Office of the Inspector General for Mental Health,
Mental Retardation, and Substance Abuse Services

Virginia Center for Behavioral Rehabilitation
Petersburg, Virginia
Inspection
James W. Stewart, III / Inspector General
OIG Report #169-08
Issued March 23, 2009

Section I - Executive Summary
The OIG conducted an unannounced inspection at the Virginia Center for Behavioral
Rehabilitation (VCBR) on November 7, 2008, with a second (announced) visit on
November 14. The purpose of this inspection was to provide an evaluative review of the
active treatment program, assess census and staffing levels, and assess progress toward
findings and recommendations made by the Office of the Inspector General (OIG) in
2007. The 2008 inspection was considerably more extensive than the 2007 visit. A
random sample of 48 residents participated in confidential interviews; the clinical records
of an additional 44 residents were reviewed; 74 staff and 9 members of facility leadership
were interviewed; and personnel and staff training records were reviewed.
The 2007 inspection was conducted in November of 2007 and resulted in OIG Report
#144-07 which outlined the following concerns about programming at the facility:
•
•

•
•

The amount of active treatment that was occurring was very limited, with an
average of 2.5 hours per week of treatment received per resident in the observed
period of time. High levels of resident boredom and inactivity existed.
Treatment planning was not sufficiently individualized; treatment goals made
little to no reference to the ultimate goal of treatment (improvement of residents’
conditions to a level where a safe return to community might be possible); clinical
assessments were out of date; and there was little use of multi-disciplinary
treatment team approaches in treatment planning meetings.
There were no vocational, educational, or recreation programs.
The facility’s mission statement was not specific about ultimate treatment
outcomes. There were differing perceptions of the mission of the facility among

1

•
•

•
•
•
•

leadership, clinical staff, security and residential staff, and residents, particularly
around the expected outcomes of services provided.
The external, formal programmatic oversight of the facility was extremely limited
and was significantly less than that provided for all other facilities operated or
licensed by the DMHMRSAS.
The roles of medical and nursing services at VCBR were not clearly defined, and
these services were not integrated with clinical treatment. Relations between
nursing services and administration were strained, and significant differences
existed between them concerning the role of nursing services at the facility.
Questions existed as to whether psychiatric services at VCBR were adequate to
identify and treat psychiatric issues.
Staff turnover was higher than at any other DMHMRSAS facility, and staff
vacancies and constant turnover significantly decreased the effectiveness of active
treatment programming. Turnover among clinical staff was an acute problem.
Direct service clinical staff, as well as medical and security staff received very
little training on treatment of sex offenders.
Facility security arrangements were seen as functioning well and provided for
adequate control of residents.

The report of the 2007 inspection included several recommendations to address these
issues, primarily through the creation and involvement of a diverse Advisory/Oversight
Committee (AOC), including external experts on sex offender treatment. DMHMRSAS
accepted these recommendations and developed a detailed plan to address all the
concerns noted by the OIG.

Summary of 2008 Review
In a number of the areas of concern noted by the OIG in 2007, some improvement has
occurred, however many challenges remain:
• The amount of active treatment provided rose from an average of 2.5 hours a
week to 6.6 hours per week for a comparable sample of residents.
o Active treatment levels actually received by residents still remain much
lower than desirable for an effective treatment program. Resident
boredom and inactivity continue, with significant behavioral results.
o Educational and recreation programming have begun and contribute to the
somewhat higher levels of constructive activity for residents.
o Vocational programming (training and jobs for residents) are considered
by the facility, the AOC, and the OIG to be a key element of an effective
treatment program. The OIG found that no residents have jobs and there
is no vocational training at this point.
o In reporting active treatment levels, VCBR presents data showing
treatment scheduled or offered, rather than what is received by residents.
Resident refusal to attend, excused absences, and staff cancellations of
classes account for an almost 50% drop from scheduled activities to
completed activities for the average resident.

2

•

•

•

•
•
•
•

•
•

•

Evaluation and treatment planning for residents have improved in specificity,
individualization, timeliness, and comprehensiveness. More improvement in
person-centered treatment planning is needed to match that provided at other
DMHMRSAS treatment facilities and to achieve what may be required for the
facility to achieve accreditation.
The facility developed new mission and vision statements which clarify the focus
of the service to be provided (recovery opportunities and support) and the quality
of the facility’s efforts (excellence). In this review of VCBR, the OIG found a
lack of clarity among staff regarding the intended outcome of the facility’s
services. The result of this lack of clarity is a workforce that is not unified in
carrying out the facility’s mission.
In 2007 the OIG recommended that the facility investigate national accreditation
programs and pursue accreditation if a suitable program is found. The facility has
decided to seek accreditation by the Joint Commission on Accreditation of
Hospitals, and a credible plan to do so now exists.
The roles of medical and nursing remain unclear and there has been nearly 100%
turnover in staffing for these services since the 2007 inspection.
Psychiatric services have increased significantly.
Overall staff turnover appears to be essentially at the same levels as in 2007.
DMHMRSAS cited VCBR turnover rates of 51.5% for FY2007 and 47.5% for
FY2008. Recruitment and retention of clinical staff have improved since 2007.
Training in sex offender topics has not been increased for residential, security,
and medical staff, who spend the most time day-to-day with residents, or for
administrative staff, who contribute decisively to the nature of the organizational
culture. Training for clinical staff has increased and improved.
Many staff express concerns for their personal safety while working in the VCBR
facility, especially those who have the most day-to-day contact with residents.
Residents, as well as members of the AOC have expressed concern that VCBR
affords the civilly committed residents at the VCBR treatment program less
comfort and fewer privileges and opportunities than prisoners in the Department
of Corrections receive. Concerns include overly spartan cells and furniture, a
harsh environment, very limited resident privilege levels with regard to phone
use, mail, television access, and personal items, and limited educational,
vocational, and recreational opportunities.
DMHMRSAS support, guidance, and facilitation of the Advisory and Oversight
Committee has been inconsistent and incomplete. The committee members have
given considerable time and insight to their task. The activities outlined in the
DMHMRSAS response to the 2007 OIG report remain unmet.

It was determined by the OIG that all recommendations made by the OIG in the 2007
report remain ACTIVE.
DMHMRSAS Response: The recent decision to seek Joint Commission
accreditation for the Virginia Center for Behavioral Rehabilitation (VCBR) is a
critical step in improving the purpose and position of VCBR within the
Department of Mental Health, Mental Retardation, and Substance Abuse Services
3

(DMHMRSAS) and will serve to grant the facility a sense of direction more in
keeping with the mission and vision of the DMHMRSAS as well as providing a
concrete guide for the development of operational procedures. The facility’s
efforts toward becoming Joint Commission accredited are having significant
positive impact on operations of the facility including, but not limited to policy
and procedure development, creating a recovery-oriented culture, and improving
the overall standards of care. Additionally, the facility has developed and
implemented a comprehensive strategic plan which includes the use of
measurable goals to thoroughly assess programming and services. The facility
will also begin implementation of a new quality assurance monitoring program in
the near future.
In order to meet Joint Commission Standards VCBR is revising its entire system
in order to support a recovery-oriented culture. Amongst the changes will be the
permanent assignment of treatment team staff for each resident, the inclusion of
nursing staff in all quarterly treatment team reviews, and modification of our
treatment plans and documentation. Treatment plans will be more personcentered and will include individualized goals with measurable objectives.
The facility is in substantial agreement with the findings of the Inspector
General’s November 2008 audit.

4

Section II – Introduction
The Office of the Inspector General conducted an unannounced inspection of the Virginia
Center for Behavioral Rehabilitation (VCBR) on November 6, 2008. A second visit on
November 14 was announced in advance to facilitate scheduling of staff interviews and
receipt of information requested from VCBR.
The purpose of these inspections was to provide an evaluative review of the active
treatment program, assess census and staffing levels, and assess progress toward
previously noted findings and recommendations, particularly those in OIG Report
#144-07, issued February 6, 2008.
Procedure for the inspection
For background observation of a similar program to VCBR, OIG staff visited the Sexual
Offenders Residential Treatment (SORT) program at Brunswick Correctional Center on
November 4, 2008. OIG staff reviewed the SORT program and interviewed staff and
residents.
During the inspections at VCBR the following activities took place:
• Interviews with 48 residents on November 6. Residents with less than 90 days at
the center were excluded from selection as they are understood to be undergoing
evaluation and orientation rather than receiving optimal treatment levels. This
sample, selected at random of those remaining, represented 42% of all of the
residents on site on November 6. Interviews were voluntary. Residents
completed written, confidential, anonymous questionnaires administered in
groups. Brief group discussions followed completion of the individual
questionnaires.
• Written interviews on November 14 with 74 staff, including leadership,
residential, security, program/clinical and medical personnel. These included
nearly all treatment staff (15), all security (25) and residential staff (18) present
that day for shifts 1 and 2, all available medical staff (7), and many
supervisor/leadership staff (9). All staff persons self-identified their roles on the
questionnaire form.
• Oral interviews with 9 members of the executive leadership team. Some, but not
all, of the executive leadership team also completed the staff interview and are
included as identified as “leadership” in the results.
• Inspection of the clinical records of 44 residents. These were selected at random
using a similar process as with the resident interviews. The record and interview
samples were different persons. This is 39% of residents present at the facility at
the time of the visits.
• Taken together, the record sample and the interview sample comprise 81% of all
the residents.
• Inspection of the personnel records of 28 staff members. Personnel records of all
program/treatment staff, as well as key leadership staff, were reviewed to assess
qualifications, experience, and training.

5

•
•
•

Observation of program and security areas and activity in the facility
Review of materials provided by the facility
Review of information provided by DMHMRSAS

Background about VCBR
The following excerpts from the Virginia Code describe the purpose of VCBR and the
conditions upon which an individual who has been committed to the facility may be
conditionally released:
VA Code §37.2-909 Placement of committed persons (A) - “Any person
committed pursuant to this chapter shall be placed in custody of the Department
(DMHMRSAS) for control, care, and treatment until such time as the person’s
mental abnormality or personality disorder has so changed that the person will
not present an undue risk to public safety. The Department shall provide such
control, care, and treatment at a secure facility operated by it or may contract
with private or public entities, in or outside of the Commonwealth, or with other
states to provide comparable control, care, or treatment. At all times persons
committed for control, care and treatment, by the Department pursuant to this
chapter shall be kept in a secure facility.”
VA Code §37.2-912 Conditional release; criteria; conditions; reports (A) - “At
any time the court considers the respondent’s need for secure inpatient treatment
pursuant to this chapter, it shall place the respondent on conditional release if it
finds that (i) he does not need secure inpatient treatment but needs outpatient
treatment or monitoring to prevent his condition from deteriorating to a degree
that he would need secure inpatient treatment; (ii) appropriate outpatient
supervision and treatment are reasonably available; (iii) there is significant
reason to believe that the respondent, if conditionally released, would comply
with the conditions specified; and (iv) conditional release will not present an
undue risk to public safety.”
VCBR became operational in 2004 at a temporary location in Petersburg and remains the
only maximum security residential treatment program for civilly-committed sex
offenders operated by the Virginia Department of Mental Health, Mental Retardation and
Substance Abuse Services (DMHMRSAS). Work was completed on the first phase of a
new purpose-built facility in Nottoway County, adjacent to Piedmont Geriatric Hospital,
in February, 2008. Residents and staff completed their move to the new facility during
February, and the facility held its public opening on February 26, 2008.
The census of the facility continued to grow rapidly over the past year. At the time of the
OIG’s last visit to the facility on November 7, 2007, the census was 60. On November 6,
2008 the census was 117 (114 on site, 3 in jail). While there had been a small number of
discharges from the facility over the past 4-plus years, all came as a result of judicial
decisions in the legal process.

6

There had been no conditional releases to the community since the opening of the facility
until November 13, 2008, on which date 2 persons were discharged on conditional
release.

Section III – Review of Progress Toward Findings from OIG Report
#144-07 (2007)
The following findings (noted in bold below) were issued in the last OIG report. The
inspections on November 7 and 14, 2008 evaluated progress on each finding.
A.

Active Treatment Findings from 2007

Finding A.1 (2007): The amount of active treatment that is occurring is very
limited, with levels of delivered treatment in 2007 falling 57% below those of 2006.
In both years levels of treatment were below the stated expectations of facility
leadership.
1. Comparison of treatment levels: 2007 – 2008
•

In the 2007 inspection OIG staff reviewed the clinical records of a sample of 16
residents to assess treatment planning and the amount of treatment received by
residents on a weekly basis during the preceding quarter. This sample (26% of
the total residents on that date) was restricted to persons defined by VCBR staff to
be in active sex offender treatment, and excluded those with behavior problems
and cognitive or psychiatric limitations and those new to the facility and being
evaluated.
o Review of service hours documented in the charts showed an average of
group treatment time of 2.5 hours per week in the 3rd quarter of 2007.

2008 Review (Comparable Sample)
•

To measure change in active treatment levels from 2007 to 2008 in a manner that
that is comparable to the 2007 sample, a similar sample of residents was
reviewed. 1 This subset sample of 21 persons (18% of census) consists of
residents in the Sex Offender Treatment Track, levels I, II, and III (1 resident).
These persons have similar characteristics and were at the same stages of
treatment as those reviewed in 2007.

1

For the 2008 review the OIG selected a much larger sample of residents than was drawn for the 2007
inspection in order to provide a view of the entire resident population. This sample is described on page 5.
To obtain the smaller sample that is comparable to the 2007 sample, a subset of this larger sample was
drawn, using the same factors as in 2007.

7

Average Weekly Hours
Sex Offender
of Treatment
Therapy and
Received by Residents in Psychoeducational
Comparable Samples
Groups

Recreational,
Substance Abuse,
Educational
Activities

Total

2007 sample (N=16)
2.5 hours/week
Not Available*
2.5 hours/week
2008 sample (N=21)
4.3 hours/week
2.3 hours/week
6.6 hours/week
* These figures only include sex offender treatment, as other services were not available in the 3rd quarter of 2007. In
2008 other activities for residents have become available.

•

With substance abuse groups, recreation groups, and education classes included,
the average for the 2008 comparison sample is 6.6 hours/week of organized
therapeutic activities in the 3rd quarter of 2008.

2008 Review (Comprehensive Sample)
•

•

In 2008, in order to get a more complete picture of treatment activity at VCBR,
OIG staff reviewed clinical records for a much larger and more diverse sample of
44 residents. This sample is fully representative of the population of VCBR and
includes persons in the subset sample described above as well as from all phases
of treatment (except, as noted above, those new to the facility). Persons with
cognitive and intellectual limitations are included in the comprehensive sample.
However, as described above, this larger sample is not directly comparable to the
2007 sample.
A comprehensive listing of average resident activity for the larger 2008 sample is
shown in the table below:

3rd Quarter 2008
Average weekly hours of activity per participant in comprehensive sample (all treatment tracks/levels)
N=44
sex offender
group treatment
(classes, groups,
broadly defined)
N=43

individual
treatment
N=6

substance abuse
treatment/education
(group, AA/NN)
N=5

vocational
activities (job
training,
employment)
N=0

3.5

.14

.65

0

recreational
activities
(organized,
sanctioned)
N=33

educational
activities
(classes,
GED, etc.)
N=15

.53

4.67

total
supervised
resident
activities for all
participating
residents
N=44**

5.5

* Averages per activity are given based on the number of persons documented as participating in that activity during
the quarter.
** Averages for residents are based on the total hours of all types of activity for each resident in the sample, averaged
on a weekly basis.

2. Active treatment goals and measurement of results
•

In 2007 little clarity about planned or prescribed levels of active treatment
existed. There were no policies or guidelines provided to the OIG for what

8

amount of active treatment residents should receive. Leadership did not show that
they tracked group treatment attendance or the degree to which treatment activity
targets were achieved. When asked by the OIG, facility leadership estimated
these variables (estimates varied significantly among key leaders), acknowledging
that they were rough estimates.
2008 Review
•
•

In 2008 leadership was able to provide documentation of specific treatment
participation goals for residents in each level of treatment, as well as records that
show actual active treatment enrollment and participation.
As shown above, OIG measurement of the amount of treatment received by
residents increased in 2008 from 2007. However, OIG measurements differ from
VCBR data presentations.
o VCBR estimated the average number of treatment hours per resident per
week (for the comprehensive sample) at 12, with a range of 5 to 21.5
hours for the 3rd quarter of 2008. OIG findings described above show an
average of 5.5 hours per week for the same period.
o According to VCBR program leadership, the higher VCBR figures reflect
treatment availability, meaning treatment scheduled or offered to the
resident. The OIG counted hours received.
o The differences in availability (VCBR data) and received treatment time
(OIG count of completed treatment hours) derive from resident absences
(excused and unexcused), resident refusal to attend treatment sessions,
ejections of residents from classes or groups and cancellations of sessions
by VCBR staff (due to staff vacancies, absences, or conflicts with other
staff activities).
o While VCBR treatment notes in the residents’ charts do document when
persons fail to receive available treatment, and usually include the reasons,
their data reports do not capture this information. The VCBR document
provided to the OIG to show treatment hours for all residents (entitled
“Individual Total Group Hours Calculations per Resident by Quarters”)
shows enrolled, planned, or available hours – not hours received or
completed.
o VCBR treatment staff note the value of reporting available or offered
hours as a demonstration of facility capability and intent and the fact that
it cannot completely control hours received due to resident choice and
other issues.
o VCBR staff said that a new data system that will be implemented shortly
that will afford greater accuracy and detail in reporting of all aspects of
treatment received.
o Resident interviews show frequent class cancellations as the second most
frequently mentioned complaint about their treatment. Full results of
resident interviews are available in the appendix.

9

DMHMRSAS Response: Our new Records Management System (RMS),
which is expected to be fully operational on March 1, 2009, will allow VCBR
to collect and analyze treatment data in useful ways. In addition to data which
is currently, routinely provided by our clinical information software (total
hours attended), we will be able to audit recordkeeping and to make
meaningful comparisons of our diverse population of residents with respect to
their assigned and completed treatment hours. Residents will be compared to
a cohort within the same treatment track, and not to residents in other
treatment tracks who likely have different assigned treatment programming
hours.
VCBR will create a report format that will:
•
•

Calculate the number of actual hours received within each treatment track
and phase of treatment
Calculate the average participation score within each treatment track and
phase of treatment and be able to analyze the treatment compliance
distribution.

VCBR is currently developing a treatment incentive plan to help address
resident’s attendance and participation in group activities. Under the
proposed plan, residents would receive a small stipend for attending at least
90% of all groups scheduled, having no behavioral events, keeping their
rooms clean and safe, etc. We hope to have this program approved and
operational on or before July 2009.

3. Quality of clinical treatment planning
In addition to assessing treatment activity, the 2007 review also reviewed treatment
planning as documented in the records. The OIG noted the following issues:
•
•
•
•
•
•

lack of individualization of clinical records
treatment goals made little to no reference to conditional release, readiness for
return to community
outdated clinical assessments (often much older that one year), completed by nonVCBR staff, often well before arrival at VCBR and not inclusive of experience at
VCBR
little use of multi-disciplinary treatment team approaches in treatment planning
meetings
no involvement of family, community representatives, etc. in treatment planning
Only group treatment was provided. Clinical leaders said that individual
treatment is not indicated for this population and it is provided only by exception.
(While most sex offender treatment programs in Virginia and other states also use
a group treatment model, many also incorporate individual therapy.)

10

2008 Review
For 2008 OIG staff reviewed 44 records using a structured checklist that assessed the
internal logic and connectedness of problem assessment, goal formulation, treatment
planning, and evaluative feedback in treatment plans. The checklist also used some
measures of recovery-based treatment models that were drawn from the 2007 and
2008 OIG reviews at DMHMRSAS mental health treatment facilities. The OIG found
that:
•

•
•

•

•
•

Each resident’s treatment plan is comprised of a standardized goal format for their
treatment track level. All residents in the track have the same goals, which are
pre-printed on the treatment planning form and specific to that treatment track.
The goals describe progress that is necessary to rise to the next treatment level.
This approach is commonplace in group treatment settings (e.g., substance abuse
treatment), but individualization of plans is often found wanting.
While the goal statements in the VCBR records are identical among residents and
relate to achievement of behavioral or learning standards within the treatment
levels, the records do show a good degree of individualization in documenting the
activities, characteristics, and progress of each resident within that treatment
level.
Even when the documentation of the resident’s progress shows specific,
individualized problems or needs (e.g., a resident who refuses to participate
regularly in treatment, does not attend classes, etc.), there are no specific,
individualized goals added to the goal statements found in the templates for each
treatment level for all residents. For example, a goal might be developed to work
with the resident on why he does not participate in treatment. The OIG did not
find any additions or modifications to the standardized treatment goals in any of
the treatment plans that were reviewed.
None of the goal statements in the standardized format explicitly address
readiness for conditional release. Very few specific references to preparation for
community living are found even in the individualized portions of the records.
The most explicit references to readiness for community placement are found in
the annual evaluations of residents when prepared by VCBR psychologists. These
include recommendations to the judges and, usually, statements of progress
necessary for VCBR to make a recommendation for conditional release.
o 39% of clinical evaluations found in the charts were performed within the
last 12 months.
o 61% of the latest clinical evaluations were performed since the resident
arrived at VCBR, by VCBR staff that are familiar with the resident and his
performance in this setting. 39% were performed by contract staff before
the resident arrived at VCBR.
o The evaluations performed by VCBR staff capture the resident in the
VCBR active treatment milieu, over time, with attendance records and
input from staff who know him, thus providing a much better base for
treatment planning, as compared to one-time evaluations by contracted
external evaluators prior to VCBR admission.

11

o The recruitment and retention of 2 additional clinical psychologists since
the 2007 review has contributed to the timeliness and thoroughness of
evaluations.
The OIG conducted a review of many aspects of the clinical record. The overall results
of the OIG review of clinical records are shown below. Items were rated by OIG staff
using a 4-point rating scale: 1 = “strongly agree,” 2 = “agree,” 3 = “disagree,” 4 =
“strongly disagree.” The scores shown are the average of scores given for each of the 44
records reviewed.
OIG Evaluation of Clinical Treatment Planning at VCBR
“The plan is ……” (N=44)
Responsive, specific to clinical assessment of the person
Individualized to that specific person’s needs and strengths
Evidence of resident involvement in developing the plan
The resident’s own goals are stated in his own words
Plan points toward return to community, has goals for release
Plan is holistic – whole person, multi-faceted – an overall rating, inclusive of
the factors below
• Education needs/goals addressed
• Vocational needs/goals addressed
• Recreational needs/goals addressed
• Medical health needs/goals addressed
• Substance abuse needs/goals addressed
• Family/social/relational needs addressed
Plan uses a treatment team, multi-disciplinary approach (based on signatures at
treatment team meetings, other references)

OIG
Rating
2.9
3.1
2.4
2.7
3.0
2.0
2.4
4.0
2.8
1.9
2.6
1.4
2.0

DMHMRSAS Response: The facility agrees with the Inspector General’s
findings. They are in the process of revising their treatment planning
documentation to meet Joint Commission requirements. They have received
several sample treatment planning forms from the Joint Commission and
other accredited facilities. The Clinical Services Director is currently
updating their treatment planning form to ensure it is more person-centered.
Plans will have more individualized resident-specific goals with measurable
objectives. They expect to have this process in place by July 1, 2009.
The facility has discussed this issue during the most recent Advisory and
Oversight Committee(AOC) meeting and will present the Committee with a
sample treatment plan to include more individualized goals and objectives
during our next meeting (April 2009).

12

4. Other treatment issues
2008 Review
•

•

In FY2007 leadership reported that individual treatment is not offered except as a
limited, temporary adjunct to group treatment on a case-by-case basis.
o 2008 service data shows this approach is still in place, with 8 of the 44
residents (18%) shown as receiving some instances of very brief one-toone treatment (an average of 1.7 hours per quarter for those who received
any individual treatment at all).
In 2007 leadership stated to the OIG that VCBR’s program concept called for
extensive availability of vocational, recreational, and educational activities, as
well as the treatment groups discussed above. Recreational and educational
activities in 2007 were virtually non-existent due to VCBR’s inability to hire and
retain teachers and recreational therapists and due to severe space limitations,
according to facility leadership.
o At the time of the 2008 review, an educational program was functioning,
offering GED and basic adult education classes. A director of education
has been hired, along with a teacher and a librarian. The program is
popular among residents who choose to use it. Ample and appropriate
space exists for these activities.
o A recreational program has begun and offers organized activities to
interested residents. There are 3 full time recreational staff persons. The
new facility has a gymnasium and outdoor recreational space.
ƒ The recreational program now has an art therapist, who offers arts
and crafts classes.
o Vocational programming has not begun, nor is there any vocational
training available. No resident jobs exist. A vocational coordinator has
joined the staff and is attempting to develop vocational opportunities, but
is encountering legal and fiscal problems due to the civil commitment
status of the residents and federal employment laws. Vocational needs
and issues are discussed more fully below (pages 38 to 39).
DMHMRSAS Response: Since the Inspector General’s audit, the Education
Department has implemented college level correspondence courses for
residents desiring college level training. Currently, there are 20 residents
enrolled in this program. Additionally, 30 residents have expressed an
interest in our new college correspondence program. The facility has
received such a positive response to their educational programming they are
in the process of expanding space to accommodate additional students.
Vocational Programming now offers courses focusing on resume writing and
job interview skills. The facility hopes to expand this program during the next
semester.

13

The staff aide position mentioned to the Inspector General and planned for
start-up during the winter of 2008/2009 has been stalled by reported problems
with payment. The facility has invited the vocational staff from Eastern State
Hospital to come to VCBR and assist them with their program design. That
consultation is scheduled for April 14, 2009. The facility has targeted July 1st
2009 as the new start-up date for the vocational work program.

Finding A.2 (2007): There is not a shared vision among facility leadership, staff,
and residents for the expected outcomes of services provided by the facility.
•
•
•

In 2007 there were inconsistencies among published mission statements and
treatment goal documents.
In 2007 there were differing perceptions of the mission of the facility among
leadership, clinical staff, security and residential staff, and residents, particularly
around the expected outcomes of services provided.
Few of those interviewed endorsed the idea of “return to the community” as a
realistic goal for most residents.
ƒ

•

75% of the staff gave negative to very negative assessments of the
possibility of the majority of residents ever achieving discharge.
ƒ Residents strongly doubted that conditional release was a real
possibility for them.
Residents’ clinical records did not have explicit goals for return to the
community.

1. Facility mission, goals, and expected outcomes
2008 Review
In 2008, facility leadership reported that they had revised the facility’s mission,
vision, and core values statements. They indicated that the process involved a retreat
and wide input from all levels of staff to shape the statements, followed by extensive
efforts with staff to explain, train, and draw attention to the mission statement.
•

The new mission/vision/values statement is very concise and is quoted here in its
entirety:
o Mission: To provide recovery opportunities and support.
o Vision: Excellence
o Core Values: Resident recovery opportunities, teamwork, effective
resource management.

•

The Code of Virginia calls for “control, care, and treatment (of committed
persons) until such time as the person’s mental abnormality or personality
disorder has so changed that the person will not present an undue risk to public

14

•
•
•

•

safety.” Furthermore, the Code establishes the criteria and specific conditions for
residents to be conditionally released.
o The new VCBR mission statement does not specifically address
conditional release, return to the community or other statements of
ultimate intent or expected outcomes that are consistent with the Code
section that established VCBR.
OIG inspectors noted wide display and promotion of the mission statement in the
facility through posters, coffee cups, pens, and other objects.
Staff surveys showed wider understanding and agreement with the mission
statements than in 2007.
When asked to state the mission in their own words, most staff made statements
that reflected portions of the statements or used terms found in the statements, but
differences existed around the inclusion of the ultimate goal of returning residents
to the community.
o 36% used language that specifically mentioned return to the community as
a goal of treatment, though no such phases exist in the official statements.
ƒ leadership and clinical staff most frequently mentioned release or
return to community (about 50% each)
ƒ residential (17%) and security (30%) used terms of release, return
to the community less often.
o 36% spoke of treatment, support, rehabilitation, and recovery, but did not
mention goals of return to the community.
o 8% made comments that doubt treatment effectiveness, stress security, and
did not mention positive treatment outcomes.
o 6% (mostly security staff) did not answer the question.
A question testing staff opinions on this subject from the 2007 staff interviews
was repeated in 2008:
Staff interview (N=74)

Strongly
Agree

I believe the treatment we are providing will
enable the majority of the residents we serve
14%
at VCBR to be rehabilitated to the extent that
they can return to live in the community.

Agree Disagree Strongly
Disagree
42%

31%

13%

56% agreed, 44% disagreed. The positive goal language was endorsed by a small
majority. In 2007, 75% disagreed.

15

•

Differences among types of staff:

Staff interview (N=74)
“I believe the treatment we are providing will
enable the majority of the residents we serve
at VCBR to be rehabilitated to the extent that
they can return to live in the community.”
Supervisor/Leadership
Program/clinical
Residential
Security
Medical

Strongly
Agree

25%
27%
6%
8%
14%

Agree Disagree

38%
67%
59%
21%
29%

13%
7%
35%
46%
43%

Strongly
Disagree

25%
0%
0%
25%
14%

Clinical staff clearly differ from other staff in their assessment of this goal. Leadership’s
views were less positive than clinical’s or residential’s.
•

A second question was phrased in the negative, to further illuminate this issue
from another perspective.

Staff interview (N=74)

Strongly
Agree

Agree Disagree Strongly
Disagree

Our main job here is really to protect
society from persons who are a danger to
17%
39%
31%
14%
our children and families and will likely
remain so forever.
• 56% agreed, 45% disagreed (rounding accounts for the total exceeding 100%).
This is a reversal of the results for the previous question, as a small majority
endorsed the negative position.
•

Differences among types of staff:

Staff interview (N=74)
“Our main job here is really to protect
Strongly
Strongly
society from persons who are a danger to our
Agree Disagree
Agree
Disagree
children and families and will likely remain
so forever.”
Supervisor/Leadership
0%
11%
67%
22%
Program/clinical
7%
33%
40%
20%
Residential
24%
59%
12%
6%
Security
20%
40%
24%
16%
Medical
33%
33%
33%
0%
• Of the staff who have the most extensive and regular contact with residents, 83%
of residential staff agreed with the negatively phrased statement, as did 66% of
the security staff.

16

•

These results may show staff ambivalence or lack of clarity about the issue of
residents’ return to the community and suggests a need to further clarify facility
mission and goals and to focus training and supervision on these issues.

Residents were also asked their perspectives on the goals of treatment at VCBR, using
the same questions. Another question asked whether they felt they knew where they
stand with regard to treatment progress:
Resident interview (N=48)
I believe the treatment I am receiving will
enable me to be rehabilitated to the extent
that I can return to live in the community
eventually.
The real purpose of this program is to keep
people locked up who will forever be
considered a danger.
The facility lets me know where I stand in
my treatment and what progress I must
show to be ready to be discharged.
•

•
•

Strongly
Agree

Agree Disagree

Strongly
Disagree

28%

38%

26%

9%

32%

30%

30%

9%

10%

25%

38%

27%

Residents endorsed the positively-phrased goal of rehabilitation to enable a return
to the community to a higher degree than do staff (66% agree with the first
statement, versus 56% of staff).
o But the negative expression of the purpose of VCBR also elicits a
(contradictory) majority of the residents - 62% favored the negative
statement.
65% of residents disagreed that they are informed about what they must do to be
ready to be discharged.
In open-ended questions in which residents were asked to state the goals of
VCBR in their own words, a slight majority (52%) had a positive view that the
goal of treatment is intended to ready them for release to the community; 48%
expressed skepticism, sarcasm, or lack of trust that this is the case.

2. Balance of correctional and treatment models and values
In 2007 discussion of goals, values, mission, and organizational culture hinged on the
balance between security and treatment models and values. OIG research and interviews
with sex offender treatment experts confirm that getting this balance right – and having
broad understanding and agreement about it among all stakeholders (leadership, staff,
residents, etc.) - is critical for effective, safe treatment. In 2007 this balance was viewed
differently among different staff groups and by residents.

17

2008 Review
•

•

The initial reaction of the Advisory and Oversight Committee 2 upon entering and
touring the new facility at VCBR and being briefed on its program was that they
were seeing a correctional facility (rather than a treatment program) in which
residents were afforded less comfort and fewer privileges and opportunities than
prisoners in the DOC. As the committee began its work and developed its focus,
concern about these issues continued. Concerns include overly spartan cells and
furniture, a harsh environment, very limited resident privilege levels with regard
to phone use, mail, television access, and personal items.
OIG interviews with residents were dominated by complaints that the VCBR
facility and program is overly restrictive and affords them less personal freedom
and privileges than they previously had in prisons. The following questions from
OIG interviews illustrate some of these concerns:
Resident interview (N=48)

The rules, privileges, and freedoms of being a civil
committee at VCBR are better than it was being an
inmate in a DOC facility.
The physical comforts of VCBR are better than what I
had at DOC.
There are enough constructive activities to fill my days.
Morale among the residents is pretty high.

Strongly
Agree

Agree

Disagree

Strongly
Disagree

6%

16%

31%

47%

11%

26%

40%

23%

4%
0%

25%
24%

25%
41%

46%
35%

o Responses on each measure are sharply negative.
o Resident response to open-ended questions and comments during informal
group discussions with OIG staff stressed these issues very strongly.
•

OIG interviews asked all staff to rate the balance of treatment and correctional
models with the following question:

“All programs that are similar to this one must find a balance between security and
treatment. In your opinion how is the current balance at VCBR?”
All staff responses:
59%
24%
17%

Tilted too much toward treatment and resident choice.
About right, about enough emphasis on security and treatment.
Tilted too much toward security and correctional approaches.

2

The 2007 report recommended the formation of an Advisory/Oversight Committee for VCBR. For a full
discussion of this process, please see pages 30 to 32.

18

•

Differences exist among different types of staff in response to this question. The
data from this question is shown in the table below as reported by the different
types of staff:

“All programs that are similar to
this one must find a balance
between security and treatment. In
your opinion how is the current
balance at VCBR?”
Supervisor/Leadership
Program/clinical
Residential
Security
Medical
•
•
•

•

Tilted too
much toward
treatment and
resident
choice
25%
47%
61%
71%
83%

About right,
about enough
emphasis on
security and
treatment.
63%
33%
17%
17%
0%

Tilted too much
toward security
and correctional
approaches.
13%
20%
22%
13%
17%

Only among leadership staff do a majority assess the balance as “about right.” At
least 66% of all other staff groups see the balance as misplaced in one direction or
the other, mostly toward too much resident choice/treatment.
Other staff see that balance as tilted too much toward resident treatment and
choice, by about a majority (program/clinical staff and residential staff) to a very
sizable majority (security and medical).
Based on discussions with staff as they completed this questionnaire, OIG staff
interpret the staff tendency to see the balance as “tilted too much toward resident
choice and treatment” as partly an indication of concerns about resident disruption
and staff safety issues discussed in the section on facility security, pages 23 to 25.
The balance of security and treatment defines the organizational culture and is a
significant factor in determining the experience and outcomes for residents and
staff. It is clear that this balance is not yet resolved and the lack of concurrence
among stakeholders is very evident.
DMHMRSAS Response:
1. To address some of the resident’s complaints, the facility has recently
made their access to DVD and periodicals procedures less rigid. All
residents are now able to purchase their own personal DVD player and
may purchase DVDs with an approved rating without separate approval.
Cable television will be installed in common areas (target date of
completion July 01, 2009). The primary privilege issue and greatest
irritant vocalized by our residents continues to be access to tobacco.
2. The facility shares the concerns identified regarding resident rooms and
the overall harsh appearance of the living areas. (These areas were
designed and were well under construction before the Facility Director
was hired.) Due to limited construction funding, there has been little
opportunity to enhance those areas. Despite the obstacles which are

19

outside the control of the facility administration the following actions have
been identified in order to create a more pleasant and “ homey”
atmosphere:
•
•
•

•

•
•

Wooden beds from the facility vacated in Petersburg have been
relocated and placed in the highest privilege unit.
A local vendor has been contracted with to widen all other slab beds.
Target date to have all beds in occupied areas widened is July 1, 2009.
Mattresses will also be replaced in order to allow for greater comfort.
Metal lockers will be replaced by more attractive wooden storage
cabinets on the highest level of privilege unit. The facility is also
working with Virginia Correctional Enterprises to design a storage
container that is both visually appealing and safe. Target date for
installation of new storage cabinets is July 1, 2009.
In an effort to decrease noise levels in problem areas there are plans
in place to purchase carpeting for all quiet rooms and seating portions
of the main dayroom area. Research into panels designed to decrease
noise levels is also under way. In addition to decreasing noise levels,
carpeting will help soften the appearance of living and service areas
throughout the facility.
The facility has contacted interior design departments at local colleges
and universities in the hopes of gaining their interest in a possible
school project centering on facility improvements.
Residents have been engaged to design murals for living areas and
prizes will be awarded to each unit for their efforts.

During our most recent meeting with the Advisory and Oversight
Committee a modified room in Unit 3 was assessed and it was agreed that,
due to limited square footage, it would not be feasible to attempt to modify
the resident desks or toilet/sink areas.
3. Current facility procedures for telephone use, mail, television access, and
personal items are in compliance with the existing Exemptions to the
Human Rights Regulations approved by the Commissioner.
The previous telephone system, which was problematic for residents as
well as their families, has been replaced with a much more affordable one.
Residents receive unlimited local minutes for fifty cents per call.
Residents can use their personal calling cards for long distance services.
Residents have the freedom to purchase the same calling cards available
to the general public (no additional costs). Facility operational
procedures clearly state that no indigent resident may ever be denied the
ability to contact a family member in the event of an emergency or their
attorney.

20

Finding A.3 (2007): The external, formal programmatic oversight of the facility is
extremely limited and is significantly less than that provided for all other facilities
operated or licensed by the DMHMRSAS.
•

The 2007 report documented areas in which facility oversight is limited and less
complete than at other DMHMRSAS facilities. OIG recommendations were
made that DMHMRSAS and the facility:
o Create and make use of an Advisory/Oversight Committee (AOC).
o Review existing national accreditation systems to determine the
appropriateness and validity of these systems for sex offender treatment
programs, and to pursue accreditation if deemed appropriate.

2008 OIG Review
•

•

The following additional oversight developments were noted.
o The facility (which previously had a separate and unique human rights
review process) was brought under the authority of the local human rights
committee that serves Piedmont Geriatric Hospital (PGH). This is
reported by the Director of Human Rights for DMHMRSAS to be
proceeding smoothly.
o The facility’s reporting and coordination contacts at DMHMRSAS were
changed at least three times since the 2007 report. Levels of supervision
of program operations and support from central office also varied.
o VCBR had removed itself from participation in the state facility pharmacy
system in 2007, but with the move to the new facility, this function is now
back under the DMHMRSAS pharmacy system umbrella, with PGH
providing this service for VCBR. However, the facility director is
considering re-privatizing these services in an effort to save money.
The Advisory/Oversight Committee’s progress is discussed on pages 31 and 32
and the facility’s efforts to become accredited are discussed on pages 35 and 36.
DMHMRSAS Response: Since the Inspector General’s audit, the facility has
begun implementation our their Strategic Plan, trained department heads on
Joint Commission requirements, and begun developing quality assurance
indicators and reports.
They have begun conducting internal Joint
Commission type audits and are currently developing action plans to address
findings. Additionally, staff from another Joint Commission Accredited
facility have been solicited to conduct a full mock Joint Commission survey.
It is important to note that in addition to their efforts to become Joint
Commission accredited, the facility receives oversight and direction from the
following agencies: DMHMRSAS Central Office, Office of the Inspector
General, Office of the Attorney General, the VCBR Advisory/Oversight
Committee, VOPA, ARMICS, the Local Human Rights Committee, and our
Facility Advocate.

21

Finding A.4 (2007): The role of medical and nursing services at VCBR is not clearly
defined and these services are not integrated with clinical treatment. Relations
between nursing services and administration are strained, and significant
differences exist between them concerning the role of nursing services at the facility.
2008 OIG Review
Interviews took place with all available nursing and medical staff (N=7).
• At the time of the 2008 review, the nursing staff had experienced nearly complete
turnover from 2007. The position of Director of Nursing had not been filled and
leadership was reviewing this role, and that of the Assistant Director of Nursing.
There were 2 full time salaried nurses (only one of whom had been there in 2007).
Some positions were vacant. The remainder of the staffing at the time of the
interview was temporary contractual staff or wage employees. A total of 20
different people were identified in a roster published November 6, but it is not
known how many were active. The medical doctor who had been employed full
time by the facility since it opened resigned at the end of October, with his last
day being November 14. Contractual physician staff was being sought on a
temporary basis. The medical staffing situation is clearly in flux.
o The unanimous and highly negative complaints expressed by nursing staff
in 2007 have dissipated. This may be a function of the 2007 staff having
dissipated, too. Medical staff who were interviewed were not aware of or
did not share the strong opinions of their predecessors.
o Complaints from 2007 about space, interference from other functions, lack
of leadership support, compliance with Board of Pharmacy requirements,
and poor pharmacy services were not repeated in 2008.
o Facility leadership attributed much of the unrest among the nursing staff in
2007 to the influence of persons now gone.
• Nurses (and facility leadership) reported that they are invited to attend treatment
planning meetings, but they rarely have time to do so.
o Record reviews showed very little presence by nursing staff at treatment
planning meetings for the 44 residents reviewed in 2008.
o Nursing staff indicated, as they did in 2007, that their services function
quite separately from clinical, residential, and security functions and that
they had little dialogue or interaction on anything other than physical
health matters.
• VCBR residents’ medical records and program (clinical treatment) records remain
completely separate documents (one electronic, one in paper form), located in
different parts of the building, and are not integrated, as was noted in 2007.
o Facility leadership expressed pride and anticipation for a new program that
will integrate clinical and medical records in an electronic record and data
system in the very near future. OIG staff witnessed a demonstration of the
proposed system.
o Medical records were not reviewed in 2008.

22

•

•

Facility leadership confirms their view that the intended role of the
medical/nursing staff is focused on physical health needs and is not like that of
mental health nurses in a psychiatric facility.
o DMHMRSAS facility operations leadership has noted that JCAOH
accreditation will require a different role for nursing and medical staff.
A small number of residents had detailed written complaints about medical
services, mostly focusing on delays in response to their requests. Complaints
about medical services were frequently mentioned (tied with 2 other issues as the
most frequently mentioned) in the informal group discussions with residents.

Finding A.5 (2007): Psychiatric services at VCBR may be inadequate to identify
and treat psychiatric issues.
•

•

At the time of the 2007 review psychiatric services had become virtually nonexistent, with the resignation of a psychiatrist who had provided extremely limited
amounts of services. For a time, VCBR used contracted vendors of psychiatric
services.
The 2007 review documented that few residents had psychiatric evaluations and
few were using psychiatric medications.

2008 OIG Review
As of September, 2008, a half time psychiatrist had been added to the staff. Facility
leadership would like her to move to full time and she is considering it. The
psychiatrist has prior experience in working with sex offenders. Clinical staff highly
value her contributions and consultation. Clinical leadership’s goal is to conduct a
psychiatric evaluation of every new resident and all other residents by referral or staff
indication. Given the facility’s plans for an upgraded psychiatric capacity that were
underway, a review of psychiatric services records was not performed.
B. Security Findings
Finding B.1 (2007): Facility security arrangements function well and provide for
adequate control.
2008 OIG Review
1. Staff concerns
•
•

Security leadership reported that the new facility provides improved security and
safety with reduced staffing requirements.
The arrangement of the facility, with many security functions provided by staff in
overhead observation areas using direct and camera monitoring, involve security
in less contact with residents and staff.

23

•
•

Security leadership indicated that increased resident activity, especially
vocational, recreational, and educational programming, would improve security
issues by reducing boredom and vacant time.
No concerns were expressed about perimeter security – preventing escape, entry
of contraband, etc. However, many staff felt anxious about their personal safety
while on the job:

Staff interview (N=74)
Strongly Agree Agree Disagree Strongly Disagree
“I feel safe working here.”
8%
27%
37%
27%
64% of staff expressed workplace safety concerns by disagreeing with this statement,
while 36% agreed.
•

Significant differences exist among different types of staff concerning this
question. Whether the staff are based and spend most of their time “inside the
sliders” (behind the sliding steel security doors, in the area where the residents
live) or in the office areas outside the sliders is strongly correlated with expressed
feelings of safety or lack thereof. Staff based “inside the sliders” are shown in the
shaded sections in the following table:

Staff interview (N=74)
Strongly Agree Agree Disagree Strongly Disagree
“I feel safe working here.”
Supervisor/Leadership
11%
56%
11%
22%
Program/clinical
20%
40%
40%
0%
Residential
0%
17%
56%
28%
Security
4%
21%
29%
46%
Medical
14%
14%
43%
29%
•

The staff interview included open-ended questions such as “what things
contribute to job dissatisfaction?” 56% of items listed by staff relate to safety,
abusive residents, feelings of powerlessness, and lack of support and
inconsistency from administration.
o Concern about inconsistency and inadequacy of discipline and
consequences for resident behavior were the leading source of staff
dissatisfaction with their jobs.
o Staff viewed lax discipline, inconsistency of consequences or lack of
consequences for bad behavior to be the leading factor that prevents
residents from making progress in their treatment.
o Commonly used language included “favor resident rights over staff
rights,” “staff not backed up (in disputes with residents).”
o Concerns in these areas were significantly greater among residential,
security, and medical staff – who spend all their time in the resident living
areas - than among leadership and clinical staff, who have offices outside
the “sliders” (the electrically-operated security doors that separate resident
living areas from training and office areas).

24

•

•
•

o Some staff expressed concern about the reliance on overhead security to
answer buzzers and open the “sliders” by remote control and the
consequent delay in their ability to exit an area. They feared that delays or
interruptions of communications would put them at risk from resident
violence should it occur.
o Some staff called for the availability of emergency response teams.
o Many staff (especially residential and security) said that the reliance on
TOVA to deal with behavioral issues and the restrictions placed on
“putting hands on residents” increase their risk and are ineffective to
regulate resident behavior.
Disruptive, noisy, angry residents raise tension levels among staff. Staff report
that they hear from residents that residents know they cannot be touched and they
taunt staff that they will be reported if staff infringe on their “freedom” to behave
as they wish. Resentment exists among residential and security staff around this
point, suggesting a very strong training and support need. Many, if not most, of
these staff come from a DOC background where the discipline authority of the
facility greatly exceeds that for a civil commitment setting.
Residents have repeatedly damaged expensive wide screen televisions and other
equipment in the facility.
The facility is attempting to implement a level and privilege system to provide
incentives and consequences for behavior, but the program is in the earliest stages
of development. The development and implementation of the new system is also
occurring during ongoing program operation and rapid population and facility
growth (a new living unit just opened). At the time of the OIG visit, residents had
just been moved to different units to implement the new level system.
o Some residents, staff, and AOC members have said that the facility
amenities (room furnishings, recreational equipment, etc.), privileges, and
resident freedoms are so minimal now, that options for levels based on
behavior rewards/consequences are very limited. And change “on the
run” on such matters is very disruptive and easily challenged.
o Differences among staff on these issues are further evidence of the need to
define and create understanding about the balance between security and
treatment issues.
o Staff and residents alike complained that procedures, policies, and rules
were constantly changing. This was one of the leading staff concerns.
Security staff especially shared these concerns.
ƒ One said, illustratively, “DOC (the Department of Corrections) is a
solid; this place is still a liquid.”

25

2. Resident concerns
•

Residents’ impressions of safety were assessed with two interview questions:

Resident interview (N=48)

Strongly
Agree
Agree

Disagree

Strongly
Disagree

“I feel safe here from threats or dangers posed
by staff.”
25%
35%
19%
21%
“I feel safe here from threats or dangers posed
by other residents.”
17%
35%
30%
17%
It is a significant safety/supervision issue that almost half (47%) of the residents
report some concerns about their safety from threats or dangers from other residents.
In written interviews and in informal discussions a small number of staff complained
about assault by other residents.

C. Workforce Findings
Finding C.1 (2007): Staff vacancies and constant turnover significantly decrease the
effectiveness of active treatment programming at VCBR. Recruitment and
retention of clinical staff is an ongoing problem at the facility.
• The Director of Human Resources for DMHMRSAS reported the following
turnover statistics for VCBR (all staff positions):
ƒ FY05 49.8%
ƒ FY06 44.8%
ƒ FY07 51.5%
o These figures were significantly higher than the next highest facility,
(CCCA, 35.5% in FY07) and double or triple that of all of the other
facilities.
o The DMHMRSAS Director of Human Resources expressed significant
concern about turnover and vacancies at VCBR.
o 2008 OIG Review
•
•

•

The final FY2008 turnover rate for VCBR was 47.5%, per DMRMRSAS Human
Resources. This does not show improvement when compared to past years and
other facilities.
The facility director reported many activities undertaken, working in concert with
the Director of Human Resources for DMHMRSAS, to enhance recruitment and
retention. These include a Recruitment and Retention Plan, increased interaction
by supervisors with new staff, greater involvement of staff in facility policy
development, enhanced training, and a planned “staff mentorship program.”
The director emphasized that the interview process has been revised to ensure that
applicants have a clearer, more realistic idea of the population served, the nature
of the work, and other factors that may help them select applicants who are less
likely to resign early from their new jobs.

26

•

•

•

In the critical area of clinical staffing, where turnover was almost 100% at the
time of the last OIG inspection, retention of staff has improved. 66% of the
clinical staff present at the last OIG visit on November 7, 2007, is still employed
after a year.
Staff still consider turnover a major problem. Staff interviews included the
following question: “On a scale from 1 (low, not a problem) to 5 (high, big
problem), how big a problem is staff turnover at VCBR?
o Average staff rating was 4.1
When staff were asked “What causes turnover at VCBR?” a number of factors
were mentioned with comparable – but rather low – frequency (5% - 8% of total
comments given):
o difficult client population, abusive, high demand
o lack of discipline with residents, residents’ rights favored over staff
o dissatisfaction with leadership, supervision
o poor communication with leadership, across departments
o inadequate training
o unsafe environment
o staff not appreciated, supported
o location of facility
o constant change of policy, procedures

A number of staff interview questions addressed many of these variables:
Staff Interviews (N=74)
Agree Disagree
I receive excellent, supportive supervision on working with sex
66%
34%
offenders from my supervisor.
I am respected and valued by the leadership of VCBR for my
65%
35%
contributions to the work of our program.
My job is professionally satisfying and rewarding.
62%
38%
I would recommend VCBR to my friends as a good place to work
53%
47%
Morale among my co-workers is pretty high.
37%
63%
The senior leadership team has created an open and comfortable
47%
53%
work environment for expressing my ideas.
Since I have been employed at VCBR I have received excellent
48%
52%
training in working with sex offenders.
•

Residents were asked to agree or disagree with the following statement:
“Turnover among treatment staff is a problem for continuity of my treatment.”
o 71% agreed.
DMHMRSAS Response: VCBR is pleased to report that for the current
FY2009 (July 2008 – February 2009), VCBR has only incurred 34 separations
with an employment level of 196 staff positions. This is a turnover ratio of
17.4%.

27

Finding C.2 (2007): Direct service clinical staff, as well as medical and security staff
receive very little training on treatment of sex offenders.
•

In 2007 OIG interviews with clinical staff and review of training records for all
staff revealed virtually no training on working with sex offenders had been made
available to staff during the past year.

2008 OIG Review
1. Training
•

•

•

•

•

•

VCBR, working with the DMHMRSAS Office of Sexually Violent Predator
Services (OSVP), developed and implemented a training program for clinical
staff. Training activities were provided by OSVP and DOC staff, and it was
arranged for VCBR staff to receive regular training at the DOC training center.
The OSVP helped initiate a joint training program for VCBR with the Sexual
Offenders Residential Treatment program at Brunswick Correctional Center
(SORT). The last Friday of each month was reserved for training activities. This
training experience was very well received by VCBR and SORT staff (OIG staff
visited SORT, reviewed that program and interviewed staff and residents on
November 4, 2008).
Training of clinical staff:
o In a report dated 10/1/08, the facility director indicated that “each current
member of the treatment staff has attended an average of 47 hours of
continuing education directly relevant to the treatment of sexual
offenders.”
o OIG review of personnel records confirmed that all of the current
treatment staff (those who have been employed longer than a few months)
have indeed received a substantial amount of relevant clinical training,
usually well in excess of 6 separate training events.
Training of executive/administrative leadership:
o OIG review of the personnel records of key leaders in security, residential
care, and executive/administrative leadership showed little to no training
received in topics relevant to sex offender treatment during the past year.
Training of residential and security staff:
o OIG review of training records of all VCBR employees showed little to no
training in sex offender treatment issues for direct service residential or
security staff over the past year. (It is noted that the required orientation
for new staff includes a brief section on working with sex offenders.)
o Training on TOVA and managing resident behavior were received by
these staff members.
The clinical program has now employed 2 persons with appropriate licensure and
sex offender treatment provider certification to provide supervision and on-the-

28

•

job training for clinical staff, supplementing the provision of supervision by the
Director of Treatment Services and the Director of Clinical Services.
All staff were asked about their prior experience in working with sex offenders,
and their satisfaction with training and supervision they have received while at
VCBR:

Staff Interviews (N=74)

Strongly
Agree
Agree

I had direct experience in working with sex
21%
offenders before I came to work at VCBR.
I receive excellent, supportive supervision
on working with sex offenders from my
23%
supervisor.*
Since I have been employed at VCBR I
have received excellent training in working
9%
with sex offenders.*
*These questions were also summarized in the table on page 27.
•

Disagree

Strongly
Disagree

26%

23%

30%

42%

19%

15%

38%

35%

17%

All staff were also asked the following question:
“Did you take part in any courses, training sessions, conferences, speakers,
workshops, etc. that are directly specific to working with sexually violent
offenders between November 2007 and November 2008? (Note: do not include
the week-long new employee orientation session that you received when you first
became employed at VCBR or routine supervision sessions with your
supervisor)”: 38% said yes, 63% said no.

2. Clinical Staff qualifications
•

The numbers, qualifications, licensure status, and Certified Sex Offender
Treatment Providers (CSOTP) status of clinical and other program staff have
improved since the 2007 OIG visit:

Professional Qualifications of
Clinical and Program Staff*
Clinical supervisors (N=4)
Therapists (N=3)
Treatment Associates (N=8)
Psychologists (N=2)
Recreation/education/vocational
specialists (N=5)
Psychiatrist (N=1)

Masters
Degree or
higher?
4 of 4
3 of 3
2 of 8
2 of 2

Licensure
(LCSW,
LPC, etc.)
4 of 4
0 of 3
0 of 8^
2 of 2

Prior sex
CSOTP Offender tx
experience?
3 of 4
4 of 4
0 of 3
0 of 3
0 of 8^
0 of 8
1 of 2
2 of 2

2 of 5

0 of 5^

0 of 5^

0 of 5

1 of 1

1 of 1

0 of 1

1 of 1

* as of December 19, 2008
^ not eligible due to lack of Masters degree or otherwise not applicable

(Treatment Associates are required to have a Bachelor’s degree in a Human Service field;
therapists require a Masters. Because of this treatment associates lead psychoeducational

29

groups, but not the therapy or process groups, which are led by therapists. Treatment
associates also provide back-up coverage and co-facilitate (when staffing levels are
sufficient) and they provide case management services.)
•
•

All therapists are in the process of acquiring licensure and CSOTP.
None of the facility’s administrative leadership has academic preparation, clinical
training, or professional qualifications in clinical or sex offender treatment areas.
DMHMRSAS Response: Between January 1 and October 1, 2008, each
member of the treatment staff attended from an average of forty-seven hours
of continuing education directly relevant to the treatment of sexual offenders.
The facility goal is to ensure each clinical staff member receives six hours of
clinical training each month. This far surpasses requirement for state
licensure. Since the Inspector General’s audit VCBR conducted a week long
intensive training program for all staff, including residential, security, and
medical staff. Topics included items such as Introduction to Sex Offender
Treatment, Interpersonal and Therapeutic Communication, Manipulation,
Policy Review, Suicide Interventions, etc.
At the time of this response the VCBR reports they have not maintained copies
of course outlines or other details of trainings referenced above. The Office of
Facility Operations has explained that maintenance of such documentation is
a standard expectation of any training plan and should be initiated
immediately for any future training. This issue will also be added to the April
1st Advisory and Oversight Agenda and incorporated into the facility plan of
correction.

Section IV – Review of Progress toward Recommendations from OIG
Report #144-07 (2007)
Recommendation 1 (2007): It is recommended that the DMHMRSAS establish a
permanent VCBR Advisory/Oversight Committee by no later than April 1, 2008.
The responsibility of this committee will be to provide appropriately specialized and
knowledgeable oversight and review of VCBR programs and operations for the
purpose of assuring maximum effectiveness of the facility and to make
recommendations for improving effectiveness to the VCBR director and the
DMHMRSAS Commissioner. It is further recommended that consideration be
given to including representatives from the following areas on the
advisory/oversight committee: experts in the treatment of violent sexual offenders
from model programs across the nation, staff of the DMHMRSAS OSVPS, other
appropriate staff from DMHMRSAS central office, the judiciary, and the
community.

30

Recommendation 2 (2007): It is recommended that the newly established VCBR
Advisory/Oversight Committee carry out the following tasks as a part of its initial
work plan:
•

•
•
•

Identify and review the factors that have contributed to low levels of
treatment, recreational, and educational activities at VCBR and develop
recommendations, including changes in facility culture, policy, procedures
and program that will significantly improve and increase the levels of activity
in these services at VCBR.
Review the role and support for medical, nursing, and pharmacy services at
VCBR and recommend any needed changes. (Response to Finding A.4).
Assess the role and adequacy of psychiatric resources at VCBR and make
recommendations for any changes that are needed.
Study the facility’s staff retention and recruitment situation, in coordination
with the DMHMRSAS Office of Human Resources, assessing such areas as
leadership, organizational culture, support of staff, training, pay and
benefits, etc., and recommend specific actions to improve staff continuity.

2008 OIG Review
•
•
•

•

•
•
•

Following DMHMRSAS’ acceptance of this recommendation, the Director of the
OSVP was charged with forming and providing staff support for the
Advisory/Oversight Committee (AOC) in February 2008.
A committee composed of 9 members was formed and met on February 12, May
2, July 15, August 8, and December 11, 2008.
Three members of the committee are sex offender treatment experts from outside
DMHMRSAS (2 are from DOC, 1 is in private practice), 1 member represents the
Attorney General’s office, and 5 are from DMHMRSAS. Staff from the OIG
monitored the last 3 meetings.
DMHMRSAS developed a detailed outline of objectives for implementation of
OIG recommendations and involvement of the AOC in response to the OIG
report. Few of the objectives or timelines of this plan were subsequently met or
even addressed. It is not clear how much, if any, involvement there was of VCBR
leadership in this product.
The AOC met and visited VCBR on July 15. This visit included presentations by
VCBR staff, a tour of the facility, and a meeting with a group of residents who
had formed an unauthorized “Resident Advisory Council.”
The August 8 AOC meeting featured a tour and presentation of SORT at the
Brunswick Correctional Center. SORT is a sex offender treatment program that is
operated by DOC.
The committee developed preliminary findings and recommendations and made
the decision to request a meeting with the Commissioner of DMHMRSAS
following its meeting on August 8. The recommendations were drafted by OSVP
staff with intensive review, editing, and approval by the AOC.

31

•

•
•

•
•

•

o The committee’s recommendations expressed major concerns about the
living conditions, levels of privilege, personal freedom, and morale of the
residents. It also expressed concerns about the lack of a work program,
limited active treatment and recreational/educational opportunities, staff
turnover and staff qualifications, and security issues. The committee
considered its concerns urgent.
On September 2, in response to a request of DMHMRSAS, OIG staff met with the
Commissioner and the director of VCBR to review recent developments and
clarify actions for the future. It was determined that the VCBR director would
develop a specific response to each item noted in the 2007 OIG report.
Responsibility for liaison to the committee and oversight of VCBR was
transferred from the OSVP to the Director of Facility Operations during this time.
Committee members were contacted by the Director of Facility Operations in
October and a conference call with the committee took place on October 24. The
committee requested to have a telephone conference call with the Commissioner,
which was held on November 4. The committee shared the concerns that had led
to its initial recommendations. A committee meeting was set up for December
11, and the Assistant Commissioner for Special Projects was appointed to staff
the AOC and organize the meeting.
The meeting on December 11 was held at VCBR, facilitated by the Assistant
Commissioner for Special Projects. The Commissioner also met with the
committee, along with key leadership of VCBR.
The December 11 meeting was a positive dialogue among VCBR leadership,
DMHMRSAS leadership, and the committee. Preliminary goals and short term
outcomes for improving conditions at VCBR were crafted and DMHMRSAS
committed to their achievement, including the following:
o measures designed to improve the residents’ living environment
(upgrading the beds and mattresses for all residents, installation of
decorations and murals in common spaces, and provision of expanded
television offerings in common areas)
o efforts to improve the organizational culture
(re-activation of the Resident Advisory Committee, establishment of an
employee advisory committee, provision of a means for senior leadership
to be more available and responsive to residents, e.g., “regular rounds”
with documentation of same)
o efforts to introduce employment opportunities and a vocational training
program.
A follow-up meeting was set for January 27, 2009.
Status of Recommendations 1 and 2 (#144-07) – DMHMRSAS support,
guidance, and facilitation of the committee has been inconsistent and incomplete.
The committee members have given considerable time and insight to their task.
The activities outlined in the DMHMRSAS response to the 2007 OIG report
remain unmet. Recommendations 1 and 2 remain ACTIVE.

32

DMHMRSAS Response: Since the last DMHMRSAS response was submitted
in October 2008 the Advisory and Oversight Committee (AOC) has had two
meetings, during which a concrete work plan was developed in an effort to
support the facility in its substantial efforts to improve the quality of services
and culture within the facility. The Commissioner attended the initial work
plan meeting. The work plan developed has identified the following areas of
focus and identified both short and long term goals for each area. Facility
staff worked actively and enthusiastically in the development of this plan:
• Living Environment
• Treatment (Recovery) Planning
• Resident Activities including Vocational Programming
• Staffing/Organizational Culture (Clinical vs. Correctional)
Professionalism of Staff
• Staff Development
• JC Accreditation
• Resident Rights and Privileges
The next meeting of the VCBR Advisory and Oversight Committee is
scheduled for April 01, 2009. The meeting will be attended by the Deputy
Commissioner, the Director of Facility Operations and Quality Improvement,
and the Assistant Commissioner for Public Relations and Quality
Improvement to develop a schedule of meetings for the year 2009, review the
work plan and receive facility updates, and discuss future planning.
Following several months of staffing changes, reorganization of the
Department structure, and the hiring of the New Deputy Commissioner whose
position is to work closely with DMHMRSAS facilities, DMHMRSAS
leadership has made an active commitment to provide consistent support to
VCBR by assuring the availability of all needed leadership, resources,
technical and legal assistance necessary to resolve any identified state and
federal barriers to the development of an effective vocational program at the
facility. In updates below, the facility reports improvements in their
Vocational programming which have already been achieved. This item will
also remain a focus for the Advisory and Oversight Committee’s work plan
and ongoing oversight.
Additional Related Finding (2008): VCBR does not compile a report of
treatment and other program activity actually received by individual residents or
by residents collectively.
Additional Related Recommendation (2008): It is recommended that
VCBR 1) initiate regular reporting of treatment and other program activity
actually received by individual residents and by residents collectively, and
2) continue to report treatment and other program activity offered.

33

DMHMRSAS Response: VCBR does collect data that reflect both actual
treatment hours received by each individual resident and collectively. The
facility Information Technology (IT) Department is currently working to
upgrade this system to include not only hours received, but also the number of
hours scheduled. This data is currently available to each treatment team
member and is used to evaluate progress towards recovery.
The new Electronic Data System will be able to provide useable data
beginning in May 2009 and will be able to provide individualized data on
program activity received by each individual as requested by the Inspector
General. The system will have the capability of providing both active
treatment hours and hours spent in assessments, consultation, treatment plan
reviews in an effort to provide consistent data for use by the facility in quality
improvement activities and by the Inspector General’s Office during future
inspections. Additional data will be collected regarding group cancellations
and causes. Treatment activity data will be collected by individual treatment
track as well as facility-wide. It should be noted in this report that no changes
have been made in treatment track descriptions and criteria for assignment
since the last submission to the OIG November 2008.
The new EDS will also be used to monitor treatment program attendance
rates across the all programs, and within treatment tracks, along with the
reasons for non-attendance and the facility will develop an operationally
relevant and recovery informed definition of “treatment refusers” and utilize
this data to plan interventions geared toward improving these numbers. There
currently exists no clear definition of “active treatment” in the operations of
VCBR. The Advisory and Oversight Committee will be including this item in
its agenda for the April 1st meeting, including it within the larger topic of
treatment planning and will provide or ensure education is provided to
treatment providers and management at the VCBR regarding standards which
exist in other DMHMRSAS behavioral health facilities.

Recommendation 3 (2007): It is recommended that the facility, in concert with the
leadership of DMHMRSAS, develop a mission and goals statement that accurately
reflects the intended purpose of VCBR and ensure that facility policies, active
leadership, program design, staff training, and individual residents’ goals and
treatment activities reflect the facility’s revised mission and goals on an ongoing,
operational basis.

2008 OIG Review
For a discussion of the facility’s development of a new mission statement during
2008, please see pages 14 to 17 of this report.

34

Status of Recommendation 3 (#144-07) – The facility’s new mission and
vision statements clarify the focus of the service to be provided (recovery
opportunities and support) and the quality of the facility’s efforts (excellence). In
this review of VCBR, the OIG found a lack of clarity among staff regarding the
intended outcome of the facility’s services. Some staff and residents hold the
view that the primary purpose of the facility is safety and security. Others believe
that the primary purpose is to prepare residents for eventual discharge into the
community. The OIG staff was not able to locate or identify any written
documentation that is available to staff and residents that states definitively what
the purpose or end result of the facility’s efforts is to be. The result of this lack of
clarity is a workforce that is not unified in carrying out the facility’s mission.
Recommendation 3 (2007) remains ACTIVE.
DMHMRSAS Response: In February 2009 VCBR submitted a newly revised
Mission, Vision, and Goals Statement to the Advisory and Oversight
Committee for their review and feedback. The document is being reviewed by
Committee members and will be discussed with the facility during the April
Committee meeting. The Advisory and Oversight Committee is charged with
ensuring the new Mission Statement is effective in its reflection on the Code of
Virginia’s statements related to the facility’s mission.

Recommendation 4 (2007): It is recommended that the DMHMRSAS, in
coordination with VCBR, review existing national accreditation systems to
determine the appropriateness and validity of these systems for sex offender
treatment programs. If it is determined that an existing accreditation system will be
of value, it is recommended that DMHMRSAS pursue accreditation for VCBR.
•

The facility leadership has said during previous OIG visits over the past 3 years
that it is considering pursuit of accreditation from JCAOH, but no tangible
progress has been presented for earlier reports.

2008 OIG Review
•
•

In 2008, the director indicated that the first stages of preparing an application for
accreditation had begun and that he thinks the program is about one and a half
years away from accreditation.
OIG staff interviewed the staff person responsible for preparing the plan for
accreditation and reviewed materials prepared to date for the process of
accreditation.
o The coordinator for accreditation and VCBR leadership have visited other
Virginia programs with similar accreditation (Marion Correctional Center
has a program that is accredited as a behavioral rehabilitation program).
The coordinator has received training at multiple national accreditation
seminars and is working with similar sex offender treatment programs in
other states that are accredited.

35

o A comprehensive plan for a process to achieve accreditation has been
developed, charting timelines and achievables in 34 categories.
o The coordinator has developed a draft “Annual Strategic and Quality
Assurance Plan – 2009” that appears to be comprehensive and is a
necessary early component for accreditation readiness.
o The process and plan is judged by the OIG to be appropriate, complete,
and well-informed by JCAOH standards and procedures.
o The first noted “start” dates for the first activities is 7/31/08, including
such activities as “finalization of organizational chart,” so the actual
planning and preparation are in the very earliest stages.
Status of Recommendation 4 (#144-07) – Remains ACTIVE.
DMHMRSAS Response: Since the Inspector General’s audit, the facility has
begun implementation our their Strategic Plan, trained department heads on
Joint Commission requirements, and begun developing quality assurance
indicators and reports.
They have begun conducting internal Joint
Commission type audits and are currently developing action plans to address
findings. Additionally, staff from another Joint Commission Accredited
facility have been solicited to conduct a full mock Joint Commission survey.
It is important to note that in addition to their efforts to become Joint
Commission accredited, the facility receives oversight and direction from the
following agencies: DMHMRSAS Central Office, Office of the Inspector
General, Office of the Attorney General, the VCBR Advisory/Oversight
Committee, VOPA, ARMICS, the Local Human Rights Committee, and our
Facility Advocate.

Recommendation 5 (2007): It is recommended that the facility, with the
involvement of DMHMRSAS staff, including the Office of Sexually Violent Predator
Services, revise and expand the provision of training in topics specific to working
with persons who are sexual offenders, and that such training occur regularly for all
employees, including treatment, medical, and security staff.
2008 OIG Review
•

See above, pages 28 to 30, for a review of VCBR efforts to improve staff training.

Status of Recommendation 5 (#144-07) – Staff training for clinical staff has
improved. Training in sex offender topics has not been increased for residential,
security, medical staff, who spend the most time day-to-day with residents, or for
administrative staff, who contribute decisively to the nature of the organizational
culture. Recommendation 5 remains ACTIVE.

36

DMHMRSAS Response: Between January 1 and October 1, 2008, each
member of the treatment staff attended from an average of forty-seven hours
of continuing education directly relevant to the treatment of sexual offenders.
The facility goal is to ensure each clinical staff member receives six hours of
clinical training each month. This far surpasses requirement for state
licensure. Since the Inspector General’s audit VCBR conducted a week long
intensive training program for all staff, including residential, security, and
medical staff. Topics included items such as Introduction to Sex Offender
Treatment, Interpersonal and Therapeutic Communication, Manipulation,
Policy Review, Suicide Interventions, etc.
At the time of this response the VCBR reports they have not maintained copies
of course outlines or other details of trainings referenced above. The Office of
Facility Operations has explained that maintenance of such documentation is
a standard expectation of any training plan and should be initiated
immediately for any future training. This issue will also be added to the April
1st Advisory and Oversight Agenda and incorporated into the facility plan of
correction.

Section V – Status of Active Findings Prior to 2007
A.

OIG Report #130-06 (May 16, 2006)

Finding 1.3 (2006): The majority of residents identified boredom as a problem,
particularly during non-programming times.
Recommendation 1.3: It is recommended that VCBR leadership in conjunction
with the residents and staff develop strategies for providing increased activities
during non-programming times. It is also recommended that the clinical staff
review the effectiveness of suspending programming for an extended period
during each review cycle.
•

This recommendation focused on low levels of constructive activities for residents
and consequent boredom at all times, but especially during the “semester breaks”
when treatment programs are suspended to enable staff to update resident
progress reports and re-tool programming.

2008 OIG Review
•

The facility reports that residents now receive Quarterly Progress Reports every
90 days after their admission to the facility. According to the facility, “This
means that their QPRs are issued continuously rather that simultaneously,
eliminating the need to stop all programming for a two week cycle every quarter
to complete the reports.”

37

•

•

•
•

•

Beginning around the time of the last OIG review, and with accelerating progress
since, VCBR reports that it has been able to develop an educational program, with
a director, teacher, and librarian, a recreational program with 3 staff and a variety
of activities, and ongoing efforts to develop a vocational program with no results
yet. These activities are said to minimize the gap in constructive activity between
semesters.
OIG staff analysis of active programming shows that the level of constructive
activities has increased over the past year.
o While organized activity levels have increased somewhat for residents,
they are still a relatively small portion of the week. The OIG documented
an average of 5.5 hours received per week for all residents in the sample.
Facility reports show an average of 12 hours constructive activity
available weekly to residents.
o Residents continue to complain that they do not have enough activity to
prevent boredom.
ƒ In response to a question that asked whether “There are enough
constructive activities to fill my days,” 71% of the sample
answered in the negative, disagreeing with that statement.
The Director of Public Safety at VCBR stated that increased levels of constructive
activity would reduce security incidents and concerns significantly.
Residents who already have a GED or high school diploma complain that the
VCBR educational program is of no benefit to them as it cannot provide college
level or vocational training.
o Residents needing college level educational training complain that there
are no computers with internet access that they can use to access distancelearning classes. Residents accept the need for an internet filter for
inappropriate content, but wish they could do correspondence courses
online.
By comparison, OIG staff (and AOC members) learned that the average resident
at SORT (the sex offender treatment program at Brunswick Correctional Center)
spends so much time per week in paid employment, educational programming,
sex offender treatment, substance abuse treatment and self help groups, religious
activities, and organized recreational activities, that they have significant
scheduling problems.

Vocational programming needs
Staff and residents report that the major missing component for constructive activity
and avoidance of the behavioral consequences of boredom is the opportunity to work
and earn money.
•

All the residents at VCBR came from DOC facilities where they had the
opportunity to earn money and purchase personal items and pay for phone calls.
Work provided valuable benefits of constructive engagement, raised self esteem,
and income for purchases of valued items at the DOC facilities, including what

38

•

•

residents say they value most: telephone contact with family and the outside
world.
o A major issue presented to the AOC and OIG by residents on the Resident
Advisory Committee on July 15 was concern about the expense of the
long distance telephone service at that time provided by VCBR. That
system has since been replaced with another, slightly improved system,
but complaints about cost of calls with the current system are virtually
ubiquitous.
In its efforts to develop work opportunities for residents, the facility has
encountered what may be a “Catch 22” in regard to work opportunities. Prisons
are able to provide work for inmates at a fraction of the minimum wage (e.g. $.20
- $.40 per hour) due to an exemption for such facilities from some federal Fair
Labor Standard Act provisions. Facilities serving persons in a civil commitment
setting such as VCBR apparently are not eligible for FLSA exemptions, and
residents must be paid at least minimum wage, or prevailing wages for similar
positions, and other fair labor laws and standards must be followed. VCBR
reports that it has been working on developing vocational opportunities since it
opened in Petersburg in 2004, but has not resolved these issues. State laws
restricting hiring of persons in direct care roles who have been convicted of
“barrier crimes” would also affect the majority, if not all, of VCBR residents.
VCBR has hired a vocational services coordinator. She has developed a proposal
to employ residents as aides to staff in a variety of work areas: Housekeeping,
Work Program, Education, Art, Library, and Recreation. The program would pay
minimum wage. It is slated to begin on a very small pilot basis early in 2009.

Status of recommendation 1.3 (#130-06): The level of treatment and other program
activity in which residents are involved at VCBR still remains very low. As a result,
resident inactivity and boredom continue, with ongoing behavioral consequences.
Most importantly, the facility does not yet offer training opportunities and preparation
for community living in the essential areas of vocational training, work readiness,
work experience, and the opportunity to earn money. This is identified by VCBR
leadership, staff, residents, the AOC, and the OIG as the most significant program
deficit. Recommendation 1.3 remains ACTIVE.
DMHMRSAS Response: Since the Inspector General’s audit, the Education
Department has implemented college level correspondence courses for
residents desiring college level training. Currently, there are 20 residents
enrolled in this program. Additionally, 30 residents have expressed an
interest in our new college correspondence program. The facility has
received such a positive response to their educational programming they are
in the process of expanding space to accommodate additional students.
Vocational Programming now offers courses focusing on resume writing and
job interview skills. The facility hopes to expand this program during the next
semester.

39

The staff aide position mentioned to the Inspector General and planned for
start-up during the winter of 2008/2009 has been stalled by reported problems
with payment. The facility has invited the vocational staff from Eastern State
Hospital to come to VCBR and assist them with their program design. That
consultation is scheduled for April 14, 2009. The facility has targeted July 1st
2009 as the new start-up date for the vocational work program.
Additional Related Recommendation (2008) - It is recommended that
DMHMRSAS provide active assistance to VCBR by assuring the availability of
all needed leadership, resources, technical and legal assistance necessary to
resolve any identified state and federal barriers to the development of an effective
vocational program at the facility.
DMHMRSAS Response: See DMHMRSAS response to Recommendations 1
and 2 (2007) on page 33 of this report.
Finding 2.2 (2006): Security and clinical staff have different perceptions regarding
the changes in programming and unit rules.
Recommendation 2.2 (2006): It is recommended that current channels of
communication be reviewed in order to enhance information flow between
clinical and security personnel. One goal of this would be to increase
opportunities for incorporating ideas and comments by security staff in unit
functioning and programming.
•
•

Beginning in 2005, OIG reviews of VCBR have noted issues of poor
communication among departments or staff function groups such as security,
programming, medical, and administration.
Issues in this area remained prominent in the 2007 report and the finding
remained active.

2008 OIG Review
•

•

Facility leadership outlined efforts it had made to improve communication
through development of the mission and values statement, involvement of the
DMHMRSAS LEEP team, formation of a director’s direct care staff advisory
committee, making computers available for residential and security staff to
participate in communications and facilitate their documentation duties, and other
activities.
A “muster” system has been created to improve communication to and between
security and residential staff. The muster is a meeting of residential and security
staff held before the start of each shift. The muster is intended to allow
administrative and program staff to communicate with all staff and to receive
feedback from them. OIG staff attended two musters to interview staff and
observed communications between supervisors and direct care staff.

40

•

OIG interviews with staff from all departments shows some concerns still exist
about communication and cooperation among departments and between
departments and administration:

Staff Interviews (N=74)
I believe that all of us – clinical, medical, residential,
security, leadership staff – are pulling together
effectively on a team basis with common goals.
•

Strongly
Agree
19%

Agree
28%

Disagree

Strongly
Disagree

38%

15%

53% disagreed, 47% agreed. Disagreement levels were higher among security
staff (64%).

Staff interview (N=74)
I believe that all of us – clinical, medical, residential, Strongly
Strongly
Agree Disagree
security, leadership staff – are pulling together
Agree
Disagree
effectively on a team basis with common goals.
Supervisor/Leadership
22%
44%
0%
33%
Program/clinical
20%
33%
33%
13%
Residential
11%
39%
39%
11%
Security
20%
16%
52%
12%
Medical
29%
14%
43%
14%
• In open-ended text questions asking staff what factors contribute most to staff
dissatisfaction with their jobs and what factors cause turnover, issues concerning
poor communication and coordination among departments and with
administration were the second most frequently listed subject.
o When asked what factors most contribute to job satisfaction, the leading
answer by far is “teamwork, support from my colleagues”, with the focus
being the staff person’s own unit or work group.
Status of recommendation 2.2 (#130-06): Remains ACTIVE.
DMHMRSAS Response: In addition to daily shift briefings described in the
Inspector General’s report, VCBR will begin holding an additional daily
briefing session each weekday. The purpose of this briefing is to discuss
current activities at the facility including special events and activities,
training, operational procedures, treatment, etc. Staff from all departments
who are not providing direct care/supervisory support will be expected to
attend this briefing.
We also believe our focus on Joint Commission accreditation will provide
staff with a greater understanding of our goals.

41

APPENDIX:
Appendix Item #1
VCBR 2008 Follow Up Inspection
Staff Interview
1. Type of staff: (check only one)
N=9 Supervisor/Leadership; N=15 Program/Clinical; N=18 Residential; N=25
Security; N=7 Medical
2. Length of service at VCBR: __1__years __8__months (average for all)
3. In your own words, what is the goal or mission of VCBR? What is the program
trying to achieve?
(results quoted in text of report)
4. On a scale from 1 (low, not a problem) to 5 (high, big problem), how big a
problem is staff turnover at VCBR?
Circle one: 1 2 3 4 5
(average: 4.1)
What causes turnover here?
(see below for responses)

Please indicate your agreement or
disagreement with the following statements.
If you do not know or the item does not apply
to you, leave the question blank. Check only
one box:
5. I receive excellent, supportive
supervision on working with sex
offenders from my supervisor.
6. I believe that all of us – clinical,
medical, residential, security,
leadership staff – are pulling together
effectively on a team basis with
common goals.
7. I am respected and valued by the
leadership of VCBR for my
contributions to the work of our
program.
8. I believe the treatment we are
providing will enable the majority of
the residents we serve at VCBR to be
rehabilitated to the extent that they can
return to live in the community.

Strongly Agree Disagree Strongly
Agree
Disagree

23%

42%

19%

15%

19%

28%

38%

15%

21%

44%

24%

11%

14%

42%

31%

13%

42

9. My job is professionally satisfying and
rewarding.
10. Overall, the residents here are treated
with dignity and respect.
11. Our main job here is really to protect
society from persons who are a danger
to our children and families and will
likely remain so forever.
12. I would recommend VCBR to my
friends as a good place to work
13. I feel safe working here.
14. Morale among my co-workers is pretty
high.
15. Senior VCBR leadership is visible,
knowledgeable, and involved in the
day-to-day operation of this program.
16. The senior leadership team has created
an open and comfortable work
environment for expressing my ideas.
17. I had direct experience in working
with sex offenders before I came to
work at VCBR.
18. Since I have been employed at VCBR
I have received excellent training in
working with sex offenders.

27%

35%

31%

7%

39%

45%

14%

3%

17%

39%

31%

14%

16%
8%

37%
27%

29%
37%

18%
27%

3%

34%

34%

30%

15%

43%

25%

17%

14%

33%

32%

21%

21%

26%

23%

30%

9%

38%

35%

17%

19. Did you take part in any courses, training sessions, conferences, speakers,
workshops, etc. that are directly specific to working with sexually violent
offenders between November 2007 and November 2008? (Note: do not include
the week-long new employee orientation session that you received when you first
became employed at VCBR or routine supervision sessions with your supervisor):
__38%__yes __63%__no
If yes, how many? (circle one) 6

5

4

3

2

1

0

20. List three things that contribute to job dissatisfaction for you at VCBR.
(see below for responses)
21. Name three things that contribute to job satisfaction for you at VCBR.
(see below for responses)
22. All programs that are similar to this one must find a balance between security and
treatment. In your opinion how is the current balance at VCBR?

43

__59%__ Tilted too much toward treatment and resident choice.
__24%__ About right, about enough emphasis on security and treatment.
__17%__ Tilted too much toward security and correctional approaches.
23. What aspects of the care and programs provided at VCBR most help
improvement for residents?
(see below for responses)
24. What aspects of care and programs provided at VCBR most hinder improvement
for residents?
(see below for responses)
25. Please make any comments you wish the Office of the Inspector General to know.
These will be kept confidential by source. If you wish to have staff from the OIG
contact you in confidence, please put down your name and number that we can
call privately.

Content analysis of text questions from the Staff Interview
#4. What causes turnover here? No clear leader in frequency of mention.
High demand, stress from residents, difficult/abusive pop
Improper, inadequate training
Not enough staff, staff ratios
Uncomfortable, unsafe environment
Residents' rights favored over staff, staff not supported, poor discipline
Dissatisfaction with leadership, question ability, lack of leadership
Poor communication (with leaders, between depts)
Constant change of rules, procedures, etc.
People get better jobs, positive turnover, promotions, school
Low pay
Lack of career path
Staff not appreciated, recognized
Favoritism
Work scheduling
Location of facility, commute
Low morale
Staff find it is just not the place for them, residents/security
#20.

List three things that contribute to job dissatisfaction for you at VCBR.

178 total comments
High demand, stress from residents, difficult/abusive pop
Improper, inadequate training, poor budget for training
Not enough staff, staff ratios, heavy schedule, no back up

2%
5%
6%

44

Uncomfortable, unsafe environment
Residents' rights favored over staff, staff not supported, poor discipline
Dissatisfaction with leadership, question ability, lack of leadership/vision
Poor communication (with leadership, between depts)
Constant change of rules, procedures, unclear
Too much turnover, recruiting/retention issues
Low pay
Lack of career path, no promotions
Unfair, closed application/interview process for promotions
Staff not appreciated, recognized, supported, backed up
Lack of opportunity for staff input on tx, policies
Favoritism
Work scheduling, lack of flex time, limited weekends off
Location of facility, commute
Low morale
Poor supervisor, super/admin does not respect/listen
Adapting to a security environment
Residents don't help themselves, low motivation, institutionalized
Lack of understanding about VCBR by outside
Other staff not qualified
Lack tools to assure security (no hands on)
Poor job security, worry about loss of job
Racial issues, separation of staff

#21

6%
15%
4%
12%
11%
3%
2%
2%
1%
7%
4%
2%
2%
1%
3%
4%
1%
1%
1%
2%
1%
2%
1%

Name three things that contribute to job satisfaction for you at VCBR.

124 total comments
Good supervisor/supervision
Being part of a team, my colleagues, teamwork
Helping/seeing residents learn, change,
Room for growth, contribution to program
Helping staff grow
Ability to advance career
Good security/safety
Personal pride in doing a good job/having skills in area
Job security, have a job, get paid
Good fringe benefits
Good budget to purchase materials
Knowledgeable staff
Supportive, flexible scheduling
Respect from residents, staff, supervisors
Good facility, flexible design, meets needs
Protecting community from sex offenders
Good, frequent training
Important, challenging work
Location convenient
Nothing positive to say

11%
24%
15%
6%
2%
2%
3%
5%
6%
7%
1%
2%
2%
3%
1%
1%
2%
2%
4%
1%

45

#23 What aspects of the care and programs provided at VCBR most help improvement
for residents?
60 total comments
Clinical staff and other departments are beginning to work together
TX gives residents feedback, allows their input, individualized
Leadership accepting positive ideas for improvement
Clinical treatment, programs, groups
Residents learn that they must be accountable, responsible
Availabilities of a variety of activities, programs
New building, nice environment
Restructuring housing, programs to fit tx needs of residents
Plans to get accreditation
Psychiatric consultation
Involvement of Human Rights staff
Education program, GED
Hope

7%
8%
3%
43%
10%
7%
3%
2%
2%
2%
2%
7%
2%

#24 What aspects of care and programs provided at VCBR most hinder improvement
for residents?
75 total responses
Lack of staff limits programming
Noise, hallways echo, disruptive environment
Resistance to change procedures, approaches
Negative, poor leadership
Inconsistency in policies and procedures responses to residents
Too much freedom, no consequences, lax discipline (residents)
Lack of staff input to programs, rules
Poor attitudes among residents, they hold themselves back
Disruptive residents hold others back
Lack of resident choice and true individualization
Nothing hinders treatment (not blank)
Poorly trained staff
Not seeing residents get released
Lack of vocational trng/work opportunities
Lack of one-to one treatment
Frequent class cancellations
Clinical leadership does not interact with residents enough
Not enough for residents to keep busy - invites trouble

1%
1%
1%
3%
17%
25%
3%
3%
3%
5%
1%
1%
1%
5%
3%
17%
1%
5%

46

# 25.

Comments – as stated, no frequency count, similar comments combined

Need more staffing
Need library, recreational programming, variety for residents
VCBR has a chance to grow and become better
Supervisors resist new ideas
Allow flex time
No consequences for residents - and they know and use that
Staff in unsafe situations
Residents still having sex, always a danger to public
Unfair promotion, interviewing practices
VCBR gives me opportunity to apply current research/knowledge to tx of SO
Staff on units turn a blind eye to misbehavior - this reinforces it
Huge power struggle within VCBR between depts - poor communication
Admin focused on mission: all meetings, procedures, directives support mission
Stress and confusion due to new program, even after 5 years
High admin do not respect staff, are demeaning
Offer incentives, higher pay to reduce turnover and raise morale
VCBR needs to show residents respect and dignity
CO needs to visit facility for more than a day and really see what we face
No privacy, supervisor belittles, harasses staff,
Racism with leadership
Leadership causes high turnover rate by over-emphasizing corrections model
Poor communication from leadership, do not invite input, discussion
Replace upper level leadership
Some staff try to scare residents
Some staff are too scared of residents to do their jobs
Clinical staff spend little time with residents and "brush them off"
RSAs need a lot more training - we are the ones who are with the resids
The director must approve me to press charges against a resident for assault
RSA and security need more than TOVA to deal with violence
VCBR is a great place to work
The only time we see the top 3 leaders is when there is a resident crisis
It is a pleasure to be in clinical with Dr. Dennis as leader
Tremendous disconnect between clinical and (med), med role unclear, confusion
After 5 years, feel mistreated, passed over, low morale, many others similar
I would like to speak with you but I am afraid I would lose my job

47

Appendix Item #2
VCBR 2008 Follow Up Inspection
Resident Interview
1. How long have you been at VCBR: __2__years __0__months (average for all
respondents)
2. In your own words, what is the goal or mission of VCBR. What is the program
trying to achieve?
Results quoted in text
3. What aspects of the care and programs provided at VCBR most help
improvement for you?
Results shown below
4. What aspects of care and programs provided at VCBR most hinder improvement
for you?
Results shown below
5. How is your time spent during the week? How much treatment and other services
do you receive on average? Base your estimates on the past month or so.
Activity

How many hours
per week do you
spend in these
activities?
Sex Offender Treatment Groups
8
Education Activities/Classes/GED 2
Vocational Training or Work
0
Substance Abuse Treatment
0
Individual Therapy
0
Recreation
Other (list)

Please indicate your agreement or
Strongly Agree Disagree Strongly
disagreement with the following statements. Agree
Disagree
If you do not know or the item does not apply
to you, leave the question blank. Check only
one box:
6. I believe that the treatment I am
receiving is helping me.
25%
42%
21%
13%
7. I believe the treatment I am receiving
will enable me to be rehabilitated to
28%
38%
26%
9%

48

the extent that I can return to live in
the community eventually.
8. The staff treat me with dignity and
respect.
9. The real purpose of this program is to
keep people locked up who will
forever be considered a danger.
10. I feel safe here from threats or dangers
posed by staff.
11. I feel safe here from threats or dangers
posed by other residents.
12. Morale among the residents is pretty
high.
13. The rules, privileges, and freedoms of
being a civil committee at VCBR are
better than it was being an inmate in a
DOC facility.
14. The treatment staff who work with me
are knowledgeable and well-prepared
for their jobs
15. Turnover among treatment staff is a
problem for continuity of my
treatment.
16. The facility lets me know where I
stand in my treatment and what
progress I must show to be ready to be
discharged.
17. There are enough constructive
activities to fill my days.
18. The physical comforts of VCBR are
better than what I had at DOC.

35%

29%

23%

13%

32%

30%

30%

9%

25%

35%

19%

21%

17%

35%

30%

17%

0%

24%

41%

35%

6%

16%

31%

47%

15%

21%

45%

19%

46%

25%

23%

6%

10%

25%

38%

27%

4%

25%

25%

46%

11%

26%

40%

23%

Content analysis of text questions from the Resident Interview
#3
What aspects of the care and programs provided at VCBR most help
improvement for you?
54 total responses
Nothing. Nothing that I did not already know, figure out, no tx
Groups, learn info, learn from others
Cognitive approach, understanding my behavior, make reasoned
choices
AA/NA
Individual attention and individualized tx, when available

13%
28%
28%
2%
9%

49

Anger management groups
Learn from other residents, on my own outside of classes
Encouragement from staff, hope, empathy, understanding
Environment - good food
Access to telephone
Education classes

2%
2%
11%
2%
2%
2%

#4
What aspects of the care and programs provided at VCBR most hinder
improvement for you?
87 total responses
Classes are too general, too unspecific, not meaningful to me
Too strict, like a prison again, few privileges to work toward
Other residents take advantage of me, sexually assaulted, stressful
environ
Lack of leisure skills, opportunities
Drug and alcohol classes, (need more)
Need more technical (voc) classes
Very frequent class cancellations
Not being allowed to select groups, attend more groups, no
input/say in tx
High turnover rate
No work
Poor organization, disorganized
Minimal hope of release
Criticism of staff, not qualified, vindictive, race biased, ex-DOC
VCBR keeps info secret, no communication with residents
Material repeats SORT/SOAP
Over-reliance on group tx inhibits revelation, openness
Favoritism
Poor medical care, unresponsive, poor tx
Staff do not listen, pre-judge, cynical,
Punishment of all for offenses of only one, some
Never given a chance to prove myself, no community exposure
Lack of treatment materials in library
If complain, ask questions, disclose, it is held against you,
manipulated
Nothing - no hindrances

8%
9%
3%
1%
1%
2%
9%
3%
3%
5%
5%
3%
10%
1%
1%
1%
1%
5%
5%
8%
3%
2%
5%
2%

Comments – written on back, in margins, as stated
Need computers (with filters) so we can do college courses
Need more groups, more variety, less repetition
Difficult, expensive to contact family

50

More of a prison than DOC
It is real torture to not have any hope/plan for release
Waited 6 months to see dermatologist
Need re-entry housing, halfway house in community
There are political powers that want us here for life

51

Appendix Item # 3
VCBR 2008 Follow Up Inspection
Record Review Form
1.

Name of resident:______________________________

2.

Date of admission to VCBR:_____________________

3.

Date of last comprehensive clinical assessment (for treatment
plan)______________

4.

Source of last comprehensive clinical assessment
DOC
DMRMRSAS SVP staff
Contracted staff
VCBR staff

____
____
____
____

5.

Treatment Track

____
____
____
____
____
____
____
____
____

6.

Assess the clinical documentation for assignment to the treatment track.

Initial Assessment
Behavioral Mgt (Phase I)
Behavioral Mgt (Phase II)
Sex Offender Treatment (Phase I)
Sex Offender Treatment (Phase II)
Sex Offender Treatment (Phase III)
Understanding Treatment (Phase I)
Understanding Treatment (Phase II)
No notation of current track

Track not noted
____
Documentation not present
____
Present - sparse, unspecific, not linked to program description
____
____________________________________________________
Present – detailed, specific, linked to program description
____
____________________________________________________
7.

8.
9.

Is there a psychiatric evaluation within the last year?
yes
____
no
____
What are the psychiatric diagnoses?_____________________________________
What psychiatric medications are
prescribed?________________________________________________________

52

10.

Assess treatment plans/goals
•
•
•
•
•
•

•
11.

Responsive, specific to clinical assessment?
Individualized?
Evidence of resident involvement in plan?
Resident’s own goals stated?
Plan points toward return to community?
Plan is holistic – whole person, multi-faceted
o Education needs/goals addressed
o Vocational needs/goals addressed
o Recreational needs/goals addressed
o Medical health needs/goals addressed
o Substance abuse needs/goals addressed
o Family/social/relational needs addressed
Plan uses a treatment team approach

SA
SA
SA
SA
SA
SA
SA
SA
SA
SA
SA
SA
SA

A
A
A
A
A
A
A
A
A
A
A
A
A

SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD

Therapeutic activities levels (number of hours of services documented in the
record for the last full quarter for which data is available. If sessions are noted
without time, convert to 1.5 hours):
Sex offender group treatment (classes, groups, broadly defined)
Individual treatment
Substance abuse treatment/education (group, AA/NA)
Vocational activities (job training, employment)
Recreational activities (organized, sanctioned, not just free time)
Educational activities (classed, GED)

12.

D
D
D
D
D
D
D
D
D
D
D
D
D

_______
_______
_______
_______
_______
_______

Assess the last two treatment planning/quarterly progress review meetings. Note
participants for each below:
(Dir clin svcs) (Mario)
(Dir tx svc) (Stephanie)
Primary Therapist
Psychiatrist
Nurse
Residential (RSA)
Security
Resident
Family/lawyer/advocate
Other

____
____
____
____
____
____
____
____
____
____

____
____
____
____
____
____
____
____
____
____

13.
Comment:_________________________________________________________
________________________________________________________________________

53

Appendix Item # 4

VCBR 2008 Follow Up Inspection
Personnel Record Review

1. Type of staff: (check only one)
___ Supervisor/Leadership ___Program/Clinical ___ Residential ___Security __Medical
2. Position title (e.g., therapist, security officer, psychiatrist,
nurse):_____________________________ Name _______________________
3. Length of service at VCBR: ____years ____months
4. Highest level of education:
____ Some High School ____High School graduate ___ AA Degree/some college
____ Bachelors Degree ____Masters Degree ___PhD/M.D.
5. For clinical, medical, and leadership staff: Current Virginia licensure or
certification (check all that apply):
___None ___LPN ___RN ___LCSW/LPC/CS/etc ___MD/Clin Psych ___CSOTP
___other, specify_______________________________________________________
6. Is there evidence of training, experience, or other preparation that is directly
specific to working with sexually violent offenders…
a. In academic preparation?

____ yes ____ no

b. In employment experience before coming to VCBR? ____ yes ____ no

c. In the last year (since November 2007)

____ yes ____ no

Number of relevant sessions: ___6 ___5 ___4 ___3 ___2 ___1

54

Appendix Item # 5
VCBR 2008
Leadership Interview
Name of Interviewee:

_________________________________________

1. If staff and/or residents want to ask questions of or share thoughts with
members of senior management how does this occur?

2. What is the planned or intended level of active treatment for residents,
expressed in hours per week/per resident?
a.

Is this documented in policy or procedure?

b.

How do you monitor this? (show results of monitoring)

c. If they show us results and the results don’t meet the expressed goal, ask
why it does not meet the goal. Otherwise don’t ask why it does not meet
the goal.

3. How do you measure the effectiveness of treatment? Show us the data you
monitor.
.
4. Do your residents have access to individual therapy? (if they say yes ask the
following:
a. How do residents access individual therapy?

b. How much individual therapy do they receive?

If they say no, ask why not.
5. Describe your efforts in the past year to increase the vocational opportunities
available to your residents. What are your goals in this area?

55

6. What actions have been taken within the past year to assure that all
administrators, staff and residents have a common understanding of the
program’s goals and mission?
7. What is the status of your application for accreditation?
8. What is the role of your medical and nursing services in the planning and
provision of treatment for your residents? Are they expected to attend treatment
planning sessions? How has this changed since November 2007?
9. What role does psychiatry have at VCBR? Do you want or need more or less?
How has this changed since November 2007?
10. Where do you get your medications and formulary? How has this changed
since November 2007? Is it satisfactory?
11. What is your current or planned use of such medications as SSRIs or antiandrogens for treatment of SVP? Why or why do you not use these
approaches?

12. We found significant turnover in your program (treatment) staff when we came
here last year. What have you done to reduce turnover? How have these efforts
worked? What effect does turnover have on provision of treatment? On
morale? What causes it? What can you do to lessen it?
13. What are your expectations for training of security staff and clinical/program
staff? How do you assess your current training efforts? What plans do you have
for the future? What resources, if any, do you need for training?
14. In past reviews we had findings that related to gaps in understanding and
communication between program and security staff concerning program issues.
What efforts did you undertake to address this issue in the last year and how do
you measure their success? What activities do you plan to continue to address
this issue?

56