Wisconsin DOC audit of Genesis Behavioral Services Options House Jan 2017
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Page 1 1 Mailing Address Scott Walker Governor Jon Litscher Secretary State of Wisconsin Department of Corrections Purchasing Services Section Division of Management Services 3099 East Washington Avenue Post Office Box 7991 Madison, WI 53707-7991 Telephone (608) 240-5571 Facsimile (608) 240-3342 Genesis Residential Service Program Contract 410036-M16-CJ05388-RFP-01 Unannounced Site Inspection- Options House Awarded to Genesis Behavioral Services, Inc. At Options Residential Services Program Award date May 1, 2016, with two-year Initial term, with two-year renewals and one-year renewal option Prepared by Richard Houser, Contract Compliance Specialist Wisconsin Department of Corrections Madison, Wisconsin January 10, 2017 Response due date February 10, 2017 Page 12 Table of Contents Scope and Purpose 3 Introduction. 3 Background 3 Auditing Methodology. 4 Observations of Options Facility ..5 Logbooks 6 Initial Issues 7 Resident and Staff Perceptions 9 Staff and Resident Interview findings regarding current programming 10 Findings from Interviews of Recently Completed Residents 11 Current and Completed Resident Comparisons 13 Interviews with Genesis Staff 13 Program Requirements pursuant to the Contract 16 Client Files 17 Sign-in Sheets for Groups 21 Phone 24 DOC Recommendations 25 Recommendations/Observations - by Options Staff 26 Additional Concerns and Observations 26 Audit Findings 29 Corrective Action Plan 30 Pa ge 13 Scope and Purpose The Wisconsin Department of Corrections (DOC) has a mission to provide opportunities for positive changes for successful reintegration of inmates to the community DOC partners with community service providers and community-based facilities to promote programs that are safe, humane, cost-efficient, and that provide work and other self-improvement opportunities to assist residents in becoming law-abiding citizens. Genesis Behavioral Services Inc. is the provider reviewed in this contract. Contract services require the provider to work with residents at Options Residential Service Program based on referral information provided by DOC to include information related to male offender Criminogenic needs. Introduction This contract serves male offenders under the care and supervision of the Wisconsin Department of Corrections (DOC), Division of Community Corrections (DCC) providing Certified Substance Abuse Services, Mental Health Services, Domestic Violence Intervention Services, Cognitive Intervention, and services to address the Criminogenic Needs of the residents. Several site visits and a review of this contract were conducted as a means to ensure the provider complies with the technical, program and performance requirements, pursuant to Section 7 of the Supplemental Standard Terms and Conditions. Due to HIPPA requirements, pseudonyms will be used to refer to actual residents referenced in this audit. Background Genesis Behavioral Services was awarded Contract 410036-M16-005388-RP-01 to provide Residential Services Programs at the Options Residential Program located at 6755 14th Avenue, Kenosha, Wisconsin. This facility is a 20-bed community based residential center for the treatment of drug abuse and cognitive intervention using DHS 75 AODA standards At the time of the inspection, 19 of the 20 beds were occupied. Ms. Delnita Thomas has been the Program Coordinator at the Options Residential Program since the contract was awarded. Options has a staff of three counselors, five resident assistants, and an office assistant. On August 15, 2016, Tracy Hudrlik, Corrections Services Supervisor contacted the DOC Contract Compliance Specialist requesting a review of the Options Residential Service Program. The request was based on staffing issues, and whether current programming complied with Genesis' proposal and contract standards. Subsequent to the request, contract information was requested from Lisa Jeschke, Program & Policy Analyst (PPA) Region 2, regarding current operations specific to the contract specifications, contract background information, service requirements and the Genesis Request Page 14 for Proposal (RFP) response to the solicitation were examined An audit itinerary, including a questionnaire for Options residents and staff, was developed with the assistance of Barb Hanson, Assistant Chief DCC Region 2, Lisa Jeschke and Rick Houser. On August 22, 2016 Lisa Jeschke received a phone call from DOC Agent Sturbaum stating that Resident Brandon (pseudonym) contacted her regarding the lack of programming, recordings and paperwork he had prepared relating to the daily operations at Options On August 24, 2016 the DOC received an unsolicited ten-page spreadsheet from Resident Brandon documenting perceived problems with the program conducted at the Options Residential Services Program This documentation noted a period between June 20 and August 9, 2016 providing a daily account of activities that were not in compliance with the contract program schedule Examples noted by Resident Brandon regarding inconsistencies in the program include: • Watching movies unrelated to authorized curriculum • Groups beginning late or completing early • Instances where groups were not conducted Resident Brandon's contention was that due to the above referenced issues, he documented his actual dosage hours as 216 instead of the 251 recorded in his client file (250 dosage hours being his targeted dosage requirement for graduation of the program). Resident Brandon later provided audio files revealing staff discrepancies to contract requirements. Under the authority of Section 7.3 of the contract, DOC initiated an audit of the contract to determine if the programs at Options were compliant with contract requirements and if the reported inconsistencies had merit. On August 30, 2016 and September 01, 2016, site visits were conducted where 42% (8) of the residents (randomly selected) and all available staff (4) were interviewed. After evaluating the staff and resident interviews, a second site visit was conducted on September 13th and September 14th to interview the remaining 10 residents and 2 additional staff not interviewed the first time. On October 4, 2016 and October 5, 2016, interviews were conducted with fifteen (15) residents that had recently successfully completed dosage hours from the Options Residential Program. Audit Methodology Listed below are the methods used for auditing the Options facility. These methods were used to determine compliance to the terms and conditions of the contract, which included the Request for Proposal response submitted by Genesis Behavioral Services Page 1 5 Sources used to assess compliance to contract requirements: • Logbooks were reviewed to note use and documentation in breathalyzer tests, urinalysis screens, resident sign in/out sheets and maintenance schedule. • A questionnaire was used as a basis for all resident interviews Incorporated into the questionnaire were questions relating to program structure, program schedules, group dynamics, facilitators and resident insights to programs and group sessions • Interviews of staff and residents were conducted to examine program schedules, group sessions, effectiveness of the curriculum, relationships between staff and residents and an avenue to allow residents and staff to speak freely on topics related to the contract. • Interviews of residents completing the program were conducted to examine consistency in house operations, staffing and program effectiveness. • A questionnaire was used as a basis for all staff interviews. Incorporated into the questionnaire were questions relating to program structure, groups facilitated, group dynamics, staff interaction and any staff insights • Client files were reviewed to examine monthly progress notes and reports, 1:1 sessions, discharge summaries (if applicable), clinical and physician signatures, dosage hours, and phase progression of the resident. At the time of this review, there were 19 residents housed at Options. Eight residents were in Phase 1, seven residents were in Phase 2 and four residents were in Phase 3. Dates of site visits. • • Assisting DOC Staff: August 30, 2016, September 01, 2016, September 13, 2016, September 14, 2016 (interviews and questionnaire of staff and residents) September 28, 2016 (review of resident files) Rick Houser, Contract Compliance Specialist Lisa Jeschke, Program & Policy Analyst (PPA) Region 2 Randy Kroll, PPA Region 7 Michael Meulemans, PPA Region 4 Sara Hugo, Corrections Field Supervisor Region 2 Observations at Options Facility During the initial site visit conducted on August 30, 2016, a walk through the house was done to observe the physical living conditions. Upon entrance into the building it was immediately noted how uncomfortably warm and humid it was inside the facility. Only two air conditioners were in the facility, one was located in the office of Ms. Thomas. The second was located in a meeting room and was not running. • House rules were posted. (per DHS 83.13(3)) • Menus available to residents (DHS 83.41(2)(c)2 • Holes in the wall plaster in bathroom D and ceiling of room 7. Page 16 • No observable holes or large cracks in the walls or ceilings in the main areas, although paint was peeling on the walls in several places. • Missing tile in the bathroom beside room 10. • Bed sheets were recently replaced. • No electrical issues were noted • There are four showers in the house. The shower head in bathroom "A" was not working. • Carpet and furniture was not excessively worn. • • Upper floor was uncomfortably warm and many fans were set up between the bedrooms in the hallways to combat the heat. Kitchen appeared clean including ovens, sink and fans. Dishes were hand washed and allowed to drip dry when we entered. • • Stained floors in the program/TV room to the right of the foyer Exhaust fan in the kitchen recently replaced. • Bedrooms appeared clean and maintained. • Missing glass panel in the program/TV room. Audit Team Introduction Programs began at 7:00 am. Alan Jackson, Resident Assistant was assembling all residents to go outside for morning stretching/exercising Exercise consisted of walking one block, after which all residents stood outside the front door and talked or smoked. Allen Jackson was asked if this was a standard method of exercise/recreation, Mr. Jackson said, "This is what we do every morning." DOC staff were introduced to Darren Taylor, Lead Counselor and Delnita Thomas, Program Coordinator. After introductions, I requested the logbooks from Ms. Thomas and they were provided. Resident interviews began at 7:45 am. Logbooks • Drug Screening Log Book The Logbook contains dates and findings for each resident. For example, resident John 20th and Anderson has three log entries in August dated August Stn, 27th with negative test results for UA and breathalyzer on each date. The logbook has all current residents' names listed on individual sheets with staff initials as conducting the tests Based on the dates noted in the log, all residents are tested on a regular basis with no entries of illegal drugs documented from the UA's or breathalyzer tests. Ms. Thomas stated that the breathalyzer is calibrated once per month. • Options House sign in/out log book The sign in/out logbook is located at the entrance of the facility and notes the date, name, in/out times and staff initials. The logbook is consistent with the Genesis RFP Page 1 7 submission and documents the purpose of sign out such as: groceries, work, doctor's appointments, etc. • Home Pass Request Form Residents in Phase 3 of the program are permitted to leave the house with staff approvals for up to 48 hours. The purpose of this leave is to allow residents to visit their home and family as part of the reintegration/socialization aspect of the program. The "Home Pass Request Form" is used for accountability of the resident and documents the resident's name, purpose, date, times, travel route, address and phone number ➢ There was no documentation in the logbook concerning follow-up or confirmation of the resident's whereabouts. • Maintenance Logbook Review of the maintenance logbook showed requests for maintenance in June and July 2016 (there was no August sheet in the logbook) Items requested for maintenance totaled 15 items for these two months. These requests consisted of such things as leaking pipe in kitchen, holes in the walls needing repair, and toilet leaks. Next to the maintenance requests are sections in the log sheet, "Maintenance Initials when Complete" and "Maintenance Date & Time Logged in and out". None of these sections of the logbook were filled out. Looking at some of the physical areas of concern in the logbook it was noticed some items were repaired and some were not. Options is currently utilizing a digital maintenance log where "maintenance tickets" are created on site and sent electronically to a centralized location where all Genesis maintenance concerns are pooled At the time of this review, there were two tickets from Options placed into the new system and recorded as completed within a week of submission. Initial Issues On September 2, 2016, Genesis received a letter from Lisa Jeschke detailing initial observations and concerns at Options (see attachment A). Further investigation into these concerns during the site visit has revealed additional information. Highlighted below are the incidents and DOC findings. REMOVAL OF THE CANDY MACHINE Issue: A candy machine was located inside Options for use by staff and residents. It was alleged that the removal of the machine was a retaliatory response by staff to house rule infractions committed by a resident DOC Findings: The owner/operator of the candy machine initiated removal of the machine due to personal medical issues. The owner has since retired and is no longer in business. Page 18 STAFF WITHOLDING TOILET TISSUE FROM RESIDENTS Issue: Options staffs were withholding toilet tissue rolls from residents and issuing tissue rolls one at a time for return of a used roll as a means for group punishment. DOC Findings: Options changed the procedure for ordering supplies from purchasing through local vendors to purchasing through Amazon, per Genesis management directive. The delivery of toilet tissue from Amazon was late. Delnita Thomas, Program Coordinator, was notified of the tissue shortage and had a staff person go to a local vendor and purchase a small supply. Ms. Thomas initiated a "roll for roll" system. The resident turned in an empty roll of toilet tissue in order to receive a full roll. This provided the dual purpose of allowing for a limited supply available to residents until the Amazon delivery was received and to prevent hoarding of toilet paper by residents. This method of dispensing toilet tissue and the reasons behind it was not fully explained to the residents, who interpreted the more restricted method of tissue distribution as a group punishment. STAFF DENYING COFFEE TO RESIDENTS Issue- Options serves only decaffeinated coffee. There was an issue of contraband entering Options, specifically instant coffee containing caffeine. DOC Findings: To determine if coffee was smuggled into the house, on August 30, 2016 (the day of the unannounced site visit) Ms. Thomas directed staff not to allow coffee for breakfast so that staff could watch to see if a resident came to breakfast with coffee in-hand and question the resident as to its origin. The residents, not knowing the intent of coffee being withheld during breakfast, addressed the concern to DOC staff while being interviewed. DOC formally notified Options to discontinue this form of group punishment. Lisa Jeschke then emailed Jody Coren, Clinical Supervisor, on September 1, 2016 to see if there was, "a clinical reason to not allow regular coffee". Ms Coren explained the withholding of coffee due to contraband issues and the reasons behind the mornings coffee restriction. The DOC withdrew its claim of "group punishment" after clarification from Options regarding this issue. RESIDENTS SLEEPING ON THE MAIN FLOOR Issue• Fans used in the resident's sleeping quarters upstairs, were not an effective climate control method during high outdoor temperatures Therefore, Ms. Thomas allowed residents to bring their mattresses to the main floor at bedtime so residents could sleep in the coolest part of the house This was confirmed per interview with Ms. Thomas on September 14th During a meeting between DOC management and Genesis Behavioral staff on 9/19/16, Genesis staff stated that they were allowing residents to sleep outside Page 1 9 of their bedrooms for the reason of being fearful of "someone dying" from the heat upstairs. DOC Findings• The Genesis RFP response states, "HVAC systems are in place to maintain temperatures conducive to residential based living environments." (page 24) This is not to be the case and brings into issue DHS violations of not providing a safe and comfortable living environment (DHS 83.43) during times of high temperatures and humidity. MEALS PREPARED UNDER DIRECT SUPERVISION Issue: Options is not utilizing a certified dietician for menu recommendations or nutritional value of the weekly meals. DOC Findings: Pursuant to Page 14 of Genesis' contract proposal, "Genesis will utilize a consultant dietician for menu planning and special diets. Under the supervision of our trained staff, residents will prepare three meals per day as part of their treatment program." STAFF THREATENING RESIDENTS Issue: Reports were received that Tasha Spears, Resident Assistant, threatened residents with strip searches as a means of gaining compliance to her orders or enforcing house rules. DOC Findings: Of 16 residents interviewed, 6 or 37 5% stated Tasha Spears has made threatening remarks to them regarding being stripped searched. Options, having conducted their own review dated October 25, 2016, confirmed that statements to residents of being strip searched did occur from Tasha Spears. Resident and Staff Perceptions Below is a compiled list of the most common statements made by residents currently at Options in response to the interviews and questionnaires conducted on August 30, September 01, 13 and 14, 2016: Residents impressions of staff o Delnita Thomas, Program Coordinator: "Knowledgeable, good counselor, caring, blunt, passionate, stressed out, does not take criticism well, good cofacilitator in 'Men-in-Trauma'." o Darren Taylor, Lead Counselor: "Knowledgeable, caring, most complemented by clients as a good counselor. Good co-facilitator in `Men-in-Trauma'." o Ashley Johnson, Counselor: (left Options in August)• "arrogant, put down clients, 'Many groups went on tangents so she could show her knowledge in other areas.' o Angie Booker, Counselor: "Knowledgeable, knows material, good counselor, but discusses too many personal problems in group." Page 110 o Patricia Price, Counselor: "Nice, assists other counselors, co-facilitator with Ms. Johnson in COG groups." "Doesn't seem to know what she's talking about" [in group]. • When asked what residents like most about the programs, the responses included: 1st helps them focus o The strong program structure implemented after May o Good to be with others with same issues o Groups are straight forward o Enjoy group "Men in Trauma" o Good counselors Staff and Resident Interview findings regarding current programming 1. Residents stated they were getting six to eight hours of programming a day. ➢ Program schedule submitted by Genesis denotes 10 hours of programming a day. Since some programming is "reflective meditation" and "constructive leisure time" this may account for the difference. 2. Staff and residents stated 1:1 sessions (between a resident and their counselor) was conducted once per week and lasted between 45 minutes to an hour. ➢ The time allocated for 1:1 sessions complies with contract requirements 3. Adherence to the current programing and group schedules and whether they start on time. ➢ Nine (47%) of the residents interviewed stated that movies would sometimes be used instead of regularly scheduled groups. Two of the residents stated they had requested the program at Options because they had heard in jail that "they watch all kinds of movies all day." When queried, residents stated the kind of movies watched included: King Kong, National Treasure, Wayne's World etc... ➢ Seven (37%) of the residents interviewed stated they were required to sign multiple sign-in sheets at one time for all groups conducted that day or for the week, whether the groups took place or not (refer to section Sign-in Sheets page 11). 4. AODA groups maintain an 8:1 ratio of residents to staff (unless a co-facilitator is also present). ➢ Options is conducting some of its groups with a ratio greater than the 8:1 allowance without using a co-facilitator. On August 30, 2016, the morning AODA group had seventeen residents with no co-facilitator (as monitored by Michael Meulemans, PPA Region 4). Sign-in sheets also demonstrate noncompliance with the 8:1 ratio requirement. This is a violation of DHS 75 ratio requirement. Page ill 5. Failure to Attend Group ➢ When asked what the consequences of not attending a group are, the response from both residents and staff was that not attending groups rarely happens. When it does, the facilitator "talks it out with the resident". 6. PREA ➢ Three residents had knowledge of PREA from previous state or county facilities. All other (16) residents were unaware of the term "PREA" nor did they know the DOC and Genesis policies or procedures regarding PREA expectations or rights should an allegation be reported. ➢ Pursuant to RFP Section 7.27(A) "The CONTRACTOR agrees to comply with the Federal Prison Rape Elimination Act of 2003, and any subsequent standards imposed by the United States Attorney General." • Standards: 28 C.F.R. § 115.233 Resident education (a) During the intake process, residents shall receive information explaining the agency's zero-tolerance policy regarding sexual abuse and sexual harassment, how to report incidents or suspicions of sexual abuse or sexual harassment, their rights to be free from sexual abuse and sexual harassment and to be free from retaliation for reporting such incidents, and regarding agency policies and procedures for responding to such incidents. (b) The agency shall provide refresher information whenever a resident is transferred to a different facility. (c) The agency shall provide resident education in formats accessible to all residents, including those who are limited English proficient, deaf, visually impaired, or otherwise disabled as well as residents who have limited reading skills. (d) The agency shall maintain documentation of resident participation in these education sessions. (e) In addition to providing such education, the agency shall ensure that key information is continuously and readily available or visible to residents through posters, resident handbooks, or other written formats. Findings from Interviews of recently Completed Residents Findings from the interviews conducted with the residents and staff at Options revealed movies being watched in lieu of groups and residents were required to sign multiple sign-in sheets for groups at one time. Because these statements supported the initial resident documentation sent to DOC, it was decided to interview residents having completed the program. Residents interviewed that recently finished the program had start dates in April and May with completion of the program in June and July of 2016. Interviews were conducted with these Page )12 individuals on October 4th and 5th. Ten out of the fifteen residents interviewed (67%) stated that the groups conducted by the staff were not consistent with the contract program schedule. Findings from the residents graduating from the program reveal the following: 1. Movies - 77% (10 of 13 — one resident did not respond) stated movies unrelated to groups/programs were used instead of staff conducting scheduled groups. Examples of movies watched during programing hours were: o Happy Gilmore o Independence Day o Hunger Games series 2. Group Punishment — defined by residents as all residents punished for one or two residents committing a rule violation or other house infraction. o 86% (12 of 14) stated group punishment was the norm for a resident committing an infraction at Options. Examples include: ■ Phone privileges were removed because a resident was on the phone for more than 15 minutes. • Beach and park trips taken away due to a resident's violation of house rules. • Evening snack taken away because a resident argued with a staff member. • Cigarette breaks taken away for all residents due to one resident's bad behavior. 3. Sign-in Sheets — Are used to verify the staff facilitator, residents attendance, and type of group conducted. The most common comments by residents were: o A stack of sign-in sheets would be given to them at one time to sign for the whole day or for a couple of days. o o Required to sign sign-in sheets whether the group actually took place or not. Would go to the park or beach at random times during the week but had to sign the sign-in sheets saying they participated in the group that was supposed to have happened while they were at the park or beach. o Would go to the store on Fridays, but still had to sign sheets that groups conducted during that time. o Refusing to sign the sign-in sheets, even when group did not occur would result in not getting credit for dosage hours or told they would be written up for refusing programs. o "Around Mid-May" sign-in sheets started being done at the time group was conducted instead of receiving a stack to sign at one time. 4. Programming — Responses by residents when asked to talk about groups or programs during their stay at Options: Page 1 13 o Groups averaged 3 to 5 hours per day. o Groups often started late. o 46% stated that homework was done in-group (instead of outside of the group). 5. Common Statements from Completed Resident Interviews Residents were asked to comment on what they liked or disliked about the programs and/or staff and if there was anything they wanted to add to the interview notes. o Enjoyed going to the park and beach and don't know why it stopped. (Staff interviewed reported the new curriculum, starting May ft, did not allow for this form of recreation). o Many residents stated they liked the "Men-in Trauma" group. o Staff complained in front of residents regarding the new programs/curriculum starting May 1. o NA (Narcotics Anonymous) was an off-site course that many residents stated was beneficial. The ability to go to this course was abruptly stopped with no explanation. ■ Note: NA was listed as part of the community self-help support group provided to residents in the contract (Genesis RFP response, page 51) Current and Completed Resident Comparisons From May 01, 2009 to April 30, 2016, Genesis Behavioral Services "Genesis" was providing Halfway House AODA services at the same address via contract 410036-M09-KJK1600-RFP-01 On May 1, 2016, Genesis was awarded the current contract. This comparison is to demonstrate operations at Options with more than just a "snapshot" of current events The following is a list of concerns and trends from both current and completed residents as Options transitioned from the old contract to the new (on May 1, 2016): Event Movies Group Punishment Prior to May 1, 2016 After May 1, 2016 77% of residents stated movies 47% of the residents stated movies were were watched in lieu of groups. watched in lieu of groups 86% of residents stated group 84% stated punishment was "fair" and group punishment was the norm for rule punishment was not an issue infractions Programs 9 out of 15 (60%) stated groups occurred less than half the time Resident's statements averaged ten hours of programing a day scheduled a. PREA: Both resident groups (current and recently completed) were not orientated to their rights and responsibilities regarding PREA. b. Sign-in Sheets: Both resident groups stated sometimes they were required to sign and print their names for groups not conducted, or had already been conducted. Page X14 Interviews with Genesis Staff On May 1, 2016, Genesis was awarded the current contract with new program requirements and curriculum. Options was one of the sites included in the new contract and was required to adapt to a new program format. Part of the interviews included questions pertaining to the new contract requirements. CONTRACT TRANSITION On May 15, 2016, a strategic partnership was entered into between Mat Talbot and Genesis with the contract continuing under Genesis. Staff reported through interviews that shortly after the start of the partnership, a combination of circumstances coming from Genesis management and specific in-house issues were causing stress within Options. Three facilitators gave the issues listed below as reasons groups were not consistently run: • Upper management positions changed creating a vacuum where no information was passed down to line staff. • Line staff became concerned that the staff cuts in management may trickle down to include them, thereby causing anxiety "wondering if I was going to have a job tomorrow " • Benefits such as health insurance were discontinued. • Being referred to as "at will employees". • The recent termination of counselor Duncan. • A PREA incident involving staff (resident assistant) with residents. During staff interviews, 50% stated they were given no formal training on the new curriculum required under the new contract. Delnita Thomas, Program Coordinator — has worked at Options for 4 years Facilitates: AODA, Family Relationships, Community Groups at night, and is cofacilitator with Mr. Taylor on "Men in Trauma". During the staff interview, Ms. Thomas stated: • Homework given to residents is mostly completed in groups (instead of being • She is aware of what PREA is but does not have a copy of the policy and would completed outside of group). not know what to do if an incident is reported. • "Groups don't get canceled and start on time except maybe in May (2016)" • "Rough passages in May and early June, things got 'discombobulated" • "I do all intakes the day they come in or ASAP the next day." Angie Booker, Case Manager - has worked at Options for two weeks (at the time of the Interview). Facilitates: Wellness, Anger Management, AODA Education, Pro-Social change, sometimes co-facilitates Cognitive Development with Ms. Price. Page 115 During staff interviews, Ms Booker stated. • 75% of homework given to residents is done during group • Knows what PREA is but doesn't know the procedure to follow should an allegation be reported. • The following statements were in the context of what Ms. Booker was feeling and hearing amongst staff: i. "Transition was terrible, then staff lost their benefits." ii. "Didn't know if they had a job day to day." hi. "There was a complete lack of structure. Some groups didn't happen as long as they were supposed to." Darren Taylor, Lead Counselor - has worked at Options 8 years Facilitates: AODA, Relationships, Men in Trauma, Pro Social Reintegration, sometimes co-facilitates AODA with Ms. Price and takes residents to the grocery store. A) During the staff interview, Mr. Taylor stated: • 75% of homework assigned to residents is done during groups • Initially stated did not know what PREA was. During the second site visit, he stated he knew what PREA was but did not know the procedure should an incident be reported. • Regarding food preparation — "Guys learn from other guys how to cook." • Two residents are assigned to the kitchen — "Don't think it's being supervised" B) Statements made regarding transition (changes in Genesis Management) • "Apologize to residents about not getting needed programming." Residents corroborated this statement during interviews. • "No accountability, no structure by corporation" [meaning Genesis] • "Lots of nights stressed." • "When we say family, we take care of each other, we weren't feeling that" • "During transition, maybe a group or two didn't happen but [instead] were given an assignment" • "Evenings and afternoons when Delnita or myself were gone- they may have watched a movie so we could get paperwork done" • He reported that he had left work many nights crying • Counselors were encouraged to go to Delnita if they felt overwhelmed Patricia Price, Counselor — has been a counselor at Options since 8/17/16 but has been at Options as Resident Assistant for 2.5 years. Facilitates or co-facilitates: Employment Readiness, AODA Relapse Prevention and Cog Groups, with Ms. Booker, Ms. Thomas and Mr. Taylor During the staff interview, Ms Price stated: • She is aware of what PREA is but not sure what to do if an incident is reported. • She has no formal training on curriculum Page 116 o • Received her first day of training the previous Monday (8/22/16) She will sometimes run cognitive group - and has no education related to this field (residents confirmed that she has run the cognitive group). o Residents stated, "Ms. Price doesn't seem to know what she's talking about." Other Staff Notations • Staff Meetings: Ms. Thomas stated staff meetings occurred every Wednesday; Mr. Taylor stated they occurred every other Tuesday; Ms. Booker stated once a month but could not recall what day of the week • Park/beach trips stopped around May 1s` because it doesn't fit into the curriculum. Program Requirements pursuant to the Contract Noted by section are contract requirements listed in the RFP. The responses are by Genesis staff followed by Genesis' RFP response to the solicitation. 5 7.4 How are continuing services provided during times of staff shortages due to planned or unplanned absences, including vacancies? Options Response: Staff stated that Options personnel "fill in for each other" during any vacancies such as illness or a vacant position. Genesis RFP submission: Staff filling in for each other may not be qualified or approved for instructing other classes. "If there are staff shortages, Genesis will ensure the program is covered and programming is completed Genesis will provide coverage for staff from other programs if they are qualified for the position that is short...and the Program Coordinator and/or Supervising Director may fill in when needed." (Genesis RFP response page 58) 5.7 5 Explain how you use classroom tools in this program such as audio, visual, verbal and experiential aides. Options Response: One counselor stated the tools used during groups include some role-playing and motivational interviewing. Two counselors stated they do not use tools but only lecture. Resident interview results indicated discussion groups was the only method utilized and did not use tools such as those cited above. Genesis RFP submission: "Genesis' staff will use strategies that will be supportive and empowering, such as Motivational Interviewing to ensure that the resident has help in all affected areas of their lives." (Page 33) Page X17 "The curricula and activities will utilize role-playing exercises." (Page 54) " 5 7.9 How is homework assigned and expectation for completion? Identify whether homework is worked on during group time or whether the homework is completed outside of the group. Options Response: Homework is partially completed during group and reviewed the next group meeting (see staff interviews for further analysis regarding use of this tool). Genesis RFP submission: Homework should not be completed during session. "The goal is to provide worksheets at the end of the session to have the resident complete and return to the next group at which time they would be shared and processed as a group." (Page 53) 5.8.2.1 Describe the manner in which you would develop and manage each participant's case plan. Options Response: We go over treatment during the 1:1 sessions. Genesis RFP submission: Staff made no mention of resident consultation with clinical supervisor or physician or the use of diagnostic tools. Nor did they mention a follow through at the resident's individual session to discuss meeting resident's abilities, speak of objectives and goals set as outlined in their individualized case plan. (Section: Program Overview) 5.8.3.7 Describe procedures for verifying accuracy of off-site/unsupervised activities signout sheets such as employment, employment search, appointments, family time, etc. and how you will ensure compliance with the rules. Options Response: Two counselors stated there is no program component for verifying off-site unsupervised activities other than verifying pay stubs. The Program Coordinator stated phone calls are made to employers and unannounced site visits to the offender work place when staffing allows. Genesis RFP submission: Although the sign-in/out logbook was utilized for residents leaving and returning to the facility for employment group, no documentation was found in client files regarding off-site verification of employment, employment search, appointments or family time. "Genesis had developed procedures for verifying the whereabouts of residents at all times." (page 64) Page 118 Client Files Pursuant to the RFP response• "Genesis counselors will be responsible for completing monthly progress reports. The report will, at minimum, detail the following: individual counseling participation, group counseling participation, and individual program assignments/treatment plan completion, progress in substance use recovery, progress in mental health group, program violations and drug test results The monthly report will be completed every thirty days and submitted to the agent of record within seven calendar days of the end of each month." (RFP response page 60). Initially, five open and two-closed client files were examined at Options. Later, the amount of files examined at Options increased to a total of twenty client files DOC Findings from contract files: 1. DHS 75.03(13) states, in part, "The treatment plan shall be reviewed and signed first by the clinical supervisor and the counselor and secondly reviewed and signed by the patient and the consulting physician." Finding: Client files showed inconsistency in the order of signatures. Signature dates indicate the files being signed by the counselor and client first DOC Recommendation: The clinical supervisor and the physician are required to make notations as they review client files and provide feedback regarding the progress or lack thereof. Given the lack of documentation and signatures by the clinical supervisor and physician, there is no documentable proof that all client files are reviewed per contract requirements. 2. A sampling of twenty client files were reviewed and showed lack of signatures from the clinical supervisor and/or physician: • Discharge/Termination Summary — Fifteen files (75%) did not have signatures of the clinical supervisor. • WI-UPC 30 and/or 60 day update, Adult Assets and Needs — Seven files did not have the signatures of the clinical supervisor or physician. • Treatment Plan for Phases 1,2 and/or 3 — client files did not have the signatures of the clinical supervisor or physician (several files contained different phases from the client that had no signatures). • Clinical Observations/Impressions — four files did not have the signatures of the clinical supervisor or physician • Standing Order form — three files did not have the signatures of the clinical supervisor or physician. • Monthly Progress Report — Twelve files did not have the signatures of the clinical supervisor or physician. Page 119 3. The Discharge/Termination Summary consists of the following elements for client assessments by the counselor: • Offender Assets and Strengths • Offender AODA Use Patterns; Negative Impact on Life; Prior Treatment • Offender Effort and Progress toward Goals • Problems Not Addressed in Treatment • Recommendations to address continuing treatment needs • Prognosis/Risk for further use and criminality • Relapse Prevention/After care Recommendations Findings: A review of the Discharge/Termination Summary in twenty client files showed identical or near identical language used in counselor notations in all files. This identical or near identical language was also found in files from different counselors (meaning counselors appear to be using the same sentences and verbiage verbatim between each other). 4. Prognosis/Risk • No assessment tool was documented in determining client risk was noted. • The basis of how the determination of a client being low, medium or high risk was not defined in the client files reviewed. 5. Relapse Prevention • Client files are not individualized per client and lack recommendations. For example: a client determined as "high level" completes the program (dosage hours) and the file has no notations stating triggers/stressors or how to cure i.e. Sober Living, peer groups. • Identical language used in client files reviewed. 6. Final Evaluation • Client files show two or more goals but does not define what the goals are. 7. A written "feedback" system was implemented by Genesis advocating for a peer approach of constructive feedback from other clients in the program. DOC Findings: Although feedback groups occur every morning from 8:00 am to 9:00 am, no documentation (feedback slips) were found in the files as specified in the contract, "Once presented, the feedback is placed in the client's file." (page 41) 8. Per Genesis RFP submission, "Staff will utilize a tracking form to document the use of reinforcers and punishers. The tracking form will be in the format of a Microsoft Excel spreadsheet." (page 40) Page 120 DOC Findings• No program manager was aware of this method of documentation. Nor did they have documentation of any kind regarding the use of reinforcers and punishers. 9. Client Employment Clients seeking employment as part of their Phase 3 program had no documentation noting their progress in seeking employment e.g. business contacted, setting up interviews Clients employed had no documentation from their work supervisor regarding job performance, attitude or progress of the client in a working environment. 10 Clinical Supervision Documentation Review Review of client charts uses the DAP (Data Assessment Plan) format. This is used to "maintain consistent methods of professional clinical documentation" (page 10). DAP is a three-part method of documentation by the staff counselor and stands for: o DATA — addresses client problems and information directly related to the client o ASSESSMENT —the staff member assessment of the client's progress in relation to "D". o PLAN — describes actions or approach taken based on "A" DOC Findings: Review of client files showed that assessments did not always address the standard language of the "D" data and the Plan did not resolve any treatments based on assessments. Example of notations in client's file: o Client, "Joshua Johnson" in Group — Family Program, Staff Signature — Darren Taylor • D: "Clients discussed clarifying issues" • A: "Client talked about letting go of unchangeable past experiences" • P• "Client to understand the effects of his behaviors on his family" o Client, "Jacob James" in Group - AODA, Staff Signature —Angela Booker • • D: "Clients talked about the biological mechanism of chemical dependency" A: "Client was attentive but did not provide feedback" (this was noted as the assessment for this client for all groups that day) • P: "Client to continue ahead with AODA education group" Page 121 These two examples exemplify the findings regarding this tool during the audit. The "D" - data was usually one sentence and did not address the client's issues or information directly related to the client. The "A"- assessment was one sentence usually stating what, if anything, the client said in group and gave no example of an assessment of the client's progress in relation to "D". The "P"- plan in most cases described the client as continuing to think about one of the topics of the group as opposed to an actions or approach taken based on "A". 11. Physician Signatures Program Coordinator, Delnita Thomas, stated the clinical supervisor, Jody Coren, met with her every two weeks and the last time she saw the physician, Dr. Gutta, was "about a month ago" Many of the client files contained unsigned signature lines of the physician and/or the clinical supervisor. When querying the clinical supervisor via email dated October 17, 2016, "How often are the files sent to the physician for signatures?" The clinical supervisor's response was, "Dr Gutta would like admission/discharges sent on real time basis " Since real time capability is not yet set up for the RSP/CRP facilities, I again asked the clinical supervisor the same question. The clinical supervisor's second response was, "The Psychiatrist reviews material following the Clinical Supervisor (ICS credential). At a minimum twice monthly but per electronic encrypted capabilities can be up to daily." Whether "psychiatrist" meant "physician" is unclear. If the clinical supervisor meant "physician", then the files reviewed do not reflect the physician viewing and signing client files every two weeks as noted by the clinical supervisor Instead, the dates beside the signature of the physician are inconsistent and show no pattern of specific times of the month where signatures are accomplished. 12. Clinical Supervisor/Physician Consultation DOC Findings: It was not clear in the client files reviewed if there is any actual discussion between the onsite staff and the clinical staff or the physician Review of the client files showed no notes from the clinical supervisor or the physician weighing in or questioning any aspect of the client's progress or suggestions/recommendations regarding treatment. 13. Registered Nurse DOC Findings: No documentation was found showing a registered nurse is assigned to Options. Page 122 Genesis RFP Submission: "Genesis has a registered nurse on staff who will conduct physical screens within 7 days of client's admission into the program " (page 59) Sign-in Sheets for Groups During interviews from both residents and staff, it was apparent that groups were not conducted as regularly as what the program schedule dictated. On October 17, 2016 as part of the audit, copies of the sign-in sheets for groups was requested on twelve randomly selected dates: • May 6, 11 and 23 • • June 3, 7 and 17 • August 1,5 and 11 July 1, 7 and 20 Sign-in sheets totaling 135 pages were examined to: • Verify all resident's that should be in a group were signed in. • Review the consistency of the sign-in sheets. • Determine if groups are facilitated by qualified staff. DOC Findings: Exhibit 1 1. Of the 135 sign-in sheets reviewed, eighteen names had been written as attending a group but had a line drawn through them implying their names were crossed off for attending the group. 2. There were two instances (on August 1st) Options did not provide sign-in sheets to verify that groups actually occurred. Exhibit 2 1. Shows the dates and times a resident signed two different sign-in sheets for groups conducted at the same time (one resident in two groups simultaneously). For example: On Friday, May 6th there were ten resident signatures identifying participation in two separate groups "Constructive Leisure Time" with facilitator Lewis Duncan and "12 Step Meeting/Support Group" with facilitator Darren Taylor from 6pm to 7pm. It should be noted that the program schedule shows these groups following one another, but the sign-in sheets document them happening at the same time. This discrepancy between the times a group occurs in the program schedule vs the times a group occurs on the sign-in sheets occurs multiple times. Exhibit 3 1. Shows the dates and times where residents have signed the group sign-in sheet for participating in a phase 1 and 2 group at the same time they are signed in for participating in a phase 3 group (this may also relate to Exhibit 1 for the lining out of resident names). Page J23 For example: On Friday, May 31-cf, Fans is in AODA Education at 9am-10:30 am (a group designed for Phase 1 and 2) and is also participating in ProSocial/Reintegration at 6pm-7:30pm (a group designed for Phase 3) the same day. ➢ Residents should have already completed the dosage hours for phase 1 and 2 prior to being in a Phase 3 group It is not known if Faris (or residents like him) are receiving Phase 1 and 2 group dosage hours while in a Phase 3 group. Exhibit 4 1. Groups conducted, whether facilitated or non-facilitated, should be supervised. According to the latest program schedule (provided by Kalb McCann dated 10/31/16) all groups have a staff members name superimposed over the group indicating who is supervising. The data in this exhibit shows sign-in sheets of groups that contain no staff identified as providing supervision or facilitation. 2. There are two notations for Monday, August ft, where Options did not provide resident sign-in sheets for the Health Education and After Care groups. Exhibit 5 1. Listed are groups where the facilitator of the group did not sign their own name. This observation is based on signatures not matching the facilitator signatures from previous sign-in sheets. ➢ For proper record keeping, only the facilitator conducting the group should sign the document. Exhibit 6 1. There are groups such as "Treatment Plan/Personal Growth Assignment" with the notation "Self Directed Group" where the staff's signature is normally placed. These groups are part of the program schedule, curriculum, and a structured task. ➢ These groups should be supervised and include the signature of the facilitator on the sign-in sheets. Exhibit 7 1. During the interviews with former residents who have completed the program, eight residents stated they were given "a stack of sign-in sheets" and directed to sign them all at once. The resident's claim this stack of sign-in sheets could be for all groups that day, for more than one day 2 Of the twelve days requested for reviewing sign-in sheets, eleven of the days show evidence of groups signing their names for multiple groups at one sitting. Sign-in sheet observations: • The listing of residents on the sign-in sheets were in identical order for the whole day, for all groups conducted. Meaning the third signature on the sign-in Page I24 sheet was the third signature on all sign-in sheets for that day, the fifth signature was the fifth on all sign-in sheets for that day and in some cases, a few days in a row. For example: On Wednesday, May 11th the 8am — 9am Community Group had residents in the identical order on the sign-in sheet as the 1pm — 2 30pm Treatment Plan/Personal Growth Group. • It appears each individual resident used the same writing utensil to sign their name on every sign-in sheet for that day (or multiple days). For example: Residents would sign in at the same location using what appeared to be the same writing utensil on every sign-in sheet for that day or for multiple days. 3 The identical order in which the resident names are on the sign-in sheets for groups being conducted throughout the day; and the writing utensils used on the sign-in sheets appearing identical for many of the residents on the sign-in sheets. The most plausible way this could be accomplished is: A. If the residents sat in the same order for every group and each resident used the same writing utensil for every group. (Keeping in mind that a group that finished at 9:00 am had the same order and used the same writing utensils at the 1:00 pm group) OR B. Once seated, the residents were given a stack of sign-in sheets for the day. Phone The phone used by the residents at Options was discontinued in August due to a $5,000 phone bill. Inquiry into phone usage was examined and compared to the groups conducted. The program coordinator stated that there is a fifteen-minute limit on phone use The program coordinator also stated there is a sign in sheet where residents can reserve time to use the phone. DOC Findings: Exhibit 8 1. The data shows the date, time and duration of phone calls are conducted when all three phases are in supervised groups. For example: On Friday, July 1st, phone call minutes were tallied when all three phases were in groups according to the sign-in sheets (and the program schedule). The time in-between groups and the times when one of the phases was not in groups were not included. The phone usage totaled 4 hours 43 minutes for the day. This means that, for this particular day, there were 9 hours of overlap where all three phases were occurring at the same time. Of those 9 hours of group, the phone was in use by residents for over half that time period (4 hours 43 minutes). Page 125 Exhibit 9 th 1. This exhibit shows phone calls made at Options from July 1st through August 15 (including weekends). Only phone calls exceeding 30 minutes are documented and are listed by the duration of the call (lowest to highest minutes). ➢ 101 phone calls made during the 46-day time-frame. ➢ Ten calls over one hour. ➢ The longest call was Saturday, August 13th totaling 1hour 43.3 minutes DOC Recommendations 1. Recreation: One complaint that kept resurfacing with the residents currently in the program is the need for recreation. The interview question, "What activities do you participate in, outside of group?" Every resident's response included a combination of the following. homework, sit around, play cards, and watch TV/movies. Half of the residents stated "more recreation" as their first response to "What would you most like to see changed in the program/curriculum?" Genesis staff noted, "Residents are only concerned with dosage hours and getting out." "...nothing to look forward to during or in-between groups," and "...nothing to relieve the tension or all day classroom setting". DOC Recommendation: That a scheduled time for "relief' from groups and instruction via recreation. This would allow both a time to let the teachings "soak in" and relieve house tensions. It should also be noted that the first scheduled item for the day "Morning Stretching/Goal Setting" appeared to be a smoke break as observed on August 30th. 2. Genesis currently uses the discharge summary, post tests and exit interviews to grade their program. There is no current method for receiving input from successfully completed residents a month (as an example) after discharge. A suggested method may be a written survey, i.e. "survey monkey" or other means of information gathering. This would allow some form of resident follow-up to gain opinions of the program in general, groups specifically and analyze resident impressions of the program to see how it relates to recidivism. 3. Notification to the DOC Region 2 PPA (Lisa Jeschke) within 10 days of the successful completion dates regarding the "additional training by Options staff" as noted in the October 17th letter by Patricia Faulhaber under Section: Audio Recordings. 4. Staff do not have shared keys to offices. When asked, "What happens if the program coordinator is sick and staff need to access to files in her office?" Staff had no response. Staff should have access all offices. Page 126 5. Interviews revealed- that residents assist residents with meal preparation. To accommodate the "Living Skills" component, residents should work with trained staff or the dietitian in the preparation of meals and special diets. 6. Currently, there is no time allotted for residents to go to the store as a group Incorporate it into the program schedule a scheduled time, with proper supervision, to allow residents to go to the store as social integration and leisure activity. Recommendations/Observations - by Options Staff 1. Curriculum is so full, focus of residents is solely on dosage hours. No time to "take it all in" we are "following the schedule instead of listening to need". 2. Some residents obtain most of their dosage hours (250) during phase 1 and 2 thus getting little dosage hours in Phase 3. This means some residents do not receive the benefits or experience of Phase 3 and leave with little or no money, work experience or community service. 3. No follow-up by DOC or Genesis when programs are changed, especially by DOC. 4. PPA's only come in when something is wrong 5. Not receiving updates on changes to DOC agents (liaisons & agents) to know who to call. 6 Consolidating intakes to a single group at a time would be more time efficient. 7. Add recreation to the program. 8. Take out wellness because also addressed in AODA. 9. Start jobs in Phase 2 and reduce dosage hours in Phase 2. Additional Concerns and Observations Store runs: Based on interviews, residents have the opportunity to go to a local store every Friday and are supervised by one staff. When not walking to the store, the Options van is used. The van holds a third of the residents at one time according to staff therefore, a trip to the store with residents involves three trips This means the first two groups are dropped off and remain without supervision until the third trip is complete. This is also the case when returning, i.e. the last load of residents are not supervised while the first two trips are conducted. 1. This current procedure is in conflict with "Genesis had developed procedures for verifying the whereabouts of residents at all times." (Genesis proposal page 64). 2. The program schedule does not provide a time allotment for residents to participate in a store run, and the sign-in sheets reviewed show groups being conducted during this time. Audio Recordings_: On October 17, 2016, a letter and audio recordings received from a former Options resident was sent to Patricia Faulhaber, Executive Director for Genesis (attachment 3). The DOC directed Genesis to provide a plan of action to address the contents of the audio recording as well as work with the DOC Region 2 PPA to coordinate a response Page 127 On November 8, 2016, Genesis submitted a letter (attachment 4) in response to the audio recordings including their findings, determinations and any remedies deemed appropriate by Genesis. Genesis Findings: • Discussion and analysis occurred between Genesis management and Options staff. • The audio recordings were identified as unacceptable conduct. • Conclusions derived from the discussions was that: o Performance shortcomings were noted including duration and nature of o Perform person-centered counseling for the residents. o Staff to maintain professional and ethical conduct at all times. o Additional training will be identified for Options staff. counseling. Concerns not addressed in the Genesis Audio response. • In the audio, resident Brandon states he did not receive the required 250 dosage hours for program completion. Although the file records 251 dosage hours, the resident states in the audio that this total is incorrect and that his actual dosage hours are considerably less. The counselor in the recording dismisses the resident's statement and no further discussion or review of the resident's file was conducted to verify or dispute the resident's claim. • There is a counselor in the audio that makes several anti-law enforcement statements. These statements, spoken in the presences of residents, include: o "I cannot deal with them people." (referencing police) o "I don't want to be around them." o "I don't like police, I don't like how they treat people." o "I won't tell them if I see anything wrong, 'cause I don't do police." o "I'm scared to be around them." o "If something is going on, there is nothing in my contract that says I have to call the police." o "I don't like calling the police on people, I'm not doing it " These statements, as taken from the recordings, were not noted in the Genesis letter as inappropriate. The recordings also show a lack of boundaries by the counselor. They are also in conflict with providing a safe environment for residents participating in a DOC sanctioned program and oppose the DOC Mission Statement of providing opportunities for positive change. Clinical Director/Supervisor An email sent on November 4, 2016 by Patricia Faulhaber noted, "Jody Coren is the Clinical Director for the entire company." Page 128 Jody Coren sent an email on November 10, 2016, stating, "Clinical Supervision is a different function than Clinical Director as described in DHS RL 160." As noted on page 16 "Findings from Contract Files" client files are not meeting contract requirements such as proper and timely signatures and consultations The new responsibilities taken on by Ms. Coren bring into question Genesis' ability to meet these contract requirements based on her expanded oversight The Genesis RFP response (page 9) and DHS 75 10 (5) (amended) Section RL 162.01 (1) requires that the clinical supervisor shall provide at a minimum: 1. Two hours of clinical supervision for every 40 hours of work performed by a substance abuse counselor-in-training. (also Genesis RFP response page 9) 2. Two hours of clinical supervision for every 40 hours of counseling provided by a substance abuse counselor. 3. One hour of clinical supervision for every 40 hours of counseling provided by a clinical substance abuse counselor. 4. One in person meeting each calendar month with a substance abuse counselor-intraining, substance abuse counselor, or clinical substance abuse counselor. This meeting may fulfill a part of the requirements above. 5. Resident files require the clinical supervisor review and approval of the following: • Releases of Information • Progress notes • Treatment plans • Staffing notes • Assessments • Discharge Summaries DOC's Concerns 1. Per the emails above, Jody Coren's new position provides a different function than her previous position. How does this affect the responsibilities of the Clinical Supervisor as detailed in the contract and DHS 75.10(5)? (see items 1— 5) 2. In the FINDINGS FROM CONTRACT FILES (page 16), several examples noted client files lacking the clinical supervisor's signature. With Jody Coren's additional responsibilities to include covering the entire company, how will supervision and oversight of the client files be improved to meet contract compliance? 3. What will be the backup/support available if Ms. Coren were on leave or unavailable? Response to PREA During the interview with , and a separate interview with Ms. Thomas, it was stated that a resident touched in an inappropriate manner on As of the date of the interview on with no Genesis staff had interviewed regarding the incident. Since this report, Genesis did eventually conduct their own investigation for a possible staff assault. Page 129 No staff at Options interviewed for this audit was aware of the procedures or policies related to PREA should an allegation of sexual assault be reported. • Per RFP proposal: Section heading AGENCY COMMITMENT TO STAFF TRAINING o "Staff working in DOC programs are trained on PREA as well as new hire orientation" (page 13) o Per RFP proposal: Section heading THE FOLLOWING TRAINING IS REQUIRED OF ALL STAFF ANNUALLY PREA — 1 hour CBRF Client Group Related Training-30 minutes • Per email from Jody Coren, Clinical Director Genesis dated 8/23/16 o Our HR will be handling PREA investigations to optimize objectivity and minimize subjectivity in accordance with DCC information provided, FIR protocol and NIC standards Audit Findings Genesis shall provide a response to the following issues unless designated as "compliant" or "no further action needed". Section: OBSERVATIONS AT OPTIONS FACILITY (page 6) ➢ Holes in the wall plaster in bathroom D and ceiling of room 7 ➢ Shower in bathroom "A" not working ➢ Missing glass panel in the program/TV room ➢ Missing tile in the bathroom beside room 10 Section: LOGBOOKS (page 6) ➢ Home Pass Request Form o Response to follow-up or confirmation of the resident's whereabouts Section: INITIAL ISSUES (page 7) ➢ Residents Sleeping on Main Floor o Detail a response to resident's living conditions during times of high outside temperatures/humidity. ➢ Meals prepared by Options o Detail a response to Options not utilizing a dietician for menu planning and special diets. Section: RESIDENT AND STAFF PERCEPTIONS (page 9) ➢ No further action needed Section: STAFF AND RESIDENT INTERVIEW FINDINGS REGARDING CURRENT PROGRAMMING (page 10) ➢ Respond to the DOC Findings under numbers 3,4 and 6 Page I 30 Section: FINDINGS FROM INTERVIEWS OF RECENTLY COMPLETED RESIDENTS (page 11) ➢ Respond to the DOC Findings under items 1— 4 and the last bullet of item 5 Section: CURRENT AND COMPLETED RESIDENT COMPARISONS (pagel3) ➢ No further action needed — Informational Section: INTERVIEWS WITH GENESIS STAFF (page 14) ➢ Under Patricia Price, Counselor o Respond to Ms. Price's statements that she: o Assists or Facilitates: Employment Readiness, AODA Relapse Prevention o Stated she has no formal training on curriculum. and Cog Groups. Section: OTHER STAFF NOTATIONS (page 16) ➢ Confirm the schedule for staff meetings at Options Section: PROGRAM REQUIREMENTS PURSUANT TO THE CONTRACT (pages 16 - 17) ➢ Respond to the following contract requirements: o 5.7.4 o 5 8.2.1 o 5.7.5 o 5.8.3.7 o 5/ 9 Section: CLIENT FILES (page 18) ➢ Respond to the DOC Findings under items 1 through 13 Section: SIGN-IN SHEETS FOR GROUPS (page 22) ➢ Respond to the DOC Findings in Exhibit 1 as it relates to residents signing their names in for a group and then lining it out. ➢ Respond to the DOC Findings in Exhibit 2 as it relates to residents signing in to two groups being conducted at the same time. ➢ Respond to the DOC Findings in Exhibit 3 as it relates to a resident signing in to phase 1&2 groups as well as phase 3. ➢ Respond to the DOC Findings in Exhibit 4 as it relates to groups being conducted ➢ Respond to the DOC Findings in Exhibit 5 as it relates to staff signing sign-in without supervising staff. sheets for other staff's supervisory/facilitating responsibilities in groups. ➢ Respond to the DOC Findings in Exhibit 6 ➢ Respond to the DOC Findings in Exhibit 7 as it relates to staff allegedly circulating a stack of sign-in sheets to multiple residents to sign off on at one time. o Address the bullets within this exhibit Section: PHONE (page 24) ➢ Respond to the DOC Findings in Exhibit 8 as it relates to high volume phone usage during scheduled groups in all three phases. Page 131 ➢ Respond to the DOC Findings in Exhibit 9 as it relates to phone usage and phone monitoring. Section: ADDITIONAL CONCERNS AND OBSERVATIONS (page 26) Respond to the DOC Findings in ➢ o Store Runs o Concerns not addressed in the Genesis Audio Response o Clinical Director/Supervisor (including the three items in the "Concerns" subsection) (page 28) Section: Response to PREA (page 29) Respond to incident with ➢ ➢ PREA training requirements for all staff Corrective Action Plan Response by Genesis It is DOC's expectation that Genesis will respond to each of the items identified in the Audit Findings section. That Genesis' response will be solutions rather than explanations to the DOC Findings and how future monitoring of the findings will be applied and maintained. To that end, pursuant to Section 7 2 of the Contract, Genesis shall provide a corrective action plan that provides the following: • Each item in the Findings section in the audit is provided a solution. • A plan of oversight to ensure the quality of services is maintained. • Any assistance the DOC may offer to meet these solutions. A response is required within 30 calendar days from the "Prepared by" date noted on the cover sheet of this review. Your response should be emailed to Cynda.Solberg@wi.gov. A six-month follow-up will be scheduled from the date of final report to re-examine compliance to the corrective action plan. DOC staff retains the right to accept or deny any or all conclusions based on Genesis' response to this audit, pursue any legal recommendations based on audit findings, and request additional information from Genesis Behavioral Services and its staff as necessary. DOC The Contract Administrator and Contract Manager should be kept apprised of any issues related to this contract and/or the need for any modifications to the contract. If you have questions, please contact Cynda Solberg at 608-240-5581. Exhibit #1 NOTE: This is a list of crossed off names on each individual sign in sheet. Date Friday, May 6th Time 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 3pm-5pm 6pm-7:30pm 6pm-7pm 6pm-7:30pm 9pm-10:30pm Group Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Pro-Social/Reintegration Constructive Leisure Time 12 Step Meeting/Support Group (secular) Constructive Leisure Time Phase 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 3 1,2 1,2,3 1,2,3 Wednesday, May 11th 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 7:30pm-9pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Cognitive Restructuring Treatment Plan/Personal Growth Criminogenic Self-Change Treatment Plan/Personal Growth Pro-Social/Reintegration Constructive Leisure Time Cognitive Skills Group Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2 3 1,2 1,2 9am-5pm 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Employment Search Cognitive Restructuring Treatment Plan/Personal Growth Health Education Treatment Plan/Personal Growth Pro-Social/Reintegration Constructive Leisure Time Community Group (Feed Back) Reflection/Meditation 3 1,2 1,2 1,2 1,2 3 1,2 1,2 1,2,3 Monday, May 23rd # of Names Crossed off 1 1 Exhibit #1 Friday, June 3rd NOTE: This is a list of crossed off names on each individual sign in sheet. 7am-8am Morning Stretch/Goal 1,2,3 8am-9am Community Group (Feed Back) 1,2 9am-10:30am AODA Education 1,2 9am-5pm Employment Search 3 10:30am-12pm Parenting (Fatherhood) 1,2 1pm-2:30pm Treatment Plan/Personal Growth Assign. 1,2 3pm-5pm Treatment Plan/Personal Growth Assign. 1,2 6pm-7pm Constructive Leisure Time 1,2 6pm-7:30pm Pro-Social/Reintegration 3 6pm-7:30pm 12 Step Meeting/Support Group (secular) 1,2,3 9pm-10:30pm Constructive Leisure Time 1,2,3 Tuesday, June 7th 8am-9am 9am-10:30am 2:30pm-4pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 9pm-9:30pm 9:30pm-10pm Community Group (Feed Back) AODA Education Wellness Group Employment Readiness Treatment Plan/Personal Growth Assign. Relapse Preventions Community Meeting (Evening) Reflection/Meditation 1,2,3 1,2 1 2 1,2 3 1,2,3 1,2,3 Friday, June 17th 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 3pm-5pm 6pm-7pm 6pm-7:30pm 6pm-7:30pm 9pm-10:30pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Constructive Leisure Time Pro-Social/Reintegration 12 Step Meeting/Support Group (secular) Constructive Leisure Time 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2,3 1,2,3 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. 1,2,3 1,2,3 1,2 3 1,2 1,2 Friday, July 1st 2 1 Exhibit #1 NOTE: This is a list of crossed off names on each individual sign in sheet. 3pm-5pm Treatment Plan/Personal Growth Assign. 1,2 6pm-7pm Constructive Leisure Time 1,2,3 6pm-7:30pm Pro-Social/Reintegration 3 6pm-7:30pm 12 Step Meeting/Support Group (secular) 1,2,3 9pm-10:30pm Constructive Leisure Time 1,2,3 Thursday, July 7th Wednesday, July 20th Monday, August 1st 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 7:30pm-9pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Relationships Men & Trauma Anger Management Treatment Plan/Personal Growth Assign. Relapse Preventions Constructive Leisure Time Cognitive Skills Group Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2 3 1,2,3 1,2,3 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 7:30pm-9pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Cognitive Restructuring Treatment Plan/Personal Growth Criminogenic Self-Change Treatment Plan/Personal Growth Pro-Social/Reintegration Constructive Leisure Time Cognitive Skills Group Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2 3 1,2 1,2 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm Community Group (Feed Back) AODA Education Employment Search Cognitive Restructuring Treatment Plan/Personal Growth 1,2,3 1,2 3 1,2 1,2 1 1 1 3 1 1 1 1 Exhibit #1 (No Offenders Listed)→→ (No Offenders Listed)→→ Friday, August 5th Tuesday, August 11th NOTE: This is a list of crossed off names on each individual sign in sheet. 2:30pm-4pm Health Education 1,2 6pm-7:30pm Treatment Plan/Personal Growth 1,2 6pm-7:30pm Pro-Social/Reintegration 3 7:30pm-9pm Constructive Leisure Time 1,2 7:30pm-9pm After Care Group 3 9pm-9:30pm Community Group (Feed Back) 1,2,3 9:30pm-10pm Reflection/Meditation 1,2,3 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 3pm-5pm 6pm-7pm 6pm-7:30pm 6pm-7:30pm 9pm-10:30pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Constructive Leisure Time Pro-Social/Reintegration 12 Step Meeting/Support Group (secular) Constructive Leisure Time 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2,3 1,2,3 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 7:30pm-9pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Relationships Men & Trauma Anger Management Treatment Plan/Personal Growth Relapse Preventions Constructive Leisure Time Cognitive Restructuring Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2 3 1,2,3 1,2,3 135 total sign in sheets 1 1 1 EXHIBIT #2 NOTE: This is a list of separate incidents on each day where an Client was signed in on two different sheets/groups going on at the same time. Date Friday, May 6th Time 6pm-7pm 6pm-7pm Groups Clients Signed In On Constructive Leisure Time 12 Step Meeting/Support Group Client Name Marty Bill Steven Joseph Larry Darron Pablo Sam David Adam Monday, May 23rd 9am-5pm 10:30am-12pm Employment Search Treatment Plan & Personal Growth Darron Friday, June 3rd 6pm-7pm 6pm-7:30pm Constructive Leisure Time 12 Step Meeting/Support Group Faris David Darron Joseph Sam Marty Pablo Bill Tuesday, June 7th 6pm-7:30pm 6pm-7:30pm Treatment Plan/Personal Growth Assign. Relapse Preventions Shawn Friday, June 17th 6pm-7:30pm 6pm-7:30pm Pro-Social/Reintegration 12 Step Meeting/Support Group (secular) Warren Larry Bill Friday, July 1st 9am-5pm 1pm-2:30pm 3pm-5pm Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Darron 6pm-7pm 6pm-7:30pm Constructive Leisure Time 12 Step Meeting/Support Group Donald Bobby Ethan Kerry Dan Wade Cliff Darron Gary Roderick 6pm-7:30pm 6pm-7:30pm Pro-Social/Reintegration 12 Step Meeting/Support Group Larry Sam Pablo Marty Darron David Thursday, July 7th Friday, August 5th 9am-5pm 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm Employment Search AODA Education Relationships Men & Trauma Anger Management Donald Cliff Kerry 6pm-7:30pm 6pm-7:30pm Treatment Plan/Personal Growth Assign. Relapse Preventions Brandon Donald Cliff Gary Bobby 7:30pm-9pm 7:30pm-9pm Constructive Leisure Time Cognitive Skills Group Donald Cliff 6pm-7:30pm 6pm-7:30pm Pro-Social/Reintegration 12 Step Meeting/Support Group Dan 6pm-7pm 6pm-7:30pm Constructive Leisure Time Pro-Social/Reintegration Jason Ethan Tanner Roderick Julius Nathan Guentzel Ben Glyn Bobby Wade Liam Exhibit 3 NOTE: These Clients have their names signed on sheets for group sessions conducted for phase 1 and 2 and phase 3, on the same day. Date Friday, May 6th Wednesday, May 11th Client Name Paul Groups Client Signed In On Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Pro-Social/Reintegration Phase of Group 1,2 1,2 1,2 3 Time 10:30am-12pm 1pm-2:30pm 3pm-5pm 6pm-7:30pm Adam Constructive Leisure Time Pro-Social/Reintegration 1,2 3 6pm-7pm 6pm-7:30pm Harry Community Group (Feed Back) Reflection/Meditation Cognitive Skills Group Pro-Social/Reintegration Employment Search 1,2 1,2 3 3 3 9pm-9:30pm 9:30pm-10pm 7:30pm-9pm 6pm-7:30pm 9am-5pm Patrick Community Group (Feed Back) Reflection/Meditation Pro-Social/Reintegration Cognitive Skills Group Employment Search 1,2 1,2 3 3 3 9pm-9:30pm 9:30pm-10pm 7:30pm-9pm 6pm-7:30pm 9am-5pm Faris Community Group (Feed Back) Reflection/Meditation Pro-Social/Reintegration Cognitive Skills Group Employment Search 1,2 1,2 3 3 3 9pm-9:30pm 9:30pm-10pm 7:30pm-9pm 6pm-7:30pm 9am-5pm Reese Community Group (Feed Back) Reflection/Meditation Pro-Social/Reintegration Cognitive Skills Group Employment Search 1,2 1,2 3 3 3 9pm-9:30pm 9:30pm-10pm 7:30pm-9pm 6pm-7:30pm 9am-5pm Shawn Community Group (Feed Back) Reflection/Meditation Pro-Social/Reintegration Cognitive Skills Group 1,2 1,2 3 3 9pm-9:30pm 9:30pm-10pm 7:30pm-9pm 6pm-7:30pm Exhibit 3 NOTE: These Clients have their names signed on sheets for group sessions conducted for phase 1 and 2 and phase 3, on the Adam same day. Community Group (Feed Back) Reflection/Meditation Pro-Social/Reintegration Cognitive Skills Group Employment Search 1,2 1,2 3 3 3 9pm-9:30pm 9:30pm-10pm 7:30pm-9pm 6pm-7:30pm 9am-5pm Monday, May 23rd Darron Cognitive Restructuring Treatment Plan/Personal Growth Treatment Plan/Personal Growth Constructive Leisure Time Employment Search 1,2 1,2 1,2 1,2 3 10:30am-12pm 1pm-2:30pm 6pm-7:30pm 7:30pm-9pm 9am-5pm Friday, May 3rd Faris AODA Education Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Constructive Leisure Time Pro-Social/Reintegration 1,2 1,2 1,2 1,2 3 9am-10:30am 10:30am-12pm 1pm-2:30pm 6pm-7pm 6pm-7:30pm Tuesday, June 7th Shawn Treatment Plan/Personal Growth Assign. Relapse Preventions 1,2 3 6pm-7:30pm 6pm-7:30pm Friday, July 1st Darron Constructive Leisure Time Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Pro-Social/Reintegration Employment Search 1,2 1,2 1,2 3 3 6pm-7pm 1pm-2:30pm 3pm-5pm 6pm-7:30pm 9am-5pm Thursday, July 7th Brandon AODA Education Relationships Treatment Plan/Personal Growth Assign. Constructive Leisure Time Relapse Preventions 1,2 1,2 1,2 1,2 3 9am-10:30am 10:30am-12pm 6pm-7:30pm 7:30pm-9pm 6pm-7:30pm Donald AODA Education Relationships Men & Trauma Treatment Plan/Personal Growth Assign. Constructive Leisure Time 1,2 1,2 1,2 1,2 1,2 9am-10:30am 10:30am-12pm 1pm-2:30pm 6pm-7:30pm 7:30pm-9pm Exhibit 3 NOTE: These Clients have their names signed on sheets for group sessions conducted for phase 1 and 2 and phase 3, on the same day. Cognitive Skills Group 3 7:30pm-9pm Cliff AODA Education Relationships Men & Trauma Anger Management Treatment Plan/Personal Growth Assign. Constructive Leisure Time Employment Seach Relapse Preventions Cognitive Skills Group 1,2 1,2 1,2 1,2 1,2 1,2 3 3 3 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 7:30pm-9pm 9am-5pm 6pm-7:30pm 7:30pm-9pm Kerry AODA Education Relationships Men & Trauma Anger Management Treatment Plan/Personal Growth Assign. Constructive Leisure Time Employment Seach Relapse Preventions 1,2 1,2 1,2 1,2 1,2 1,2 3 3 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 7:30pm-9pm 9am-5pm 6pm-7:30pm Gary AODA Education Relationships Men & Trauma Anger Management Treatment Plan/Personal Growth Assign. Constructive Leisure Time Relapse Preventions 1,2 1,2 1,2 1,2 1,2 1,2 3 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 7:30pm-9pm 6pm-7:30pm Bobby Relationships Treatment Plan/Personal Growth Assign. Constructive Leisure Time Relapse Preventions 1,2 1,2 1,2 3 10:30am-12pm 6pm-7:30pm 7:30pm-9pm 6pm-7:30pm Exhibit #4 Staff Facilitated and Supervised Non-Facilitated Group Session: (No Facilitator Noted) Date Time Group Phase Friday, May 6th 7am-8am 8am-9am 9am-5pm 1pm-2:30pm 3pm-5pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 1,2,3 1,2,3 3 1,2 1,2 Wednesday, May 11th 7am-8am 8am-9am 9am-5pm 1pm-2:30pm 6pm-7:30pm 9pm-9:30pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Treatment Plan/Personal Growth Community Group (Feed Back) 1,2,3 1,2,3 3 1,2 1,2 1,2 Monday, May 23rd 9am-5pm 1pm-2:30pm 6pm-7:30pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Employment Search Treatment Plan/Personal Growth Treatment Plan/Personal Growth Constructive Leisure Time Community Group (Feed Back) Reflection/Meditation 3 1,2 1,2 1,2 1,2 1,2,3 Friday, June 3rd 7am-8am 8am-9am 9am-5pm 1pm-2:30pm 3pm-5pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 1,2,3 1,2 3 1,2 1,2 Tuesday, June 7th 6pm-7:30pm 9pm-9:30pm 9:30pm-10pm Treatment Plan/Personal Growth Assign. Community Meeting (Evening) Reflection/Meditation 1,2 1,2,3 1,2,3 Friday, June 17th 7am-8am 8am-9am 9am-5pm 1pm-2:30pm 3pm-5pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 1,2,3 1,2,3 3 1,2 1,2 Friday, July 1st 7am-8am 8am-9am 9am-5pm 1pm-2:30pm 3pm-5pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 1,2,3 1,2,3 3 1,2 1,2 Thursday, July 7th 7am-8am 8am-9am 9am-5pm 6pm-7:30pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Assign. Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 3 1,2 1,2,3 1,2,3 Wednesday, July 20th 7am-8am 8am-9am Morning Stretch/Goal Community Group (Feed Back) 1,2,3 1,2,3 Exhibit #4 Staff Facilitated and Supervised Non-Facilitated Group Session: (No Facilitator Noted) Date Time Group Phase 9am-5pm 1pm-2:30pm 6pm-7:30pm 9pm-9:30pm 9:30pm-10pm Employment Search Treatment Plan/Personal Growth Treatment Plan/Personal Growth Community Group (Feed Back) Reflection/Meditation 3 1,2 1,2 1,2 1,2 8am-9am 9am-5pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 7:30pm-9pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Health Education Treatment Plan/Personal Growth Constructive Leisure Time After Care Group Community Group (Feed Back) Reflection/Meditation 1,2,3 3 1,2 1,2 1,2 1,2 3 1,2,3 1,2,3 Friday, August 5th 7am-8am 8am-9am 9am-5pm 1pm-2:30pm 3pm-5pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 1,2,3 1,2,3 3 1,2 1,2 Tuesday, August 11th 7am-8am 8am-9am 9am-5pm 6pm-7:30pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Treatment Plan/Personal Growth Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 3 1,2 1,2,3 1,2,3 Monday, August 1st (No Clients Listed)→→ (No Clients Listed)→→ Exhibit #5 NOTE: It appears that these facilitators did not sign their own name. This does not include names that have been typed, only hand written. Date Friday, July 1st Time 6pm-7:30pm Group Pro-Social/Reintegration Phase 3 Facilitator Name Ducan 10:30am-12pm Parenting (Fatherhood) 1,2 Darren 6pm-7pm Constructive Leisure Time 1,2 P. Price Thursday, July 7th 7:30pm-9pm Constructive Leisure Time 1,2 P. Price Wednesday, July 20th 6pm-7:30pm Pro-Social/Reintegration 3 Ashley 7:30pm-9pm Cognitive Skills Group 3 Ashley Exhibit #6 Staff Facilitating Group Session: "Self Directed Group" Date Friday, May 6th Time 9am-5pm 1pm-2:30pm 3pm-5pm Group Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Phase 3 1,2 1,2 Wednesday, May 11th 9am-5pm 1pm-2:30pm 6pm-7:30pm Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 3 1,2 1,2 Monday, May 23rd 9am-5pm 1pm-2:30pm 6pm-7:30pm 7:30pm-9pm Employment Search Treatment Plan/Personal Growth Treatment Plan/Personal Growth Constructive Leisure Time 3 1,2 1,2 1,2 Friday, June 3rd 9am-5pm 1pm-2:30pm 3pm-5pm Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 3 1,2 1,2 Tuesday, June 7th 6pm-7:30pm Treatment Plan/Personal Growth Assign. 1,2 Friday, June 17th 9am-5pm 1pm-2:30pm 3pm-5pm Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 3 1,2 1,2 Friday, July 1st 9am-5pm 1pm-2:30pm 3pm-5pm Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 3 1,2 1,2 Thursday, July 7th 9am-5pm 6pm-7:30pm Employment Search Treatment Plan/Personal Growth Assign. 3 1,2 Wednesday, July 20th 9am-5pm 1pm-2:30pm 6pm-7:30pm Employment Search Treatment Plan/Personal Growth Treatment Plan/Personal Growth 3 1,2 1,2 Monday, August 1st 9am-5pm 1pm-2:30pm 6pm-7:30pm 7:30pm-9pm Employment Search Treatment Plan/Personal Growth Treatment Plan/Personal Growth Constructive Leisure Time 3 1,2 1,2 1,2 Friday, August 5th 9am-5pm 1pm-2:30pm 3pm-5pm Employment Search Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 3 1,2 1,2 Tuesday, August 11th 9am-5pm 6pm-7:30pm Employment Search Treatment Plan/Personal Growth 3 1,2 Exhibit #7 In addition to the clients' signatures being in the exact same order throughout the day on different sign in sheets, it also appears that each individual client used the same writing utensil to sign their name on each sign in sheet. Date Friday, May 6th Time 1pm-2:30pm 3pm-5pm Group Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Phase 1,2 1,2 6pm-7pm 6pm-7:30pm Constructive Leisure Time 12 Step Meeting/Support Group (secular) 1,2 1,2,3 7am-8am 8am-9am Morning Stretch/Goal Community Group (Feed Back) 1,2,3 1,2,3 1pm-2:30pm 2:30pm-4pm Treatment Plan/Personal Growth Assign. Criminogenic Self-Change 1,2 1,2 9pm-9:30pm 9:30pm-10pm Community Group (Feed Back) Reflection/Meditation 1,2 1,2 Monday, May 23rd 10:30am-12pm 1pm-2:30pm Cognitive Restructuring Treatment Plan/Personal Growth 1,2 1,2 Tuesday, June 7th 8am-9am 9am-10:30am Community Group (Feed Back) AODA Education 1,2,3 1,2 Friday, June 17th 8am-9am 9am-5pm 9am-10:30am 10:30am-12pm 1pm-2:30pm 3pm-5pm 6pm-7pm 6pm-7:30pm 9pm-10:30pm Community Group (Feed Back) Employment Search AODA Education Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Constructive Leisure Time 12 Step Meeting/Support Group (secular) Constructive Leisure Time 1,2 3 1,2 1,2 1,2 1,2 1,2 1,2,3 1,2,3 Friday, July 1st 7am-8am 8am-9am 9am-10:30am 10:30am-12pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Parenting (Fatherhood) 1,2,3 1,2,3 1,2 1,2 1pm-2:30pm 3pm-5pm 6pm-7pm 6pm-7:30pm 9pm-10:30pm Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Constructive Leisure Time 12 Step Meeting/Support Group (secular) Constructive Leisure Time 1,2 1,2 1,2,3 1,2,3 1,2,3 7am-8am 8am-9am 9am-5pm 6pm-7:30pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) Employment Search Relapse Preventions Cognitive Skills Group Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 3 3 3 1,2 1,2,3 Wednesday, May 11th Thursday, July 7th Exhibit #7 In addition to the clients' signatures being in the exact same order throughout the day on different sign in sheets, it also appears that each individual client used the same writing utensil to sign their name on each sign in sheet. Date Time Group Phase 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 7:30pm-9pm AODA Education Relationships Men & Trauma Anger Management Treatment Plan/Personal Growth Assign. Constructive Leisure Time 1,2 1,2 1,2 1,2 1,2 1,2 Wednesday, July 20th 7am-8am 8am-9am 9am-10:30am 9am-5pm 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 6pm-7:30pm 6pm-7:30pm 7:30pm-9pm 7:30pm-9pm 9pm-9:30pm 9:30pm-10pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Employment Search Cognitive Restructuring Treatment Plan/Personal Growth Criminogenic Self-Change Treatment Plan/Personal Growth Pro-Social/Reintegration Constructive Leisure Time Cognitive Skills Group Community Group (Feed Back) Reflection/Meditation 1,2,3 1,2,3 1,2 3 1,2 1,2 1,2 1,2 3 1,2 3 1,2 1,2 Monday, August 1st 8am-9am 9am-10:30am 10:30am-12pm Community Group (Feed Back) AODA Education Cognitive Restructuring 1,2,3 1,2 1,2 9pm-9:30pm 9:30pm-10pm Community Meeting (Feed Back) Reflection/Meditation 1,2,3 1,2,3 7am-8am 8am-9am 9am-10:30am 10:30am-12pm Morning Stretch/Goal Community Group (Feed Back) AODA Education Parenting (Fatherhood) 1,2,3 1,2,3 1,2 1,2 1pm-2:30pm 3pm-5pm 6pm-7pm Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. Constructive Leisure Time 1,2 1,2 1,2 6pm-7:30pm 9pm-10:30pm 12 Step Meeting/Support Group (secular) Constructive Leisure Time 1,2,3 1,2,3 7am-8am 8am-9am 9am-10:30am 10:30am-12pm Morning Stretch Community Group AODA Education Relationships 1,2,3 1,2,3 1,2 1,2 6pm-7:30pm 7:30pm-9pm Treatment Plan/Personal Growth Assign. Constructive Leisure Time 1,2 1,2 Friday, August 5th Thursday, August 11th 2:30pm-4pm 9pm-9:30pm 9:30pm-10pm Anger Management Community Group Reflection/Meditation 1,2 1,2,3 1,2,3 Exhibit #8 NOTE: These are phone calls made during overlaps of ALL 3 phases. Phone calls under 5 minutes were not included. Date Friday, July 1st Time 7am-8am Phase 1,2,3 Group Constructive Leisure Time 9am-5pm 10:30am-12pm 1pm-2:30pm 3pm-5pm 3 1,2 1,2 1,2 Employment Search Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. Treatment Plan/Personal Growth Assign. 7/1/2016 7/1/2016 7/1/2016 7/1/2016 7/1/2016 7/1/2016 7/1/2016 7/1/2016 7/1/2016 7/1/2016 PM PM PM PM PM PM PM PM PM PM 22 5 7 6 13 5 7 12.5 6 10 6pm-7pm 6pm-7:30pm 6pm-7:30pm 1,2 3 1,2,3 Constructive Leisure Time Pro-Social/Reintegration 12 Step Meetin/Support Group (secular) 7/1/2016 6:03:50 PM 7/1/2016 7:07:03 PM 7/1/2016 7:14:19 PM 17.3 5 26 9pm-10:30pm 1,2,3 Constructive Leisure Time 7/1/2016 9:05:32 PM 7/1/2016 9:25:50 PM 7/1/2016 9:39:05 PM 7/1/2016 10:04:48 PM 16.9 14 25 28 Total Time of Phase Overlap 9 Hours Phone Number Called Date & Time of Call 7/1/2016 7:04:50 AM 7/1/2016 7:28:55 AM 1:50:54 2:23:07 3:26:44 3:44:32 3:52:03 4:06:12 4:15:04 4:27:54 4:44:03 4:48:55 Duration of Call 23.3 34 Total Time of Phone Usage 4 Hours, 43min Date Thursday, July 7th Time 8am-9am Phase 1,2,3 Group Community Group (Feed Back) 9am-5pm 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 3 1,2 1,2 1,2 1,2 6pm-7:30pm 6pm-7:30pm Phone Number Called Date & Time of Call 7/7/2016 8:30:39 AM 7/7/2016 8:47:18 AM Duration of Call 16 18 Employment Search AODA Education Relationships Men & Trauma Anger Management 7/7/2016 11:56:33 AM 7/7/2016 1:10:35 PM 7/7/2016 1:22:53 PM 7/7/2016 1:34:13 PM 7/7/2016 2:00:39 PM 7/7/2016 3:03:18 PM 7/7/2016 3:07:01 PM 7/7/2016 3:28:25 PM 7/7/2016 3:35:09 PM 7/7/2016 3:46:16 PM 7/7/2016 3:58:26 PM 17 11 10 6 6 5 6 6.1 12 13 6.5 1,2 3 Treatment Plan/Personal Growth Assign. Relapse Preventions 7/7/2016 7/7/2016 7/7/2016 7/7/2016 6:39:52 6:47:09 7:07:45 7:19:11 PM PM PM PM 6.1 12 11 18 7:30pm-9pm 7:30pm-9pm 1,2 3 Constructive Leisure Time Cognitive Skills Group 7/7/2016 7/7/2016 7/7/2016 7/7/2016 7/7/2016 7:35:58 7:53:59 8:16:50 8:46:37 8:53:49 PM PM PM PM PM 18 18 27 8 5 9pm-9:30pm 1,2,3 Community Group (Feed Back) 7/7/2016 9:02:15 PM 7/7/2016 9:20:02 PM 15 12 9:30pm-10pm 1,2,3 Reflection/Meditation 7/7/2016 9:32:21 PM 7/7/2016 9:36:59 PM 6 23 Total Time of Phase Overlap Total Time of Phone Usage 11 Hours 5 Hours, 12min Date Wednesday, July 20th Time 7am-8am Phase 1,2,3 Group Morning Stretch/Goal 8am-9am 1,2,3 9am-5pm Phone Number Called Date & Time of Call 7/20/2016 7:19:33 AM 7/20/2016 7:28:50 AM 7/20/2016 7:34:38 AM 7/20/2016 7:48:25 AM Duration of Call 9 5 15 15 Community Group (Feed Back) 7/20/2016 8:22:01 AM 8 3 Employment Search 9am-10:30pm 1,2 AODA Education 7/20/2016 10:28:26 AM 7/20/2016 10:38:22 AM 11 10 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 1,2 1,2 1,2 Cognitive Restructuring Treatment Plan & Personal Growth Criminogenic Self-Change 7/20/2016 10:58:56 AM 6 7/20/2016 11:04:21 AM 7/20/2016 11:20:18 AM 7/20/2016 11:43:54 AM 7/20/2016 11:53:41 AM 7/20/2016 1:25:35 PM 7/20/2016 1:32:15 PM 7/20/2016 1:38:32 PM 7/20/2016 1:54:25 PM 7/20/2016 2:37:16 PM 7/20/2016 2:46:09 PM 7/20/2016 2:58:56 PM 7/20/2016 3:21:17 PM 7/20/2016 3:30:42 PM 7/20/2016 3:35:20 PM 7/20/2016 3:41:22 PM 7/20/2016 3:59:11 PM 11 19 6 9 6 7 17 8 10 11 12 9 6 7 7 12 6pm-7:30pm 1,2 Treatment Plan & Personal Growth 7/20/2016 7/20/2016 7/20/2016 7/20/2016 7/20/2016 7/20/2016 7/20/2016 6:03:49 6:36:01 6:45:21 6:50:13 7:00:29 7:11:17 7:29:45 PM PM PM PM PM PM PM 7/20/2016 7:36:34 PM 29 5 5 6 7.7 19 7 5 Date Time Phase Group Phone Number Called Date & Time of Call 7/20/2016 7/20/2016 7/20/2016 7/20/2016 7:57:30 8:19:08 8:27:57 8:51:36 PM PM PM PM Durration of Call 21 10 20 32 Total Time of Phase Overlap Total Time of Phone Usage 11 Hours 6 Hours, 42min Date Time Phase Group Monday, August 1st 8am-9am 1,2,3 No Sign In Sheet →→ 9am-5pm 9am-10:30am 10:30am-12pm 1pm-2:30pm (2:30pm-4pm) No Sign In Sheet →→ Date & Time of Call Durration of Call Community Group (Feed Back) 8/1/2016 8:33:23 AM 8/1/2016 8:48:38 AM 14 8 3 1,2 1,2 1,2 (1,2) Employment Search AODA Education Cognitive Restructuring Treatment Plan & Personal Growth (Health Education) 8/1/2016 10:26:57 AM 8/1/2016 11:59:05 AM 8/1/2016 1:41:27 PM 8/1/2016 2:11:02 PM 8/1/2016 2:20:22 PM 8/1/2016 2:25:33 PM 8/1/2016 2:40:35 PM 8/1/2016 2:49:19 PM 8/1/2016 3:09:15 PM 8/1/2016 3:14:01 PM 8/1/2016 3:29:26 PM 8/1/2016 3:48:56 PM 8/1/2016 3:53:44 PM 6 5 9 10 5 6 6 13.3 6 6 6 6 6 6pm-7:30pm 6pm-7:30pm 1,2 3 Treatment Plan & Personal Growth Pro-Social/Reintegration 8/1/2016 7:29:24 PM 10 7:30pm-9pm (7:30pm-9pm) 1,2 (3) Constructive Leisure Time (Aftercare) 8/1/2016 8/1/2016 8/1/2016 8/1/2016 8/1/2016 8/1/2016 8/1/2016 8/1/2016 PM PM PM PM PM PM PM PM 10 21 9 5 19 12 8.9 16 9pm-9:30pm 1,2,3 Community Meeting (Feed Back) 8/1/2016 9:23:06 PM 30 9:30pm-10pm 1,2,3 Reflection/Meditation 8/1/2016 9:23:06 PM 8/1/2016 9:51:29 PM 30 9 Total Time of Phase Overlap Phone Number Called 7:29:24 7:43:43 8:06:26 8:14:24 8:18:36 8:38:04 8:49:49 8:59:32 Total Time of Phone Usage 4 Hours, 52min 11 Hours Date Time Phase Group Friday, August 5th 7am-8am 1,2,3 8am-9pm Date & Time of Call Durration of Call Morning Stretch/Goal 8/5/2016 7:26:31 AM 8/5/2016 7:32:01 AM 7 13 1,2,3 Community Meeting (Feed Back) 8/5/2016 8:29:09 AM 8/5/2016 8:38:24 AM 9 6 9am-5pm 9am-10:30am 10:30am-12pm 1pm-2:30pm (3pm-5pm) 3 1,2 1,2 1,2 (1,2) Employment Search AODA Education Parenting (Fatherhood) Treatment Plan/Personal Growth Assign. (Treatment Plan/Personal Growth Assign.) 8/5/2016 1:08:41 PM 20 No Sign In Sheet →→ (6pm-7pm) 6pm-7pm 6pm-7:30pm (1,2) 3 1,2,3 (Constructive Leisure Time) Pro-Social/Reintegration 12 Step Meeting/Support Group (secular) 8/5/2016 6:02:56 PM 8/5/2016 6:26:26 PM 8/5/2016 6:45:18 PM 24 20 23 No Sign In Sheet →→ No Sign In Sheet →→ (7pm-8:30pm) (1,2,3) (9pm-10:30pm) (1,2,3) (12 Step Meeting/Support Group (secular)) (Constructive Leisure Time) 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 7 10 17 21 5 28 No Sign In Sheet →→ Phone Number Called 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 8/5/2016 1:33:34 1:44:08 2:00:11 2:23:12 3:10:43 3:34:44 3:42:03 3:57:30 4:33:36 4:51:19 7:08:38 7:19:34 7:36:31 7:59:41 8:20:27 9:33:12 PM PM PM PM PM PM PM PM PM PM PM PM PM PM PM PM 9 6 16 45.7 21 7 9 16 19 11 Total Time of Phase Overlap Total Time of Phone Usage 12.5 Hours 6 Hours, 10min Date Time Phase Group Thursday, August 11th 7am-8am 1,2,3 Morning Stretch/Goal Phone Number Called Date & Time of Call Durration of Call 8/11/2016 7:15:52 AM 9 8/11/2016 7:25:28 AM 8/11/2016 7:52:21 AM 24.9 9 8/11/2016 8:33:01 AM 8 8/11/2016 10:26:30 AM 8/11/2016 1:05:15 PM 8/11/2016 1:29:42 PM 8/11/2016 1:51:29 PM 8/11/2016 2:16:04 PM 8/11/2016 2:24:47 PM 8/11/2016 2:29:18 PM 8/11/2016 2:41:05 PM 8/11/2016 2:54:56 PM 8/11/2016 3:35:53 PM 8/11/2016 3:48:05 PM 7 8 7 23 6 6 6 5 18 11 8 8am-9am 1,2,3 Community Group (Feed Back) 9am-5pm 9am-10:30am 10:30am-12pm 1pm-2:30pm 2:30pm-4pm 3 1,2 1,2 1,2 1,2 Employment Search AODA Education Relationships Men & Truama Anger Management 6pm-7:30pm 6pm-7:30pm 1,2 3 Treatment Plan/Personal Growth Assign. Relapse Preventions 8/11/2016 6:58:06 PM 8/11/2016 7:11:15 PM 12.5 17 7:30pm-9pm 7:30pm-9pm 1,2 3 Constructive Leisure Time Cognitive Skills Group 8/11/2016 7:31:55 PM 8/11/2016 8:45:22 PM 5 21 9pm-9:30pm 1,2,3 Community Directed Group 8/11/2016 9:05:43 PM 8/11/2016 9:16:19 PM 8/11/2016 9:19:59 PM 6 5 13 9:30pm-10pm 1,2,3 Reflection/Meditation 8/11/2016 9:31:58 PM 8/11/2016 9:36:17 PM 8/11/2016 9:41:02 PM 5 6 11 Total Time of Phase Overlap Total Time of Phone Usage 12 Hours 4 Hours, 18min Exhibit #9 NOTE: These are the 101 phone calls, lasting more than 30 minutes long, between July 1st and August 15th Phone Calls More than 30 Minutes Long Phone Number Called Date & Time of Call 8/14/2016 8:13:39 PM 7/15/2016 5:44:43 PM 7/16/2016 1:16:30 AM 7/16/2016 11:01:34 PM 7/17/2016 11:00:57 AM 7/18/2016 7:12:17 AM 7/23/2016 8:48:59 PM 7/28/2016 5:45:42 AM 8/3/2016 7:15:16 AM 7/14/2016 5:11:53 AM 7/19/2016 5:33:30 PM 7/20/2016 8:51:36 PM 8/3/2016 3:23:48 PM 8/3/2016 6:43:57 PM 7/2/2016 12:59:17 PM 7/2/2016 6:56:33 PM 8/6/2016 8:32:47 PM 7/16/2016 2:07:53 PM 7/17/2016 9:00:12 PM 8/4/2016 4:23:39 PM 8/6/2016 10:27:24 PM 8/6/2016 11:17:34 PM 7/24/2016 7:40:30 PM 7/1/2016 7:28:55 AM 7/25/2016 8:12:45 PM 8/3/2016 4:50:43 PM 8/6/2016 11:06:53 AM 8/6/2016 9:18:47 PM 8/7/2016 7:07:17 PM 8/12/2016 5:11:13 PM 7/27/2016 6:40:45 PM 8/3/2016 12:19:43 PM 8/13/2016 9:46:22 AM 8/13/2016 4:18:04 PM 7/1/2016 11:19:40 PM 7/13/2016 1:16:48 PM 7/31/2016 9:56:48 PM 8/2/2016 6:16:18 AM 8/14/2016 12:12:20 PM 7/31/2016 8:49:00 PM 7/26/2016 12:59:42 PM 7/27/2016 4:19:53 PM 7/31/2016 2:14:29 PM 8/13/2016 3:16:11 PM 8/13/2016 10:24:30 PM 8/14/2016 6:16:45 PM 8/7/2016 8:32:21 AM 7/24/2016 12:59:02 PM Durration of Call 30.5 31 31 31 31 31 31 31 31 31.7 32 32 32 32 32.1 32.5 32.5 33 33 33 33 33 33.7 34 34 34 34 34 34 34 34.1 34.5 34.5 34.5 35 35 35 35 35 35.3 36 36 36 36 36 36 36.1 37 7/30/2016 10:04:24 AM 8/2/2016 1:25:52 PM 8/5/2016 8:55:13 PM 7/3/2016 11:35:34 AM 7/22/2016 7:17:49 AM 7/27/2016 1:52:52 PM 8/15/2016 1:26:35 PM 7/3/2016 8:29:31 PM 7/17/2016 7:39:18 PM 7/23/2016 7:29:21 AM 7/24/2016 11:55:04 AM 7/25/2016 4:51:41 PM 7/31/2016 9:30:16 AM 7/9/2016 6:41:17 PM 7/12/2016 2:54:41 PM 7/28/2016 6:21:42 AM 8/13/2016 7:32:45 PM 8/13/2016 8:14:55 PM 8/14/2016 10:25:28 AM 7/30/2016 10:42:44 PM 8/5/2016 2:23:12 PM 7/30/2016 8:59:30 PM 8/4/2016 8:45:29 PM 8/8/2016 6:37:47 PM 7/30/2016 12:32:33 AM 8/6/2016 9:55:04 AM 7/31/2016 12:30:35 PM 7/2/2016 4:21:43 PM 7/30/2016 10:58:40 AM 8/12/2016 9:08:14 PM 7/16/2016 10:12:50 PM 7/23/2016 5:54:08 PM 7/29/2016 2:19:53 PM 7/3/2016 1:37:22 PM 7/22/2016 7:36:54 PM 7/22/2016 2:07:04 PM 7/23/2016 12:26:21 PM 8/4/2016 12:22:27 PM 8/6/2016 6:34:22 PM 7/23/2016 1:35:00 PM 7/23/2016 10:11:54 PM 7/31/2016 7:12:38 AM 7/31/2016 7:39:30 PM 8/13/2016 2:12:15 PM 7/23/2016 6:59:01 PM 8/6/2016 7:32:28 PM 7/23/2016 2:31:00 PM 7/24/2016 8:04:13 AM 8/6/2016 12:33:21 AM 8/7/2016 4:07:07 PM 8/6/2016 3:53:40 PM 8/7/2016 12:25:06 PM 8/13/2016 12:29:57 AM 37 37 37 38 39 39 39 41 41 41 41 41 41 42 42 42 42 44 44 44.1 45.7 47 47 47 47.3 47.7 48 48.1 48.1 49 50 50 50.9 53 54 55 55 55 56.5 57 57 59 59 60 61.3 62 65 72 73 74 78 92.5 105.3