Department of Criminal Justice's Complaint Resolution and Investigation Functions State Auditors Office 2008.pdf

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John Keel, CPA
State Auditor

An Audit Report on the

Department of Criminal Justice’s
Complaint Resolution and
Investigation Functions
September 2008
Report No. 09-004

An Audit Report on

The Department of Criminal Justice’s
Complaint Resolution and Investigation
Functions
SAO Report No. 09-004
September 2008

Overall Conclusion
The Department of Criminal Justice
(Department) substantially complies with
its policies and procedures relating to
investigating and resolving offender and
employee grievances, investigating
complaints, and processing allegations of
policy violations and criminal behavior.
The Department also conducted Offender
Protection Investigations in accordance
with its Safe Prisons Plan and ensured that
offenders were safely housed.

Background Information
At the end of fiscal year 2007, 139,577
offenders were incarcerated in 101
Department facilities, and 16,074 offenders
were incarcerated in 20 private facilities. The
Department was authorized to have 39,030
full-time equivalent employees for fiscal year
2008. During fiscal year 2007 and the first
half of fiscal year 2008:

The Offender Grievance Program processed
376,421 grievances.

The Health Services Division processed

46,492 offender medical grievances and

Most of the related programs that auditors
12,364 Patient Liaison Program complaints.
reviewed had adequate policies and
The Office of the Inspector General opened
7,186 criminal, administrative, and
procedures, and the Department
informational cases.
substantially complied with required
The Safe Prisons Program conducted 34,436
timeframes for processing complaints,
offender protection investigations.
grievances, and inquiries. However, the
The Ombudsman Program processed 31,071
complaints and inquiries.
Department could improve documentation
The Human Resources Division processed
and review controls to ensure that (1) data
1,492 employee grievances and 1,120 Equal
entered into automated systems is
Employment Opportunity complaints.
accurate, (2) offenders are aware of
current program updates and revisions, and
(3) complaints and inquiries that are
referred to other divisions or prison units and state jails are properly tracked.
The Department’s Offender Grievance Program, Health Services Division, Office of
the Inspector General (OIG), Safe Prisons Program, Ombudsman Program, and
Human Resources Division coordinate their activities to resolve allegations,
complaints, and grievances. Department divisions and the OIG also made
appropriate referrals to properly address complaints and grievances. However, the
Department could strengthen certain coordination activities between its divisions
and the OIG.
Auditors administered 1,641 surveys to offenders incarcerated at seven stateoperated or privately operated prison units and state jails (units). Results indicate
that offenders are not always aware of the offender grievance process and are
concerned about issues such as retaliation and the appearance that grievance staff
This audit was conducted in accordance with Texas Government Code, Sections 321.0132 and 321.0134.
For more information regarding this report, please contact Anita D’Souza, Audit Manager, or John Keel, State Auditor, at (512) 9369500.

An Audit Report on
The Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004

members lack objectivity and independence. Also, survey results indicate that the
Department’s efforts to increase awareness of the Safe Prisons Program have been
effective; however, improvements are needed to increase offenders’ awareness
about how to access the OIG and how to file a complaint about medical services.
Auditors also administered 673 surveys about the employee complaint and
grievance process to Department employees at prison units and state jails, parole
offices, and other Department offices. These survey results indicate that a
majority of Department employees are aware of the complaint and grievance
processes and how to obtain assistance from human resources staff.
Auditors also communicated other, less significant issues to the Department in
writing.

Summary of Management’s Response
The Department agrees with the recommendations in this report. Detailed
responses are included in the Detailed Results section of this report.

Summary of Information Technology Review
The Department has adequate general information technology controls and
application controls over three computer systems. However, the Department
could make improvements to ensure the integrity and security of system data.
Auditors identified opportunities for improvement in the areas of data integrity
and management of data that is extracted from the systems.

Summary of Objectives, Scope, and Methodology
The objectives of the audit were to:
¾

Determine whether the Department is complying with policies and procedures
and best practices governing the screening, investigation, and resolution of
allegations of criminal behavior, serious policy violations, and serious offender
and employee grievances.

Determine whether the OIG, Office of the Ombudsman, Offender Grievance
Program, Human Resources Division, and other areas of the Department
effectively coordinate their activities to resolve complaints and allegations of
criminal behavior, serious policy violations, and serious offender and employee
grievances.

The scope of the audit included reviewing and analyzing data from September 2006
through February 2008 for Department programs and information systems relating
to offender and employee grievances, third-party inquiries and complaints, and
investigations. In addition, auditors administered surveys to 1,641 offenders and

An Audit Report on
The Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004

673 employees at seven units, as well as at parole offices and other Department
offices.
The audit methodology included collecting information and documentation,
performing selected tests and procedures, analyzing and evaluating the results of
tests, conducting interviews with staff at the Department, and administering
offender and employee surveys.

iii

Contents

Detailed Results
Chapter 1

The Department Coordinates Its Activities to Resolve
Complaints and Grievances, But Department Divisions
Could Improve Certain Coordination Activities .................. 45
Chapter 3

Offender Survey Results Indicate That the Department
Should Improve Efforts to Increase Awareness of How to
File Complaints with the OIG or the Health Services
Division ................................................................. 49

Appendices
Appendix 1

Objectives, Scope, and Methodology.............................. 52
Appendix 2

Results of the State Auditor’s Office Survey of Offenders
and Employees ........................................................ 55
Appendix 3

Department of Criminal Justice Prison Units and State
Jails (State-Operated and Privately Operated) .................. 58
Appendix 4

Safe Prisons Program Office Reporting Information ............ 62

Detailed Results
Chapter 1

The Department’s Investigations of Offender and Employee
Grievances Substantially Complies with Policies and Procedures;
However, the Department Could Strengthen Documentation and
Review Controls
The Department of Criminal Justice (Department) substantially complies with
its policies and procedures for screening, investigating, and resolving
complaints and grievances. Most of the related programs that auditors
reviewed had adequate policies and procedures, and the Department
substantially complied with required timeframes to process the complaints,
grievances, and inquiries. The Department should strengthen documentation
and review controls over its investigations to ensure that (1) data entered into
automated systems is accurate, (2) offenders are aware of current program
updates and revisions, and (3) complaints and inquiries that are referred to
other divisions or prison units and state jails are properly tracked.
Chapter 1-A

The Department’s Offender Grievance Program Ensures Its Staff
Substantially Complied with Policies and Procedures for Screening,
Investigating, and Resolving Offender Grievances
Offender Grievance Program
Offenders use a two-step process to
resolve issues or concerns that arise
inside a prison unit or state jail (unit).
Offenders submit grievance forms via
grievance boxes or directly to unit
grievance staff. Unit grievance staff
screen, investigate, or refer the
grievance and formally respond to the
offender on the original grievance form.
If an offender wants to appeal the
response, he or she submits an appeal to
the unit grievance staff, who forward the
appeal to the Central Grievance Office
for processing.

The Offender Grievance Program (Program) substantially complied
with policies and procedures for screening, investigating, and
resolving grievances and grievance appeals of offenders in prison
units or state jails (units). In addition, the Program substantially
complied with time frames established by Department policy.
However, the Division should improve its controls relating to
documentation of offender grievance files and the completeness of
grievance investigations and responses. The Program processed
376,421 grievances from September 1, 2006, through February 29,
2008 (see Table 1 on next page).

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 1

Table 1

Offender Grievances Processed by the Program
September 1, 2006, through February 29, 2008

Type of Grievance
Unit-level Offender Grievances
Offender Grievance Appeals
Totals

Fiscal Year 2007

September 1, 2007
through
February 29, 2008

Total

219,386

100,423

319,809

37,196

19,416

56,612

256,582

119,839

376,421

Source: Offender Grievance Case Tracking System.

Auditors conducted testing of 376 offender grievances at 7 units and 80
grievance appeals and determined that grievance investigators (1) correctly
filled out unit-level grievance forms, (2) appropriately assigned issue and
outcome codes, (3) ensured that grievances were signed by appropriate
personnel, and (4) documented extensions for unit-level grievances in
accordance with the Department’s Offender Grievance Operations Manual.
Grievance investigations also were properly documented using the Program’s
investigation worksheet. In addition:

Five of six (83 percent) offender grievances and appeals reviewed that
mentioned a grievance investigator were processed by an alternate
grievance investigator.

All 376 offender grievances reviewed and 77 of 80 (96 percent) of
grievance appeals reviewed were completed and responded to within the
time frames established by the Department.

All 13 offender grievances reviewed relating to either a sexual assault or
sexual abuse were handled appropriately and in accordance with the
Department’s Safe Prisons Plan (see Chapter 1-D for more information on
the Safe Prisons Plan).

Auditors surveyed offenders at seven units. Seventy-three percent of the
offenders responding said they knew how to access Program grievance forms,
and 57 percent said they knew how to access Program policies (see Table 3 on
page 5). Other results included:

52 percent stated they were not afraid to file grievances.

55 percent of offenders responding stated they were not told about the
grievance system.

78 percent said they did not trust the grievance investigators.

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SAO Report No. 09-004
September 2008
Page 2

Screening Criteria
The Program has 11 screening criteria
that may be used by Unit Grievance
Investigators for offender grievances,
and 6 screening criteria for appealed
grievances. These criteria were
established to limit the number of
frivolous complaints and to teach
offenders to use the Program
responsibly. The Program does not
investigate or respond to grievances
that are screened out.
Source: Offender Grievance
Operations Manual.

78 percent stated that the grievance system does not work.

The Program took corrective action in 13 percent of all offender
grievances and appeals, and it determined that no further investigation
was warranted in 64 percent of grievances and appeals (see Table 2).
Unit Grievance Investigators screened out (returned for correction or
resubmission) 22 percent of the unit-level and appealed grievances from
September 1, 2006, through February 29, 2008 (see text box for more
information on screening criteria).

Table 2

Grievance Outcomes for Offender Grievances and Appeals Filed
September 1, 2006, through February 29, 2008

Outcome
a
Code Used

242,029

64%

82,327

22%

Grievance screened/returned to the offender for
correction and re-submission.

30,150

Resolved with some action taken. (The
Department changed policies or procedures,
corrected offender records, returned offender
property, or took other corrective action.)

17,610

Resolved through the grievance process with
some action taken.

2,369

Voluntary withdrawal of grievance by the
offender.

1,034

Grievance included with a use of force report.

470

Referred to the Office of the Inspector General
(OIG) for appropriate action.

178

Administratively closed.

Property issues.

b
b

b
Totals

Definition

Percent of
Grievances/Appeals
Receiving Code

Determined no further investigation was
warranted (investigated and returned to the
offender).

Number of
d
Grievances

376,260

100%

Grievances investigators use these codes to close grievances based on the results of an investigation.
The Program no longer used these outcome codes after August 31, 2007.

Auditors identified an additional 21 grievance records that were incorrectly assigned Ombudsman Program
outcome codes.
d
The number of grievances that are closed is lower than the number of grievances opened (processed) in Table 1.
Sources: Offender Grievance Case Tracking System and Offender Grievance Operations Manual.
An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 3

The Program has extensive policies and procedures related to establishing an
offender grievance process; however, it does not ensure that grievance staff is
consistently trained.
Texas Government Code,
Section 501.008
“The Department shall develop and
maintain a system for the resolution
of grievances by inmates housed in
facilities operated by the Department
or under contract with the
Department that qualifies for
certification under Title 42, United
States Code, Section 1997e, and the
Department shall obtain and maintain
certification under that section.”

Structure of Offender
Grievance Program
The Program is comprised of three
levels of staff: (1) central grievance
staff, (2) regional grievance staff, and
(3) unit grievance staff. Staff in the
Central Grievance Office address
grievance appeals. Regional
grievance staff members are available
to assist unit grievance staff and
address some grievance appeals. Unit
grievance staff process unit-level
grievances and forward appeals to the
Central Grievance Office.

In accordance with the Texas Government Code (see text box), the
Department has extensive policies and procedures clearly defining what
an offender grievance is and providing guidelines for how these
grievances should be processed. In addition, the Program established
the Offender Grievance Operations Manual, which provides guidelines
for collecting, screening, investigating, documenting, responding to, and
closing offender grievances. However, the Program does not ensure that
unit-level grievance staff receive consistent training on the grievance
process.
At all units auditors visited, new grievance staff were trained by the
unit’s existing grievance staff, even though the Offender Grievance
Operations Manual states that regional supervisors are responsible for
new employee training (see text box for structure of grievance staff). In
addition, Unit Grievance Investigators attend quarterly regional training
and electronically receive Program updates. While some Unit
Grievance Investigators mentioned other training opportunities, their
responses were inconsistent and some Unit Grievance Investigators were
not aware of recent changes in the Safe Prisons Program. Without
consistent training, there is an increased risk that grievance staff will not
appropriately process offender grievances in accordance with
Department policies and procedures.

The Program ensures that offenders have appropriate access to the grievance
process; however, it does not ensure that all Program information is current
and available to offenders through various avenues.

Offenders at the seven units that auditors visited have access to grievance
forms in both English and Spanish. Each unit also had an appropriate number
of grievance boxes and adequately posted grievance instructions in prominent
locations, as required by Department procedures. All seven unit’s law
libraries also contained copies of all Department policies required to be
available for review by offenders. Although not required, the law libraries
also had older versions of the Offender Grievance Operations Manual, which
could help offenders better understand the grievance process.
Upon arriving at the unit, offenders are given information about the Program
during an orientation session. This information is presented either through a
unit-specific orientation packet1, a Department Offender Orientation
Handbook, a Department-produced video, or a combination of these
resources. However, the Department’s and unit’s handbooks that auditors
reviewed contained inconsistent information about the Program. Some
1

Not every unit has its own unit-specific orientation packet.
An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 4

handbooks inform offenders that they are able to withdraw a grievance after
submission, even though, as of September 1, 2007, offenders are no longer
able to withdraw a grievance. In addition, the handbooks may not be useful
for illiterate offenders or non-English or non-Spanish speaking offenders.
2008 State Auditor’s Office
Survey of Offenders
Auditors surveyed 1,641 offenders at 7
units about the Program. The survey
asked offenders to rate their level of
agreement or disagreement with 19 survey
statements.
Offenders also were given the opportunity
to provide additional comments regarding
the grievance process. A total of 790
offenders (48 percent of respondents)
provided comments regarding the
grievance process and other topics.
(See Appendix 2 for more information on
survey responses.)

While auditors determined that offenders have appropriate access to
the Program information, 55 percent of offenders responding to an
auditor-conducted survey stated they were not told how the grievance
system works, and 16 percent stated they did not know how to access
the grievance forms (see text box for background information on the
survey and Table 3 for selected survey results). Four percent (30 of
790) of survey comments said offenders had to learn about the
grievance process from other offenders or were not able to understand
the process due to illiteracy or other language-related obstacles.
Seventy-nine percent of offenders surveyed also disagreed that unit
staff, when asked, would help the offenders complete a grievance
form, even though Department procedures state that “assistance
[completing the form] may be sought from an employee.”

In addition, survey responses indicate that offenders feel that the grievance
system does not work and that Department management does not take
immediate action to address safety and welfare concerns of offenders.
Table 3

Survey Results Related to Offenders’ Awareness and Perceived Accessibility of Grievance Process

Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

1. I was told how the grievance system works at
the Department of Criminal Justice.

32%

55%

2. I know where to access the offender grievance
c
policies.

57%

32%

3. I can file a grievance when needed.

65%

26%

5. If I want to file a grievance, I know how to
access the grievance form.

73%

16%

6. If I ask, staff will help me complete my
grievance.

79%

9. I know how to file an appeal if I am not
satisfied with the outcome.

49%

36%

10. I always get to keep a copy of my grievance
form.

45%

35%

12%

13. I feel the grievance system works in the
Department of Criminal Justice.

78%

Survey Statement

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SAO Report No. 09-004
September 2008
Page 5

Survey Results Related to Offenders’ Awareness and Perceived Accessibility of Grievance Process

Survey Statement
19. The Department of Criminal Justice’s
management takes immediate action to address
c
safety and welfare concerns of offenders.
a
b
c

Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

13%

12%

71%

Respondents who agreed or strongly agreed with an individual survey statement were grouped together in the “Agree” column.
Respondents who disagreed or strongly disagreed with an individual survey statement were grouped together in the “Disagree” column.
The percentages do not all sum to 100 percent due to rounding.

The Program should ensure that unit grievance employees maintain the
confidentiality of grievances and the appearance of objectivity and
independence to improve offender confidence in and perception of the
Program.

Although Program staff substantially complied with Department policies and
procedures, offender survey results indicate that offenders have some
concerns regarding (1) the independence and trustworthiness of Unit
Grievance Investigators, (2) retaliation from staff for filing a grievance, and
(3) the confidentiality of grievances. Specifically:

Fourteen percent (107 of 790) of survey comments related to a perception
of grievance staff members’ bias or lack of independence.

Fifty-three of 56 (95 percent) grievances reviewed at 1 unit were
appropriately forwarded. The remaining 3 (5 percent) grievances were
forwarded in their entirety to the unit chaplain, the law library, or to a
correctional officer. According to Program procedures, the grievance
investigator should have provided only a summary of the grievance to the
investigating authority. If grievance investigators do not take appropriate
steps to protect the confidentiality of grievance information, offenders
may perceive the process as untrustworthy, as indicated by the fact that 4
percent (33 of 790) of survey comments said correctional staff had viewed
confidential grievance forms or referred to other confidentiality concerns.

Fifty-two percent of survey respondents stated they were not afraid to file
grievances; however, 78 percent disagreed that they could trust their Unit
Grievance Investigator(s) (see Table 4 on the next page). In addition, 32
percent (252 of 790) of survey comments referred to having a fear of
retaliation from staff.

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SAO Report No. 09-004
September 2008
Page 6

Table 4

Survey Results Related to Offenders’ Awareness and Perceived Accessibility of Grievance Process

Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

4. I am not afraid to file a grievance.

52%

35%

7. I feel that grievances are screened properly
by the Unit Grievance Investigator.

10%

77%

8. After filing a grievance, I always get a
response.

41%

11%

37%

11%

11. I trust the Unit Grievance Investigator(s)
c
at this facility.

10%

78%

12. Staff has never retaliated against me for
filing a grievance.

16%

11%

62%

11%

Survey Statement

a
b
c

Department and Program management should ensure the following to increase
offender confidence in the Program:

Ensure that grievance staff gathers and retains evidence from all possible
sources in the grievance file. Although 305 of 326 (94 percent) offender
grievances tested received a thorough investigation, a minimal amount of
supporting documentation and investigative evidence was retained in the
grievance files. Some grievance files contained only a statement from the
offender and a statement from a Department staff member, usually a
correctional officer. In a majority of these cases, the Unit Grievance
Investigator concluded there was insufficient evidence to substantiate the
offender’s allegations. Eleven percent of offender survey comments
responded that grievance investigations were ineffective because they
usually resulted in an officer’s statement against an offender’s statement.

Ensure that grievance staff identify Department employees who are
consistently the subject of offender grievances and report trends to unit
management. Twenty-five percent of the issue codes used most often by
grievance investigators to classify grievances relate to a complaint made
against Department staff (see Table 5 on next page). Although they are
not required to do so, unit grievance staff have the ability to generate
reports from the Offender Grievance Case Tracking System to identify
which staff have been mentioned in offender grievances and how many
times that individual has been a party to a grievance.

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SAO Report No. 09-004
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Page 7

Table 5

Grievance Issue Codes Used Most Often by Grievance Investigators
September 1, 2006, through February 29, 2008
Issue Code
Used

Number of
Grievances

Percent of
Grievances

815

30,020

Unprofessional staff conduct.

899

27,739

Staff complaint grievance that has been screened
out.

814

21,245

Allegation of staff denial/Interference with an
activity (such as recreation or showers).

599

19,672

Facility operations grievance that has been screened
out.

499

15,438

Disciplinary grievance that has been screened out.

401

13,434

Improperly charged (Disciplinary Case).

810

12,664

Allegations of staff use of profanity/epithets/
taunting/badgering/intimidation.

515

12,260

Property lost/missing/damaged/stolen.

500

9,217

Food services issues.

512

8,510

Confiscated/contraband property.

509

7,580

Recreation (offenders denied recreation by staff or
other factors prevent access to recreation).

Definition

Source: Offender Grievance Case Tracking System.

Ensure that grievance staff provide offenders with reasonably detailed
responses. Most of the responses to grievances reviewed by auditors were
general and contained few details about the investigation and conclusion.
While standardized responses may not be a Program deficiency and could
be used to increase Program efficiency, including specific details about the
offender’s grievance could help promote the credibility of the grievance
program among offenders. Sixteen percent of offender survey comments
were critical that offenders seemed to receive the same, standardized
response from grievance investigators.

Ensure that grievance staff are aware of their level of professionalism and
perceived objectivity while in the presence of offenders. At some units,
auditors observed grievance staff engaging in casual conversations with
members of the correctional staff while in the presence of offenders.
While this may not be inappropriate, grievance staff should try to avoid
actions that may lead offenders to perceive that the grievance investigators
are not independent and objective.

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September 2008
Page 8

The Program should improve notification of unit personnel and documentation
of grievance extensions in its grievance files and automated grievance system.

Grievance investigators did not consistently notify the correct unit personnel
about grievances that alleged an emergency situation exists. Specifically:

Four of 21 (19 percent) grievances tested in which an offender claimed a
life endangerment situation lacked documentation showing that the
appropriate unit personnel were notified as required by the Department’s
Offender Grievance Operations Manual (see text box for
Notifications to Unit Personnel
notification requirements).

If an offender claims his or her life is
endangered from another offender, the Unit
Grievance Investigator is required to
immediately notify the Unit Chief of
Classification and the Unit Major via e-mail,
followed by a telephone call to the highest
ranking security supervisor on duty. If an
offender claims his or her life is endangered
from staff, the Unit Grievance Investigator is
required to immediately notify the Unit Warden
and the highest ranking security supervisor on
duty using the same notification process.

One of two (50 percent) appealed grievances alleging that an
offender was in fear of life endangerment from staff tested
lacked documentation that the warden was notified.

In one of two (50 percent) unit-level grievances tested in
which the offender claimed he was a victim of extortion, the
Unit Grievance Investigator did not coordinate the
investigation with the Unit Extortion Officer in accordance
with Program procedures.

Source: Offender Grievance Operations Manual.

Although some unit personnel were notified by grievance investigators for the
grievances discussed above, Unit Wardens should be notified in accordance
with Department policies and procedures to ensure they are aware of
emergency situations on the unit and that appropriate actions are taken.
Grievance Categories and Timeframes
Grievances are classified in one of three
categories:

Emergency: Life endangerment situations,

requests for protection, sexual assault,
sexual abuse, extortion, and medical-related
allegations.

Specialty: American with Disabilities Act
issues, preferential treatment, nonemergency medical, religion, and
discrimination based on gender or
nationality.

In addition, grievance investigators did not consistently notify
offenders that it would take longer than the required time frames
to address their grievance. If grievance staff do not send
offenders extension notifications, as required by Department
policy, offenders may conclude that their grievances were
ignored (see text box for grievance categories and timeframes).
Specifically:

Twelve of 13 (92 percent) applicable unit-level grievance
files had a documented extension form.

Twenty-one of 23 (91 percent) applicable grievance appeal
files had a documented extension form.

Seven of 23 (30 percent) grievance appeal extensions
reviewed were not properly documented in the comments
section of the Offender Grievance Case Tracking System
(Grievance System). The Offender Grievance Operations
Manual states that extensions are to be documented in the
Grievance System’s comments field by including the initials
of the individual authorizing the extension. In all seven

Regular: Classification matters,

communication, disciplinary, facility
operations, legal, staff complaints, and
other miscellaneous issues.

Unit Grievance Investigators have 40 days to
investigate and respond to offender grievances.
The Department (Central Grievance Office) has
35 days in which to investigate and respond to
offender grievance appeals. An extension may
be filed by grievance investigators for the same
number of original days. Grievances related to
disciplinary cases must be addressed within 30
days, and they are not eligible for an extension.
Source: Offender Grievance Operations Manual.

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SAO Report No. 09-004
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Page 9

cases, the initials were not documented as required. If grievance
extensions are not properly documented, the Department cannot monitor
who granted the extension.
The Program could improve controls to ensure that grievance data is accurate
and secure.

The Department has adequate information technology controls over its
Offender Grievance Case Tracking System (Grievance System) to control
access to the mainframe system and to manage its data (see
Offender Grievance Case
text box). However, the Department could improve some
Tracking System
controls to better ensure the integrity of system data.

The Department uses the Offender
Grievance Tracking System (Grievance
System) to document and track offender
grievances. The Grievance System allows
users to quickly view grievance history and
generate reports to identify trends, such
as repeated grievance issues or staff
involvement. The following employees
have access to the Grievance System:

Unit, regional, and central grievance
office staff.

Unit Wardens, regional staff, and
department heads.

Administrative Review and Risk
Management Division staff.

Health Services Division staff.
Office of the Inspector General staff.
Any other Department employee by
request.

Program staff use data extracted from the Grievance System
for analysis and reporting because it is easier to perform
analysis using other software, such as Microsoft Excel and
Access, than it is to use the Grievance System. Program staff
extract data for analysis because the Grievance System does
not contain the functionality to provide all needed reports and
conduct analysis. The risk of data errors increases if the data is
changed outside of the automated Grievance System controls.
In addition, a number of technical support staff and contractors
have unnecessary access to Grievance System data, which
increases the risk of unauthorized changes made to the data.
However, requests to improve the Grievance System are a low
priority for the Department’s Information Technology
Division.

In addition, the Grievance System does not allow for the efficient tracking of
grievance due dates. The Grievance System automatically calculates due
dates—40 days for unit level grievances and 35 days for grievance appeals. It
does not, however, calculate accurate due dates for disciplinary-related
grievances, which must be investigated and resolved within 30 days. Also,
the Grievance System does not update the due date if an extension has been
filed. Grievance staff must manually insert the correct due date in a comment
field. However, this field is not used to generate an “Overdue Report,” which
lists all outstanding grievances. As a result, grievance staff must conduct a
time-consuming review of the report to determine which grievances are
overdue and which have been granted an extension.
The Program does not consistently ensure that accurate outcome codes are
entered into the Grievance System. Auditors identified 21 grievance records
that were incorrectly closed using an Ombudsman Program outcome code; an
Offender Grievance Program outcome code should have been used.

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Recommendations

The Department should:

Ensure that new and current grievance staff are adequately trained in
accordance with Department policies and procedures.

Ensure that units provide offenders with current Program information and
consider using additional avenues to promote Program awareness among
offenders.

Ensure that the appropriate unit personnel are notified in accordance with
policies and procedures for all grievances containing allegations of life
endangerment or emergency situations.

Ensure that grievance staff enter extension data into the Offender
Grievance Case Tracking System in accordance with Program policies and
procedures.

Minimize the need for users to extract data from the Offender Grievance
Case Tracking System and to perform their work outside of the system
controls, and develop compensating controls to ensure that extracted data
is reliable and secure.

Limit the number of technical support accounts.

Ensure that the Information Technology Division prioritizes enhancements
of the Offender Grievance Case Tracking System so that user requests to
strengthen necessary controls are completed in a timely manner.

Consider updating the Offender Grievance Case Tracking System to
automatically calculate a 30-day due date for disciplinary grievances and
to recalculate a new due date for grievances that have had extensions filed.

Ensure that grievance records are closed using the accurate outcome
codes.

Management’s Response

The Department should ensure that new and current grievance staff are
adequately trained in accordance with Department policies and procedures.
TDCJ agrees. The Offender Grievance Operations Manual will be updated to
reflect that all grievance staff are to be trained within 30 days of their
effective hire date and a 'New Employee Training Verification of Training'
form will be completed and signed. Regional Grievance Supervisors will train
new Unit Grievance Investigator (UGI) III's and II's; and, when appropriate,
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will allow delegation to the UGI III or II to train other staff. In addition,
Regional Grievance Supervisors will ensure adequate training was provided,
and will provide additional training, when appropriate.
The Department should ensure that units provide offenders with current
Program information and consider using additional avenues to promote
Program awareness among offenders.
TDCJ agrees. The Offender Orientation Handbook is being revised to reflect
current information which includes the offender grievance procedure. The
Administrator of Offender Grievance will instruct Unit grievance staff to make
themselves available to the offender population during mass movement, such
as meal times, in order to answer questions, resolve issues and distribute
grievance forms if needed. Additional efforts, including publishing a notice in
the offender newspaper 'The Echo' and posting the notice at each unit in the
Law Library and in the housing areas, will be made to provide current
information and to enhance awareness of the grievance program.
The Department should ensure that the appropriate unit personnel are
notified in accordance with policies and procedures for all grievances
containing allegations of life endangerment or emergency situations.
TDCJ agrees. The instructions for notifying the appropriate personnel
regarding allegations of life endangerment or emergency situations will
continue to be provided to grievance staff in Chapter IV "Processing Step I
Grievances" of the Offender Grievance Operations Manual. Training
regarding the notification process for allegations of life endangerment or
emergency situations will be provided by the Central Grievance Office staff in
regional bi-annual trainings.
The Department should ensure that grievance staff enter extension data into
the Offender Grievance Case Tracking System in accordance with Program
policies and procedures.
TDCJ agrees. The Information Technology Division will update the Offender
Grievance Case Tracking System (GR00) by adding a 'date of extension' field.
This enhancement should reduce staff entry errors, allow for retrieval of all
grievances that have been extended and assist administration in determining
whether extensions are applied appropriately.
The Department should minimize the need for users to extract data from the
Offender Grievance Case Tracking System and to perform their work outside
of the System controls, and develop compensating controls to ensure that
extracted data is reliable and secure.
TDCJ agrees. The Information Technology Division and Central Grievance
Office will determine what information is extracted and corrected each month
and then create a mainframe screen for making corrections to the system.
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The Department should limit the number of technical support accounts.
TDCJ agrees. The Information Technology Division will identify who has
access to the Offender Grievance Case Tracking System (GR00) and as
appropriate revoke their access.
The Department should ensure that the Information Technology Division
prioritizes enhancements of the Offender Grievance Case Tracking System so
that user requests to strengthen necessary controls are completed in a timely
manner.
TDCJ agrees. The Information Technology Division will coordinate with
Agency Executive Management to ensure the enhancements to the Offender
Grievance Case Tracking System are appropriately prioritized.
The Department should consider updating the Offender Grievance Case
Tracking System to automatically calculate a 30-day due date for disciplinary
grievances and to recalculate a new due date for grievances that have had
extensions filed.
TDCJ agrees. This capability is currently being analyzed and as appropriate
the Information Technology Division will modify the system.
The Department should ensure that grievance records are closed using the
accurate outcome codes.
TDCJ agrees. The grievance system outcome codes were updated November
2007 to reflect the following 'active' outcome codes listed in the Offender
Grievance Operations Manual: C, D, H, R, T & U. These are the only
outcome codes that can now be entered into system. The 21 grievances
referenced in the audit were prior to this change. TDCJ Mainframe emails
were forwarded to the affected units for the 21 grievances on September 4,
2008. Grievance staff was instructed to pull the respective grievance from the
offender's file, review the response provided and correct the outcome code in
the GR00 that matches the response. All corrections were completed on
September 8, 2008.

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Chapter 1-B

The Unit-level Medical Departments and the Health Services
Division Substantially Comply with Policies and Procedures
Relating to Medical Grievances, Inquiries, and Investigations

Medical-related Offender Grievances
The University of Texas Medical Branch at
Galveston and the Texas Tech University
Health Sciences Center provide medical
services to offenders incarcerated in
Department units. The Health Services (HS)
Division’s Office of Professional Standards
provides guidance on processing offender
complaints about medical services.
However, the HS Division provides no
oversight of the processing of medical
grievances by the unit-level medical
departments. The Offender Grievance
Program oversees medical grievances.
Medical-related offender grievances include
complaints relating to:

Existence of or improper response to a
medical emergency.

Denial of medical treatment or
medication.

Unit-level medical staff substantially comply with policies and
procedures that govern the investigation and resolution of offender
grievances containing medical-related complaints (see text box for
examples of complaints). However, unit-level medical staff should
improve controls relating to investigation file supporting
documentation and grievance signature authority.
The Health Services Division (HS Division) substantially complies
with policies and procedures that govern the investigation and
resolution of appeals for medical offender grievances and Patient
Liaison Program inquiries. However, the HS Division should
improve controls relating to investigation file supporting
documentation and the entry of data into its automated system.
Unit-level medical staff and Unit Grievance Investigators
investigated and resolved medical grievances in a timely manner.

Conduct of medical personnel.
Inadequate or ineffective medical

The Department recorded 25,830 medical-related grievances filed
by offenders in fiscal year 2007 and 11,345 medical-related
treatment.
grievances filed by offenders during the first half of fiscal year
Inadequate or ineffective dental care.
Inadequate or ineffective psychiatric or
2008. Auditors tested 188 medical grievance files and noted no
psychological programs.
significant errors. The Unit Grievance Investigators, in
Denial or improper dispensing of
coordination with the unit-level medical departments, ensured that
medication.
these 188 grievances (1) were delegated to the correct medical
personnel for investigation, (2) were processed using the correct forms, and
(3) received timely responses that addressed the grievance complaints. They
also ensured that investigation extensions were documented in accordance
with Department policies and procedures.

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Table 6 lists the number of medical-related offender grievances and appeals
processed by the Department from September 1, 2006, through February 29,
2008.
Table 6

Medical-related Offender Grievances Filed in
Fiscal Year 2007 and First Six Months of Fiscal Year 2008
Type of Grievance

September 1, 2007,
to February 29, 2008

Fiscal Year 2007

Unit-level Medical
Grievance

25,830

11,345

37,175

5,751

3,566

9,317

31,581

14,911

46,492

Appeals of Medical
Grievance Response
Total

Total

Source: Offender Grievance Tracking System.

Unit Grievance Investigators most often categorized medical-related offender
grievances and appeals using issues codes related to medication issues, denial
of access to medical treatment, ineffective or inadequate medical treatment,
and improper processing of medical grievances (see Table 7).
Table 7

Medical Issue Codes Used Most Often for Medical-related Grievances and Appeals
Fiscal Year 2007 and First Six Months of Fiscal Year 2008
Number of
Grievances

Percent of
Total Medical
Grievances

Issue Code
Used

6,152

13%

621

Medication issues (denial or delay, dispensing issue,
alternative medication dispensed or requested).

6,023

13%

611

Denial of access to medical care and services (refusal of
treatment, denial or delay in medical treatment,
canceled or missed appointment).

5,660

12%

623

Not satisfied with treatment (ineffective, inadequate, or
insufficient treatment).

5,489

12%

699

Improper or unprocessed medical grievance (grievance
was screened out and not investigated).

3,091

601

Relating to conduct of medical personnel (physicians,
nursing staff, dentists, psychologists, psychiatrists,
physician assistants).

1,851

642

Issues relating to medical co-payments.

Issue Code Description

Source: Offender Grievance Tracking System.

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Unit Grievance Investigators and unit-level medical departments do not always
ensure that medical grievance files consistently include documentation
supporting the response.

Unit-level medical staff sufficiently documented the offenders’ grievance and
the steps taken to investigate complaints. However, the Unit Grievance
Investigators and the unit-level medical staff did not consistently retain
documentation to support responses to the grievances.
Auditors reviewed 187 medical-related grievances entered into the Offender
Grievance Tracking System from September 1, 2006, through February 29,
2008. Of these, 174 files (93 percent) had sufficient documentation
supporting the medical department’s response to the grievance. Nine of the
remaining 13 files lacked (1) supporting documentation from the pharmacy
log for the medication ordered and dispensed to the offender, (2)
documentation from medical records to show appointments scheduled for the
offender, or (3) documentation of the department policy referred to in the
grievance response as to why the offender did not meet criteria for
psychological treatment.
Unit Grievance Investigators could not find 4 of the 13 grievance files, even
though the offenders were still assigned to those units. Department policies
and procedures require documentation to be obtained to support responses to
offender grievances. This documentation may include copies from clinical
records, logs, rosters, appointment books, and any written records that may
document the provision of services. A lack of adequate supporting
documentation (1) limits the Department’s ability to ensure that responses to
medical-related offender grievances are valid and (2) may expose the
Department to increased risk during any subsequent grievances or litigation.
The Unit Grievance Investigators generally ensure that the investigation and
response to medical-related grievances are reviewed; however, they could
improve their processes to ensure that the reviews are conducted and
documented by the appropriate supervisor.

Of the 187 medical-related grievances reviewed by auditors, 177 (95 percent)
files contained sufficient documentation showing that the grievances had been
reviewed by the unit’s Practice Manager, Health Administrator, or District
Practice Manager, as required by Department policies. Unit Grievance
Investigators could not locate four grievance files, and three files contained
medical grievances signed by an Administrative Associate, which does not
comply with Department policy. Starting September 1, 2007, the signature
authority for medical-related grievances changed from the Unit Warden to the
Practice Manager or Health Administrator. The Administrative Associate
who signed the three grievances reviewed is assigned to a unit that does not
have an authorized Practice Manager or Health Administrator and was
unaware of who should sign the grievances. The HS Division subsequently
provided instructions stating that the District Practice Managers should sign
the grievances in these situations. In addition, three files contained only a
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signature stamp. While Department policy does not discuss the use of
signature stamps, the use of the stamps without a corresponding personal
signature does not provide assurance that the appropriate individual reviewed
the file to ensure that the investigation and response to a grievance is
sufficient and complies with Department policies.
Appeals of Medical
Offender Grievances
Offenders can submit an appeal of a
grievance response to their Unit
Grievance Investigator, who forwards
all appeals to the Central Grievance
Office in Huntsville. Appeals of
medical-related grievances are then
forwarded to the HS Division’s Office
of Professional Standards for
investigation and response. After the
response is signed by the appropriate
HS Division supervisor, the appeal is
returned to the Central Grievance
Office for administrative close-out
and forwarding of the written
response to the offender.

Patient Liaison Program
The Patient Liaison Program
investigates inquiries from third
parties regarding access to health
care for offenders; offenders are not
permitted to submit complaints
directly to the Patient Liaison
Program. The Patient Liaison
Program investigates complaints of
inappropriate health care delivery to
determine whether the offender
received access to medical services in
a timely manner, whether the
offender received access to a
professional medical judgment, or
whether services ordered by the
providers have been available
consistently and in a timely and
effective manner. Complaints are not
within the purview of the Patient
Liaison Program.

The HS Division investigates and resolves appeals of medical-related
grievances in compliance with Department policies and procedures.

Auditors reviewed a sample of 60 medical grievance appeals
processed between September 1, 2006, and February 29, 2008, and
found that all (1) used the correct investigation forms, (2) were
reviewed and signed by the appropriate HS Division supervisors,
and (3) were processed within the required timeframes. In
addition, 58 of 60 files (97 percent) files tested contained
responses that addressed the grievance appeal complaints and
included sufficient documentation supporting the HS Division’s
response to the appeal (see text box).
The HS Division investigates and resolves Patient Liaison Program
inquiries in compliance with Department policies and procedures.

The HS Division’s Office of Professional Standards processed
12,364 Patient Liaison Program inquiries between September 1,
2006, and February 29, 2008:

8,135 inquiries in fiscal year 2007.

4,049 inquiries during the first six months of fiscal year 2008.

The inquiries include questions relating to offender medical
treatment and requests for information (see text box). All 60
inquiry files reviewed by auditors were processed in a timely
manner. Fifty-seven of 58 files (98 percent) contained responses
that addressed the inquiries; 2 of the 60 inquiries did not require a
response from the HS Division. In addition, all inquiry files
reviewed by auditors that required a release form to be signed by
the offenders contained evidence that the release was obtained.

The HS Division ensures that Patient Liaison Program inquiries are investigated
thoroughly; however, it could improve its processes to ensure that inquiry files
consistently include supporting documentation.

Forty-nine of 53 (92 percent) Patient Liaison Program inquiry files reviewed
by auditors contained sufficient documentation to indicate that a thorough
investigation was performed. Four inquiry files lacked documentation to
support the inquiry response. The missing documentation included medical
records to support treatment information listed in the response, telephone
inquiry forms (which show the complaint information), and the offender
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correspondence to the HS Division. The HS Division’s Patient Liaison
Program Training Manual states that the inquiry case packets should include
all supporting documentation. This documentation may include medical
records, interview write-ups, computer screen prints, and other records. A
lack of adequate supporting documentation (1) limits the HS Division’s ability
to ensure that Patient Liaison Program responses to inquiries and complaints
are valid and (2) may expose the Department to increased risk during any
subsequent grievances or litigation.
The HS Division should improve its controls over the entering of inquiry case
dates into its Patient Liaison Program database.

The HS Division’s Office of Professional Standards (Office) uses the Patient
Liaison Program database to track and maintain information about the Patient
Liaison Program cases it receives, investigates, and closes. Office
investigators and administrative staff have the capability to enter and edit data
relating to inquiry content, date the inquiry was received, investigator
information, response to the inquiry, and date the inquiry was closed. The
database does not interface with other Department systems.
Auditors tested 60 Patient Liaison Program inquiry cases and identified one
case in which the database contained a case open date that was after the case
closed date. HS Division staff stated that the database does not have an edit
control to prevent this type of error.
In addition, auditors analyzed all inquiry case information entered into the
database from September 1, 2006, through February 29, 2008, and identified
the following:

214 cases (in addition to the case noted above) listed a date the case was
received that was after the date the case was closed.

Four closed cases had no closed date listed.

One case used a unit designation that was not included in the
Department’s unit code listing.

Office management confirmed the discrepancies in the data. While the
number of inquiry cases with errors is not significant, errors in the database
could affect the HS Division’s use of the data for reporting and case
performance evaluations.

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Recommendations

The Department should ensure:

Unit medical employees retain adequate supporting documentation for
responses to medical offender grievances in compliance with Department
policies and procedures.

Unit Grievance Investigators require that all supporting documentation be
present before closing out a medical grievance.

Unit Grievance Investigators retain all medical grievance documentation
for offenders assigned to their units.

Unit Grievance Investigators accept medical grievances signed by only
authorized personnel and that grievances do not include a stamp as a
signature.

The HS Division maintains documentation to support the investigation and
resolution of Patient Liaison Program inquiries.

The HS Division implements controls over the data entry of case date
information into the Patient Liaison Program database to prevent and
detect errors.

Management’s Response

The Department should ensure unit medical employees retain adequate
support documentation for responses to medical offender grievances in
compliance with Department policies and procedures.
TDCJ agrees. The unit-level grievance investigator, in conjunction with the
Unit Health Administrator/Practice Manager will ensure that unit medical
employees obtain and retain adequate support documentation for the
responses to medical offender grievances. Training curriculum is being
developed for annual training to unit medical providers on the processes
required for documenting grievances.
The Department should ensure Unit Grievance Investigators require that all
supporting documentation be present before closing out a medical grievance.
TDCJ agrees. The unit-level grievance investigator and the Unit Health
Administrator/Practice Manager have been provided the Documents and
Forms Required for Investigation of Medical Grievances form to record all
supporting documentation utilized in the formulation of the unit-level Step 1
Medical Grievance response. The Unit Health AdministratorlPractice
Manager and unit-level grievance investigators will work together to ensure
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that medical documentation as well as security statements are documented on
the form and present in the Step 1 packet. Training curriculum is being
developed for annual training to unit medical providers on the processes
required for documenting Step 1 grievances.
The Department should ensure Unit Grievance Investigators retain all
medical grievance documentation for offenders assigned to their units.
TDCJ agrees. The Administrative Review and Risk Management Division will
ensure unit grievance coordinators retain or archive these records. Annual
training will be provided to unit medical providers on the processes required
for handling Step 1 grievances. Audits will be conducted to ensure that
medical grievance documentation is being kept in accordance with policy and
the records retention schedule.
The Department should ensure Unit Grievance Investigators accept medical
grievances signed by only authorized personnel and that grievances do not
include a stamp as a signature.
TDCJ agrees. The TDCJ Health Services Division staff was made aware of
this practice during the SAO audit and corrective action was taken at that
time.
The Department should ensure the HS Division maintains documentation to
support the investigation and resolution of Patient Liaison Program inquiries.
TDCJ agrees. This Health Services Division Patient Liaison Program will
review current auditing process and develop a more consistent method of
review to ensure documentation is maintained.
The Department should ensure the HS Division implements controls over data
entry of case date information into the Patient Liaison Program database to
prevent and detect errors.
TDCJ agrees. An exception report will be run monthly and utilized to review
and find such errors. This information will be reported to the senior
management in the monthly Quality Control reports.

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Draft Copy – Working Papers
Penalty for Public Release

Chapter 1-C

The Department’s Office of the Inspector General Substantially
Complies with Its Policies and Procedures Governing Investigations
Office of the Inspector General (OIG)
The OIG, which reports directly to the
Board of Criminal Justice, receives
allegations from several sources, including
offenders, offenders’ family members,
attorneys, legislators, other Department
divisions, prison unit employees, and
referrals of offender and employee
grievances filed at the prison units.
The OIG opens two types of cases:
administrative and criminal.
Administrative cases are related to
investigations of possible violations of
employees’ general rules of conduct,
including improper use of force and
retaliation; criminal cases are related to
investigations of possible felony crimes
involving offenders or prison unit staff.
In addition, the OIG opens information
files to conduct preliminary investigations
to determine whether there is sufficient
evidence to open an administrative or
criminal case.

The Office of the Inspector General (OIG) substantially complies
with its policies and procedures that govern the screening,
investigation, and resolution of criminal and administrative cases
(see text box). The OIG screened cases properly, provided a timely
response for cases referred by the Offender Grievance Program,
included required documentation in the case files to support its
Investigative Reports, and ensured that the first line supervisor and
General Counsel reviewed the cases. The OIG also referred
sustained administrative cases to the appropriate Department
division and communicated criminal case information to the Special
Prosecution Unit. However, the OIG could strengthen controls over
the review of criminal cases and over the entering of case date
information into its Case Management System.
The OIG opened 5,566 criminal and administrative cases and 1,620
information files from September 1, 2006, through February 29,
2008 (see Table 8).

Table 8

Office of the Inspector General Cases Opened
During Fiscal Year 2007 and the First Six Months of Fiscal Year 2008

Type of Case
Criminal Cases
Administrative Cases
Information Files

a
Totals

Cases Opened from
September 1, 2007,
to February 29,
2008

Total Cases Opened

3,194

1,708

4,902

444

220

664

1,106

514

1,620

4,744

2,442

7,186

Cases Opened
During Fiscal Year
2007

Some information files also would be classified as criminal or administrative cases if evidence was
sufficient to open a case (the information files would be closed and the criminal or administrative cases
would be opened).

Source: Office of the Inspector General Case Management System.

As of May 5, 2008, the OIG had closed 5,006 of the 7,186 cases opened from
September 1, 2006, through February 29, 2008 (see Table 9 on the next page).

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Table 9

Status of Office of the Inspector General Cases Opened and Closed
Fiscal Year 2007 and First Half of Fiscal Year 2008 (as of May 5, 2008)
Case Type

Cases Closed

Criminal Cases
Administrative Cases
Information Files
Totals

Cases Still Open

Total

3,366

1,536

4,902

320

344

664

1,320

300

1,620

5,006

2,180

7,186

Source: Office of the Inspector General Case Management System.

The majority of administrative cases that the OIG opened in fiscal year 2007
and the first half of fiscal year 2008 were (1) referred directly to the unit
investigator from correspondence assigned to the investigator or from
individuals at the prison units and (2) referred to the OIG by unit grievance
staff members (see Table 10).
Table 10

Referral Sources for Administrative Cases Opened by Office
Fiscal Year 2007 and First Six Months of Fiscal Year 2008
Referral Source

Number of Cases

Percent of Total

Directly to Investigator

304

46%

Grievance System

182

27%

Use of Force Review

Directly to Investigative
Department

Unit Warden

Office Director of Investigations

Ombudsman Program

Equal Employment Opportunity
Complaints

Inspector General

Governor’s Office/Office of the
Attorney General/Legislature

Texas Board of Criminal Justice

Parole Division

Department Executive Director

Total

664

Note: The percentages do not sum to 100 percent due to rounding.
Source: Office of the Inspector General Case Management System.

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The OIG does not always ensure that reviews of its criminal cases comply with
its policies.

The OIG ensures that first-level reviews of criminal case files are consistently
completed by its Lieutenants once the investigations are completed.
However, the OIG does not always ensure that criminal case
Structure of OIG’s Departments
investigations are consistently reviewed and approved by the
The OIG comprises three departments: (1)
Regional Captain, as required by OIG policy (see text box for
Administrative Support and Programs, (2)
Investigations, and (3) General Counsel.
information on the Office’s internal structure). Eleven (21 percent)
The Investigations Department is divided
of 53 criminal case files tested by auditors were not reviewed by the
into four regions. Each region is managed
by a Regional Captain and is authorized
Regional Captains. OIG management stated that current OIG’s
two or three Lieutenants, who assist the
practices is to have either a Lieutenant or the Regional Captain
Captains in managing the region and serve
as first-line supervisors to the
review and approve a criminal case; only high-profile or sensitive
investigators. The Investigations
cases receive reviews by both the Lieutenant and Regional Captain.
Department is authorized 79 Investigators.
The Administrative Support Department
However, OIG policy OIG-03.35 states that all criminal cases should
includes one investigation region and is
be reviewed first by a Lieutenant to ensure accuracy and then by the
authorized 18 Investigators and two
Lieutenants.
Regional Captain, who approves the case. The policy does not
distinguish whether different types of cases should receive differing
levels of review. Without a secondary review for certain types of cases, the
OIG may increase its risk that the investigative findings and disposition in a
criminal case may be incorrect, which also may increase the risk of
subsequent litigation.
Although screened and investigated in accordance with policy, almost half of
the criminal cases opened by the OIG during fiscal year 2007 and the first six
months of fiscal year 2008 ended with no charges being filed against the
suspects, and 20 percent of the opened cases ended with a suspect being
prosecuted (or had a prosecution pending). Table 11 lists the disposition of
criminal cases, as of May 5, 2008, that were opened by the OIG between
September 1, 2006, and February 29, 2008.
Table 11

Disposition of Criminal Cases Opened by the OIG During
Fiscal Year 2007 and First Six Months of Fiscal Year 2008 (as of May 5, 2008)
Disposition

Number of Cases

Percent of Total

No Charges Filed

2,141

44%

Blank (investigations that have not progressed to
the point where a disposition can be determined)

1,529

31%

Alternative Prosecution (defendant was
prosecuted by another law enforcement agency
other than the OIG)

564

12%

Prosecution Refused by District Attorney

211

Prosecution Pending

187

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Disposition of Criminal Cases Opened by the OIG During
Fiscal Year 2007 and First Six Months of Fiscal Year 2008 (as of May 5, 2008)
Disposition

Number of Cases

True Billed (grand jury indicted the defendant and
the defendant was bound over for trial)

Percent of Total
106

Sentenced

No Billed (grand jury refused to indict the
defendant and the case was not sent forward for
trial)

Complainant Refused to Cooperate in Prosecution

4,902

100%

Dismissed (charges dismissed by a judge and the
defendant was not tried for the crime)
Totals
Source: Office of the Inspector General Case Management System.

The OIG should improve controls over the entering of case date information into
its Case Management System.
Case Management System
The automated Case Management System
(System) is used only by the OIG and it
does not interface with any other
Department system. Case managers in
the OIG’s Records Department open cases
in the System and make changes to case
information. Investigators do not have
access to the System and contact Case
Managers to update case information.
There are certain regional OIG staff
members and members of OIG’s Special
Prosecution Unit with limited edit
capability to update case information in
the System.

The OIG uses its Case Management System (System) to track
and maintain information about its cases (see text box).
However, the OIG should strengthen controls to ensure that daterelated information in its System is accurate. Auditors tested 63
criminal, administrative, and informational case files and
identified one file (2 percent) containing a close date that was
different than the close date in the System. The OIG confirmed
that the closed date should be the date listed in the case file.
In addition, auditors analyzed the population of all case
information data entered into the System between September 1,
2006, and February 29, 2008 and identified the following:

17 criminal cases had case open dates that were after the case closed dates.

One administrative case was classified as closed, but it lacked a date in the
case closed field.

Two information files had file open dates that were after the file closed
dates.

The OIG confirmed the discrepancies and stated that it would make the
appropriate corrections to the System. While the number of cases with errors
is not significant, errors in the System could affect management’s use of the
data to track cases and for reporting purposes.

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Recommendations

The OIG should:

Ensure that both Lieutenants and Regional Captains review and approve
criminal cases in compliance with OIG-03.35, or revise this policy to
specify whether differing types of cases require different levels of review.

Implement controls over the data entry of case date information into its
Case Management System to prevent and detect errors.

Management’s Response

The OIG should ensure that both Lieutenants and Regional Captains review
and approve criminal cases in compliance with OIG-03.35, or revise this
policy to specify whether differing types of cases require different levels of
review.
The OIG agrees. Policy will be revised to specify when differing types of cases
require different levels of review.
The OIG should implement controls over the data entry of case date
information into its Case Management System to prevent and detect errors.
The OIG agrees. The controls over the data entry of information will be
reviewed and modified as appropriate.

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Chapter 1-D

The Department Substantially Complies with the Safe Prisons Plan
Related to Its Safe Prisons Program; However, It Should Improve
Controls Over Documentation of Investigations
Offender Protection
Investigations (OPIs)
Anyone who believes that an offender
may need protection can initiate an
offender protection investigation.
The Unit’s Major oversees the
investigation and ensures that the
offender is safely housed while the
investigation is conducted. For
sexual abuse incidents, the Office of
the Inspector General (OIG) and the
Department’s Emergency Action
Center are notified. In addition to a
unit investigation, the OIG may
conduct a criminal investigation. The
unit investigative report is forwarded
to the Unit’s Chief of Classification.
The Unit Classification Committee
decides whether to grant the
offender a change in housing, work
assignment, work-shift hours, or
recommend a unit transfer.

Safe Prisons Program
The Department implemented the
Safe Prisons Program to prevent
offender-on-offender sexual abuse.
The Safe Prisons Program also
encompasses acts of violence or
aggression that may lead to sexual
abuse. In accordance with Texas
Government Code Section 501.011,
the Department has adopted a zerotolerance policy regarding sexual
abuse of an offender.

The Department’s Safe Prisons Program developed the Safe Prisons
Plan to govern offender protection investigations (OPIs) and prevent,
record, and monitor acts of offender-on-offender sexual abuse (see
text box for more information on OPIs). The Safe Prisons Program
Office provides training to unit staff and reports safe prison-related
information, such as alleged sexual assaults and the number of OPIs
conducted (see text box for more information on the Safe Prisons
Program). Within the units, there is a Safe Prisons Program
Coordinator, who provides sexual abuse awareness to unit staff and
offenders, assists the Warden with the implementation and monitoring
of the Safe Prisons Program, and may participate in the OPI process.
The Department conducted OPIs in accordance with the Safe Prisons
Plan. Specifically, the units ensured (1) that offenders were safely
housed until the Unit Classification Committee reviewed and made a
decision on the protection request, (2) OPIs were properly approved,
and (3) OPIs were completed in the appropriate time frame. In
addition, the Department properly notified the Emergency Action
Center and the Office of the Inspector General (OIG).

The Department conducted 34,436 OPIs from September 1, 2006,
through February 29, 2008. The 7 units where the Department
conducted the highest number of OPIs were large units in which the
offender population exceeded 2,000; these accounted for 31 percent of
all OPIs the Department conducted during this time period. Private
facilities, which include privately operated units, state jails, and other
contracted facilities, conducted the fewest OPIs with 4 percent of all
OPIs conducted during this time period. (See Appendix 4 for
information about the number of OPIs conducted in each region.)
The Department does not consistently ensure that OPI logs are accurately
documented.

Forty of 188 (21 percent) OPI log entries reviewed by auditors at the 7 units
visited were not documented in accordance with Department policy. Of these
40 OPI log errors, 6 were data entry errors. The remaining 34 errors were due
to the unit’s classification staff’s inadequate monitoring and misunderstanding
of the documentation process. For example, the incident type was not
documented correctly for one unit. Inaccurate OPI log documentation may
result in the Department not adequately tracking and reviewing offender
protection requests, which could affect offenders’ safety.

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The Department completed OPIs in a timely manner; however it did not always
obtain authorized extensions.

Offender Protection Investigation
Time Frames
Time frames for OPIs are contingent on the
offender’s housing placement (administrative
segregation, transient status, or general
population) pending the Unit Classification
Committee’s decision on the protection
request.
Administrative segregation – The Warden or his
designee shall complete an investigation within
72 hours of the time the request for protection
was received. The Warden may authorize an
extension for an additional 72 hours.

The Department completed 183 of 188 (97 percent) OPIs reviewed
by auditors within the appropriate time frame in accordance with
the Safe Prisons Plan (see text box). Twenty-five of these OPIs
required an authorized extension from the unit’s warden to
complete the investigation. However, the Department did not
obtain an authorized extension for 3 (12 percent) of these
investigations.
The Safe Prisons Program Office provides adequate training to
Program coordinators and unit staff.

Each unit is required to have a Safe Prisons Program Coordinator
(coordinator), who is responsible for providing sexual abuse
awareness information to unit staff and offenders. The
coordinators receive sexual abuse awareness training from the Safe
Prisons Program Office, and they receive annual Program training
General population – An investigation report
on conducting OPIs and tracking Program activity that complies
must be completed, reviewed, and signed
within 12 hours of the time a request for
with the Safe Prisons Plan. Unit correctional officers receive
protection was received.
training from coordinators on (1) how to recognize the signs of
Source: Safe Prisons Plan.
sexual abuse, (2) the referral process of an alleged sexual abuse
incident, (3) sexual abuse prevention and response techniques, (4) awareness
and sensitivity of life endangerment situations, and (5) the methods to track
and prevent extortion issues.
Transient status – The investigation must be
completed within 72 hours of the offender’s
placement in transient housing. The Warden
may authorize an extension for an additional 72
hours.

The Department did not always ensure that all units displayed the appropriate
zero-tolerance policy postings informing staff and offenders about the process
for reporting sexual assaults.

Texas Government Code, Section 501.011, requires each unit to display zerotolerance policy information about how to report possible sexual abuse of
offenders. The zero-tolerance policy information is required to be displayed
in the Chief Administrator’s office, employees’ break room, employees’
cafeteria, and at least six additional locations on the unit. Although the
Department typically posted information in more locations than mandated by
statute, some of the units visited by auditors did not have all of the appropriate
zero-tolerance policy postings. Specifically:

One of 7 units visited did not have the appropriate posting in the Chief
Administrator’s office.

Two of 7 units visited did not have the appropriate postings in the
employees’ cafeteria and at a minimum of six additional locations on the
unit.

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The Safe Prisons Program Office accurately reported Program activity; however,
it did not ensure that it received all units’ monthly Program reports.

The Safe Prisons Program Office, which reports Program activity to the
Correctional Institution Division on a monthly basis (see text
Safe Prisons Program Reports
box), accurately reported Program activity related to OPIs
The Safe Prisons Program Office reports monthly
conducted and Extortion Investigation Team activities for the
Program activity to the Department’s Correctional
seven units visited by auditors. The Safe Prisons Program
Institution Division’s executive management.
Office reported that 3,820 OPIs were conducted and 6,628
These reports include:
Number of alleged sexual assaults reported.
Extortion Investigation Team activities were completed from
Number of alleged sexual assault cases
September 1, 2006, through February 29, 2008. Extortion
accepted by the OIG for investigation.
Investigation Team activities include the number of safe
Number of OPIs conducted.
prisons investigations. Auditors determined that these
Extortion Investigation Team activities.
numbers were accurate.
The Safe Prisons Program Office obtains OPI data
from the Department’s Classification Division’s
monthly report, Extortion Investigation Team data
from each unit’s monthly Program report, and
sexual assault data from the Department’s
Emergency Action Center. The OIG provides the
number of alleged sexual assault cases accepted
by the OIG.

The Safe Prisons Program Office, however, did not report
Program activities from July 2007 to February 2008 for one of
the seven units visited by auditors because the Safe Prisons
Program Office did not receive that unit’s monthly Program
reports. The Safe Prisons Plan requires the Safe Prisons
Program Office to analyze and evaluate trends in Program activity. Without
obtaining all monthly reports, the Safe Prisons Program Office cannot ensure
it is accurately analyzing and evaluating trends.

The Safe Prisons Program Office reported 836 alleged sexual assaults; the OIG
determined that 321 of these were appropriate to open for investigation.

The Department reported 836 alleged sexual assaults from September 1, 2006,
through February 29, 2008, according to the Safe Prisons Program Office.
Nine units had the highest number of reported sexual assaults, accounting for
40 percent of the reported sexual assaults during this time period. Eight of
these units are large facilities (in which offender population exceeds 2,000),
and one unit was a medium-size facility (in which the offender population is
between 1,000 and 2,000).
Thirty units did not report any alleged sexual assaults during this time period.
Private facilities, which include privately operated units, state jails and other
contracted facilities, had the fewest reported alleged sexual assaults,
accounting for approximately 2 percent of all reported alleged sexual assaults.
(See Appendix 4 for the number of reported alleged sexual assaults in units in
each region.) The OIG determined it should open an investigation for 321 of
the 836 (38 percent) reported alleged sexual assaults from this time period.

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Recommendations

The Department should:

Ensure units accurately document the OPI log and, when needed, obtain
authorized extensions.

Ensure all units comply with all zero-tolerance policy postings required by
Texas Government Code, Section 501.011.

Ensure that the Safe Prison Program Office obtains monthly Program
reports from all units.

Management’s Response

The Department should ensure units accurately document the OPI Log and,
when needed, obtain authorized extensions.
TDCJ agrees. TDCJ will emphasize the monitoring of the OPI Log, and
documentation of OPI extension requests, through the Operational Review
process. In addition, TDCJ will review current monitoring procedures and
enhance training curriculum to ensure staff responsible for documenting the
OPI Log and granting an extension for an OPI are properly trained.
The Department should ensure all units comply with all zero-tolerance policy
postings required by Texas Government Code, Section 501.011.
TDCJ agrees. TDCJ will implement the following initiatives to ensure all units
are aware of the Zero-Tolerance Policy postings required by the Texas
Government Code, Section 501.011:
a. Specific language requiring adherence to the Zero-Tolerance Poster
policy will be added to the Safe Prisons Plan.
b. The Safe Prisons Program Management Office will enhance
training to emphasize compliance with the Government Code,
specifically identifying locations that the Zero- Tolerance Poster will
be displayed.
c. The Operational Review checklist for the Safe Prisons Program will
be revised to ensure adherence to the policy regarding the placement
of the Zero-Tolerance Poster.
d. An Agency wide email will be used to immediately communicate the
requirements of the Zero-Tolerance Poster policy.

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The Department should ensure that the Safe Prison Program Office obtains
monthly Program reports from all units.
TDCJ agrees. The Safe Prisons Program Management Office will enhance
current practices to ensure all units are submitting the monthly program
reports in a timely manner by notifying agency administrators of
delinquencies, and requiring facilities submitting delinquent reports to submit
documentation detailing corrective action.

Chapter 1-E

The Department’s Ombudsman Program Substantially Complies
with Applicable Rules and Regulations Governing Its Processes for
Complaints and Inquiries
The Department’s Ombudsman Program received 31,071 complaints and
inquiries from elected officials and the general public during fiscal
Ombudsman Program
year 2007 and the first six months of fiscal year 2008 (see Table
The Department’s Ombudsman Program
12 on the next page). The Ombudsman Program substantially
receives complaints and inquiries from elected
complies with applicable rules and regulations governing its
officials and the general public. Complaints
and inquiries can be filed by telephone, e-mail,
processes for the screening, resolution, and communication of
U.S. mail, and in person. The Ombudsman
these complaints and inquiries (see text box). The Ombudsman
Program responds to inquiries or coordinates
investigations with other Department divisions
Program:
or units.

The Ombudsman Program comprises the
Ombudsman Coordinator’s Office, the
Correctional Institutions Division Ombudsman
Office, and the Parole Division Ombudsman
Office.

Responded to complaints and inquiries received by the
Ombudsman Coordinator’s Office in a timely manner.

Provided training to Department employees and promoted
public awareness about its purpose and functions.

Effectively communicated with other Department divisions and units
regarding investigations pertaining to complaints or inquiries.

However, the Ombudsman Program could improve the timeliness of responses
from the Correctional Institutions Division Ombudsman Office and the Parole
Division Ombudsman Office. In addition, the Ombudsman Program should
strengthen its controls by developing and implementing uniform policies and
procedures and improving its process for tracking responses to complaints and
inquiries referred to other divisions and units.
The Ombudsman Case Tracking System (System) contains good controls over
access to the System and management of the data; however, additional
controls are needed to ensure the integrity and security of System data.

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Table 12

Complaints and Inquiries Received by the Ombudsman Offices
September 1, 2006, through February 29, 2008
Number of
Complaints and
Inquiries Received

Percent of Total

4,354

14%

Correctional Institutions Division

14,292

46%

Parole Division

12,425

40%

31,071

100%

Office
Ombudsman Coordinator’s Office

Totals
a

The Ombudsman Coordinator’s Office also addressed complaints and inquiries from
private facilities; 715 of these 4,354 complaints and inquiries were from private facilities.

Source: Ombudsman Case Tracking System.

The Ombudsman Program trains Department staff and promotes public
awareness about the Ombudsman Program in accordance with Department
policies.

Department policy requires the Ombudsman Program to train staff on
handling complaints and inquiries from the public and how to properly utilize
the Ombudsman Program offices. To accomplish this, the Ombudsman
Program has provided in-service training for Wardens, Assistant Wardens,
and Majors; and training sessions for Contract Monitors in the Department’s
Private Facility Contract Monitoring/Oversight Division.
Department policy also requires the Ombudsman Program to develop
informational materials to ensure that the general public, as well as elected
officials, are aware of the Ombudsman Program and its operations. To
accomplish this, the Ombudsman Program (1) provides brochures to family
members of incarcerated offenders, (2) publicly addresses conferences and
organizations for family members of incarcerated offenders, (3) posts signs at
units and district parole offices, and (4) participates in Department legislative
workshops. Additionally, the Ombudsman Program coordinates with
Department administrators, regional directors, and Wardens to speak at public
functions to raise general awareness of the operations of units and state jails.
The Ombudsman Program does not always track responses to complaints and
inquiries it refers to other divisions and units.

The Ombudsman Program referred 2,445 complaints and inquiries—8 percent
of the 31,071 complaints and inquiries the Ombudsman Program received—to
other divisions or units for investigation from September 1, 2006, through
February 29, 2008 (see Table 13 on the next page). If the investigating
division or unit provides a written response directly to the individual(s) who
submitted the complaint or inquiry, Department policy requires the division or
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Page 31

unit to provide a copy of the response to the Ombudsman Program. However,
auditors noted that in some instances, the Ombudsman Program did not
receive a copy of the final response provided by the investigating division or
unit. Specifically:

Fifty-eight of 60 (97 percent) files tested for complaints or inquiries
referred by the Ombudsman Coordinator’s Office included a copy of the
response provided by the investigating division or unit.

Fifty-eight of 60 (97 percent) files tested for complaints or inquiries
referred by the Correctional Institutional Division Ombudsman Office
included a copy of the response provided by the investigating division or
unit.

Fifty-six of 60 (93 percent) files tested for complaints or inquiries referred
by the Parole Division Ombudsman Office included a copy of the
response provided by the investigating division or unit.

Although the number of files lacking a copy of the response is not significant,
it is important that the Ombudsman Program receives copies of the responses
provided by the investigating division or unit so it can ensure that complaints
or inquiries received a written response within the appropriate time frames.
Table 13

Ombudsman Program Referrals of Complaints and Inquiries
September 1, 2006, through February 29, 2008
Division or Department Receiving the Referral

Number of
Referrals

Percent of Total
Referrals
9

303

12%

726

30%

563

23%

Office of the Inspector General

Mail System Coordinators Panel

351

14%

239

10%

136

Private Facility Contract Monitoring/Oversight Division
Classification and Records
Community Supervision and Corrections Departments
Functional Managers

Office of the General Counsel
Health Services Division

Other

Board of Pardons and Parole
Rehabilitation and Reentry Programs Division
Victim Services
Totals
a

2,445

100%

A functional manager is a Department employee who is responsible for a particular functional area within

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Ombudsman Program Referrals of Complaints and Inquiries
September 1, 2006, through February 29, 2008
Division or Department Receiving the Referral

Number of
Referrals

Percent of Total
Referrals

the Department (for example, Prison Units and State Jails, Chaplaincy Program, Commissary and Trust Fund
Department, Human Resources Division, and other similar areas).
b
Complaints that cannot be addressed by the Ombudsman Program, such as offender grievances or those
that the Department has no authority to address, are referred to the appropriate division or entity.
c
The percentages do not sum to 100 percent due to rounding.
Source: Ombudsman Case Tracking System.

The Ombudsman Program lacks written, uniform policies and procedures.

The Ombudsman Program lacks written, uniform policies and procedures for
the processing of complaints and inquiries. Department Executive Directive
02.03 requires the Ombudsman Coordinator’s Office to develop uniform
policies and procedures for the Department’s Ombudsman Program. Without
documented, uniform procedures, the Department cannot ensure that all
Ombudsman Program offices process complaints and inquiries in a consistent
manner.
The Ombudsman Program provided timely responses to complaints and inquiries
received by its Coordinator’s Office; however, it did not adequately ensure that
complaints received by its Correctional Institutions Division and Parole Division
offices always received timely responses.

Department Executive Directive 02.03 establishes time frames for
acknowledging and responding to complaints and inquiries received by the
Ombudsman Program (see text box). However, the
Ombudsman Program Time Frames for
Ombudsman Program does not always ensure that all its
Responding to Complaints and Inquiries
offices comply with these timelines. Specifically:

Complaints and inquiries from the general

public are required to receive an
acknowledgement within 10 business days of
receipt and a final response within 30 business
days of receipt.

All 60 complaints and inquiries tested at the Ombudsman
Coordinator’s Office received a response within required
timelines.

Fifty-seven of 60 (95 percent) complaints and inquiries
tested at the Correctional Institutions Division Ombudsman
Office received responses within the required time frames.
The three remaining complaints and inquiries were
exceptions due to data-entry errors that caused the response
due dates to be calculated incorrectly.

Fifty-four of 60 (90 percent) complaints and inquiries
tested at the Parole Division Ombudsman Office received a
response within the required 10 business days.

Complaints and inquiries from elected officials
are required to receive an acknowledgement
within 5 business days of receipt and a final
response within 10 business days of receipt.

Allegations of life threatening situations

pertaining to incarcerated offenders are
required to be reported immediately to the
appropriate unit administration for
investigation. An acknowledgement of receipt
is sent to the person who submitted the
complaint advising that action is being taken.
The Ombudsman Program also provides a final
response to the person(s) who submitted the
complaint immediately upon completion of the
investigation.

Source: Department Executive Directive 02.03.

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The Parole Division Ombudsman Office received 12,245 complaints from
September 1, 2006, through February 29, 2008, which represents 40 percent
of the 31,071 complaints received by the Ombudsman Program. The Parole
Division Ombudsman Office has three full-time employees. Auditors noted
problems in this office’s ability to ensure that responses are provided on a
timely basis and ensure the accurate entry of data in the Ombudsman Case
Tracking System. The resources allocated to the Parole Division Ombudsman
Office may not be sufficient to address its workload.
The Ombudsman Program accurately reported its activities; however, it should
improve controls over its reporting of performance target results.

The Ombudsman Program prepares and submits quarterly management
reports to the Department’s executive management, the Legislative Budget
Board, and the Office of the Governor that contain information
Performance Measures Established by the
about its activities and its progress toward performance targets
Ombudsman Program
(see text box). The Ombudsman Program accurately reported
The General Appropriations Act (80th Legislature)
its activities in its management reports for fiscal year 2007 and
requires the Department to develop performance
the
first two quarters of fiscal year 2008.
targets for its Ombudsman Program and report the
results annually to the Legislative Budget Board
and the Office of the Governor. The Ombudsman
Program developed and reports the results for the
following performance targets:

However, the Ombudsman Program reported inaccurate results
for one performance target—“95 Percent of
95 Percent of General Public Inquiries Will Be
Emergency/Priority Inquiries Will Have an Investigation
Addressed within 30 Working Days.
Initiated within Two Days.” Auditors’ recalculated results for
95 Percent of Legislative Inquiries Will Be
all four quarters of fiscal year 2007 and the first two quarters of
Addressed within 10 Working Days.
fiscal year 2008 differed from the results that the Ombudsman
95 Percent of Emergency/Priority Inquiries Will
Have an Investigation Initiated within Two
Program reported by more than 5 percent. In addition, all of
Days.
the performance target results in the Ombudsman Program’s
95 Percent of All Inquiries Will Be Resolved
quarterly management reports are results from the previous
within 90 Days.
quarter and, therefore, do not accurately portray the results for
95 Percent of All Speaking Engagements Will Be
Conducted as Scheduled.
the reported quarter. For example, the results listed in the
Source: Ombudsman Coordinator’s Office
management report as first quarter of fiscal year 2007 results
strategic plan, fiscal years 2006 and 2007.
are actually fourth quarter of fiscal year 2006 results. The
reports, however, do not note this difference.
The Ombudsman Program lacks documented policies and procedures for
preparing the performance targets within the quarterly management reports,
including obtaining the correct data, calculating results, and reporting results.
Also, the Ombudsman Program does not conduct an independent review of
the calculations to ensure accuracy. Without documented procedures, the
Ombudsman Program cannot ensure that its reported performance target
results are prepared consistently and accurately.
The Ombudsman Program could improve controls over data management to
ensure that the data is secure and reliable.

The Ombudsman Case Tracking System (System) contains good controls over
access to the System and management of the data; however, additional
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Ombudsman Case Tracking System
The Ombudsman Case Tracking System
(System) is a fully automated and
integrated tracking system used to process
complaints and inquiries from the public
and elected officials. The System provides
the ability to store and retrieve
information through a System-generated
tracking number, offender identification
number, name of requestor, type of
complaint, unit or office of complaint, and
nature of complaint .
Users include staff from the Ombudsman
Program offices, Offender Grievance
Program Office, Office of the Inspector
General, Office of the General Counsel,
and Food and Laundry Services. Prison
Wardens, Assistant Wardens, and
Administrative Assistants also have access.

controls could be implemented to ensure the integrity and security
of the data that is extracted from the System (see text box).
Ombudsman Program staff use data extracted from the System for
analysis and reporting because it is easier to perform analysis using
other software, such as Microsoft Excel and Access, than it is to
use the System. Because the extracted data is stored in a shared
network folder, security over the data is weakened. In addition,
the risk of data errors increases if the data is changed outside of the
automated System controls. Additionally, a number of technical
support staff and contractors have unnecessary access to System
data and could alter data without authority.

Ombudsman Program staff extract data from the System because
the System does not contain the functionality to provide all needed
reports and conduct analysis. However, requests to improve the
System are a low priority for the Department’s Information
Technology Division.
In addition, the Parole Ombudsman Division Office did not always correctly
enter the sources of complaints and inquiries into the System. Fifty-six of 60
(93 percent) complaints and inquiries tested in the Parole Division
Ombudsman Office correctly identified the source of the complaint as being
legislative or a member of the general public. These two sources have
different time frames for required responses, and entering the sources
incorrectly into the System could cause an untimely response to a complaint
or inquiry. The Ombudsman Program does not have a process for reviewing
information entered into the System to ensure accuracy.
Recommendations

The Department should:

Develop and implement written, uniform policies and procedures for its
Ombudsman Program for the processing of complaints and inquiries.

Ensure that divisions and units provide the appropriate ombudsman office
a copy of responses to complaints and inquiries referred to the divisions
and units by the Ombudsman Program.

Assess the staffing and workload in the Parole Division Ombudsman
Office to ensure that it has adequate staff to handle the workload and
provide responses to the individual(s) filing the complaint or inquiry
within required timeframes.

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Develop and implement documented procedures for calculating the results
of the Ombudsman Program offices’ performance target results, including
a documented independent review to ensure accuracy of the information.

Ensure that the Ombudsman Program accurately depicts the performance
target results for the quarter reported in its management reports.

Minimize the need for users to extract data from the Ombudsman Case
Tracking System and to perform their work outside of the system controls,
and develop compensating controls to ensure that extracted data is reliable
and secure. This should include improving network folder security
controls.

Limit the number of technical support accounts.

Ensure that the Information Technology Division prioritizes enhancements
of the Ombudsman Case Tracking System so that user requests to
strengthen necessary controls are completed in a timely manner.

Ensure that the Parole Division Ombudsman Office enters the appropriate
sources of complaints into the Ombudsman Case Tracking System.

Management’s Response

The Department should develop and implement written, uniform policies and
procedures for its Ombudsman Program for the processing of complaints and
inquiries.
TDCJ agrees. A procedures manual has been drafted to establish uniform
procedures for the entire Agency Ombudsman Program. This manual will be
distributed when finalized.
The Department should ensure that divisions and units provide the
appropriate ombudsman office a copy of responses to complaints and
inquiries referred to the divisions and units by the Ombudsman Program.
TDCJ agrees. Divisions and units will be instructed to send copies to the
Ombudsman Program when a response to a complaint or inquiry has been
provided.
The Department should assess the staffing and workload in the Parole
Division Ombudsman Office to ensure that it has adequate staff to handle the
workload and provide responses to the person(s) filing the complaint or
inquiry within required timeframes.
TDCJ agrees. Staffing will be reviewed and will be adjusted as necessary to
ensure the Parole Division Ombudsman Office is adequately staffed.
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The Department should develop and implement documented procedures for
calculating the results of the Ombudsman Program offices' performance
target results, including a documented independent review to ensure accuracy
of the information.
TDCJ agrees. Performance measures are being reviewed and the
methodology will be documented in order ensure that accurate measurements
are taken of all complaint or inquiry responses. A supervisory review will be
conducted to ensure the accuracy of the information.
The Department should ensure that the Ombudsman Program accurately
depicts the performance target results for the quarter reported in its
management reports.
TDCJ agrees. The management report will note specifically that data is from
one quarter prior to the current time frame.
The Department should minimize the need for users to extract data from the
Ombudsman Case Tracking System and to perform their work outside of the
System controls, and develop compensating controls to ensure that extracted
data is reliable and secure. This should include improving network folder
security controls.
TDCJ agrees. The Information Technology Division will enhance the OCTS to
include limitation of users extracting data.
The Department should limit the number of technical support accounts.
TDCJ agrees. The Information Technology Division will identify who has
access to the Ombudsman Case Tracking System and as appropriate revoke
their access.
The Department should ensure that the Information Technology Division
prioritizes enhancements of the Ombudsman Case Tracking System so that
user requests to strengthen necessary controls are completed in a timely
manner.
TDCJ agrees. The Information Technology Division will coordinate with
Agency Executive Management to ensure the enhancements to the
Ombudsman Case Tracking System are appropriately prioritized.
The Department should ensure that the Parole Division Ombudsman Office
enters the appropriate sources of complaints into the Ombudsman Case
Tracking System.
TDCJ agrees. Parole Division Ombudsman Office staff will be trained to
ensure appropriate data entry.

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Chapter 1-F

The Department Appropriately Screens Employee Grievances and
Equal Employment Opportunity Complaints; However, It Should
Improve the Timeliness of EEO Reviews and Investigations
The Department’s Human Resources Division (HR Division) has adequate
policies and procedures for the screening, investigation, and
Employee Grievance Program
resolution of employee grievances and Equal Employment
An employee grievance allows
Opportunity (EEO) complaints (see text box for descriptions of these
Department employees to seek resolution
complaints). All employee grievances tested were screened
to unfair or inequitable treatment
regarding employment-related matters
appropriately, and all EEO complaints tested were screened and
such as wages, hours, disciplinary actions,
resolved appropriately by the HR Division. However, the HR
or working conditions.
Division should improve the timeliness of supervisory reviews of
An Equal Employment Opportunity
complaint may be filed by an employee
EEO complaint investigations. In addition, the HR Division’s Case
who believes he or she has been subjected
Management System accounts for all employee grievances and EEO
to discrimination based on race, color, sex
(gender), religion, national origin, age (40
complaints.
or above), disability, or genetic
information. Any harassment or
retaliation is also prohibited.

Source: Department of Criminal Justice.

The HR Division appropriately screens employee grievances and EEO
complaints.

The HR Division reported it closed 2,612 employee grievances and
EEO complaints from September 1, 2006 through February 29, 2008 (see
Table 14 on the next page). Auditors tested 30 employee grievance files and
60 EEO complaints that were opened from September 1, 2006, through
February 29, 2008. For all 90 grievances and complaints tested, the HR
Division (1) appropriately screened them in accordance with the Department’s
policies and procedures, (2) referred them to the appropriate program area,
and (3) coded them properly in the HR Division’s Case Management System.
The grievances and complaints were not always referred to the appropriate
program area within seven days as required by Department procedures;
however, the delays were justifiable and reasons for the delays were
adequately documented. Specifically:

Twenty-four of 30 (80 percent) grievances tested were referred to the
appropriate program area by the intake office within seven days of the
case creation date as required by Department procedures.

Fifty-one of 60 (85 percent) EEO complaints tested were referred to the
appropriate program area within seven days of the case creation date as
required by Department procedures.

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Table 14

Employee Grievances and EEO Complaints Closed
Fiscal Year 2007 and First Half of Fiscal Year 2008

Case Type
Employee Grievances
EEO Complaints
Totals

Cases Closed in
Fiscal Year 2007

Cases Closed from
September 1, 2007,
through February
29, 2008

Total Cases Closed

1,020

472

1,492

798

322

1,120

1,818

794

2,612

Source: HR Division’s Case Management System reports.

The HR Division conducts thorough EEO investigations and resolves
complaints appropriately, but it should improve the timeliness of its
reviews.

EEO Investigation and
Review Process
EEO complaints are referred to the
HR Division’s EEO Section for
investigation. The EEO Section
Director reviews investigative reports
to ensure the information collected
supports the recommended
resolution. Once the investigative
reports are approved, the HR
Division’s Director of Employee
Relations (or designee) determines
the resolution and the Office of
General Counsel reviews the cases for
legal sufficiency.

All 58 EEO complaint files reviewed by auditors contained sufficient
documentation to indicate that a thorough investigation was performed
(see text box). Twelve of the 58 (20 percent) investigations had not been
completed within 60 days of their assignment to an investigator as
required by the HR Division’s procedures. However, 11 of the 12
investigations had an approved extension request and the delays appeared
to be reasonable. In addition, the HR Division sufficiently documented
the reasons for the delay in its Case Management System.
The HR Division appropriately resolved all 58 EEO complaints tested. In
at least 95 percent of the 58 complaints tested, auditors found that EEO
complaint resolution documentation (1) reflected a conclusion to the
investigation and any action taken, (2) contained sensitive information in the
file that was handled confidentially by the investigator, and (3) included
documentation of the notification of the appropriate parties regarding the
outcome.
The HR Division consistently performs supervisory reviews at various levels
to ensure that cases are handled appropriately. Once the EEO Section
approved the investigations, all 58 EEO complaints tested were reviewed and
routed by the Director of Employee Relations within 5 days as required by HR
Division procedures. However, auditors identified some delays in the
supervisory reviews of the EEO investigative reports that affected the overall
timeliness of the review process. Specifically:

Only 40 (60 percent) of 58 EEO complaints tested were reviewed and
subsequently forwarded by the Section Directors within 7 days of the case
being routed to them as required by Department procedures.

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Fifty-three (91 percent) of 58 EEO complaints tested were reviewed and
returned to the EEO Section by the Office of General Counsel (OGC)
within 7 calendar days as required by Department procedures.

Untimely processing of EEO complaints may lead to decreased employee
morale and increases in complaints filed externally with the Equal
Employment Opportunity Commission or the Texas Workforce Commission’s
Civil Rights Division.
The HR Division’s Case Management System was complete and accurate and has
adequate controls over user access; however, additional controls are needed to
ensure the continued integrity of the data.
HR Division’s Case
Management System
The HR Division documents all
information it obtains
throughout the employee
grievance and EEO complaint
process in a database stored on
its automated Case Management
System. Human resources staff
at the prison units and at the
Department level do not have
access to the HR Division’s
system.

The HR Division’s Case Management System accounted for all
employee grievances and EEO complaints initiated by the units (see
text box). Auditors compared the information in hard copy case files
for employee grievances and EEO complaints at six prison units to
the data in the Case Management System. Data for 317 of 319 (99
percent) files tested were complete and accurate in the System.
Auditors did not review case files at the privately operated prison
unit visited by auditors because this prison unit does not have
Department employees.

The HR Division has adequate controls and procedures in place to
control user access to its Case Management System; however, the
HR Division should improve controls to ensure that case information data in
the system continues to be complete, accurate, and secure. Specifically:

The Case Management System does not check the format or validity of
key data, such as the location codes for employee grievances and EEO
complaints.

Programmers can make unsupervised changes to the Case Management
System, which could compromise the integrity of the data.

Improvements in physical security controls are needed to decrease the risk
that unauthorized people may physically access the Case Management
System’s server room.

Additional controls over user logon access are needed.

Auditors communicated details of these suggested controls to Department
management in writing.
Survey results indicate that the majority of Department employees are aware of
the employee grievance and EEO complaint processes.

Auditors surveyed 673 Department employees at 6 prison units, 9 parole
offices, a Correctional Institution Division regional office, the Private
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Facilities Monitoring and Oversight Division office, the Community Justice
Assistance Division office, and the Administrative Review and Risk
Management Division office. Auditors received voluntary survey responses
from 12 percent of the 3,116 employees at the prison units visited and 39
percent of the 736 employees at the non-unit offices visited. Auditors also
received 50 comments from these same respondents.
Seventy-six percent of the respondents stated they are aware of the processes
to file an employee grievance and EEO complaint; 81 percent of the
respondents stated they knew where to access the policies and procedures for
employee grievances and EEO complaints. Eighteen percent of employees
surveyed stated they did not know how to file an appeal to an employee
grievance if needed; however, 86 percent of employees surveyed stated they
knew they could go to the human resources staff for assistance in filing an
employee complaint or grievance. Table 15 lists selected employee survey
results regarding awareness of the grievance process (see Appendix 2 for a
complete copy of the survey and responses).

Table 15

Selected Employee Survey Results about Awareness of Grievance Process
Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with Survey
b
Statement

Survey Statement
Not Applicable to
Respondent

1. I am aware of the policies related to
the employee complaint and grievance
processes at the Department of Criminal
Justice.

76%

14%

2. I know where to access the policies
regarding the employee the employee
complaint and grievance process.

81%

10%

3. If needed, I know I can seek
assistance from human resources staff to
file a complaint or grievance.

86%

9. I know how to file an appeal if I’m
not satisfied with the outcome.

49%

15%

18%

Survey Statement

a
b

In addition, employee survey results indicate that a majority of Department
employees are confident in the established employee grievance process—only
18 percent disagreed that the complaint and grievance system works.
However, 28 percent of the employees surveyed and 18 percent of the survey
comments indicated that employees fear retaliation from co-workers or
supervisors if they file a grievance or complaint.
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Only 4 percent of employees surveyed indicated they did not receive a
response to a grievance or complaint and 6 percent stated they did not receive
a response in a timely manner. Ten percent of the employees surveyed were
not satisfied with the response provided. Table 16 lists selected employee
survey results regarding satisfaction with the employee grievance process (see
Appendix 2 for a complete copy of the survey and responses).

Table 16

State Auditor’s Office Survey of Department Employees
Survey Results Related to an Established Grievance Process

Survey Statement

Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey Statement
Not Applicable to
Respondent

4. I feel that complaints and grievances
are screened properly.

46%

30%

15%

5. I can file a complaint or grievance
without fear of retaliation from a coc
worker or supervisor.

42%

25%

28%

6. After filing a complaint or grievance, I
received a response.

26%

14%

56%

7. I received responses and resolution to
my complaint or grievance in a timely
c
manner.

21%

16%

56%

8. When I filed a complaint or grievance,
I was satisfied with the response.

14%

17%

10%

59%

10. If I have a complaint or grievance, I
am confident that the Department of
Criminal Justice will address it
appropriately and fairly.

50%

27%

18%

11. I feel the employee complaint and
grievance system works in the
c
Department of Criminal Justice.

40%

32%

18%

a
b
c

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Recommendations

The Department should:

Ensure that EEO complaints are reviewed in a timely manner by all
divisions involved.

Add automated controls and update the database design to ensure the
integrity and usability of the Case Management System data.

Ensure that only documented and approved changes are made to the Case
Management System.

Improve physical security and logon access controls.

Management’s Response

The Department should ensure that EEO complaints are reviewed in a timely
manner by all Divisions involved.
TDCJ agrees. The EEO section of Human Resources will immediately
commence developing methods and procedures to ensure EEO complaints are
reviewed in a timely manner by EEO Section Directors. Changes to the
Manual Case Tracking System (CTS) and the Case Management System
(CMS) are being developed that will allow Section Directors to request and
document extensions to the review process timelines when extenuating
circumstances occur.
The Department should add automated controls and update the database
design to ensure the integrity and usability of the Case Management System
data.
TDCJ agrees. The development of edit checks enabling the Case Management
System (CMS) to read additional codes from the Payroll/Personnel System
(PPS) will increase the integrity and usability of the data. The new CMS is
currently in development and will include these enhancements.
The Department should ensure that only documented and approved changes
are made to the Case Management System.
TDCJ agrees. The programmers who revise and create new code will not
migrate such code into the system. Procedures are being developed to ensure
other individuals will be responsible for future code migration into the
database.

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The Department should improve physical security and logon access controls.
TDCJ agrees. The Department will upgrade the physical security of the server
room by replacing the locking mechanism. The server room key will be
properly secured at all times.

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SAO Report No. 09-004
September 2008
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Chapter 2

The Department Coordinates Its Activities to Resolve Complaints and
Grievances, But Department Divisions Could Improve Certain
Coordination Activities
The Offender Grievance Program, Health Services Division, Office of the
Inspector General (OIG), Safe Prisons Program, Ombudsman Program, and
Human Resources Division coordinate their activities to resolve allegations,
complaints, and grievances. These Department divisions also made
appropriate referrals to properly address complaints and grievances.
Grievances filed through the Offender Grievance Program and third-party
inquiries relating to offenders made through the Ombudsman Program were
referred to the OIG when necessary. The OIG was also properly notified of
Offender Protection Investigations that required a criminal investigation. In
addition, the Ombudsman Program, Health Services Division, and OIG have
access to the Offender Grievance Tracking System, which reduces duplication
of efforts to resolve inquiries and investigations. However, the Department
could strengthen certain coordination activities between its divisions and the
OIG.
Chapter 2-A

The Department Consistently Coordinates with the OIG and
Emergency Action Center for Safe Prisons Activities; However, It
Could Improve Communication Between the OIG and the Safe
Prisons Program
Reports of Sexual Abuse
An offender may report a sexual
abuse incident to any
Department employee, who
notifies the shift supervisor at
the unit. The shift supervisor
notifies the OIG and the
Department’s Emergency Action
Center. The OIG may conduct a
criminal investigation, and the
Emergency Action Center
notifies the Safe Prisons Program
Office.

The Department’s units consistently coordinate their activities with the
OIG and the Emergency Action Center.

The Department coordinates its offender protection investigations with
the OIG and the Emergency Action Center in accordance with the Safe
Prisons Plan, which requires that the OIG and the Emergency Action
Center be notified by the unit for all alleged sexual assaults reported
(see text box). At the seven units visited, all reported sexual assault
allegations tested between September 1, 2006, and February 29, 2008,
were reported to the OIG and the Emergency Action Center as
required.

The OIG should ensure that it notifies the Safe Prisons Program that a sexual
assault suspect has been successfully prosecuted.

The Department’s Safe Prisons Plan requires the OIG to inform the Safe
Prisons Program after a sexual assault suspect has been successfully
prosecuted. However, OIG management stated they were not aware of this
requirement. The Safe Prisons Program is responsible for informing the
victim about the status of the assailant. In addition, the Safe Prison Program
Manager is required to record the prosecution information in the Unit
Classification Review system to identify the assailant as a sexual predator.
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Unit Classification uses this information to assign offender housing and grant
protection status. If the OIG does not provide the sexual assault prosecution
information, the Safe Prisons Program Manager may not be able to effectively
provide notifications to victims and the assailant may not be classified
correctly, which could pose a danger to other offenders.
Recommendation

The OIG should ensure that it notifies the appropriate Safe Prisons Program
staff after a successful prosecution of a sexual assault suspect.
Management’s Response

The OIG agrees. The OIG will notify the Safe Prison Program staff after a
successful prosecution.

Chapter 2-B

The Health Services Division and Offender Grievance Program
Could Improve Coordination of Grievance Procedures
The Health Services Division (HS Division) and Offender Grievance Program
(Grievance Program) could improve coordination of their written grievance
procedures.

Auditors identified some discrepancies between the written procedures issued
by the HS Division and those used by the Grievance Program. It is important
that these two divisions coordinate effectively to ensure that medical-related
grievances are processed correctly and in a timely manner.
HS Division’s complaints process procedures require unit-level medical
departments to investigate a grievance, formulate a response, obtain the
authorized signature, and return the grievance to the Unit Grievance
Investigator within 10 working days. The medical staff at 6 of 7 units that
auditors visited were aware of this requirement, while none of the grievance
investigators at the 7 units were aware of this HS Division-set timeline.
Instead, unit-level medical staff used a variety of timeframes, including those
provided by Unit Grievance Investigators, whose written procedures in the
Offender Grievance Operations Manual require a unit-level medical employee
to complete investigations and return the grievance to the Unit Grievance
Investigator within 10 days for grievances containing multiple issues and
within 30 days for grievances solely about medical issues. The HS Division
procedures do not distinguish between grievances containing multiple issues
and those with medical-only issues for its 10-working day timeframe.
Of medical grievances filed between September 1, 2006, and February 29,
2008, 143 of 182 (79 percent) tested were investigated and completed by the
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unit-level medical staff within 10 working days. Of the grievance
investigations that took the unit-level medical staff longer than 10 days to
complete, all were completed within 30 days.
During this audit, HS Division management revised its guidelines effective
June 25, 2008, to require unit medical staff to investigate and return the
completed grievance to the Unit Grievance Investigator within 40 calendar
days. However, this change may cause grievances to be returned to the
offenders beyond the timeframes established by the Grievance Program. It is
important that the HS Division coordinate any change in its investigation
timelines with Grievance Program management to ensure that medical-related
offender grievances are investigated and resolved in a timely manner.
In addition, there is a discrepancy between the written procedures of the HS
Division and those of the Grievance Program regarding the grievance
information that should be provided to unit medical staff. The HS Division’s
complaints process procedures state that the Unit Grievance Investigator
should provide a narrative of the grievance, while the Grievance Program’s
manual states that unit-level medical staff should receive the entire grievance
form for medical-only grievances and only the grievance narrative for
multiple-issue grievances.
Not all units had current information about the Patient Liaison Program.

Offender orientation packets at two of seven units auditors visited had older
versions of a Health Services handout, which stated that the Patient Liaison
Program is available to offenders. However, as of September 1, 2004,
offenders can no longer submit complaints about medical services to the
Patient Liaison Program, and the HS Division revised its handout to reflect
this change in April 2005. This out-of-date information may lead offenders to
submit complaints to the HS Division in error. Offenders from all units
submitted 4,013 letters to the Patient Liaison Program between September 1,
2006, and February 29, 2008, which accounted for 32 percent of the total
Patient Liaison Program inquiries during that time. As a result, HS Division
staff had to send a letter to each offender submitting a complaint explaining
that offenders must now use the Offender Grievance Program or file a
complaint with unit staff. In addition, offenders who submit complaints to the
wrong division may have their concerns addressed in a less timely manner.
Recommendations

The Department should:

Ensure that medical grievance written procedures and requirements are
standard across the Health Services Division and the Offender Grievance
Program.

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Ensure that units have the most current version of Health Services-related
information.

Management’s Response

The Department should ensure that medical grievance written procedures and
requirements are standard across the Health Services Division and the
Offender Grievance Program.
TDCJ agrees. The Informal Resolution Process Manual has outdated
information about the Offender Grievance Process. TDCJ Health Services
Division is in the process of reviewing all of the departmental policy and
procedure manuals, as well as all supporting documentation (i.e. Informal
Resolution Process Manual) to determine the revisions that are needed. The
manual will be revised and limited to the Informal Resolution Process. For
complaint programs other than the Informal Resolution Process, staff will
utilize the policies and process manuals prepared by the proponents for those
programs.
The Department should ensure that units have the most current version of
Health Services-related information.
TDCJ agrees. The current (April 2005) version of the Health Services
Offender Information handout will be distributed again to all units, and unit
staff will be instructed to destroy previous versions.

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Chapter 3

Offender Survey Results Indicate That the Department Should Improve
Efforts to Increase Awareness of How to File Complaints with the OIG
or the Health Services Division
Auditors surveyed 1,641 offenders at 7 selected units. Results for 14 of the 19
survey questions were discussed in Chapter 1-A. The remaining five survey
questions address offenders’ awareness of (1) the Safe Prisons Program, (2)
access to the Office of the Inspector General (OIG), and (3) how to file
complaints about medical services. Based on the survey results, the
Department’s efforts to increase awareness of the Safe Prisons Program
appear effective; however, improvements are needed to inform offenders
about how to access the OIG and how to file a complaint about medical
services. (See Appendix 2 for all offender survey responses.)
Survey results indicate that offenders are aware of the Safe Prisons Program.

Seventy percent of offenders surveyed stated they were told about the Safe
Prisons Program, and 73 percent know how to report a sexual assault incident
(see Table 17). Offenders are provided a sexual assault awareness brochure
during offender orientation and have access to sexual assault zero-tolerance
policy postings at the units.
Table 17

Survey Results Related to Offenders’ Awareness of the Safe Prisons Program
Respondents
Who Agreed
with Survey
a
Statement

Respondents
Who Were
Neutral about
Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

17. I was told about the
c
Safe Prisons Program.

70%

21%

18. I know how to report
a sexual assault incident.

73%

15%

Survey Statement

Respondents who agreed or strongly agreed with an individual survey statement were grouped together in the
“Agree” column.
b
Respondents who disagreed or strongly disagreed with an individual survey statement were grouped together in the
“Disagree” column.
c
The percentages do not sum to 100 percent due to rounding.

Survey results indicate that some offenders are not aware of how to access the
OIG or file a medical-related grievance.

Although offenders are provided written information about their options for
contacting the OIG in the Offender Orientation Handbook and in some unit

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orientation materials, 63 percent of offenders surveyed stated they do not
know how to access the OIG (see Table 18).
Table 18

Survey Results Related to Offenders’ Awareness of Access to the Office of the Inspector General

Survey Statement

Respondents
Who Agreed
with Survey
a
Statement

Respondents
Who Were
Neutral about
Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

24%

63%

16. If needed, I know
how to access the Office
of the Inspector General.
a

In addition, offenders are provided written information about their options for
filing complaints about medical services in the Offender Orientation
Handbook and in some unit orientation materials; however, fewer than half of
the offenders surveyed said they knew how to file an informal complaint (47
percent) or formal complaint (48 percent) about medical services (see Table
19).
Table 19

Survey Results Related to Offenders’ Awareness of Filing Complaints About Medical Services

Survey Statement
14. I know how to file an
informal complaint about
medical services using an I-60.

15. I know how to file a formal
complaint (Step I) about medical
services.

Respondents
Who Agreed
with Survey
a
Statement

Respondents
Who Were
Neutral about
Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

47%

42%

48%

39%

Respondents who agreed or strongly agreed with an individual survey statement were grouped together in the “Agree”
column.
b
Respondents who disagreed or strongly disagreed with an individual survey statement were grouped together in the
“Disagree” column.
c
The percentages do not sum to 100 percent due to rounding.

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Recommendations

The Department should:

Consider using additional, non-written methods of communication to
increase awareness of the grievance process among offenders who may
have difficulties reading.

Consider providing follow-up sessions with offenders to reinforce the
information about the grievance process.

Management’s Response

The Department should consider using additional non-written methods of
communication to increase awareness of the grievance process among
offenders who may have difficulties reading.
TDCJ agrees. The five hour videotape and Peer Education Program verbally
discuss programs, to include the Offender Grievance Program, to ensure an
offender who is illiterate receives notice of the grievance program. In
addition, the Administrator of Offender Grievance will instruct Unit grievance
staff to make themselves available to the offender population during mass
movement, such as meal times, in order to answer questions, resolve issues
and distribute grievance forms if needed. Other additional nonwritten
methods of communication to increase awareness of the grievance process
among offenders shall be researched. Further, although they are written
forms of communication, additional efforts, including publishing a notice in
the offender newspaper 'The Echo' and posting the notice at each unit in the
Law Library and in the housing areas, will be made to provide current
information and to enhance awareness of the grievance program.
The Department should consider providing follow-up sessions with offenders
to reinforce the information about the grievance process.
TDCJ agrees. Procedures are being developed to direct unit grievance staff to
proactively offer assistance to offenders. In addition, the Administrator of
Offender Grievance will instruct Unit grievance staff to make themselves
available to the offender population during mass movement, such as meal
times, in order to answer questions, resolve issues and distribute grievance
forms if needed.

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Page 51

Appendices
Appendix 1

Objectives, Scope, and Methodology
Objectives
The objectives of the audit were to:

Determine whether the Department of Criminal Justice (Department) is
complying with policies and procedures and best practices governing the
screening, investigation, and resolution of allegations of criminal
behavior, serious policy violations, and serious offender and employee
grievances.

Determine whether the Office of the Inspector General, Office of the
Ombudsman, Offender Grievance Program, Human Resources Division,
and other areas of the Department effectively coordinate their activities to
resolve complaints and allegations of criminal behavior, serious policy
violations, and serious offender and employee grievances.

Scope
The scope of the audit included reviewing and analyzing data from September
2006 through February 2008 for the following programs and related
information systems:

Offender Grievance Program.

Employee Grievance and Equal Employment Opportunity Complaints.

Office of the Inspector General (OIG).

Ombudsman Program.

Safe Prisons Program.

Health Services Division.

In addition, auditors administered surveys to 1,641 offenders and 673
employees at 7 prison units, as well as parole offices and other Department
offices.
Methodology
The audit methodology included collecting information and documentation,
performing selected tests and other procedures, analyzing and evaluating the
An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 52

results of tests, conducting interviews with agency management and staff, and
administering offender and employee surveys.
Information collected and reviewed included the following:

Data from the automated systems at the Department, including the
Offender Grievance Case Tracking System, Human Resources Case
Management System, Ombudsman Case Tracking System, and Office of
the Inspector General and Health Services case database systems.

Department and Office of the Inspector General policies, procedures,
guidelines, and manuals.

Department and Office of the Inspector General documentation including
organizational charts, management reports, grievance and complaint files,
investigation case files, grievance and investigation logs, and program
activity reports.

Procedures and tests conducted included the following:

Analyzed data from the Department’s automated systems and databases.

Tested unit-level and appealed offender grievance files, Patient Liaison
Program case files, Office of the Inspector General case files, Offender
Protection Investigation files, Ombudsman Program case files, employee
grievance files, and Equal Employment Opportunity complaint files to
ensure consistency and compliance with Department policies and
procedures.

Reviewed Offender Grievance Program, Safe Prisons Program, and
Ombudsman Program training documentation to ensure compliance with
Department policies and procedures.

Reviewed Ombudsman Program audit tools and documentation.

Conducted walk-through inspections at seven selected state-operated and
privately operated prison units and state jails (units) to determine offender
accessibility to the Offender Grievance Program.

Conducted walk-through inspections at selected units to determine
offender awareness of the Safe Prisons Program and visitor awareness of
the Ombudsman Program.

Administered surveys to offenders and Department employees.

Tested general and application controls of Department mainframe systems
involved in the processing of offender and employee grievances and
complaints, and performed data query validations.

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 53

Criteria used included the following:

Texas Government Code, Chapters 493 and 501.

Department and Office of the Inspector General policies, procedures,
manuals, and guidelines, including the Offender Orientation Handbook
and the Safe Prisons Plan.

Department of Criminal Justice Web site.

Project Information
Fieldwork was conducted from February 2008 through July 2008. We
conducted this performance audit in accordance with generally accepted
government auditing standards. Those standards require that we plan and
perform the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable basis
for our findings and conclusions based on our audit objectives.

Jennifer R. Wiederhold, CGAP (Project Manager)

Sherry Sewell, CGAP (Assistant Project Manager)

Mark A. Cavazos

Jennifer Lehman, MBA, CGAP

Jaime J. Navarro

Amadou N’gaide, MBA, CFE

Robert Pagenkopf

Jeannette Quiñonez

Adam M. Wright

Marlen Randy Kraemer, MBA, CISA, CGAP (Information Systems Audit
Team)

Rachelle Wood, MBA, (Information Systems Audit Team)

J. Scott Killingsworth, CIA, CGAP, CGFM (Quality Control Reviewer)

Worth Ferguson, CPA (Quality Control Reviewer)

Anita D’Souza, JD, CFE (Audit Manager)

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 54

Appendix 2

Results of the State Auditor’s Office Survey of Offenders and
Employees
The State Auditor’s Office surveyed 1,641 offenders—12 percent of the
offender population at 7 selected prison units—and asked the respondents to
rank their level of agreement or disagreement with 19 statements related to the
grievance process, program accessibility, program awareness, and program
reliability. Offenders also were asked about their awareness and perceived
accessibility of other programs related to the offender grievance process.
Table 20 lists the survey results. (See Chapters 1-A and 3 for analysis of
survey responses.)
Table 20

Survey Results Related to Offenders’ Awareness and Perceived Accessibility of Grievance Process

Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

1. I was told how the grievance system works
at the Department of Criminal Justice.

32%

55%

2. I know where to access the offender
grievance policies.

57%

32%

3. I can file a grievance when needed.

65%

26%

4. I am not afraid to file a grievance.

52%

35%

5. If I want to file a grievance, I know how to
access the grievance form.

73%

16%

6. If I ask, staff will help me complete my
grievance.

79%

7. I feel that grievances are screened properly
by the Unit Grievance Investigator.

10%

77%

8. After filing a grievance, I always get a
response.

41%

11%

37%

11%

9. I know how to file an appeal if I am not
satisfied with the outcome.

49%

36%

10. I always get to keep a copy of my
grievance form.

45%

35%

12%

11. I trust the Unit Grievance Investigator(s)
at this facility.

10%

78%

12. Staff has never retaliated against me for
filing a grievance.

16%

11%

62%

11%

13. I feel the grievance system works in the
Department of Criminal Justice.

78%

Survey Statement

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 55

Survey Results Related to Offenders’ Awareness and Perceived Accessibility of Grievance Process

Respondents Who
Agreed with Survey
a
Statement

Respondents Who
Were Neutral
about Survey
Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey
Statement Not
Applicable to
Respondent

14. I know how to file an informal complaint
about medical services using an I-60.

47%

42%

15. I know how to file a formal complaint
(Step I) about medical services.

48%

39%

16. If needed, I know how to access the Office
of the Inspector General.

24%

63%

17. I was told about the Safe Prisons Program.

70%

21%

18. I know how to report a sexual assault
incident.

73%

15%

19. Department of Criminal Justice’s
management takes immediate action to
address safety and welfare concerns of
offenders.

13%

12%

71%

Survey Statement

a
b

Note: The percentages do not all sum to 100 percent due to rounding.

The State Auditor’s Office also surveyed 673 Department of Criminal Justice
(Department) employees at selected units, parole offices, and other
departments and asked them to rank their level of agreement or disagreement
with 11 statements related to the employee grievance and complaints
processes. Table 21 lists the results. (See Chapter 1-F for analysis of these
survey responses.)
Table 21

Survey Results Related to Department Employees’ Awareness of Grievance Process
Respondents Who
Agreed with
Survey
a
Statement

Respondents Who
Were Neutral about
Survey Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey Statement
Not Applicable to
Respondent

1. I am aware of the policies related to the
employee complaint and grievance
processes at the Department of Criminal
Justice.

76%

14%

2. I know where to access the policies
regarding the employee complaint and
grievance process.

81%

10%

3. If needed, I know I can seek assistance
from human resources staff to file a
complaint or grievance.

86%

Survey Statement

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 56

Survey Results Related to Department Employees’ Awareness of Grievance Process
Respondents Who
Agreed with
Survey
a
Statement

Respondents Who
Were Neutral about
Survey Statement

Respondents Who
Disagreed with
b
Survey Statement

Survey Statement
Not Applicable to
Respondent

4. I feel that complaints and grievances
are screened properly.

46%

30%

15%

5. I can file a complaint or grievance
without fear of retaliation from a coworker or supervisor.

42%

25%

28%

6. After filing a complaint or grievance, I
received a response.

26%

14%

56%

7. I received responses and resolution to
my complaint or grievance in a timely
manner.

21%

16%

56%

8. When I filed a complaint or grievance, I
was satisfied with the response.

14%

17%

10%

59%

9. I know how to file an appeal if I’m not
satisfied with the outcome.

49%

15%

18%

10. If I have a complaint or grievance, I am
confident that the Department of Criminal
Justice will address it appropriately and
fairly.

50%

27%

18%

11. I feel the employee complaint and
grievance system works in the Department
of Criminal Justice.

40%

32%

18%

Survey Statement

a
b

Note: The percentages do not all sum to 100 percent due to rounding.

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 57

Appendix 3

Department of Criminal Justice Prison Units and State Jails (StateOperated and Privately Operated)
There are 66 state-operated prison units and state jails and 12 privately
operated prison units and state jails. Table 22 lists the prison units’ and state
jails’ (units) offender capacity and population and number of employees
(budgeted and actual). See Figure 1 on page 61 for a map of the units. There
are additional state-operated and privately operated facilities, such as preparole transfer facilities, intermediate sanction facilities, and substance abuse
facilities, that were not included in the list because auditors did not consider
them for site visits.
Auditors conducted site visits and administered surveys at the following units:

Allred Unit.

Bridgeport Correctional Center.

Clements Unit.

Dominguez State Jail.

Mountain View.

Murray Unit.

Neal Unit.

Table 22

Offender Population and Employees at Department of Criminal Justice Prison Units and State Jails
(as of February 29, 2008)
Map
Number

Unit Name

Type

County

Region

Offender
Capacity

Offender
Population

Budgeted
Employees

Actual
Employees

Allred

Prison

Wichita

3,682

3,602

978.0

872.0

Bartlett

Private State
Jail

Williamson

Private

1,049

1,047

224.0

177.0

Beto

Prison

Anderson

3,471

3,321

781.0

514.0

Boyd

Prison

Freestone

1,330

1,327

290.0

247.0

Bradshaw

Private State
Jail

Rusk

Private

1,980

1,963

285.0

238.0

Bridgeport

Private Prison

Wise

Private

520

113.5

82.5

Briscoe

Prison

Frio

1,342

1,335

295.0

257.0

Byrd

Prison

Walker

1,365

1,007

293.0

267.0

Central

Prison

Fort Bend

III

1,060

994

288.0

266.0

Clemens

Prison

Brazoria

III

1,215

1,073

342.0

283.0

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 58

Offender Population and Employees at Department of Criminal Justice Prison Units and State Jails
(as of February 29, 2008)
Map
Number

Unit Name

Type

County

Region

Clements

Prison

Potter

Cleveland

Private Prison

Liberty

Private

Coffield

Prison

Anderson

Cole

State Jail

Connally

16
17

Offender
Capacity

Offender
Population

Budgeted
Employees

Actual
Employees

3,714

3,582

1077.0

883.0

520

124.8

97.8

4,139

4,085

1000.0

656.0

Fannin

900

803

216.0

210.0

Prison

Karnes

2,848

2,833

719.0

524.0

Dalhart

Prison

Hartley

1,040

1,022

295.0

203.0

Daniel

Prison

Scurry

1,342

1,321

309.0

238.0

Darrington

Prison

Brazoria

III

1,931

1,868

576.0

476.0

Dawson

Private State
Jail

Dallas

Private

2,216

2,183

426.0

377.0

Diboll

Private Prison

Angelina

Private

518

517

131.0

121.0

Dominguez

State Jail

Bexar

2,276

2,072

371.0

334.0

Eastham

Prison

Houston

2,474

2,447

746.0

491.0

Ellis

Prison

Walker

2,404

2,355

681.0

538.0

Estelle

Prison

Walker

3,273

3,154

980.0

701.5

Estes

Private Prison

Johnson

Private

1,040

1,037

198.1

163.1

Ferguson

Prison

Madison

2,421

2,369

696.0

459.0

Formby

State Jail

Hale

1,100

932

268.0

249.0

Gatesville

Prison

Coryell

2,115

2,007

691.0

660.0

Gist

State Jail

Jefferson

III

2,276

2,146

372.0

324.0

Goree

Prison

Walker

1,321

999

357.0

317.0

Henley

State Jail

Liberty

III

576

564

122.0

114.0

Hightower

Prison

Liberty

III

1,342

1,317

328.0

295.0

Hilltop

Prison

Coryell

553

521

253.0

245.0

Hobby

Prison

Falls

1,342

1,294

310.0

309.0

Hughes

Prison

Coryell

2,900

2,857

723.0

677.0

Huntsville

Prison

Walker

1,705

1,692

451.0

375.5

Hutchins

State Jail

Dallas

2,276

2,045

386.0

347.0

Jester III

Prison

Fort Bend

III

1,131

1,037

275.0

255.0

Jordan

Prison

Gray

1,008

992

267.0

211.5

Kegans

State Jail

Harris

III

667

574

160.0

145.0

Kyle

Private Prison

Hays

Private

520

518

106.0

85.0

Lewis

Prison

Tyler

2,190

2,164

576.0

498.5

Lindsey

Private State
Jail

Jack

Private

1,031

1,022

217.0

171.0

Lockhart

Private Prison

Caldwell

Private

500

498

186.4

145.4

Lopez

State Jail

Hidalgo

1,100

1,001

262.0

237.0

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 59

Offender Population and Employees at Department of Criminal Justice Prison Units and State Jails
(as of February 29, 2008)
Map
Number

Unit Name

Type

County

Region

Offender
Capacity

Offender
Population

Budgeted
Employees

Actual
Employees

Luther

Prison

Grimes

1,316

1,262

306.0

273.5

Lychner

State Jail

Harris

III

2,276

2,045

396.0

351.0

Lynaugh

Prison

Pecos

1,374

1,347

292.0

205.5

McConnell

Prison

Bee

2,900

2,852

755.0

517.5

Michael

Prison

Anderson

3,221

3,132

851.0

613.5

Moore, B.

Private Prison

Rusk

Private

500

498

130.0

106.0

Mountain View

Prison

Coryell

645

600

298.0

288.0

Murray

Prison

Coryell

1,313

1,251

329.0

310.0

Neal

Prison

Potter

1,690

1,677

349.0

275.5

Ney

State Jail

Medina

576

570

131.0

112.0

Pack

Prison

Grimes

1,478

1,428

328.0

292.0

Plane

State Jail

Liberty

III

2,276

2,163

383.0

339.0

Polunsky

Prison

Polk

2,900

2,881

761.0

612.0

Powledge

Prison

Anderson

1,137

1,061

296.0

279.0

Ramsey

Prison

Brazoria

III

1,891

1,689

430.0

366.0

Roach

Prison

Childress

1,842

1,443

300.0

271.5

Robertson

Prison

Jones

2,900

2,869

740.0

690.5

Rudd

Prison

Terry

612

605

142.0

136.0

Sanchez

State Jail

El Paso

1,100

1,004

270.0

242.0

Scott

Prison

Brazoria

III

1,130

1,033

296.0

244.0

Smith

Prison

Dawson

2,125

2,084

595.0

442.0

Stevenson

Prison

DeWitt

1,342

1,338

291.0

263.0

Stiles

Prison

Jefferson

III

2,897

2,881

735.0

610.5

Stringfellow

Prison

Brazoria

III

1,212

1,118

303.0

265.0

Telford

Prison

Bowie

2,832

2,807

699.0

606.0

Terrell

Prison

Brazoria

III

1,603

1,541

401.0

354.0

Torres

Prison

Medina

1,342

1,330

295.0

257.0

Vance

Prison

Fort Bend

III

378

294

110.0

106.0

Wallace

Prison

Mitchell

1,502

1,369

312.0

224.0

Wheeler

State Jail

Hale

576

543

122.0

118.0

Willacy County

Private State
Jail

Willacy

Private

1,069

1,064

205.0

163.0

Woodman

State Jail

Coryell

900

846

237.0

236.0

Wynne

Prison

Walker

2,621

2,588

699.0

532.5

Source: Department of Criminal Justice.

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 60

Figure 1

Prison Units and State Jails in Texas

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 61

Appendix 4

Safe Prisons Program Office Reporting Information
The Safe Prisons Program Office reports Safe Prisons Program activity to the
Department Criminal Justice’s (Department) Correctional Institutions
Division’s executive management on a monthly basis. The Safe Prison
Program Office (Office) also is responsible for analyzing and evaluating
trends in extortion, sexual abuse, and other aggressive offender behavior. The
Office obtains its offender protection investigation (OPI) data from the
Department Classification Division’s monthly report and the alleged sexual
assault data from the Emergency Action Center. (See Chapter 1-D for more
information about Safe Prisons Program reporting.)
As Table 23 shows, Region IV conducted the highest number of OPIs, with
6,189 of 34,436 (18 percent) OPIs conducted from September 1, 2006,
through February 29, 2008. Private facilities, which include privately
operated units, state jails, and other contracted facilities, conducted the fewest
OPIs, with 1,314 of 34,436 (4 percent) OPIs conducted during this same time
period.
Table 23

Offender Protection Investigations
September 1, 2006, through February 29, 2008
Investigations
conducted

Location
Region I

3,865

Region II

6,112

Region III

5,865

Region IV

6,189

Region V

5,067

Region VI

6,024

Private Facilities

1,314
Total

34,436

Source: Safe Prisons Program Office.

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 62

Region VI reported the highest number of alleged sexual assaults, with 192 of
836 (23 percent) alleged sexual assaults reported from September 1, 2006,
through February 29, 2008 (see Table 24). The private facilities reported the
fewest alleged sexual assaults, with 13 (2 percent) of all alleged sexual
assaults reported during this same time period.
Table 24

Alleged Sexual Assaults Reported to Safe Prisons Program Office
September 1, 2006, through February 29, 2008
Alleged Sexual Assaults
Reported

Location
Region I

109

Region II

176

Region III

145

Region IV

Region V

139

Region VI

192

Private Facilities

13
Total

Source: Safe Prisons Program Office.

An Audit Report on the Department of Criminal Justice’s Complaint Resolution and Investigation Functions
SAO Report No. 09-004
September 2008
Page 63

836

Copies of this report have been distributed to the following:

Legislative Audit Committee
The Honorable David Dewhurst, Lieutenant Governor, Joint Chair
The Honorable Tom Craddick, Speaker of the House, Joint Chair
The Honorable Steve Ogden, Senate Finance Committee
The Honorable Thomas “Tommy” Williams, Member, Texas Senate
The Honorable Warren Chisum, House Appropriations Committee
The Honorable Jim Keffer, House Ways and Means Committee

Office of the Governor
The Honorable Rick Perry, Governor

Department of Criminal Justice
Members of the Board of Criminal Justice
Mr. Oliver J. Bell, Chairman
Mr. Gregory S. Coleman, Secretary
Mr. John “Eric” Gambrell
Mr. Charles Lewis Jackson
Ms. Janice Harris Lord
Mr. R. Terrell McCombs
Mr. Tom Mechler
Mr. J. David Nelson
Mr. Leopoldo “Leo” Vasquez III
Mr. Brad Livingston, Executive Director

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