Performance Assurance

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Performance Assurance Audit: Reports

National Administrative Segregation Audit Report

December 2002


Statement of Assurance

Summary of Findings
Recommendations and Action Plans


Statement of Assurance

In accordance with the Performance Assurance internal audit calendar for 2002-2003, the National Administrative Segregation Audit was conducted for the Correctional Service of Canada (CSC). The objectives of the audit were twofold: 1) to assess the compliance of the sites visited to legal and policy requirements; and 2) to identify and assess the institutional and regional internal control systems in place to monitor and control the segregation process. A total of 49 sites were audited. All maximum and medium-security institutions and those institutions which do not have on-site segregation units, but whom retain responsibility for completing casework of inmates segregated elsewhere, were audited. This is the fifth such audit to be conducted since 1996.

This internal audit assessed compliance against the administrative segregation standards in the Corrections and Conditional Release Act (CCRA), the Corrections and Conditional Release Regulations (CCRR), and Departmental Policy (Commissioner's Directive and Standard Operating Practices). During the audit period (July 2001- March 2002), a random sample of cases (15 voluntary and involuntary cases per site) were selected. Approximately 568 cases were examined. It should be noted that smaller samples were reviewed at some sites and feedback provided to the extent possible.

All documentation pertaining to the case for the selected segregation period was reviewed by at least two national auditors. In addition, local policy, manuals, forms, handbooks, etc., were examined and interviews with staff and inmates were conducted. Visual observations of the segregation units were also completed.

The internal audit conclusions found in this report were based on the assessment of findings against pre-established criteria agreed upon by the Performance Assurance Sector (NHQ), the Segregation Unit (NHQ) and Regional Segregation Oversight Managers, and reflect the audit work carried out from May to July 2002.

It is the opinion of the Performance Assurance Sector that sufficient audit work has been performed and the necessary evidence has been gathered to support the conclusions contained in this audit report.

Summary of Findings

Much improvement has been noted with respect to adherence to standards for administrative segregation. Many sites have also taken great strides in working with offenders to explore alternatives to segregation and have, as a result, kept segregated populations to a minimum. However, the formal scope of the audit was limited to a compliance and internal control system assessment of the segregation process.

The following are the findings of the audit team:

Departmental Policy

Finding #1: CD 590 "Administrative Segregation" was not updated to reflect the changes to policy identified in the previous Administrative Segregation audit.

During the planning phase of the audit, it was noted that suggested policy amendments originating from the previous administrative segregation audit (FY 1998-1999) were not finalized. Therefore, the following policy amendments/clarifications are required to CD 590 "Administrative Segregation":

  • Timeframe in which inmate receives written notification of the institutional head's decision resulting from a segregation review board. Policy currently states that written notification be provided within 48 hours of the review. This requirement should read two (2) working days.
  • Warden's weekly visit. Policy currently states that if the daily visit has been delegated, the Warden or his deputy are required to conduct weekly visits of the segregation unit. The current expectation is that the Warden or his acting is required to conduct the weekly visit.


In addition to the above, clarification is needed with respect to information sharing and administrative requirements for Segregation Review Board Hearings held specifically for offender release from segregation.

All site-specific policy (Standing Orders) was reviewed and was found to be in compliance with policy requirements.

Quality of Documentation

Finding #2 - Documentation of alternatives explored prior to administrative segregation and reasons for placement have improved.

As part of the audit, a review of the quality of placement rationales and alternatives to segregation was conducted for the cases selected.

Administrative Segregation Placement Rationales

Examination of both the placement rationale and the First Working Day Review was performed in order to assess the quality of the reasons for placement. Often, sites provided the necessary amount of detail in the First Working Day Review to substantiate the reason for placing the offender in administrative segregation. It was noted that at some sites the amount of detail provided in the placement rationales, of one or two cases, was limited. The cases identified were discussed with institutional staff. As a result of these discussions, it became apparent that additional information existed that was not documented in the appropriate reports.

In past administrative segregation audits, this issue of limited detail for placement was more widespread. It is evident that sites have improved in this area.

Alternatives to Administrative Segregation

Prior administrative segregation audits identified this area as problematic. Very little to no information was documented to substantiate that other alternatives were reviewed prior to placing an offender in segregation. For the current review, audit teams noted significant improvement in the documentation of alternatives.

The most prevalent issue with the documentation of alternatives was with the use of templates. Although templates are encouraged to be used as a guide for exploring options, placements/First Working Day Review documentation must show specific options that were explored for the case. Often, auditors found that only the template was included in the documentation. It must be evident in the documentation that some thought was given to ensuring that segregation was indeed "the last alternative". While discussing the problematic cases with institutional staff, it was apparent that other alternatives were indeed explored. These alternatives were, however, not all documented.

Attention to Detail

Finding #3 - Minor deficiencies relating to attention to detail were observed at many of the sites visited.

Although not as frequent as in the past, minor occurrences were noted with respect to attention to detail. Audit teams found incidents of missing documentation/information, such as legal calls, daily exercise and daily/weekly visit notations, inmate signatures, dates, reports, etc. In most cases, the absence of information (specifically dates, signatures and reports) impacted on the auditors ability to confirm that segregation board decisions and admission information were shared with the offender within the required timeframe.

In addition, some difficulty was noted with meeting required timeframes for notifying offenders of hearings and sharing information prior to the hearing. Audit teams found that a few cases (at approximately ¼ of the sites visited) were not in full compliance with the requirement of completing this notification process three days prior to the Segregation Review Board.

Role of Regional Segregation Oversight Manager (RSOM)

Finding #4 - No standard internal control system is in place to monitor compliance with administrative segregation standards.

In addition to the compliance-oriented assessment of the segregation process, the audit team reviewed the role of the RSOMs and the regional internal control system for administrative segregation.

File reviews of the cases selected indicated that all RSOMs are conducting the Regional 60-Day Reviews in accordance with policy. However, the quality of the regional assessment for the 60-Day Reviews varied from region to region. Some RSOMs meet with offenders and complete/record a detailed assessment in the Regional 60-Day Review report. Others rarely meet with the offender and provide limited documentation in the report.

The RSOM's work description states that a key client-service result is to:

Provide continuous monitoring of the use of administrative segregation through reviews, regional hearings and audits to ensure compliance with legal, policy and procedural requirements defined by the CCRA, CCRR, CDs and SOPs and ensuring the effective and timely solutions to release and reintegration are being implemented.

The RSOMs interviewed indicated that their primary focus is on long-term segregation cases and alleviating offenders' segregation status. Systems are in place in most regions to monitor long-term segregation cases through monthly institutional status submissions and OMS/RADAR statistical reports. However, no standard regional or national internal control system is in place to monitor compliance to legal and policy requirements. Although, some RSOMs have completed compliance oriented spot checks of units in their region, these are sporadic and have only been completed when time permits and at the RSOM's own initiative.

Within the last year, a control tool for administrative segregation was established to allow sites to monitor their segregation units. National headquarters requested the completion of two assessment reports, from the institutions, within the last year. In addition, a handful of institutions, complete assessment reports on a routine basis, such as Dorchester Institution. Results are shared with the institutional management team and issues addressed in-house.

It appears that although a key responsibility for RSOMs is to ensure segregation units are in compliance with legal, policy and procedural requirements, no process is in place regionally or nationally to allow for a consistent assessment of compliance to requirements. Although assessment reports are occurring they are opportunity driven. It appears that a mechanism for monitoring and addressing compliance related issues, both regionally and institutionally, needs to be established and maintained.

Recommendations and Action Plans

On-site and regional debriefings were conducted by audit teams at which time audit findings were discussed. Site specific action plans have been submitted by all institutions and approved by the Regional Deputy Commissioners. Specific areas requiring improvements have been, or are in the process of being, addressed.

The following are the recommendations of the audit team and the subsequent action plans submitted by National Headquarters:

Recommendation #1

CD 590 "Administrative Segregation" be updated to include current practices and clarify those issues addressed in the report.

Action by: Assistant Commissioner, Policy, Planning and Coordination

Action Plan: The policy will be amended this fiscal year.

Recommendation #2

In order to strengthen the internal control system for administrative segregation, a framework be established nationally, to monitor compliance with legal and policy requirements and address deficiencies on a systematic basis. Incorporation of compliance reviews and assessment reports is suggested.

Action by: Assistant Commissioner, Correctional Operations and Programs

Action Plan: The national framework for monitoring compliance in administrative segregation will include:

Institutional monitoring through bi-yearly completions of self-assessments. Results will be reported to the Regional Segregation Oversight Manager (RSOM) who will submit a regional summary to the Regional Deputy Commissioner and NHQ - Administrative Segregation of Correctional Operations and Programs Sector. Action plans will be submitted to the RSOM for monitoring.

Regional monitoring through yearly compliance reviews of each site conducted/coordinated by the RSOM. There will be a particular focus on any identified deficiencies from previous assessments/reviews/audits. The RSOM will submit a Regional Summary to the RDC and NHQ - Administrative Segregation of Correctional Operations and Programs Sector. Action plans will be submitted to the RDC and monitored through the RSOM.

National Headquarters, through the Administrative Segregation of Correctional Operations and Programs Sector, will receive all regional summaries of the institutional self-assessments and regional compliance reviews. They will monitor the status of compliance nationally, identify systemic weaknesses and provide national direction on compliance issues. A compliance status report will be submitted yearly to the Senior Deputy Commissioner.

Recommendation #3

That the Segregation Unit at NHQ and Regional Segregation Oversight Managers work closely with sites to address site-specific issues discussed during the debriefings.

Action by: Assistant Commissioner, Correctional Operations and Programs

Action Plan: All Institutional Action Plans have been submitted and approved by the Regional Deputy Commissioner's.

All Regional Action Plans have been reviewed and accepted by NHQ - Performance Assurance and Correctional Operations and Programs.

A summary of the Best Practices identified in the Action Plans submitted will be forwarded to the Regional Segregation Oversight Managers (RSOMs) for distribution within their regions.

A conference call will be completed with the RSOMs where the audit results will be discussed. The compliance framework will be communicated which includes the expectation of bi-yearly institutional self-assessments and yearly compliance reviews of each site. A focus will be placed on those deficiencies identified as serious.

Training requirements identified in the Action Plans will be monitored by the RSOMs. They will assist in the training where required.

A verification review of the Institutional Action Plans in response to this audit will be coordinated by NHQ - Performance Assurance before the end of the fiscal year.