Structured Intervention Unit Audit Readiness Engagement

Introduction

The Audit Readiness of the Structured Intervention Unit (SIU) was conducted as part of Correctional Service of Canada’s (CSC) 2020-2022 Evergreen Risk-Based Audit Plan. The Audit Readiness of the SIU is being undertaken by the Internal Audit and Evaluation Sector (IAES) to assist the Service in preparing for the Audit of the SIU which is to occur in fiscal year 2022-2023 to position the organization for the comprehensive review that must be undertaken by the committee of the Senate, of the House of Commons or of both Houses of Parliament (S.40.1, Bill C-83 - An Act to Amend the CCRA and Another Act).

The Structured Intervention Unit was created through Bill C-83 which abolished administrative segregation and introduced the concept of the SIU. This legislation received Royal Assent on June 21, 2019 and came into force on November 30, 2019.

Inmates may be transferred to an SIU if they have acted in a way that may, or has, jeopardized the security of an inmate or any other person, including themselves, or the security of an institution, or if they could interfere with an investigation. They are about helping inmates and providing them with the continued opportunity to engage in interventions and programs to support their safe return to a mainstream inmate population. While in an SIU, inmates have access to the same types of programs, services and activities as inmates in a mainstream inmate population. Inmates within the SIU must be provided with the opportunity for a minimum of fours hours every day of time out of their cell, and two hours of meaningful human contact. 

The current audit readiness engagement was completed to identify strengths and areas for improvement of the Structured Intervention Units prior to conducting the full audit assurance engagement. The period under review for the audit readiness engagement was from November 2019 to October 2021.

The COVID-19 global pandemic have had a significant impact on the operations of CSC. It is understood that certain aspects of the implementation and operation of the SIU have been affected and therefore could explain some of the observations noted in this audit readiness engagement.

Legislation and policy framework

Legislation

The legislative requirements for the SIU are contained within Sections 31 to 37 of the Corrections and Conditional Release Act (CCRA) and Sections 20 to 23.07 of the Corrections and Conditional Release Regulations (CCRR). CCRA Section 32 (1) states that “the purpose of a structured intervention unit is to:

1. provide an appropriate living environment for an inmate who cannot be maintained in the mainstream inmate population for security or other reasons; and
2. provide the inmate with an opportunity for meaningful human contact and an opportunity to participate in programs and to have access to services that respond to the inmate’s specific needs and the risks posed by the inmate.”

Policy framework

A Commissioner’s Directive and two Guidelines have been developed for the SIU. The purpose of Commissioner’s Directive 711-Structured Intervention Units is to ensure an inmate’s transfer to a Structured Intervention Unit is used as the least restrictive measure necessary and for the shortest time possible, consistent with the protection of society, staff and inmates when there are no reasonable alternatives that could address the inmate’s risk and to ensure an effective correctional planning process that responds to the inmate’s specific need and risk. Guidelines 711-1 and 711-2 provide staff with guidance and supporting information about the SIU authorization and transfer process, the review and decision process, and the correctional planning process.

Objective and methodology

Previous work completed

In November 2019, the IAES undertook a review of the implementation related to the SIU. The purpose of this initial review was to provide timely feedback of the policy framework prior to the policy suite coming into force. This review focused on ensuring the policy suite and legislation were congruent, identifying inconsistencies between the proposed policy suite and existing policies, and identifying areas where the policy suite was not clear. The review identified 22 areas for consideration and the SIU Implementation team agreed to review these areas for possible inclusion as part of the next update to the policy suite. In November 2021, an interim policy bulletin was promulgated and clarified many of the noted areas.

Audit Readiness objective

The overall objective of this engagement is to assist CSC strategically to identify gaps and areas for improvement that are required to ensure the successful implementation of the SIU. This engagement will be used to prepare the organization for an internal audit assurance engagement planned for 2022-2023.

Data sources reviewed

Throughout the audit readiness process, the following data sources were reviewed and analyzed:

• The SIU- LTE application;
• Situational Reports;
• Site Transfer lists;
• National Deployment Standards;
• Scheduling and Deployment System;
• Barrier and Threat Risk Assessment Reports; and
• Casework records and offender reports from the Offender Management System.

Sampling methodology

Using the data sources available, the team has completed a thorough review of a sample of offender files to assess overall compliance. For the file review of the SIU, the team selected a total of 50 files representing inmates with an admission date between August, 2020 and February, 2021. For the file review of restricted movement, the team selected 47 files representing inmates with an admission date between November, 2019 and May, 2021. For each inmate file reviewed, we followed the inmate through their entire stay beginning at the authorization date up to the date that the inmate is transferred out of the SIU (if applicable).

For other analyses such as assessing compliance of Threat Risk Assessments and Staff vacancies and turnover, the team used the available data sources going back to the implementation of the SIU.

Interviews

Regional interviews were conducted with Assistant Deputy Commissioner Correctional Operations and SIU - Senior Project Officers. In addition, at select sites, Correctional Managers and Managers, Assessment and Intervention were also interviewed.

In addition, the team regularly communicated with members from the SIU implementation team and SIU operations team from National Headquarters.

Observations

Legislation and policy compliance

What we expected

We expected to find that CSC was complying with the various requirements of relevant SIU Legislation and CSC’s Policy Suite.

Working well

• Generally timelines where decisions need to be made are respected.
• SIU Review Committees (SIURC), which review the case of the offender confined in an SIU and make a recommendation that may include returning an inmate to mainstream population or to alter the conditions of confinement, were generally being chaired by the appropriate position.
• Immediate needs checklist, which is a screening tool designed to help non-clinical CSC staff identify offenders who may be at risk for suicide was being completed upon authorization.

Areas for improvement

Documentation of decision making criteria is weak

Throughout an inmate’s stay in the SIU, many different review processes and decisions need to take place. Each of these decisions must be accompanied by a document that includes considerations of various criteria to ensure that the SIU is the least restrictive alternative for the inmate. This documentation must include enough details within the decision to provide an external reader the full backstory and the reasoning for the decision.

To assist the decision makers, content guidelines have been developed to provide guidance on what is required in the specific decisions made throughout an inmate’s stay in an SIU. Using the content guidelines staff must provide the details required for each of the criteria and ensure that enough information is provided to meet the legislative requirements.

Although the content guidelines were being adhered to in most cases, sufficient details were not always provided in the documentation to support that CSC met the various legislative criteria for the specific decision.

Verbal decision sharing is not being documented appropriately

Throughout the inmate’s SIU stay, there are many legal requirements for the notification of certain upcoming decisions as well as the sharing of decisions made within a certain timeframe. This includes verbal sharing of the notification that a decision will take place, the verbal sharing of the decision within one day, and written notification of the decision within two days.

While reviewing the inmate notification data in the LTE and the notes entered in the offender’s casework records within the Offender Management System (OMS), in the vast majority of cases, there was no documented sharing of the decisions with the inmate.

Due to Covid-19 travel restrictions, the review team has not conducted site visits and has not had the opportunity to review written documentation at the site level.

SIU Threat Risk Assessments related to barrier restrictions are not always being completed consistently

Barriers that mediate inmate interactions with others in an SIU must be deemed to be the least restrictive measure necessary to manage the risk the inmate presents to the safety of staff and offenders as well as the security of the institution.

Upon authorization to the SIU, an SIU Threat Risk Assessment (SIU-TRA) must be completed for the inmate to determine inmate associations and movement. Where barriers are used on an inmate, a daily SIU-TRA must be completed to confirm the need for continued use, to amend the use or type of barrier, or to discontinue the use. This ensures that offenders in the SIU are to be provided with the least restrictive measures possible for all interactions.

Based on our file review the required SIU-TRAs were not always being completed within one day of being transferred to an SIU and offenders on barrier restrictions did not consistently have daily SIU-TRAs completed.

Governance

What we expected

We expected to find that roles, responsibilities and a clear governance structure were in place and documented.

Working well

• Institutional roles and responsibilities are defined within the Commissioner’s Directive and associated Guidelines.
• NHQ has created an overall governance structure with two overarching teams which help run the SIUs.

Areas for improvement

The role of the SIU Regional Senior Project Officer vary significantly by region.

Commissioner Directive 711 clearly states the main responsibilities for the Regional Senior Project Officer and states that they will: be the primary contact for the IEDM for case management inquiries, coordinate the sharing of information required by the IEDM, ensure SIU sites coordinate sharing of IEDM recommendations and decisions within the required timeframes, prepare SIU case reviews for the Assistant Deputy Commissioner Correctional Operations, provide advice and support to institutions to ensure compliance with SIU legal, policy and procedural requirements.

The review team found that although the responsibilities were provided in the Commissioner’s Directive, there were inconsistencies on how the Regional Senior Project Officers viewed their role which created differences in how these individuals managed and their day-to-day duties and supported the SIUs. Due to the lack of a formal job description of the Regional Senior Project Officer their interpretation of their day-to-day duties varied significantly between regions. This leads to inconsistent support and expectations from the SIUs, and regional management.

More direction is needed to assist sites in dealing with challenges.

NHQs role is to provide support and guidance on how to manage the SIUs across the country.  Institutions have identified certain areas where they require additional guidance and direction. Two examples that came up consistently to the review team were the management of mental health cases and individuals who refuse to reintegrate.

Inmates authorized for transfer to SIU will be referred for a health assessment, including mental health. The assessment will focus on the inmate’s health status, and consideration of a referral for health services. Some offenders transferred to the SIU have mental health concerns and it is difficult to determine an alternative for these inmates.

Throughout an SIU stay, decisions are made regularly to determine whether the inmate continues to meet the criteria to remain in the SIU. If a decision is made that the inmate no longer meets the SIU requirements, the inmate should be transferred out to an appropriate alternative. In some instances inmates refuse to leave the SIU even though a reasonable alternative has been identified and a transfer-out decision was made.

For the two examples above there is a lack of clear direction on issues brought up by the institutions resulting in institutions struggling in being able to reintegrate the inmates in an SIU to an appropriate alternative.

Resourcing

What we expected

We expected to find that human resourcing needs have been identified and that there is sufficient staff available to meet the operational needs of the SIUs.

Working well

• Resourcing standards exist specifying the number of employees working in each SIU.
• There has been progress made on identifying various options to assist SIUs in scheduling the social programming officers.

Areas for improvement

There has been a significant amount of turnover in SIU staff, both for correctional officer and other positions.

Staff turnover occurs when a staff member leaves a position for any reason. Since the Implementation of the SIU in November of 2019, a significant number of correctional and non-correctional staff have left their position in the SIU.

Through an analysis of available human resource data and the Schedule and Deployment System, the review team found that a large number of staff are no longer working in the SIU. For the period between June 2020 and May 2021, the correctional manager position has been the most stable as only 20% of staff in this position have turned over. However, there has been significantly less stability in the correctional officer positions (CX-01 and CX-02). For intervention staff, a similar review was completed between the period of June 2020 and May 2021. The turnover of these staff resulted in 29% of staff at the men’s institutions being new to the SIU position.

With a high amount of turnover of staff, new staff do not have the same knowledge obtained from the initial onboarding orientation. Thus, possibly creating challenges to ensure that the SIUs are functioning effectively.

There is a significant amount of vacancies for SIU staff.

The national standards for the deployment of correctional officers establishes the required number of security posts for each type of activity taking into account the various institutional types. These positions have been resourced based on the expected staff requirement for the SIUs. Vacancies in these positions create an operational challenge as individuals who are less familiar with the operations of the SIU need to fill these positions as a result.

Through an analysis completed in October 2021, the team noticed that 18% of the SIU correctional officer positions were vacant. In many institutions the number of vacancies was significantly higher. For example, the CX-2s for some institutions had a vacancy rate as high as 80%. The intervention vacancy rates are lower than operational at 16%.

With a high vacancy rate, it is difficult for the SIU staff to ensure compliance with the policy as a routine and expectations of the unit are not always understood. With staff substitutions there is more pressure on current staff that are working in the unit as they have to take on additional workload to ensure the legislative and policy requirements are met.

Orientation and training

What we expected

We expected to find that staff have received training specific to working in the SIU.

Working well

• Initial orientation was provided to staff that would be working in an SIU at implementation.
• Refresher training related to the LTE-application is currently underway for all staff and is scheduled to be completed by end of November 2021.

Areas for improvement

Orientation and training is not provided to all employees who are assigned to the SIU.

Although initial onboarding orientation has been provided to staff working in the SIU as of the implementation date, there has been no ongoing national orientation/training to new staff entering the SIU. The review team did not find any specific training required as part of the National Training Standards for CSC.

The review team found that the Correctional Training Program for new correctional officers included a module related to the SIU. It was also found that similar training was available for correctional managers, assistant wardens, and wardens as part of their orientation/training for their new role. However, there is currently no SIU training for existing staff transferring to the SIU from another unit.

Although CSC implemented processes to improve training, staff transferring to the SIU are not receiving official training thus may not have all the necessary training required to work in the SIU.

Infrastructure and equipment

We expected to find that the infrastructure and equipment in place supported the achievement of the objectives of the SIU. However, due to the Covid-19 Pandemic and travel restrictions the review team was unable to fully assess this.

The review team did find that not all individuals were consistently using the provided equipment. Handheld devices have been provided to all SIU sites in order to facilitate the interactions between the officers and the inmates in the SIU. These devices should be used throughout the day to track the activities that the officers offer the inmates to ensure that all details are documented in a timely manner at the time activities are being offered, however since the implementation of the SIUs, some institutions have had technological issues impacting their ability to consistently use the handheld devices. Through analysis of the LTE application data, the review team noted that staff are not consistently entering all activities using the handheld device, thus interactions are not being recorded immediately and therefore the information may not be accurate or timely.

Infrastructure and equipment will be reviewed in detail in the upcoming Audit of the SIU in the 2022-2023 fiscal year.

Restricted movement

As per the definition in Commissioner's Directive 711, an inmate authorized for a transfer to an SIU, who is incarcerated at an institution without an SIU, may be subject to restricted movement which may restrict their movement and interactions with others, subject to safety and security considerations, until a transfer can be effected to an SIU.  An inmate subject to restricted movement has all of the same rights and restrictions as an inmate placed in an SIU.

This engagement focused primarily on institutions which had an SIU, however, the review team did complete a file review to examine operational compliance and conducted interviews with select sites.

Through file review, the team found that many of the challenges with documentation that were found with the SIU sites were occurring at the restricted movement sites namely, providing detailed documentation of decision making criteria.

Through interviews with select sites, the review team found that most sites were only using restricted movement when all other alternatives have been exhausted. Though interviews, the sites did not indicate that there were any additional challenges to note regarding restricted movement. The table below indicates the number of restricted movement cases by region since December 2019.

As determined by our upcoming Risk-Based Audit Plan consultations, restricted movement may be included in the upcoming Audit of the SIU or in a separate engagement.

Number of restricted movement admissions by region

	Between January and May 2021	Between December 2019 and December 2020
Atlantic	75	107
Quebec	36	96
Ontario	8	56
Prairies	4	32
Pacific	0	0
Total	123	291

Source: LTE-App Data extracted by Performance Measurement and Management Reports on May 23, 2021

Table showing the number of restricted movement admissions by each region (Atlantic, Quebec, Ontario, Prairies, Pacific, and total) between January and March 2021 and between December 2019 and December 2020.

Conclusion

The Structured Intervention Units have been a historic transformation of the federal correctional system that saw the abolition of administrative segregation. This new model made important reforms that provide more structured and effective interventions to inmates that address their specific needs and risks, with the goal of facilitating their reintegration into a mainstream inmate population as soon as possible. The COVID-19 global pandemic started in March 2020, four months after the November 30, 2019 implementation date of the SIU. The pandemic had a significant impact on CSC including both the implementation and the operation of the SIUs.

Overall the team completed a review of various data sets and conducted interviews to formulate observations related to the ongoing operation of the Structured Intervention Units. However, due to the Covid-19 Pandemic, the team was unable to travel and conduct site visits to the SIUs. As a result, there are a few aspects of the SIUs that were not included in this engagement, which will be included as part of the Audit Assurance Engagement on the SIUs which is to commence in fiscal year 2022-2023. These include:

• The sharing of various written decisions within the required timeframe;
• Infrastructure and equipment; and
• Compliance of the deployment and scheduling of correctional officers within the SIUs.

While the audit readiness engagement noted many areas where they SIUs are functioning as intended, numerous areas for improvement have been identified. It is recommended that management examine the noted areas and take action to address them to ensure compliance with the legislation and policy requirements.