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HV 9506 033 1999

378-01-137 September 1999

Offender Records Management Review

Perforniance Assurance Sector National Headquarters

Correctional Service of Canada

Performance Assurance Sector National Headquarters

Correctional Service of Canada

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TABLE OF CONTENTS

Executive Summary

Introduction

Finding #1: General file maintenance problems were identified at most sites 3 visited.

Finding #2: Offenders submitting requests through ATIP may not be receiving all 6 existing information.

Finding #3: The use of in-house forms is widespread in all regions. 7

Finding #4: A variety of documents are being kept on the top of Case Management 10 files.

Finding #5: Critical Document Inserts (CDIs) are still used sporadically in two 11 regions.

Finding #6: Most sites visited were unclear as to their responsibilities with respect to the creation, retention and destruction of Warrant Expiry (WED) / High Risk Offender packages.

Finding #7: Victim information on the Case Management File is not always being filed or stored appropriately.

Finding #8: Interviewees were not receptive to the idea that OMS be adopted as the official offender file.

Finding #9: Resource levels and associated responsibilities vary from one 16 responsibility centre to the other.

Finding #10: Staff indicated a need for better direction and support with respect to 17 the management of offender records.

Finding #11: Offender files are not always stored in a secure manner. 18

Finding #12: Files maintained by central registries and in parole offices are 20 generally well controlled. There are often fewer controls over those offender files stored in other areas of the institution (sub-registries).

Annexe A - Objectives and Issues

Annexe B - Responsibility Centres Visited

Annexe C - Sample of forms with different distribution lists

Annexe D - In-house forms

Annexe E - Numbered forms that were not listed in the ORSM or were not filed according to the ORSM

EXECUTIVE SUMMARY

The review of offender records was conducted by the Audit Division of the Performance Assurance Sector from May to July, 1999. Eight institutions and five parole offices were visited in the five regions. All file banks (except Health Care and Psychiatric Treatment Centre) for approximately 120 offenders were examined for a total of 850 files. The audit team reviewed only those documents that had been placed on the offender's file since their transfer to the institution being audited.

The purpose of the review, which was requested by the Operational Support branch of the Conectional Operations and Programs sector, was to collect information on the offender records management process across CSC. Two aspects were examined: the content of the various file banks and the management and controls over the files (eg., secure storage, sign-out mechanisms, etc.).

The following is a summary of the observations that were made by the audit team:

Finding #1: General file maintenance problems were identified at most sites visited. In most files reviewed, the audit team found that documents had been misfiled, were not in chronological order or were not properly attached to the file (stapled, loose, etc.). In addition, duplicate copies of documents were also found during file review. Little quality control is being done on offender files.

Finding #2: Offenders submitting requests through ATIP nzay not be receiving all existing information. The audit team examined the process of printing and filing documents from OMS and found this is not always done consistently. Given that the paper file is the main source used in the sharing of information with the offender through ATIP, some documents which are printed sporadically (or not at all) are not being shared. A primary example is casework records.

Finding #3: The use of in-house forms is widespread in all regions. Each site visited had a number of locally-created forms in use. In some cases, different versions of a form for a same purpose were found in more than one responsibility centre, and sometimes within the same facility. The process required by policy for the validation and approval of new forms at the national level is not being followed.

Finding #4: A variety of documents are being kept on the top of Case Management files. CSC policy requires that certain forms be kept on top of all other documents on the CM file for ease of access. All other documents are to be filed in chronological order. The audit team found a wide variety of documents on the top of the CM files reviewed, as well as some of the other file banks, contrary to current policy.

Finding #5: Critical Document Inserts (CDIs) are still used sporadically in two regions. The audit team reviewed 39 CDIs. Many of the documents found in the CDIs originated from OMS or were originals (according to policy, only copies are to be kept on the CDI). In addition,

interviewees indicated that although CDIs were still being maintained, their use has diminished over the years.

Finding #6: Most sites visited were unclear as to their responsibilities with respect to the creation, retention and destruction of Warrant Expiry (WED) / High Risk Offender packages. No major concerns were noted with the timeframes for creating and receiving these packages. However, various practices were in place with respect to their storage and maintenance. Some packages reviewed did not contain the minimum documentation required by policy.

Finding #7: Victim information on the Case Management File is not always being filed or stored appropriately. Following the Victim Notification audit last fiscal year, a recommendation was made to file victim information in a separate folder. During the current review, the team still found originals or copies of victim information filed chronologically on the CM file. Issues with respect to the proper classification of this information as Protected C, and the associated storage requirements were also identified.

Finding #8: Interviewees were not receptive to the idea that OMS be adopted as the official offender file. Interviewees were asked whether they felt that OMS could eventually replace the paper file as the official offender record. Most did not feel that this would be possible in the near future, even if the means for electronic signatures were in place.

Finding #9: Resource levels and associated responsibilities vary from one responsibility centre to the other. Many sites reported that they had insufficient resources to deal with the volume of offender files, or that the resources available had several other responsibilities to fulfill. Many staff had little experience in the area of offender records and most training offered is "on-the-job".

Finding #10: Staff indicated a need for better direction and support with respect to the management of offender records. The Offender Records System Manual (ORSM) is the current policy manual for offender records issues. However, many sites reported that it is not often referenced. Many interviewees expressed a need for consultation, guidance and communication with records staff when changes are considered to policy that impacts on their area.

Finding #11: Offender files are not always stored in a secure manner. The audit team examined the cabinets and rooms in which offender files are being stored. Many sites visited need to examine their current set-up to ensure that security requirements are met and risks of loss are minimized.

Finding #12: Files maintained by central registries and in parole offices are generally well controlled. There are often fewer controls over those offender files stored in other areas of the institution (sub-registries). The audit team examined access and sign-out procedures, as well as inventory controls and issues relating to missing files. As above, some sites need to examine their current practices in order to ensure a proper control over offender information.

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INTRODUCTION

The review of Offender Records is part of the National Headquarters (NHQ) Perfoirnance Assurance audit calendar for the 1999/2000 fiscal year.

An examination of offender records and the process of records management was requested by the Operational Support branch of the Correctional Operations and Programs Sector. The purpose of this review was to determine the scope of issues and concerns identified at the "Development of an Offender Information Management Strategy" workshop held in February 1998. Key themes identified in this workshop, which frame the basis for this review, are identified below:

• Streamlining the case management file; • Reducing the reliance on the paper file by recognizing OMS as the official file for some

information; • Reviewing information management policies and practices in all regions and NHQ to

determine the extent of compliance to records management policies; • The importance of ensuring that operational policies and procedures adequately detail the

information management requirements and accountabilities; and • Information sharing.

The revièw examined the processes in place to manage offender records, including resourcing issues, security, access controls, structure and file transfers. In addition, the team determined to what extent the content of files varied across responsibility centres. This included issues relating to standard national policies and procedures, verifying that records are filed according to the Offender Record System Manual (ORSM) and the Records Management Operation Procedures Manual (RMOPM), printing and filing of OMS forms and the use of official CSC and in-house forms. The ultimate goal of this review was to provide feedback to NHQ and regions in order to ensure consistency in all regions by standardizing practices and determining effective and efficient processes in records management. Objectives and issues for the audit are included as Annex A of this report.

Preliminary reviews were conducted at Pittsburgh Institution and the Ottawa Parole Office in the Ontario Region in April 1999. In order to assess regional variances, one to two institutions and a parole office were visited in all five regions from May to July 1999. A list of the responsibility centres visited can be found in Annex B.

Findings were collected through file reviews and interviews with Administration Services, Case Management and Security staff. The files of ten inmates were reviewed at each institution and at least five were examined in each parole office. The following file banks were reviewed for each inmate from the date the inmate transferred to the responsibility centre:

• Admission and Discharge (AD) • Case Management (CM)

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• Critical Document Inserts (CDI) (where applicable) • Discipline and Dissociation (DD) • Education and Training (ET) • Employment (EMP) • Preventive Security (PS) • Psychology (PSY) • Sentence Management (SM) • Visits and Correspondence (VC) • Warrant Expiry (WED) /High Risk Offender Packages (where applicable)

Team members assigned to the audit were:

Francine Deschamps Gabriela Freyenmuth Pat Johnson (Regional Headquarters Prairies) Debbie Paris (Halifax Parole, Atlantic) Trish Trainor Ca Lenh Ung Julie Westall

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FINDINGS

Objective 1: To determine the extent to which the content of offender files varies from one responsibility centre and region to another.

Finding #1: General file maintenance problems were identified at most sites visited.

The audit team examined 850 files in 13 responsibility centres in five regions:

Table #1 - Number of Files Reviewed

Number of Number of File Bank Institutional Files Community Total Number of

Reviewed Files Reviewed Files Reviewed Case Management (CM) 79 44 123 Sentence Management (SM) 70 -- 70 Admission and Discharge (AD) 78 -- 78 Discipline and Dissociation (DD) 81 -- 81 Psychology (PSY) 83 37 120 Preventive Security (PS) 77 16 93 Employment (EMP) 78 -- 78 Education and Training (ET) 78 -- 78 Visits and Correspondence (VC) 78 -- 78 Critical Document Insert (CDI) 27 12 39 Warrant Expiry (WED) / High Risk Offender Packages -- 12 12

' TOTAL '729 121 . 850

In general, it was found that the physical condition of the files was good (i.e., not tom or ripped, not over-full, etc.). In the majority of files reviewed, however, problems were identified with respect to the following:

a) Misfiling: Two types of misfiling were identified. The most common were cases where the audit team found documents that had been placed in the wrong file bank (for example, urinalysis results on the PSY file, original Post Search reports and visitors applications in the PS file bank, originals in CDIs, etc.). This issue was particularly evident in Parole Offices, given that they maintain only the CM, PSY and PS file banks and that most documents produced or received are filed on the CM bank. As a result, if the offender is returned to custody, information that would normally be found on one of the other file banks (for example, education information) remains on the CM bank.

At three institutions visited, documents for an offender were found on another offender's file. One possible explanation for this is the order in which files are stored. Although not an issue

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with the central registries visited, it was reported that file banks are not always stored according to the national FPS standard in some responsibility centres. Many of the sub-registries visited store files in alphabetical order. This can contribute to misfiling due to similar inmate surnames.

b) Multiple copies of documents on the same file bank: In half of the sites visited, this was a particular problem. Given the wide distribution of some documents to different individuals, central registry often receives several copies of a single document for filing. Interviewees indicated that, where possible, attempts were made not to file identical documents, but noted in some cases that they could not always be sure that they were unique. Staff in the records office did not feel that they are responsible for destroying documents even where there appears to be a duplication. Rather, the responsibility for deciding and analysing what is filed rests with the originators of the documents and the staff who are sending them to the file.

c) Chronological order: Chronological order problems were evident in approximately three quarters of the sites visited. Staff indicated that they have insufficient time and resources to verify whether documents are in proper order (refer to quality control segment below) and place them on file as they are received. Other contributing factors were duplicate (or multiple) copies of a single document being sent for filing at different times and the bulk filing of casework records.

d) Documents attached to file iackets/Loose filing: The audit team noted that documents are frequently being attached to the inside front jacket of files. Examples include the Standard (Offender) Profile, OMS printouts, checklists, personal property records, etc. In contrast, there were also cases where documents had not been properly affixed and were loose in the file.

e)Proper classification of documents: The Departmental Security Procedures Manual (DSPM) states that "no classified information or Protected C information is to be sent by unencrypted...electronic mail. Protected B information may be sent by unencrypted...electronic mail, only if a written threat and risk assessment indicates it to be safe to do so." The audit team noted that e-mail messages found on file were not following this directive, and they were rarely identified as containing protected information (for example, e-mails containing specific information about an offender's case or relating to victim notification). Staff should be made aware (or reminded) of the requirements with respect to the classification of documents they produce.

f) Poor condition of transferred files: Numerous staff indicated that transferred files are often in poor condition upon arrival (i.e., not in chronological order, files not labeled properly, signatures missing on documents, etc.). Staff in Prairies have adopted the practice of communicating file problems to the sending institution. Improvements have been noted.

2) Backfiling: Staff indicated that they often face vast amounts of filing backlog. A number of contributing factors were identified, including time and resource issues, backfiling for offenders transferred or released from other facilities, and the volume of documents (OMS or paper forms) produced on each case. On this latter point, it was noted that some cases generate a vast amount of paper (eg., ETAs, UTAs, travel permits, etc.) which quickly fills the file and often makes it difficult to find specific information effectively.

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h) Draft documents / missing signatures: Staff indicated that, in the past, draft (unlocked) documents were frequently sent for filing. In one site, if a draft document was already printed, it was signed and filed rather than printing a new locked copy. The word "draft" would be covered with correction fluid.

It would appear, however, in most sites, that measures have been taken to reduce this occurrence as very few unlocked / draft documents were found on file during the audit. Interviews revealed that in some institutions, draft documents are returned to the sender. In others, drafts are filed temporarily and removed when the final version is received. In another institution, a clerk has been assigned the duty of printing all offender documents and controlling what is filed.

In other cases, the final (locked) version was on file, however required signatures (staff or offender) were missing. Staff indicated that they often received one copy signed by the appropriate manager and another by the offender, rather than both on one copy. This results in multiple copies of a document on file (as in point b above).

i) Distribution Lists: Although the ORSM is the manual that identifies where official CSC forms are to be filed, this listing does not always agree with the distribution lists printed on each individual form or OMS. Annex C illustrates a sample of forms with contradicting distribution lists.

In addition, in some sites, staff indicated that the ORSM, OMS or form distribution lists are not followed, rather the document is filed in the bank identified by the person sending it for filing. This is in accordance with the ORSM, which indicates that "the person originating or receiving an offender record is responsible for its classification". This however, has resulted in the inconsistencies that are apparent in the filing of offender information.

Other distribution concerns identified during the review:

• Some official CSC forms are not being distributed to the appropriate file bank/OPI. Several packages with all carbon copies attached to the form were found on file (indicating that the information had not been distributed/shared). One common example of this is form CSC 1064 "Notification to Provide Urine Sample";

• At least two sites are altering the official distribution lists on CSC and OMS documents; • Staff indicated that some form distributions are not appropriate. For example, staff

questioned the significance of filing inmate request forrns on the case management file (as required by the ORSM) when the subject matter deals with a Health care issue. At least one region has amended this practice and now files inmate request forms in the most appropriate file bank, depending on the nature of the request; and

• Staff commented that "distribution lists are often wrong and very hard to change". Staff reported that requests to amend distribution lists have been made to NHQ to no avail.

This is an issue that illustrates the need for policy holders to ensure better consultation, communication and coordination with records management when developing new forms.

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Quality Control: In accordance with the ORSM, "periodic inspections of the files on extended charge [files in the sub-registries] should be conducted by the Records Clerk to ensure that files are being maintained properly by the user offices". The audit team found that there is very little quality control of the files being conducted in either central registry or in the sub-registries. Interviewees indicated that this has been hindered by time and resource limitations and that attempts are made to review files when they are transferred in and/or out. It is possible that the file maintenance problems identified could be minimized by a more active quality control process.

Case Management A and B files: The approach to the use and storage of Case Management A and B is inconsistent. In two regions, the files are archived. When the offender is transferred to another region, the files are recalled and forwarded to the new region. In the other three regions, these file banks are held in the institution, and are accessible by case management staff.

Finding #2: Offenders submitting requests through ATIP may not be receiving all existing information.

The audit team sought to identify documents that were not printed from OMS and/or placed on offender files. Vast inconsistencies were found from one region to another, and from one responsibility centre to the other. In general, documents that require a signature are filed, and these same documents are usually those that are shared with the offender. Documents not requiring signatures such as casework records, standard profiles, psychological notes, memos to file, etc., are printed and filed sporadically. Interviewees reported that little direction is available for staff to know what should be printed and what should be filed.

The primary concern with respect to this issue relates to requests through Access to Information and Privacy (ATIP). Given that hard copy file banks are generally used as the main source (and often the only source) of information for ATIP requests, it is possible that the offender may not receive all the information that would have been shared (prior to OMS). It was indicated to the audit team that OMS and/or POs are rarely consulted when processing these requests. As a result, pertinent information, may not be included in the requests. The information received could be inconsistent from one site to the next.

In a memo dated March 11, 1998, the Director General of Offender Reintegration indicated that "casework records do not have to be routinely printed and placed on the offender's paper file". The memo continues by stating that "the only time that a parole officer should need to print casework records is when they are needed for sharing...". The audit team found that some sites print casework records weekly, others monthly or only when necessary. Filing is also sporadic; some file casework records chronologically, others in bulk by most recent date and some not at all. File reviews confirmed that casework records were generally filed onto the CM file. However, records were also found on other files such as Employment, CDIs and Education and Training, depending on the subject content.

Staff interviewed were not all aware of the direction not to print casework records. In addition, some were confused as to what filing practices were to be followed when casework records were

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printed in order to conduct quality controls. Some indicated that these records were destroyed in light of the fact that they were available on OMS. Others reported that casework records were filed once the quality control process had been completed.

Some sites have attempted to include POs in the process with limited success. One institution has assigned the responsibility of printing and filing all OMS information to one clerk. As a result this individual can easily identify what is missing from the hard copy files.

The findings of the audit team are consistent with those outlined in the Policy Bulletin on CD 095 "Information Sharing with Offenders", dated 98/01/22. It states that:

The Correctional Investigator has expressed a concern that offenders may not be receiving all the personal information to which they are entitled when they submit requests. It is likely that this is due to the fact that not all of the sources of offender information, in particular Offender Management System (OMS) reports, are being reviewed when responding to the requests.

The accompanying letter, signed by the Acting Commissioner, requires "that a response to an offender request for personal information includes information in OMS. Any official information ... that is in OMS but is not on the paper file needs to be included". It further suggests that "records and operational staff work together to ensure that ... a concerted effort is made to ensure that all requested information found in either the paper or electronic format is collected".

The results of the current audit would indicate that this is still not occurring. Many interviewees expressed a concern with respect to the implementation of such a process and the additional time and effort required to identify all information that is not on the paper file. Of particular concern was the extent to which this would be impacted by the length of incarceration of the offender and the information generated by institutions prior to the transfer to the institution receiving the access request.

This issue will also need to be considered if OMS is to be used as the official file (refer to finding #8).

Clear policy direction, identifying the process and specific responsibilities, should be provided with respect to this issue (refer to recommendation #3 under finding #10).

Finding #3: The use of in-house forms is widespread in all regions.

A large number of various in-house forms were found in all five regions. Although staff were aware of the existence of most in-house forms at their institution, no record was available of what forms were being used. In a limited number of cases a local listing or database was kept, however it was generally outdated.

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Treasury Board policy on "Government Information Holdings" states that

...all forms used to collect information be reviewed ... and ... government institutions control forms creation and use, regardless of the media in which they appear ... A designated departmental authority should review all new or revised forms to ensure that the information is clearly presented and that the form meets the functional requirements of both the institution and its user. Forms must meet all statutory and government policy requirements including those related to the Privacy Act, the Official Languages Act, the Federal Identity Program and...this policy.

CD 201 on "Forms Management" further simplifies the above by requiring that in-house forms must be approved by NHQ. Very few staff were aware of the process to validate in-house forms or of the existence of the CD. Of those sites that were aware of, or followed, the appropriate procedures few ensured that these steps were followed. As a result, certain legal or policy requirements, as stated above, may not be met when developing in-house forms. The audit team found that in some sites visited, measures have been taken to reduce the number of in-house forms. In addition, some sites have a system in place to share new forms with other responsibility centres.

It was noted in at least two sites visited that official CSC forms have been amended to suit the needs of the institution. For example, at one institution visited, form CSC 289 "Activity Record" was being used as a "90 Day Correctional Plan Review".

The team collected the in-house forms found during the review, and examined them to determine whether an equivalent official CSC forms exists, whether more than one institution or parole office had identified the need for a particular form, or whether amendments need to be made to official CSC forms. In all but one site visited, various versions of at least one form (or different forms) were used to record similar information at a single site. A list of the types of forms found are summarized in Annex D.

Examples of in-house forms found where national forms exist include the following:

In-house form description Equivalent CSC form 1. Inmate Personal Property Records CSC 514 "Inmate Personal Property Record" 2. Travel Permit Form CSC 344 "Travel Permit" 3. Employment Application Forms CSC 843 "Inmate Application for Employment" 4. Referral to Psychological Services CSC 450 "Psychological Services, Referral to the

Psychologist" 5. Offender Call List Application

CSC 1130 "Offender Application for Authorization to Access a Telephone Number"

6. Interception of Communications CSC 1035 "Statement Concerning Private Communications"

7. Inmate Request Forms CSC 1122 "Inmate's Request"

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Some content differences were noted. In some cases, interviewees indicated that the national form did not contain all the information that the site wanted to collect. As a result, some in-house forms expanded on the equivalent national form. However, other in-house forms reviewed by the audit team were missing information contained in the national form. The two interception of communications in-house forms reviewed were both missing a phrase with respect to the consequences of the inmate's "refusal to acknowledge" and one was missing a witness signature block.

In addition to official and in-house fonns the audit team found various OMS printouts (Quiz reports or print-screens) on file. A number of in-house databases were also identified. The following list provides an example of databases that are being used:

• Residence lists; • Caseload lists; • Employment lists; • BF systems (i.e., Guggan, Excel); • Inmate Records Program (Central Registry); • Pay System; • Psychological Assessment Database; • Electronic victim contact log; and • A&D programs.

These systems have also contributed to the wide variety of "unofficial" information / reports found on offender files. Staff were unable to confirm that these systems are purged when a pardon is issued. There appears to be little control over the management of infoimation with respect to most in-house databases.

With respect to BF databases, most sites had a local system in place for this purpose rather than the OMS system. It was reported that Mountain is the only site in the Pacific Region that uses the OMS BF system. The OMS data assurance officer has developed a checklist for Parole Officers to ensure that the BF system is completed properly and utilized to its full potential. It was reported that the OMS BF system is sufficient for the POs' needs.

The issue of in-house forms and databases has an impact on many areas of the Service's operations. In particular, if information is not properly recorded, or if in-house forms do not meet legal and policy requirements, this could have far-reaching implications in processes such as decision-making and incident investigations. The need to review both official and un-official forms was also raised by the Policy Review Task Force in their 1996 report.

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RECOMMENDATION #1

a) That an in-depth review be conducted of all in-house forms to determine whether there is a need to develop any national forms (or modify existing forms), or whether some of the information could be incorporated (in the long-term) into OMS.

ACTION BY: Assistant Commissioner, Corporate Services and Assistant Commissioner, Correctional Operations and Programs

b) In the interim, that each responsibility centre maintains an inventory of in-house forms (including a brief description of their purpose). In addition, responsibility centres should ensure that in-house forms meet the appropriate policy and legal requirements and that existing national forms are used where possible. This should be preceded by a review of the form to confirm whether it continues to be needed and/or filed on the offender's file.

ACTION BY: Wardens and District Directors

Finding #4: A variety of documents are being kept on the top of Case Management files.

According to ORSM the Case Document Checklist (CDC) and Criminal Profile Report (CPR) "must be placed on file atop all other documents in Case Management file". With the implementation of Operation Bypass and the incorporation of the CPR into the Correctional Plan, the following direction was given in a memo from the Chief, Recorded Information Management (NHQ), dated 99/03/17:

We have been advised that the Document Checklist is to remain as the topmost document on file. If the Correctional Plan / Criminal Profile was done after 99/02/01, it is to be filed as the second topmost document on file. In cases, where there is already an existing Criminal Profile which has not been included in a new Correctional Plan, then it is to be filed as the second topmost document on file.

The majority of staff interviewed indicated that they were generally aware of this requirement, although had not necessarily seen the memo mentioned above. File reviews found that at least one site visited in every region maintained old versions of the above noted documents on top of the file. In addition, other documents were found during file reviews, including: SIR Scale, Penitentiary Placement, New-Offender Case Management Checklist, NPB Hearing Waiver, Victim Notification Alerts, Office ALERT Checklist, Progress Summary, Institutional Detention Review, Correctional Plan, Standard Profile, etc.

In addition, several versions of a same document were also found. In these cases, only the most recent version should be maintained on the top of the file (as supported by the above directive) and previous versions filed chronologically in the file.

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It was further noted that if a file is received that contains additional documents in the top-most plastic folder, then these are not normally removed or filed in chronological order. As a result, some plastic folders are quite full and it is often difficult to find important information (i.e., CPR), which defeats the intent of the process.

The audit team noted that topmost documents are being kept in other file banks. Current policy only allows for this to be done on the CM file. Examples of this practice include:

• SM: at one institution, sentence information and calculations were found in a plastic folder on top of the file;

• PSY: at three sites visited, some files contained a temporary confidential docket with research data;

• VC: some files at one institution contained additional yellow folders with private family visit notifications and private family visit referral decision sheets;

• PS: at two sites, a temporary confidential docket containing mostly OMS information was found; and

• Documents were attached to front of the file jacket (eg., Standard Profile) in various file banks.

It is suggested that responsibility centres take the necessary action to purge topmost documents and ensure that only those required by policy remain. This could be done over a period of time, for example, as files are transferred or a small number of files on a regular basis.

Finding #5: Critical Document Inserts (CDIs) are still used sporadically in two regions.

According to the ORSM:

In order to facilitate access to essential case management documentation, the CDI contains copies not originals of vital, current documents necessary for the ongoing management and supervision of the offender and decision making purposes.

The ORSM further identifies a number of CSC and NPB documents to be placed in the CDI. Examples include the Correctional Plan, Case Document Checklist, General Statistical Information, Warrant of Apprehension and Suspension of Day Parole, etc. Of the 23 documents listed, in the ORSM, approximately 52% are OMS documents, 39% are hard copy forms and at least 9% are now obsolete.

Of the five regions visited only Ontario and Pacific have an active CDI file bank. However, the use and maintenance of CDIs in these two regions are sporadic. The three remaining regions indicated that CDIs have been discontinued or as in one region, never used at all. In most cases, staff reported that CDIs received from other regions are destroyed once it is ensured that there are no originals found in the CDIs.

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Of the 39 CDIs available for review, the following observations were made by the audit team:

• Content - The CDIs examined do not represent a collection of consistent documents. A wide range of documents including psychological reports, waivers, community assessments criminal profiles, FPS sheets, casework records, inmate generated letters, etc. were contained in the CDIs. Some CDIs contained no information at all. In conjunction with the finding that most CDIs were being stored as a separate file bank, it appears that these inserts serve more as shadow files;

• Originals - Originals such as staff notes, case summaries and letters were found on CDIs. Due to the lack of time and resources there appears to be no systematic quality control of CDIs;

• Disposition - Staff reported, in one region, that CDIs are being archived rather than destroyed. It was indicated to the audit team that staff are following a regional direction dated 97-09-06. Where CDIs are being destroyed, the content is not always verified to ensure that originals are removed.

• Purging - It was reported that clerks are generally responsible for purging CDIs. This is contrary to the ORSM, which requires the parole officer "to extract or destroy any documents (copies) which he/she feels are outdated or irrelevant ... Content is entirely the responsibility of Case Management";

• Use is inconsistent - Two sites indicated that CDIs are periodically reviewed for decision purposes by Management. Only one site reported that Parole Officers reference CDIs; and

• CDIs are creating duplicate files - Because most of the information contained in the CDIs was available on OMS and the offender file, staff commented that CDIs are becoming more and more obsolete and redundant.

As indicated above, CDIs appear to serve more as shadow files. On this same topic, the audit team also confirmed the use of various other shadow files in at least four responsibility centres visited. Staff indicated that the maintenance of these files requires a large amount of additional resources to make photocopies and print extra copies from OMS.

The tem "shadow file" is used to describe files containing copies of official information. These files are generally kept in regular file folders, in employee offices (other than central registry or sub-registries). Policy does not allow shadow files to be kept, as all offender information should be stored in official file banks which . No other records should be maintained (the ORSM states that "temporary dockets or unofficial files should not be created").

At this time, there has been no firm national decision taken to discontinue the use of CDIs. Direction has not been given to remove this requirement from the ORSM. Until this occurs, the use of CDIs will continue to be inconsistent across CSC.

12

RECOMMENDATION #2

a) That a decision be taken and clearly communicated with respect to the continued use (or discontinuation) of CDIs.

b) That the result of this decision be reflected in the ORSM.

ACTION BY: Assistant Commissioner, Corporate Services and Assistant Commissioner, Correctional Operations and Programs

Finding #6: Most sites visited were unclear as to their responsibilities with respect to the creation, retention and destruction of Warrant Expiiy (WED) / High Risk Offender packages.

The preparation of these packages was reviewed at medium- and maximum-security institutions visited (very few are required at minimum-security facilities). The receipt and handling of these packages were examined at Parole Offices visited. In all, twelve WED packages were reviewed.

Preparation: The audit team found that there were varied interpretations of the requirements of CD 782 on "Sharing Offender-Related Information". This policy states that the preparation of WED packages is the responsibility of each Institutional Parole Officer in some cases, and the Area Director in others.

At one institution visited, it was reported that packages are completed differently depending on which Parole Office the package is being sent to. Most Parole Offices expect the sending institution to complete the package. Others only require that a current photo of the offender be provided and complete the package themselves. Still other Offices want only a list of the relevant documents that should be included in the package.

The audit team found that some of the packages reviewed did not contain the minimum documentation required by CD 782. Some interviewees indicated that they often do not receive all of the information they require.

Receipt: CD 782 requires that "the releasing institution shall prepare a comprehensive information package and forward it to the CSC area parole office...at least sixty (60) days prior to release at warrant expiry." Parole Offices indicated that almost all packages are received within the required timefi-ame.

Retention / Destruction: It was noted that half of the Parole Offices visited retain WED package copies after the offender has reached his/her WED. Given that the content of the packages are copies of documents already on the offender file, only the covering letter and a list of documents provided should be retained on an administrative file (and the offender's file for ATIP purposes) and the remainder should be destroyed.

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Finding #7: Victim information on the Case Management File is not always being filed or stored appropriately.

The NHQ Performance Assurance Sector conducted a Victim Notification audit last fiscal year. The final report completed in September of 1998 recommended that a separate official victim file bank be created. Presently, the Correctional Operations and Programs Sector is taking steps to finalize an SOP ("Disclosing Information to Victims") which implements this recommendation. In the interim, not all staff have been made aware of the required practices to ensure that victim information is filed appropriately and not shared with the offender.

Victim information is designated as Protected C due to its extreme sensitivity that may, "if revealed, endanger somebody's life..." (DSPM, Page 2). During the audit, victim information was found filed chronologically on the CM file bank in three regions visited. It was indicated to the audit team that this is a common practice in some regions. In other regions, a separate red file folder is used to hold all victim information. This folder is inserted into the most recent CM file. However, staff expressed concern regarding this practice, stating that mistakes may happen. This was confirmed by the audit team, when victim information was found filed chronologically in the CM file in the regions using this practice.

Policy indicates that "where a file contains material with a mixture of documents, it must be marked and handled to reflect the highest level document it contains" (DSPM, Chapter 3 - Security of Information and Assets). This was generally found not to be occurring. Files were not marked as Protected C or marked as containing victim information. Victim documents were also not being marked as Protected C in the file bank. Staff reported that when an access request is received, hard copy file banks are the main source for the collection of information for the request. There is a potential that victim information may be shared with the offender, in particular where it is still being filed chronologically on the CM file.

In addition to the above, it was noted that police agencies often include victim information in police reports and forward this package to CSC where it is placed on the CM file. Again, there is a danger that this information may be shared with the offender, particularly if it is being shared by a staff member who is not familiar with the requirements related to victim information.

The above practices also have storage implications. Protected B CM files are stored on open shelves in secure rooms. Protected C information should be stored in an approved locked container. According to policy, any file containing Protected C information must be stored in a locked container. In most responsibility centres, this is presently not occurring with respect to victim information. This is also true where victim coordinators store victim information in their offices.

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Finding #8: Interviewees were not receptive to the idea that OMS be adopted as the official offender file.

With few exceptions, there appeared to be a general consensus among staff interviewed that it will not be possible, in the near future, for OMS to be maintained as the primary source of offender information. The audit team met with staff in administration and case management to discuss this issue. The following comments were made regarding the above issue:

a) Not all documents are available on OMS. These include court documents, police reports, in-house forms and some CSC forms, etc.;

b) Many documents require signatures and OMS does not yet have the capability to record electronic signatures;

c) OMS is not always operational or is often slow, which can make information retrieval difficult;

d) Some «users are not comfortable with operating a computer and as a result are reluctant or refuse to use OMS;

e) Some interviewees felt that OMS is not user-friendly and that it is often difficult to find information in a timely manner. It was felt that OMS is a good system for storing large quantities of offender information, but not to retrieve it;

f) Since the implementation of OMS, some staff feel that the result has been the creation of more paper at a faster rate; and

g) Many users find it much easier to view documents on hard copy than on a computer screen.

The first two comments were the most common provided to the audit team. Nevertheless, the team members often repeated the question, asking whether OMS could be adopted as the official file if these two issues were resolved (i.e., if electronic signatures were available and non-OMS documents were scanned into the system). It was found that there was still a general reluctance to the idea. Many of the other comments (c through g) were in response to this second form of the question.

With respect to the fact that not all documents are available on OMS, the audit team verified whether any external information was being scanned or otherwise imported into OMS. Scanning is occurring at some of the sites visited. Documents such as contract psychological reports, court documents and judges comments are presently being sc anned into OMS. The primary concern in these cases is the disposition of the original document, which at this time, are being filed on the offender file.

In the Quebec region, a project has been initiated to scan court documents and remove all references to persons (names, addresses, phone numbers, etc.) other than the offender. This project is being coordinated by the Operational Support Branch of the Correctional Operations and Programs Sector. This information will then be made accessible on a common intranet site, although currently, they are being printed and placed on the offender file. Staff will be able to locate a document based on the type, the name of the offender, or the case number. Copies of the unpurged documents will still be made available (i.e., to the NPB), although procedures are being developed to ensure that only the purged document is shared with the offender.

15

Objective 2: To examine the process in place to manage offender records.

Finding #9: Resource levels and associated responsibilities vary from one responsibility centre to the other.

Resourcing

Although the audit team had hoped to compare resource levels at the various central registries visited (as a measure of the inmate population or offenders under supervision), this proved to be a difficult task given the wide variety of responsibilities held by staff. For example, some are only responsible for offender files, others are tasked with case management preparation and clerical services, switchboard and mail duties, administration support to senior management, finance, preparation of legal documents such as warrants, etc. Titles for staff responsible for records vary from Case Management Clerk, to Unit Clerk, to Records Management Clerk, to Case Documentation Clerk. Although most of these positions are classified as CR-03, staff reported that some clerks responsible for sub-registries are classified higher (i.e., some psychological clerks are CR-04), although again, a comparison is difficult because of the varied responsibilities. There is less consistent classification for administration supervisors in the community. Classifications vary form CR-04, to CR-05, to AS-02. Their institutional counterpart, the Chief of Administration, was normally an AS-02 classification and report to the Assistant Warden, Management Services. Staff indicate frustration over low classifications for clerical staff as well as the apparent inconsistency of responsibilities and classifications between regions.

In addition, the vast majority of sites reported that not enough resources were available to keep up with the proper management of offender records (i.e., filing, quality control). This is a concern for many institutions, especially those who are expanding their population within the next few months. All interviewed indicated that at least one to two additional full-time positions are required in their central registry. Sub-registries also indicated that additional help was required.

Training

Very little formal training was identified. Most institutions indicated that training was "on-the-job" and passed from one staff member to the other. Even less training was provided to staff in sub-registries. The Prairie and Quebec regions were the only regions where staff interviewed were aware of a regional training course on records management.

In many sites, staff turnover in the offender records area is frequent. In order to facilitate the training of new staff, some responsibility centres have developed their own local training manuals.

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Finding #10: Staff indicated a need for better direction and support with respect to the management of offender records.

Direction

Staff reported that direction, guidance and support is lacking locally, regionally and nationally. Although better in some regions, staff feel that they are often left "out of the loop". At many responsibility centres, Case Management staff decide what is to go to each file bank rather than records staff. Due to conflicting direction, staff indicated that they are often confused with respect to where information should be filed.

Staff also expressed frustration that, in their opinion, records management is not seen as a priority. Staff reported that they are not often consulted or provided training regarding operational decisions that involve administration issues (i.e., Operational Bypass). Staff indicated that they feel that such issues are not given much attention at the national level, and that they often do not know who to contact at NHQ for decisions.

The audit team noted that there does not appear to be a consistent communication link between central registries and sub-registries. When asked where/whom questions are directed, sub-registries could not always identify a position or person. Policy, as well as amendments, are also inconsistently communicated to sub-registries and some central registries (mainly in the community).

Policy

At each institution visited, the Standing Order (SO) 202 on Records Management was examined. Approximately half of the institutional SOs reviewed were well written and in accordance with national policy. The remaining SOs needed to be updated to reflect current practices and procedures, were missing information such as a list of staff who have access to file banks, and/or repeated requirements found in higher policy documents.

Only three of the five Parole Offices visited had an SO. Of those that did, many of the same problems, indicated above, were noted.

In addition to the SO, the ORSM is the national procedural document developed to provide guidance to records management staff. Although most central registry staff were aware of the ORSM's existence and content, most reported that it was not a helpful guide, and as a result rarely referenced. Where OMS or fonn distribution lists or local/regional procedural manuals are used for filing documents, staff reported that these are not always in line with the ORSM (or with each other). Some sub-registries were not familiar with any of the above manuals nor policy relating to records management.

As noted under "training", local procedural manuals are being used at some of the sites visited. These manuals range from complex documents to checklists. The Prairie region has a regional manual, which appears to incorporate parts of the ORSM. This manual is also used as a regional

17

training manual. The Quebec region has developed a manual that focuses on the process to be followed for the transfer of offender files.

It is further noted that CD 202 "Recorded Information Management" primarily refers to the security issues and storage of files. Neither the CD, nor the ORSM, currently address many of the issues raised in this audit. As a result, the following recommendation is made:

RECOMMENDATION #3

That the Corporate Services Sector and the Correctional Operations and Programs Sector work together to develop a policy providing clear direction to those responsible for offender records management. Information in the ORSM and CD 202 should be updated to reflect any changes. The policy should take into consideration each issue raised in this audit report and identify specific processes and responsibilities.

ACTION BY: Assistant Commissioner, Corporate Services and Assistant Commissioner, Correctional Operations and Programs

Finding #11: Offender files are not always stored in a secure manner.

The audit team examined the physical security of the file rooms as well as the cabinets in which files are being stored. The following observations were made:

Filing rooms - Filing rooms (central registries and sub-registries) did not all meet fire and security standards (eg., mesh ceilings). In one institution, files are being stored in Institutional Parole Officers' (IPO) offices.

Inmate employees - It was reported at seven sites visited that inmates are working in close proximity to offender files. Some of these offenders are filing documents on offender records and shredding protected information. Others are working as cleaners or clerks in areas where they may have access to files, often without direct supervision. This is contrary to the DSPM, which states that

... offenders have no Security Clearance or Reliability Status and must be denied access to classified and designated information. Particular care must be exercised to ensure that offenders see no protected or classified information about staff members and about any other offender. ... [inmates are] not permitted to work in areas where any of the above information is stored unless they are supervised closely enough to guarantee they cannot get access to the information.

Locking mechanisms and practices - Container locking mechanisms do not all meet security standards (key lock filing cabinets, combination locks with no bar, etc.). A few security practices also did not meet appropriate standards. For example, one site has a designated room in

18

which files are stored overnight. Although this room has a password locking mechanism, staff leave the door open until the last staff member leaves the building. In addition, a few central registries did not meet the requirements of a security zone. The registry was open to all staff and access was not limited to authorized personnel only.

In addition, as previously mentioned, Protected C documentation is not always being stored according to the requirements in the DSPM. For example, in one institution visited, PS files are kept in a locked bar filing cabinet for which the key is the same as that which unlock the door to the office. Another example is the storage of victim information (as discussed under finding #7).

Overnight storage of files - Where files were not returned to central registry at the end of each day, offender files were stored overnight in various locations, including staff offices, staff homes, or other designated cabinets/rooms within the institution. In most cases, these did not meet the security and fire standards for the storage of offender file.

Removal of files from facility - Four sites indicated that files are removed from the facility. Some sites allow this practice only with written authorization from the Warden or Unit Manager. This authorization practice was, in most cases, required by a standing order. At other sites, staff reported that files are taken home without the need for prior approval, or that files could be removed without anyone realizing it due to a sign-out process which does not require that files be returned each day (refer to finding #12 below). Three of the four sites indicated that proper security containers are not used to store files when they are removed from the facility.

Interviewees indicated that this concern no longer relates solely to paper files. Given the amount of information that is now available in electronic format through OMS or other databases, the removal (and associated risks) of information through other means is also a concern. Even where files are returned each evening to central registry, staff can still print documents from OMS or save offender information onto a diskette or lap-top.

Storage concerns: At least six responsibility centres visited reported a lack of space for files. As a result, some files are being stored in boxes and in rooms that do not meet proper security and fire standards (as discussed above). This included sites where problems will be encountered with upcoming expansion plans. At these facilities, appropriate space allocations will need to be examined in order to ensure compliance with policy.

Other forms of media: The audit team briefly examined the issue of offender information not recorded in OMS or on paper (eg., diskettes, video tapes, audio tapes, etc.). The majority of this information is not the responsibility of central registries, but rather are stored, controlled and disposed of by others within the institution (IPSO, CCO, etc.).

Threat/Risk Assessments (TRA) - Treasury Board policy stipulates that "...assets are to be safeguarded according to minimum standards and an assessment of related threats and risks" (Chapter 1-1 Security Policy). The Manager's Handbook (as described in the Security Policy) goes further to state that "managers should review security needs for the information and assets under their control by assessing related threat and risks." No recent threat and risk assessment of

19

areas containing offender files has been conducted at any of the sites visited. Bowden Institution was the only institution visited that was aware of an assessment having been conducted (1986).

Part I of the DSPM includes a section on the assessment of threat and risk as well as a threat and risk assessment worksheet. It indicates that the TRA must be revised at least once per year.

RECOMMENDATION #4

That each facility examines the storage of offender files to ensure that they are in compliance with the appropriate security requirements. This should include a threat-risk assessment.

ACTION BY: Wardens, District Directors (monitored through Regional Performance Assurance)

Finding #12: Files maintained by central registries and in parole offices are generally well controlled. There are often fewer controls over those offender files stored in other areas of the institution (sub-registries).

Structure

Most sites visited operate their records management structure in accordance with CD 202 and the ORSM. With one exception, all institutions visited operate a central registry which, at the very least, stores CM and DD files. The remaining files, PS, SM, PSY, etc., are kept in other areas of the institution, called sub-registries. Parole offices only store CM, PSY and PS (where applicable) files. These files are generally held in central registry.

In all sites visited, clerks were responsible for the operation of central registries. The overall records management role, at most sites, falls under the responsibility of the Chief of Administration (Institution) or the Office Manager (Parole Office). These positions are seen as supervisory and advisory roles. In sub-registries, however, the management of offender records falls under the responsibility of a variety of staff, including clerks, security staff, or others as available (eg., nurses responsible for the Health care sub-registry), who are not under the supervision of the administrative division.

Although most sites adhere to the structure outlined in the CD, some sites operate very unique records management structures. One institution visited in the Pacific region, stores only dormant files in central registry. CM, CDIs and DD files are held in the units in each IPO's office. Content and maintenance of these files is the responsibility of the IPOs and the unit clerks. The remaining files are stored in sub-registries within the institution. Although this structure has obvious security concerns, the Chief of Administration has no supervisory role over the records. Staff reported that direction regarding the file banks generally comes from Case Management. During the file review process, a large number of inconsistencies were identified by the audit

20

team at this institution. It was suggested during the institutional and regional debriefings that a review of the above structure be undertaken with a view to centralizing files and ensuring greater consistency and adherence to policy.

In one third of sites visited, central registry is located far from POs offices. The audit team found that in these cases, shadow files were more likely to be created. It was also reported that this would also likely be the case where central registry is located outside of the main gate of the institution.

Although the ORSM requires that "periodic inspection of files on extended charge [sub-registries] should be conducted by the Records Clerk to ensure that files are being maintained properly by the user offices", this is not taking place.

Access/sign-out:

According to the ORSM, "when a file is taken out of its holding area, the name and office of the user as well as the date are noted on the charge-out card, as well as the file jacket; the card is then replaced in the cabinet in lieu of the file". This is required to ensure consistent tracking of all files. It further indicates that "when a file is held in an office other than the Records Office ... the holder then assumes responsibility for ensuring that the Service's regulations on the maintenance of and access to offender files are respected". The audit team observed a number of different charge-out procedures, which are presented in the three sections below.

Institutional Central Registries

The majority of central registries visited maintain good control of the file banks stored in this area. Access normally occurs on a "need to know" basis. Only records clerks are permitted to enter the central registry to retrieve requested files. However, charge-out procedures were found to be inconsistent. File jackets and charge-out cards are not always being completed properly by all sites and files are not being replaced by charge-out cards in the filing system. It was noted that at least four of the central registries visited maintain a logbook, in addition to the above, which records charge-out information. This was used as a central database to record all charge-outs for each day. It also served as a reminder to administration staff as to which files were not returned on time to ensure follow up action is taken. One site uses their Master Control Index Cards to sign-out files.

Institutional Sub-registries

The most common charge-out practice available to sub-registries is signing out the file jackets. This, however, is not being used. In fact, only a small number of cases were found where consistent file jacket sign-out was occurring, primarily with respect to PS files. In addition, it was noted that although clerks are responsible for these files, access is not restricted and users may walk in and remove files. Sub-registries reported, however, that there is generally very little access to files fi-om staff outside of the sub-registry area and that files are not often removed fi-om there.

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Parole Offices

Five parole offices were visited during the audit. All sites operated central registries. However, the access and sign out controls varied from one office to the next. At two parole offices, all staff have access to the central filing room and no charge-out procedures are in place to track file access. At another office, all staff have access to the file room and are required to complete charge-out cards, but do not sign the file jacket. At the two remaining sites, access was limited to records clerk. However, file jackets were not consistently being signed, but one office did maintain an in-house file control sheet.

General access sign/out issues

At most sites, files were required to be returned at the end of each working day. In others, however, staff were allowed to keep them for up to one month before a request was made to bring it back to update the filing. Still others did not have a specific time period for the return of files. In these institutions, there is a concern with respect to the secure storage of these files when not maintained in central registry, and the risk that a file could go missing and unnoticed for some time.

Although staff reported that file access is normally on a "need to know" basis, it is evident from some of the above findings that there are no controls in place to verify that this type of access is indeed occurring. According to the ORSM "classified information should be made available only to persons who have an appropriate security clearance and who need to have such information to perform their duties. This information may not be disclosed to persons merely because of position level or their security clearance." In addition, some responsibility centres visited where external agencies are used for cleaning could not confirm that the required security clearances had been obtained. They fu rther indicated that these individuals were often unsupervised in areas where files are stored.

Inventory Control

Inventory control is maintained through the use of Institutional and Community Master Control Index Cards (MCIC). Some sites indicated that the MCICs have been replaced by automated index systems, i.e. Ontario region. It was reported that these systems record the same information as the MCICs, as allowed by the ORSM. At one site, staff in sub-registries maintained, in addition to central registry, a second set of MCICs, which is a duplication of effort and is not necessary if a complete inventory is kept by central registry.

A concern was expressed with respect to file transfers and inventory controls. Transferred files are not consistently being forwarded to central registry once received by the institution. File inventory was found to generally be the responsibility of central records. Staff reported that some files are forwarded directly to sub-registries, bypassing central records. If sub-registries do not notify central registry that these files have been received, inventories are not complete.

In addition, staff indicated that difficulties were being encountered with Health care and psychology. At some sites, procedures require that HC and PSY files be sent directly to the sub-

22

registry for fear that someone may access the file. Administration staff indicate that this creates problems because they are required to verify which and the number of files received. This information is not always provided to them by the sub-registries.

It is suggested that, where possible, all file transfers be sent to central registry and that central registry staff be permitted to vere the number of files delivered to the institution. Where this is not feasible, sub-registries should ensure that central registry is advised of the number of volumes received for each offender.

The ORSM lists the community operational units that are eligible to receive PSY and/or PS files for released offenders. Four of the five Parole Offices visited reported having difficulty receiving PSY or PS files when an offender is released. Institutions refuse to send them or the Parole Office must call and specifically request them. It is noted, however, that only two of these four sites are listed in the ORSM as being eligible to receive these files.

Missing Files

Missing files were reported by most sites visited. Staff indicated that informal local inquiries were conducted to find missing files and a few proceeded to the regional level. Staff, however, are generally aware of the procedures to follow to report missing files. The Prairie region has developed regional forms to ensure process is better understood and consistently reported. There is also a requirement that missing information is to be reported on Security Incident Reports so that NHQ is notified in a timely manner. It would not appear as though this is routinely occurring.

According to the ORSM, "a file is created only when a new record is received or produced and when it has been verified that the pertinent file on which to store it does not exist". In order to better track and control PS and DD files, however, the Quebec region now creates each of these files for all offenders during the reception process (as opposed to creating them as they are needed). Interviewees noted that prior to the implementation of this practice, missing PS and DD files were not always noticed as not all offenders had one.

It is suggested that this practice be reviewed to determine whether it should be implemented elsewhere for better file control. If so, then the ORSM may need to be amended to allow for the change.

The primary concern noted during the review of this issue is the potential link between the possibility of a missing file and the level of control over access and sign-out, as well as the inventory control process when offenders are transferred or released. As a result, the following recommendation is made:

23

RECOMMENDATION #5

That each facility review their current access and sign-out process to ensure compliance with policy requirements and an adequate control over offender files.

ACTION BY: Wardens, District Directors (monitored through Regional Performance Assurance)

24

ANNEX A Objectives and Issues

Objective 1: To determine the extent to which the content of offender files varies from one responsibility centre and region to another.

1.1 There is a consistent approach to printing information fi-om OMS at all sites.

1.2 There is a consistent approach to filing information on an offender's official aper) file at all sites?

1.3 Mechanisms are in place to control the existence and content of file inserts / packages (i.e., CDIs, WED packages, etc.).

Objective 2: To examine the process in place to manage offender records.

2.1 What resourcing levels are in place at each responsibility centre?

2.2 What policies and procedures are in place, regional or local, to facilitate the management of offender records?

2.3 Where are the various offender file banks stored and what physical security measures are in place in each area?

2.4 There are mechanisms in place to control access to and sign-out of offender files.

ANNEX B Responsibility Centres Visited

Atlantic Region

Dorchester Penitentiary Moncton Parole Office

Quebec Region

Federal Training Centre Joliette Institution Hull Parole Office

Ontario Region

Warkworth Institution Kingston Parole Office

Prairie Region

Bowden Institution Drumheller Institution (Minimum security annex) Southern Alberta District Parole Office

Pacific Region

Ferndale Institution Mountain Institution Vancouver Parole Office

ANNEX C Sample of forms with different distribution lists

Fôrrit Nuitibèr: : Title:Offtiriliiiin , ORSM:. ,: • "OMSDitiltiütiOn ' e.deâilyS-FOilii: - : _ — OMS and Distribution : Q:ébii -ginàfiCl ,dciiy) , :

CSC - 0002 Psychological Assessment 0 = CM 0 = Offender Adm. File, C = NPB Report C = PSY Regional, NPB District Office,

Originator CSC - 0080 Transfer Warrant 0 = SM No distribution list indicated CSC - 0199 Escort Temporary Absence/ 0 = CM 0 = Escort, (R-92-11) VVork Release Permit C = In mate CM File CSC - 0294 Community Assessment 0 = CM 0 = Inmate File, C = CDI, NPB CSC - 0344 Travel Permit 0 = CM 0 = Parolee's file, C = To Police

Destination, NPB, Police where Parolee's repo rt ing, RCMP, Parolee

CSC - 0338 Special Report 0 = CM 0 = Inmate File, C = NPB Regional Div., Inmate, SM Officer

CSC - 0430 Progress Summary Report 0 = CM 0 = Inmate CM File, C = Inmate, CD!, NPB Regional, SM Officer (if appl.)

CSC - 0831 Notification of l/m Release 0 = DD 0 = Inmate from Segregation C = CM C = DD

CSC - 965 Criminal Profile Report 0 = CM 0 = Inmate File, C = PS File, NPB, Inmate, CDI

CSC - 966 Case Document Checklist Note 1 0 = Inmate (R-91-11) C = NPB CSC - 0994 Community Risk/Needs 0 = CM 0 = CM

Management Scale Note 2 C = Inmate (Community Intervention Scale)

CSC - 1099 Inmate Progress Report 0 = CM 0 =1/m, C = CM, (94-06) Program Ass. Supervisor Notes: 1. Original in chronological order in CM File and copy is to remain as the top most document on the CM File. 2. Copy of the most recent on CDI while offender is in the Community.

UM • OM MI Mall MI MI OM OM UM OM MI • • • MI

ANNEX D In-house forms

'BI i VP0 MP° Fl MI 1)1: TOTAL,

Initiate ReqUest-Forni (varibUs purposes)

3 1 1 1 3 1 1

Inmate Request Form (specific) 3 4 Request/Notice Regarding Personal Information

1 2

Notice/Response regarding Urn requests

1

Sharing of Information Checklist (by-pass) Sharing of Information (Individual 1 4 5 2 National Parole Board Hearing/Review Sharing of Information

1 1 1 2 1

Notice to 1/m Regarding Parole Review/Supervision Conditions

1 1 2 3

NOtice/Information Regarding' Inmate -RéleaSe -• . • .

7

Guidelines For Community Supervision of 1/m on Work Release

1

1 :Ç$ 'ej Management Checklist/Case Management File Audit

2 1 2

Grille de Vérification Gestion des Peines

1 2

Of-fender Management Review Board Checklist

1

Employment Application Suspension-or Termination From Program/Work

1 1 1 1 1 3

Décision ;- Job Placement:Notification . _

and Amendment. -- -

1 1 2 1

IMIIIII11111111111111111111111111111111111111•111•11111111111111111111111M11111111111111111111111111111I

1 1 1 1 1 1 2 1

TOTAL MI VP0 DI CPO KPO WI MPO CFF JI HPO

Form Regarding Urn Work Information 1 Job Descriptions 2 Performance Evaluation/Assessment 1 2 1 1 1 Pay Review . (adjustment and correction and etc.

2 1 1 3 1 1

CDI File Contents Checklist 1 1 1 1 1 Information Regarding WED (checklist, notifications)

2 2

Security Clearance Information 3 1 ,Rettitiee: Offender- Call List ApPlicatiôn 1 Record of Phone Calls 1 Inrnate Called NurnberS List 1 1 Program Interview/Decision or Revievv Sheet

1 2 5

Program Application 1 Program Referral Shéet 1 1 1 Referral/Assessment Regardin Offende r Program

ex 2 1

Consent and Refusal of Sek Offender Program' -.

2 1

Information on Other Programs (i. e . reports, assessment/risk/checklist)

5 5 1 4

Urinalysis Program 1 2 1 Student Report/Review or Student Evaluation

1 3 2 2

Psychologists notes/assessment/evaluation

1 2 4 1 2 1 1

Referral to Psychological'Services 1 1 1 2

-CFF TOAL FI : MI DI CPO, INI DP JI

Segregation Peychological AssessMent.-Form-

1

Request for Psychology . Evaluation 1 Visitor Risk Notification 1 1 Visit Checklists 3 Priva Family Visit (various issues: information, notifications

1 2 3 1 1 5

List of VisitorsNisitor Registry 1 2 1 1 Décisions Regarding Visit (various reasons)

1 1 2 6

Authorization to Release Information 1 1 1 Communication Interception (authorization)

1 2 1 4

Privacy Act/Issues 1 2 1 Various Consent/Authorization Forms 1 2 Form Indicating file closed or Accessed for Release of Information

1 1 1

Search,'Séi±ure oflterns and. Conteaband

3 2 2 1 1

Notice Regarding Charge/Disciplinary . Action

4 1 2 1

Inforniation Regarding • . Segregation(1;6: - placement, notice

1 3 1

Sentence/Parole Computation 1 3 1 1 ETAIUTA Request (i.e. notice, reasons, conditions)

1 5 2 1 2 2

Federal ,Transfer -Waiver of 1.5 Days Delay 'Period

1

1 Weekend Pass.Application Form 1 1

BI W I KPO Ji HPO FI MI CPO DP MPO CFF TOTAL

1 Urn Transferred Prior to Cor pletion of Assessments Temporary Absence Financial Sheet(Annex)

1

Résident 's Log Sheet (i/m movement) Bedroom Checklist/Room Inspection Intensive Supervision Log Unit Monitor/Supervisor Sheet Escape Checklist Admission and Discharge Checklist

2 1 2 1 3

2 1

2 2 Admission Forms or Admission Record

1 1

Admission and Discharge Property Briefing

2 1 1

1 Intake Assessment data (admission checklist)

1 1 1 Inmate release/clearance/Dischar Form/Checklist Initial Release Interview Checklist 2 3 1 1 1 Orientation/Réception Forms/Questionnaires

1 2 3 1 1 1

Various Rules and Regulations Forms 2 2 1 2 2 1 1 1 1 1 1 Inmate Acknowledgement of

Boundaries Letters . to,External Agencieà-Requesting 1/hrInfo. (i .e. police reports)

1 2

Notice,to•lm -Regarding Grievance Procedure

1

Ilin.PersOnat,Property:RecOrd: , 1

CFF VP0 BI DI CPO WI MPO HPO •

Aùthorized Personal Effects List Items Purchased or Returned

1 1 1 2

Notice to 1/m Regarding Parce Received

1

Notification of Case Managernen Team

2

Information Regarding Victims (request, notification)

2 1 1 1 5

Notification to Parole Officer Regarding new Caseload

1

1 Notice Regarding Judge's Comment Notification Regarding Child Sexual Assault Victims

1

Notice t , . Regarding the Safekeeping of Files Inmate Work Order for Computer Equipment

1

1

Inspection f. Computers. Info/Notice Regarding Community Residential Facility

1 2

1 Form Indicating Documents are from Previous Sentence Information Data Sheet 1

2 District Dut Officer Report Transfer from Savings to Curren Account

1 1

Waiver/Postponements/Withdrawals Annex Daily Briefing Shee Cbuet ApPearanée

1 1 1

1 2 1

MI DI CPO DP MPO CFF 'JI HPO , TOTAL

Notice Indicating Inmate Arrival at or Transferred to Institutions

1 3

Verification of Files/Documentation Transferred/Received Self-Help Libra Tattoo Confirmatice Hobby License Prisoner Receipt Gate Pass Effect Receipt

1 1 3 1

1 1 1 1

1 1

TOTAL 34 48 15 19, 10 419 7

Wi

1•111MIIIIIIIIIIIIIIMIII11111111111111•1■ 1111111•111•11111111•11111•111•11

ANNEX E Numbered forms that were not listed in the ORSM

or were not filed according to the ORSM

I I I I I I u I I I I I I

CSC 1-12 CSC 1-15 CSC 56 CSC 80 CSC 174

CSC 232-1 CSC 345 CSC 413

CSC 471-1 CSC 480

CSC 482 CSC 487 CSC 542 CSC 598 CSC 600 CSC 651 CSC 699 CSC 753 CSC 754 CSC 813 CSC 827 CSC 828 CSC 842

CSC 1040 CSC 1051

CSC 1064-1 CSC 1070 CSC 1082 CSC 1083

CSC 1083-1 CSC 1089

CSC 1090

CSC 1092 CSC 1122

CSC 1123 CSC 1128 CSC 1130 CSC 1135 CSC 2002 CSC 2002 CSC 2003 CSC 2005 CSC 2006 CSC 2013 CSC 2017

CSC 2018-2 CSC 2019

CSC 2019-1

VC CM CM, PSY CM AD, PS SM EMP PSY, CM SM

DD, CM, CM, PSY, EMP VC, PS CM, PS, PSY PS CM, PS, PSY CM, PS, DD VO, AD CM CM, AD PSY, VO, ET PSY CM CM CM CM PS PS CM, PS

CM, DD, VO, SM, EMP

CM, SM, PSY, PS CM, SM, VC, PS, AD, EMP, ET, PSY CM, SM AD PS, VC, CM, AD PS CM, EMP, ET, PSY EMP, CM, ET CM,EMP Intake, CM, CM PS, DD DD DD DD DD,

CSC or NPB FORM

ORSM FILE BANKS TITLE

HO SM

CM

HO

CM

Inmates' Money (Policy) Conditions et Reglements de Programs de Placements Exterieurs Referral For Consultant and Report Transfer Warrant Regional Inmate Personal Property Cell Card Security Intelligence Report Reason for Supervision of Parole, Day Parole , Statutory Release Inmate Employment Board Bi-Monthly Pay Report Progress Notes and Doctor's Order Criminal Convictions Conditional + Absolute Discharges + Related Information Contraband Seizure tag Consent For Disclosure of Personal Information (Inmate) Inmates' Visitor Control Registry Letter of Release Request for Correction Visiting Application Request for Transmission of message via facsimile Escort Briefing Use of Force Offender Records Recall Notice Offender Records Transmittal Note + Receipt Request for Return of Forfeited Items Offender Data Card Suicide Risk Assessment + Referral Facsimile Transmission (Cover Sheet) Notification to Provide Urine Sample Community VVork Release Referral Decision Sheet Post TA/Work Release Evaluation Report Incident Report for IPSO/RHQ/NHQ Incident Update UTA Pre-Release Referral Sheet or Offender Security Level Referral Sheet Referral Decision Sheet (Private Family, UTA/ETA Pre-Release, Work Release Institutional Transfer, Offender Security Level) Detention Review Pre-Screening Inmate Request

Letter for federal Inmates Purchase Order Offender Application for Authorization to Access Telephone # Notification of Interception Communication Program Performance Report (final) Program Performance Report "interim" Correctional Plan Review History Preliminary Assessment Report Intake Assessment Post Search Report Involuntary Segregation Placement Reg. Segregation Review (60 Days) Review of Offender's Segregated Status/1 Day Seg. Review Review of Offender's Segregated Status - Fifth VVorking Day Review

I

CSC or NPB ORSM FILE BANKS TITLE FORM

CSC 2020 DD, Sharing of Information Institutional Review

CSC 2022 AD 1/m Statement of Consent to Abide by Conditions Governing Wm Owned Computers

CSC 2023 EMP Program Board Decisions/Inmate Suspension From a Program

CSC 2024 EMP Acknowledgement of Privacy Issue

CSC 2026 CM Criminal Profile Update

CSC 2027 CM Correctional Plan Progress Plan

CSC 2027 -1 CM Suivi du plan correctional/Progress Assessment

CSC 2028 VC, CM Assessment for Decision

CSC 9000 SM Transfer Warrant Regional

CSC 9003 CM Criminal Profile Report Amendment

CSC XXX CM Notice of Suspension From a Program Assignment NPB 65 CM NPB Detention Review Decision Sheet NPB 73 CM, SM NPB Accelerated Parole Review Decision Sheet NPB 79 CM Waiver NPB 82 CM Pre-Release Decision Sheet NPB 83 CM, SM Letter from NPB with NPB Post -Release Decision Sheet NPB 85 CM Postponement/Withdrawal