This Department Order establishes a comprehensive method for evaluating Department operations. The audit program includes audits at the institutional level through the Peer Review Program and audits at the agency level through established general principals of auditing. Reviews and audits shall be conducted using evidence-based data gathering methods and shall be designed to assist in ensuring compliance with directives and developing best practices through sound correctional principals.

The Division Director for Support Services:

• Through the Inspector General, is responsible for overall management of the Department’s Internal Audit Program.
• In consultation with the Division Director for Offender Operations, is responsible for establishing a schedule for Peer Reviews.

Division Directors are responsible for:

• Determining the need for audits in their area of responsibility and coordinating scheduling and resource management for conducting audits.
• Coordinating corrective measures for areas where an audit has revealed discrepancies or non-compliance with statute, standards or other written instruction.
• Briefing the Director and other executive staff on results of audits and action plans.

The Inspector General, through the Audit Unit, is responsible for collecting and reporting information developed through each audit.

The Division Director for Offender Operations through the Regional Operations Directors and Wardens is responsible for providing resources for the Peer Review program.

Regional Operations Directors, in consultation with the Division Director for Offender Operations and Wardens are responsible for:

• Reviewing Peer Review reports and action plans.
• Ensuring that corrective measures are adequate, implemented and maintained.
• When necessary coordinating with the Audit Unit in identifying areas of significance and/or concern in individual audits.
• Selecting and assigning Subject Matter Experts to participate in Peer Reviews.

The Audit Unit through the Inspector General is responsible for conducting audits as assigned.

Wardens, in coordination with the Audit Unit and Regional Operations Directors, are responsible for facilitating Peer Reviews conducted at their institution and for scheduling staff in support of the Peer Reviews as Subject Matter Experts.

1.1.1    Peer Reviews as outlined in Section 606.04 or this Department Order.

1.1.2    Contract Audits, consisting of a detailed, systematic evaluation of contractor and departmental compliance with a contract providing services or goods to the Department such as Food Service, Inmate Store operations and contract bed facilities.

1.1.3    After-action assessments and reports which may include assistance in evaluating Department systems and processes or developing information as part of the review of any significant incident or any other situation in which an evaluation is deemed necessary.

1.1.4    Vulnerability Assessments as a process of identifying, quantifying and prioritizing (or ranking) the deficiencies in a security system. Such an assessment may include system tests, security challenges or other methods of determining the effectiveness of the system and are typically conducted outside of a Peer Review.

1.1.5    Agency Operations/Management, which may address any areas of operation, written instruction or process not identified by or included with a Peer Review or other audit process or otherwise not specifically identified in this Department Order and generally conducted based on need.

1.1.6    Compliance Audits in response to state and federal statutes, which may be required by the statute. Examples include compliance with the "Americans with Disabilities Act," "Prison Rape Elimination Act" and other state and federal education statutes.

1.1.7    Other special reviews.

1.2    The Peer Review process as outlined in section 606.04 may be used to conduct any audit. The Audit Unit may modify the process to fit the circumstance if necessary.

1.3    The Director, Deputy Director or Division Director may identify an issue that should be evaluated in conjunction with a Peer Review.

1.4    In collaboration with the Director or Deputy Director and appropriate Division Director the Audit Unit may make recommendations to include issues in the Peer Review process or may recommend special reviews and audits for consideration.

1.5    The Audit Unit develops data collection methods, conducts reviews, assesses and analyzes data. The Audit Unit shall:

1.5.1    Facilitate audits to include management of processes, resources and staff dedicated to each audit.

1.5.2    Collect data as outlined in this Department Order and the related Technical Manual.

1.5.3    As required, disseminate information obtained through individual audits to the Director, Deputy Director and appropriate Division Director.

1.5.4    Provide technical assistance to staff who requests an audit.

1.6    In consultation with the Director, Deputy Director or appropriate Division Director, the Audit Unit shall identify source material to be prepared as Data Collection Instruments (DCIs). Such material may include:

1.6.1    State and federal statute,

1.6.2    Department Orders, Director’s Instructions and Technical Manuals,

1.6.3    Correctional Standards published by professional organizations, when approved by the Director or appropriate Division Director,

1.6.4    Other material, such as Institution Orders or Post Orders, when approved by the Director or appropriate Division Director.

1.7    In conjunction with a Peer Review, or as required by the Director or appropriate Division Director, the Audit Unit may monitor plans to bring the institution or system into compliance with written requirements.

1.8    The Audit Unit shall provide instruction and guidance for all individuals who are assigned to Peer Reviews or other reviews and audits.

606.02    REQUESTING AND SCHEDULING AN AUDIT - Internal Audits conducted by the Audit Unit shall be coordinated through the Division Director for Support Services.

1.1    Peer Reviews shall be conducted as scheduled.

1.2    The Audit Unit shall conduct audits as outlined in section 606.01.

1.3    The requestor, in consultation with the Audit Unit, shall recommend the scope of the audit.

1.4    The Audit Unit shall determine appropriate methodologies, develop DCIs and advise the requestor regarding time frames for completion and reporting requirements.

1.5    Required reports, data and distribution of information shall be determined by the Division Director for Support Services.

1.6    The requestor shall provide support to the Audit Unit as needed.

606.03     REPORTS/DATA COLLECTION -  The Audit Unit shall collect data and reports form each audit.

1.1    Reporting shall include appropriate follow-up reports and/or status reports as needed. At a minimum, reports shall include:

1.1.1    An Executive Summary which identifies the scope of the audit, the methodology used, the audit team members, summary of the audit findings and any other information determined to be relevant.

1.1.2    Results of the audits, which are reported as findings.

1.1.3    Recommendations when appropriate.

1.2    When an audit identifies an agency-level issue, the issue shall be reported separately.

1.3    On a schedule determined by the Division Director for Support Services, audit data shall be reported:

1.3.1    To the Policy Unit for consideration in modifying, changing or updating Department Orders or other written instruction.

1.3.2    To the Staff Development and Training Bureau for use in determining training needs.

1.3.3    Other agency staff as needed.

1.4    Peer Review reports shall be prepared and distributed as outlined in section 606.04.

1.5    Audit reports, other than Peer Reviews, shall be prepared and distributed as determined by the requestor in consultation with the Audit Unit.

1.6    When appropriate, any report may be distributed electronically, as a hard copy or both.

1.7    Data collected regarding findings, frequency of findings and other relevant data shall undergo appropriate analysis and be reported as required.

606.04    PEER REVIEW PROGRAM - Peer Reviews shall be conducted at state prisons and in-state contract bed facilities at least annually, on a schedule developed by the Audit Unit in consultation with the Division Directors.

1.1    The Peer Review shall focus on pre-identified Core Competencies, but may also include any correctional system, procedure, directive or other issue identified by the Director or appropriate Division Director.

1.1.1    Competency Teams comprised of Subject Matter Experts (SMEs) ascertain institutional compliance under the guidance of Audit Unit staff.

1.1.2    Audit Unit staff coordinates activities and supervises the review process analyzing and reporting results as required.

1.1.3    Wardens and Bureau Administrators take corrective action as needed.

1.1.4    The Division Director for Offender Operations, Deputy Division Director for Offender Operations and Regional Operations Directors monitor results and corrective action.

1.2    The Peer Review Process consists of three phases:

1.2.1    Planning and Preparation – Coordinated by members of the Audit Unit.

1.2.2    Administration of the Review – Conducted on site at the facility undergoing the review.

1.2.3    Post-Review Activities – Including the development and implementation of action plans by the Division Director for Offender Operations, follow-up monitoring and reporting results by the Audit Unit.

1.3    A Peer Review:

1.3.1    Is Team Based – Consisting of a three-person team of SMEs for each competency.

1.3.1.1    Two team members are external SMEs. The third team member is an internal SME.

1.3.1.1.1    External SMEs may be assigned to multiple competencies.

1.3.1.1.2    Wardens shall identify each internal SME. This SME may be specifically assigned to the unit being assessed or may represent the institution for the entire competency.

1.3.1.1.3    SMEs shall be selected to limit travel when possible.

1.3.1.2    An Audit Unit staff member shall be the fourth team member.

1.3.1.3    Teams at Contract Bed facilities shall be a single external SME who shall be a Department-employed individual and a single internal SME representing the vendor.

1.3.2    Is Compliance Based – Institutional performance for each competency is measured against specific standards outlined in DCIs provided by the Audit Unit.

1.3.3    Provides assistance in correcting areas where the institution is not in compliance with a requirement.

1.4    Selection of External SMEs - Wardens and the Audit Unit, in consultation with Division Directors, shall assign external SMEs for all Peer Reviews to include, but not limited to, all Divisions and the vendor. Such assignments shall be based on schedules, knowledge of the subject matter and needs of the institution and shall ensure that all Divisions provide SMEs for their respective areas of responsibility.

1.4.1    The Regional Operations Directors or Bureau Administrators in consultation with the Audit Unit shall establish institutional criteria for selection as an SME. Regional Operations Directors shall consider:

1.4.1.1    Length of service. At least one year of service as a correctional professional.

1.4.1.2    Actual service in the area of expertise. Supervision of an area is acceptable however, to be an SME for a particular competency, the staff member should have practical experience in the area of at least six months.

1.4.1.3    Current involvement in the specific competency. Past service in the specific area is acceptable, but length of time elapsed should be taken into account.

1.4.1.4    Current performance. The SME shall have at least an overall rating of "3" on their latest PACE evaluation.

1.4.1.5    In consultation with the Audit Unit, other criteria as deemed necessary.

1.4.2    Regional Operations Directors or Bureau Administrators shall:

1.4.2.1    Select SMEs for each review when requested by the Audit Unit.

1.4.2.2    For each review, provide the Audit Unit with an SME list no later than 30 days prior to the scheduled start date of the review.

1.4.3    Wardens or Bureau Administrators shall:

1.4.3.1    Develop and publish a process by which staff who is interested in becoming external SMEs can apply in writing.

1.4.3.2    Accept applications for, or select SMEs as needed and forward the names of individuals selected to the Regional Operations Director.

1.4.3.3    Assign staff as necessary to be involved in the review process as SMEs.

1.4.3.4    Ensure that staff assigned to travel as a result of selection as an external SME are provided appropriate lodging, per diem and transportation in accordance with applicable travel regulations.

1.4.3.5    Ensure staff is assigned as external SMEs and that they are available for the duration of the assigned review without conflicts in scheduling.

1.4.4    Any staff member wishing to participate may request to be considered for assignment as an external SME through their chain of command.

1.5    Competencies

1.5.1    The Audit Unit shall:

1.5.1.1    In consultation with the Director, Deputy Director and the appropriate Division Director, identify Core Competencies that are to be included in the Peer Review Program.

1.5.1.2    Develop a review schedule for Core Competencies ensuring that at least annually, the Division Directors review and approve Core Competencies included as a regular part of the Peer Review Program.

1.5.2    When appropriate, the Director, Deputy Director or appropriate Division Director may include performance or compliance issues that have not specifically been identified as a Core Competency in the Peer Review.

1.6    Planning for the Review

1.6.1    Assigned Audit Unit staff shall coordinate preparation for individual reviews in consultation with the appropriate Regional Operations Director and Warden. Audit Unit staff shall:

1.6.1.1    Ensure that the Warden is briefed regarding schedules, the needs of the team, logistical details and other pertinent information.

1.6.1.2    Coordinate review activities with the Warden including scheduling of orientation, training, meetings, briefings and other activities associated with preparation and delivery of the review.

1.6.1.3    Assist Regional Operations Directors and Wardens in the selection of SMEs.

1.6.1.4    Publish information regarding schedules keeping the institution and all participants fully informed.

1.6.1.5    Prepare materials to be used during the review.

1.6.1.6    Ensure that the Warden and each SME is provided with DCIs and other relevant material in a timely fashion.

1.6.1.7    Prepare and provide training to SMEs as required.

1.6.2    Wardens shall:

1.6.2.1    Select internal SMEs to be assigned to the Institution Peer Review Team for each Core Competency and provide the list to the Audit Unit when requested. The internal SME shall:

1.6.2.1.1    Serve as the institution’s primary contact for questions and information regarding the review, such as, sample size, methodology, observations, staff interviewed and decisions reached, etc.

1.6.2.1.2    Coordinate with the Warden or designee to identify resources necessary to correct a finding when appropriate.

1.6.2.2    Determine, in consultation with the assigned Audit Unit staff, which Core Competencies are "Not Applicable" at a particular unit or institution.

1.6.2.2.1    A competency may be declared "Not Applicable" only if none of the requirements of the DCI are conducted at the unit or institution. A competency whose operations are solely managed at the institution level may be declared "Not Applicable" at the unit, but shall be assessed at the institution.

1.6.2.2.2    A decision to declare a competency "Not Applicable" shall be documented in writing by the Warden and approved by the appropriate Regional Operations Director, and become part of the permanent record for that review.

1.6.2.3    Provide logistical support to the Institution Peer Review Team, including equipment, administrative assistance and work space when requested.

1.6.2.4    Ensure that internal SMEs are made available for the duration of the review and are available for flexible schedules, when necessary.

1.6.3    Internal and external SMEs shall:

1.6.3.1    Ensure that scheduling conflicts do not exist during the scheduled time of the review. SMEs shall be available and on-site as needed during the entire period of the review unless released by Audit Unit staff.

1.6.3.2    Be available for training/orientation as required.

1.6.3.3    Advise their chain of command of any issues that may impact availability.

1.6.3.4    Become familiar with the DCIs for their assigned competency.

1.7    Administering an Review – Each Peer Review shall take place on-site at the institution beginning with an orientation session for the Institution Peer Review Team, the Warden and selected institutional staff including Deputy Wardens, and others at the discretion of the Warden. If necessary, the orientation session may include appropriate training for Institution Peer Review Team members.

1.7.1    Wardens, in consultation with Audit Unit staff shall:

1.7.1.1    Designate an area adequate for providing an orientation.

1.7.1.2    Reserve work space for Audit Unit staff and Institution Peer Review Team members.

1.7.1.3    When necessary, provide for the substitution of internal SMEs in the event that the assigned SME becomes unavailable.

1.7.2    Audit Unit staff shall conduct an orientation ensuring, at a minimum that:

1.7.2.1    Competency Teams are identified and provided direction in determining institutional compliance with each DCI.

1.7.2.2    Required duties of the Competency Team are identified ensuring that all team members are provided with DCIs, schedules, and other necessary material.

1.7.2.3    Wardens are briefed regarding specific details relevant to the review.

1.7.3    The Audit Unit shall establish activities associated with the review to include, at a minimum:

1.7.3.1    Developing daily schedules and reporting requirements for the Institution Peer Review Team.

1.7.3.2    Identifying a member from each Competency Team as its coordinator.

1.7.3.3    Establishing a schedule for assessing the institution that minimizes the impact on daily operations.

1.7.3.4    Providing day-to-day guidance and supervision to the Institution Peer Review Team.

1.7.3.5    Resolving conflicts, providing technical assistance to staff involved in the process at all levels and making final decisions regarding issues identified during the review.

1.7.3.6    Briefing the Warden, Deputy Wardens, Bureau Administrators and Executive Staff.

1.7.4    Competency Teams shall, under the direction of assigned Audit Unit staff:

1.7.4.1    Organize their daily schedule and arrange meetings, briefings and other activities required by Audit Unit staff. Each team coordinator shall be responsible for coordinating team activities and schedules.

1.7.4.2    Objectively evaluate each area of their assigned competency using the DCIs provided. An institution or unit may be in total compliance with a particular competency or may be out of compliance in any specific area resulting in a finding or findings as appropriate.

1.7.4.2.1    All measurable items of the DCI shall be evaluated using the methodology established by the Audit Unit.

1.7.4.2.2    There shall be no disruption in normal activities, such as conducting a simulation or test, without the permission of the Audit Unit staff and the Warden.

1.7.4.3    Function as a unit. No one team member supervises the other and no one individual is being evaluated in terms of performance.

1.7.4.4    Cooperate in determining findings, developing remedies and providing On-the-Job Retraining (OJRT).

1.7.4.5    Agree on results, or in situations where agreement is not possible, bring the issue to the Audit Unit staff facilitating the review who shall make a final determination.

1.7.4.6    Make every effort to bring the institution into compliance, completing the finding before the conclusion of the review.

1.7.4.7    Determine, when appropriate, a remedy for each finding identified during the review. Remedies:

1.7.4.7.1    May include assistance with physical plant needs or other written directives.

1.7.4.7.2    May include development of a system to ensure compliance.

1.7.4.7.3    Shall not include excessive use of resources without the express permission of the Warden and Audit Unit staff.

1.7.4.8    Provide appropriate OJRT when a finding is identified.

1.7.4.9    May, when authorized by the Audit Unit staff, provide an initial debriefing to unit Deputy Wardens or their designee upon completion of the Competency review at that unit.

1.7.4.10    May identify issues that the Warden may need to be aware of that are not part of the DCIs. Such issues shall be reported to Audit Unit staff as Management Information.

1.7.4.11    Document the results of their review including:

1.7.4.11.1    A clear and concise finding statement.

1.7.4.11.2    A remedy statement.

1.7.4.11.3    An OJRT statement clearly identifying actions that assist in resolving the issue and prevent a reoccurrence.

1.7.4.11.4    The current "Status of the Finding."

1.7.5    Audit Unit staff shall meet with each Competency Team on a set schedule during the review to assess the team’s evaluations.

1.7.5.1    In the event a team has reported findings, all team members shall be present during a debriefing with Audit Unit staff.

1.7.5.2    In the event an area is reported to be in compliance, only the external team members shall be required to report results.

1.7.5.3    The results of a team’s review are final upon completion of the debriefing and approval of the Audit Unit staff member.

1.7.6    Audit Unit staff shall evaluate results reported by each Competency Team, and:

1.7.6.1    Resolve conflicts and provide guidance to each team clearly identifying findings and management information.

1.7.6.2    Assist the teams by documenting the results of their reviews, ensuring that the results include necessary remedies and OJRT and, when appropriate, findings are resolved while the team is on site.

1.7.6.3    Assist the teams in developing appropriate remedies and providing OJRT as needed.

1.7.6.4    Act as the final decision maker in instances when a Competency Team cannot reach an agreement.

1.7.6.5    Make a final determination as to the validity of each finding to include assisting the team in researching the issue and making a final decision.

1.7.6.6    Identify Management Information issues and report them.

1.7.6.7    Report the results to the Warden and provide assistance in correcting findings.

1.7.6.8    Record the data.

1.7.7    Determining results of an Review

1.7.7.1    The Audit Unit staff shall prepare a report for distribution on the final day of the review. The report of findings shall include an Executive Summary and a report of findings as outlined in section 606.02. Review results shall include:

1.7.7.1.1    Results categorized by unit and Competency.

1.7.7.1.2    A remedy for each finding.

1.7.7.1.3    OJRT for each finding

1.7.7.1.4    A status of the finding.

1.7.7.2    At a minimum, reports or excerpts shall be distributed to:

1.7.7.2.1    The Warden and other staff as needed at the conclusion of the review.

1.7.7.2.2    The Regional Operations Directors for a determination whether or not any finding(s) is significant or of special concern.

1.7.7.2.3    The Division Directors.

1.7.7.2.4    The Inspector General.

1.7.7.3    Audit Unit staff may prepare separate reports, distributed through the appropriate chain-of-command, for agency-level issue(s) as outlined in section 606.03.

1.8    Post Review Activities

1.8.1    The Audit Unit shall:

1.8.1.1    Forward an initial copy of the report to the Division Directors through the chain of command.

1.8.1.2    Conduct a follow-up visit no less than 60 days after concluding the on-site portion of the review with the Warden. During the return visit Audit Unit staff shall review Action Plans, implementation of the plans and make a determination to close each finding as complete, refer the finding to the appropriate Division Director or continue follow-up activities.

1.8.1.3    At the conclusion of the return visit, prepare a status report for the Division Directors, Regional Operations Directors, Warden and the Inspector General.

1.8.1.4    Continue to monitor plans in progress at 45-day intervals after the visit.

1.8.1.5    90 days after completing a return visit, in consultation with the Warden and the appropriate chain-of-command make a determination regarding the status of any item(s) that are left open. All items shall be completed by successful implementation of the Action Plan or referred to the appropriate Division Director.

1.8.2    Wardens shall:

1.8.2.1    Review reports and develop action plans in order to correct any findings that were not completed during the review, providing the Action Plans to the Audit Unit no later than 30 days following the review.

1.8.2.2    In consultation with the Audit Unit, ensure that Action Plans are implemented or in progress prior to the scheduled return of Audit Unit staff.

1.8.2.2.1    When possible, Action Plans shall be fully-implemented prior to the return visit.

1.8.2.2.2    Any item not corrected at the time of the follow-up visit shall be monitored by the Warden and the Audit Unit with updates at a minimum of 45 day intervals.

1.8.2.3    Brief their chain-of-command on the results of the review as directed.

1.8.2.4    Coordinate the follow-up activities with Audit Unit staff.

1.8.3    Regional Operations Directors shall:

1.8.3.1    Review the findings and make a determination as to whether or not any area of concern or significance exists within one week of receipt of the initial report and immediately advise the Division Director for Offender Operations.

1.8.3.2    At the discretion of the Division Director for Offender Operations:

1.8.3.2.1    Monitor review results and actions taken by the Warden.

1.8.3.2.2    Review any item identified for consideration as an agency-level issue and provide comment or recommendations as required.

1.8.3.3    Brief the Director, Deputy Director and Division Directors as needed.

1.8.4    Division Directors shall:

1.8.4.1    Monitor the institutional response to findings in their area of responsibility.

1.8.4.2    Take appropriate action(s) to address those issues identified in the Review Reports as an agency-level issue.

1.8.4.3    Conduct or participate in briefings with the Director, Deputy Director, Regional Operations Directors, Wardens and other staff as needed.

606.05    PROGRAM REVIEW - When appropriate, the Audit Unit shall conduct reviews of the Internal Audit Program, which shall focus on improving the quality of audits and ensuring that appropriate methods and technical information are being used while conducting audits. 

1.1    The Division Director for Support Services, through the Audit Unit Manager may convene ad-hoc teams consisting of technical experts working in concert with Audit Unit staff.

1.1.1    The Division Director for Support Services shall request that staff be assigned from other divisions as needed.

1.1.2    A group may be formed to review Core Competencies and Peer Review processes as outlined in section 606.03 or in support of other potential review areas as outlined in section 606.01.

1.1.3    Team members shall serve as technical expert advisors and shall include a diverse group of staff from various units within the agency such as:

1.1.3.1    Wardens, Deputy Wardens and uniformed staff members

1.1.3.2    Complex Administration staff

1.1.3.3    Administrative Support staff

1.1.3.4    Health Care Professionals

1.1.3.5    Business and Finance staff

1.1.3.6    Community Corrections staff

1.1.3.7    Research staff

1.1.4    Teams shall provide a forum for the exchange of technical information and shall consider, at a minimum:

1.1.4.1    Standardization of methods, to include a continuous review of DCIs, sample size, data gathering techniques and minimum information required.

1.1.4.2    Use of comparable methods.

1.1.4.3    The quality of audits.

1.1.4.4    Opportunities for improvement to the Internal Audit Program.

1.1.4.5    The identification and mitigation of risks.

1.1.4.6    Improvement in training opportunities and support to the agency.

1.1.4.7    Recommendations for revisions to Department Orders and other written instructions, as appropriate.

1.2    The Division Director for Support Services shall establish a standing committee representing all Divisions and providing assistance to Division Directors, the Inspector General, the Audit Unit and the Policy Unit with respect to matters involving the Internal Audit Program, written directives and the internal control functions of the agency.

1.2.1    Committee members shall include:

1.2.1.1    The Regional Operations Directors.

1.2.1.2    The Bureau Administrators.

1.2.1.3    The Audit Unit Manager.

1.2.1.4    The Policy Unit Manager.

1.2.2    The Committee shall provide a continuous review of the Internal Audit Program and consider:

1.2.2.1    Risk Review and mitigation as related to components of the Internal Audit Program.

1.2.2.2    Agency compliance with legal and regulatory requirements.

1.2.2.3    Evaluation of audits and the identification of risk factors associated with individual findings.

1.2.2.4    The evaluation of agency-level issues and appropriate recommendations.

1.2.2.5    Increasing participation, awareness of and input into the Internal Audit Program.

1.2.2.6    Other criteria as deemed necessary.

1.2.3    The primary functions of the Committee include:

1.2.3.1    Monitoring State and Federal legislation that may impact the Internal Audit Program.

1.2.3.2    Reviewing operational issues internal to the agency including significant incidents, trends and best practices.

1.2.3.3    Evaluating the adequacy of internal controls.

1.2.3.4    Developing and standardizing classification of risks associated with findings resulting from audits.

1.2.3.5    Recommending revisions to Department Orders and other written instructions.

1.2.3.6    Identifying areas that may benefit from or require an audit.

1.2.3.7    Providing written reports and recommendations to the Division Directors, as appropriate.

1.2.4    The Committee chair shall be selected and the position rotated as determined by the Division Director for Support Services in consultation with the Division Directors for Offender Operations and Program Services.

• Requirements for facilitating a Peer Review shall include:
  • Preparation of materials for Wardens, SMEs and other staff involved in the process.
  • The training program for individuals selected as SMEs.
  • Orientation programs.
  • Reporting requirements.
  • Report preparation and distribution.
  • Travel arrangements for Audit Unit staff.
• Guidelines for conducting audits shall include:
  • Methodologies.
  • Development of DCIs.
  • General audit standards.
  • Report writing.
  • Data collection and analysis.
• Guidelines for facilitating review groups.

Within 90 days of the effective date of this Department Order Division Directors shall evaluate their areas of responsibility and coordinate with the Audit Unit to ensure that where appropriate operational or statutory responsibilities are included in audit programs. Consideration shall be made, at a minimum to:

• The "Americans with Disabilities Act."
• The "Prison Rape Elimination Act (PREA)."
• The "First Freedom Project."
• The "Individuals with Disabilities Education Act (IDEA) of 2004."
• Educational requirements as outlined in Department Order #910, Inmate Education and Resource Center Services, and Department Order #920, Inmate Special Education Services.
• Federal Education Association (FEA) laws.
• Community Corrections Operations.
• Contract Compliance.
• Inmate Release Procedures.
• Security Systems.
• Program Delivery including counseling and treatment programs, mental health programs and medical services.
• Business or Financial Management Systems.
• Strategic Plans.

AGENCY-LEVEL ISSUE – Any issue identified during an audit that is beyond the control of the Warden, Administrator and/or the Audit Unit to directly address or correct. Issues may include the identification of a directive that should be considered for change, a forms-related problem, budget or finance or other issues. Typically, these issues affect the agency as a whole rather than just a single unit or institution.

COMPETENCY TEAM – A pre-identified group SMEs, assigned to evaluate the performance of an institution in one or more specific Core Competencies during a Peer Review. The Team is responsible for evaluating compliance with written instructions (DCIs) correcting discrepancies when possible, providing on-the-job retraining, and aiding in the development of action plans for non-compliant issues that cannot be corrected during the Peer Review and which will be reevaluated during a follow-up visit by Internal Audit Unit Staff.

CORE COMPETENCY – A core competency is fundamental knowledge, ability, or expertise in a specific correctional operational area, subject area or skill set. Core competencies are those activities that are essential to effective operation of a prison or prison unit, such as key control, perimeter operation or searches. Core Competencies are pre-determined and subject to periodic review and revision.

DATA COLLECTION INSTRUMENTS (DCIs) – A compilation of directives and/or other regulatory material such as written instruction, state and federal statutes, best practices or correctional standards. DCIs include the regulatory material and standard data collection practices and shall provide adequate information to allow a trained SME or auditor to collect and report relevant findings. DCIs are designed to collect, analyze and report data regarding the results of an audit.

FINDING – A determination discovered during an audit that an issue is not in compliance with a specific section of a DCI. When evaluating performance for efficiency, a finding may identify an area where a best practice or other improvement may benefit the agency.

INSTITUTION PEER REVIEW TEAM – An ad hoc team of external and internal SMEs under the leadership of assigned Audit Unit staff, which conducts a Peer Review at a designated institution. The purpose of the review is to identify areas of non-compliance (findings) and assists in correcting those areas, provide on-the-job retraining, and aid in the development of action plans when an immediate correction is not possible.

INTERNAL AUDIT – Any internal audit, evaluation, assessment or analysis of Department operation, facility operation. An audit may be structured using the Peer model, or may be conducted by an internal auditor(s) assigned to the Audit Unit using generally accepted auditing procedures.

MANAGEMENT INFORMATION – Any issue that is beyond the requirements of the DCIs in use during a particular Peer Review. Management information may consist of a practice that the Warden may consider for use at his or her institution, the identification of a process or individual that is particularly noteworthy at the institution being assessed; or the identification of a problem or issue that a Warden may want to consider correcting.

ON-THE-JOB RETRAINING (OJRT) - Training provided to unit staff by SMEs to help correct and prevent the reoccurrence of a finding. OJRT may include an explanation of the relevant written instruction, assisting unit management in developing a training program or assisting the unit in developing systems to ensure compliance.

PEER REVIEW - A review that measures institutional compliance with select areas of correctional operation. Each Peer Review is administered by Audit Unit staff assigned to facilitate the process providing guidance to Competency teams consisting of external and internal SMEs for each Competency measured. The entire team is identified as an Institutional Peer Review Team consisting of individual Competency Teams.

REMEDY - A written plan that immediately resolves a situation where a finding has been identified. The Core Competency team is responsible for developing remedies for each finding in their area.

STATUS OF FINDING - A specific Peer Review term for which the two accepted responses are "Completed" or "Action plan to be implemented." In the event that Audit Unit staff determine that a finding relates to an issue outside of the institution’s control, they may order the finding "referred to agency management." A finding:

• Is only complete when a specific action has taken place to completely resolve the issue, for example, a master key inventory updated to include all required information. In situation where documentation is an issue, it is not possible to complete the finding during the actual audit.
• Shall only be considered complete if final action is taken during the time that the Institution Peer Review Team is actually conducting the review on-site.
• May be referred to agency management when Audit Unit staff determines that the issue is beyond the control of the Warden. Examples may include a necessary update to a written instruction or an item that is related to a significant financial expenditure.

SUBJECT MATTER EXPERT (SME) – A staff member assigned to participate in a Peer Review or other internal audit activity and who is recognized by correctional professionals or agency management as a leader with expertise in a specific area such as key control, inmate classification or visitation. SMEs are provided training specific to the Peer Review process and may be certified for being selected for successive Peer Reviews. An individual may be selected as an external SME assigned to participate in a Peer Review at an institution other than the one he or she works at or an internal SME participating in the review at his or her assigned institution. An SME may be a staff member from any functional area of the Department including Offender Operations, Program Services, Support Services and the Director and Deputy Director's offices.

Dora Schriro

Director