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DEPARTMENT OF CORRECTIONS

BEHAVIORAL HEALTH PROGRAMS

NOVEMBER 2016

PERFORMANCE AUDIT

THE MISSION OF THE OFFICE OF THE STATE AUDITOR
IS TO IMPROVE GOVERNMENT
FOR THE PEOPLE OF COLORADO

LEGISLATIVE AUDIT COMMITTEE
Representative Dan Nordberg – Chair

Representative Dianne Primavera – Vice-Chair

Senator Rollie Heath
Senator Chris Holbert
Senator Cheri Jahn

Representative Tracy Kraft-Tharp
Senator Tim Neville
Representative Lori Saine

OFFICE OF THE STATE AUDITOR
Dianne E. Ray

State Auditor

Monica Bowers

Deputy State Auditor

Trey Standley
Vickie Heller
Kevin Amirehsani
Laura Bravo
Philip Siegel
Shannon Wawrzyniak
Meghan Westmoreland
Stefanie Winzeler

Audit Manager
Team Leader
Staff Auditors

AN ELECTRONIC VERSION OF THIS REPORT IS AVAILABLE AT
WWW.STATE.CO.US/AUDITOR
A BOUND REPORT MAY BE OBTAINED BY CALLING THE
OFFICE OF THE STATE AUDITOR
303.869.2800
PLEASE REFER TO REPORT NUMBER 1556P WHEN REQUESTING THIS REPORT

OFFICE

OF THE STATE AUDITOR

November 21, 2016

DIANNE E. RAY, CPA
——
STATE AUDITOR

Members of the Legislative Audit Committee:
This report contains the results of a performance audit of the Behavioral
Health Programs within the Department of Corrections. The audit was
conducted pursuant to Section 2-3-103, C.R.S., which authorizes the State
Auditor to conduct audits of all departments, institutions, and agencies of
state government, and Section 2-7-204(5), C.R.S., which requires the State
Auditor to annually conduct performance audits of one or more specific
programs or services in at least two departments for purposes of the SMART
Government Act. The report presents our findings, conclusions, and
recommendations, and the responses of the Department of Corrections.

OFFICE OF THE STATE AUDITOR
1525 SHERMAN STREET
7TH FLOOR
DENVER, COLORADO

80203

303.869.2800

CONTENTS
Report Highlights

1

CHAPTER 1
OVERVIEW

3

Behavioral Health Program Administration
Program Funding and Expenditures
Audit Purpose, Scope, and Methodology
CHAPTER 2
MENTAL HEALTH SERVICES AND TREATMENT

4
6
7
11

Identifying Mental Health Needs
RECOMMENDATION 1

12
21

Planning Treatment and Providing Services
RECOMMENDATION 2
RECOMMENDATION 3

24
34
35

Continuing Management of Offenders with Mental Health Needs 38
RECOMMENDATION 4
48
CHAPTER 3
HOUSING OFFENDERS WITH SERIOUS MENTAL ILLNESSES

53

Use of Isolated Confinement
RECOMMENDATION 5

56
67

Residential Treatment Programs
RECOMMENDATION 6

71
83

Close Custody Housing Units
RECOMMENDATION 7

86
92

CHAPTER 4
SEX OFFENDER TREATMENT AND MONITORING PROGRAM
Risk Assessments
RECOMMENDATION 8

95
97
103

Sex Offender Treatment Enrollments
RECOMMENDATION 9
CHAPTER 5
OVERALL PROGRAM MANAGEMENT

105
116
119

Program Staffing
RECOMMENDATION 10

120
126

Assessing Program Effectiveness
RECOMMENDATION 11

127
135

REPORT

HIGHLIGHTS

BEHAVIORAL HEALTH PROGRAMS

DEPARTMENT OF CORRECTIONS

PERFORMANCE AUDIT, NOVEMBER 2016
CONCERN
The Department of Corrections (Department) lacked adequate processes and data to monitor staff for compliance with its
regulations and standards and to demonstrate the effectiveness of its Mental Health Services Program (Mental Health
Program) and the Sex Offender Treatment and Monitoring Program (Sex Offender Program). Additionally, for the Sex
Offender Program the Department did not use a risk-based approach to prioritize offenders for enrollment.











KEY FINDINGS
The Department has implemented significant programmatic changes to the Mental
Health and Sex Offender Programs in recent years, but does not have adequate
information or performance measures to fully assess the impact of the changes or the
effectiveness of the programs in serving the Department’s overall mission or the
program purposes.
Mental Health Program staff did not always assess and record offender mental health
needs consistently, timely, and in accordance with requirements. In addition, staff did
not always properly update offender treatment plans and lacked evidence that they
provided an adequate number of mental health contacts.
The Department lacked adequate data to monitor out-of-cell time for offenders with
serious mental illness and can improve some of its controls to better ensure that it
meets provisions in Senate Bill 14-064 and Department regulations limiting the use of
long-term isolated confinement.
The Department has not established effective controls to ensure that sex offenders are
adequately assessed and prioritized for treatment under the Sex Offender Program.
The number of sex offenders enrolled in treatment each year decreased from 484 in
2012 to 465 in 2015, while the number of offenders awaiting treatment increased,
from 1,527 in 2012 to 1,979 in 2015.
Over Fiscal Years 2015 and 2016, the Department had a staff vacancy rate, generally,
of over 20 percent for the Mental Health Program and over 30 percent for the Sex
Offender Program. Staffing constraints contributed to a number of the problems we
identified.

BACKGROUND
 The Mental Health and Sex
Offender Programs provide
treatment to help offenders
better manage mental illness and
maintain appropriate behavior,
ensure safety at the prison
facilities, and promote successful
offender reintegration in the
community upon release.
 As of December 31, 2015 the
Department had identified 6,926
offenders as having mental
health treatment needs and 1,979
offenders as needing sex offender
treatment.
 Senate Bill 14-064 prohibits the
housing of offenders with mental
illness in long-term isolated
confinement
unless
exigent
circumstances exist.
 In Fiscal Year 2016, the
Department
received
$16.8
million for the Mental Health
Program and $4.4 million for the
Sex Offender Program.

KEY RECOMMENDATIONS
• For the Mental Health Program, improve controls over offender assessments and coding, and other aspects of
service provision, including conducting systematic monitoring activities to identify and correct problems. For
the Sex Offender Program, improve controls over sex offender assessments, and implement written
enrollment and prioritization policies and procedures.
•

Improve oversight and documentation of out-of-cell hours offered to and received by offenders in the
Residential Treatment Programs, and improve controls over prohibiting offenders with serious mental illness
from being housed in long-term isolated confinement.

•

Improve controls over evaluating the performance of the Mental Health and Sex Offender Programs,
including establishing performance goals and measures, improving information systems, and monitoring goal
achievement.

FOR FURTHER INFORMATION ABOUT THIS REPORT, CONTACT THE OFFICE OF THE STATE AUDITOR
303.869.2800 - WWW.STATE.CO.US/AUDITOR

CHAPTER 1

OVERVIEW

The Department of Corrections (Department) is responsible for
administering Behavioral Health Programs for offenders
incarcerated at state correctional facilities. These programs
provide offenders with mental health, substance abuse, and sex
offender treatment. According to Department policy, the
overarching purpose of these programs is “to promote effective
offender management and successful re-entry into the
community,” which supports the Department’s overall mission
of “holding offenders accountable and engaging them in
opportunities to make positive behavioral changes and become
law-abiding, productive citizens.”

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

4
In recent years the Department’s Behavioral Health Programs have
undergone significant changes to address evolving best practices and
legislative requirements. For example, the Department contracted for
an evaluation of its sex offender program that recommended several
improvements in a 2013 evaluation report, including better
prioritization of treatment based on an offender’s needs and risk to
reoffend. In addition, Senate Bill 14-064, enacted in Calendar Year
2014, prohibits housing offenders with serious mental illness in longterm isolated confinement unless there are exigent circumstances.
Long-term isolated confinement can have a negative impact on
offenders’ mental health and ability to integrate back into the
community upon release. As discussed in the following chapters, the
Department has made changes to its programs in response to the
evaluation and legislation, and the Department has been appropriated
a significant number of additional staff to implement these changes
and improve the care it provides offenders.

BEHAVIORAL HEALTH PROGRAM
ADMINISTRATION
The Department’s Behavioral Health Programs are one branch of the
Department’s Division of Clinical and Correctional Services (Clinical
Services). Behavioral Health Program staff are responsible for
assessing offenders’ treatment needs, and providing management and
treatment of all offenders with long- or short-term behavioral health
needs.
IDENTIFYING TREATMENT NEEDS. All offenders who are under the
Department’s custody go through a standardized intake process, at the
Denver Reception and Diagnostic Center. During intake, staff conduct
initial assessments of all offenders to identify any behavioral health
needs. Data on all offenders is maintained in the Department of
Corrections Information System (DCIS), the Department’s central
offender management system. DCIS includes behavioral health coding
for all offenders. This information is used to make decisions about
facility placement, custody level (e.g., minimum security, maximum

5

TREATMENT PROGRAMS. For offenders identified as having treatment
needs, Behavioral Health Program staff offer treatment, which can
include crisis intervention, individual counseling, group therapy, and
self-directed exercises. Generally, offenders with the highest level of
identified needs receive more treatment services. Offenders’
participation in ongoing treatment is voluntary, although if an
offender declines treatment it may impact his or her ability to be
paroled and affect placement within correctional facilities. Behavioral
Health Programs include three areas:
 THE MENTAL HEALTH SERVICES PROGRAM (MENTAL HEALTH
PROGRAM), which provides services that include ongoing clinical
treatment for offenders with established mental health disorders
and/or developmental disabilities; crisis intervention for disturbed
and self-injurious offenders; and rehabilitative programs and
transitional services for offenders releasing to the community.
Treatment can be offered to offenders housed in either the general
population or in separate, specialized units that provide a
residential setting for high needs offenders called Residential
Treatment Programs (RTPs). As of December 2015, there were 406
offenders participating in the Department’s three RTPs.
 THE ALCOHOL AND DRUG SERVICES PROGRAM (ALCOHOL AND
DRUG PROGRAM). In December 2015, the Department reported that
74 percent of all offenders had substance abuse treatment needs.
Depending on the severity of needs, treatment can include self-help
groups, substance abuse education, residential treatment, or
outpatient treatment in the form of classes or group therapy. The
most intensive treatment for the highest needs offenders is offered

REPORT OF THE COLORADO STATE AUDITOR

security), and enrollment in treatment and services. Behavioral Health
Program staff also reassess the behavioral health needs of offenders as
needed, and work in collaboration with correctional officers and other
staff to identify changes in an offender’s treatment needs. For
example, an offender’s needs may change as the offender makes
progress in treatment or when an offender experiences a crisis, such as
a suicide attempt.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

6
through residential programs in living units that are separate from
the general population, and are called Therapeutic Communities.
Treatment under a Therapeutic Community includes structured
activities and therapy 7 days per week and requires a minimum 6month stay. As of December 2015, there were 656 offenders
participating in a Therapeutic Community.
 THE SEX OFFENDER TREATMENT AND MONITORING PROGRAM (SEX
OFFENDER PROGRAM), which provides treatment and monitoring
services for sex offenders in accordance with extensive statutory
requirements and treatment standards set by the Sex Offender
Management Board (within the Division of Criminal Justice at the
Department of Public Safety). As of December 2015, there were
465 sex offenders enrolled in the Sex Offender Program, and about
2,000 additional sex offenders the Department had identified as
eligible who were awaiting enrollment.
CONTINUING MANAGEMENT UPON RELEASE. As offenders near their
release date (either mandatory or discretionary parole, or discharge
due to completion of sentence), the Department offers pre-release
services, such as developing individualized transition plans and
preparing forms to relay behavioral health information, including
mental health treatment and needs information, to the State Board of
Parole (Parole Board), the Department’s Division of Parole, and
treatment providers in the community. Once paroled, offenders can
access treatment that is offered by community mental health centers or
private behavioral health practitioners that are approved by the
Department’s Approved Treatment Provider Program.

PROGRAM FUNDING AND
EXPENDITURES
As shown in EXHIBIT 1.1, for Fiscal Year 2016, the Department
received a total of $30.1 million for its Behavioral Health Programs.
Of this amount, over 98 percent was general funds. In addition, the
Department was appropriated 292.2 full-time-equivalent (FTE) staff

7

EXHIBIT 1.1. BEHAVIORAL HEALTH PROGRAMS
EXPENDITURES1 AND FTE
FISCAL YEARS 2014-2016 (IN MILLIONS)
PROGRAM

Mental Health
Program
FTE
Alcohol & Drug
Program
FTE
Sex Offender
Program
FTE
TOTAL
EXPENDITURES
TOTAL FTE

FY 2014

FY 2015

FY 2016

PERCENT CHANGE
FY 2014-2016

$14.4

$14.8

$16.8

17%

126.2

127.1

151

20%

$8.5

$8.7

$8.9

5%

85.4

85.4

85.4

0%

$3.2

$4.3

$4.4

38%

42.8

55.8

55.8

30%

$26.1

$27.8

$30.1

15%

254.4

268.3

292.2

15%

SOURCE: Office of the State Auditor analysis of Joint Budget Committee documents.
1
Does not include funding for offenders within the community (e.g., on parole, under
community supervision), or funding for offender psychiatric prescription medicine.

AUDIT PURPOSE, SCOPE AND
METHODOLOGY
We conducted this audit pursuant to Section 2-3-103, C.R.S., which
authorizes the State Auditor to conduct audits of all departments,
institutions, and agencies of state government, and Section 2-7-204(5),
C.R.S., the State Measurement for Accountable, Responsive, and
Transparent Government (SMART) Act. This audit was prompted by
a legislative request that expressed concerns regarding the effectiveness
and efficiency of the Department’s Mental Health Program and Sex
Offender Program, including the adequacy and availability of care,
staffing, and information systems. The audit was conducted from
September 2015 to September 2016. We appreciate the assistance
provided by the management and staff of the Department of
Corrections during this audit.

REPORT OF THE COLORADO STATE AUDITOR

for the Behavioral Health Programs, a 15 percent increase since Fiscal
Year 2014.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

8
We conducted this audit in accordance with generally accepted
government auditing standards. Those standards require that we plan
and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based on
our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
The key objectives of the audit were to assess the Department’s
policies, procedures, and practices within its Mental Health Program
and Sex Offender Program related to:
 Providing offenders with the evidence-based mental health and sex
offender treatment and services that Department staff determine
they need, within the framework of the Department’s
Administrative Regulations and Clinical Standards.
 Ensuring offenders with serious mental illness are not placed into
long-term isolated confinement in violation of Senate Bill 14-064.
 Maintaining adequate staffing to offer appropriate and timely
treatment and services.
 Monitoring and reporting the effectiveness of these programs based
on the programmatic purposes established.
To accomplish our audit objectives, our work included:
 Interviewing approximately 30 Department management and staff
members at five correctional facilities and headquarters, within
Clinical Services and other Department divisions, about the Mental
Health and Sex Offender Programs. We also interviewed other state
employees including staff from the Governor’s Office of
Information Technology, the Office of the State Controller, and the
Division of Human Resources; members of the workgroup created
by Senate Bill 14-064; members of the Sex Offender Management
Board; and members of the Parole Board.

9

 Reviewing information maintained by the Department regarding:
offenders’ diagnoses, mental health assessments, sex offender
assessments, mental health treatment plans, mental health contacts,
mental health transition forms completed prior to release,
offenders’ out-of-cell time in RTPs, and placement of offenders in
isolated confinement.
 Reviewing a statistically valid sample of 50 offenders transferred
between facilities from November 1, 2015, to November 15, 2015.
 Assessing the reliability of the Department’s data used to manage
offenders with behavioral health needs.
 Reviewing Department data on staffing levels and recent
appropriation history.
As described throughout this report, we reviewed a variety of data
from the Department to assess the extent to which the data
demonstrated that the Department is complying with applicable
standards—specifically,
statutes,
Department
Administrative
Regulations, and Department Clinical Standards. Over the course of
the audit, and prior to finalizing this report, when we identified
situations that appeared to be out of compliance with these standards,
or otherwise of concern, we provided relevant information to
Department staff and management for response and discussion. We
used the Department’s responses, additional information provided,
and the total audit evidence collected to reach our conclusions under
audit standards. Because this performance audit did not include an
assessment in any area that required clinical expertise, and rather,
included a general management and program review based on
statutory requirements and Department regulations and standards, we
did not consult with any behavioral health specialists outside of the
Department to complete our work.

REPORT OF THE COLORADO STATE AUDITOR

 Visiting five correctional facilities, including the three that house
the Department’s RTPs.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

10
We planned our audit work to assess the effectiveness of those internal
controls that were significant to our audit objectives. Our conclusions
on the effectiveness of those controls are described in the audit
findings and recommendations.
The objectives of our audit were focused on the Department’s Mental
Health Program and Sex Offender Program and the audit did not
include a review of other programs within Clinical Services, such as
the Alcohol and Drug Program. We also did not review behavioral
health services provided to offenders upon release from prison through
the Parole Division, Community Corrections, or other behavioral
health service providers in the community, such as programs
administered through the Department of Human Services or nonprofit organizations.

CHAPTER 2

MENTAL HEALTH
SERVICES AND
TREATMENT

The purpose of the Mental Health Services Program (Mental
Health Program) is to provide mental health treatment and
services to offenders with mental health treatment needs
incarcerated in state correctional facilities, assist offenders in
managing mental illness and maintaining appropriate behavior,
help ensure the safety of all individuals at the prison facilities,
and promote offenders’ successful reintegration into the
community upon release.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

12
Mental Health Program staff use their clinical expertise, as well as
evidence-based treatment and best practices, to conduct assessments
and, using the assessment results, identify whether an offender’s
current mental health state and behavior warrants treatment. To
ensure consistency across facilities and clinicians, and quality of care,
the Department has established requirements and guidelines for
Mental Health Program staff in its Administrative Regulations and
internal Clinical Standards.
For offenders with treatment needs, staff develop individual treatment
plans outlining a course of treatment for the offender. Offender
mental health treatment could include group therapy sessions,
individual counseling, and self-directed exercises to provide effective
coping skills and promote stabilization. Some offenders may need
ongoing, long-term therapy to manage a diagnosed mental health
disorder, and in some cases these offenders are placed in one of the
Department’s three Residential Treatment Programs (RTPs), where
they receive the highest level of therapeutic services. Other offenders
may only need short-term, point-in-time treatment, such as an
intervention to cope with bereavement.
We reviewed the Department’s management of offenders’ mental
health needs and treatment within the Mental Health Program for
compliance with Administrative Regulations and Clinical Standards,
and found that, overall, the Department can improve its processes,
internal controls, and information systems to promote more consistent
compliance with the Department’s regulations and standards, which
are intended to ensure that offender mental health needs are
consistently identified and addressed, as discussed in this chapter.

IDENTIFYING MENTAL
HEALTH NEEDS
Mental Health staff at the Department’s central intake facility perform
initial mental health assessments of the offenders upon their

13

Staff use the Department’s mental health coding system to identify
offenders’ treatment needs and record them in the Department of
Corrections Information System (DCIS). The coding system assigns
offenders alphanumeric codes that indicate their level of need for
mental health services at the time of assessment, as well as whether the
offender has received a psychiatric diagnosis of a specific mental
illness or illnesses; for example, an offender who has received a
“major mental illness” diagnosis receives an “M” code in DCIS. Staff
are required to assign all offenders both a psychological code and a
developmental disabilities code. Both codes use a scale ranging from
level 1 through 5, with level 1 indicating no treatment needs and level
5 indicating the most acute treatment needs. This scale is based both
on an offender’s treatment history and his or her current mental health
status. Thus, an offender’s stability while incarcerated, as indicated by
his or her behavior, may result in his or her psychological code
moving up or down the scale. For example, an offender who has not
exhibited any mental health issues but who then displays behavior
indicative of a mental illness may move up on the Department’s 1 – 5
scale, and that would signify to staff that the offender needs a higher
level of mental health services and monitoring.
Offenders may fall at the higher end of the coding scale (i.e., level 3 or
higher) after receiving a psychiatric diagnosis and their assessment
results. Specifically, Mental Health staff use two assessments, the Brief
Psychiatric Rating Scale (Rating Scale), which assesses the offenders’
symptom severity, and the Resource Consumption Scale (Resource
Scale), which measures the offenders’ current need for resources, to
determine the offenders’ treatment needs level.
The Department’s assessment and coding process, which is outlined in
its internal Clinical Standards, is a critical control for ensuring that
offenders receive the treatment they need and are housed in the proper

REPORT OF THE COLORADO STATE AUDITOR

incarceration, to identify potential mental health treatment needs and
refer offenders to Mental Health Program staff for further
assessments, as needed, in order to determine the appropriate
placement and course of treatment.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

14
facility. Specifically, staff are responsible for using mental health
coding to determine how often an offender needs to be seen by a
mental health therapist, as well as what facility and housing unit
would be appropriate. For example, according to Clinical Standards,
offenders with a psychological code of level 4 should receive monthly
monitoring by Mental Health Program staff to ensure that they remain
stable while they are incarcerated, and offenders with a developmental
disabilities code of level 4 should be recommended for specialized
services reserved for offenders with an impairment in intellectual
functioning.

WHAT AUDIT WORK WAS PERFORMED
AND WHAT WAS THE PURPOSE?
We reviewed statutes and the Department’s Administrative
Regulations and Clinical Standards to determine the Department’s
requirements and guidelines for assessing offenders’ mental health
needs, and use of DCIS to code and track those needs. We reviewed
mental health coding, diagnosis, and Rating/Resource Scale assessment
information in DCIS for the 46,931 offenders who were in the
Department’s custody at any point during the period of July 1, 2012,
through December 31, 2015, which included 17,977 offenders
incarcerated as of December 31, 2015. We also reviewed the
programming controls the Department uses to manage offender
mental health information in DCIS. Further, we interviewed
Department management and staff to understand their processes for
identifying and coding offenders’ mental health needs.
The purpose of our work was to determine whether Department staff
assessed and coded offenders’ mental health needs in DCIS in a
consistent, timely manner, in accordance with the Department’s
Administrative Regulations and Clinical Standards.

15

Overall, we found that Department staff did not always assess and
code offender mental health needs in DCIS in a consistent, timely
manner, in accordance with the Department’s Administrative
Regulations and Clinical Standards. Specifically:
 DEVELOPMENTAL DISABILITIES CODES WERE NOT ASSIGNED TO ALL
OFFENDERS. We found that, of the 46,931 offenders we reviewed,
370 (1 percent) were not assigned any developmental disabilities
coding in DCIS during their terms of incarceration, as required.
Under the Department’s Clinical Standards, staff are required to
assign all offenders a developmental disabilities code, using the
Department’s 1 – 5 scale (and offenders with no developmental
disabilities needs are coded level 1).
 MENTAL

HEALTH CODING DID NOT ALWAYS FOLLOW CLINICAL

STANDARDS.

We found that, of the 7,753 offenders incarcerated as
of December 31, 2015, who had a psychiatric diagnosis in DCIS, a
total of 276 (4 percent) were not assigned the appropriate
psychological coding indicating the diagnosis, as required by
Clinical Standards. Specifically:

►

For 190 offenders with a “major mental illness” diagnosis, staff
did not assign the appropriate psychological code in DCIS to
indicate this type of diagnosis. The Department’s Clinical
Standards require staff to assign an offender a psychological
“major mental illness” code (an “M” code) if the offender is
diagnosed with a mental illness that appears on the Department’s
list of major mental illness diagnoses. Of the 7,753 offenders
who had a psychiatric diagnosis, 1,843 had records showing a
major mental illness diagnosis; of these, we found that 190 (10
percent) were not assigned the appropriate “M” coding. Staff
initially assigned a major mental illness code as required to 80 of

REPORT OF THE COLORADO STATE AUDITOR

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY AND HOW WERE THE
RESULTS MEASURED?

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

16

►

these offenders, but staff later removed the code in DCIS even
though these offenders’ diagnoses did not change.
For 86 offenders with a psychiatric diagnosis, staff did not assign
the appropriate psychological code level in DCIS. Staff coded
these offenders at psychological code level 1, which indicates no
mental health needs, even though an offender with any type of
psychiatric diagnosis should not be coded as having no mental
health needs according to Clinical Standards.

 TEMPORARY

PSYCHIATRIC DIAGNOSES WERE NOT ALWAYS UPDATED

IN A TIMELY MANNER.

Of the 9,203 instances where an offender was
assigned a temporary diagnosis in DCIS between July 1, 2012 and
December 31, 2015, we found that 1,735 (19 percent) were not
updated in a timely manner. The Department’s Clinical Standards
state that staff may use temporary coding to indicate a temporary
diagnosis, such as an adjustment disorder, and requires staff to
update the temporary coding within 6 months. For the 1,735
instances we found that were not updated as required, the
temporary coding remained in place for between 1 week and 8
years beyond the 6 month deadline.

 RATING

AND RESOURCE SCALE ASSESSMENTS WERE SOMETIMES LATE

OR MISSING.

Of the 6,926 offenders with a psychological code level
of 3 or higher who were incarcerated as of December 31, 2015, we
found one or more problems with the assessments for 1,213
offenders (18 percent). Specifically, the Department’s Clinical
Standards require staff to conduct both the Rating Scale and
Resource Scale assessments for offenders with a psychological code
of level 3 or higher. For offenders coded psychological level 3, staff
must conduct the assessments every 6 months; for offenders coded
psychological level 4 or 5, staff must conduct the assessments every
month. We found that:
►

67 offenders (1 percent) did not have any Rating Scale
assessment recorded in DCIS, and 70 offenders (1 percent) did
not have any Resource Scale assessment. Sixty-one of these
offenders did not have either assessment recorded in DCIS.

17

1,081 offenders (16 percent) did not have a Rating Scale
assessment conducted in a timely manner, and 1,096 offenders
(16 percent) did not have a Resource Scale assessment conducted
in a timely manner; these assessments ranged from 3 days to
more than 3 years overdue. For 1,032 of these offenders, neither
assessment was conducted in a timely manner.

Additionally, we reviewed 3,464 inmates who had their
psychological code level changed by facility Mental Health staff
from April 1, 2013 to December 31, 2015, and found 280 instances
(8 percent) where staff changed an offender’s psychological code
level in DCIS without recording any Rating Scale assessment score
associated with the level change. Clinical Standards state that
psychological code “[l]evels are based on a concrete formula that
includes the score on a standardized symptom severity inventory
[Rating Scale] coupled with a resource consumption scale [Resource
Scale].”

WHY DID THESE PROBLEMS OCCUR?
The Department lacks a number of controls to help ensure that
offenders’ mental health needs are accurately identified and recorded,
in a timely manner and in accordance with Administrative Regulations
and Clinical Standards.
First, the Department’s current offender database, DCIS, does not
have the capability to allow staff to run regular reports showing
whether or not offender mental health coding is accurate, based on
Rating/Resource Scale assessments and psychiatric diagnosis, and is
updated in accordance with Clinical Standards; DCIS also allows staff
to change offender coding without review or approval by supervisory
staff. Further, while Clinical Standards require that certain mental
health coding be assigned when an offender is diagnosed with a major
mental illness, DCIS does not have the capability to reflect multiple
diagnoses for an offender, or situations when a clinician has
determined that an offender has a provisional diagnosis (which is

REPORT OF THE COLORADO STATE AUDITOR

►

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

18
used, in place of a principal diagnosis, when the clinician cannot yet
assess whether the offender’s condition meets the full criteria for a
diagnosis that is outlined in professional guidelines in the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders manual). The Department stated that because DCIS will
only allow staff to assign an offender a temporary or principal
diagnosis, and not multiple or provisional diagnoses, the offender’s
coding—compared to the diagnosis listed in DCIS—may appear
inaccurate. For example, if an offender has a major depressive
disorder, based on the Department’s Clinical Standards for coding
offenders in DCIS, the offender’s coding should reflect that he or she
has a major mental illness. However, clinicians will sometimes not
assign this coding if there is a more pressing concern that needs to be
addressed first, such as a personality disorder (instead staff would
assign mental health coding associated with the personality disorder,
as this is the primary treatment area), or, clinicians may give an
offender a diagnosis in which the clinician thinks he or she will
ultimately meet full criteria (and this provisional diagnosis may not
align with the coding in DCIS during that time period).
The Department stated that DCIS was implemented over 20 years ago
and as such, is an antiquated, legacy system that cannot provide the
controls we have identified here as lacking and is not capable of
allowing mental health coding that could both reflect the presence of a
major mental illness and an offender’s primary treatment area.
Further, because the Department is replacing DCIS with a new system
that will be capable of addressing these problems, the Department has
not established other controls outside of DCIS to monitor mental
health coding and assessments, and address problems in a timely
manner. The Department stated that it plans for the new system to
contain controls to better monitor and manage all offender
information; however, this new system is not scheduled to be fully in
place for 2 to 4 years. We discuss the data management system issues
that we identified further in CHAPTER 5.
Second, the Department stated that it experiences high turnover and
staffing shortages on a routine basis among Mental Health Program

19

Finally, Department management stated that staff are allowed to
deviate from the requirements and guidelines for assessments and
coding in Clinical Standards if such deviation is warranted, based
upon an individual staff member’s clinical judgment of the offender’s
mental health status and needs. That being said, the Department does
not track when a deviation from Clinical Standards, such as changing
an offender’s psychological code without conducting Rating/Resource
Scale assessments, has occurred, nor does the Department necessitate
supervisory review or approval in instances when staff wish to deviate
from requirements and guidelines to ensure deviations are appropriate.

WHY DO THESE PROBLEMS MATTER?
When an offender’s mental health needs are not properly identified
and coded as required, there is a risk that the offender may not receive
appropriate monitoring and attention to mitigate any behavioral issues
that may arise from these needs, such as behavior that threatens
offender or staff safety, or is disruptive to facility operations.
Moreover, when the Department does not enforce its requirements,
there is a risk that the approximately 150 mental health staff members
will not adequately provide treatment in a consistent manner and that
data entry errors or other mistaken coding will be assumed to be
deviations to requirements based on staff clinical judgment (which
could lead to errors not being corrected). These risks are heightened
due to the high turnover rate of Mental Health Program staff, which

REPORT OF THE COLORADO STATE AUDITOR

staff. The Department stated that as a result, the issues we identified
here and in other sections of this report were caused, in part, by a lack
of adequate staffing resources. When the Department does not
maintain an adequate number of staff on a consistent basis, it has to
routinely determine which tasks must take priority over other tasks,
and expects some gaps in staff knowledge of the Department’s
processes and requirements, as well as their ability to always meet all
requirements, including ensuring that mental health coding is accurate
in DCIS and when assessments should be conducted. We discuss the
mental health staffing issues that we identified further in CHAPTER 5.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

20
means that many staff are new and may not be familiar with
Department requirements and the rationale for those requirements.
Additionally, the Department makes decisions about disciplinary
actions and restrictive housing placement based, in part, on an
offender’s mental health needs and associated coding in DCIS. As
such, if an offender’s coding is not accurate, there is a risk that the
offender may be placed in facility or cell housing arrangements that
are prohibited by statute and the Department’s regulations. For
example, the Department is prohibited from placing an offender with
a major mental illness (such as major depressive disorder) in restrictive
housing maximum security, unless exigent circumstances are present.
Mental health coding in DCIS is the mechanism for clinical staff to
communicate to correctional staff that an offender has a major mental
illness, without disclosing confidential health information. However, if
staff do not assign mental health coding to reflect a major mental
illness, there is a risk that correctional staff responsible for disciplinary
actions will be unaware of which offenders are prohibited from
placement in restrictive housing maximum security. We discuss issues
we saw with some offenders being inappropriately placed in restrictive
housing maximum security due to inaccurate coding further in
CHAPTER 3.
Finally, offenders with a psychiatric diagnosis of a major mental
illness or developmental disabilities are eligible for specialized services
in the community once they are released from prison. For example, the
Department stated that paroling offenders are assessed for case
management services including a referral to publicly funded
community mental health centers so that the offender may continue to
receive treatment once released into the community. If an offender is
not identified and coded as having specialized needs upon release,
there is a risk that the offender may not be referred for treatment upon
release. For example, we saw that 670 offenders in the Department’s
custody were released from prison during the audit period with
temporary coding still in place upon release, indicating that they may
have had a mental illness, but that further evaluation would have been
required to make this determination.

21

The Department of Corrections (Department) should strengthen its
controls to better ensure that its staff conduct timely mental health
assessments of offenders and accurately enter assessment information
and coding into its offender management database, per requirements,
by:
A Implementing information system and/or manual controls to
identify instances of when staff change offender coding and
assessment results.
B Conducting systematic monitoring activities of offender coding and
assessments, such as ongoing supervisory review or other periodic
reviews, to identify, investigate, and correct any instances where
offenders’ mental health coding, including psychological,
developmental disabilities, and temporary coding and psychiatric
diagnoses, do not conform to Administrative Regulations or
Clinical Standards, or are otherwise inaccurate or missing. This
should include using the monitoring information to identify staff
training needs and adjust the training provided to target areas for
improvement on an ongoing basis.
C Implementing processes to notify staff when assessments are
coming due or when temporary mental health coding will need to
be updated.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: MARCH 2017.
While the Department agrees that it can strengthen its processes,
internal controls, and information systems to better ensure that

REPORT OF THE COLORADO STATE AUDITOR

RECOMMENDATION 1

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

22
offender mental health needs are consistently identified and
addressed, risks identified by the audit team are mitigated by other
internal Department processes such as multi-disciplinary team
meetings involving mental health clinicians to ensure restrictive
housing assignments are appropriate and consistent with DOC
policy especially as it relates to housing assignments prohibited by
statute, as well as, follow up treatment services in the community
which involves the assessment of all paroling offenders for service
needs. Our current electronic system does not allow staff to
indicate a provisional diagnosis and forces them to instead assign a
diagnosis that would be consistent with a lower P code. The
Department agrees to implement manual controls in the form of an
audit tool developed by the Quality Management Program to
review instances when staff change offender coding and
assessments until our new electronic system (eOMIS) is fully
implemented and reporting features enable supervisors to review
these changes for appropriateness.
AUDITOR’S ADDENDUM: Although the Department reports that its
processes, such as multi-disciplinary team meetings related to
restrictive housing placements and assessment of paroling
offenders, mitigate the risks we identified, these processes would
not mitigate the risk of offenders who are not properly assessed
and coded not receiving monitoring and treatment in accordance
with Department standards. Further, although the multidisciplinary team meetings described in the Department’s response
may mitigate the risk of improper placement of offenders, proper
coding in DCIS also serves as an important control. As discussed
in CHAPTER 3, we identified several improperly placed offenders
who also lacked proper coding in DCIS.
B AGREE. IMPLEMENTATION DATE: MARCH 2017.
Audit findings resulting from the audit tool developed by the
Clinical Services Quality Management Program (QMP) staff
described in No:1 Part:A above will be submitted to facility mental
health supervisors for review. Supervisors will use this information
to identify, implement and document completion of targeted staff

23

C AGREE. IMPLEMENTATION DATE: NOVEMBER 2016.
A report with this information is currently being generated and
submitted to facility mental health supervisors/Health Services
Administrators and subsequently passed on to the appropriate
mental health clinician on a monthly basis. Steps are then taken by
the clinician to ensure these assessments are updated and
documented. It warrants mentioning that the numbers of
assessments and T qualifiers reported as overdue (in these monthly
reports) are inflated due to the current electronic system
automatically and inaccurately registering offenders upon intake
(at the Denver Reception and Diagnostic Center) as overdue. These
particular assessments are not performed on intake due to them
not being applicable at that point in the offender’s incarceration.
The Department’s new electronic system (eOMIS) will correct this
inaccuracy of the reports; however, the reports will continue to be
generated until that time to catch applicable cases.

REPORT OF THE COLORADO STATE AUDITOR

training for improvement. Additionally, a clinical standard has
recently been developed and implemented to guide designated
mental health clinicians in clinical supervision duties and
responsibilities. Clinical supervision includes regular oversight and
review of a clinician’s case work, including mental health
assessments and coding of offenders in a timely and appropriate
manner.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

24

PLANNING TREATMENT
AND PROVIDING
SERVICES
The Department’s Mental Health Program staff are responsible for
developing treatment plans and providing regular mental health
services to offenders. Treatment plans are individualized to each
offender’s risks and needs and generally include current diagnoses and
mental health assessment results, treatment goals, and specific planned
therapeutic interventions, as well as the minimum frequency that
Mental Health Program staff should meet with the offender. Staff
update treatment plans periodically and in response to significant
events or changes to the offender’s mental health (e.g., exhibition of
self-harming behavior or discharge from an infirmary). According to
Clinical Services staff, treatment plans are the primary method of
setting offender treatment and behavior goals, and tracking progress
towards those goals.
Additionally, the Department provides assorted mental health services
to offenders that the Department calls “mental health contacts,”
including various assessments of offenders’ mental health, responses to
crises, and treatment sessions. The Department offers these mental
health services on a regular basis to offenders previously identified by
staff as having moderate-to-severe mental health needs (i.e., a
psychological code level of 3, 4, or 5), and, as needed, to offenders
without identified moderate-to-severe mental health needs but who
request treatment or are experiencing a crisis, such as a recent attempt
at self-injury or the onset of mental illness symptoms.

25

We reviewed statutes, Department Administrative Regulations and
Clinical Standards, and interviewed Division of Clinical and
Correctional Services (Clinical Services) management as well as 16
Mental Health Program staff at four facilities to gain an
understanding of the Department’s controls for ensuring that staff
create and update treatment plans and provide mental health contacts,
as required. Clinical Standards specify that staff should enter all
treatment plans and mental health contacts into DCIS; as such, we
also assessed electronic DCIS data as follows:
 CREATION AND REVIEW OF TREATMENT PLANS UPON ARRIVAL. We
reviewed data for all 5,327 offenders with moderate-to-severe
mental health needs (i.e., offenders with a psychological code of 3,
4, or 5) who were incarcerated at a Department facility as of
December 31, 2015, and who transferred between facilities from
July 2014 to December 2015, to determine if Mental Health
Program staff established or reviewed these offenders’ treatment
plans within 30 days of offenders arriving at the new facility, as
required by Clinical Standards. Clinical Services management stated
that for such newly-arriving offenders, staff should first review the
new offender’s existing treatment plan (if one exists) to determine if
it sufficiently addresses the offender’s current mental health needs,
and then create a new treatment plan if the existing one does not
adequately address the offender’s current needs or if no treatment
plan is in place.
 UPDATES TO TREATMENT PLANS. We reviewed data for all 6,926
offenders with moderate-to-severe mental health needs who were
incarcerated at a Department facility as of December 31, 2015, to
determine if each had a treatment plan that was updated in the last
6 months, since Clinical Standards requires that treatment plans be
reviewed and updated at least every 6 months.

REPORT OF THE COLORADO STATE AUDITOR

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

26
 CONTENTS OF INDIVIDUALIZED TREATMENT PLANS. We selected a
non-statistical sample of 15 of the 7,897 offenders with moderateto-severe mental health needs who received mental health treatment
in Calendar Year 2015 and we reviewed 33 treatment plans for
these sampled offenders. The purpose of our review was to
determine if the plans included accurate information that complied
with Clinical Standards, which require that each plan contain: (1)
the offender’s diagnoses, (2) current Rating Scale and Resource
Scale scores, (3) problem areas, (4) treatment goals or objectives,
(5) specific planned therapeutic interventions, and (6) the minimum
frequency of mental health contacts that Mental Health Program
staff must maintain with the offender.
 MENTAL HEALTH CONTACTS. We reviewed data on mental health
contacts that occurred between July 1, 2014 and December 31,
2015, for offenders in a Residential Treatment Program (RTP) and
those not in an RTP. First, we reviewed mental health contact data
for a non-statistical, random sample of 10 offenders at the
Centennial Correctional Facility RTP, out of 389 offenders enrolled
during this time period. Second, we reviewed data for 6,492
offenders with moderate-to-severe mental health needs who, as of
December 31, 2015, were incarcerated at a Department facility but
who were not in an RTP. The purpose of our reviews was to assess
whether staff regularly met with offenders in accordance with the
frequencies established in Clinical Standards, described below, to
provide group or individual therapy, to conduct a mental health
assessment, or to respond to an offender mental health crisis. Staff
should meet with:
►
►
►

Offenders with a psychological code level of 5 once per week.
Offenders with a psychological code level 4 once per month.
Offenders with a psychological code level 3 once every three
months, unless the Department has approved a level 3 offender
for less frequent monitoring intervals of up to 9 months due to
stability of his or her mental illness.

27

Overall, we found that Mental Health Program staff did not always
properly establish and update individualized treatment plans and did
not always provide an adequate number of mental health contacts to
offenders, based on Department requirements. Specifically, we found
the following problems:
 LACK OF NEW TREATMENT PLANS AND DOCUMENTATION OF REVIEW.
Of the 5,327 offenders with moderate-to-severe mental health needs
who arrived at a facility, either due to a transfer from another
facility or new period of incarceration, between July 2014 and
December 2015, we found that Mental Health Program staff did
not establish a new treatment plan for 2,566 offenders (48 percent)
within 30 days of arrival. According to Clinical Services
management, for some number of these offenders, Mental Health
Program staff may have determined a new treatment plan was not
needed, because the offender already had a sufficient plan in place
from the previous facility; when we reviewed DCIS, it did appear
that in some instances offenders had existing plans. However, the
Department has no way of verifying that the existing plans were
reviewed, and reviewed on time, for any of the 2,566 offenders we
identified.
 TREATMENT PLANS NOT REGULARLY UPDATED. Of the 6,926
offenders with moderate-to-severe mental health needs, we found
that, as of December 31, 2015, Mental Health Program staff had
not updated treatment plans for 2,193 offenders (32 percent) in the
last 6 months, as required. For 1,059 offenders (15 percent), staff
had not updated treatment plans in over a year and half.
 INCOMPLETE AND INACCURATE TREATMENT PLANS. Of the 33
treatment plans included in our sample, we identified at least one
problem with 17 individualized treatment plans, with four of these
treatment plans containing two problems each. Specifically:

REPORT OF THE COLORADO STATE AUDITOR

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY?

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

28
►

►

►

►
►

►

9 treatment plans did not contain the minimum frequency of
mental health contacts.
5 treatment plans incorrectly listed the offender’s current mental
health coding.
4 treatment plans did not contain valid Resource Scale scores
(scores were outside the range of possible scores for this
assessment).
1 treatment plan did not describe the offender’s problem areas.
1 treatment plan did not contain the offender’s current Rating
Scale and Resource Scale scores.
1 treatment plan did not include planned therapeutic
interventions.

 LACK OF TIMELY MENTAL HEALTH CONTACTS. Of the 6,492
offenders with moderate-to-severe mental health needs not housed
in a RTP, we found that, as of December 31, 2015, staff had not
conducted a mental health contact for 1,054 (16 percent) in the
required time periods. Specifically:
►

We reviewed DCIS data for 93 offenders assessed as a
psychological code level 4 to determine if, as of December 31,
2015, each had been offered a mental health contact in
December, since Clinical Standards require that level 4 offenders
have a monthly mental health contact. We found that 18
offenders (19 percent) did not have a mental health contact in
December 2015.

►

We reviewed DCIS data for 6,399 offenders assessed as a
psychological code level 3 to determine if, as of December 31,
2015, each had been offered a mental health contact in
accordance with Clinical Standards, which require a mental
health contact every 3 months, unless approved for less frequent
6- to 9-month intervals. We found that 1,036 offenders (16
percent) did not have a mental health contact in their required
and approved time periods.

Of the sample of 10 offenders housed in the Centennial
Correctional Facility RTP, we did not identify any offenders who

29

WHY DID THESE PROBLEMS OCCUR?
Overall, Clinical Services management indicated that staff do not
always update treatment plans and offer mental health contacts in a
timely manner, as required, when the facilities are not fully staffed. In
these cases, Clinical Services management stated that staff prioritize
their most pressing duties and the most high-needs offenders, which
can lead to treatment plan updates and scheduled mental health
contacts being untimely for some offenders. Department management
stated that such triaging of the most high-needs offenders is
acceptable, though not ideal, when there are limited staffing resources
since other Department staff—including correctional officers and
medical staff—interact with offenders on a daily basis and can notify
Mental Health Program staff if it appears that any offender is urgently
in need of mental health care. We further discuss staffing in CHAPTER
5. High turnover can also contribute to problems with new staff not
always receiving proper training in a timely manner, which in turn can
lead to them not following requirements; the Department stated, for
example, that inadequate training caused lengthy delays in the
updating of treatment plans and the lack of compliance with all
required content in all treatment plans.
Additionally, the Department does not have adequate controls to
ensure that Mental Health Program staff maintain updated
individualized treatment plans, include required and accurate
information in treatment plans, and provide timely mental health
contacts. We identified the following additional reasons for the
problems that we saw:
 INADEQUATE DOCUMENTATION REQUIREMENTS. Clinical Services
management stated that it does not require Mental Health Program
staff to document if and when they conduct a review of a newlyarrived offender’s treatment plan and determine that the offender’s
existing treatment plan sufficiently addresses the offender’s current

REPORT OF THE COLORADO STATE AUDITOR

did not receive mental health contacts within the timeframes
established by Clinical Standards.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

30
mental health needs. Moreover, Clinical Services management
stated that it does not currently have a method that Mental Health
Program staff could use to document such reviews of treatment
plans in DCIS, and thus, would have to make changes in DCIS to
facilitate
this
documentation.
However,
without
such
documentation it is not possible to monitor whether staff have
completed the review as required.
 LACK OF SUFFICIENT MONITORING. In general, the Department does
not systematically monitor staff creation and updating of treatment
plans, or staff provision of mental health contacts, to ensure
compliance with requirements. Instead, the Department stated that
it relies on peer reviews of Mental Health Program staff and
sporadic facility-specific and Department-wide audits to ensure that
staff create and update complete and accurate treatment plans
according to requirements, and offer required mental health
contacts; however, these methods are not comprehensive for
various reasons. First, peer reviews are not performed for a
majority of Mental Health Program staff and are only scheduled
every other year. Second, facility audits of offender mental health
case files are only conducted on a sample of 10 offenders at each
facility every other month. Finally, the Department does not always
ensure that the issues identified in Department-wide audits
regarding compliance with treatment plan and mental health
contact requirements are addressed in a timely manner.
The Department could use DCIS data to perform more
comprehensive monitoring of offender treatment plans and mental
health contacts. For example, the Department could create a report
from data currently captured in DCIS that shows which offenders
at each facility have a treatment plan that is almost expired (older
than 6 months) or that has already expired. Currently, individual
supervisors at the facilities do not have access to this type of tool
but are responsible for ensuring that their staff follow requirements
regarding treatment plans. Using such a report, supervisory staff
could notify the Mental Health Program staff member assigned to
each offender that the treatment plan needs to be updated, and

31

WHY DO THESE PROBLEMS MATTER?
Altogether, the problems we identified with the development, content,
and timeliness of individualized treatment plans and provision of
mental health contacts may prevent offenders from receiving the
treatment they need in a timely manner. Lack of such treatment can
negatively impact an offender’s behavior while incarcerated and the
offender’s re-integration into the community once released.
Specifically, each offender has unique treatment needs and treatment
needs can change quickly based on offenders’ treatment, personal
experiences, and mental state. Therefore, there is a risk that if staff do
not create and update treatment plans with adequate individualization
for offenders with moderate-to-severe mental health needs, an
offender’s specific risks and needs may not be addressed.
Additionally, without treatment plans that are complete, accurate, and
updated in a timely manner, the Department may not be ensuring that
it provides offenders with the right tools to help them cope with their
specific problem areas. For example, Mental Health Program staff
work with offenders to develop therapeutic interventions and
activities, such as completing specific “homework” assignments
(worksheets), keeping an “anger log” to track instances of anger, or
attempting to improve tone of voice and body language when
distressed. Offenders can rely upon such interventions and activities in
the time periods between scheduled mental health contacts, which may
be several months, but the effectiveness of such coping tools is
diminished if they are not designed for the current and unique needs of
each offender.

REPORT OF THE COLORADO STATE AUDITOR

follow up as needed until an updated treatment plan is completed.
This type of monitoring would help the Department better ensure
compliance with its requirements, identify the staff members or
facilities falling behind or in need of additional training, determine
the best use of the Department’s limited staff, and free up
supervisors’ time to focus on their offender caseloads and ensuring
quality of care by their staff.

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32
Similarly, without a review of an offender’s treatment plan upon
arrival at a new facility, Mental Health Program staff cannot always
ensure that the offender’s treatment continues uninterrupted at the
new facility. Additionally, if staff are reviewing treatment plans for
new offenders, but not documenting such review, there is risk that two
(or more) staff may review one newly arrived offender’s treatment
plan, which could be a waste of staff time. Furthermore, without
documentation, management cannot ensure that staff are completing
these reviews in a timely manner.
Without complete and accurate information in an offender’s treatment
plan, and completion of these treatment plans in a timely manner,
there is a risk that information about an offender’s mental health
needs, past treatment, and recommended treatment is not properly
communicated among Mental Health Program staff as needed.
Specifically, individualized treatment plans act as a way to relay
information regarding an offender’s treatment needs and planned
interventions from an offender’s primary clinician to other Mental
Health Program staff members with whom the offender may interact.
Over the course of their incarceration, offenders may work with a
number of different Mental Health Program staff due to changing
treatment needs, transfers among facilities, or staff turnover. This risk
is particularly high due to the high level of staff turnover at the
Department, as discussed in CHAPTER 5.
Without regular meetings with offenders who staff have identified as
having moderate-to-severe mental health needs, in accordance with the
minimums required by Clinical Standards, Mental Health Program
staff may not be able to track treatment goals or identify emerging
mental health issues and make adjustments to treatment interventions.
Relatedly, without consistently offering timely mental health contacts,
the Department risks not being able to satisfy Department policy,
which, according to Administrative Regulations, is “to provide mental
health services that are oriented towards improvement, maintenance
or stabilization of offenders’ mental health, contribute to their
satisfactory prison adjustment, [and] diminish the public risk

33
REPORT OF THE COLORADO STATE AUDITOR

presented by offenders upon release…” [Administrative Regulation
700-03.I].

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

34

RECOMMENDATION 2
The Department of Corrections (Department) should improve its
controls over individualized mental health treatment plans for
offenders by implementing a method to document Mental Health
Services Program staff’s determination that an existing treatment plan
for a newly arrived offender with moderate-to-severe mental health
needs is current and appropriate and thus a new treatment plan is not
needed.

RESPONSE
DEPARTMENT OF CORRECTIONS
AGREE. IMPLEMENTATION DATE: MARCH 2017.
The Department will implement a method to document mental health
clinicians’ determination that an existing treatment plan for a newly
arrived offender with moderate-to-severe mental health needs is
current and appropriate and thus a new treatment plan is not needed.
The requirement for this documentation will need to be programmed
in the new electronic health record (EHR) so the implementation date
is only an approximate.

35

The Department of Corrections (Department) should improve its
controls over planning mental health treatment and providing mental
health services by:
A Systematically monitoring (1) the timeliness of staff review and
creation of treatment plans for all newly arrived offenders with
moderate-to-severe mental health needs; (2) updates to treatment
plans for all relevant offenders, and contents of treatment plans by
using data currently captured in DCIS (i.e., offenders’ mental
health coding, their movements between facilities, and the dates of
previous treatment plans); and (3) data collected through the
method implemented in RECOMMENDATION 2. This should include
using the monitoring information to correct any problems
identified in a timely manner.
B Systematically monitoring mental health contacts for all offenders
with moderate-to-severe mental health needs to ensure that Mental
Health Services Program staff conduct timely mental health
contacts, in accordance with the Department’s Clinical Standards.
This should include using the monitoring information to correct
any problems identified in a timely manner.
C Identifying staff training needs through the monitoring activities
implemented in PART A and PART B and, on an ongoing basis,
adjusting the training provided to target areas for improvement.
D Continuing such monitoring with implementation of
Department’s new electronic offender information system.

the

REPORT OF THE COLORADO STATE AUDITOR

RECOMMENDATION 3

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

36

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: MARCH 2017.
The audit report speaks to treatment planning and the lack of
sufficient monitoring to determine treatment plan development and
the completion of updates. The Department is implementing a new
electronic health record (EHR) in November 2016 (the first phase
of a multiphase project). Up to this point, the Department has had
to prioritize all programming changes with the Office of
Information Technology (OIT) based on criticality with the
understanding that DCIS for clinical use would be rendered
obsolete when the EHR went live. Although treatment plans do
not drive the success of an offender, they are road maps that
identify treatment options. Offenders, who are unstable or are
experiencing a decline in daily functioning, are identified through
various modes of communication between other DOC staff who
are working with offenders 24 hours a day. Treatment planning is
only one aspect of providing treatment to offenders.
Clinical Services Quality Management Program staff will develop
an audit tool to systematically review treatment plans for newly
arrived offenders with moderate-to-severe mental health needs and
the need for treatment plan updates on relevant offenders until the
new electronic system (eOMIS) is programmed to do this, which
may not happen until the end of 2017.
B AGREE. IMPLEMENTATION DATE: MARCH 2017.
Quality Management Program staff will develop an audit tool to
monitor mental health contacts for offenders with moderate-tosevere mental health needs to ensure that mental health clinicians
conduct timely mental health contacts in accordance with clinical
standards. Information gleaned from this monitoring will be
communicated with facility mental health supervisors and the

37

C AGREE. IMPLEMENTATION DATE: MAY 2017.
Utilizing information through monitoring activities implemented in
No: 3, Part A and B above, facility mental health supervisors will
identify and implement individualized staff training needs to
address targeted areas for improvement on an ongoing basis. Inservice training will be documented in anecdotal staff records held
by mental health supervisors.
Areas for improvement identified through clinical supervision will
be addressed through that process in accordance with the new
clinical standard.
D AGREE. IMPLEMENTATION DATE: DECEMBER 2017.
The Department will ensure the programming of the new
electronic offender management information system (eOMIS) to
include the monitoring of mental health treatment plan
development and updates, as well as mental health contacts, in
accordance with clinical standards which may not happen until the
end of 2017.

REPORT OF THE COLORADO STATE AUDITOR

Health Services Administrators (HSAs) to ensure identified
problems are corrected in a timely manner. As stated previously, a
clinical standard has recently been developed and implemented to
guide designated mental health clinicians in clinical supervision
duties and responsibilities. Clinical supervision includes regular
oversight and review of a clinician’s case work, including timely
mental health contacts with offenders on their caseload.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

38

CONTINUING
MANAGEMENT OF
OFFENDERS WITH
MENTAL HEALTH NEEDS
To identify offenders in need of treatment and reduce the risk of
offenders’ treatment being interrupted when the Department transfers
offenders between correctional facilities, the Department has
established evaluation procedures for staff to follow. Specifically,
Clinical Services staff conduct Mental Health Screenings (Screenings)
for transferred offenders, during which time offenders answer
questions about current mental health needs and past mental health
treatment, and staff observe the offenders’ current mental health state;
offenders are then referred, as needed, for further assessment and
treatment based on the results of their Screenings. Mental Health
Program staff document Screenings by completing a Screening form.
Additionally, Mental Health Program staff provide behavioral health
treatment and needs information to various outside parties when an
offender with moderate-to-severe mental health needs is being released
back into the community. Specifically, staff at Department facilities
use an electronic Mental Health Transition Form (Transition Form or
Form) in DCIS to document various types of information, including:
 Protected, private mental health information that, according to the
Health Insurance Portability and Accountability Act (HIPAA),
cannot be shared without offender consent. This confidential
information includes specific diagnoses, medications, assessment
scores, and the date and location of any scheduled appointments at
a community mental health center.

39

Parole officers, who are under the purview of the Department’s
Division of Parole (Parole Division), can use the information in a
Transition Form to better manage offenders, encourage appropriate
behavior, and avoid parole revocation. For example, parole officers
could learn from the Transition Form that an offender has been
prescribed medication to manage symptoms of a mental illness, which
may include inappropriate behavior; if the parole officer then sees
these symptoms, the officer would understand that the offender may
have stopped taking the medication, which would allow the officer to
address the offender’s refusal to take, or inability to access, the
medication.
If the offender agrees, all information in the Transition Form—
including the protected, private information—may be shared with the
offender’s community parole officer once the offender starts parole, as
well as with the State Board of Parole (Parole Board) in preparation
for the offender’s parole hearing. If the offender does not consent to
share his or her private, protected information, then only the
remaining non-confidential information may be made available to the
offender’s community parole officer and the Parole Board.

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
We reviewed statutes, the Department’s Administrative Regulations
and Clinical Standards, and American Correctional Association
Standards implemented by the Department. We also interviewed the

REPORT OF THE COLORADO STATE AUDITOR

 Non-protected information that can be shared without offender
consent, including history of assaultive behavior, a list of programs
attended while in the custody of the Department and the offender’s
quality of participation in the programs, concerns about
dangerousness to self or others, and community treatment
recommendations (such as substance abuse, anger management, or
general mental health treatment).

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

40
Department’s Mental Health Program management and staff,
two Parole Board members and Parole Board staff, and Parole
Division staff. Additionally, we reviewed:
 Data from DCIS for 730 offenders that the Department transferred
between facilities (excluding temporary transfers for less than a
day) from November 1 through 15, 2015, to determine whether the
Department conducted and documented a Screening upon each
offender’s arrival at his or her new prison facility. We also reviewed
available hardcopy Screening forms for a random sample of 50
offenders for whom no Screenings were documented in DCIS. We
excluded from our review offenders who transferred to Colorado
Territorial Correctional Facility (Territorial), because the
Department told us Territorial is often used as short-term housing
for offenders (sometimes for only a few days) while processing them
for court appearances, as they are paroling, or while providing
them with medical care, and it may not be practical to conduct
Screenings for such short-term transfers. We also excluded from our
review any temporary transfers for less than a day.
 Data for all 5,257 offenders with moderate-to-severe mental health
needs released to parole from July 2012 through December 2015,
to determine whether the Department completed an electronic
Transition Form for each offender in DCIS.
Overall, the purpose of the audit work was to determine
whether the
Department
complies
with
the
following
requirements applicable to offenders
transferring
between
prison facilities or being released to parole:
 STAFF MUST CONDUCT A SCREENING WHEN OFFENDERS TRANSFER TO A
NEW FACILITY. The Department has implemented an American
Correctional Association operational standard that mandates “an initial
mental health screening at the time of admission to the facility by a
mental health trained or qualified mental health care
professional” (American Correctional Association Standard 4-4370
for Adult Correctional Institutions). Similarly, Department Clinical

41

 STAFF

MUST COMPLETE A

TRANSITION FORM

FOR OFFENDERS WITH

MENTAL HEALTH NEEDS RELEASED TO THE COMMUNITY.

According
to Administrative Regulations [Administrative Regulation 700-26.I
and 26.II.C], when an offender with ongoing mental health needs is
released into the community, staff must use the electronic
Transition Form in DCIS to document the offender’s treatment
needs and “provide appropriate information regarding mental
health needs to those individuals responsible for the offender’s
management and supervision...” Clinical Standards specify that
staff must complete this electronic form for all offenders with
moderate-to-severe mental health treatment needs (i.e., offenders
with a psychological code of 3, 4, or 5, regardless of their
psychiatric diagnosis). Additionally, prior to an offender’s parole,
the offender’s case manager is required to “present a copy of the
‘Mental Health Transition’ form to the Parole Board at the time of
the parole hearing” [Administrative Regulation 700-26.IV.I].

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY?
Overall, we found that Department staff do not always conduct
Screenings and complete the Transition Form, as required. Specifically
we found:
MENTAL HEALTH PROGRAM STAFF DID NOT CONDUCT AND DOCUMENT
TIMELY SCREENINGS FOR SOME TRANSFERRED OFFENDERS. Based on our
audit work, we estimate with 95 percent confidence that Screenings
never occurred or were not documented in either hard copy or
electronic form for between 26 and 81 (between 4 and 11 percent) of
the 730 transfers in our review. To reach this conclusion we first
reviewed the 730 offenders described above and found that the
Department did not have electronic documentation in DCIS showing
that a Screening was completed for 271 (37 percent). Clinical Services

REPORT OF THE COLORADO STATE AUDITOR

Standards specify that “[a]ll offenders are screened for mental
health concerns upon transfer to another facility.”

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

42
management stated that staff can use hardcopy forms to document
Screenings without entering the forms into DCIS, so the screenings
may have been done but not recorded in DCIS. To estimate the
number of the 271 transfers for which the Department also lacked
hardcopy documentation of a Screening, we then selected a
statistically valid, random sample of 50 transfers and found that the
Department could not provide any documentation of a Screening for 9
(18 percent) and did not indicate that any of the 9 were for a short
time period where completing a form would not have been practical.
The results of this statistical sampling are the basis for our conclusion
on the range of transfers for which Screenings never occurred or were
not documented.
MENTAL HEALTH PROGRAM STAFF DID NOT COMPLETE AND DOCUMENT
TIMELY TRANSITION FORMS FOR THE MAJORITY OF PAROLED OFFENDERS
WITH MENTAL HEALTH NEEDS.

First, we found that the Department did
not maintain Transition Form records for any offenders who paroled
prior to July 11, 2013, though the requirement to complete the form
was implemented in February 2012. For these offenders we were
unable to determine whether staff completed the Transition Form.
Second, when we reviewed the records for the 4,113 offenders with
moderate-to-severe mental health needs who were paroled between
July 11, 2013, and December 31, 2015, we found that staff did not
complete the electronic Transition Form for about 2,700 offenders (66
percent). Third, the Department does not have adequate requirements
regarding a timeframe for completing Transition Forms that specify
the earliest and latest that a Form should be completed. Specifically,
the Parole Board stated that offenders’ parole hearings can be
scheduled up to three months in advance of the date they are eligible
for parole, and Clinical Standards generally require that offenders
with moderate-to-severe mental health needs be seen by Mental
Health Program staff at least every 3 months; in light of this, it would
appear that Transition Forms completed more than six months before
a parole date risk not including the most current offender information.
We found that of the total 1,414 Transition Forms completed, 291 (21
percent) were completed more than 6 months before an offender was
released.

43

Overall, the Department does not have adequate controls to ensure
continuing management of offenders with mental health needs when
an offender is transferred between prison facilities or released to the
community. We identified the following reasons for the problems that
we saw.
LACK OF MANAGEMENT OVERSIGHT. The Department has not
implemented any system of management control for completing
Screenings or Transition Forms in accordance with requirements. For
example, the Department stated that it does create reports from data
currently captured in DCIS that list offenders with moderate-to-severe
mental health needs who are releasing soon, however, these reports do
not include information regarding which offenders are missing a
Transition Form. If these reports were updated to list which offenders
were missing a Form, and management periodically monitored these
updated reports, management could identify (1) staff who are not
completing Forms, and who, instead, rely on telephone calls and email
to transmit this type of information instead of the Transition Form,
and (2) staff who incorrectly believe that a Transition Form is not
required in instances when an offender is released to Community
Corrections (to serve time at a “halfway house”) or to another
jurisdiction prior to being paroled (such as a county jail to appear at a
court appearance or to another state or the federal government).
Clinical Services management stated that some Forms were not
completed due to these misunderstandings of requirements and
reliance on informal information transmissions as opposed to use of
the Transition Form. Similarly, the Department has no systematic
review method to ensure that Screenings are completed, in part
because some staff record Screenings only in hard copies, which limits
management’s ability to perform comprehensive monitoring of
Screenings.
OFFENDER REFUSAL TO RELEASE MENTAL HEALTH INFORMATION.
According to Department management, when offenders do not
provide permission to release the protected mental health information

REPORT OF THE COLORADO STATE AUDITOR

WHY DID THESE PROBLEMS OCCUR?

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

44
that is contained in the Transition Form to outside entities, such as
community parole officers and the Parole Board (such permission is
required by Administrative Regulation 700-26.IV.E), Mental Health
Program staff often do not consider completing the Transition Form
to be a priority and so often do not complete the Form. However, it is
worthwhile completing Transition Forms for these offenders because
there is some information on the Transition Form that is not protected
mental health information and that could be provided to parole
officers and the Parole Board even without an offender’s permission,
such as whether the Mental Health Program staff think the offender is
a danger to him- or herself or others.
INCOMPLETE POLICIES AND PROCEDURES. Administrative Regulations
and Clinical Standards lack specific requirements for continuing
management of offenders with mental health needs in the following
three areas:
 SCREENINGS FOR TEMPORARY TRANSFERS. Clinical Services
management stated that offenders may temporarily transfer to a
new facility—including transfers to Territorial—for a short time,
and as such, it would be inefficient for staff to conduct a new
Screening for each temporary transfer and that both Department
Clinical Standards and the American Correctional Association
operations standards only intend for Screenings to be conducted for
transfers of a more long-term nature. However, neither
Administrative Regulations nor the Department’s Clinical
Standards state that Screenings are not needed for short-term
transfers; define how many days (or hours) an offender would need
to be at a facility before a Screening would be required; or describe
how to handle transfers for unknown lengths of time, such as when
an offender goes to an infirmary. Further, the Department does not
require staff to indicate in records when a Screening has not been
completed because staff determined that the transfer was
temporary. As a result the Department cannot provide oversight to
determine the appropriateness of all instances where staff forego a
Screening.

45

 TIME FRAME FOR COMPLETION OF THE TRANSITION FORM. During
the period audited, the Department had not established adequate
written policy defining the time period that staff have to complete
Transition Forms, which would include the earliest that a Form
should be completed (so that it is not outdated) and the latest that it
should be completed (so it is available to both the Parole Board and
the offender’s parole officer). Clinical Services management stated
that in February 2016 it implemented a policy that states that the
Form should be completed at least 21 days before an offender
paroles; however, the updated policy does not require staff to
update the Form if it was completed too early before the offender is
paroled and so the information may be outdated (e.g., more than 6
months old). Moreover, if staff follow this new requirement and
complete the Form only 21 days before an offender’s parole
eligibility date, the Transition Form may not be available to the
Parole Board for use during the parole hearing, since parole
hearings can be set up to 3 months prior to an offender’s parole
eligibility date.

REPORT OF THE COLORADO STATE AUDITOR

 METHODS OF DOCUMENTATION. The Department does not have
specific requirements related to how staff should document
Screenings, leading some staff to electronically enter Screening
results into DCIS and others to rely on hardcopies. Clinical Services
management stated that it has not required staff to enter all
Screening results into DCIS because some facilities do not have
computers in the intake areas and must rely on paper
documentation. As such, requiring that staff at these facilities input
the Screening data into DCIS electronically would be duplicative
and time-consuming. However, a lack of electronic data limits
management’s ability to monitor staff and ensure that the
Screenings are completed as required. Further, Department
management indicated that at some facilities, staff record the full
results of the Screening on paper forms, and then note in DCIS that
the Screening had been completed instead of re-entering the entire
form in DCIS—this process requires minimal staff time and allows
for management review and monitoring.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

46
LACK OF STAFF RESOURCES. Department management indicated staffing
shortages contribute to the problems we found with timely
completions of Transition Forms and that, while it recognizes the
importance of passing along mental health information and the other
information contained in the Form, staff do not typically prioritize
completing Transition Forms above providing services to currently
incarcerated offenders when staff have limited time to complete their
duties (see CHAPTER 5 for our discussion of staffing issues).

WHY DO THESE PROBLEMS MATTER?
Because the Department does not always conduct and document, in a
timely manner, offender Screenings and Transition Forms, there is a
risk that offenders’ mental health needs may go unmet and that
necessary information is not provided to the Parole Division and the
Parole Board, which may, in turn, increase the risk that offenders will
be involved in incidents at their new facilities, recidivate upon release,
or have their parole revoked. Specifically:
 Without completing a Screening, there is a risk that offenders may
not be scheduled for initial appointments with Mental Health
Program staff as quickly as needed at their new facility and that
staff at the new facility will be unaware of offenders’ mental health
status and treatment needs when they arrive. Ultimately, timely and
appropriate mental health treatment is a key part of the
Department’s controls to ensure the safety of offenders and
correctional staff and reduce the number of assaults, disruptions at
facilities, and offender self-harming behavior. Moreover, without
documentation in DCIS that the Screening was conducted, or the
acceptable reason why a screening was not conducted, management
does not have a way to monitor that these Screenings are completed
in a timely manner for all offenders and that any exception to the
requirement to conduct a Screening (e.g., the related transfer is
temporary) is appropriately applied.
 Without completing a Transition Form, the offender’s mental
health history and current needs are not shared with the Parole

47

Finally, Parole Division staff stated that they find helpful even
the information contained on the Form that is not protected/
confidential mental health information as it assists with
understanding the offender’s personal history, which, in turn,
can assist when they make decisions regarding the offender;
therefore, if Mental Health Program staff at the facilities do not
complete these non-confidential parts of the Form, the Parole
Board and Parole Division may not have all the information they
need to appropriately and effectively make decisions regarding
parolees.

REPORT OF THE COLORADO STATE AUDITOR

Board, which is responsible for determining whether the offender
can be adequately supervised in the community, or with the
offender’s parole officer, which may limit his or her ability to
appropriately manage the offender based upon their mental health
status. Further, without the Transition Form, information regarding
offenders’ past and current treatment may not be effectively
communicated to outside entities, and the offender’s treatment
while in the community may be less effective because it may be
interrupted, not based on past treatment or current mental health
needs, or duplicative.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

48

RECOMMENDATION 4
The Department of Corrections (Department) should improve its
controls related to continuing management of offenders with mental
health needs by:
A Providing sufficient monitoring to ensure that Mental Health
Screenings (Screenings) are completed in accordance with
requirements in a timely manner.
B Providing sufficient monitoring to ensure that Mental Health
Transition Forms (Transition Forms) are completed, for all
offenders leaving the Department’s custody in accordance with
requirements in a timely manner. For offenders who refuse to grant
permission to share their protected mental health information at
the time that they are releasing from a Department facility, the
Department should ensure that the Transition Forms are
completed with information that is not protected under the
Health Insurance Portability and Accountability Act (HIPAA).
C Implementing Department Administrative Regulations or Clinical
Standards that (1) provide requirements for completing Screenings
for temporary offender transfers and transfers for unknown
lengths of time; (2) require staff to electronically document
completion of Screenings or their determination that a Screening is
not necessary; and (3) define appropriate time frames for
completing Transition Forms, including both the earliest and latest
time frames.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: MARCH 2017.

49

AUDITOR’S ADDENDUM: As explained in the report, our findings
were based on a lack of any (electronic or hard copy)
documentation showing either that Screenings were conducted for
non-temporary transfers or that staff determined that Screenings
were not necessary because the transfers were temporary. We
excluded from our analysis transfers for less than 1 day and other
transfers the Department reported likely did not have a Screening
because the transfer was for a short period (i.e., transfers to
Territorial). The transfers in our statistically valid sample that
lacked any evidence of having a Screening done were those the
Department did not tell us were for a short time period where
completing a form would not have been practical.
B AGREE. IMPLEMENTATION DATE: MARCH 2017.
Though there are several inaccuracies in the audit report regarding
the use of the Transition Form as it relates to parole board
decisions and the impact on offender success in the community

REPORT OF THE COLORADO STATE AUDITOR

Though the Department agrees that it can improve the timely
completion of mental health screenings through systematic
monitoring, it disagrees with the information provided in the audit
report as it relates to screenings for temporary transfers and
methods of documentation. The Department has consistently been
determined to be in compliance with the American Correctional
Association (ACA) standards in these areas through yearly audits
throughout the agency. Screenings are not required for offenders
admitted to infirmaries because more thorough assessments are
conducted on every offender upon admission. The electronic
documentation of mental health screenings has never been
required; however, the new EHR will require the electronic
documentation of these screenings. To improve controls through
the monitoring of mental health screening completions, the Quality
Management Program will develop an audit tool to be
administered quarterly at each facility until programming is
completed in the new eOMIS to provide electronic monitoring
(which will not be available until later next year).

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

50
without a Transition Form, the Department does agree that we can
improve the monitoring of Transition Form completions.
AUDITOR’S ADDENDUM: The report includes an accurate description
of the use of the Transition Form based on information we
received from the Department, the Division of Parole, and the
Parole Board.
Quality Management Program staff will develop an audit tool to
monitor the completion of Transition Forms in accordance with
clinical standards. Monitoring information will be shared with
facility mental health supervisors and Health Service
Administrators (HSAs) to ensure identified problems are corrected
in a timely manner.
For offenders who refuse to grant permission to share their
protected mental health information at the time they are releasing
from a Department facility, the Department will ensure that the
Transition Forms are completed with information that is not
protected under the Health Insurance Portability and
Accountability Act (HIPPA). Clinical standards will be modified to
include this information to clarify this responsibility.
C PARTIALLY AGREE. IMPLEMENTATION DATE: MARCH 2017.
1 The Department disagrees with this recommendation and will
not write policy to the exception. Policy currently exists with
language directing staff as to when screenings will be
conducted. It is not possible to include all variables in the
policy that would meet the exception.
2 Though electronic documentation of mental health screenings
will be required with the new EHR, documentation to the
exception will not be required and is not supported. We will be
specifically monitoring those areas where a screening is
required.
3 Agree: current standards will be modified to include both
timeframes.

51
REPORT OF THE COLORADO STATE AUDITOR

AUDITOR’S ADDENDUM: Although the Department told us it does
not expect staff to conduct Screenings for temporary transfers, its
written policies and procedures do not indicate this or provide any
written guidance to staff on the circumstances under which a
Screening is not required for a transferring offender. Further, if
Department staff do not document instances where they determine
a Screening is not required, it is not clear how the Department can
monitor to ensure staff follow the procedures intended by the
Department.

CHAPTER 3

HOUSING OFFENDERS
WITH SERIOUS MENTAL
ILLNESSES

Historically, the Department of Corrections (Department)
housed some offenders, including offenders with significant
mental health needs, in long-term isolated confinement to assist
with the safe operation of the facilities. Isolated confinement,
which is commonly called “solitary confinement,” is when an
offender is housed alone in a single cell for the vast majority of
each day without contact with other offenders and with limited

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

54
contact with Department staff.
In recent years, correctional systems, including the Department, have
taken steps to limit the use of long-term isolated confinement,
particularly for offenders with serious mental illnesses, because long
periods of isolation can contribute to deterioration in offenders’
mental health.
According to the Department, in practice, it considers the confinement
of an offender for 22 hours or more a day alone in a cell to be
“isolated confinement,” although neither the Department nor statute
defines this term. Prior to June 2014, units within Department
facilities that housed offenders in these conditions on a long-term basis
were known as “administrative segregation” and are now referred to
as “restrictive housing maximum security” (RH-Max).
In addition, statute does not define “serious mental illness,” but
Department Administrative Regulations state that an offender has a
serious mental illness if he or she:
 Has one or more psychiatric diagnoses specified in the
Department’s Administrative Regulations and Clinical Standards,
such as schizophrenia or bipolar disorder, or
 Has “regardless of diagnosis…[a] high level of mental health needs
based upon high symptom severity and/or high resource demands,
which demonstrate significant impairment in [his or her] ability to
function within the correctional environment” (Administrative
Regulation 650-04.III). Based on Clinical Standards this would
include offenders with psychological coding (as discussed in detail
in CHAPTER 2) at a level of 4 or 5.
Senate Bill 14-064 established provisions limiting the use of isolated
confinement for offenders with serious mental illness, stating that the
Department “shall not place a person with serious mental illness in
long-term isolated confinement except when exigent circumstances are
present.” Since 2014, the Department has made significant changes to

55

 LIMITING THE USE OF RH-MAX. Specifically, RH-Max may only be
used as a response to certain offenses committed by incarcerated
offenders (such as engaging in a riot or murder), only for
predetermined time periods for a maximum period of 12 months,
and not for offenders with serious mental illness.
 CREATING HOUSING ALTERNATIVES TO RH-MAX. It is Department
policy to place offenders with serious mental illness who need to be
removed from the general population of offenders due to safety
concerns or treatment needs in specialized housing units called
Residential Treatment Programs (RTPs) or Close Custody Housing
Units. To help ensure the safety of offenders and staff, these
housing options both generally house offenders in single cells and
only allow offenders to interact with one another out of their cells
for a limited number of hours each day, and only in small groups
under close staff supervision. Additionally, the RTPs further offer
offenders with serious mental illnesses intensive mental health
therapy.
 ADOPTING

A GOAL TO DISCONTINUE THE PRACTICE OF RELEASING

RH-MAX TO THE COMMUNITY. Instead,
the Department’s new practice is to first either place offenders back
into the general offender population prior to release or to transition
offenders to Close Custody Housing Units before release to the
community. The Department has stated that these methods assist
with offender resocialization to improve the likelihood of a
successful reintegration.
OFFENDERS DIRECTLY FROM

 PLACING A LOWER CAP ON DISCIPLINARY SEGREGATION.
“Disciplinary segregation,” a short-term sanction for offenders who
have committed a violation of the Code of Penal Discipline, has the
same conditions of confinement as RH-Max. In late 2015, the
Department capped the number of days that any offender—
including those with serious mental illness—could spend in

REPORT OF THE COLORADO STATE AUDITOR

its policies and practices related to its use of long-term isolated
confinement, including:

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

56
disciplinary segregation at 30 days. Department management has
stated that, since then, it has considered the housing of an offender
in isolated confinement to include both RH-Max and disciplinary
segregation, beyond 30 days to constitute “long-term” isolated
confinement.
The Department reports that these changes in policy and practice have
significantly reduced the number of offenders in administrative
segregation and RH-Max from about 1,500 offenders in 2011 to
about 700 in 2013 and further to approximately 160 to 200 in 2015.
Our audit work found several problems which indicate that the
Department can improve its processes, policies, and internal controls
related to housing offenders with serious mental illness, particularly
with respect to: consistently conducting timely mental health reviews
of offenders housed in RH-Max; use of long-term isolated
confinement in some situations; and offering of, and documentation
related to, out-of-cell hours for offenders housed in the RTPs and
Close Custody Housing Units.

USE OF ISOLATED
CONFINEMENT
The Department sometimes houses offenders, including those with
serious mental illness, in isolated confinement. Isolated confinement
can take various forms, but Department policy outlines two types,
which are differentiated from one another based on expected duration
and purpose:
 SHORT-TERM

ISOLATED
CONFINEMENT
(“DISCIPLINARY
SEGREGATION”). When an offender engages in violent or disruptive
behavior, staff can immediately segregate the offender to isolated
confinement. Once this happens, the Department generally initiates
an investigation into the offender’s behavior, and conducts a
hearing if it appears that the offender violated the Code of Penal

57

 LONG-TERM ISOLATED CONFINEMENT (“RH-MAX”). The
Department places offenders who it determines “have demonstrated
through their behavior that they pose a significant risk to the safety
and security of staff and other offenders” in isolated confinement
for more lengthy periods of time, following a due process hearing.
The Department’s current policy prohibits housing offenders in
RH-Max longer than 12 months absent documented and approved
exigent circumstances (e.g., serious assault on a staff member
resulting in injury), with the maximum length of placement
determined in advance by the type and severity of an offender’s
offense. As discussed, offenders with serious mental illness may not
be placed in RH-Max. As of December 31, 2015, the Department
housed 196 offenders in RH-Max.

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
We reviewed statutes, Department Administrative Regulations and
Clinical Standards, and the recommendations from a 2011 external
review by the National Institute of Corrections related to the
Department’s administrative segregation policies and practices. We
also interviewed Department management and staff, including
Division of Clinical and Correctional Services (Clinical Services) staff

REPORT OF THE COLORADO STATE AUDITOR

Discipline, which lays out the rules that offenders must follow in
prison facilities. If the Code of Penal Discipline hearing determines
that the offender committed a Code of Penal Discipline violation,
then the Department can, for some violations, sentence the offender
to a period of isolated confinement, which, during the audit period,
ranged from 15 to 60 days. As of December 31, 2015, the
Department housed at least 326 offenders in disciplinary
segregation, of which 45 had a serious mental illness. As discussed
below, the Department lacked adequate information for us to
determine exactly how many offenders were housed in disciplinary
segregation at two facilities.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

58
and correctional officers at five facilities, and six of the nine members
of the workgroup created by Senate Bill 14-064 to advise the
Department on treatment of offenders with serious mental illness in
long-term isolated confinement. Additionally, we reviewed electronic
records in DCIS for the 4,254 offenders recorded as having a serious
mental illness in the Department’s mental health coding from June
2014 through December 2015 and we also reviewed DCIS data for a
random sample of ten offenders (of the 196) housed in RH-Max as of
December 31, 2015.
The purpose of our work was to evaluate the Department’s controls
for ensuring that it does not place a person with serious mental illness
in long-term isolated confinement except when exigent circumstances
are present, as required by Senate Bill 14-064, codified at Section 171-113.8, C.R.S. The Department has established various processes to
adhere to this requirement, including the following:
 MENTAL HEALTH REVIEWS REQUIRED PRIOR TO PLACEMENT INTO
RH-MAX. The National Institute of Corrections recommended in
2011 that the Department conduct a mental health review that
includes an in-person, out-of-cell interview with the offender before
the Department places him or her into administrative segregation to
ensure that the offender does not have a serious mental illness.
 ONGOING

MENTAL HEALTH REVIEWS ARE REQUIRED FOR OFFENDERS

RH-MAX. Mental Health Services Program (Mental
Health Program) staff are required to conduct a “psychological
evaluation” every 30 days that an offender remains in RH-Max
[Administrative Regulation 650-03.IV.F.21.b].

PLACED IN

 OFFENDERS WITH SERIOUS MENTAL ILLNESS SHOULD NOT BE PLACED
IN RH-MAX. Staff are restricted from making such placements
unless there are exigent circumstances and the Director of Prisons
and Deputy Executive Director give approval [Administrative
Regulation 650-03.IV.C.2.a.1]. According to Department
management, no approvals for exceptions to this requirement were

59

 OFFENDERS MUST BE REMOVED FROM RH-MAX IF A SERIOUS MENTAL
ILLNESS IS DISCOVERED. If staff discover that an offender in RH-Max
has a serious mental illness, the Department must transfer the
offender out within 30 days [Administrative Regulation 65004.IV.B.9].
 OFFENDERS

SHOULD NOT BE HOUSED IN DISCIPLINARY SEGREGATION

60 DAYS. From June 2014 to October 31, 2015,
Administrative Regulations restricted staff from housing any
offender, including those with serious mental illness, in disciplinary
segregation longer than 60 days, which includes any time spent in
segregation prior to a Code of Penal Discipline hearing
[Administrative Regulations 650-03.IV.B.1 and 150-01.IV.E.3.o.5].
The Department updated Administrative Regulations on November
1, 2015, to lower this cap to 30 days.

FOR MORE THAN

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY AND WHY DID THEY
OCCUR?
We found that the Department did not consistently adhere to the
policies and practices discussed above during the period we reviewed.
The problems we identified, and the causes of these problems, are
described below.
 THE DEPARTMENT

DID NOT CONDUCT IN-PERSON, OUT-OF-CELL

RHMAX. We reviewed Department documentation for a non-statistical
sample of 10 offenders housed in RH-Max as of December 31,
2015, to determine if the Department conducted an in-person, outof-cell, mental health review for each offender before placement
into RH-Max. We found that the Department did not complete
mental health reviews that included out-of-cell interviews for any of

MENTAL HEALTH REVIEWS BEFORE PLACING OFFENDERS INTO

REPORT OF THE COLORADO STATE AUDITOR

provided through December 2015 for the period covered by our
audit.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

60
the 10 offenders in our sample before the Department placed them
into RH-Max. None of the 10 offenders in our sample were
identified as having a serious mental illness prior to being placed in
RH-Max and Clinical Services management stated that, instead of
requiring a mental health review for all offenders before placement
into RH-Max, it conducts reviews only for offenders previously
identified as having serious mental illnesses. This practice could
result in a lack of evaluation for offenders with newly developing
serious mental illnesses or those who only recently began exhibiting
severe symptoms of a mental illness. In addition, Clinical Services
management reported that the reviews it does conduct involve
reviewing files and holding meetings among staff—which may or
may not include the offender—rather than conducting out-of-cell
interviews with each offender.
During the audit period, the Department did not have a written
policy or guidance that stipulates the expectation that all offenders
referred to RH-Max undergo a mental health review that involves
an out of cell interview. That said, if a mental health review was
conducted and it showed that the offender had a serious mental
illness, then Mental Health Program staff were required to inform
Offender Services, the central headquarters division that handles
offender housing assignments, that the offender could not be placed
in RH-Max.
 THE DEPARTMENT

DID NOT CONSISTENTLY CONDUCT TIMELY

RH-MAX. We
reviewed documentation for the 82 mental health reviews
conducted during the above-referenced sample of 10 offenders’
stays in RH-Max to determine if each review was conducted in a
timely manner, in accordance with Administrative Regulations. Of
these 82 mental health reviews, we found that the Department did
not conduct four (5 percent) within 30 days of the offender’s
starting RH-Max or within 30 days of their last mental health
review, in accordance with Administrative Regulations; specifically,
the four late mental health reviews were conducted an average of
almost 7 days late.
MENTAL

HEALTH

REVIEWS

FOR

OFFENDERS

IN

61

In addition, the Department lacks a systematic method, such as
database system prompts or periodic staff assessment of
comprehensive reports that list offenders nearing their review
deadline, to alert Mental Health Program staff members when
offenders need to be reviewed and help staff prioritize their time to
offenders who have gone the longest without a review and are
approaching their review deadline.
 THE DEPARTMENT PLACED THREE OFFENDERS WITH SERIOUS MENTAL
ILLNESS INTO RH-MAX. Of the 631 total offenders placed into RHMax between June 2014 and December 2015, we found that staff
made unallowable RH-Max placements for three offenders with
serious mental illness (0.5 percent).
►

For two of these offenders, Mental Health Program staff had
identified the offenders as having a serious mental illness, but did
not properly enter mental health coding into DCIS that would
have alerted staff that the offenders had a serious mental illness
and, therefore, should not have been placed in RH-Max (see
CHAPTER 2: IDENTIFYING MENTAL HEALTH NEEDS related to
proper coding of offenders with serious mental illness).

REPORT OF THE COLORADO STATE AUDITOR

According to the Department, staff scheduling can result in staff not
conducting mental health reviews. Specifically, Mental Health
Program staff schedule specific days each month to conduct mental
health reviews for offenders in RH-Max units; however, if any or
all reviews are cancelled due to interruptions in a unit’s operations
(such as a lockdown), then staff may not always conduct the next
mental health review for the affected offenders within the required
timeframe. Similarly, when an offender transfers from one unit to
another, the scheduled date for the new unit’s mental health reviews
may be later in the month than the previous unit’s scheduled
reviews, causing the time between reviews to exceed the allowed
number of days. The Department stated that, in both scenarios, unit
schedules limit the ability of staff to re-schedule cancelled mental
health reviews or accommodate newly arrived offenders.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

62

►

For the other offender, the Department stated that this
placement was caused by Mental Health Program staff not
realizing that the offender had been assigned to, but had not yet
started, RH-Max. Clinical Standards require that, if staff’s
updating of an offender’s mental health coding—including
identification of the offender as having a serious mental illness—
requires the Department to change an offender’s housing
placement, staff must notify Offender Services, the office at
central headquarters that arranges housing assignments, so that
it can initiate a transfer. In this case, Mental Health Program
staff did not realize that updating the mental health coding
required notifying Offender Services to preclude RH-Max
placement. This was caused by the Department lacking controls
during the audit period to ensure that offenders entering RHMax do not have a serious mental illness. Department
management stated that in 2016 it implemented a system alert in
DCIS that sends a notification to Offender Services when an
offender who has been assigned to, but not yet started, RH-Max,
has their mental health coding changed to reflect the presence of
a serious mental illness, which allows for Offender Services to
halt the pending RH-Max assignment. The Department also
reported adding a process to conduct additional reviews before
placing offenders into RH-Max.

 THE DEPARTMENT DID NOT REMOVE SIX OFFENDERS FROM RH-MAX
WITHIN 30 DAYS OF DISCOVERING THAT THEY HAD SERIOUS MENTAL
ILLNESSES. Of the 653 offenders housed in RH-Max from June 2014
through December 2015, we found that Mental Health Program
staff identified six offenders (0.9 percent) as having a serious mental
illness during their time in RH-Max, yet did not transfer these
offenders within the required 30 days. Specifically:
►

Clinical Services management reported that staff did not realize
that two offenders were in RH-Max at the time that they were
determined to have serious mental illnesses, and therefore staff
did not expedite transfers out to meet the 30-day requirement.

63

►

For one offender, the Department reported that after the
offender was coded as having a serious mental illness staff began
working to find an appropriate alternative placement in a Close
Custody Housing Unit, but were not able to make the placement
within the 30 day requirement and as such, the offender
remained in a segregation environment until he could be
transferred.

►

For the other three offenders, while Mental Health Program staff
diagnosed them as having a serious mental illness during their
time in RH-Max, staff did not appropriately update the
offenders’ mental health coding, which the Department uses to
ensure that offenders with serious mental illness are not housed
in RH-Max. See CHAPTER 2: IDENTIFYING MENTAL HEALTH
NEEDS for our recommendations related to proper coding of
offenders with serious mental illnesses.

 THE DEPARTMENT

HOUSED

36

OFFENDERS WITH SERIOUS MENTAL

60 DAYS. Of
the 7,737 offenders housed for any number of days in disciplinary
segregation from June 2014 through October 31, 2015, we found
that 36 offenders (0.5 percent) had serious mental illnesses and
remained in disciplinary segregation beyond the 60-day limit and,
on average, spent 84 days in segregation. Specifically, we found
that:
ILLNESS IN DISCIPLINARY SEGREGATION LONGER THAN

►

►
►

3 offenders spent 120 total days or more in segregation,
including one offender who spent 236 days in segregation.
20 offenders spent 68 to 119 total days in segregation.
13 offenders spent from 61 to 67 total days in segregation.

Most of the problems we identified occurred during Calendar Year
2014, with the Department showing improvement in 2015. The

REPORT OF THE COLORADO STATE AUDITOR

During the audit period, the Department did not have any
automated system to ensure timely transfers of offenders newlyidentified as having a serious mental illness.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

64
Department attributed these improvements to several policy and
practice changes it made in 2015. Specifically:
►

Prior to March 2015 staff were not following existing
requirements stating that any time an offender spends in
isolation prior to a Code of Penal Discipline hearing be credited
to their disciplinary segregation sentence. In November 2015, the
Department updated its requirements, including specifying in
Administrative Regulation 650-03.IV.A.2 that the maximum
days in segregation allowed “will include any initial period of
removal from general population.” This updated policy appears
to have resulted in improvements to staff complying with the
requirement.

►

The Department stated that some offenders stayed in isolation
after their sentences were complete while the Department looked
for a suitable housing assignment, thus increasing offenders’ time
in isolated confinement. Related to this, the Department stated
that in March 2015 it began requiring staff to count the days
that the Department spent finding a new housing assignment as
part of the total days in segregation. Specifically, staff now
identify new housing assignments before sentences are completed
so that offenders can immediately be transferred out of
disciplinary segregation upon completion. This change in
practice appears to have resulted in improvements to the amount
of time it takes to transfer an offender after completion,
however, the Department has not yet established written
requirements, in Administrative Regulations regarding
disciplinary segregation or elsewhere, to ensure that staff
continue these practices going forward.

►

The Department stated that some offenders refused to leave
segregation after their disciplinary segregation sentence was
completed, leading to a longer period of isolated confinement. In
light of this, in Spring 2015 the Department began requiring staff
to hold meetings and to initiate consultations with offenders who
refuse to leave disciplinary segregation to identify placements in

65

Additionally, in the Spring of 2015, Department management began
reviewing reports that listed the number of days offenders had
currently spent in segregation to assist with identifying offenders
nearing the cap of total days in segregation. However, the report that
the Department used during the audit period to track this time did not
include offenders in all facilities; specifically, it excluded those in
segregation at Colorado State Penitentiary and in segregation at one
unit of Limon Correctional Facility.

WHY DO THESE PROBLEMS MATTER?
According to Department management, the housing of an offender
with serious mental illness in long-term isolated confinement can have
negative effects on an offender’s mental health, which creates risks of
inappropriate offender behavior during incarceration that could
threaten offender and staff safety and negatively impact the offender’s
successful reintegration into the community. As of December 31, 2015
the Department housed 17,977 offenders, who frequently transfer
between facilities and whose mental health statuses may change over
time; as such, it is important that the Department have strong controls
to track the locations, conditions of confinement, and mental health
statuses of offenders to ensure that offenders with serious mental
illness are not placed in long-term isolated confinement. Although the
offenders affected by the problems we found represent a relatively
small proportion of the total prison population, a mistake with even a
single offender can have a severe impact. In addition, the issues we
identified increase the risk of financial impacts to the State since
improper placement of offenders with serious mental illness in longterm isolated confinement, in addition to being contrary to statute and

REPORT OF THE COLORADO STATE AUDITOR

other units that were acceptable to the offender (such as a new
facility or a Close Custody Housing Unit). This change in
practice also appears to have resulted in improvements to the
amount of time it takes staff to identify placements in other units
for offenders, however, the Department has not yet established
written requirements to ensure that staff continue these practices
going forward.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

66
Department policy, could subject the Department to lawsuits and
damage awards.
Additionally, in November 2015, the Department revised its
Restrictive Housing Administrative Regulation [Administrative
Regulation 650-03] to further limit the number of days that offenders
can stay in disciplinary segregation, reducing the 60 day cap to 30
days to stay current with national best practices for housing offenders
in segregation, which have trended towards shorter time periods.
Based on the problems we found, this additional limit creates a risk
that the Department may find even more challenging to the task of
removing offenders from disciplinary segregation before the allowed
time period expires.

67

The Department of Corrections (Department) should improve its
controls related to housing offenders with serious mental illness in
long-term isolated confinement by:
A Adopting written policies reflecting the expectation that an out-ofcell mental health review be completed for each offender that the
Department considers for restrictive housing maximum security
(RH-Max) before the placement occurs.
B Implementing controls, such as staff assessment of reports that
identify offenders who need reviews, to ensure that staff conduct
timely mental health reviews for all offenders housed within RHMax units and for all offenders assigned to RH-Max before their
placement into RH-Max.
C Implementing controls to ensure that staff (1) prevent RH-Max
placement when an offender is determined to have a serious mental
illness between assignment to RH-Max and such placement
starting, and (2) initiate a transfer within 30 days when offenders
are discovered to have a serious mental illness while housed in RHMax. This could include new programming in DCIS to monitor the
mental health coding of offenders assigned to RH-Max and that
alerts Offender Services if any such offenders are coded as having a
serious mental illness and, thus, cannot be housed in RH-Max.
D Adopting written policies related to the practices started in Spring
of 2015 which include addressing situations where offenders refuse
to leave segregation and counting the full time offenders spend in
segregation when applying time limits.
E Updating the Department’s current monitoring report for offenders
in segregation to include all offenders housed in all facilities,
including those currently excluded from the report, and using this
report to monitor that offenders with serious mental illness are not

REPORT OF THE COLORADO STATE AUDITOR

RECOMMENDATION 5

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

68
housed in segregation longer than allowed by Administrative
Regulations and Department guidance.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: NOVEMBER 2016.
The Department has clarified policy language (11-8-16)
regarding face-to-face out-of-cell evaluation by a mental health
clinician for each offender being considered for RH-Max (now
known as Extended Restrictive Housing) before placement
occurs. Administrative Regulation 650-03 states: “Prior to the
multi-disciplinary staffing, a mental health review (out of cell
interview) will be conducted by mental health on all offenders
being considered for Extended Restrictive Housing.”
The Department would like to correct an inaccuracy in the
audit report which states, “Staff are restricted from making
such placements unless there are exigent circumstances and the
Director of Prisons and Deputy Executive Director give
approval…”. “According to Department management, no
approvals for exception to this requirement have been
provided.”
The Department explained that there has been one approval for
exception to this requirement.
AUDITOR’S ADDENDUM: During the audit report finalization
process, the Department informed us that there was one
approval for exception to Administrative Regulation 650-03
that had occurred outside of our audit review period. We
clarified the report to accurately state that there were no
approvals during the period we reviewed (through December
2015).

69

The Department agrees that timely mental health reviews for
RH-Max offenders should be conducted. As stated in the audit
work, the Department did not conduct timely mental health
reviews on four offenders in RH-Max and the reviews averaged
almost 7 days late.
AUDITOR’S ADDENDUM: This recommendation was also based
on our finding that the Department did not conduct in-person
out-of-cell reviews prior to placing offenders in RH-Max.
Facility schedules currently provide for routine contacts with
offenders in RH-Max that include opportunities to meet with
mental health staff. To improve manual controls of offenders in
RH-Max who need timely mental health reviews, Quality
Management Program staff will develop an audit tool to verify
that mental health contacts occur in a timely manner.
C AGREE. IMPLEMENTATION DATE: AUGUST 2016.
The Department agrees that controls could be improved related
to housing offenders with serious mental illness in long-term
isolated confinement. As such, the Department has
implemented the below measures:
1 Offender Services completes a staffing review summary for
all offenders being reviewed by central classification and the
director of prisons for placement in RH-Max. The staffing
review summary shows the offender’s current P code and
IDD code. Upon approval of the staffing review, offenders
are designated RH- Max.
2 A daily automated report identifies offenders who are
designated RH-Max and have a P code change to include
any M qualifier or elevated code of more than 3. When an
offender meets the above criteria, a report is automatically

REPORT OF THE COLORADO STATE AUDITOR

B AGREE. IMPLEMENTATION DATE: MARCH 2017.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

70
emailed to: central classification, mental health program
administrator at headquarters, case management supervisor
at Sterling Correctional Facility, deputy directors of prisons
and director of prisons. The report will cause central
classification to move offenders assigned to RH-Max that
have a P code changed to a serious mental illness.
D PARTIALLY AGREE. IMPLEMENTATION DATE: NOVEMBER 2015.
On November 1, 2015 AR 650-3 Restrictive Housing was
updated to include language to include any initial period of
removal from population in the 30 day limit in restrictive
housing as a disciplinary sanction. Offenders refusing to leave
segregation is addressed in individualized treatment and case
plans and will not be added to policy. We cannot write policy
for every exception that we encounter.
AUDITOR’S ADDENDUM: The intent of this recommendation is
for the Department to reflect certain practices it has put in
place in written policies or regulations. Written policies are a
best practice to ensure that established procedures are
maintained over time. The changes the Department made to
Administrative Regulation 650-3, referenced in the response
above, do not reflect the Department’s practice of identifying
new housing assignments, before an offender’s segregation
sentence is completed and requiring staff to count the days
spent finding new housing as part of the total days in
segregation or the practice of requiring staff to hold meetings
and consult with offenders who refuse to leave disciplinary
segregation.
E AGREE. IMPLEMENTATION DATE: SEPTEMBER 2016.
The Department’s current monitoring report for offenders in
segregation has been updated to include all offenders housed in
segregation at all facilities. The report is used by facility
management staff to ensure offenders are not housed in
segregation longer than allowed by regulation.

71

The Department has established RTPs at three facilities: Centennial
Correctional Facility (Centennial) in 2013, and Denver Women’s
Correctional Facility (Denver Women’s) and San Carlos Correctional
Facility (San Carlos) in 2015. The purpose of the RTPs is to provide
offenders with mental illnesses and developmental disabilities with an
environment that allows for more frequent opportunities for treatment
than traditional correctional facilities, promotes socialization, and
helps develop skills necessary to function within the general
population of offenders at correctional facilities and within the
community upon release. In addition, offenders with mental illness are
more likely to exhibit behavioral issues, which can necessitate their
removal from the general population of offenders to ensure their
safety and that of other offenders and Department staff. RTPs offer an
alternative to placing these offenders in long-term isolated
confinement, which, for offenders with serious mental illness, is
prohibited under statute and can worsen offenders’ mental conditions.
Within each RTP, offenders with mental illness and developmental
disabilities generally reside in single cells in specific units of each
facility that are separate from units that house general population
offenders. Each RTP provides incentives to offenders—such as more
time out of cell or provision of a television for an offender’s cell—as
they demonstrate progress in treatment and the ability to behave
appropriately. In general, the RTPs set aside specific times each day of
the week, based on weekly schedules, to offer offenders time out of
their cells for therapeutic and non-therapeutic activities, though the
adjustments can be made to the schedules to accommodate holidays,
staff absences, or emergencies. Therapeutic activities include:
individual therapy, which is one clinician meeting individually with an
offender in private; group therapy, which is one or two clinicians
meeting with groups of up to 16 offenders; and recreational therapy,

REPORT OF THE COLORADO STATE AUDITOR

RESIDENTIAL
TREATMENT PROGRAMS

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

72
such as clinician-led music or art activities. Non-therapeutic activities
are not led by clinicians, but generally allow offenders to congregate in
small groups and socialize, and may involve such activities as playing
games, watching movies, or going to the gym. According to
Administrative Regulations, the purpose of such activities is to
promote “pro-social interactions” [Administrative Regulation 65004.III.R]. Additionally, individual offenders may request the use of
“de-escalation rooms,” which are rooms “for offenders to practice
self-calming skills to manage their behavior and emotional state in a
safe and calm environment” [Administrative Regulation 650-04.III.D].

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
We reviewed statutes, and the Department’s Administrative
Regulations and Clinical Standards related to administering the RTPs.
We interviewed Department management and staff, including 13
clinicians and six correctional officers assigned to the RTPs, and we
toured all three RTPs to understand their operations, how
requirements on out-of-cell time have been implemented, and how
management provides oversight.
Further, we reviewed information that the Department has maintained
to document the out-of-cell hours offered to RTP offenders during
Calendar Year 2015 – both therapeutic and non-therapeutic – and
assessed its reliability. Specifically, we reviewed information from
separate databases maintained by the RTPs and by the Department’s
Office of Planning and Analysis, both of which track therapeutic outof-cell time. In addition, we reviewed whether data was maintained by
each RTP facility to track non-therapeutic out-of-cell time.
We also evaluated whether the Department’s controls, as
implemented, ensure compliance with Senate Bill 14-064, codified at
Section 17-1-113.8(1), C.R.S., which states that the Department “shall
not place a person with serious mental illness in long-term isolated

73

The Department provided the following criteria related to out-of-cell
time:
 ON AVERAGE, AT LEAST 2 HOURS PER DAY OF OUT-OF-CELL TIME.
Although “long-term isolated confinement” is not defined by
statute or Administrative Regulations, the Department stated that it
considers this term to mean housing offenders alone in their cells
for more than 22 hours per day on a long-term basis. Therefore, we
expected that offenders in RTPs would be offered, on average, at
least 2 hours of out-of-cell time daily to avoid being in long-term
isolated confinement.
 AT

LEAST

20

HOURS PER WEEK FOR THERAPEUTIC AND NON-

THERAPEUTIC CONTACT.

Administrative Regulations state that all
offenders housed in an RTP must be “offered a minimum of ten
out-of-cell therapeutic contact hours per week and a minimum of
ten out-of-cell non-therapeutic contact hours per week”
[Administrative Regulation 650-04.IV.A.4]. The Department
defines “therapeutic contact hours” as out-of-cell activities
“facilitated by behavioral health, psychiatry, nursing and/or
medical staff” [Administrative Regulation 650-04.III.AB].

REPORT OF THE COLORADO STATE AUDITOR

confinement except when exigent circumstances are present.” As
previously discussed, the bill does not provide a definition of “longterm isolated confinement” or limit its application to specific facilities
or locations within the state correctional system. However, based on
the plain meaning of the term and discussions with the Department,
we interpreted the bill as intending that offenders with serious mental
illness not be housed alone in cells for long periods of time with
minimal opportunities for social contact. Although the Department
intends for RTPs to offer a therapeutic environment distinct from
what it considers long-term isolated confinement and has implemented
policies consistent with this intent, offenders with serious mental
illness in RTPs are housed alone in cells and thus, we expected the
Department to have controls related to out-of-cell time and treatment
that ensure that RTPs function as intended by Department policy and
Senate Bill 14-064.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

74
Additionally, at the time of the audit, the Clinical Services
management (i.e., the Chief of Behavioral Health Services and the
Assistant Director of Clinical Services) was responsible for
enforcing these requirements [Administrative Regulation 650-04].

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY?
Overall, we found that the Department could not demonstrate that it
offered out-of-cell hours to all offenders housed in the RTPs during
the time periods that we reviewed in accordance with Administrative
Regulations and Department guidance. Our review indicates that it is
likely that some offenders did not receive an adequate number of outof-cell hours during some weeks, but because of inconsistencies in the
Department’s tracking of out-of-cell time, which are discussed in the
following sections, we could not reliably determine the total number
of out-of-cell hours offered to all offenders in RTPs. However, based
on the data available we identified the following problems:
 The RTP-maintained databases indicate that the Department did
not offer 10 therapeutic hours to an average of about 28 (7 percent)
of the offenders participating in the three RTPs each week from
October to December 2015. On average, staff did not offer 10
therapeutic hours to 14 percent of offenders at Denver Women’s, 7
percent of offenders at Centennial, and 6 percent of offenders at
San Carlos. During the period we reviewed there were about 391
total offenders in the three RTPs each week.
 The Office of Planning and Analysis databases indicate that the
Department did not offer an adequate number of therapeutic hours
to 284 of the 738 offenders (38 percent) housed in the RTPs during
Calendar Year 2015. Of these, 193 offenders (26 percent of the
total reviewed) were short at least 5 percent of their expected
number of total hours during the course of their enrollment.
 Based on data collected by facilities for non-therapeutic hours for
the periods we reviewed, we found that offenders were not all

75

WHY DID THESE PROBLEMS OCCUR?
We identified several issues that contributed to the Department not
offering the required number of out-of-cell hours to offenders in RTPs.
THE DEPARTMENT LACKS A CENTRALIZED SOURCE OF DATA TO TRACK
OUT-OF-CELL HOURS FOR OFFENDERS HOUSED IN RTPS. Specifically, we
found that during Calendar Year 2015, the Department tracked
offender out-of-cell time using eight separate databases. These
included the following:
 Three databases maintained by the Office of Planning and Analysis
tracking therapeutic out-of-cell hours at the three RTPs. Staff
populate these databases using information provided by RTP
Mental Health staff and use the database to provide reports to
Department management.
 Three separate databases, maintained by Mental Health Program
staff at each RTP, also tracking therapeutic out-of-cell hours. RTP
staff use these databases to monitor out-of-cell therapeutic hours at
their facilities and also to provide reports to Department
management.

REPORT OF THE COLORADO STATE AUDITOR

offered at least 10 hours of non-therapeutic out-of-cell time per
week, or 40 hours over the course of a month (since a month
generally consists of 4 weeks). Specifically, at Centennial, out of an
average of about 199 offenders enrolled in the RTP each month in
Calendar Year 2015, we found that the Department did not offer
the minimum 40 non-therapeutic hours per month to an average of
seven offenders (4 percent) each month. For Denver Women’s, out
of the average of about 43 offenders in the RTP each week from
June 2015 to December 2015, we found that the Department did
not offer at least 10 non-therapeutic hours each week to an average
of four offenders (9 percent). Due to data limitations, discussed
below, we could not determine whether offenders at San Carlos
were offered the minimum number of non-therapeutic out-of-cell
hours.

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76
 Two separate databases, maintained by facility correctional officers
at the Denver Women’s RTP and Centennial RTP, tracking
offenders’ non-therapeutic out-of-cell time. Facility staff used these
databases to monitor out-of-cell time. The third RTP, San Carlos,
did not maintain a database to track non-therapeutic hours.
Because each of these databases tracks either offenders’ therapeutic or
non-therapeutic hours, but none track both, the Department lacks a
source of information to monitor offenders’ total out-of-cell time.
Further, because separate staff are responsible for entering
information into each database, we found inconsistencies between
data sources and inaccuracies which make it difficult to reliably
determine the number of therapeutic and non-therapeutic out-of-cell
hours offered to offenders to assess whether staff offer 10 hours of
each to offenders every week. For example, we found the following
issues:
 OFFICE
AND

OF

PLANNING

CONSISTENTLY

OFFENDERS.

AND

ANALYSIS

TRACK

STAFF DID NOT ACCURATELY

THERAPEUTIC

HOURS

OFFERED

TO

Specifically, according to Clinical Services
management, due to Office of Planning and Analysis staff’s lack of
familiarity with the RTPs’ operations and RTP staff not consistently
providing complete information on therapy sessions, Office of
Planning and Analysis staff frequently did not track when offenders
were not available for therapy (such as if the offender was off
grounds for court appearances for a week), leading to an
appearance that such offenders were not offered enough hours
when they actually were not available for therapy. Clinical Services
management reported that although the Office of Planning and
Analysis databases were intended to function as the official record
of RTP offenders’ therapeutic time out of cell, due to these issues, it
does not consider these databases to be reliable for tracking out-ofcell time. Furthermore, we found that Office of Planning and
Analysis staff categorized some time when offenders could not
attend therapeutic sessions—due to a lack of a treatment room,
staff shortages, or the offender attending a different therapy session

77

 RTPS

WERE

INCONSISTENT

IN

TRACKING

AND

CATEGORIZING

OFFENDERS’ THERAPEUTIC OUT-OF-CELL HOURS IN THEIR INDIVIDUAL
DATABASES.

Staff did not always note a reason why an offender was
not offered enough hours in a given week and, when staff did note
this information, the categories staff used were not consistent. For
example, one RTP tracked offenders who were unavailable for
therapeutic hours as in “segregation” because they were on a
mental health watch after having a crisis, while the two other RTPs
noted this as “mental health watch.” Furthermore, during the audit
period one RTP did not track newly arrived offenders’ therapeutic
hours until their first Friday in the RTP (the first day of a tracking
week), even if, for example, they arrived at the RTP 6 days earlier,
on a Saturday; the other two RTPs add new offenders to their
databases as they arrive and start tracking their hours immediately,
though note their arrival as the reason why 10 hours may not have
been reached for that week. Moreover, even within a single RTP,
data was not consistently tracked; for example, to document that
staff believed offender behavior prevented safe participation in
therapy, one RTP used three different terms in its database:
“behavior,” “level suspended,” and “inappropriate.” Also, two
RTPs considered offender use of a de-escalation room as
therapeutic contact hours even though, when using these rooms,
offenders are alone without clinician interaction, which does not
appear to comply with the requirement that offenders’ out-of-cell
“therapeutic contact hours” should be “facilitated by behavioral
health, psychiatry, nursing and/or medical staff.”
 TWO RTPS

DID NOT TRACK NON-THERAPEUTIC HOURS OFFERED TO

EACH OFFENDER ON A WEEKLY BASIS.

Centennial tracked offering of
non-therapeutic hours on a monthly basis, which prohibited us, and
Department management, from being able to determine whether the
requirement for offering 10 non-therapeutic hours to each RTP
offender each week was satisfied. San Carlos did not track whether
staff offered the minimum number of non-therapeutic hours to

REPORT OF THE COLORADO STATE AUDITOR

at the same time—as therapeutic time offered to, but refused by, the
offender.

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78
offenders. Denver Women’s electronically tracked non-therapeutic
hours for each offender by each week.
According to Department management, it has been aware of some of
the issues we identified regarding the Department’s tracking of out-ofcell time for offenders. The Department also reported that because the
RTPs at San Carlos and Denver Women’s were established in April
2015, and all three RTPs underwent operational reforms in the
summer of 2015, the Department did not have a consistent process to
track data during the period we reviewed. According to the
Department, in 2016 after the three RTPs were implemented and
operational it began implementing new processes for RTPs to track
therapeutic and non-therapeutic hours, with these changes aimed at
improving accuracy, reducing duplicative data entry, and consistently
tracking hours in the same way across the RTPs.
In addition, although at the time of our audit Administrative
Regulation 650-04.V.A stated that Clinical Services is responsible for
enforcing the regulation that requires offering 10 therapeutic and 10
non-therapeutic hours each week, Clinical Services management stated
that, in practice, it is not appropriate for Clinical Services to oversee
non-therapeutic hours, which are offered by correctional officers.
They explained that, instead, facility wardens who fall under the
purview of the Director of Prisons are responsible for offering these
non-therapeutic hours, and, thus, should be responsible for enforcing
the provision of these hours and providing their own method(s) of
managing the offering of these hours; as such, this is the system that
the Department has established in practice and that we reviewed for
our audit work. However, dividing responsibility for offender out-ofcell time between therapeutic and non-therapeutic hours can result in
inconsistent practices and make it difficult to assess, for a given
offender, the total out-of-cell hours offered each week. Further, based
on these practices it is not clear which part of the Department is
responsible for ensuring that offenders receive an adequate number of
total out-of-cell hours.

79
DO NOT ALWAYS OFFER SCHEDULED OUT-OF-CELL TIME DUE TO

FACILITY OPERATIONAL INTERRUPTIONS AND OFFENDER BEHAVIOR.

To
ensure adequate staffing, space, and facility safety, RTP staff offer outof-cell time on a carefully coordinated schedule. These schedules are
designed to ensure that staff offer offenders at least 10 hours of both
therapeutic and non-therapeutic hours out-of-cell each week.
However, staff described various situations that affect RTPs’ abilities
to offer scheduled out-of-cell time, including Mental Health Program
staff or correctional officer shortages or scheduling conflicts, unit
maintenance, lack of room availability, lockdowns, or other facility
operations such as fire drills. Relatedly, offenders sometimes have
appointments with other facility staff, such as with a dentist or case
manager, which make them unavailable for scheduled therapeutic outof-cell time. In addition, staff reported that RTPs do not offer out-ofcell hours to specific offenders if they believe the offenders could be a
danger to themselves, other offenders, or staff.
Documentation from the Department indicated that some offenders
were not offered the required number of out-of-cell hours due to such
operational
interruptions
and
offender
behavior,
though
Administrative Regulations do not specify any exceptions to the
requirement of offering 10 out-of-cell therapeutic hours and 10 out-ofcell non-therapeutic hours, and we saw some instances where staff
made up for hours missed by offering additional hours later in a week
or lengthening the time of other scheduled out-of-cell activities.
According to the Department, operational interruptions are
unavoidable and it has not established written policies to direct staff
on how to address these situations because there are too many
variables to create an effective policy. However, because of the lack of
adequate data we discuss above, the Department has not been able to
determine the impact that these issues may have on offenders’
treatment and total out-of-cell time and assess whether operational
changes could reduce the impact.
THE DEPARTMENT HAS HAD DIFFICULTY HIRING RTP STAFF. The
General Assembly allocated the Department new staff, including 24
new Mental Health Program positions for Fiscal Year 2016, and

REPORT OF THE COLORADO STATE AUDITOR

STAFF

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

80
Department management has indicated that filling these new positions
at the RTPs has been helpful for assisting with its ability to offer outof-cell hours. However, Department management states that it
remains difficult to fill open Mental Health Program positions at the
RTPs and that turnover is high. In our review we found that as of
December 31, 2015, the facilities that host the RTPs had vacancy rates
for Mental Health Program staff between 21 percent and 39 percent.
Having fewer staff to provide treatment to offenders limits the
Department’s ability to provide out-of-cell hours and makes it more
difficult to offer individual treatment sessions. We discuss the staffing
issues that we identified further in CHAPTER 5.
Additionally, we saw that offenders frequently refused to participate
in offered out-of-cell hours. From our review of data in the RTPmaintained therapeutic hours databases for October through
December 2015, we found that offenders refused offered out-of-cell
therapeutic hours 57 percent of the time across all RTPs and types of
offered therapy (individual, group, and recreational therapy), with
offenders attending about an average of 5 hours of therapy each week
out of a total of 11 offered therapy hours each week. Each RTP’s
offering of therapeutic hours was split between group and individual
therapy offerings, with about 95 percent of all offered hours being
group therapy sessions and 5 percent of offered hours being individual
therapy sessions. Refusal rates varied at each RTP depending on the
type of therapy offered:
 At San Carlos, offenders refused 74 percent of offered group
therapy hours and 13 percent of offered individual therapy hours.
 At Centennial, offenders refused 58 percent of offered group
therapy hours and 30 percent offered individual therapy hours.
 At Denver Women’s, offenders refused 24 percent offered group
therapy hours and 6 percent of offered individual therapy hours.
Additionally, from our review of data on Centennial’s non-therapeutic
hours for Calendar Year 2015, we found that offenders refused 41

81

According to Clinical Services staff and management, offender refusal
is a difficult issue to address because offenders with serious mental
illnesses may fear social interaction or may be unwilling to talk about
their mental illnesses with other offenders. Further, some offenders
must be physically tethered to a table during treatment to ensure
safety and, thus, sitting for a 2-hour therapy session may be physically
uncomfortable and make offenders reluctant to come out for therapy.
Also, although at times RTP staff will remove offenders from their cell
by force, for example when conditions in the cell present a health
concern, staff stated that doing so can have a negative impact on
offenders’ mental health and is generally avoided if possible. Despite
these challenges, the Department should continue to monitor offender
refusals to assess the impact on offenders’ overall participation in outof-cell hours.

WHY DO THESE PROBLEMS MATTER?
The Department has stated that offering out-of-cell hours is a “key
component” of the RTPs, which “promote pro-social behavior and
treatment progress while meeting behavioral goals... to prepare
offenders for successful community transition while ensuring the
safety of employees and offenders.” Therefore, if the Department does
not consistently offer all hours, there is a risk that offenders may not
progress in treatment. There are also risks of inappropriate offender
behavior during incarceration that would threaten offender and staff
safety and of negative impacts on offenders’ successful reintegration

REPORT OF THE COLORADO STATE AUDITOR

percent of offered hours each month. Due to a lack of reliable data, as
described above, we were not able to determine a refusal rate of nontherapeutic hours for San Carlos. Similarly, we were not able to
determine a refusal rate of non-therapeutic hours for Denver Women’s
for the whole test period due to staff not distinguishing in their
database between offender refusals and instances where staff merely
did not offer hours; that being said, from our review of November and
December 2015 non-therapeutic hours data for Denver Women’s,
when staff began distinguishing offender refusals, we found that
offenders refused 30 percent of offered hours each week.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

82
into the community upon release. Further, if the Department does not
offer adequate out-of-cell time there is a financial risk to the State.
Specifically, this risk is recognized in a March 2015 budget request
from the Department for additional staff, which states that if
“offenders cannot get the recommended out-of-cell time, this could be
considered ‘long-term confinement’ as set forth in [Senate Bill 14-064]
and put the Department at risk of litigation.”
Additionally, without accurate, consistent, and useful reports and data
Department management cannot properly oversee the RTPs to
determine whether and to what extent the programs are effective and
in compliance with requirements. For example, data that do not
accurately inform management whether offenders were offered the
minimum number of out-of-cell hours make it difficult for
management to determine whether each RTP is in compliance with
Administrative Regulations. Furthermore, without accurate and
complete data the Department will not be able to ensure that it uses its
limited resources as effectively as possible and provides accurate
public reports on the RTPs.
Finally, by requiring two sets of staff—Office of Planning and Analysis
staff and staff at the RTPs—to both track the same therapeutic hours
data, Department management was not making good use of staff time
and resources, particularly as staff indicated that such tracking was
cumbersome and time intensive and management indicated that
staffing shortages are common. Department management did state
that in 2016 it began implementing a new system whereby roster and
attendance information is maintained electronically for use by both
the Office of Planning and Analysis and the RTPs; if this new system is
appropriately implemented, this would prevent two groups of staff
from entering and maintaining the same information and provide the
same tracking information to the two groups for the different types of
reports produced related to the RTPs.

83

The Department of Corrections (Department) should improve its
oversight and documentation of out-of-cell hours offered and received
by offenders in the Residential Treatment Programs (RTPs) by:
A Implementing procedures to ensure uniformity across all three
RTPs in its methods of counting and categorizing both therapeutic
and non-therapeutic out-of-cell hours, including the hours offered,
cancelled, attended, and refused.
B Updating its Administrative Regulations to ensure clear
responsibility for oversight of out-of-cell hours—therapeutic, nontherapeutic, and total—and to ensure that staff follow the
established requirements.
C Reviewing the information collected in PART A to ensure
compliance with Department requirements regarding out-of-cell
hours and Senate Bill 14-064, and optimizing offender
participation in out-of-cell hours. This should include analyzing
the impact of the number of hours offered, cancelled, attended,
and refused on total out-of-cell time and making changes if
necessary.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: MARCH 2017.
Even though there is a disagreement between the auditors and the
Department regarding the intent of SB14-064 and whether or not
residential treatment programs fall under that statute, the
Department does agree that procedures could be implemented to
ensure uniformity across the three RTPs in the collection and

REPORT OF THE COLORADO STATE AUDITOR

RECOMMENDATION 6

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

84
documentation of non-therapeutic out-of-cell activities. The
Department has already implemented an electronic process for
collecting therapeutic out-of-cell time in all RTPs. Prior to this
electronic system, the Department collected this same information
through a manual paper process. With this, the Department has
been able to demonstrate therapeutic out-of-cell time offered for
each offender in the all three RTPs for quite some time. The
Department maintains that offenders in RTPs may refuse to come
out of their cells at various stages of their treatment and we will
not use force to remove them. We will continue to utilize treatment
modalities to support and encourage out of cell time which will be
documented in individual treatment plans and not be defined in
policy.
AUDITOR’S
ADDENDUM:
We
acknowledge
that
the
Department disagrees that RTPs are included within the
requirements of Senate Bill 14-064. As discussed, Senate Bill
14-064, codified at Section 17-1-113.8(1), C.R.S., states that
the Department “shall not place a person with serious mental
illness in long-term isolated confinement except when exigent
circumstances are present.” The bill does not provide a
definition of “long-term isolated confinement” or limit its
application to specific facilities or locations within the state
correctional system or exclude RTPs from this requirement.
B DISAGREE.
The Department does not agree that this oversight needs to be
specified in policy, therefore this language has been removed.
Individual position descriptions indicate that wardens are
responsible for the oversight of offender management in prisons
and health services administrators are the local health authorities
and responsible for the oversight of clinical services in prisons.
Ensuring therapeutic and non-therapeutic out-of-cell hours are
offered according to policy is a collaborative effort among clinical
and non-clinical RTP staff.

85

C AGREE. IMPLEMENTATION DATE: MARCH 2017.
Clinical Services does and will continue to utilize information
related to out of cell activities to make changes/improvements.
Facility mental health supervisors, HSAs and program
administrators will communicate these changes in writing on a
quarterly basis to the Chief of Behavioral Health Services.

REPORT OF THE COLORADO STATE AUDITOR

AUDITOR’S ADDENDUM: The Department did not report the policy
change referenced in its response until immediately prior to the
finalization of this report. Although this change may address our
finding regarding Clinical Services not following Administrative
Regulations, it does not address the risk of maintaining separate
monitoring of therapeutic and non-therapeutic out-of-cell hours
offered, which makes it more difficult for the Department to
monitor the total number of out-of-cell hours its staff offer to
offenders in RTPs.

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86

CLOSE CUSTODY
HOUSING UNITS
In 2014, the Department established new Close Custody Housing
Units, which include Management Control Units and Close Custody
Transition Units (Transition Units), for offenders who, due to their
behavior, pose a threat to the safe operation of a correctional facility
and as such, need a heightened level of supervision. Management
Control and Transition Units house offenders who are assigned to
single cells and who must be closely supervised during their time out
of cell. Although Management Control Units and Transition Units
house similar offenders, offenders in Transition Units generally have
more out-of-cell opportunities and other privileges, such as additional
canteen purchases and eligibility for participation in educational
programs. Close Custody Housing Units may be used to house
offenders who have a serious mental illness and require close custody
supervision but who are unwilling or unable to participate in RTPs,
and are prohibited from being placed in long-term isolated
confinement absent documented and approved exigent circumstances,
pursuant to Section 17-1-113.8, C.R.S..
Offenders in Close Custody Housing Units spend time out of their
cells for a variety of reasons, such as for recreation, program
participation, and visits by case managers and clinicians. Facility
correctional officers create and use monthly unit schedules that
delineate daily out-of-cell time for small groups of offenders, which
typically are scheduled in 2 hour blocks of time throughout each day.
While these blocks are the main times when offenders are allowed out
of their cells, individual offenders may also leave their cells at other
times for occasional appointments elsewhere in the facility, such as
with a case manager or a dentist.
Correctional officers use handwritten, paper shift logs to document
the actual out-of-cell time that they offer to offenders each day,

87

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
We reviewed statutes and Department Administrative Regulations,
and interviewed Department management and staff regarding out-ofcell time for offenders in Close Custody Housing Units. We also
reviewed unit schedules and hard copy shift logs from December 2015
for all of the Close Custody Housing Units at the Colorado State
Penitentiary to determine if staff documented offering offenders in the
units out-of-cell time in accordance with the requirements listed
below.
 Offenders housed in Management Control Units must be offered 4
hours of out-of-cell time per day, unless “safety and security
concerns” necessitate the suspension of out-of-cell time
[Administrative Regulation 600-09.IV.G.1.b and 2.b].
 Offenders housed in Transition Units must be offered 6 hours of
out-of-cell time per day unless “safety and security concerns”
necessitate the suspension of out-of-cell time [Administrative
Regulation 600-9.IV].

REPORT OF THE COLORADO STATE AUDITOR

including when groups of offenders are offered scheduled out-of-cell
time and for specific offender appointments. The shift logs are also
used to track other activities that happen in the unit, such as
unscheduled interruptions to the unit’s operations (e.g., lockdowns,
fire alarms, physical maintenance). As of December 31, 2015, the
Department housed 430 male Close Custody Housing Unit offenders,
of which 32 had a serious mental illness, in 33 pods within five units
at one facility, Colorado State Penitentiary; as of the same date, the
Department housed four female Close Custody Housing Unit
offenders, of which three had a serious mental illness, in one unit at
Denver Women’s Correctional Facility.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

88
 Staff must document all out-of-cell time for offenders housed in
Close Custody Housing Units [Administrative Regulation 60009.IV.C.11].

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY AND WHY DID THEY
OCCUR?
We found that the Department does not have documentation that
offenders in Close Custody Housing Units are offered the amount of
out-of-cell time stipulated in its regulations due to incomplete
documentation. Further, our review of unit schedules and shift logs for
the Close Custody Housing Units at Colorado State Penitentiary for
December 2015 does not indicate that offenders were regularly offered
the number of out-of-cell hours that Administrative Regulations
require, though the offenders may have been offered additional out-ofcell hours that were merely not documented. Specifically, in the shift
logs, we only found documentation to confirm that offenders were
offered the following amounts of time out of cell:
 An average of 2 hours and 55 minutes of out-of-cell time each day
for offenders in Management Control Units, rather than the 4 hours
required.
 An average of 4 hours and 33 minutes of out-of-cell time each day
for offenders in Transition Units, rather than the 6 hours required.
We also found the amount of time documented as offered to offenders
varied from these averages depending on the specific Close Custody
Housing Unit and the pod in each unit in which they were housed. For
example, staff only documented in shift logs offering an average of 2
hours and 13 minutes of out-of-cell time to offenders each day in one
pod included in our analysis. Further, Administrative Regulations
indicate that offenders may be held in a Close Custody Housing Unit
for more than 30 days. Thus, there is a risk that if staff only offered
the hours that were documented, these offenders were in their cells for
an average of 21 hours and 47 minutes per day, which is only slightly

89

Our findings do not necessarily indicate that staff are not following
the Department’s requirements since fewer out-of-cell hours may be
offered when safety and security concerns necessitate the cancellation
of scheduled out-of-cell time, and such cancellation is allowable per
policy. However, our findings do indicate that there is a risk that, for
some individual offenders including those with serious mental illness,
the Department may not be offering at least 2 hours of out-of-cell time
each day and, therefore, the conditions in Close Custody Housing
Units could fall within the Department’s definition of “long-term
isolated confinement.”
Furthermore, neither we nor the Department can be sure that
offenders are routinely offered out-of-cell time in accordance with the
regulations because the Department does not adequately document
and monitor the number of out-of-cell hours it offers to offenders in
Close Custody Housing Units. Specifically:
 THE DEPARTMENT

DOES NOT HAVE A SYSTEMATIC METHOD TO

MONITOR THE NUMBER OF OUT-OF-CELL HOURS IT OFFERS TO

CLOSE CUSTODY HOUSING UNITS. Management does
not regularly review documentation to ensure that offenders are
offered an adequate amount of out-of-cell hours. The
documentation of out-of-cell time for pods in the shift logs consists
of numerous handwritten notes, completed in three separate shift
logs each day that staff do not compile into any kind of summary
or aggregate form, such as a summary report or electronic
spreadsheet that is regularly reviewed. Facility management stated
that they rely on staff to keep them informed about out-of-cell
offerings through conversations and meetings instead.
OFFENDERS IN

 DOCUMENTATION OF OUT-OF-CELL TIME IS INCOMPLETE. For out-ofcell hours scheduled in December 2015, staff did not document in
shift logs whether they offered all out-of-cell hours that appeared

REPORT OF THE COLORADO STATE AUDITOR

less than the 22 hours of time in a cell that the Department considers
long-term isolated confinement if it occurs over a period longer than
30 days.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

90
on the monthly unit schedules. Specifically, staff did not document
in the shift logs whether 15 percent of scheduled out-of-cell hours
in the Management Control Units were actually offered or whether
these hours were cancelled, and did not document the same for 9
percent of the out-of-cell hours scheduled for Transition Units. The
Department stated that the monthly unit schedules, which show
that offenders are scheduled to receive blocks of out-of-cell time
each day, fulfill the requirement to document all out-of-cell time for
offenders housed in Close Custody Housing Units. However, these
schedules provide planned, not actual, out-of-cell time offered.
Based on our review of shift logs and schedules, actual operations
of units often vary from the monthly unit schedules (such as due to
lockdowns or fire alarms). Further, the Department stated that due
to a lack of training staff did not consistently document out-of-cell
hours in the shift logs.

WHY DO THESE PROBLEMS MATTER?
Without adequate documentation and monitoring that can provide
accurate information as to the out-of-cell hours offered, the
Department cannot ensure that the conditions of confinement for
offenders in Close Custody Housing Units comply with Administrative
Regulations and are not essentially long-term isolated confinement.
Further, if the Department does not offer an adequate number of outof-cell hours to offenders in Close Custody Housing Units, then there
is a risk that these offenders’ mental health could worsen, which, in
turn, could negatively affect offenders when they are released to the
community or placed in the general offender population and create a
safety risk in the community or within correctional facilities.
Moreover, the Department uses Close Custody Housing Units to
transition offenders from restrictive housing maximum security to
assist with offender “re-socialization,” either as offenders near release
to the community or as the Department believes they have begun to
show appropriate behavior that would allow more interactions with
other offenders and staff. As such, if the Department does not offer an
adequate number of out-of-cell hours to offenders in Close Custody

91

Finally, without adequate monitoring that can provide accurate
information as to the out-of-cell hours staff have offered, the
Department may be misreporting the conditions of confinement for
offenders in Close Custody Housing Units to policymakers. For
example, statute [Section 17-1-113.9, C.R.S.] requires the Department
to annually report to the Judiciary Committees of the Senate and
House of Representatives of the Colorado General Assembly on the
Department’s internal reform efforts related to administrative
segregation (i.e., long-term isolated confinement). The Department
stated in its Fiscal Year 2015 report submitted under this requirement
that offenders housed in Management Control Units are “allowed out
of their cells for a minimum of four hours per day” and offenders in
Transition Units are “allowed out of their cells for a minimum of six
hours per day.” Although this is an accurate statement of the
Department’s policy, based on our work it would not be accurate for
the Department to report the same information for the period we
reviewed, since the records we reviewed indicated that staff often
cancel out-of-cell hours and have been shown to offer no out-of-cell
time to some offenders on a given day or over multiple consecutive
days.

REPORT OF THE COLORADO STATE AUDITOR

Housing Units, effective re-socialization of offenders transitioning
from restrictive housing maximum security may be hindered.

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RECOMMENDATION 7
The Department of Corrections (Department) should improve its
controls to ensure that staff offer out-of-cell hours, in accordance with
Administrative Regulations and statute, to offenders housed in
Management Control Units and Close Custody Transition Units
(Transition Units) by:
A Providing staff appropriate training to consistently document the
out-of-cell hours offered to offenders in Management Control
Units and Transition Units, as well as the reasons why any
scheduled hours were not offered.
B Implementing processes to periodically monitor offender out-ofcell time through management review of the information collected
through implementation of PART A.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: MARCH 2016.
The Department agrees that controls needed to be improved to
appropriately document out of cell time offered to offenders
assigned to Management Control Units and Transition Units. Staff
have been appropriately trained to consistently document on the
shift log out of cell time offered to Management Control Units and
Transition Units. The documentation includes a beginning and
end time, and reasons why scheduled time may not have been
offered.
The audit work found inconsistencies in the
documentation for out of cell time offered. The report indicates
there is a risk that staff may have offered fewer hours than
required by policy, but there is no factual basis to support this
correlation.

93

A review of the Department’s offender grievance database did not
disclose any grievances relating to staff offering fewer hours than
required by policy. The audit work further identifies a risk that by
offering fewer hours than required by policy, that conditions in
Management Control Units and Transition Units could fall within
the Department’s definition of “long term isolated confinement.”
Long term isolated confinement is defined as being confined to a
cell for 22 hours per day for more than 30 days. The audit work
did not conclude that Management Control Units and Transition
Units met the definition for long term isolated confinement.
AUDITOR’S ADDENDUM: The Department did not inform us that, in
March 2016, it had implemented changes to documenting out-ofcell time offered to offenders in Management Control Units and
Transition Units until after our fieldwork concluded in September
2016, which was too late in the audit to allow us to evaluate the
impact of the changes.
B AGREE. IMPLEMENTATION DATE: MARCH 2016.
The Department agrees that monitoring is necessary to ensure
appropriate documentation for out of cell time offered to offenders
in Management Control Units and Transition Units. At the end of

REPORT OF THE COLORADO STATE AUDITOR

AUDITOR’S ADDENDUM: As explained in the report, based on the
documentation the Department could provide, we could not
confirm that staff offered the number of hours to offenders in
Management Control Units and Transition Units as is required by
Administrative Regulations. Further, in some cases the number of
hours that we could confirm staff offered was just over 2 hours per
day on average (or equivalent to offenders spending just under 22
hours per day in their cells), meaning there is a possibility that
some offenders just barely avoided being in situations deemed as
isolated confinement. In addition, the Department lacked other
procedures to monitor the out-of-cell time offered to offenders in
these units on average over time. These findings provide a factual
basis to support our conclusion that there is a risk that offenders
were not offered an adequate amount of out-of-cell time.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

94
each shift, the unit lieutenant reviews and signs the shift log
verifying accuracy relating to documented out of cell time offered
to Management Control Units and Transition Units. On the
following business day, the unit captain reviews and signs the shift
log. The audit reported suggested that the Department not rely on
schedules for documentation of out of cell time and suggested that
the lack of aggregate data in a spreadsheet hindering management
staff from reviewing out of cell time offered. The Department is
nationally accredited by the American Correctional Association. As
such, standards compliance during national audits can be
determined by schedules or logs. Additionally, Management
Control Unit and Transition Unit staffs’ priority is to supervise
high risk offenders to ensure facility safety and security. Limited
staff resources do not allow for a shift in this priority to take the
time to compile aggregate data in a spreadsheet.
AUDITOR’S ADDENDUM: The focus of this recommendation is on
management’s periodic review of the documentation of out-of-cell
time to assess and promote compliance with Administrative
Regulations and statute across the Department. The Department’s
response does not indicate that management uses or plans to use
the information recorded in shift logs over time to determine
whether offenders in Management Control Units and Transition
Units are offered adequate out-of-cell time. Rather, the
Department’s response only indicates that it has established
processes to ensure accurate documentation on a daily basis. Thus,
it is unclear whether the Department agrees with the
recommendation.
Further, the audit does not recommend the Department aggregate
out of cell time in a spreadsheet or discontinue the practice of
using schedules.

CHAPTER 4

SEX OFFENDER
TREATMENT AND
MONITORING PROGRAM

The Sex Offender Treatment and Monitoring Program (Sex
Offender Program) is a cognitive behavioral program that
provides specialized treatment and monitoring services for sex
offenders while they are incarcerated within Department of
Corrections (Department) facilities. Sex offenders may become
eligible to participate in the Sex Offender Program after they
have indicated a willingness to undergo treatment and are within
4 years of parole eligibility.

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Under the Sex Offender Program, enrolled offenders receive group
therapy to address factors associated with sexual offending behaviors
and recidivism. Sex offender treatment, according to the Department,
focuses on cognitive behavioral therapy to address criminogenic
factors and change distorted thinking patterns and behaviors that are
associated with sexual offending. The Sex Offender Program operates
in accordance with the treatment standards established by the Sex
Offender Management Board (Board), which was established within
the Department of Public Safety under Section 16-11.7-103(1), C.R.S.,
and is responsible for developing the standards and guidelines for the
assessment, evaluation, treatment, and behavioral monitoring of sex
offenders in the criminal justice system (in prison, on probation, on
parole or under community supervision).
In August 2012, the Department commissioned an outside evaluation
by Central Coast Clinical and Forensic Psychology Services, Inc., of
the Sex Offender Program’s efficacy and cost-effectiveness. The
consultants provided an evaluation report in January 2013 that found,
in part, that the Sex Offender Program could make “significant
improvements” in using sex offender “risk to reoffend” as a basis for
identifying adult male sex offenders’ treatment needs. (The
Department stated that female and juvenile risk and treatment needs
are not yet measurable, based on available research.) After the 2013
evaluation, the Department restructured the Sex Offender Program
and the Administrative Regulations that govern the program.
Specifically, the Sex Offender Program began providing a second tier
of treatment to adult male sex offenders with “more intensive
treatment needs.”
Our audit work focused on the Department’s implementation of the
2013 evaluation recommendations and restructuring of the Sex
Offender Program to better address the need for increasing treatment
availability to eligible adult male sex offenders. In this chapter, we
discuss how the Department has not established effective controls to
ensure that sex offenders are adequately assessed and prioritized for
treatment, and has not increased the number of sex offenders it enrolls
in treatment annually.

97

According to the 2013 evaluation, it is important for the Department
to assess sex offenders’ risk to reoffend in order to determine their
treatment needs, be properly responsive while providing treatment,
and prioritize which offenders should receive treatment first. As such,
the 2013 evaluation recommended that the Department establish a
process, supported by research, for measuring each sex offender’s level
of risk to reoffend. Prior to the evaluation, the Department conducted
several different types of evaluations for sex offenders but none that
measured the offender’s risk of reoffending in order to determine
treatment needs. The Department agreed with the 2013 evaluation
recommendation and reported that it had fully implemented the
recommended risk assessment process as of September 2014 by
modifying its existing assessment process, for adult male sex offenders,
to include the following two risk assessment tools:
 THE STATIC 99-REVISED

(STATIC ASSESSMENT), FOR
UNCHANGING RISK FACTORS. The Department uses this “static”
assessment to identify a baseline risk level for reoffending. The
Static Assessment is designed to review factors about the offender
that generally do not change, such as the offender’s history of sex
offense, and assigns the offender a risk level based on a scoring
system. According to the Department, sex offenders are assessed
using the Static Assessment at the beginning of their term of
incarceration.
ASSESSMENT

 THE SEX OFFENDER TREATMENT INTERVENTION AND PROGRESS
SCALE (PROGRESS ASSESSMENT), FOR VARIABLE RISK FACTORS. The
Department uses this “dynamic” assessment for sex offenders who
have been enrolled in treatment to conduct periodic reviews of
factors that may change over time, such as whether the offender
takes responsibility for, or is in denial of, his sexual offense
behavior. The Progress Assessment also assigns each offender a risk
level based on a scoring system. According to the Progress

REPORT OF THE COLORADO STATE AUDITOR

RISK ASSESSMENTS

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

98
Assessment manual, offenders are assessed upon intake for
treatment and may receive additional assessments over time.

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
We reviewed the 2013 evaluation report and the Department’s
implementation plan for addressing the recommendations and
interviewed Department management and staff regarding sex offender
assessment processes. We also reviewed statutes, the Department’s
Administrative Regulations, and the standards and guidelines issued
by the Board that include requirements for releasing sex offenders
back into the community. Further, we reviewed all of the
Department’s electronic data related to risk assessments for:
 The 4,378 adult male sex offenders eligible for risk assessments
who were in the Department’s custody as of December 31, 2015.
 The 592 adult male sex offenders who were enrolled in the Sex
Offender Program at any point between April 1, 2014, and
December 31, 2015.
The purpose of our work was to determine whether and to what
extent the Department has implemented the recommendation from the
2013 evaluation to implement a risk assessment process to identify an
offender’s risk to reoffend by “systematically applying an empirically
validated risk assessment tool to grade offenders into different risk
levels.” This recommendation aligns with Section 16-11.7-103(4)(b),
C.R.S., which requires the Department to determine offender Sex
Offender Program treatment by “a current risk assessment and
evaluation” and the 2011 Board Standards and Guidelines that state
that “assessment and evaluation should be an ongoing practice in any
program providing treatment for sex offenders.”
Specifically, we evaluated whether the Department used the Static and
Progress Assessments for adult male sex offenders incarcerated as of

99

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY?
Overall, we found that the Department has not fully implemented the
risk assessment process recommended in the 2013 evaluation and
included in its associated implementation plan. Specifically, we
identified the following issues:
 MISSING STATIC ASSESSMENTS. As of December 31, 2015, a total of
4,378 adult male sex offenders were incarcerated at the Department
and should have been assessed with the Static Assessment. Of these,
we found that 581 (13 percent) did not have a Static Assessment in
the database. The Department stated that it does not have any
documentation of a Static Assessment (e.g., a hard copy assessment)
for 424 (73 percent) of these offenders, indicating that these may
not have been conducted. For an additional 87 offenders (15
percent), staff did not record the assessment in the database field
designated for identifying the assessment was done—instead, staff
used a narrative “notes” field to indicate that they had conducted
the assessment or to provide a reason why it was not conducted.
Additionally, from April 1, 2014 through December 31, 2015, of
the 592 sex offenders enrolled in Sex Offender Program treatment
groups, one did not have a Static Assessment recorded in the
database and eight did not have a Static Assessment recorded in the
correct database field.
 MISSING PROGRESS ASSESSMENTS. As of December 31, 2015, a total
of 257 offenders were enrolled in the Sex Offender Program and
had been participating in treatment for at least 2 weeks. Of these
257 sex offenders, we found that 124 (48 percent) did not have a
Progress Assessment in the database. The Department stated that it

REPORT OF THE COLORADO STATE AUDITOR

December 31, 2015. We also evaluated whether Department staff
enter sex offenders’ risk assessment results and risk levels into the
Department’s centralized database to facilitate assigning sex offenders
to treatment and prioritizing offenders for enrollment in the Sex
Offender Program.

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

100
does not have any documentation of a Progress Assessment for 10
offenders (4 percent), indicating that these may not have been
conducted, and that the assessments were ultimately conducted for
51 offenders but were not recorded in DCIS during the audit review
period. For an additional 63 (25 percent), staff did not record the
assessment in the database field designated for identifying the
assessment was done—instead, staff used a narrative “notes” field
to indicate that they had conducted the assessment.

WHY DID THESE PROBLEMS OCCUR?
The Department has not established effective controls to ensure that
staff identify every sex offender’s level of risk to reoffend and
document the information appropriately. Specifically:
 INADEQUATE WRITTEN POLICIES AND PROCEDURES ON COMPLETING
ASSESSMENTS. Although staff are provided training and guidance
manuals published by the creators of the Static and Progress
Assessments, the Department lacks adequate written policies within
its Administrative Regulations or Clinical Standards. Administrative
Regulation 700-19 states that staff are required to “continually
assess individual treatment needs to determine appropriate
treatment recommendation” and that “individualized treatment
goals will be based on continual assessment by the clinical team,”
but do not specify which risk assessment tools are used, who must
be assessed, or when assessments must be conducted.
 CENTRALIZED DATA-KEEPING NOT REQUIRED. The Department does
not have any written policies requiring staff to record assessments
in the centralized offender database, and in the appropriate data
fields. The Department stated that, during the period we reviewed
for the audit, staff were allowed to independently track the
assessments using hard copy records.
 LACK OF SYSTEMATIC MONITORING. Sex Offender Program
management does not routinely confirm whether all sex offenders’
risk assessments are completed, done in a timely manner, and

101

WHY DO THESE PROBLEMS MATTER?
The intent of the 2013 evaluation recommendation to implement a
risk assessment process was to allow the Department to systematically
assign different levels of treatment on the basis of the risk assessments.
Overall, the issues we identified inhibit the Department’s ability to
effectively accomplish this intent. When adequate controls are not
established and used—including written requirements and
standardized processes that staff are held accountable for following—
the Department cannot ensure that staff are basing sex offender
treatment on the risk of reoffending and the individual’s treatment
needs. The Department plays an important role in sex offenders’
continuum of care as they move through the criminal justice system,
and for some offenders, back into the community after their release
from prison. When the Department does not use a system of treatment
provision based on assessed needs and risk of reoffending, some sex
offenders may not receive the treatment they need and some may
receive unneeded treatment that is funded by Colorado citizens, and
that inhibits providing treatment to other sex offenders on the
Department’s Sex Offender Program referral list.
Further, when Static and Progress Assessment results are not entered
into the appropriate fields in the offender database, Sex Offender

REPORT OF THE COLORADO STATE AUDITOR

recorded appropriately in the electronic database. The Department
stated that it is unable to generate an aggregated report within the
database to identify which sex offenders should, but do not, have a
Static or Progress Assessment. The reports that are available are
those showing the sex offenders who do have an assessment
recorded, and, separately, the full list of all sex offenders. While this
information could be cross-referenced and used to determine who
does not have an assessment, currently managers do not have a
more efficient method of monitoring whether assessments are being
conducted as intended. As a result, the Department only becomes
aware of offenders who have not undergone the assessments when
the assessments are needed to, for example, assign the offender to a
treatment group or prepare for a Parole Board hearing.

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Program staff report that to confirm whether the assessments were
conducted, so that they are able to identify treatment needs for
offenders, staff must undergo a resource-intensive process of looking
through each individual offenders’ clinical notes and hard copy files
before the offender can be enrolled in the correct treatment group, or
recommended for parole.

103

The Department of Corrections (Department) should improve its
controls for ensuring that Sex Offender Treatment and Monitoring
Program (Sex Offender Program) staff are conducting and using the
risk assessments for eligible sex offenders by:
A Implementing written policies and procedures, in Administrative
Regulations or Clinical Standards, regarding the Static 99-Revised
and Sex Offender Treatment Intervention and Progress Scale risk
assessments, including requirements that the assessments must be
conducted, when they must be conducted, that they must be
recorded in the centralized offender database, and in the
appropriate data fields.
B Establishing a process for routine and systematic monitoring of
risk assessments to help ensure that staff conduct the assessments
in a timely manner. This could include cross-referencing
informational reports from the offender database to identify
offenders who are missing assessments.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: MARCH 2017.
The Department has had procedures in place that include time
frames for the administration of risk assessments. The Sex
Offender Treatment Intervention and Progress Scale (SOTIPS) is a
dynamic risk assessment that is administered after the offender is
in treatment and requires clinical judgement in determining when it
will be administered. Guidance related to the time frames are
included in the SOTIPS manual which is available to all clinicians.
The Department will add language to existing clinical standards to

REPORT OF THE COLORADO STATE AUDITOR

RECOMMENDATION 8

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

104
reference the use of the risk assessment manuals. Clinical Services
will continue to modify guidelines to reflect best practices in the
administration of assessment instruments which includes clear
direction for staff.
AUDITOR’S ADDENDUM:
This
recommendation
included
implementing policies related to both the timing of assessments
and documenting the assessments in the Department’s database.
The Department’s response does not indicate whether its new
policy language will include changes related to the documentation
of assessments. Thus, it is unclear whether the Department intends
to fully implement this recommendation.
B AGREE. IMPLEMENTATION DATE: MARCH 2017.
To improve its controls for ensuring staff are completing risk
assessments in accordance with clinical standards and guidelines,
Quality Management Program staff will develop an audit tool that
will identify any issues with their completion and/or
documentation.

105

The Department states in its Administrative Regulation 700-19 that
the intent of the Sex Offender Program is to “provide specialized sex
offense specific treatment to identified offenders to reduce recidivism
and enhance public safety by providing a continuum of identification,
treatment, and monitoring services throughout incarceration.” As of
December 31, 2015, the Department had 4,611 adult male sex
offenders in custody and of these offenders, 1,979 were awaiting Sex
Offender Program treatment, meaning that they had been identified as
ready and willing to begin treatment and were included on the Sex
Offender Program referral list; 257 were currently, and 292 had
previously been enrolled in treatment; and 2,083 were determined to
be either ineligible or not recommended for treatment by the
Department. Generally, the reasons these offenders were not receiving
or awaiting treatment is that they refused to be treated, denied that
they needed treatment, or had an eligibility date for potential parole
that was greater than 4 years, making them ineligible for treatment
according to the Department.
In Calendar Year 2015, a total of 749 sex offenders were sentenced
and placed in the Department’s custody. Under statute, convicted sex
offenders receive one of two types of sentences, as follows:
 LIFETIME SUPERVISION SENTENCES. The Colorado Sex Offender
Lifetime Supervision Act of 1998 (Lifetime Supervision Act)
provides for indeterminate sentencing for offenders convicted of
certain sex offenses on or after November 1, 1998, as prescribed in
Section 18-1.3-1003(5), C.R.S.. These offenders have a minimum
sentence they must serve, but in order to be released from prison,
they must also demonstrate that they have “successfully progressed

REPORT OF THE COLORADO STATE AUDITOR

SEX OFFENDER
TREATMENT
ENROLLMENTS

DEPARTMENT OF CORRECTIONS BEHAVIORAL HEALTH PROGRAMS, PERFORMANCE AUDIT –NOVEMBER 2016

106
in treatment and would not pose an undue threat to the community
if released under appropriate treatment and monitoring
requirements” [Section 18-1.3-1006(1)(a), C.R.S.]. In practice, this
means that when the Parole Board considers a sex offender with a
lifetime supervision sentence for parole, the Department must first
confirm that the offender has received sex offense treatment while
incarcerated, and has made progress in treatment based on criteria
set by the Board [Section 18-1.3-1009(1), C.R.S.].
 DETERMINATE SENTENCES. An offender with a determinate sentence
has a pre-determined date when his sentence will end and is not
required to undergo treatment and supervision while incarcerated
unless it is recommended. Generally, sex offenders with determinate
sentences have been convicted of sex offenses that:
►

Are also listed in the Lifetime Supervision Act [Section 18-1.31003(5), C.R.S.] but these offenders were convicted prior to
when the Act was established in 1998.

►

Are not listed in the Lifetime Supervision Act but are listed in
other statutes, including within the definition of “sex offense”
regarding standardized treatment for sex offenders [Section 1611.7-102(3), C.R.S.], the definition of “unlawful sexual
behavior” in the Colorado Sex Offender Registration Act
[Section 16-22-102(9), C.R.S.], and criminal convictions that are
not a sex offense but involved unlawful sexual behavior as
described in the Colorado Sex Offender Registration Act [Section
16-22-103(2)(c)(IV), C.R.S.].

Under either sentence, some offenders may receive a lifetime sentence
without a possibility for parole. Additionally, under Colorado
Regulations the Parole Board considers offenders’ progress in
treatment, regardless of sentence type, as a factor when deciding
whether to grant them parole prior to their mandatory release date [8
C.C.R. 1511-1 (6.04)(A)(4)].

107

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
We reviewed statutes, including the Lifetime Supervision Act and
statutes governing the Board, the Department’s Administrative
Regulations, and the Board standards and guidelines. We also
reviewed the 2013 evaluation and the Department’s implementation
plan for addressing the recommendations, and interviewed
Department management and staff, and staff at the Colorado
Governor’s Office of Information Technology (OIT), regarding Sex

REPORT OF THE COLORADO STATE AUDITOR

It has been a significant challenge for the Department to provide
treatment to all sex offenders in its custody who have been identified
as ready and willing to undergo treatment. Compared to the 1,979
awaiting treatment at the end of Calendar Year 2015, between
Calendar Years 2012 and 2015, the Department was only able to
enroll an average of 68 new offenders per year. To address this
problem and improve the quality of the treatment it provides
offenders, the Department contracted for the independent evaluation
of the Sex Offender Program, which recommended in a 2013
evaluation report that the Department improve by better prioritizing
enrollment of offenders based on the “risk, needs, responsivity”
model. Under the recommended model, the evaluation stated that the
Department should consider an offender’s risk to reoffend when
providing treatment and better target the amount and type of
treatment it provides offenders based on their needs. The evaluation
indicated that this approach would maximize the benefit of the
Department’s limited resources and improve the quality of treatment.
In addition, the Department went from an appropriation for the Sex
Offender Program of 40.8 FTE in Fiscal Year 2013 to 51.8 in 2014,
then to 55.8 in 2015. The Department indicated that its expectation
was that implementing the evaluation recommendations and receiving
the additional FTE would provide it with the means to improve Sex
Offender Program operations, increase its ability to provide treatment,
and thereby reduce the large referral list.

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108
Offender Program enrollments and referral list management. We
reviewed Department documents that it provided regarding the 2013
evaluation and Joint Budget Committee documents regarding Sex
Offender Program staffing and funding authority for Fiscal Years
2013 through 2015. Further, we reviewed the Department’s electronic
data for sex offenders referred to and enrolled in the Sex Offender
Program who were incarcerated between Calendar Years 2012
through 2015, including data to track offender risk assessments,
enrollment into the Sex Offender Program and placement into
treatment phases and groups, and sentence information. We also
reviewed the Sex Offender Program referral list and the programmatic
parameters used to generate the list and the priority order of offenders
on the list.
The purpose of our work was to determine whether and to what
extent the Department has:
 IMPROVED ENROLLMENT PRIORITIZATION, based on implementing
the 2013 evaluation recommendation to use risk of reoffending to
identify offenders for treatment. The evaluation recommended that
the Department use the offender assessments to focus treatment
provision accordingly, with higher risk offenders receiving the most
treatment and lower risk offenders receiving either less treatment,
to align with their needs, or no treatment prior to release, since
some of these offenders can be successfully treated while on parole
or within community corrections. The Department agreed with the
recommendation to assess offenders to focus treatment provision,
and reported that the Sex Offender Program would assess offenders
for treatment, using the Static and Progress Assessments to
determine risk levels, and higher risk offenders would generally
receive the most treatment. Further, the General Assembly indicated
its preference for treating offenders based on their risk to reoffend
when it passed House Bill 16-1345, which directs the Board to
incorporate the “risk, needs, responsivity” model when updating
sex offender treatment standards and guidelines, which it is
required to do by July 2017.

109

 INCREASED SEX OFFENDER PROGRAM ENROLLMENTS based on
receipt of additional FTE resources and programmatic changes
made to implement the 2013 evaluation recommendations.

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY?
Overall, we found that the Department does not always prioritize
offenders with a higher risk to reoffend or a lifetime supervision
sentence for treatment and has not increased the number of sex
offenders it enrolls in treatment annually. Specifically:
LOWER

RISK, DETERMINATE SEX OFFENDERS WERE PRIORITIZED FOR

ENROLLMENT.

We found that following the 2013 evaluation, the
Department has not improved its prioritization of enrollments based
on offender risk, as determined by risk assessments and its
requirements under the Lifetime Supervision Act. Instead, as shown in
EXHIBIT 4.1, in the years following the 2013 evaluation the
Department has increased the number of lower-risk, determinatesentenced offenders it has enrolled. The number of lower risk,
determinately sentenced sex offenders enrolled increased from 6 in
2012, to 30 in 2015.

REPORT OF THE COLORADO STATE AUDITOR

 MAINTAINED TREATMENT PROVISION for offenders sentenced under
the Lifetime Supervision Act, which was enacted to ensure that
offenders who have committed certain crimes receive, and show
progress in, treatment prior to being released back into the
community. For these offenders, Section 18-1.3-1001, C.R.S.,
states, "The general assembly hereby finds that the majority of
persons who commit sex offenses, if incarcerated or supervised
without treatment, will continue to present a danger to the public
when released from incarceration and supervision… The general
assembly further finds that some sex offenders respond well to
treatment and can function as safe, responsible, and contributing
members of society, so long as they receive treatment and
supervision."

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110
EXHIBIT 4.1. NEW SEX OFFENDER PROGRAM
ENROLLMENTS1 BY SEX OFFENDER TYPE AND STATIC
ASSESSMENT RISK LEVEL2
CALENDAR YEARS 2012 THROUGH 2015
HIGHER RISK
Lifetime Supervision Offenders Enrolled1
Lifetime Supervision Offenders on Referral List3
Proportion of new enrollments to total offenders
LOWER RISK
Lifetime Supervision Offenders Enrolled1
Lifetime Supervision Offenders on Referral List3
Proportion of new enrollments to total offenders
HIGHER RISK
Determinate Offenders Enrolled1
Determinate Offender on Referral List3
Proportion of new enrollments to total offenders
LOWER RISK
Determinate Offenders Enrolled1
Determinate Offenders on Referral List3
Proportion of new enrollments to total offenders
TOTAL NEW ENROLLMENTS

2012

2013

2014

2015

19
59
24%

11
64
15%

9
71
11%

6
87
6%

67
263
20%

56
305
16%

20
308
6%

23
366
6%

0
277
0%

3
349
1%

0
414
0%

9
427
2%

6
632
1%
92

4
793
1%
74

2
809
0%
31

30
768
4%
68

SOURCE: Office of the State Auditor analysis of Department data as of December 31, 2015.
1
Adult male sex offenders that were enrolled for the first time in the Sex Offender Program
over the Calendar Year.
2
Only offenders with a Static Assessment are included in this exhibit. Offenders who did not
have a documented assessment are not included.
3
Adult male sex offenders who were included on the Sex Offender Program referral list at the
end of each Calendar Year.

The 30 enrolled lower risk offenders with a determinate sentence were
placed in treatment in 2015 while a total of 941 offenders with either
a lifetime supervision sentence or a high risk to reoffend were still
awaiting treatment, which indicates that these offenders were not
prioritized for treatment.
ENROLLMENTS IN THE SEX OFFENDER PROGRAM HAVE DECREASED. As
shown in EXHIBIT 4.2, we found that the Sex Offender Program has
decreased the number of offenders enrolled in treatment despite
receiving appropriations for additional FTE in Fiscal Years 2014 and
2015. In addition, the number of offenders awaiting treatment has
grown from 1,527 in Calendar Year 2012, to 1,979 in Calendar Year
2015.

111

Total Sex Offenders Enrolled
Total Sex Offenders on Referral
List
Proportion of
enrollments to Total Offenders

2012

2013

2014

2015

484

474

474

465

PERCENTAGE
CHANGE
CALENDAR
YEARS
2012-2015
-4%

1,527

1,607

1,846

1,979

30%

24%

23%

20%

19%

-5%

SOURCE: Office of the State Auditor analysis of Department of Corrections Sex Offender
Program enrollment data as of December 31, 2015.

WHY DID THESE PROBLEMS OCCUR?
We identified the following reasons for the Department’s lack of
increase in Sex Offender Program enrollments, and indicators it has
not prioritized offenders who have a higher risk to reoffend or a
lifetime supervision sentence for treatment.
THE DEPARTMENT

HAS NOT YET IDENTIFIED AND IMPLEMENTED A

SYSTEMATIC APPROACH TO PRIORITIZE SEX OFFENDERS FOR TREATMENT.

Overall, we found that the Department’s current practices do not align
with policies, and the Department’s current policies and automated
system controls do not prioritize offenders based on risk level as
recommended by the 2013 evaluation. Specifically:
 In April 2014, the Department revised Administrative Regulation
700-19, which specifies the order in which sex offenders must be
placed on the referral list. However, the updated Administrative
Regulation 700-19 does not cite risk to reoffend as a requirement
for prioritizing offenders for placement in Sex Offender Program
treatment; rather, the Administrative Regulation uses the offenders’
parole eligibility date to provide the order in which offenders
awaiting treatment should be prioritized. Also, when the
Administrative Regulation was revised in 2014, the Department
removed requirements in the Administrative Regulation language
that stated that offenders with a Lifetime Supervision sentence
should be prioritized before offenders with determinate sentences.

REPORT OF THE COLORADO STATE AUDITOR

EXHIBIT 4.2. SEX OFFENDER PROGRAM ENROLLMENTS
CALENDAR YEARS 2012 THROUGH 2015

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Additionally, the database programming that automatically
generates the referral list for Sex Offender Program enrollment does
not use risk to reoffend as a factor for prioritizing offenders.
 In practice, when Sex Offender Program treatment slots open staff
upload the referral list to an Excel database to pair it with offender
classification and security information, and then discuss, as a team,
which offenders should be enrolled in the open treatment slots.
Staff select offenders for enrollment based on this discussion, not
the order generated by the referral list. Staff stated that they select
offenders with both Lifetime Supervision and determinate
sentences, and that they have not been instructed to only select, or
to prioritize, offenders with a specific sentence or with a higher risk
to reoffend. Staff stated that they do consider these factors but
generally, they prioritize offenders who are approaching a parole
eligibility date.
Program management stated that the current practice of using the date
an offender is eligible for parole is the correct way to prioritize
offenders and adheres to the Department’s Administrative Regulation.
However, neither the Administrative Regulation nor the automated
programming for generating the list cite risk to reoffend as a factor
that staff must use for prioritizing offenders for enrollment, as
recommended in the evaluation.
By establishing clear guidance and a systematic process to prioritize
the enrollment of offenders in the Sex Offender Program, the
Department will be better able to meet its obligations under the
Lifetime Supervision Act while focusing resources on offenders with a
higher risk to reoffend, as recommended in the 2013 evaluation.
However, in doing so the Department may also need to seek policy
guidance. Specifically, we found the 2013 evaluation recommendation
to assess offender risk to reoffend and focus treatment on higher risk
offenders may at times conflict with the goals of the Lifetime
Supervision Act. While lifetime supervision sex offenders have been
convicted of serious offenses, the Static and Progress Assessments
often score these offenders as having a lower risk of reoffending and

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It is unclear based on the 2013 evaluation and the Lifetime
Supervision Act, which type of offender should have priority for
treatment. For example, lower risk lifetime supervision sex offenders
may be important to treat because they have a better chance for
success upon release and will be incarcerated until they are treated
(prioritizing this offender would be consistent with the Lifetime
Supervision Act). However, higher risk, determinately sentenced
offenders may be important to treat because they are more likely to
reoffend and will eventually be released (prioritizing this offender
would be consistent with the 2013 evaluation). Currently, the
Department staff lack any policy guidance, either from Administrative
Regulations, the 2013 evaluation, statute, or the Board to choose
between the two. The Board is currently considering how to
incorporate the risk, needs, responsivity model and must promulgate
new rules by July 2017 under House Bill 16-1345, and the
Department stated that it is working with the Board to ensure that Sex
Offender Program staff have clear guidance for selecting offenders for
enrollment that takes into account the risk, needs, responsivity model
provided in the 2013 evaluation and the Lifetime Supervision Act.
THE SEX OFFENDER PROGRAM

CONTINUES TO LACK ADEQUATE STAFF

ENROLLMENTS.

We found that the
Department has not been able to fill and maintain the 15 additional
FTE positions it was appropriated in Fiscal Years 2014 and 2015.
Specifically, of the additional 15 FTE appropriated, as of Fiscal Year
2015 the Department had only hired and maintained four additional
staff. Of these, one staff member was hired for training and supportive
services and does not provide direct treatment to offenders. According
to the Department, although it has the funding and spending authority
to hire additional staff, due to the nature of the job and locations
RESOURCES

TO

INCREASE

REPORT OF THE COLORADO STATE AUDITOR

with fewer treatment needs, with only about 17 percent of lifetime
supervision sex offenders on the referral list rated as higher risk.
Conversely, the assessments might rate a determinately sentenced
offender as having a higher risk of reoffending and greater treatment
needs; about 29 percent of determinately sentenced offenders on the
referral list are considered higher risk.

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away from central population centers, it has been difficult to recruit
and retain qualified staff for the Sex Offender Program. We discuss
the Department’s staffing issues further, in CHAPTER 5.

WHY DO THESE PROBLEMS MATTER?
Because the Department’s resources for treating currently incarcerated
sex offenders do not meet the current need for treatment, when the
Department does not effectively allocate its limited resources and does
not establish and maintain a working system to prioritize and enroll
the sex offenders most in need of treatment while incarcerated, it
creates significant public safety risks, inequities, negative financial
impacts, and negative impacts on treatment effectiveness.
At the current rate of enrollment it will take over 8 years to enroll the
1,979 offenders who are currently awaiting treatment (this time
estimate does not include any new offenders who may be referred for
treatment). Further, because of a lack of clear policies and procedures
for prioritizing offenders for treatment, there is a risk that some
offenders may have to wait much longer if newly referred offenders
are prioritized before those offenders. The large referral list, combined
with a lack of written prioritization policies results in multiple
significant risks:
 HIGHER

RISK OFFENDERS WITH DETERMINATE SENTENCES BEING

RELEASED TO THE COMMUNITY WITHOUT TREATMENT.

On the
December 2015 referral list, a total of 360 determinately sentenced
offenders with a mandatory release date had been assessed by the
Department as having a higher risk to reoffend. Of the 360, there
were 80 higher risk offenders with a mandatory release date in
2016. Considering that completion of treatment in the Sex Offender
Program takes offenders 2 years, on average, it is unlikely any of
these offenders will complete treatment before release, despite being
willing to participate.

 OFFENDERS

WITH LIFETIME SUPERVISION SENTENCES REMAINING IN

PRISON INDEFINITELY.

Because lifetime supervision sex offenders

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 INCREASED COSTS TO THE STATE. Because lifetime supervision sex
offenders must be treated prior to being released and determinately
sentenced offenders may be more likely to be paroled prior to their
mandatory release date if they receive treatment, a long referral list
impacts the overall prison population. Considering that a single
offender costs about $36,000 per year to incarcerate and there are
1,231 offenders on the referral list who have passed their parole
eligibility date, the annual cost to the State could be as much as $44
million each year that these offenders continue to be incarcerated.
 NEGATIVE IMPACTS ON TREATMENT EFFECTIVENESS DUE TO LENGTHY
WAITING TIMES FOR TREATMENT. The 2013 evaluation found that
lengthy wait times affect offenders once they are in treatment, by
causing offenders to be fearful of removal and to “appease the
treatment provider” instead of genuinely engaging in treatment.

REPORT OF THE COLORADO STATE AUDITOR

cannot be released until they are treated, they may spend much
more time in prison than required by their minimum sentence if the
Department does not enroll them in treatment. We identified 236
lower risk offenders with Lifetime Supervision Act sentences
awaiting treatment who had reached or passed their parole
eligibility date and had not been enrolled in the Sex Offender
Program.

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RECOMMENDATION 9
The Department of Corrections (Department) should ensure that the
Sex Offender Treatment and Management Program (Sex Offender
Program) provides the maximum benefit to public safety and the State
of Colorado by:
A Establishing written enrollment and prioritization policies and
procedures, in Administrative Regulations or Clinical Standards,
that incorporate offenders’ risk to reoffend and treatment needs.
The policies and procedures should take into account the
requirements of the Colorado Sex Offender Lifetime Supervision
Act of 1998 and requirements set by the Sex Offender
Management Board’s standards and guidelines as updated
pursuant to House Bill 16-1345.
B Ensuring that its automated tools for generating the Sex Offender
Program referral list reflect these policies and procedures.

RESPONSE
DEPARTMENT OF CORRECTIONS
A AGREE. IMPLEMENTATION DATE: JUNE 2016.
There have been many changes implemented in the Sex Offender
Treatment and Monitoring Program (SOTMP) since the 2013
evaluation; and the program continues to evolve as changes are
made in Sex Offender Management Board (SOMB) standards. The
Department maintains that it does have policy and procedures in
place that indicate the prioritization of offenders in treatment
based on the offender’s risk to re-offend and treatment needs,
while considering the Lifetime Supervision Act, the SOMB
standards and guidelines, and the 2013 evaluation. The audit
report recognizes the lack of direction by any of these interest

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AUDITOR’S ADDENDUM: Although the Department may have
policies and procedures intended to prioritize offenders in
treatment based on their risk to re-offend while considering the
Lifetime Supervision Act, the SOMB standards, and the 2013
evaluation, as noted in the report, the results of our work indicate
these policies and procedures are not accomplishing such an intent.
We found that the Department has not improved its prioritization
of enrollments into the Sex Offender Program based on offender
risk, as determined by risk assessments and its requirements under
the Lifetime Supervision Act. Instead, the Department has
increased the number of lower-risk, determinate-sentenced
offenders enrolled. Although the Department’s response indicates
that it implemented this recommendation in June 2016, the
Administrative Regulation changes the Department made at that
time retained similar processes for prioritization as those in place
for the period we reviewed and thus do not appear to address the
recommendation. Because the Department does not indicate that it
plans further changes to its policies or practices, we do not
consider the recommendation implemented and it is not clear
whether the Department agrees with the recommendation.
B AGREE. IMPLEMENTATION DATE: DECEMBER 2018.
Creating automated tools for generating the referral list is planned
for the next phase of the Department’s eOMIS. Completion of this
phase is due to be implemented in 2017/2018. Until that time, the
Department will need to continue with current practice which
includes a manual process by the Offender Services and the
SOTMP administrator to ensure there is a balance of offenders
placed in treatment as described in No 9: Part: A.

REPORT OF THE COLORADO STATE AUDITOR

groups as it relates to the best treatment enrollment prioritization.
The Department has and will continue to ensure the appropriate
balance of offenders in treatment while balancing these factors.

CHAPTER 5

OVERALL PROGRAM
MANAGEMENT

The programs and services under the Department of Corrections
(Department) Division of Clinical and Correctional Services
(Clinical Services), including the Mental Health Services Program
(Mental Health Program) and Sex Offender Treatment and
Monitoring Program (Sex Offender Program), were established
under Administrative Regulations to provide offenders with
services that “maintain basic health and prevent other than
normal physical and emotional deterioration” and to serve the
mission to “promote effective offender management and
successful re-entry into the community.”

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During the audit we reviewed the Department’s overall management
of offender service provision under the Mental Health Program and
the Sex Offender Program in achieving the agency, division, and
program missions. As discussed throughout the report, the
Department has made significant operational changes to these
programs in recent years, including the establishment of three
Residential Treatment Programs (RTPs), restructuring of its Sex
Offender Program, and increased staffing. These changes were
intended to improve the effectiveness of the programs, and the
Department has reported that implementing the program changes, as
well as continuing to develop these programs—including
implementing new services such as “de-escalation rooms” offenders
may request to use to avoid experiencing a mental health crisis—has
been successful. The Department also reported that all three of the
RTPs show annual improvements including, for example, a growth in
the percentage of offenders who “successfully complete” the RTP.
During our review, we found that overall the Department has
implemented and continues to implement programmatic changes to
the Mental Health and Sex Offender Programs, but that the
Department’s information and performance measures are not
adequate to allow for an assessment of the impact of the recent
changes or the effectiveness of the programs in serving the
Department’s overall mission of “holding offenders accountable and
engaging them in opportunities to make positive behavioral changes
and become law-abiding, productive citizens.” Additionally, the
Department’s ongoing information system and staffing issues, which
contribute to many of the issues identified in this report, create
challenges to the Department’s ability to ensure and demonstrate the
effectiveness of these programs, as discussed in this Chapter.

PROGRAM STAFFING
For Fiscal Year 2016, the Department was appropriated $16.8 million
and 151 Full-Time Equivalent (FTE) staff for the Mental Health
Program, and $4.4 million and 55.8 FTE for the Sex Offender

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EXHIBIT 5.1. DEPARTMENT OF CORRECTIONS
ANNUAL FTE AND APPROPRIATIONS (IN MILLIONS)
FOR MENTAL HEALTH AND SEX OFFENDER PROGRAMS
FISCAL YEARS 2013 – 2016
2013
MENTAL HEALTH PROGRAM
Total FTE
Total Appropriation
SEX OFFENDER PROGRAM
Total FTE
Total Appropriation

2014

2015

2016

PERCENTAGE
CHANGE

130.8
$12.0

126.2
$14.4

127.1
$14.8

151.0
$16.8

15%
40%

40.8
$3.0

42.8
$3.2

55.8
$4.3

55.8
$4.4

37%
47%

SOURCE: Office of the State Auditor analysis of Joint Budget Committee documents.

The Clinical Services Director is responsible for planning, directing,
and administering all health care services for offenders at all
Department facilities, including using the Clinical Services
management team to conduct personnel operations, and report to
Department executive management on any health care needs at the
facilities. This includes monitoring Mental Health Program and Sex
Offender Program staffing needs at all of the facilities and making
adjustments as needed.
Mental Health and Sex Offender Program staff members may be
licensed or unlicensed, though the Department stated that generally its
policy is to try to hire licensed staff. All Mental Health and Sex
Offender Program staff, once hired, receive ongoing professional
training from Department and external sources, and are assigned to a
specific facility and work schedule; staff are also, on a rotating basis,
required to work an “on-call week” in addition to their regular work
schedule to respond, as needed, to on-call emergencies that arise.

REPORT OF THE COLORADO STATE AUDITOR

Program. As shown in EXHIBIT 5.1, both appropriated funding and
FTEs allocated to these programs have increased significantly since
Fiscal Year 2013. The Mental Health and Sex Offender Programs
include program management staff and staff who are assigned to
specific facilities to provide treatment directly to offenders; Mental
Health Program staff provide treatment primarily at 14 facilities, and
Sex Offender Program staff provide treatment at 6 facilities.

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WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
Throughout the audit, we reviewed statutes, State Personnel Rules,
Department Administrative Regulations and Clinical Standards, and
spoke with 30 Department staff members at five facilities and the
Central Headquarters, including executive and program management;
clinical staff and supervisors; facility security officers; and staff within
Human Resources, the Office of Planning and Analysis, and the
Quality Management Program. We reviewed Department offender
data and staffing data, including staff exit interviews and retention
reports from Fiscal Year 2015, and Joint Budget Committee budget
documents for the Mental Health and Sex Offender Programs.
The purpose of our work was to determine whether the Department
has been effective at managing core staff resources for the Mental
Health and Sex Offender Programs, in accordance with the following:
 Clinical Services is required to conduct ongoing staffing analyses
and planning to determine the staffing needs to provide services as
required [Administrative Regulation 700-01.IV and V]. Clinical
Services collects and evaluates monthly and annual staff-to-offender
ratio data at each facility. In Fiscal Year 2014, it also established a
“Retention Committee” that is responsible for compiling staff
retention reports using, in part, information gathered from exit
interviews and staff surveys.
 Section 24-17-102(1), C.R.S., provides that each state agency,
including the Department, must institute and maintain systems of
internal accounting and administrative control, and in 2016, the
Office of the State Controller adopted the Standards for Internal
Control in the Federal Government (Green Book) as the State
standard for internal controls, that all state agencies must follow.
Principle 4.05 of the Green Book states, “Management recruits,
develops, and retains competent personnel to achieve the entity’s

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WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY?
Over the last several years, the Department has requested and received
funding for additional FTE for the Mental Health and Sex Offender
Programs, but has not been able to maintain full staffing for these
programs. We found that over Fiscal Years 2015 and 2016, the
Department had a vacancy rate, generally, of over 20 percent for the
Mental Health Program and over 30 percent for the Sex Offender
Program. Throughout the audit, when we spoke with Department
management and staff about the issues we identified and have
included in this report (specifically RECOMMENDATIONS 1, 2, 3, 4, 6,
and 9), an ongoing lack of adequate staff resources was cited as one
root cause of many of the challenges the Department faces in
identifying and addressing offenders’ behavioral health needs.
Department executive and program management stated that because
of the continual staffing shortages, it expects that current staff
members will continue to experience shortfalls in meeting the Mental
Health and Sex Offender Programs’ requirements and standards that
the Department has established.

WHY DID THESE PROBLEMS OCCUR?
In general, the nature of the responsibilities of the Mental Health and
Sex Offender Program positions, and in some cases the remote
geographical areas where these positions are located, present
significant challenges for maintaining full staffing. The Department
has taken steps to address these ongoing challenges, including
increasing Mental Health and Sex Offender Program staff salaries in
February 2014 and establishing the Clinical Services Retention
Committee in Fiscal Year 2014 to identify potential retention issues
and make recommendations to management. For example, in talking

REPORT OF THE COLORADO STATE AUDITOR

objectives. Management considers the following…Provide
incentives to motivate and reinforce expected levels of performance
and desired conduct, including training and credentialing as
appropriate.”

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124
with staff and reviewing exit interview notes and the summary
documents maintained by the Retention Committee, we found that the
Department’s on-call policies and outside training policies highlight
common concerns identified by staff as undermining morale and
impeding staff retention. To address the concerns regarding the on-call
policies, the Department has implemented policy changes to reduce the
number of instances of when staff must be called back in to work for
an offender emergency, by allowing nursing staff already on site to
respond to some emergencies. Mental Health and Sex Offender
Program staff are still required to work on-call and some staff do still
have complaints in this area that the Retention Committee continues
to collect information about. Additionally, regarding the Department’s
policies on outside training, it stated that it stopped paying for most
expenses related to outside training in 2008 due to the economic
downturn. As such, the Department may be able to continue to make
adjustments in these areas that could improve Mental Health and Sex
Offender Program staff retention.
Additionally, within the scope of our audit, we assessed information
regarding the Department’s practices for allocating job responsibilities
among staff, for tasks related to identifying and addressing offender
mental health needs. We found that Mental Health and Sex Offender
Program staff are responsible for significant amounts of
administrative, data-entry work to ensure that offender mental health
information, such as information related to needs assessments,
treatment plans, facility transitions and screenings, and program
enrollments, is maintained in the offender databases. In some cases the
administrative workload has resulted in offender coding errors (such
as inaccurate and untimely mental health coding, see
RECOMMENDATION 1) and staff failing to adhere to policies (such as
not filling out transition forms when offenders are released to
the community, see RECOMMENDATION 4). For many of the
administrative tasks, the Department has not analyzed whether
adding administrative FTE, of whom clinical expertise and training
is not required, could improve staffing overall and allow clinical
staff to focus more time on treatment provision.

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The Department’s resource constraint challenges make an already
difficult working environment more difficult for staff and
management. If staff retention issues are not adequately addressed,
they will erode the Department’s ability to operate effectively and will
continue to generate systemic operational problems. For example, the
problems we identified in Mental Health Program staff’s ability to
conduct core work to ensure offender assessments, treatment plans,
and Transition Forms are completed as required, and in Sex Offender
Program staff’s ability to increase program enrollments, were reported
by the Department to be caused in part by a lack of sufficient staff.
Overall, the Department may continue to experience staff retention
and morale issues for these programs but the Department does have
an ongoing responsibility to recruit, develop, and retain competent
staff in order to achieve the programs’ objectives. As such, providing
staff with the best possible working environment within its resource
constraints is important for reducing retention issues that may not be
resolved by receiving additional FTE allocations.

REPORT OF THE COLORADO STATE AUDITOR

WHY DO THESE PROBLEMS MATTER?

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RECOMMENDATION 10
The Department of Corrections (Department) should continue to
evaluate and address staff retention for the Mental Health Treatment
Program and the Sex Offender Treatment and Monitoring Program.
This should include continuing to look for strategies to improve
retention over time, such as implementing further policy changes when
possible that address common concerns among staff.

RESPONSE
DEPARTMENT OF CORRECTIONS
AGREE. IMPLEMENTATION DATE: NOVEMBER 2016.
Clinical Services will continue to examine staff retention in the
behavioral health programs and implement strategies to improve
based on a variety of considerations including staff concerns.

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Over the last several years and currently ongoing, the Department has
made significant changes to the Mental Health and Sex Offender
Programs which were intended to address evolving best practices in
the mental health and correctional industries, comply with changes in
law, and to advance its overall mission of “holding offenders
accountable and engaging them in opportunities to make positive
behavioral changes and become law-abiding, productive citizens.” For
example, when the Department began its extensive Administrative
Segregation reform efforts and removed offenders with significant
mental health needs from long-term isolated confinement, the Mental
Health Program, and the Sex Offender Program, also underwent
restructuring in order to provide treatment and services that would
align with the Department’s overall reform efforts, maintain safety,
and ensure offender access to treatment. This included establishing
and revamping the three Residential Treatment Programs (RTPs) and
the close custody units, like the Management Control Units, adjusting
the treatment and services provided to some offenders housed in the
general population, and changing procedures for enrolling and
treating offenders in the Sex Offender Program.

WHAT AUDIT WORK WAS PERFORMED,
WHAT WAS THE PURPOSE, AND HOW
WERE THE RESULTS MEASURED?
Throughout the audit, we reviewed statutes, Department
Administrative Regulations and Clinical Standards, and spoke with
Department management and staff, and Office of Information
Technology (OIT) staff who assist the Department in managing its
databases, to identify the core policies and practices for administering
the Mental Health and Sex Offender Programs. We also reviewed
information that Department management uses to oversee the

REPORT OF THE COLORADO STATE AUDITOR

ASSESSING PROGRAM
EFFECTIVENESS

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128
programs, including data from the Department’s offender
management database, DCIS, and other databases; reports from the
facilities where offenders are housed and treated and reports from
Clinical Services to executive management; and documents from the
Department’s Program Oversight Committee.
The purpose of our audit work was to assess the Department’s system
for evaluating the performance of the Mental Health and Sex Offender
Programs in achieving their purposes based on the following:
MENTAL HEALTH SCOPE OF SERVICE. The Department has set the
following policy in Administrative Regulation 700-03.I, defining the
Mental Health Program: “It is the policy of the [Department] to
provide mental health services that are oriented towards improvement,
maintenance or stabilization of offenders’ mental health, contribute to
their satisfactory prison adjustment, diminish public risk presented by
offenders upon release, and aid the [Department] in the maintenance
of an environment that preserves the basic human rights and dignity of
offenders, correctional [Department] employees, and contract
workers.”
DEPARTMENT REQUIREMENTS. The Clinical Services Director is
responsible for “the establishment and maintenance of an offender
health record and related system-wide electronic data systems,
associated policy and procedures that assure…compliance with state
and federal laws” [Administrative Regulation 700-01.IV.B.3].
THE SMART GOVERNMENT ACT AND STANDARDS FOR INTERNAL
CONTROL. The State Measurement for Accountable, Responsive, and
Transparent (SMART) Government Act, established in 2010, and the
Green Book provide an additional framework for evaluating the
Department’s oversight of the Mental Health and Sex Offender
Programs. The SMART Act’s legislative declaration states that
agencies should operate under a “performance management
philosophy” and that “a system of continuous process improvement is
a critical and necessary component” of this philosophy [Section 2-7201(1)(b) and (e), C.R.S.]. Additionally, Section 24-17-102(1), C.R.S.,

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 “Management should define objectives clearly to enable the
identification of risks and define risk tolerances” [Principle 6.01].
 “Management should use quality information to achieve the entity’s
objectives” [Principle 13.01].
 “Management should establish and operate monitoring activities to
monitor the internal control system and evaluate the results”
[Principle 16.01].

WHAT PROBLEMS DID THE AUDIT
WORK IDENTIFY AND WHY DID THEY
OCCUR?
Overall, we found that the Department lacked sufficient information
to assess the effectiveness of its Mental Health and Sex Offender
Programs and could improve its system for evaluating the performance
of these programs, as discussed in the following sections.
THE DEPARTMENT

HAS NOT ESTABLISHED PERFORMANCE MEASURES

MENTAL HEALTH AND SEX OFFENDER PROGRAMS.
Specifically, the Department does not have performance measures and
associated goals regarding the extent to which Mental Health Program
or Sex Offender Program treatment has improved, maintained and
stabilized offenders. Throughout the audit, we requested but the
Department did not provide information on the specific performance
measures and targeted goals used by management to assess these
programs. Rather, the Department provided some data that it stated

AND GOALS FOR THE

REPORT OF THE COLORADO STATE AUDITOR

provides that every state agency, including the Department, must
institute and maintain systems of internal accounting and
administrative control, and in 2016, the Office of the State Controller
adopted the Green Book as the State standard for internal controls
that all state agencies must follow. The Green Book provides the
following key principles related to evaluating the effectiveness of
programs:

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130
showed trends in some areas across all offenders or across a facility,
and for the Mental Health and Sex Offender Programs. Specifically,
the Department has focused on information such as the number of
offenders enrolled, completing, and terminating from treatment
programs; the quantity of treatment sessions offered; and the number
of mental health watches that occurred. These measures are valuable
for management purposes, such as showing the implementation of
Department policies and ability to ensure that program services are
provided to offenders, but are limited in their ability to indicate the
impact treatment is having on offenders, the environment in
correctional facilities, or the safety of the community when offenders
are released, and as such do not allow the Department to demonstrate
its ability to measure whether and the extent to which those services,
in practice, are furthering the core purposes of these programs.
Further, during the audit we found that the Department has not
established a process to review the effectiveness of its treatment
programs’ curricula. Specifically, we found that the Department
approved treatment program curricula for the Mental Health and Sex
Offender Programs that were in use as of December 2015, including a
core treatment program for the RTPs. These curricula are used by staff
to guide offenders’ therapy. Currently, the Department has not
conducted any review or established a process to review whether or to
what extent the programming has aided in furthering the
Department’s and the program purposes and missions. Review of
these treatment programs is particularly important because many of
them, including the RTP program and at least four others, are not
evidence-based, meaning that the curricula as it has been implemented
at Department facilities were not confirmed to be effective through
evidence-based research prior to being implemented by the
Department. The treatment programs were reviewed and approved by
Clinical Services prior to being implemented and were implemented
relatively recently; additionally, the Department stated that the
curricula use a “cognitive behavioral treatment modality” that is
considered “the gold standard” in treatment. However, now that the
curricula is in use the Department will need to collect information

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THE DEPARTMENT LACKS QUALITY INFORMATION FOR ITS MENTAL
HEALTH AND SEX OFFENDER PROGRAMS. In preceding chapters we
noted multiple issues with the Department’s tracking of information to
monitor the treatment and services it offers offenders. These problems
with quality data inhibit the Department’s ability to measure the
impact of its programs and “[assure] compliance with state and
federal laws.”
 Coding that the Department uses to track offenders’ mental health
status, diagnoses, and treatment needs is not always accurate in
DCIS, and DCIS does not have system controls necessary to ensure
accurate coding (RECOMMENDATION 1).
 The Department lacked consistent, reliable information to track
offenders’ out-of-cell hours in RTPs and Close Custody Housing
Units to ensure compliance with Senate Bill 14-064 and Department
requirements (RECOMMENDATIONS 6 and 7).
 The Sex Offender Program data did not include risk assessment
results for some offenders and some assessments were only stored in
narrative form in text-based data fields, making it difficult for
management to compile summary information and prioritize
offenders for treatment according to their risk level
(RECOMMENDATION 8).
This audit did not include a technical, IT system review of DCIS, but
did include work to assess system reliability and validity as it relates to
the specific audit objectives. Through that assessment, we identified
deficiencies in the design and operation of DCIS that contributed to
the issues of data quality mentioned above. These deficiencies include
the following:
 DCIS DOES NOT ALLOW CORRECTION OF ERRONEOUS DATA ENTRIES.
For example, if a staff member creates a record for an offender in
DCIS that he or she later realizes is not accurate, or that includes

REPORT OF THE COLORADO STATE AUDITOR

relevant to the impact of these programs so that it can determine if
and the extent to which they are effective within Colorado’s facilities.

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132
incorrect auto-populated date information because the staff
member was delayed in creating the entry, the record or entry
cannot be changed or deleted. As a result, incorrect information is
maintained in DCIS and is not easily distinguishable from the
correct information. Specifically, we saw hundreds of instances
where staff entered offender crisis information in DCIS incorrectly,
then typed “delayed entry” or “not valid” into the narrative clinical
notes field to indicate the record was not accurate, or entered a new
record where they typed “correction” in a new note to indicate that
the previous entry was incorrect. Without manually going through
each record and reading every notes field, we could not identify—
and Department management cannot identify—which records and
fields are accurate. Maintaining incorrect records in DCIS also
prohibits compiling accurate summary information to manage and
monitor overall statistics and trends, and identifying anomalies for
an offender or group of offenders without first having to go
through the time intensive process of reading the narrative entered
into the clinical notes in order to identify and extract the incorrect
data.
 DCIS

DOES NOT HAVE SYSTEM CONTROLS TO PROHIBIT BLANK,

DUPLICATE,

ENTRIES.

DCIS is not
programmed to require or prompt staff to enter key mental health
information to ensure that offender records are complete. For
example, DCIS is not programmed to prevent staff from saving or
closing out of an offender’s record without entering coding to
indicate whether or not the offender has a developmental disability.
Additionally, DCIS is not programmed to limit specific entries in
data fields that align with Department requirements—for example,
only allowing staff to enter the mental health coding for “major
mental illness” when they have selected a diagnosis on the list of
major mental illnesses in DCIS.
OR

MISALIGNED

RECORD

Because of the limitations in DCIS’ capabilities and controls,
Clinical Services staff use a variety of other methods to track some
offender mental health data; for example, staff generally manage
information about offender mental health crises and watches, and

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Department management indicated that many of the problems we
identified related to program objectives, information, and performance
monitoring occurred because the Department was making major
changes to its programs during the periods we audited. Specifically,
Senate Bill 14-064 was passed in Calendar Year 2014 and the
Department’s implementation of the RTP model to treat offenders
with serious mental illness was still in process during Calendar Year
2015. As a result, the Department was still in the process of setting
policies and procedures and training staff during the period we
audited and is still making refinements to its objectives, methods for
collecting data, and monitoring of staff. Similarly, the Sex Offender
Program underwent major changes to address the 2013 evaluation
recommendations. In addition, management frequently cited problems
with DCIS as a major barrier to establishing adequate controls and
monitoring compliance. For example, in several of our
recommendations, management indicated that DCIS was not capable
of capturing information that would be necessary to review
compliance or assess overall results. According to the Department, it is
in the process of replacing DCIS with a modern system and expects to
be able to address many of the issues raised in our audit when the
system is fully in place, which it anticipates will be in about 2 to 4
years.

WHY DO THESE PROBLEMS MATTER?
Without adequate processes and information to identify whether and
to what extent the Mental Health and Sex Offender Programs are

REPORT OF THE COLORADO STATE AUDITOR

RTP enrollments, outside of DCIS. Staff reported using email and
face-to-face conversations to track and communicate information
about crises, RTP enrollments, and other areas, as well as using
multiple Microsoft Excel and Access databases that staff have
created. However, these methods do not ensure that the
Department maintains adequate, centralized documentation of this
information, or automated mechanisms to ensure that the
Department has quality data to monitor performance and
compliance with applicable laws and Administrative Regulations.

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134
achieving their intended outcomes and complying with applicable
requirements, the Department cannot fully gauge program
effectiveness and is less able to identify problem areas, address issues,
and hold staff accountable. This hinders the Department in achieving
its overall mission, and in demonstrating that the $20 million the
Department spends annually on its Mental Health and Sex Offender
Programs is being used as effectively as possible.
Further, when Senate Bill 14-064 was codified into statute, it required
the Department to significantly change its operations regarding
offender mental health. The Department established a new way of
serving offenders with severe mental health needs in the form of the
RTPs, which it has reported are a success and a model for other states
to follow. Although the data the Department currently collects shows
that it has implemented significant programmatic changes in recent
years, by establishing performance measures and associated goals, and
improving its tracking of data related to its programs’ intended
outcomes, the Department can better demonstrate the effectiveness of
these changes.

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The Department of Corrections (Department) should improve its
controls related to evaluating the performance of its Mental Health
Treatment Program and Sex Offender Treatment and Monitoring
Program by:
A Establishing performance goals and measures that demonstrate the
effectiveness of the treatment it provides offenders in achieving its
intended outcomes. This should include evaluating the effectiveness
of its treatment program curricula.
B Making improvements to its information systems to provide
management with quality information to evaluate performance and
monitor compliance with applicable laws, Administrative
Regulations, policies, and procedures. This should include ensuring
that its new information system has the capability of tracking
information necessary to measure performance as defined by goals
and measures established in PART A above, has adequate controls
to ensure data integrity, and minimizes the need to use other,
external systems.
C Monitoring its performance in achieving it goals using the
information available through use of the improved system
discussed in PART B and making operational changes as needed to
improve performance if it does not achieve program goals.

RESPONSE
DEPARTMENT OF CORRECTIONS
A PARTIALLY AGREE. IMPLEMENTATION DATE: DECEMBER 2017.
The Department does not agree with the information provided in
the audit report regarding the Department’s lack of adequate goals

REPORT OF THE COLORADO STATE AUDITOR

RECOMMENDATION 11

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136
and performance measures to evaluate whether mental health is
achieving its overall purpose. The Department believes that rates of
assaults, the number of mental health watches and other offender
mental health crises, program completions, use of de-escalation
cells, treatment refusals, increased social interaction of offenders,
uses of force, number of offenders completing SOMB criteria, etc.
DO provide an indication of the impact treatment has on
offenders, the correctional environment, and the safety of the
community when offenders are released. The Department does
intend to identify measurements to evaluate the effectiveness of its
treatment program curricula with assistance from its developers.
We believe that the new eOMIS will be critical in helping us
acquire the information needed to make this determination.
AUDITOR’S ADDENDUM: As discussed in the report, the Department
provided some data and reports that showed trends in some areas
across all offenders or across a facility, and for the Mental Health
and Sex Offender Programs. These data provide some indicators of
the effect of the programs, but much of the data were not
comprehensive, were not specific to offenders who had received
treatment from the programs, or were not reliable. Additionally,
the Department lacked quantifiable goals and associated
performance measures that can consistently and reliably be used to
evaluate the effectiveness of the programs in achieving their
intended outcomes.
B AGREE. IMPLEMENTATION DATE: DECEMBER 2017.
The Department agrees with the audit report as it relates to the
challenges we face on a daily basis with the use of an antiquated
electronic system. We agree that improved information gleaned
from efficient collection of data in a new electronic system will
benefit management in the evaluation of its programs and
ultimately the offender population.
C AGREE. IMPLEMENTATION DATE: DECEMBER 2018.
We agree that improved information gleaned from efficient

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REPORT OF THE COLORADO STATE AUDITOR

collection of data in a new electronic system will benefit
management in the evaluation of its programs and will more
effectively lead to operational improvements.

 

 

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