Title of Regulation: 6VAC15-20. Regulations Governing Certification and Inspection (amending 6VAC15-20-10, 6VAC15-20-30, 6VAC15-20-40, 6VAC15-20-50, 6VAC15-20-70, 6VAC15-20-80, 6VAC15-20-90, 6VAC15-20-100, 6VAC15-20-120).

Statutory Authority: § 53.1-5 of the Code of Virginia.

Effective Date: December 21, 2011.

Agency Contact: Jim Bruce, Regulatory Coordinator, Department of Corrections, P.O. Box 26963, Richmond, VA 23261-6963, telephone (804) 674-3303 ext. 1130, FAX (804) 674-3017, or email james.bruce@vadoc.virginia.gov.

Summary:

The amendments remove references to audits of state correctional facilities and probation and parole districts to reflect the changes in the authority of the Board of Corrections pursuant to Chapter 375 of the 2011 Acts of Assembly.

Part I
Definitions

6VAC15-20-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Appeal" means the action taken by a facility or program administrator when there is disagreement with a compliance audit finding.

"Audit report" means the official report of compliance audit findings prepared by the Compliance and Accreditation Unit supervisor for the department and submitted to the board.

"Board" means the State Board of Corrections.

"Certification analyst" means a person assigned to the Compliance and Accreditation Unit who serves as chairperson or team leader of the certification team.

"Certification/accreditation team" means persons appointed by the Compliance and Accreditation Unit manager or the American Correctional Association to conduct compliance audits.

"Community residential program" means any group home, halfway house, or other physically unrestricting facility used for the housing, treatment, or care of adult offenders established or operated with funds appropriated to the Department of Corrections from the state treasury and maintained or operated by any political subdivision, combination of political subdivisions, or privately operated agency within the Commonwealth.

"Compliance and Accreditation Unit" means the organizational unit of the department responsible for scheduling and conducting compliance audits to board standards.

"Compliance" means that no deficiency was cited by the certification team or that cited deficiencies have been corrected through completion of the tasks identified in the plan of action.

"Compliance audit" means an on-site official review of a facility or program by the certification team to evaluate compliance with standards promulgated by the board.

"Compliance and Accreditation Unit local facilities supervisor" means an individual responsible to the Compliance and Accreditation Unit manager for supervising the Board of Corrections' local facilities inspections.

"Compliance and Accreditation Unit manager" means an individual responsible to the Deputy Director of Administration for managing the Board of Corrections' certification process.

"Compliance and Accreditation Unit supervisor" means an individual responsible to the Compliance and Accreditation Unit manager for supervising the Board of Corrections' certification process.

"Compliance documentation" means specific documents or information including records, reports, observations and verbal responses required to verify compliance with standards by a facility or program.

"Decertified" means a status imposed by the board when it is determined that a facility or program has not met a minimum acceptable level of compliance with standards.

"Deficiency" means noncompliance with a specific standard.

"Department" means the Department of Corrections.

"Deputy director" means the administrative head or designee of a division of the Department of Corrections.

"Director" means the Director of the Department of Corrections.

"Facility" means the physical plant of a state, local or private correctional facility or community correctional facility.

"Facility or program administrator" means the individual responsible for the operation of a facility or program subject to standards, rules or regulations of the board.

"Inspection" means an on-site official review of a local correctional facility by local facilities managers to assess compliance with life, health and safety standards promulgated by the board.

"Interim compliance audit" means an on-site official review of a facility or program by the Compliance and Accreditation Unit to evaluate compliance with standards promulgated by the board which occurs at an interval other than the regular schedule as provided in 6VAC15-20-20. The interim compliance audit may consist of a determination of compliance with all standards applicable to the facility or program or may be limited to specific standards as directed by the board.

"Life, health and safety alert" means a process by which the board is provided immediate notice by department staff of life, health and safety deficiencies identified in local facilities/programs.

"Life, health, safety standards" means those standards directly related to life, health or safety issues as identified by the board.

"Local correctional facility" means a jail, regional jail, or lockup.

"Plan of action" means a document stating what has been or will be done to bring all deficiencies into compliance with standards, including a description of the activities undertaken, staff responsibilities, and a time table for completion.

"Preparatory audit" means an unofficial review of a facility or program by regional staff or the Compliance and Accreditation Unit to evaluate compliance with standards promulgated by the board.

"Private correctional facility" means a facility that is operated by an entity which has entered into a legal agreement to provide any correctional services to the Department of Corrections with respect to inmates under the custody of the Commonwealth.

"Probation and parole district" means under the authority of the Director of the Department of Corrections, the Commonwealth is divided into as many separate districts as deemed necessary to provide professional investigation and supervision of the offender in the community under conditions of probation, parole or postrelease supervision and special conditions as set by the court or the Parole Board.

"Probationary certification" means a status granted by the board for a specific period of time to correct deficiencies within the control of the facility or program.

"Program" means a system of services provided to offenders by probation and parole offices and other community-based services.

"Region" means the geographic area in which a facility or program is located as established by the department.

"Regional director" means the administrative head of a specific geographic region within the department.

"Regional office" means the administrative offices of a specific region within the department.

"Unconditional certification" means that a facility or program is in 100% compliance with all applicable standards based upon the receipt of the plan of action.

"Variance" means a decision by the board to suspend the requirements of a specific standard for a specific period of time.

Part II
Certification Process

6VAC15-20-30. Frequency of audits.

A. All state, local, and private and community correctional facilities and community residential programs operated by or affiliated with the department shall be audited every three years.

1. The regional office or local facilities' office facility staff shall notify the Compliance and Accreditation Unit supervisor in writing within 30 days after a new facility or program accepts the first offender.

2. The regional office staff shall conduct a preparatory audit of a new facility or community residential program during the first six months of operation.

3. The Compliance and Accreditation Unit shall conduct a compliance audit during the second six months of operation and on a regular schedule thereafter as provided by this section.

B. The scheduled compliance audit may be postponed for up to six months due to bona fide security or emergency situations.

1. The facility or program administrator shall notify the Compliance and Accreditation Unit manager and provide details of the circumstances requiring the postponement.

2. The Compliance and Accreditation Unit supervisor shall complete a written notice of change and send copies of the approved written notice of change to the board, facility or program administrator, the appropriate regional director and the team members.

C. Any state, local, or private or community correctional facility or community residential program may be scheduled for an interim compliance audit at the direction of the board. An interim audit may be scheduled for a facility or program that has:

1. Undergone renovations or additions that have resulted in additional inmate capacity or significant changes to the numbers and duties of security staff;

2. Exhibited difficulty in maintaining compliance with the board's standards;

3. Been cited for noncompliance with the board's standards as a result of Department of Corrections inspections, Department of Health inspections or informal visits made by Department of Corrections' staff; or

4. Been placed in probationary or decertified status.

6VAC15-20-40. Preparation for audit.

A. The Compliance and Accreditation Unit supervisor shall develop an annual audit schedule.

1. The schedule shall be submitted to the Compliance and Accreditation Unit manager for review, comment and approval.

2. Upon approval, the Compliance and Accreditation Unit supervisor shall:

a. Disseminate the final schedule as appropriate, and

b. Review the schedule as necessary and make adjustments for additional audits.

3. Changes to the final audit schedule shall be agreed upon by the Compliance and Accreditation Unit manager.

4. The Compliance and Accreditation Unit supervisor shall notify the facility or program administrator of the change. Changes shall not extend the audit date beyond the established frequency limits without board approval.

B. The Compliance and Accreditation Unit manager shall appoint certification team members.

1. Team members shall have prior audit experience or have completed certification training.

2. At least one person shall be a staff member of the same type of facility or program being audited.

3. All team members shall be from outside of the region in which the facility or program is located. The certification team auditing local correctional facilities shall consist at minimum of a certification analyst and a local facilities manager.

4. The certification analyst shall act as team leader and shall coordinate and facilitate the audit.

C. The Compliance and Accreditation Unit shall notify the facility or program administrator in writing at least 30 days prior to a compliance audit.

D. A certification analyst should visit the facility or program administrator prior to an audit to discuss the audit process as needed. The visit shall be documented and approved by the Compliance and Accreditation Unit supervisor.

6VAC15-20-50. On-site audit procedures.

A. The certification analyst shall, on the first day of the audit, orient the team to the audit process and afford the facility or program administrator an opportunity to brief the team on aspects of the facility or program that may have a bearing on the audit.

B. The facility or program administrator shall grant the team access to all documents, staff and areas of the facility or program that are relevant to establishing compliance.

C. A facility or community residential program with an approved variance shall provide such documentation to the certification team.

D. Data shall be collected through documentation, interview and observation.

E. The certification analyst shall brief the facility or program administrator daily on audit progress and preliminary findings. At this time, the facility or program administrator may introduce additional data having a bearing on the team's findings.

F. The entire certification team shall be included in compliance decisions.

1. When a team member finds an indication of noncompliance, the team member shall notify the entire team and provide all available information regarding the standard in question.

2. The team leader shall obtain consensus of the members to the compliance.

3. If a consensus cannot be obtained, the matter shall be referred to the Compliance and Accreditation Unit supervisor.

G. The team shall hold a final debriefing with the facility or program administrator to discuss the team's compliance audit findings.

H. At the request of the facility or program administrator, the certification team shall report compliance audit findings to facility or program staff.

6VAC15-20-70. Development of a plan of action.

A. A plan of action shall be developed for all deficiencies noted in the compliance audit findings. The plan of action must identify the following:

1. The tasks required to correct a noted deficiency;

2. The personnel responsible for completing the tasks; and

3. The actual or proposed date of task completion.

B. The facility or program administrator shall submit the plan of action to the regional office or Compliance and Accreditation Unit (for local facilities) as appropriate within 10 working days of receipt of the notification of deficiencies.

C. The regional director or designee, or Compliance and Accreditation Unit manager shall review the plan of action. If approved, it shall be submitted within 10 working days of receipt as follows:

1. Regional director to the Deputy Director of Community Corrections;

2. Regional director to the Deputy Director of Operations;

3. Compliance and Accreditation Unit manager.

D. The Deputy Director of Community Corrections/Deputy Director of Operations/Compliance and Accreditation Unit manager shall approve, amend, or return the plan of action to the regional director or local facility or program administrator for revision within 10 working days of receipt.

E. D. The regional director or local facilities facility or program administrator shall complete any revision requested and return the plan to the Deputy Director of Community Corrections/Deputy Director of Operations/Compliance Compliance and Accreditation Unit manager within 10 working days of receipt.

F. E. The Compliance and Accreditation Unit manager may grant one 30-day extension to a facility or program administrator for the development of a plan of action. The Compliance and Accreditation Unit manager shall notify the board of the extension and its justification. The board may grant additional extensions.

G. F. If a facility or program administrator fails to submit a plan of action within the time specified, the Compliance and Accreditation Unit supervisor shall submit the audit report with recommendations to the board.

6VAC15-20-80. Variance requests.

A variance may be requested by a facility or program administrator when unable to comply with a standard.

1. Variance requests shall be submitted along with the plan of action for any deficiencies cited during the audit. Local correctional facilities shall submit the variance request directly to the board with the plan of action. Variance requests from other facilities/programs shall follow the procedures listed below. Variance requests shall include:

a. The standard that cannot be met;

b. Justification for variance; and

c. The time frame for the variance.

2. Local correctional facilities and community adult residential programs shall submit the variance request directly to the board.

3. The regional director shall make a recommendation on the variance request and submit it and the plan of action to either the Deputy Director of Operations or Deputy Director of Community Corrections.

4. The Deputy Director of Operations or Deputy Director of Community Corrections shall review the variance request or requests and either submit them to the board with a recommendation for approval or return the disapproved request to the regional director.

5. The Compliance and Accreditation Unit manager, for the deputy director, shall forward the variance request to the board with a recommendation for approval.

6VAC15-20-90. Appeal process for audits/inspections and schedule.

A. The appeal review levels are: Board of Corrections will review appeals for locally or privately operated community facilities or community residential programs.

1. Deputy Director of Operations for state correctional facilities;

2. Deputy Director of Community Corrections for state community correctional units and probation and parole districts;

3. Board of Corrections for locally or privately operated community facilities or programs.

B. Appeals shall be submitted to either the regional office or the Compliance and Accreditation Unit (as noted above) along with the plan of action within 10 working days of receipt of the notification of deficiencies. The regional director or the Compliance and Accreditation Unit supervisor shall submit the appeal and the plan of action to the Deputy Director of Operations/Deputy Director of Community Corrections within five working days of receipt to the board.

C. If the appeal is denied at any level, the facility or program administrator may request that the appeal be forwarded to the next level.

D. Each appeal level shall complete its review of the appeal and notify the Compliance and Accreditation Unit supervisor of its decision within five working days upon receipt of the appeal.

E. C. Upon completion of the board's review of the appeal, notification of the decision shall be forwarded no later than five days after the board meeting to the facility or program administrator.

F. D. If the appeal is ultimately denied by the board, the Compliance and Accreditation Unit will review and confirm the submitted plan of action and present a final recommendation for consideration by the board at the following board meeting.

6VAC15-20-100. Board action on audit results.

A. The Compliance and Accreditation Unit supervisor shall submit audit reports to the board no later than 60 days after completion of the audit. Audit reports shall include:

1. A list of deficiencies;

2. Plans of corrective action and completion status;

3. Similar deficiencies from the previous audit; and

4. Recommended action for consideration by the board.

B. Based upon the audit report the board shall take one of the following actions:

1. A letter requesting corrective action on deficiencies within a specific time frame shall be issued to the facility or program.

2. A certificate of unconditional certification shall be issued to a facility or community residential program that has complied with all applicable standards.

3. A letter of probationary certification may be issued to a facility or community residential program that has not met all applicable standards if the board grants a specific period of time to correct deficiencies. The department shall provide periodic status reports to the board.

4. A letter of decertification will be issued by the board when a facility or community residential program does not meet the requirements for certification within the time limits approved by the board. The Compliance and Accreditation Unit supervisor shall provide status reports to the board during this period and notify the board when all deficiencies have been corrected.

C. A facility or community residential program's certification status shall remain in effect until subsequent board action.

6VAC15-20-120. Actions that can be taken when decertified.

When a facility or community residential program is decertified the board may consider taking the following actions in compliance with statutes, policies, and procedures established by the board, the department, or other state or federal agencies:

1. Board action for facilities or community residential programs that are state or privately operated may include, but not be limited to, the following:

a. The facility or program administrator authorized to take action may bring about a reorganization of the facility or community residential program structure or other personnel actions deemed necessary to bring it into compliance with standards; or

b. The facility or community residential program may be closed in accordance with established procedures.

2. Board action for facilities and community residential programs that are locally operated may include, but not be limited to, the following:

a. Recommend that the facility or program administrator authorized to take action bring about a reorganization of the facility or community residential program structure or other personnel actions deemed necessary to bring it into compliance with standards;

b. Recommend that the facility or community residential program be closed or contractual agreements terminated in accordance with established procedures; or

c. Initiate proceedings for the withholding of funds under the appropriate sections of the Code of Virginia.