The second objective of this audit focused on CSC's compliance with legislation and policy, and noted a number of areas are in compliance. However, there are a few areas where improvements can be made.

From a security point of view, CSC manages inmate transfers with due regard to policies, staff and inmate safety. CSC can further improve its documentation as well as its continuum of care for its inmates. It could also strive to seek more efficient and economical ways to operationalize its inmate transfers.

Audit evidence was gathered through a number of methods such as: interviews with staff at NHQ and in the regions, and a review of documentation and detailed testing.

Interviews: Over 200 interviews were conducted during the planning and examination phases of this audit, both in person and via video conference. Those interviewed at the institutions included: institutional heads, assistant wardens operations, managers assessment and intervention, parole officers, correctional managers, correctional officers, security intelligence officers, and health care staff. While at RHQ, those interviewed included the regional transfer coordinators, assistant deputy commissioner correctional operations and finance staff. In addition, interviews were conducted with the onboard transfer coordinators, and a number of staff at NHQ including the National Transfer Coordinator and others who are involved in the transfer process.

Review of Documentation: Relevant documentation, such as federal legislation, Commissioner's Directives and Guidelines, financial records, as well as supporting documents for key controls were reviewed.

Sampling Strategy: A sample of inmates transferred between April 1^st, 2014 and August 1^st, 2015 was selected, as was a sample of inmates who had transfers denied between the periods of April 1^st, 2014 and September 1^st, 2015.

For the transfers that took place, we selected a mix of inter- and intra-regional transfers, which included voluntary, involuntary and penitentiary placements. Parameters were put in place to select files based on the sending institution and not the receiving institution, as it is typically the sending institution who is responsible for preparing and sharing the paperwork associated with a transfer. The audit team also selected, where possible, files based on institutions where either a site visit or videoconference took place. With these parameters, files were randomly selected using computer-assisted auditing tools.

Observations: Observations were performed of the air and ground transfer processes.

Analytical and File Review: Detailed analytical reviews and testing of OMS and on-site inmate files were conducted to determine whether the requirements of the transfer policies were being followed. A total of 234 files were used to complete over 550 tests.

Site Selection: For sites that were visited as part of the audit, selection was based on the number of previous visits by Internal Audit and their proximity to RHQ. For sites where videoconferences took place, selection was based on their proximity to other sites and the number of visits by Internal Audit. Annex B provides details of the sites visited.

Past CSC Internal Audit work was used to assist in scoping the audit work.

Review of Mental Health Commitments (2015):

In response to a recommendation made in the Audit of Regional Treatment Centres and Regional Psychiatric Centre in 2011, CSC committed to: "[the] development of a process to ensure that professional assessments are requested and shared with the decision maker prior to making any inmate segregation, transfer and disciplinary decisions." A CSC Internal Audit review found that all processes discussed in the commitment were developed and integrated into CSC policy.

Audit of Population Management (2013):

This audit found that the average length of time for transfers to take place was 6.8 days for penitentiary placements and 7.5 days for non-penitentiary placements. The reasons indicated included: a lack of bed space at the receiving institution; the inmate starting a program at the sending institution resulting in the transfer being delayed until the program was completed; incompatibility issues between the inmate being sent to an institution and an inmate already at the institution; and a lack of space on the intra- or inter-regional transport. As well, based on interviews, the audit team found that sites were at times sending inmates to institutions that may not have had the best reintegration potential.

Audit of Regional Treatment Centres and the Regional Psychiatric Centre (2011):

The audit found that CSC did not consistently have documentation on file to demonstrate it had considered the inmate's state of mental health and mental health needs in decisions to transfer an inmate to a Treatment Centre.

As a result of these findings, a new policy was developed and implemented to ensure mental health needs are considered and documented as part of the transfer process.

Audit of Offender Transfers (2003):

In general, this audit found that the majority of voluntary and involuntary transfer reports reviewed were complete in addressing rationale for transfer; however, these reports usually (but not always) met the required timeframes. Further, it was not always evident that the final decision made by the Institutional Head contained a rationale for the transfer decision. Finally, the audit determined that the lack of bed space at some institutions resulted in delays in executing transfer warrants for penitentiary placement, voluntary and involuntary transfers as well as inter- and intra-regional transfers.

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 opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with management. The opinion is applicable only to the area examined.

The audit conforms to the Internal Auditing Standards for Government of Canada, as supported by the results of the quality assurance and improvement program. The evidence gathered was sufficient to provide senior management with proof of the opinion derived from the Internal Audit.

The following table outlines the audit criteria developed to meet the stated audit objective and audit scope: