November 25, 1998

The Honorable Janet Reno
Attorney General
United States Department of Justice
Washington, D.C. 20531

Dear Attorney General Reno:

Enclosed is the report you requested for an independent review of the management and operations of the Northeast Ohio Correctional Center (NEOCC) in Youngstown, Ohio, owned and operated by the Corrections Corporation of America (CCA). This report is part of the action plan discussed in your August 7, 1998, letter to Governor of Ohio George V. Voinovich.

The report is the culmination of over three months of research and interviews to evaluate the District of Columbia's efforts to place approximately 1,700 District inmates in NEOCC and to understand the deficiencies, errors, and mismanagement that led to a series of unfortunate occurrences, including disruptions, escapes, and the deaths of two inmates. The research was conducted by a team of experts with extensive backgrounds in various aspects of correctional management, with oversight by key staff of the Office of the Corrections Trustee. The report contains 19 major findings regarding the management and operations of the District's Department of Corrections and NEOCC. The report also contains 24 major recommendations for CCA, NEOCC, and the District of Columbia Department of Corrections on the operations, management and oversight of NEOCC to assist in the long-term improvements necessary to assure the safety of inmates, staff, and the community.

Thank you for the opportunity to assist in this most important project.

Sincerely,

//signature//

John L. Clark

Corrections Trustee



Table of Contents for Report


Table of Contents

Introduction

Executive Summary


Introduction

A. Mission and Scope of the Trustee's Review

On August 5, 1998, Attorney General Janet Reno appointed the Corrections Trustee for the District of Columbia to perform an in-depth review and inspection of the security procedures, management practices and work opportunities of the Northeast Ohio Correctional Center (NEOCC). This appointment was in response to urgent requests from Ohio Governor George V. Voinovich and the U.S. Congress after several highly publicized problems occurred at the institution. The Corrections Trustee shared these requests with Margaret Moore, then Director of the District of Columbia Department of Corrections.

The Attorney General asked the Trustee to prepare a comprehensive report which addressed a number of public concerns and to make recommendations for corrective actions. The purpose of this review was to address the operational procedures, policies and practices and to help restore public confidence in the facility's ability to effectively accomplish its mission. On behalf of Ohio officials and Congress, the Department of Justice requested that the Corrections Trustee initiate a study to examine the:

1. Management style utilized at NEOCC and the extent to which the more serious problems might reasonably have been prevented or minimized;

2. Manner in which all intervening incidents in Ohio were handled by the institution's staff as they occurred, and subsequently how the administrators of the facility and other Corrections Corporation of America (CCA) managers responded to these incidents;

3. Steps taken by CCA and the District of Columbia's Department of Corrections (DOC) to rectify weaknesses and prevent future occurrences;

5. Adequacy of inmate work opportunities;

6. Level of staff compliance or noncompliance with NEOCC policies, as well as NEOCC's communication with local law enforcement, DOC, and other governmental agencies;

8. Comprehensive, long-term solution to the problems identified including specific recommendations for next steps or actions regarding relevant policy, procedures and operational issues.

Based on the scope of this review as defined above, the principal areas reviewed include:

The results and subsequent recommendations from this review are found in this report. The report begins with a brief history and overview, followed by an evaluation of the managerial, operational and security aspects of the institution, the contract administration and oversight, and the institution's relationship with the national, state, and local contingents; and concludes with a list of recommendations for corrective actions.

Attached as Appendix 1 are the letters of Governor Voinovich, Attorney General Reno, Congressman Tom Davis, and Deputy Attorney General Eric H. Holder defining the purpose and scope of the present review.

B. Role of the Office of the Corrections Trustee

The National Capital Revitalization and Self-Government Improvement Act of 1997, Public Law 105 -33, established the position of Corrections Trustee to serve as an independent Officer of the District of Columbia government. As established, the Trustee is appointed directly by the Attorney General of the United States, after consultation with leading officials of various branches of the District government, and may only be removed by the Attorney General. John L. Clark was appointed by Attorney General Janet Reno to serve in this capacity September, 1997, and was sworn in shortly thereafter.

The mission of the Office of the Corrections Trustee is: to provide financial oversight to the District of Columbia's Department of Corrections (DOC); to facilitate the closure of the Lorton complex and the transfer of all sentenced felons to federal custody by December 31, 2001; and to ensure the District of Columbia develops and maintains a viable correctional system which promotes the safety of staff, inmates and the community. The responsibilities of the Office of the Corrections Trustee are carried out by a small staff who possess extensive experience in the field of corrections.

C. Team Membership and Structure

The Corrections Trustee selected a team with a wealth of correctional experience at the federal, state, and local levels to conduct the on-site review of NEOCC. Collectively, the team possessed a vast degree of correctional experience from serving in positions such as correctional director, warden, classification expert, chief physician, and security administrator. These participants included:

Principal Review Team Members

John Clark Corrections Trustee; Former Assistant Director of the Federal Bureau of Prisons and experienced warden, including at United States Penitentiary Marion, Illinois, and Chief of the Bureau's Correctional Programs Branch (Classification).

Devon Brown Project Director and Deputy Trustee; Former Director of the Montgomery County Maryland Department of Correction and Rehabilitation, Assistant Commissioner of the Maryland Division of Correction, and Warden for the Maryland Department of Public Safety and Correctional Services.

Stan W. Czerniak Security Team Leader; Assistant Secretary of Corrections, Florida State Department of Corrections.

Jasper Clay Lead Classification Reviewer and Senior Advisor to the Trustee; Former Vice-Chairman, U.S. Parole Commission, and Parole Commissioner for the Maryland State Parole Board.

H. Vic Loy Management Team Leader and Assistant Trustee; Former Warden, Deputy Regional Director, and Program Review Branch Chief for the Federal Bureau of Prisons.

Dr. Glenn Johnson Health Services Reviewer; Former Medical Director, Texas Department of Corrections; Senior Auditor for the National Commission on Correctional Healthcare.

James Upchurch Statewide Security Administrator, Florida Department of Corrections.

Review Team Members from the Office of the Corrections Trustee

Phil Armold, Doug Caulfield, George Diffenbaucher, Jennifer La Point, and Marcia Murray

Steve Loudermilk, Security Consultant

Observer

Norman Hills Regional Director, Ohio State Department of Rehabilitation and Corrections.

In support of the on-site review, the adequacy and status of the contract between CCA and DOC were reviewed by Victor Stone, General Counsel for the Office of the Corrections Trustee and by Richard Crane, former Chief Legal Counsel for the Louisiana Department of Corrections and Director of the Correctional Law Project of the American Correctional Association, who currently specializes in the legal aspects of privatization. Bradley Kyser and Gary Katsel of the Office of the Corrections Trustee provided significant editorial assistance to this report.

D. Methodology

NEOCC Chronology

Spring 1996 CCA begins construction on NEOCC after signing a development agreement with the City of Youngstown.
Fall 1996 Initial discussions begin between CCA and the District of Columbia for a contract which would place 1500 prisoners in NEOCC.
February 1997 The agreement breaks down due to problems related to the procurement and contracting process in the District of Columbia.
May 1997 A short term 4 month contract is signed for 900 DOC prisoners to move to NEOCC. The facility opens and 900 prisoners are immediately transferred over a period of three weeks.
May 30, 1997 A disruption is reported at the NEOCC. Reportedly, inmates threatened correctional staff and refused to lock down. After inmates refused several direct orders to return to their cells, tear gas was used to restore order.
August 1997 Subsequent to the May tear gas incident, inmates file a class action lawsuit in U.S. District Court of the Northern District of Ohio. It is still ongoing.
Summer/Fall 1997 A series of stabbings and assaults occur including several on NEOCC staff.
September 1997 A one year contract, with four option years is awarded by the DC Financial Authority to CCA for 1440 beds. The contract was amended to increase bed space to 1700.
October 1997 NEOCC houses 1700 DOC inmates. The DOC hires a consultant firm, Pulitzer Bogard & Associates, to provide periodic/monthly contract monitoring of the facility
February/March 1998 Two homicides at the facility prompted major operational changes and a national focus on the administration of NEOCC. CCA removes the warden and replaces him with a more seasoned warden in CCA's system.
March 1998 The Ohio Legislature passes House Bill 293 providing for closer regulation of private prisons in Ohio. Several of its stipulations soon have an impact on NEOCC. In addition, the U.S. District Court orders a complete reclassification of the entire NEOCC inmate population using the National Council on Crime and Delinquency's (NCCD) instrument, as well as, the removal of all felons with classifications of maximum security.
April 1998 U.S. District Court issues an injunction temporarily prohibiting the DOC from transferring additional inmates to the facility.
May 1, 1998 Extensive controversy was sparked between NEOCC and the Ohio Legislature when the chairwoman, several staff and associates of Ohio's Correctional Institution Inspection Committee were denied entrance for a surprise NEOCC inspection.
June 1998 One hundred nineteen maximum security inmates were transferred based on the results from the NCCD reclassification.
July 25, 1998 Six inmates who were serving long sentences for very serious, violent offenses escape from NEOCC. All were eventually recaptured.
August 7, 1998 After a request for an NEOCC inspection from Ohio Governor Voinovich, Attorney General Reno appoints DC Corrections Trustee, John L. Clark to perform an in-depth review of the management, security and work opportunities at NEOCC and prepare a comprehensive report which addressed the issues raised and include recommendations for corrective actions. Virginia Congressman Tom Davis, Chair of the House Subcommittee on the District of Columbia requested that a copy of the report be forwarded to the Congress and the General Accounting Office (GAO) for review.
September 17, 1998 The contract between the City of Youngstown and CCA expires due to Ohio statue requirements. An interim renewal contract was signed while renegotiation of the remaining issues continues.

Executive Summary

Part A: Major Findings

Overview. The Northeast Ohio Correctional Center has experienced pivotal failures in its security and operational management as a result of seriously flawed decisions by leaders of both CCA and DOC. Expediency and the pressure of short-term objectives often prevailed over good judgement and sound correctional management procedures. Identification and resolution of problems were too often delayed by the failure to perform self-assessment and management oversight. It is reasonable to conclude that certain of the most serious problems which endangered the safety of the public, the staff or the inmates were preventable or subject to mitigation. These as well as other findings are listed below and expounded upon in their respective chapters.

A. Activation and Early Period of Operations at Youngstown

F-1. In response to a perceived emergency need for contract prison beds, the District of Columbia rushed into an abbreviated procurement process which minimized competition. The result was a flawed contract, at a somewhat inflated price, with weak requirements on the contractor and minimal provisions for enforcement. (Chapter II)

F-2. The prison was not adequately prepared to open and was overwhelmed by a precipitous rush to fill it. Even though serious problems began immediately, inmates continued to be sent at an accelerated pace. ( Chapter III)

F-3. DOC and CCA failed to perform rigorous case reviews and to carefully select the population for transfer, which contributed substantially to many of the problems that quickly surfaced at NEOCC. Managers of both organizations were informed, willing and mutually responsible players in the transfer of large numbers of inmates who could not be considered medium or high-medium under any reasonable correctional standard. DOC selected scores of inappropriate cases, all of which CCA uncritically accepted. Until recently, NEOCC never developed a capacity for inmate classification and screening. (Chapter IV)

F-4. DOC was irresponsible in sending over 200 inmates who required individual separation from other particular inmates at NEOCC, at times providing minimal file documentation. It is unacceptable correctional practice to house such separation cases in a general population facility. NEOCC accepted and kept these cases, without developing adequate procedures for managing their safety needs until after a homicide resulted from the poor procedures. (Chapter IV)

F-5. In the critical area of staff/ inmate relations, a poor level of communication and trust prevailed since the opening of the facility, although more recently there has been a significant effort toward improvement by management. (Chapter VI)

F-6. Staff/inmate relations were severely harmed by a prolonged episode in the spring of 1998 during which an extensive search of all housing units was instituted following the two murders. Unnecessarily harsh and humiliating procedures were systematically employed, souring internal relations. There were a number of allegations of excessive use of force by staff teams. This incident, which appeared to have been directed or tolerated by a corporate management team, continues to have serious negative ramifications on the safe and secure management of the facility. This event has never been adequately investigated and reported on by management of DOC or CCA. (Chapter VI)

B. Continuing Issues and Concerns

F-7. In a pattern of flawed security attributable to both corporate and institutional management deficiencies, NEOCC failed to accomplish the basic mission of correctional safety. Most notably, there were two homicides, a major escape, numerous stabbings, assaults against inmates and staff, and the widespread presence of dangerous weapons among inmates. (Chapter V)

F-8. There is little indication that the local management received significant guidance in security procedures from corporate management, except in reaction to major problems. To a lesser extent, the serious security failures are also attributable to the inadequate oversight of the contract by the DOC. (Chapter V)

F-9. A destructive pattern of extensive inmate idleness continues to prevail. There are few constructive work or program opportunities for most prisoners, which directly violates DOC's contract. Most inmates spend virtually all their time confined to small, noisy living units. This inmate idleness could become a permanent pattern if not soon corrected. (Chapter VI)

F-10. Procedures put in place to manage large numbers of separation cases constitute a major problem, severely limiting operations of the facility and aggravating idleness. (Chapters IV, VI)

F-11. Until recently, NEOCC has not demonstrated the capability to identify and correct its own problems. Numerous major changes in procedures, programs and leadership have been spurred primarily in reaction to intervening negative events or external forces. CCA is reluctant or unable to perform internal audits or after-action reviews, with accompanying analytical reports following significant incidents of security breakdowns. (Chapter VII)

F-12. In response to the major problems and extensive public criticism, CCA management took a decisive step in March 1997 by bringing in a new warden and certain other upper management officials. While there were initial missteps, the new warden and his management team have had a positive impact, bringing a greater sense of organization and coherent progress toward goals. (Chapter VII)

F-13. The management of NEOCC has not at any time developed an operational plan of action, including identification of such elements as the administration's major priorities for the facility, specific objectives, target dates or persons and offices responsible for achieving those objectives or solving critical problems. There is no mechanism for evaluating and measuring progress toward achieving those priorities and objectives. (Chapter VII)

F-14. External relations with the Youngstown community as well as law enforcement leaders have been severely damaged, adding to the prison's difficulties. There is a strong perception that after first winning the good will of the community prior to opening, CCA' s NEOCC leadership soon adopted a posture of independence and isolationism. (Chapter VIII)

F-15. In the critical area of law enforcement procedures, NEOCC has shown disorganization and a lack of adequate coordination and cooperation with investigatory and prosecutorial agencies. The investigation of possible criminal behavior occurring at NEOCC has suffered from a lack of clear management policy and procedures, resulting in confusion and the mishandling of investigatory procedures. Joint interagency emergency assistance plans have not been adequately finalized and implemented nor have any joint emergency preparation exercises been planned or conducted. (Chapter VIII)

F-16. A number of officials voiced a concern that CCA exhibits a limited sense of public accountability and responsiveness as it carries out a sensitive societal mission on behalf of governmental jurisdictions. (Chapter VIII)

F-17. The lack of correctional experience on the part of almost all staff, especially supervisors, has severely hampered NEOCC's attempts to manage a difficult inmate population. In spite of the commitment and enthusiasm of line staff as a group, they are not yet sufficiently experienced and trained for their duties. (Chapter IX)

F-18. The DOC initially took little responsibility for its role of monitoring the operations at NEOCC, until confronted with major problems in Federal Court, public opinion and political scrutiny. Although DOC has appointed a Contract Monitor, it has not yet developed an adequate oversight management function at DOC headquarters. (Chapter XI)

F-19. There has been significant, though fragile, improvement at NEOCC in the past several months. In particular, there has been a marked reduction in reported violence and disruption, with most of the more troublesome inmates having recently been removed. The facility appears to be more organized and is working on solving many of its previous problems. The situation remains vulnerable and significant problems persist. Long-term success can be achieved only if there is a strong commitment to improvement and accountability by CCA and DOC, along with close public scrutiny in the District and Ohio. (Chapter XII)

Executive Summary

Part B: Major Recommendations

Introduction. A list of the major recommendations is presented below, while additional recommendations of lesser magnitude can be found at the end of each chapter, where applicable.

Major Recommendations

R-1. The existing contract should be modified to hold the NEOCC management more accountable for adhering to contract provisions by including specific procedures and penalties for noncompliance. Specific language should be added covering the policies and procedures for determinations of contract noncompliance and include a preset schedule of financial penalties that attach to such contract breaches. Penalties should be scaled to account for the number of inmates affected, and repeat violations should be penalized more heavily. In addition, the justification for the pricing structure should be closely reevaluated. (Chapter II)

R-2. DOC should ensure that any future activation of a new contract facility be well organized and gradual, with feasible start-up schedules, on-site monitoring and a willingness to alter plans to adapt to the realities of the situation. (Chapters II, III)

R-3. DOC should clearly define criteria for the selection of inmates for any future transfer to contract facilities. Sufficient time should be allowed for the DOC and the contract facility to screen referrals and determine if adequate information is available, and for the contractor to object to the transfer of any inmate not suitable under the terms of the contract. (Chapter IV)

R-4. DOC should ensure that future contract facilities have in place, before inmates arrive, a sound screening and classification capacity to use as a basis for assigning inmates to housing units, identifying individual security needs, and directing inmate involvement in work and program activities. (Chapter IV)

R-5. NEOCC should better emphasize the central importance of its inmate classification and the quality of its case management capacity. Additional classification training is important for not only the case management counselors and the classification supervisor, but also for upper management administrators who review the recommendations and decisions made by other staff. (Chapter IV)

R-6. The process of classifying inmates must be stabilized and confusion eliminated, after three different systems or models have been used in quick succession at NEOCC. Consistent with the direction of Congress in the 1999 District of Columbia Appropriations Act, the Federal Bureau of Prisons (BOP) model should be adopted as the permanent system, and staff should be well trained in its implementation. (Chapter IV)

R-7. DOC must immediately work with NEOCC to remove all existing separation cases from the facility and to ensure that no future known separation/enemy cases are sent to NEOCC. NEOCC must develop precise procedures for the management of any future separation cases, which may occur from local incidents where a strong animosity arises. Staff and supervisors should be thoroughly trained to carry out these sensitive procedures. In no instance should separation cases be allowed to be housed simultaneously in general population. (Chapter IV)

R-8. CCA corporate headquarters must provide systematic direction and periodic oversight for NEOCC's operational security procedures, including regular, formal security audits performed by specialists coming from outside the local NEOCC management. Care should be taken to ensure that written plans of action are formulated and implemented to correct deficiencies and weaknesses. (Chapter V)

R-9. CCA/NEOCC should implement the findings and recommendations of the security audit performed as part of this current review, as well as those made by DOC in the After Action report following the July 1998 escapes and all DOC monitoring findings. (Chapter V)

R-10. The highest priority must be given to reducing the longstanding issue of inmate idleness and providing daily activity outside the living units for all prisoners, in order to meet the requirements of the contract and to establish sound correctional practice. Constructive work, training, educational and other program opportunities must be provided consistent with contract requirements, as well as significantly increased opportunities for off-unit recreation. (Chapter VI)

R-11. Until there are significant additional opportunities for constructive daily activities, the population of the facility should be reduced, preferably to 1,000 prisoners, since a greater number of idle prisoners invites many different serious problems, as has been experienced at NEOCC. (Chapter VI)

R-12. NEOCC management must prioritize efforts to improve staff-to-inmate relations and communications. Several measures toward this end would include increased accessibility of upper management staff and unit management staff, as well as the provision of various types of training for all staff in areas like interpersonal communications and cultural diversity, while at the same time eliminating unnecessary displays of force. (Chapter VI)

R-13. Search procedures, when deemed necessary, should be conducted in an accepted professional fashion, making full effort to respect the physical integrity and personal property of inmates. (Chapter VI)

R-14. CCA/NEOCC management should significantly increase its capacity for ongoing internal controls and operational self-assessment, including a process to identify problems and submission of written plans of action for implementation of solutions for deficiencies. (Chapter VII)

R-15. When serious incidents occur, CCA should conduct after-action reviews, prepare written analytical reports, and implement action plans to prevent such events in the future. All reports that pertain to NEOCC issues as well as those at similarly situated institutions should be readily available to DOC. (Chapter VII)

R-16. CCA/NEOCC should develop a detailed, written plan of action which identifies the facility's major priorities and problems, with objectives, target dates, and persons and offices responsible for implementation of each area. A major part of the plan should address the recommendations identified in this report and the plans for achieving them. Staff at all levels should be aware of this plan and of the major priorities of the facility and their role in achieving the objectives. There should be a mechanism for evaluating and measuring the progress toward meeting those priorities and objectives. (Chapter VII)

R-17. CCA/NEOCC should make a concerted effort to establish better relations with all elements of the local community and to allow itself to be held publicly accountable for the manner in which it carries out its sensitive and difficult public function. (Chapter VIII)

R-18. It is of particular importance that NEOCC focus on improving its working relations with local, state and federal law enforcement and prosecutorial agencies. Priority must be given to establishing appropriate, agreed upon procedures and clear written policy for handling possible criminal behavior at NEOCC. Also of importance is finalizing and implementing joint, interagency emergency assistance plans and conducting joint emergency preparation exercises. (Chapter VIII)

R-19. CCA should transfer more experienced mid-level supervisors to NEOCC. These more seasoned correctional managers are essential to ensure that basic correctional and security techniques and practices are taught and enforced in daily operations. (Chapter IX)

R-20. Consistent with CCA policy and to increase the basic readiness of staff at all levels, NEOCC should design and implement a formal 40 hour annual in-service training program. The course curriculum should be designed with input from supervisors and managers to better target observed weaknesses and areas of poor performance. (Chapter IX)

R-21. NEOCC could benefit from increased ethnic diversity among its senior managers, especially in view of the make-up of the inmate population. While the ethnic mix among the line staff is good, a balanced minority representation is lacking in the top echelons after recent personnel changes. Given the current staff/inmate tensions at the NEOCC, such increased diversity among the senior officials would be helpful. (Chapter IX)

R-22. In the area of medical services, NEOCC should implement the recommendations of all DOC monitoring reports and of the findings of this current report. (Chapter X)

R-23. DOC should supplement the current full-time contract monitor at NEOCC with additional professional and clerical assistance. Assistance should also be periodically provided to the local monitor by DOC headquarters subject matter experts, such as those from the areas of security, health services and case management. (Chapter XI)

R-24. DOC should establish a contract oversight unit in its headquarters that would have as its sole responsibility the monitoring of all contract facilities holding DOC prisoners. The unit would develop and administer oversight guidelines, coordinate various forms of on-site monitoring, and ensure the proper implementation of plans of action or imposition of penalties for noncompliance. (Chapter XI)

Additional Recommendations

AR-1. Unit management and security functions should be separated. Unit managers now report to the chief of security. This is not conducive to an atmosphere in which case management typically thrives. It sends a mixed message, and unit staff is prone to be less accessible to the inmates. (Chapter IV)

AR-2. The practice of having the Special Operations and Response Team continually visible in the halls in full riot gear should be discontinued. (Chapter IV)

AR-3. Significant improvements should be made in technology and automation, particularly in integrating basic inmate information with security/custody classification and separation orders (if any remain at the NEOCC). (Chapter VII)

AR-4. As decisions are made about changes in operations, care should be taken to keep the NEOCC's body of policy current, so that staff learn to rely upon and use those policies, as well as to maintain an authoritative history of policies that were in place. (Chapter VII)

Executive Summary

Part C: Narrative Description

Overview. The Northeast Ohio Correctional Center (NEOCC) in Youngstown, Ohio, opened on May 15, 1997 and immediately began having a long series of serious breakdowns in its most basic functions of security and safety. Both the Corrections Corporation of America (CCA) and the District of Columbia Department of Corrections (DOC) repeatedly made seriously flawed decisions, as expediency often prevailed over good judgment and sound management procedures. It is reasonable to conclude some of the major incidents were preventable.

In early 1997, Margaret Moore, the former Director of the District of Columbia Department of Corrections and her administrators were faced with a crumbling situation at the Lorton prison complex, to wit, a dangerous downward spiral combining repeated violence with stringent court-ordered population limits, a history of previous management problems, and crowded housing in dilapidated and insecure facilities. At that time, CCA approached District officials with a proposal to house at least 1,500 inmates in a new, very strongly designed prison the corporation was building on speculation in Youngstown, a large facility for which they had no prospective population.

An opportunity which very well could have worked out to the great benefit of both organizations, as well as for the City of Youngstown, was squandered by a short-sighted, quick-fix approach. CCA repeatedly practiced inadequate correctional management and DOC, eager to grasp a simple solution, failed to properly administer and monitor the process. Following the long series of devastating breakdowns at NEOCC, both CCA and DOC, each in their own way, have taken steps to remedy the situation, although circumstances remain very fragile and the facility is a long way from gaining a solid footing or any final resolution.

A continued high level of attention by both organizations, not to mention close public scrutiny, will be necessary for the ultimate success of this project, which is so important to both parties, as well as to the community of Youngstown.

A. Background Developments

To understand the problems of the past eighteen months at NEOCC, it is helpful to understand recent historical developments of the three principal parties, the City of Youngstown, CCA and DOC. (Reference Chapter I)

After a long period of economic problems, the City of Youngstown had been eagerly pursuing a course of attracting one or more prison projects to the area for several years, targeting the present NEOCC site for a state prison. When those attempts failed, they were approached by CCA with a proposal to build a large private prison there.

As a large and rapidly growing private prison management company, CCA was looking for new business opportunities in that region, an area of the country in which private prisons had generally not been opened. The negotiations led to the signing of a development agreement between CCA and Youngstown in March 1996. The agreement clearly called for the prison to be of medium security. CCA rapidly began construction and substantially completed the facility by early 1997. At the same time, the company went about seeking a jurisdiction that needed beds for its inmates.

CCA had been in negotiations with the District of Columbia before and during this period to purchase and manage a relatively new, urban high-rise facility in Washington, D.C. known as the Correctional Treatment Facility (CTF). They were thereby familiar with the deteriorating and very public crisis facing the Department of Corrections, with the resulting urgent need to remove troublesome inmates from the Lorton complex. CCA officials offered a proposal to the District for use of the Youngstown facility.

For its part, DOC was faced with multiple problems and very few viable alternatives. In addition to functioning as a municipal jail system, the District for decades had maintained a parallel, state-like responsibility of administering its own prison system for sentenced felons. For that purpose, it operated a complex of seven prisons in the suburban Virginia community of Lorton, at times housing more than 7,000 inmates. In 1997, the number was down slightly to approximately 6,000 at the complex.

The Lorton facilities were poorly designed for their current mission, being almost exclusively open-bay dormitories with few of the secure cells commonly used to house long term inmates. The facilities had been allowed to badly deteriorate and a number of other management problems had long plagued the complex. This crisis culminated in a series of violent, sometimes deadly assaults and other disruptions, particularly at the Occoquan prison, a nominally medium security facility which was forced to manage a very tough, higher security inmate population. With Occoquan on the verge of disaster, DOC officials in January of 1997 transferred at least 175 of the most disruptive cases out of the Washington, D.C. metropolitan area to local jails, in anticipation of the successful completion of DOC/CCA negotiations on the use of NEOCC.

B. Rapid Procurement Process

In the context of this ongoing crisis, CCA had approached the District with its Youngstown proposal and the DOC was eager to do business. Because of the perceived emergency, the District entered into a very rushed procurement process, shortcutting some of the normal practices used in competitively bidding the award of a large prison management contract. Competition from other companies was effectively impossible, and the District suffered in the results. (Reference Chapter II)

There were several difficulties and delays in the business negotiations, but the ultimate result of this hurried process was a contract with a number of flaws that still plague this project. Some of the primary deficiencies are:

C. Highly Accelerated Start-up Pace Results in Major Problems

After a February version of the contract was rejected, an interim contract for 900 medium and high-medium inmates was signed May 13, 1997, sparking a precipitous rush to fill the facility. Normal correctional management precautions in the opening of a new secure prison were ignored by CCA and DOC, as each party was highly motivated to move as quickly as possible to fill all the contracted beds. DOC was eager to relieve pressures by ridding troublesome inmates from its system. CCA had a vacant prison with a payroll and other expenses. Expediency prevailed over sound judgment, leading quickly to devastating consequences with long-lasting impact. (Reference Chapter III)

During the interim period of negotiations from winter through May of 1997, DOC and CCA had been preparing for the opening of the facility. It is very clear that both sides were committed to the transfer of many difficult inmates, regardless of any contract language. Articles in the local Youngstown paper as early as February quoted Margaret Moore, the Director of the DOC, as saying that the inmates to be sent were "young, aggressive, and violent." The city of Youngstown had its first hint of the troubles to come.

During the contract negotiation period, numerous discussions about the selection of inmates were conducted between the parties. NEOCC administrators and staff traveled to the District to review files and to consult with DOC officials. Plans were made for transportation, including for the disruptive Occoquan cases and other inmates that had been temporarily transferred to out of state facilities. Newly hired NEOCC staff consistently report being informed in training that the facility was to receive the "worst" of DOC's cases. CCA seemed confident that its new, very strongly built facility would compensate for the inexperience of staff and the difficult nature of the inmates.

However, the facility was not prepared or adequately organized for opening. Policies in a number of areas were nonexistent or inadequate, especially for the type of operation planned. A number of supervisory staff had little or no experience in prison operations. There was not an orderly plan of operation in place and any number of important processes were unorganized.

Any chance the inexperienced supervisors and their newly-minted staff may have had with this population was shattered by the joint decision of CCA and DOC to bring in the inmate population at a highly accelerated pace. Most experienced prison systems move deliberately and systematically in the start-up period of new secure prisons, especially those housing prison-wise inmates. Usually, the phase-in processes lasts at least several months, sort of a shakedown cruise for new staff, also allowing time to discover any unanticipated deficiencies in the building or its security. A pace of no more than 80 to 100 inmates per week would be common.

Beginning two days after the contract was signed, a total of 904 inmates were moved to NEOCC in 17 days, with 156 arriving in one day. Staff were overwhelmed. It would have been physically impossible to perform in any satisfactory manner the processing of so many inmates. Even with the most experienced staff, an agency would have to bring in a large contingent of temporary staff to accomplish such an accelerated process. Identification and other intake paperwork are required. Medical screening must be done. Classification and case screening is critical and time consuming. Bedding, toiletries and clothing must be dispensed. Inmates' personal property from the sending institution must be inventoried, searched, and distributed. The list of such preliminary procedures is extensive.

For the activation process to succeed, it is of critical importance from the beginning that staff be in command of the facility and of its activities. It is vital that there be an atmosphere of order and control. There was no chance for that to happen at NEOCC, as staff frequently describe the first weeks as a period of chaos. The prison-wise inmates quickly took advantage of the disorganization, being additionally aggravated when they learned that provisions had not been made to have their individual property transported and distributed in a timely fashion.

Almost immediately, some inmates began to fashion weapons out of various material and equipment. A serious disruption occurred within two weeks and a series of assaults and stabbings began, including attacks on staff. A class action lawsuit was quickly filed on behalf of inmates, alleging a number of problems.

In spite of the pattern of problems, as soon as the permanent contract was signed in September, 513 more inmates were rapidly transferred in less than two weeks, and following a contract modification a few weeks later another group of 309 arrived in five days. The new staff continued to be overwhelmed with problems.

D. Selection and Classification of Cases for NEOCC

The selection and classification of cases sent to NEOCC have been matters of significant public dispute and confusion, particularly as to how and why the breakdowns in operation occurred and where the responsibility lies. Indeed, these issues are core ingredients in the NEOCC controversies that prompted the current review. This report treats these issues in significant detail in Chapter IV.

The failure of DOC and CCA to perform rigorous case reviews and to take care in the selection of the population for transfer contributed substantially to many of the problems which quickly surfaced at NEOCC. Managers of both organizations were informed, willing and mutually responsible players in the transfer of large numbers of inmates who could not be considered medium or high-medium under any reasonable correctional standard.

Common practice in any interagency transfer of inmates dictates that the contract should specify the type of inmates to be sent and the necessary review process for accepting inmates. Based on DOC's contract with CCA, the cases at NEOCC were to be medium or high-medium using the DOC classification instrument. In reality, the DOC classification system did not contain a category of high-medium, although there was such a category in common, informal use within the DOC daily operations. It is apparent that from early on the joint working assumption on the part of CCA and DOC was that the high-medium category was a subset of the broader category of medium. To them, this was an implicitly agreed upon method of "widening the net" from the traditional category of medium, without technically including Maximum security inmates. Thus, CCA could technically attempt to meet the letter of the development agreement it had negotiated with the City of Youngstown, to which DOC had not been a party.

1. Failure to Screen Cases. The contract clearly gave CCA the right to receive and review full background classification information from DOC and to reject unacceptable cases prior to transfer. Such a stringent review is common practice by correctional agencies receiving inmates in an interagency transfer. CCA is an experienced correctional agency which is frequently involved in such contracts and in accepting out-of-state cases from other agencies. It is a reasonable assumption that the company would have had in place on an agency-wide basis and at NEOCC adequate screening procedures, including a practice that no inmates would be accepted without sufficient classification material. As part of this process, it would be expected that they would have a trained case management staff to closely review all incoming cases.

CCA and the first administration of NEOCC did not have any such capacity in place before the facility was opened or for almost one year after the first inmates arrived. Not until the Federal Court intervened and forced the issue was such a measure implemented. NEOCC simply took all cases sent its way by DOC without exercising its right to previously review case material or to reject cases. When it was clear that a number of very sophisticated inmates with long sentences and histories of institutional disruption had arrived and were causing problems, there still was no prior review process nor any attempt to reject cases or to exercise the right to return them. This failure is of particular concern in the case of more than 200 inmates who had separation needs from each other and who should not have been allowed to remain in the same institution. NEOCC continued uncritically accepting these cases. For its part, DOC's top management knowingly sent many of the most troublesome cases in its system, regardless of their security level. The first 200 inmates to arrive were primarily the dispersed troublemakers from Occoquan and other cases that had been moved out of state.

For transfers beyond this first group, DOC had set up a central point of review for cases to be sent, and the staff there, reportedly working nearly round the clock, tried to adhere to criteria set out by the DOC administration. Those written criteria however, did not make reference to the security level or score of inmates. Over 2,000 cases were reportedly screened to find the balance of the first 900 sent.

Subsequently, as part of the full 1,700 NEOCC population, 274 cases were sent from the Maximum Facility at Lorton, about 40% of that facility's population, most of whom had been on lengthy lock-down for disciplinary reasons. Another 880 were sent from the troubled Occoquan facility, so that over half its population went to NEOCC. Conversely, a number of minimum security cases were also transported there.

Although some abbreviated set of file material was sent on each inmate, too often it was not adequate. Of particular concern was the lack of adequate medical records material. Unquestionably, as with so many other problems with this project, many of these latter shortcomings are directly attributable to the precipitous pace at which staff were forced to work to implement the policy decisions of management.

2. Successive Changes to Two Other Classification Models. As part of the proceedings in the class action lawsuit in U.S. District Court, NEOCC was ordered in late winter of 1998 to adopt a modified classification system, that of the National Council on Crime and Delinquency (NCCD) and to reclassify all inmates under that system. Dr. James Austin from NCCD was instrumental in guiding that review for CCA, ending in June. The review resulted in identifying 119 maximum security cases which the court required to be removed. Most were removed to two other CCA facilities in Tennessee and New Mexico under the same contract. Perhaps not surprisingly, both these facilities soon encountered significant difficulties in their management of this population.

In the wake of the controversy following the July escape, DOC agreed to adopt the Federal Bureau of Prisons classification system for NEOCC, a much more stringent model it had already implemented at the remainder of its facilities earlier in the year. It would transfer all inmates rated above medium on that system. In an amendment sponsored by Congressman James Traficant of Ohio, that decision was subsequently made a requirement of Federal Law by Congress in the 1999 District of Columbia Appropriations Act. That Congressional requirement will be effective April 1, 1999.

An initial review of NEOCC cases using the Federal model indicates that over 500 additional cases exceed medium security by that model and must be removed. That transfer process is underway. Upon its completion, NEOCC should be cleared of all higher security cases and will be housing only cases which are reasonably considered to be medium security. The process is also well underway to remove all separation/enemy cases. The resulting impact of all these changes to the population should mean that the management of the facility can function in a much more orderly and secure manner.

Since the initial activation period, both the DOC and the CCA/NEOCC leadership have instituted many improvements in this area and appear to be committed to responsibly handling the selection and classification of inmates. While there still are considerable necessary improvements to be made to the case classification capacity at NEOCC, the management staff have made a good start in recent months and seem committed to rectifying the severe inadequacies of the earlier period which led to such problems.

E. Security Issues

During the first 15 months of NEOCC operation, there were fundamental breakdowns attributable to the institution and corporate management, in meeting their most basic security missions: to protect the community from escape; to maintain order and control; and to protect the safety and lives of the institution's staff and inmates. To some extent, the serious security failures are also attributable to DOC's inadequate oversight of the contract. Some of the major occurrences were:

Beyond those areas strictly related to physical or procedural security, overall security at NEOCC has been severely hampered by other fundamental operational problems, including extensive inmate idleness, the presence of groups of inappropriately classified inmates and separation cases, the inexperience of most supervisory and line staff, and poor levels of staff/inmate relations and communication. The chaos following the accelerated initial transfer of inmates had a lasting effect on the state of control and security at the facility.

In a variety of areas, NEOCC failed to adequately manage its most basic security responsibilities. As a major example, almost immediately after the first groups of inmates were received at NEOCC, inmates began to fashion weapons out of a variety of pieces of material and equipment. In many cases, this was possible because, in the rush to get the facility up and running, care was not taken by CCA to purchase material and equipment which would be safe from tampering by inmates. Food carts, laundry carts and numerous other examples exist of everyday equipment being harvested for steel rods and other pieces of metal. At least 110 such weapons have been discovered, too often only after they had been used in assaults. (Appendix 5 contains a list of these weapons.)

Similar problems existed in procedures for searches of inmates, their cells and other areas, most particularly failures in the highest security unit which led to the stabbing death of an inmate. Likewise, procedures for movement of inmates around the facility and within the high security unit were inadequate, including procedures for properly applying handcuffs. Perimeter security procedures were flawed in several ways, both in relation to the management of the perimeter fence line and in control of the front and rear entrances to the facility. Other examples of such basic procedural flaws are summarized in Chapter V.

1. Two Homicides. The long series of stabbings and assaults culminated in two homicides in a three-week period in February and March of 1998. On February 22, Derrick Davis was murdered in a cell by at least two inmates, apparently in a dispute over some minor personal property. While no unusual management or security concerns have come to light other than the presence of weapons, it must also be emphasized that neither CCA nor the DOC performed any after-action reviews to examine the circumstances surrounding the incident, as would normally be expected.

On March 11, in a devastating convergence of security lapses, Bryson Chisley was murdered in the high security, long-term segregation unit in an incident which should never have happened. Chisley and his assailant had previously inflicted serious injuries on each other in a knife fight in December. Inexcusably, they were not carried as official separation cases and were housed in the same unit and taken out simultaneously to adjacent enclosed recreation cages. During the process of being returned to their cells while in shackles in a group of five inmates, the assailant slipped his handcuffs and, with the assistance of the individual who was the principal assailant of Davis three weeks earlier, brutally stabbed Chisley to death.

Detailed in Chapter V is an extensive list of major security errors in this case, most of them attributable to lax management by the institution administration. The chief failures, in addition to the separation procedure breakdown, were that movement procedures in this unit were poor, searches of inmates and their cells were almost nonexistent (the unit log showed none for the preceding four months), restraint application procedures were inadequate and inconsistent, and oversight of line staff by supervisors had broken down. Additionally, Chisley's wife had been unsuccessfully imploring the administration to have him moved away from the other inmate in light of the previous altercation and continuing threats. She had gone so far as to take her case to the local press. All this, sadly, was to no avail.

CCA sent a group of senior officials to review the operations of the facility in the wake of the murder and made significant changes to operations, including replacing the warden with one of the members of the Review Team, Jimmy Turner. Inexplicably, that Review Team produced no after-action report nor any written document with findings or recommendations or plan of action for improvement. DOC sent a Review Team which produced a thorough report. That document is attached as Appendix 6. The CCA management team instituted a lengthy institution-wide lock-down in order to search for weapons and to classify and stratify the housing of the inmate population. Those measures seem to have had the effect of regaining a good measure of staff control over the facility, although the manner of conducting the search remains problematic, (as described in Section F. 1).

2. July Escape. On Saturday afternoon, July 25, 1998, six inmates all serving long sentences for violent crimes escaped through the perimeter fence system of NEOCC. This precipitated a major emergency for the local community and turned intense media scrutiny and public attention on the facility. The escape is still under investigation by the U.S. Marshals Service and criminal prosecution by the U.S. Attorney's Office; therefore, a number of relevant details were not available to this Review Team. The Review Team did however, have access to sufficient preliminary information, including some review documents of CCA and DOC, to outline the main issues involved.

Shortly after noon on a clear, sunny day, 219 inmates from the Low Medium wing of the facility were moved to the largest of three recreation yards, Yard Three, for a routine period of summer recreation. Although all six escapees were serving very long sentences and five of the six were convicted murderers, they were assigned to the Low Medium security housing unit. They were counted and processed to the yard through a malfunctioning metal detector by five relatively inexperienced correctional officers.

The five staff assigned may have been sufficient for coverage had they been allowed to remain on their assigned posts and if sufficient procedures for coordinated movement and rotation were established. Apparently, there was no planned system of movement. After 45 minutes, at 1:00 p.m., one of the two officers assigned to the baseball field was reassigned to cover an indoor housing unit and did not return until 2:10 p.m., by which time the escape had undoubtedly occurred. Reports show that other officers were allowed to leave their posts to use the rest room for unspecified periods. It is possible that the outside yard area went completely unsupervised for as long as 40 minutes. The large group of inmates may have been involved in distracting officers or in providing a human wall, thus shielding the view of staff.

During the entire period of recreation, no supervisors visited the area nor were there any telephone checks. In fact, the shift commander, a captain, turned over command of the entire facility to a very inexperienced lieutenant. The captain's activities are mostly unaccounted for, as he reportedly completed paper work in an isolated office.

Sometime during this period, the six inmates cut a four-foot hole in the heavy gauge chain-link inner perimeter fence near the recreation yard, proceeded past some razor ribbon and then cut another hole in the outer fence before escaping undetected by staff, including the those in the two perimeter patrol vehicles on duty. Fortunately, no large numbers of inmates chose to take similar advantage and follow the route of these six. The source of the cutting tool or how it was moved around by the inmates is still unclear. The remaining inmates were returned to their units, without having been counted off the yard as policy provides. At approximately 2:40 p.m., a unit manager was informed of the escape by an inmate. Staff immediately found the hole in the fence and began a count procedure to determine how many inmates might be missing. There is significant controversy and some confusion over the reporting of the escape to the local police. It was at least 30 minutes, and likely more, after initial discovery of the escape before a duty officer made an official call to the police. After the arrival of law enforcement authorities, there was additional confusion and lack of coordination, due to the lack of an interagency emergency plan.

There followed an extensive manhunt, as the six inmates were gradually apprehended. The last one was arrested in upstate New York several weeks later. Because most of the inmates were arrested in the immediate area, close to the prison, it appears there was no elaborate preplanning and little or no outside assistance.

In addition to this current review, CCA and DOC each performed after-action reviews and the Ohio Legislature's Correctional Institution Inspection Committee reviewed and reported on the escape. Based on those reports and its own research, the Review Team found that there were several primary contributing factors in this incident:

A number of recommendations were made by both the DOC and CCA Review Teams. NEOCC kept the recreation yard closed for more than two months while they made significant upgrades to security and followed through on implementation of the recommendations. During the current review, the independent security audit team found that most recommended modifications had been made and identified additional physical and procedural changes. The NEOCC administration committed to implementing these additional requirements.

One of the greatest concerns of the Review Team is the immediate need for institution and corporate mangers to monitor the attention given to supervision and training of inexperienced staff and uniformed supervisors.

3. Management Failures on Security. Another major concern of the Review Team was that fundamental security was repeatedly compromised by the larger corporate structure's apparent inability to (1) assure the implementation of adequate security in a newly opened facility; and (2) learn from major security breakdowns at one facility, while rectifying similar problems or instituting preventive measures at other secure facilities. In the latter regard, there have been several similar escapes at other CCA facilities.

Some of these escapes, including the NEOCC incident, might have been prevented had CCA implemented company-wide reviews or changes, based on weaknesses found in earlier escapes or if it had in place effective internal controls and security audit processes. The Review Team discovered no company-wide policy changes or alerts to wardens on lessons learned from these escapes.

Similarly, after the major failures occurred in the procedures at NEOCC's high security unit leading to the Chisley homicide, very similar incidents occurred in recent months involving problematic DOC inmates transferred from NEOCC to two other CCA facilities. In both cases, high security inmates slipped their handcuffs while being escorted by staff in the high security segregation units.

In the first incident, at CCA's Torrance County New Mexico facility in early August 1998, a DOC inmate from the high security unit being removed from a small, fenced recreation cage managed to slip his cuffs, assault the officer and take his keys. He then freed approximately ten other inmates from adjacent recreation areas who engaged in a serious brawl with a number of responding staff. At least five staff were injured and required hospital attention. The incident was only brought under control when security staff fired a warning shot. Had that action not been taken promptly, the incident might well have had a more serious or even tragic conclusion.

Again, CCA indicates it conducted an on-site review of the circumstances surrounding this incident, but failed to produce a report containing findings or recommendations for improvements to this facility as well as, similar units around their system. They asserted that the incident was not serious enough to warrant such a report.

In an incident reminiscent of the March Chisley murder at NEOCC, a homicide occurred at the CCA's Mason, Tennessee, facility on the evening of August 27, 1998. Two inmates transferred from NEOCC , who apparently had developed some animosity, engaged in an incident two weeks before. Despite orders not to do so, staff removed both of them from their lock-down cells at the same time in the high security unit, one for a phone call and the other for a shower. After they both produced weapons, one slipped his handcuffs and brutally stabbed the other to death.

The Review Team has not been able to determine, after repeated requests, whether CCA performed an after-action review of the incident. Only recently, did CCA prepare and forward information regarding the remedial changes they made in response to DOC's review of this tragedy. This review is attached as Appendix 9. The findings of multiple breakdowns in basic security procedures and the lack of proper supervision were almost a carbon copy of the findings at NEOCC in the Chisley case.

4. Detailed Security Audit of NEOCC. Because of the serious controversies surrounding the security of the NEOCC facility, the Trustee's office commissioned a very detailed audit of the current state of institution security, by a team of independent experts who used a nationally accepted audit instrument and process. The audit team performed a week long comprehensive review from September 21-25, that focused on current operations rather than on earlier operations or problems. The full report is included as part of Chapter V.

It is important to note that this was the first security audit conducted at NEOCC. In spite of all the accumulated problems, CCA had never undertaken such an audit, neither by in-house company security experts, nor by contracting with available outside experts.

In summary, the security audit team found that over recent months under Warden Turner major progress had been made in a number of areas and most technical security procedures were sound or in the process of being rectified. Although several significant weaknesses and a number of areas needing attention were identified, the security audit team did not find that the technical security procedures are fundamentally flawed or particularly out of line with the level which might be found at most comparable, relatively new facilities when given a similarly intense audit. They found that significant corrective steps have been taken and are ongoing to rectify some of the fundamental breakdowns in earlier security procedures described above.

There were two remaining major areas of critical concern and weakness noted by the audit:

It will be of critical importance for long-term success and safe management that CCA/NEOCC take steps to implement the numerous recommendations contained in the report and to continually monitor itself in maintaining standards of acceptable security.

F. Management of Inmate Population

1. Idleness. The CCA/DOC contract requires NEOCC to provide "sufficient programming to allow every general population inmate to participate in programs of occupational training and industrial or other work . . . " or " . . . to participate in meaningful educational, vocational, drug treatment or work programs..." NEOCC has never come close to complying with those requirements. While there are some opportunities for daily work and training, or educational and drug treatment programs, the pervasive idleness of most inmates has remained a salient, negative feature of NEOCC throughout its existence.

The majority of inmates do not have regular work assignments but work for only a few minutes each day on tasks in the living unit. At the time of the review, only 153 inmates had jobs outside of the living unit. Seventy percent of these inmates worked in the kitchen while the remaining 30% worked in the laundry, commissary, education, or on a maintenance detail.

On average, educational and vocational training programs provide inmates with no more than six to eight hours per week. There is only sporadic recreation off the units. The provision of meals in the small housing units, an approach which enhances control, further cuts movement and reinforces the sense of idleness. The one program which does consistently provide meaningful, constructive activity is the Addictions Treatment Unit program which involves about 60 inmates. The institution was planning to double the size of that program by expanding to another housing pod. The idleness is aggravated by procedures that are necessary due to the housing of separation/enemy cases in general population. These procedures prohibit inmates housed in separate wings from using recreation, educational, and program space simultaneously. Once all the separation cases are removed, hopefully in the near future, NEOCC should be able to expand some of its program participation. The inmate idleness has become a destructive pattern that will evolve into a part of the institution's culture if allowed to continue much longer.

2. Inmate/Staff Relations. The Review Team was continually struck during its visits by the poor level of communication and lack of trust between inmates and staff, although the current warden has recognized this problem and has more recently made a start in prioritizing this area for improvement. (See Chapter VI)

These relations were severely damaged by a prolonged episode in the spring of 1998 during which an extensive search of all housing units was instituted following the two murders. Unnecessarily harsh and humiliating procedures were employed, souring internal relations. This incident continues to have serious negative ramifications on the safe and secure management of the facility. Although it was understandable and acceptable to lock down the inmates and to perform extensive searches for weapons, the manner of the searches went well beyond common or necessary correctional practice and seemed intended to systematically degrade and humiliate all the inmates. Apparently, the intention was to assert a sense of control over the inmate population.

These procedures were implemented by a group of senior managers sent in by CCA, including the current warden. To accomplish this, emergency teams heavily outfitted in riot gear, after performing a customary strip search of each inmate, refused to allow the inmates to at least cover themselves with shorts and led them shackled and naked out of their cells where they forced them to lie on the floor in groups or to kneel, leaning with their face against the wall for 30 to 60 minutes while the cells were searched. Frequently, female staff were present in the units providing backup or medical support for the operation. Some of them reported to this Review Team being embarrassed for the inmates. Inmates who objected were forcibly removed to segregation by the special operations and response teams (SORT), at times with the use of stun shields. Official NEOCC reports account for more than 40 forcible moves by teams during this period.

There were complaints by inmates, and in some cases confirmed by other staff, of brutality and excessive use of force by some SORT teams. A summary of these allegations made to an on-site DOC Review Team is found in their report which is attached as Appendix 6. This episode and the issues and complaints raised regarding it have never been adequately investigated and reported on by the management of CCA or DOC.

This episode started the current warden's administration off on a very negative note. He could not provide the Trustee's Review Team with any legitimate correctional management rationale for the extreme manner in which these searches were carried out over a period of weeks.

These findings raise a concern that CCA management either planned and carried out this inappropriate episode or that they encouraged or condoned it through their on-site management team. It was only after the insistent intervention of top management from DOC that the procedure was slightly altered, as the search teams began their second wave of searches through the facility. At that point, inmates were allowed to put on shorts while lying on the floor or kneeling against the wall.

Because of the serious complaints of staff abuse during this period, the Director of the DOC requested the top management of CCA to investigate the allegations, sending along a group of photographs taken by DOC's Review Team. In spite of several requests, CCA has not responded by producing any report and asserts it has lost the photos. Also, CCA has not responded to similar requests from the Trustee's Review Team, forcing the conclusion that as a correctional entity CCA does not possess the capacity to perform an effective internal investigation, is unwilling in this case to perform such an important function, or at the very least will not release the results of such a review to proper authorities. These failures have hampered and obstructed important work of both the DOC and Trustee's Review Teams.

At the same time, it must be concluded that it was imprudent of the Director of the DOC to have allowed a private company to investigate itself where some of the credible complaints describe actions bordering on unconstitutional or even criminal behavior and to have done so orally, not in writing. It was also unwise to have sent the Polaroid photos without making any copies or sending a cover letter. However, when the Director did not receive a quick response, she wisely referred the case to the FBI for investigation.

G. Operational Management and Controls, A Reactive Mode

NEOCC management has either been one of passivity in the beginning -- trying to get by with the hand dealt it -- or eventually one of continually reacting to events generated by inmates or by the intervention of outside forces. Slower in coming, was proactive management which might include any internally driven innovation through self-assessment and good planning. (Reference Chapter VII)

Numerous major changes in procedures, programs and leadership have been spurred primarily only in reaction to such intervening events and outside forces like the series of assaults, murders and escapes, the class action law suit, the close scrutiny of an Ohio legislative committee, widespread attention and criticism of elected officials and the local and national media, oversight reports by DOC, the passage of Ohio House Bill 293, and the current review ordered by Attorney General Reno. There is little evidence of internally driven change and improvement.

1. Limited Capacity for Self-assessment. This evidence of reactive management raises questions about CCA's and NEOCC's capabilities for ongoing internal controls, self-assessment, and internal audits. Effective management of a correctional institution requires a system of continual supervisory review, ongoing self-assessment, identification of weaknesses and corrective actions, both internally at the institution level and externally from the corporate level.

Except for an early medical audit and preaudit assistance conducted in preparation for the recent American Correctional Association accreditation audit, CCA had completed no other internal or external audits of NEOCC, at least none that the administration could produce for the Review Team.

As mentioned, the Review Team has been repeatedly told that no report was generated by CCA's visiting management team after the two murders. Thus, there are no written analysis and recommendations that could be implemented at NEOCC or shared with managers at other CCA institutions, specifically those holding the difficult inmates transferred from NEOCC. Unfortunately, similar security breakdowns occurred in at least two other CCA facilities as referenced in Chapter V. Likewise, the Review Team was told that no assessment report was written after the disturbance by DOC inmates in August at CCA's Torrence, New Mexico, facility nor after the homicide in Mason, Tennessee.

On several occasions, Review Team staff were informed by CCA administrators that written reports were not done after critical incidents on advice of legal counsel. It is apparent that more importance was given to concerns for documents turning up in subsequent litigation than with correcting past problems or with preventing future ones in various facilities.

2. Recent Progress, Accreditation Audit. With NEOCC's new leadership, there appears to be a more internally driven form of management, and an attempt to get ahead of events and outside scrutiny. One example is the recent initiation of the process to seek accreditation of the facility through the American Correctional Association (ACA) and the National Commission on Correctional Healthcare (NCCH). These arduous processes involve months of self-assessment and internal review, including periodic assistance and review by accreditation specialists from corporate headquarters. The actual ACA Accreditation audit was scheduled for late October, just as this report was being written. CCA appears to be throwing the full weight of its corporate resources behind assisting NEOCC in this project. Based on the intense preparation and focused improvements, there is a strong likelihood of favorable results.

The concern of this Review Team is for sustainable progress. Once this particular impetus for internal auditing fades along with other intense outside scrutiny, CCA and NEOCC leadership must ensure that it has a formal, ongoing system for self-assessment that not only identifies deficiencies, but then corrects them.

3. Operational Policies. A good policy system for a correctional agency should provide requirements and guidance for all major processes, programs, and procedures. As well as could be reconstructed, this review found that there were not adequate written policies in place at NEOCC for key operations for much of the first year of activation. In particular, they were inadequate for the DOC felon population NEOCC began receiving in May 1997. Often those policies were not adapted from the generic CCA corporate format to meet the specific, detailed needs of the NEOCC operation. In fact, the NEOCC warden indicated to the Review Team his dissatisfaction with many of the policies in place when he arrived in March 1998.

In reaction to the intervening events, a great deal of corporate and institutional effort has been thrown into correcting these shortcomings. Virtually every policy in place has been finalized or reformulated in the past seven months. The result of these efforts is very encouraging and is a credit to the present administration, as the current set of operating policies is very functional.

4. Automation. Another area of concern about operational management that emerged during the Trustee's review was the NEOCC's limited use of technology. While some of the security measures are extremely dependent on technology, other key operations are impaired by inadequate equipment and resources, particularly in the area of information technology. Several of the key areas showing deficiencies were the inmate information system, the database for separation orders, and basic office and communications technology.

5. Leadership Change. While there may have been other deficiencies in CCA's management approach, it did take decisive steps in an attempt to improve the situation. Over time, NEOCC virtually removed the entire top management of the facility, including replacing the warden, two assistant wardens and the chief of security. This last position, in fact, has turned over twice. There has been an infusion of new staff in certain other positions at the next intermediate level.

Warden Turner had formerly been a warden elsewhere for CCA, but more recently had been promoted to a key position of executive leadership at corporate headquarters. Assigning him from that position to the warden at NEOCC in its darkest days, on balance, has proven to be an effective move. He, however, made a critical lapse in judgment immediately upon arrival by allowing the widespread searches in March and April to be conducted in such a demeaning and unnecessarily harsh manner. Likewise, it was four months after his appointment that the July escape occurred, with all the attendant security and management problems associated with it.

More recently, this new leadership team, particularly Warden Turner, has had a positive impact, as noted in several sections of this report. Overall, there is a greater sense of organization and coherent progress toward goals. It was observed that there has been an improvement in staff morale, accompanied by increased loyalty and pride in the organization. By moving his office from the front administration area to the busy inner part of the facility, the warden has given a strong signal about the importance of communication between line staff and inmates. There are also indications of improvements in the priority given to relations with local leaders and law enforcement agencies. Again, a principal concern of the Review Team is the sustainability of the progress made. How much of the change is being built into the fabric and structure of the operation, versus being dependent on the strong personalities and experience of the new leaders who could be moved along at any time?

Another concern is the repeated removal or transfer of minority staff in top management positions, particularly since the inmate population is almost exclusively African American. A void has been created with the recently announced transfer of an assistant warden, the last of four minority members of the top level administration. Hopefully, this trend will not have a negative impact on the already strained relations between staff and inmates.

For now, significant progress has been made by the new leaders in overcoming the considerable problems of the first year of operation.

6. Lack of an Organized, Written Plan of Action. Although progress has been made by the current administration, the Review Team had a significant concern that, as with the administration of the first warden in the activation of the facility, there is no evidence of an organized, written plan of action that is guiding the management of the facility and which is available to staff at all levels. If the current progress is to take root and be sustained, it is important for major problems, priorities, and objectives to be identified along with target dates for completion and persons and offices made responsible for meeting those objectives.

H. External Relations and Public Accountability

Poor external relations with the Youngstown community are principal among the problems presently confronting NEOCC. While the facility initially received a favorable response from the political and lay structure of the City, public disapproval and suspicion have since added to the prison's difficulties. While the current warden has made recent efforts to improve this situation, considerable ongoing progress is warranted.

Prior to the opening of the facility, CCA officials eagerly sought and eventually achieved from city leaders ratification of its proposal to build a prison in Youngstown. The City was receptive to CCA's desire to establish a presence in their locality and officials of CCA cultivated local leaders in a number of ways during this period. During that same period, it is now clear, CCA was moving forward with plans to accept and manage at NEOCC a group of the most difficult inmates from the troubled DOC Lorton complex. Once the prison was established, little effort was made by NEOCC to maintain a partnership with citizens or public officials or to create an open line of communication with area law enforcement agencies. Rather, isolationism, a posture of independence and inaccessibility, characterized NEOCC's approach.

As the frequency of adversities at the prison increased, both public and official concern rapidly became directed upon the internal operations of the facility. Moreover, the appearance of isolationism and unresponsiveness to public inquiry on the part of CCA and NEOCC leadership significantly contributed to an environment of community mistrust of the corporation that quickly translated into fear for public safety.

Public trust and community relations were again severely damaged in May 1998, when the institution refused admittance to the Correctional Institution Inspection Committee, an official group representing the Ohio Legislature. The group was led by its Chair, a State Senator, and included another member along with staff and associates. This denial intensified the already problematic relations between NEOCC and government authorities.

1. Local Law Enforcement Concerns. The relationship between NEOCC and local law enforcement agencies is seriously strained and constitutes a problem of major magnitude. Interviews with the Mahoning County Sheriff and Youngstown Chief of Police revealed a climate of tension and lack of professionalism. While there have been recent signs suggesting improvement in their interactions, a rapprochement has only begun.

The lack of interagency coordination was made evident during the July 25, 1998, escapes of six inmates. As reported by both the Sheriff and Police Chief, law enforcement personnel arrived at the prison only to find near chaos, an absence of organization, and no agreed upon, preplanned response. Although a mutual assistance emergency agreement existed at the time of the escapes, the document was fragmented and incomplete. Procedures for addressing hostage taking, inmate evacuation or mass disturbance were not included. More recently, the plan has been updated, but at the time of the Review Team's last major visit, the current version had not been officially activated, since it had not been signed by any of the authorities who would be directly involved in its implementation.

Serious concerns over the manner in which criminal investigations are processed at NEOCC have been expressed by local law enforcement officials. There is obviously some role confusion on the part of NEOCC management in relation to criminal matters, as it does not have adequate policy or a clear understanding of its responsibilities.

A review of police records revealed that these public authorities were not typically alerted when stabbings took place at the prison and only learned of their occurrence through notification by local hospital personnel. Furthermore, when victimized by inmate assaults, employees have often been left to seek criminal charges in their capacity as private citizens, receiving minimal support from NEOCC officials in the filing of their reports. There is no clear policy or understanding among the administration at NEOCC as to procedures for referring possible crimes to police, nor is there clear understanding even by the warden of which person or office carried that responsibility.

This lack of clear policy and management direction was brought into focus in the botched handling by NEOCC staff of the follow-up to the Derrick Davis murder. It is not appropriate for employees of a private company to perform an independent criminal investigation of a murder. In spite of original assertions that CCA staff had not conducted an investigation parallel to that of police and prosecutors, it was surprisingly revealed to prosecutors only during the trial of two accused assailants that a NEOCC staff member did conduct a parallel investigation, including inappropriately making tape recordings of interviews. The result of this admission was that the two suspects were allowed to plead guilty to lesser charges and to receive relatively short concurrent sentences. This mishandling of the case provoked a strong public complaint from the county prosecutor's office.

Over the past few months, the current administration has made efforts to remedy some of the previous disharmony, including reaching out to the local Chief of Police. Likewise, the recent creation of a Citizens Advisory Committee by NEOCC is seen as a positive step toward community outreach and inclusion. While the development of the Citizens Advisory Committee is considered to be favorable, its ability to reverse what appears to be deep-seated public skepticism regarding NEOCC is uncertain. Nevertheless, the first meeting of the group was held this fall and, if vigorously pursued, the process has the potential to assist NEOCC in rebuilding its community relations.

2. Limited Sense of Public Accountability. Finally, the Review Team repeatedly heard a concern from a number of public officials and others interviewed that there is a very limited sense of public accountability evidenced by CCA. This concern cuts across several areas addressed throughout this report and is consistent with a number of the findings of this review, summarized in Chapter VIII. In short, a significant credibility gap exists in many quarters for CCA as to the company's commitment to be fully accountable to public representatives, especially in view of the fact that it is well reimbursed for carrying out a very sensitive public, societal mission on behalf of various governmental authorities.

I. Staffing/Human Resource Management

The Review Team found the staffing level of 518 authorized positions to be adequate. This number includes contract staff, such as medical and food service personnel. The overwhelming number of these employees had been hired from the local area, fulfilling CCA's agreement with local city leaders. Unfortunately, the vast majority had no correctional experience, placing them and the institution at a severe disadvantage in dealing with a prison-wise group of offenders in a large facility. With the poor match of inmates to staff and supervisors at NEOCC, it could reasonably be concluded that CCA and DOC have been very fortunate that the degree and extent of documented problems have not been more severe.

1. Lack of Experienced Uniformed Supervisors. Of particular concern is the lack of experience among mid-level managers and uniformed supervisors at NEOCC. Especially at a newly opened facility, it is this rank of staff which must be counted upon in a correctional environment to provide guidance to newly hired staff. By their own words and actions, it is vital that these supervisors demonstrate in a variety of circumstances the control, confidence and organizational skills necessary to successfully manage and communicate with the inmate population. At NEOCC, however, many individuals placed in supervisory or senior officer positions lack the experience and training to adequately perform this function. A review of employee personnel records, revealed that among the 30 sergeants, 16 had no prior correctional experience, 13 had less than five years, and none had as many as ten years. Among nine lieutenants (assistant shift supervisors), one had more than 10 years, two had between five and ten years, and the other six had fewer than five years, including two with no prior correctional experience. Finally, among the six captains (shift supervisors), while two had more than ten years in the field, none of the other four had as much as five years experience. In one case, a correctional officer was promoted through the ranks to captain in one year.

The majority of the time during a 24-hour/seven day a week prison operation, it is these captains and lieutenants who are the ranking officials in command of the facility, and it is frequently during evening and weekend hours that critical incidents occur. For example, during the July escape on a Saturday afternoon, the captain in charge of the institution effectively turned command over to a lieutenant with less than five years prison experience and less than one year as a supervisor. He had worked for less than one year for CCA at

another facility and had recently come to NEOCC, apparently to acquire a promotion. The experience level of the captain could not be ascertained, as he had been terminated by the company.

In this context, it must be understood that more than any other factor, the July escapes were due to staff inattention and supervisory failure. In most areas of the facility, at most times during the week, the same very thin level of supervisory experience prevails, leaving NEOCC's security and operations still vulnerable. As time proceeds and barring extensive attrition, the supervisory staff will gradually grow in experience.

In part, this problem can be attributed to CCA's very elastic process for promotions. While they do have requirements for promotion to various ranks of uniformed supervision, corporate policy allows wardens to waive any and all requirements when making certain selections. A review of personnel files indicates that this discretionary option has frequently been used at NEOCC.

2. Line Staff Experience, Morale and Training. With the emphasis on local hiring, it is not surprising that 80% of the correctional officers hired were new to corrections. Interviews conducted revealed that most believed they were ill-prepared because of their lack of experience and training to deal with this inmate population. At the same time, the interviews showed the morale and sense of loyalty to the current administration to be quite good.

The amount of pre-service training has been expanded in recent months in an attempt to make adjustments for the low level of experience. It must be noted that the pre-service training does not include a basic firearms course for all uniformed staff, a concern expressed by a number of staff. There is also a concern by this Review Team that in-service training for on-the-job employees is insufficient.

J. Health Services Management

In a pattern similar to that found in other functional areas at NEOCC, the health services department initially experienced significant disorganization and operational failures, before more recently making significant improvements. (See Chapter X)

Medical services are subcontracted by CCA to Emergency Medical Services Association (EMSA), a private health services firm based in Florida. As the primary managers of NEOCC, CCA retains significant responsibility with EMSA for the ensuing problems. Likewise, DOC was seriously at fault in several areas, most principally its failure to forward acceptable medical files and its delay in providing consistent medical oversight.

Staffing of the department at present is sufficient, with a total of 55, including one full-time physician. At the time of activation the health services staffing levels were deficient. In addition, most of the staff and administrators had no prior experience in prison health care, a disadvantage which was compounded by inadequate assistance and training provided

by EMSA corporate officials. Administrators reportedly were left virtually on their own following less than one week of training at EMSA headquarters.

When the institution opened and the rapid influx of inmates began, the medical operation was overwhelmed with the arrival of 400 inmates the first week and 500 more within days. There was no means to adequately perform the basic intake procedures. Further complicating the process was DOC's failure to provide adequate medical records and, in many cases, not sending any file at all. A final contributing factor was that many inmates arrived needing special medical attention, including 250 of the first 900 who needed chronic care for such pre-existing conditions as asthma, HIV, diabetes, high blood pressure, and heart disease. In fact, management of chronic care cases remained a significant problem for a long period. In spite of the fact that the lack of medical records was identified immediately as a problem, NEOCC continued to accept every case sent and rapidly bring in hundreds of cases, without insisting on its contractual prerogative of receiving an adequate case file before accepting the prisoner in transfer.

It is also noted that allegations of inadequate medical care constituted one of the major issues in the inmates' class action suit filed in U.S. District Court in the summer of 1997. In spite of intervening improvements in the medical services, inmates were found by the current review to maintain a persistent negative view of the quality of health care provided, possibly going back to the initial problems.

1. Oversight Begins. In July 1997, DOC conducted a review of health services which revealed a number of serious problems, including inadequate staffing levels, a backlog of sick call requests, and incomplete record keeping by the physician. Of serious concern was that neither CCA nor EMSA had performed any on-site reviews since activation, in spite of the problems. A strong recommendation was made for closer monitoring of this area.

Perhaps in response to these findings, CCA and EMSA conducted a joint medical audit in September 1997, resulting in findings of similarly critical deficiencies in record keeping and routine sick call procedures, where there was a four-week delay. It also revealed that, four months after opening, 200 of the 250 chronic care cases had not yet been medically screened and more than 400 inmate medical records had not been received from DOC. They also found various security breaches, primarily attributable to staff inexperience. They have begun to remedy the deficiencies.

A more routine pattern of monitoring and evaluation by DOC began in January 1998 following the retention of a consultant firm to perform this function. A number of deficiencies began to be resolved. During this year, there has been a steady improvement in the medical services to the point where this review determined them to be much more organized and well functioning, though not without some areas of continued concern.

2. Review of Current Operations. Because of the sensitivity of the area, the Trustee's Office engaged a nationally recognized specialist in auditing of correctional health care services to perform a review. In general, he found the department to have made significant progress and to be well functioning. He noted areas deserving of commendation, including management of HIV patients and nursing care coordination.

There was a major concern in the area of the management of inpatient beds in the department, leading to several recommendations. Several other problem areas rise to a lesser degree of concern. Among them are backlogs in the performance of laboratory tests, eye exams and dental visits. The management of chronic disease clinics appeared to only recently have become acceptable and is in need of close scrutiny.

In concluding this summary, the Review Team determined that a commendation for upgrading the department should go to the current EMSA health services administrator.

K. Contract Oversight and Management by DOC

The effectiveness of any government contract for services is directly tied to the vigor and organization of the monitoring effort by the contracting agency. This principle is especially true in the case of a large prison holding difficult inmates. Managing such a large, remote contract as NEOCC was a new area for DOC, and it adapted slowly and ineffectively to its responsibilities. DOC seemed relieved when the large group of difficult inmates was transferred to NEOCC, but its top management was not prepared to take the next step of providing close oversight through an experienced, on-site monitoring staff.

The DOC Executive Deputy Director, the second ranking official in the department, was designated as the contract administrator responsible for the day- to-day monitoring of the contract. That official was stationed in the District of Columbia and made only brief, sporadic visits to NEOCC. As a result, when the large scale transfer of inmates to the institution overwhelmed the operations and problems quickly arose, the contract administrator was not around to identify issues and request immediate intervention. When the initial problems became known, the DOC Director detailed other Department of Corrections officials, including another Deputy Director and the Chief of the Warrant Squad, to audit the performance of the NEOCC. This audit required two trips to the facility and took place May 28-30, 1997, and August 11-14, 1997. The audits found a number of serious concerns that needed to be addressed. Some of the concerns identified at that point were factors in the serious incidents that followed. The auditors also recommended that DOC send a team to the facility monthly to ensure contract compliance.

Since there was no full-time monitor at NEOCC throughout this period, and CCA was not independently reporting information about the difficulties it was experiencing unless a direct request came from DOC, it is not surprising that neither the contract administrator nor the audit team was fully briefed about the nature and extent of the problems at NEOCC. It was not until serious operational problems were raised in the class action suit in U.S. District Court that DOC took the initiative to hire a consultant firm to provide oversight.

In November 1997, DOC located and hired a consultant firm to monitor the Youngstown contract on a less than full-time basis. Because these contract monitors were not on site, considerable time, money and effort were consumed by their constant travel. While that firm was well organized and established a very systematic reporting and accountability system, its range of expertise was limited and it did not identify and require remedial action on certain serious security and operational problems. In the meantime, since shortly after the opening of NEOCC, the Chair of the Judiciary Committee of the D.C. City Council had been regularly and publicly encouraging the DOC Director to put a full-time monitor on-site at NEOCC. This sentiment was echoed by other public advocates for the inmates and the inmates' families.

After several futile attempts to locate an on-site monitor from within its own department, DOC shifted its focus to Ohio, including advertising in the local papers. DOC's prolonged efforts were finally successful when the Director of the Ohio Department of Rehabilitation and Correction arranged for an experienced Deputy Warden to be placed at NEOCC on loan to DOC starting in July 1998. He currently remains in place. DOC needs to significantly expand and better organize its contract monitoring function, as it continues to broaden the number of remote contract locations to transfer its inmates.

L. Summary of Current Status of NEOCC

While considerable progress has been made at NEOCC in recent months, the situation is still fragile. The future of this project which is so important for CCA and DOC as well as the community of Youngstown is uncertain. Under the pressure of devastating breakdowns and the resultant intense public scrutiny, CCA has made extensive efforts to improve its institutional operations and to begin to mend its relations with the community. DOC has likewise shown a serious commitment to: improve its oversight of the NEOCC contract, carefully screen transferring inmates and remove separation cases.

Under the leadership of the new warden, Jimmy Turner, significant advancement has been made in such areas as policy development and security procedures, general organization, positive communication between inmates and staff, and rebuilding ties to the local community. In addition to the reduced population size and a lower security profile of the population after the removal of over 600 higher security inmates now in progress, other hopeful developments are the growing experience level of staff and the apparent genuine interest of community leaders to see the facility succeed, in spite of previous problems.

Still, the operation remains extremely vulnerable, in that the various positive changes are not deeply rooted and the experience level of most staff and supervisors is very low. There is no organized, written plan of action for the management of the facility. In a secure correctional environment such as NEOCC, with inmates serving substantial sentences, other incidents and problems will likely occur to challenge the progress. How such events are handled will be a major factor in the long-term success of NEOCC. The longer the facility can go without any significant problems, the better its chance of success. An overriding concern is the pervasive inmate idleness which must be addressed in order to give the facility its chance to function as a safe and normal prison.

For long-term success to be achieved, it will take the full commitment to progress, accountability and mutual cooperation on the part of both CCA and DOC, as well as persistent public scrutiny and a touch of luck.

Chapter I

Previous Developments and Events Influencing NEOCC Contract

Introduction. The paths of three separate organizations, the City of Youngstown, the District of Columbia Department of Corrections and the Corrections Corporation of America, crossed at the Northeast Ohio Correctional Center. A brief summary of developments in the recent history of each of these organizational players should provide context for the succeeding analysis of events at the NEOCC.

A. The City of Youngstown, Ohio

As a mid-sized industrial city, Youngstown suffered serious economic losses over the past two decades with the decline locally of the steel industry and other sources of employment. As part of a strategy to develop the local economy and promote employment, civic leaders in the mid-1980's identified the current NEOCC property as a potential site to offer the State of Ohio for a new state prison. After a great deal of effort on the part of Youngstown leaders, the state selected another site in neighboring Trumbull County, the current site of Ohio's Trumbull Correctional Institution.

Eventually, Youngstown was successful in having the new Ohio State Penitentiary built on another site within the city limits and a large federal prison was also built in the area, near the city of Elkton. In general, it has been conveyed to the Review Team that prisons came to be viewed as "friendly, economically viable projects," and there was little serious opposition to their establishment. The community at large and the elected leaders became relatively sophisticated on correctional matters after some years of involvement with siting issues.

Reportedly, initial contacts between CCA officials and city leaders began several years ago when it became clear the current site would not be used by Ohio as a state prison. These negotiations eventually led the city to offer the site to CCA, including certain financial incentives, such as infrastructure lines, a three-year tax exemption and sale of the property for $1.00. Although CCA had no immediately identified source of prisoners, the project received strong backing from local and state governments. In March 1996, the city and CCA signed a detailed Development Agreement for the building and operation of a 1,500 bed medium security prison. Construction began very quickly.

B. CCA/City of Youngstown 1996 Development Agreement for Operation of a Prison

The Development Agreement between CCA and the City of Youngstown was designed to facilitate CCA's construction of a prison within the city's predesignated Enterprise Zone by offering CCA economic development incentives. It was incorporated by the parties as a binding covenant running with the deed to the property on which the prison was to be built.

CCA agreed to construct a 1500 bed medium security prison as a private enterprise which would contract with "various government entities, in numerous states, to house prisoners." In addition, CCA agreed to invest $35-40 million in construction costs and create approximately 350 full time, permanent job opportunities at the prison with a total annual payroll of $8 million within three years after the prison was completed. The first 1000 prison beds were to be open on or about July 1, 1997; an additional 500 beds were to be added on or before December 31, 1997.

With respect to the hiring of employees for the operation of the project, CCA committed to giving "first preference to residents of the City of Youngstown, and second preference in hiring to residents of Mahoning County." Included in this commitment was CCA's use of its best efforts to purchase goods and services from Youngstown-based businesses. Furthermore, CCA agreed to make 50 prison cells available to city prisoners at a cost "less than the cost paid by all other governmental entities" which house prisoners there.

Other standard provisions provided that CCA:

CCA also agreed to pay the costs of any breach of the Development Agreement, any damages caused by any inmate while in CCA's custody, and the cost of any city services resulting from any escape.

In exchange, the City Council authorized the transfer to the Company of 103 acres of land by quit claim deed, and granted the Company a tax exemption for three years from taxes that would otherwise have been levied on all of the personal property first used in the business and on all of the increases in the assessed valuation of the real property (or, at the option of the city, an equivalent tax incentive financing agreement that would provide the same net financial benefit to the Company). The city also agreed to provide that adequate utilities, including water, sewer, natural gas and electricity, were available at the site, and to waive its water and sewer line tap-in fees.

C. District of Columbia Department of Corrections

1. Troubled History. For several years, the District of Columbia Department of Corrections has faced a wide variety of problems, making it the continual focus of multiple court challenges and public scrutiny. Its difficulties have been well known in the public arena and in the American corrections industry. The very troubled recent history of the District of Columbia Department of Corrections (DOC) had a strong bearing on the shape and timing of the NEOCC project.

2. Dual Function. For a number of decades, DOC has functioned as both a local and state-like system. As a typical municipal system, it detains pre-trial, pre-sentence and other cases for the local Superior Court, probation and parole violators, and those misdemeanor or felony cases sentenced to relatively short terms. For the most part, those cases have been held at two secure high-rise urban facilities, the Central Detention Facility (CDF or the D.C. Jail), and the adjacent Correctional Treatment Facility (CTF). Some of the minor offenders have been housed in several community facilities operated or contracted by DOC.

At the same time, due to the unique status of the District of Columbia, DOC also performed the state-like function of housing convicted felons. These cases were primarily held in a 3,000 acre complex of seven prisons in Lorton, Virginia.

3. Urban Municipal Facilities. The D.C. Jail is a large high-rise facility in the District built in the mid-1970's. Throughout is existence it has had a series of problems resulting in successful court challenges, and for over 10 years it has operated with a court-ordered capacity of 1674 inmates.

Adjacent to the Jail, the Correctional Treatment Facility opened in May 1992 with a single cell capacity of 890. In view of other problems and needs in the DOC, the Congress funded $70 million of the $85 million construction costs and directed that the facility primarily provide for the needs of drug, diagnostic and other treatment programs, female offenders and an inpatient infirmary. It has performed those functions, while taking on others, including holding overflow cases from the jail. Of all the DOC facilities, it is the newest and by far the best maintained facility.

In 1997, the CTF was sold to CCA by the District for $52 million. The District is paying an annual leaseback fee of $2.6 million, and ownership will revert to the District after 20 years. CCA manages and staffs the facility with an average population of 800 at a current daily cost of approximately $82 per inmate, having retained a large number of experienced former DOC employees and supervisors.

4. The Lorton Complex. Built on 3,000 acres of federally owned land in Virginia about twenty miles south of the District, the Lorton complex is composed of seven separate prison facilities of various sizes and security levels, from minimum to maximum. For the most part, these facilities have been poorly maintained for several years, adding to other operational difficulties.

Many aspects of these correctional facilities have long been under court challenge. The federal courts have closely overseen the operations, including establishing a full-time office of the Special Officer of the Court, staffed by several monitors and expert consultants. There has been a stream of negative publicity about the complex for years, and the neighboring communities and governmental entities have campaigned to have the facilities closed.

5. Problematic Classification and Security Issues. Excluding the Minimum and Maximum facilities, the other five Lorton facilities for some time functioned, at least nominally, at the medium security level. The open dormitory style architecture found in these facilities has presented the DOC with a huge obstacle to effective correctional management and control.

In most correctional systems, medium security inmates are housed in more restrictive environments with cells as opposed to the open dormitories used at Lorton.

In practical and operational terms, there were distinct differences between the five medium security facilities, both in the profiles of the populations and in the security procedures and program opportunities in place. Occoquan functioned at the highest security level, holding the most difficult general population inmates in the DOC, while the Central and Youth Facilities were more program oriented and held the more middle-of-the-road cases. The Medium Facility had a very vulnerable perimeter security and held the least difficult population.

Because of various pressures or deficiencies in the system, placement of prisoners among the institutions often was haphazard and inconsistent with the traditional methods used to determine the appropriate classification. Large groups of the inmates housed in these "medium" facilities at Lorton would have been considered of a higher custody in other systems and held in a more restricted environment, such as close or high custody. This was due in part to their long and sophisticated histories of criminal behavior or institutional misconduct. DOC eliminated the close custody several years ago to tailor its classification system to meet the practical realities of its inadequate and dysfunctional open dormitory architecture.

6. Occoquan Problems. Although Occoquan was nominally a medium security facility, by necessity it was required to house a sophisticated and difficult population in an inadequate facility and with little constructive activity for inmates. Thus, a long series of dangerous problems occurred during the 1990's, including disruptions, numerous assaults on staff and inmates and several homicides. These and other factors contributed to a severe breakdown in the management's ability to control this population. The federal court continually intervened, including mandates that greatly increased staffing.

Despite court intervention, things did not improve and by late 1996 and early 1997, concerns about possible serious disturbances or a full inmate take-over of the prison began to surface. In order to prevent these potential occurrences, DOC and Lorton management made an emergency decision in early January 1997 to remove the 175-200 most difficult and problematic inmates from Occoquan and place them in several contract jails in central Virginia, that were under contract with the U.S. Marshal Service.

Simultaneously, DOC's negotiations with CCA over the Youngstown contract were ongoing, and it was the stated hope of the DOC leadership to soon move these troublesome cases permanently to NEOCC. These difficult 175 inmates eventually became the first cases transferred to NEOCC in May 1997. Before arriving at NEOCC, some of the inmates had been moved twice to other contract facilities after causing serious problems. CCA's correctional center in Panama City, Florida was among these contract facilities that temporarily housed groups of these problematic inmates. This episode is described in more detail in Chapter III.

7. Pattern of Previous Disruptions with DOC Groups Transferred to Remote Sites. In recent years when the DOC has been under similar pressure from operational problems and intervening federal courts, it has constantly turned to jurisdictions in distant areas to take its prisoners under contract, usually with resultant problems.

In 1988 a large group of DOC inmates who were transferred to the Washington State Department of Corrections, became dissatisfied with being so far from home and engaged in serious, disruptive behavior in an attempt to force authorities to return them. Extensive publicity followed, leading the governor of the state to intervene and request their removal. Ultimately they were returned to Lorton.

A similar episode occurred in the early 1990's when another group was transferred to the CCA facility in Mason, Tennessee. Again, this group quickly began exhibiting negative behavior and prison authorities found it necessary to use considerable force to control the inmates. The situation eventually stabilized, but the prisoners were later returned due to DOC's shortage of available funds to cover the contract.

As a result of these and similar episodes, conventional wisdom among the Lorton inmate population is the way for prisoners to get themselves moved back to Lorton is to demonstrate negative behavior at contract facilities.

With this history in mind, it was quite predictable that the initial groups going to NEOCC would try to challenge the control of the staff by becoming unruly. As outlined in Chapter III, NEOCC administrators were well aware of this pattern, partly because some of them had been involved in the Mason, Tennessee and Panama City, Florida episodes. Thus, NEOCC managers developed a plan in conjunction with DOC top officials, that they thought would prevent this problem from occurring.

8. Initial Lorton Downsizing and Role of Youngstown Contract. Counter to the national trend, the overall count of prisoners in the DOC for various reasons diminished in the mid-1990's from over 11,000 to about 9,700 in 1996 and has remained constant in the interim. Most of this reduction was in the sentenced felon count, and it enabled DOC to reduce the level of crowding at its Lorton facilities.

The reduction in this population and a combination of financial, security and operational reasons, led to policy decisions by the DOC and the District's political leadership to close Lorton's Modular Facility in 1996 and the Medium Facility in 1997. The first CCA Youngstown contract of May 1997 for 900 beds directly helped facilitate the closure of the 900 beds at the Medium Facility.

Currently, confusion exists in what was reported publicly and comments relating to that period. The first closures are described as being driven either by court mandates or by Congressional direction rather than by DOC policy decisions, and that it was in the face of these external mandates that DOC was forced to turn to the Youngstown contract. Those descriptions are inaccurate.

9. Congress Mandates Lorton Closure by 2001. In 1997, Congress and the Administration completed a major review of the organization and management of the District's public agencies. A joint decision was made to relieve the District of some state-like functions, including the housing of convicted felons, thus leading to the landmark National Capital Revitalization and Self-Government Improvement Act of 1997.

The Revitalization Act, which became effective on October 1, 1997, mandates that the Lorton complex be closed by December 31, 2001, which gives the DOC four years to make this transition. By that date the Federal Bureau of Prisons must house all DOC felons in its institutions or contract facilities. The other mandated deadline was for the BOP to contract for the housing of 2,000 of these cases by December 31, 1999. Since DOC initiated the NEOCC contract before the Revitalization Act was signed, the movement of prisoners from Lorton to outside contracts like NEOCC is not in any way mandated or directed by this law.

D. Corrections Corporation of America

The Corrections Corporation of America is the largest private prison management company in the country, being publicly traded on the New York Stock Exchange. It came into existence in 1983 and has grown very rapidly, particularly in the 1990's. It now operates over 70 prisons and jails in this country and overseas, holding over 65,000 inmates, making it larger than most state prison systems.

It operates prisons in a number of states around the country under a variety of arrangements. Sometimes it manages facilities owned by public jurisdictions, while more commonly it builds, owns and operates its own facilities, holding prisoners under contract with one or more jurisdictions. While these facilities are commonly built in response to competitively awarded contracts, the company also builds prisons on speculation without a previously awarded contract arrangement, as in Youngstown.

As mentioned above, the long-standing operational and financial problems of the DOC were well known in many circles at the time CCA approached the District government. Undoubtedly, the company was very aware of these problems when, as part of its widely acknowledged aggressive strategy of growth and acquisition, CCA sought out the DOC in 1996 and made an unsolicited offer to purchase and manage the CTF. After a competitive procurement process, the District awarded the contract to CCA and sold the facility as outlined in Section B.3. above.

After consummation of the Development Agreement in Youngstown in March 1996, CCA quickly began construction of the facility and it was substantially completed in early 1997. In the interim, CCA, which had already been in discussions with the District of Columbia regarding the sale of the CTF, offered beds at the Youngstown facility to the troubled D.C. Department of Corrections. The contracting process is outlined in Chapter II.

Chapter II

Procurements and Contract

Introduction. The immediate need for prison bed space by DOC officials, coupled with the desire by CCA to fill its new vacant prison facility in Ohio, led to a request for bids for bed space from DOC officials that virtually eliminated competition, leaving CCA the sole acceptable bidder to house more than a thousand DOC inmates.

Several of the contract's significant provisions and defects are also traceable to this immediate need for, and the rush to fill, this vacant prison bed space. Because of the rush to prepare the invitation for bids, contractual provisions detailing the monitor's duties and the procedures necessary to resolve contract noncompliance problems are insufficient.

A. Initial DOC/CCA Contacts

As noted in Chapter I, population pressure at the Lorton prison facilities and the need to find long term housing for roughly 200 disruptive DOC inmates housed in other contract facilities resulted in the requirement to identify alternate housing. As a result, the DOC Director sent a letter to the Director of the DC Department of Administrative Services (DAS) in December 1996 explaining that DOC was in dire need of additional prison beds.

Discussions took place with the Appleton Group, a municipal economic development group in Appleton, Minnesota, about the possibility of its providing prison beds to the District of Columbia under an intergovernmental agreement. The Appleton Group offered DOC private prison beds it had available at CCA's new NEOCC facility in Youngstown, Ohio. Shortly thereafter, the DOC Director visited the NEOCC.

At the end of December, DOC officials reported that they had conducted an unsuccessful telephone survey of five private prison companies to locate other sources of prison beds to immediately house 1,000 District of Columbia inmates. In addition, the Appleton Group officials were advised that CCA's private NEOCC prison facility could not be utilized pursuant to an intergovernmental agreement.

B. The Initial Unsuccessful Proposal

In early January 1997, a proposal to house approximately 1700 DOC inmates was received by DAS officials. The proposal, which was cosponsored by the Appleton Group and CCA, provided that 1500 DOC inmates would be housed at NEOCC and 200 more at another CCA facility in Florence, Arizona, called the Central Arizona Detention Center (CADC). That facility had been operating since October 1994. CCA indicated that the new NEOCC

facility in Youngstown would be ready to accept the first 1000 DOC inmates in mid-February 1997 and the remaining 500 inmates at the beginning of April.

Under DC appropriations law, multi-year sole source obligations up to five years in length could be authorized, but not extended. Therefore, a single full five year contract was proposed which would have cost DC $172 million over the life of the contract. In February, this proposal was submitted for approval by the Mayor's Office to the DC City Council and to the DC Financial Responsibility and Management Assistance Authority (Control Board). The proposal specified a rate of $43.41 per inmate per day in the first year, increasing steadily to $60.55 per inmate per day in the fifth year.

Prior to final action on the proposal, various objections to the proposal emerged. Among the issues raised were the following concerns:

As a result of these concerns, the DC City Administrator withdrew the proposal in March 1997 and the DAS began work on a formal "invitation for bids" (IFB) to cover this same five year prisoner housing need.

C. The Formal 5 Year Prison Bed Procurement and Award

On April 21, 1997, the DAS issued IFB No.7349-AA-03-1-HT (IFB7349). That solicitation sought bids to house 1438 (later increased by amendment to 1440) medium and high medium custody male inmates in single or double cells within a 500 mile radius of DC for one year, but allowing for four additional one year option periods. All objections to the classification of any inmate were to be made on the basis of the DC Department of Corrections' classification system. The contract awards were to be made in lots of no less than 360 prison beds in a single location, i.e. no more than four lots, each of which must meet the Standards for Adult Correctional Institutions, Third Edition (1991) of the American Correctional Association. After several minor amendments to IFB7349 required by, among others, the DC Office of the Corporation Counsel, the bidding period was extended to June 27, 1997. Because of the immediate need for the inmate housing, the contract was required to start within 14 days from the date of award.

On September 9, 1997, DAS awarded the contract to CCA. CCA's June 27 bid to house these inmates at NEOCC was the only responsive bid. The only other bid received was officially determined to be non-responsive to two of the solicitation's amendments. In addition, one other potential bidder lodged a complaint that they were unable to submit a bid in response to the solicitation as it was written. That potential bidder objected that the solicitation was "not consistent with industry practice which generally allows the selected contractor 10-14 months to construct a new facility." The letter suggested that if an "emergency" requiring immediate prison bed space existed, then the current solicitation should be limited to a one year period and the additional four-year terms should be bid separately.

The number of inmates was increased from 1440 to1700 on October 8, 1997. The number was increased again to1727 on June 9, 1998. It was subsequently reduced back to 1700 on June 22, 1998.

D. Substantial Price Increases in the Long term Bid

The successful bid by CCA specified a rate of $53.50 per inmate per day in the first year, a 23% increase over its earlier January 1997 bid price of $43.41, with no substantial decrease in the numbers of prisoners to be housed or increase in the services to be provided. This increase in cost amounted to more than $5 million per year, and more than $27 million over the five year life of the contract.

The contract also contained annual inmate per diem increases to $55.00 in the second year, $58.63 in the third year, $60.54 in the fourth year, and $62.51 in the fifth year. This represented a 3% increase over the base price in each option year except the second option year when, inexplicably, the increase was 6.6%.

In sum, it appears that the rush to procure beds by the District, and CCA's awareness of the lack of competition from other likely bidders, proved to be to CCA's advantage and cost the District millions of dollars.

E. The DC Control Board's Interim Prison Bed Procurement Process and Award

In order to meet DOC's continuing and urgent need for immediate prison beds during the course of the DAS contracting process for the five year contract, the Control Board decided to exercise its own special authority to procure an interim 4 month contract for temporary prison beds designed to fill the gap until the IFB7349 procurement was completed.

As a result, on April 30, 1997, the Control Board issued IFB No. 97-B-022 (IFB022), the terms of which were substantially similar to IFB7349. The new IFB, posted electronically on the Department of Commerce's CBDNet internet site on April 23, 1997, called for bids by May 8 to house 900 medium and high medium custody male inmates in single or double cells within a 500 mile radius of DC from May 15, 1997 until September 30, 1997. An optional one year extension was also required in case some delay arose in finalizing IFB7349. Objections to the classification of any inmate were to be made on the basis of the DOC's classification system. IFB022 also required that within 8 days of the contract award, transportation of groups of at least 225 inmates per week must be arranged by the contractor. The contract awards were to be made in lots of no less than 225 prison beds in a single location, i.e. no more than four lots, each of which must meet the Standards for Adult Correctional Institutions of the American Correctional Association.

When the Control Board contracting officer made the award on May 13, 1997, CCA's bid to house these 900 inmates at NEOCC was the sole bidder and was selected. CCA's bid specified a rate of $55.00 per inmate per day for the length of the contract.

F. Substantive Contractual Provisions of Particular Interest

1. Classification. On the subject of classification, both of these two IFB's successfully won by CCA required that shortly after the transfer to the contract facility of each inmate, the contractor shall furnish to DOC "an admission summary and a reclassification study report outlining the inmate's custody level, housing assignment, medical/psychiatric status, education, and vocational assessment." IFB022 required that these reports be furnished "[w]ithin thirty (30) days following the transfer" of the inmate; IFB7349 required that these reports be furnished "[w]ithin fifteen (15) days following the transfer."

In addition, both IFB's required in identical language that the DOC:

"will only send, and the Contractor shall only be required to keep, medium and high medium inmates in accordance with [DOC's] classification system. [DOC] [shall] at its own expense and within forty-five (45) calendar days, upon notice from the contractor, take back an inmate if the Contractor determines and [DOC] concurs that the inmate is no longer a medium and high medium inmate."

Both IFB's also provided that prior to receipt of an inmate, the contractor could object to transfer of an inmate based upon the inmate's pretransfer materials made available to the contractor.

2. Inmate Training and Education. On the subject of inmate training and employment, both IFB's required in identical language:

"The Contractor shall have sufficient programming to allow every general population inmate to participate in programs of occupational training and industrial or other work...."

3. Inmate Programs. On the subject of inmate programs, both IFB's required in identical language:

"The Contractor agrees to provide sufficient programs to allow every general population inmate to participate in meaningful education, vocational, drug treatment or work programs...."

G. Concerns About the Procurement Process and the Contracts

As noted above, the primary criticism received in response to the District's public solicitation by a potential bidder was that the immediacy of the need effectively nullified DOC's ability to bid competitively. That same problem was highlighted by the Review Team's contributing consultant, Richard Crane, a nationally recognized expert who specializes in the procurement of correctional services, who reviewed IFB7349. In pertinent part, Mr. Crane stated:

"...by requiring that the facility be ready to accept inmates within 14 days of the contract award, the District reduced the competition for this contract to practically zero. One of the important benefits of privatization is the competition it brings to the process. Writing a solicitation which negates all or most competition can result in the award of a contract to an entity which, while competent, may not have the same incentive to provide top level services."

"[The process needed to elicit] other bidders who could have taken some of these inmates rather than placing so many hardened inmates into one new facility."

Mr. Crane also concluded that problems resulted from:

Mr. Crane's full report can be found in Appendix 3.

H. Finding and Recommendations

Finding of Major Concern

The Review Team cited the following major concern in this chapter.

F-1. In response to a perceived emergency need for contract prison beds, the District of Columbia rushed into an abbreviated procurement process which minimized competition. The result was a flawed contract, at a somewhat inflated price, with weak requirements on the contractor and minimal provisions for enforcement.

Major Recommendations

R-1. The existing contract should be modified to hold the NEOCC management more accountable for adhering to contract provisions by including specific procedures and penalties for noncompliance. Specific language should be added covering the policies and procedures for determinations of contract noncompliance and include a preset schedule of financial penalties that attach to such contract breaches. Penalties should be scaled to account for the number of inmates affected, and repeat violations should be penalized more heavily. In addition, the justification for the pricing structure should be closely reevaluated.

R-2. DOC should ensure that any future activation of a new contract facility be well organized and gradual, with feasible start-up schedules, on-site monitoring and a willingness to alter plans to adapt to the realities of the situation.

Chapter III

Institution Activation

Introduction. The activation of any new prison is one of the most sensitive operations correctional managers can face, often being marked with some growing pains. Typically, many of the staff are new to corrections, making training and the daily supervision and assistance by experienced supervisors critical. When the new facility houses tough, sophisticated inmates as in this case, the level of difficulty escalates as does the need for staff training and experienced supervisors.

The serious breakdowns which occurred in the initial security, safety and general operations of the NEOCC facility go far beyond the typical range of growing pains of a new prison. These breakdowns soured the atmosphere and left a legacy of problems that continue to have a negative impact as the current administration seeks to dig the operations out of a deep hole.

In retrospect, the facility was not prepared and organized to handle this population. Whatever chance the inexperienced supervisors and line staff may have had was diminished by the joint decision of DOC and CCA to short-cut usual precautions by rapidly placing inmates at a highly accelerated pace in May 1997 -- over 900 in just 17 days. In spite of those serious problems, when the second contract was signed in September 1997, both parties repeated the earlier rapid escalation by transferring in another 500 inmates in just 13 days.

Understanding the manner in which this process developed is critical to an analysis of the troubles at NEOCC.

A. Summary of Pre-activation Developments

1. CCA Completes a Strong, Well-Built Facility. CCA constructed a very strong facility, though not one without flaws. This facility stands in contrast to the outmoded, poorly maintained facilities at the DOC's Lorton Complex and gave great hope to managers at CCA and in the DOC that its operation would represent a step forward in managing a difficult portion of the DOC's population

By January 1997, the NEOCC had been substantially completed and was close to being ready for opening. Although there has been considerable publicity about NEOCC being a medium security prison due to the contractual arrangement, the structure itself has impressed a number of correctional administrators from other systems as being well-suited for use as a maximum security facility, one step short of a Super-Max prison.

In contrast to the numerous open-bay dormitories at the Lorton complex, all NEOCC general population living units are comprised of two-man cells in relatively small, contained units. There is a small, secure control center or "bubble" with an officer supervising two or three contiguous pods of from 32 to 40 cells each. Except for three somewhat open recreation yards and the gymnasium, all movement is indoors, carried out in secure corridors which have a number of centrally controlled sliding grilles. In addition to the normal high security administrative detention unit, plans were developed and implemented early-on to convert a second unit to a long-term lock-down detention area for troublesome inmates.

Whether for purposes of economy or control it is not known, but there was no central dining room built, so all meals are prepared and moved to the living units. This feature adds to control on one hand, but otherwise increases inmate idleness and the time they remain in the living units. There is limited space for vocational training and no prison industry building.

In each housing pod there is only a single, open day room area, adjacent to the cells, where inmates spend most of their time. Since there are no rooms for television viewing, there are two T.V. sets playing out in the open area, making for a loud, noisy atmosphere. Also, showers are open in the day rooms with a short dividing wall, providing inmates no degree of privacy from each other or from female staff.

As was learned by sad experience in July, there were flaws in the perimeter fence-line configuration and in the microwave detection system. Hopefully, these perimeter deficiencies have been adequately rectified.

One general concern raised by several reviewers is the size of the facility as it relates to managing a general population operation. NEOCC has a capacity for 2,000 inmates. As there is limited space for vocational training, education and work to constructively occupy such a large number of general population inmates, the facility may be more suited to a very controlled, high security operation or to a short-term detention operation.

Despite these observations, the facility is very strongly built and designed for control, factors which in retrospect likely have contributed to limiting the emerging problems at NEOCC and to controlling the tough, sophisticated population which was originally sent there. In other words, were it not for these architectural features, problems most likely would have been worse.

2. Disruptive Inmates, Who Later Were Transferred to the NEOCC, Are Transferred from Occoquan to Other Contract Facilities. On January 8, 1997, DOC decided it had to do something quickly to maintain control of the Occoquan Facility at Lorton. Intelligence reports were warning of an inmate plan to take hostages and take over the administration building. Occoquan was the remaining institution housing the majority of Lorton's higher custody level inmates, even though its "open dormitory" design was less than desirable for that type of inmate population. In the previous year, there had been three killings and over 100 serious inmate-on-inmate assaults, and the DOC's control of that institution was already marginal at best. The DOC Director decided that 175 to 200 of the most dangerous or disruptive inmates were to be transferred out immediately.

From a list of all Occoquan inmates, a team of DOC officials identified 175 inmates, who were immediately transferred to four Virginia institutions - Portsmouth Jail, Virginia Beach Jail, Glochester County Jail, and the Piedmont Regional Jail. The team attempted to categorize

those inmates in regard to their dangerousness and to select which of the four institutions would be most appropriate to house them.

The inmates who had been transferred to Portsmouth and Gloucester County actually did well enough there to stay at that location until they were transferred to the NEOCC in May 1997. Inmates in the other two facilities were so disruptive, however, that the local officials requested that they be removed. Some went to the Federal Bureau of Prisons and some to other Virginia state facilities. Others went to facilities in Southern Georgia, where they continued to be disruptive, and were then transferred to two facilities in Northern Florida, including the Bay County facility in Panama City, operated by CCA. There, they were still so disruptive that CCA asked for them to be removed, but Director Moore prevailed upon CCA officials to hold them for about another 60 days, until the DC contract with the NEOCC at Youngstown could be finalized.

3. CCA's Plan for Handling Troublesome Population. Because there had been a delay from the planned February opening of NEOCC due to the contractual problems outlined in Chapter I, CCA had the situation of an interim period during which they had a staff hired and on board and a payroll to meet. They also were apparently committed to taking a group of very troublesome inmates.

From the Review Team's interviews and research, it appears that the CCA and NEOCC administrators were confident they had a plan that could handle this level of inmate. A key element of the plan was their confidence in the strong architecture of the facility they had constructed. In consultation with administrators in DOC, they were committed to dealing swiftly to control any inmates who showed themselves to be troublesome, primarily by locking them in administrative detention for long periods if necessary, thus the need to convert a second unit for this purpose.

Likewise, there was a well-considered joint commitment by CCA and DOC not to return to Lorton inmates who proved troublesome at NEOCC, as such a response would re-enforce disruptive behavior and encourage negative actions by others.

At the same time, the administration worked during the interim to train staff in dealing with difficult inmates. Some new staff remember being told to prepare for the "worst of the worst." One training measure CCA took was to transfer a number of their incoming staff for periods of temporary duty at the facility to the Correctional Treatment Facility in the District of Columbia which CCA manages for the DOC. CCA considered it would be very helpful to have such on-the-job experience with a group of DOC inmates similar to those headed to NEOCC. This planning and preparation went on during the period from February to May 1997, at which time the interim contract was signed and the first inmates were moved.

B. Initial May 1997 Inmate Deployment Period

1. Accelerated Influx of Population Undercuts Plans. All the preparations were then overwhelmed by the poorly considered joint decision of CCA and DOC to move a very large number of difficult inmates in a very short time period -- 904 in 17 days, over 400 a week. DOC was motived by a number of serious operational pressures at Lorton and by the pressure from the jurisdictions holding the Occoquan cases. CCA apparently was motivated by pressure from DOC, as well as by having the liabilities of an empty facility and an ongoing payroll and other expenses.

It is common practice for most systems to open new facilities very methodically, even at lower security prisons. It might be typical to use a pace of 80 to 100 inmates per week, such as with the Virginia Department of Corrections in receiving inmates in its new Sussex II facility with 1,300 DOC cases beginning in January. One large state correctional system reported it typically phases in offenders to a new institution over a period of six months.

The NEOCC warden and staff understood fully that the first inmates they would receive were those who had been scattered out of Occoquan because of fears of an inmate takeover there - "young, aggressive, and violence-prone." Likewise, officials in the city of Youngstown had some idea of what to expect, based on public statements by the DOC Director, as reported in several local newspaper articles in early 1977.

In any case, in May 1997, it was those 175 inmates -- identified by the DC DOC as dangerous and disruptive -- plus 26 more who had been in U.S. Marshals custody -- who were the first to be sent to NEOCC.

Records show that, of the first 900 inmates who came from the DOC, only 77 came from the Medium Facility - the one that was to be closed. Over 500 came from Occoquan and over 200 from the Maximum Security facility. The inmates at Occoquan were generally classified at the higher range of "medium" custody -- what DOC termed "high-medium." Most inmates that were transferred to NEOCC - even after the first two hundred identified as disruptive - were generally classified as high-medium or even maximum.

The staff were overwhelmed in many ways. In the early days and weeks, there was a state of disorganization that has been described by various staff and some managers as chaotic. There was no effective case screening or stratification of the housing of a wide mix of levels of inmates. Medical screening and treatment was disorganized. Policies and procedures in a number of routine areas simply did not work, but the crush of numbers inhibited effective modification. The list could go on.

There is no indication that there was any written activation plan and check-list provided by corporate management to the local administration. Nor does it seem that there was any significant oversight by the headquarters to ensure there were adequate policies and plans in place and that uniformed and non-uniformed supervisors who were virtually new to prison work were well-prepared for their task.

2. Prison-wise Inmates Overmatch Staff. On the inmate side of the equation, NEOCC would require major adjustments to be made by many. Of course, coming from the more open, free-wheeling atmosphere at most of the Lorton facilities, many of the inmates were jarred by the controls of their new situation. Others were coming from months in lock-down settings in

local jails or at the Lorton Maximum security facility. Still others were minimum custody or had been held in protective custody units, although often only at their own request for no identifiable reason.

Though most were allowed out of their cells all day after arrival at NEOCC, there was almost no constructive activity or movement out of the tight housing units, thus leading to extensive idleness. Add to this situation a very inexperienced cadre of mid-level supervisors directing an even less experienced group of line staff and there was a volatile situation.

However, it also must be noted that many inmates expressed the hope that, despite the distance from home, if they were patient things would be better in this clean, new facility than at Lorton. Most have remained compliant throughout their time at NEOCC, not getting into trouble or receiving incident reports.

One can only imagine what it must have been like on the receiving end - over 900 inmates in about 17 days. Staff interviewed for the review of medical services indicated that the start up of the facility was "chaotic" and disorganized. The first NEOCC warden stated that just doing basic intake processing was an enormous task, since they were "receiving buses every day." Sometimes unit managers were assigned to actually ride on those buses to review files en route.

NEOCC managers indicated that, basically, NEOCC "took what DC gave us" and "did not question custody classifications." The NEOCC staff had no DOC custody classification manuals, nor training in DOC's classification system.

Everyone agrees that case management and classification were severely hampered by a lack of information in the files, as well as some information that was unreadable because of poor copying. Not receiving medical files was a particular problem. NEOCC staff frequently asked for missing material, but they "didn't always get it."

Of particular concern was the number of separatees - as many as 250 -- which severely hampered their ability to provide what the contract called for - programs and recreation.

3. Serious Problems Begin Immediately. On May 30, 1998, within two weeks of the arrival of the first inmates, there were serious disturbances. One precipitating factor was the fact that much of the inmates' personal property either had not arrived at the NEOCC or had not been distributed. Inmates in one of the housing units refused to go to their cells and made threats toward staff and "to trash this place." Because of the increasing danger, staff were ordered out of the unit, ultimatums to return to their cells were made, and inmates began putting Vaseline and towels over their heads, believing that gas would be used to control the situation.

A supervisor ordered that approximately three canisters of gas be dropped in each housing unit, and the inmates poured water on them, placed garbage cans over them, and threw them into the showers. Within minutes, a similar incident occurred in another housing unit, and again gas was used to quell that disturbance. Later that day, similar incidents occurred in two more housing units.

Inmates began making weapons -- regarded in corrections as an indicator that inmates do not feel safe -- and within a month two inmates were stabbed - one three times and the other four times, while sleeping in his cell. In July two more inmates were stabbed and another assaulted staff while being examined for possible stab wounds. There were also a number of "use of force" incidents, usually because an inmate refused to comply with an order, which often required the use of gas to gain control of the inmate.

C. More Troubles as Expansion Plans Continue

In addition to these control issues, it appears that many aspects of NEOCC's operations were unsettled and disorganized. It is unclear how many of these problems were reported to DOC, since there was no on-site contract monitor and the facility's records were often inadequate. NEOCC's major response to these incidents and the increasing dangerous tone of the facility was to establish a long-term segregation unit for those inmates identified as serious management problems.

In the meantime contract negotiations continued for additional 540 beds, later to be a total of 800 new beds -- for up to 1,700 inmates.

In July 1997 NEOCC inmates filed a civil rights class action in Federal Court for injunctive relief alleging they had been subjected to excessive force, that staff were not properly trained, that inmates were not protected from attacks by staff and other inmates, that medical care was inadequate, and that the inmate grievance system was ineffective. The documents filed stated that staff who had transferred into NEOCC believed that the amount of contraband there, particularly homemade knives, far exceeded that found in other facilities in which they had worked.

Meanwhile, serious incidents continued to occur. In August an inmate struck an officer in the eye with a broom handle, another struck an officer in the head, and there were other use-of-force incidents, some of which involved the use of gas.

In September 1997 a permanent contract was awarded to CCA for 1,440 beds. In almost a carbon copy of the disastrous May 97 inmate deployment, in the latter half of September an additional 513 inmates were transferred to NEOCC - 222 from Occoquan, 54 from the Maximum Facility, 42 from the Medium Facility, and the balance from other DOC facilities. A few weeks later, the contract was amended to provide for up to 1,700 beds and another 309 were sent in five days.

D. Summary: Impact of Activation Process and Accelerated Inmate Deployment

Too many inmates were transferred into NEOCC too fast. The NEOCC leadership thought they could rely on the strength and design of the facility itself to manage the population they were to receive, but many procedures were not well thought out and were not firmly in place for the population they received. Inmates quickly became disrespectful and disruptive, and many did not feel safe. They armed themselves, and serious incidents resulted. Inexperienced staff were

overwhelmed and not skillful enough to control serious contraband or to effectively communicate with and control inmates.

NEOCC did not adjust quickly enough or recognize that they were not ready for another large influx of inmates. DOC did not effectively monitor the situation, and it was naive or irresponsible for DOC and CCA to continue to send in tough inmates at such rapid rates.

E. Finding and Recommendation

The Review Team concurs that there is one finding and recommendation in this chapter. They are:

Finding of Major Concern

F-2. The prison was not adequately prepared to open and was overwhelmed by a precipitous rush to fill it. Even though serious problems began immediately, inmates continued to be sent at an accelerated pace.

Major Recommendation

R-2. DOC should ensure that any future activation of a new contract facility be well organized and gradual, with feasible start-up schedules, on-site monitoring and a willingness to alter plans to adapt to the realities of the situation.

Chapter IV

Selection, Classification and Transfer of Inmates

Introduction. Inmate classification and case selection for the NEOCC facility have been matters of significant public dispute and confusion, particularly as to how and why breakdowns occurred and where the responsibility lies. Indeed, these issues are core ingredients in the adversities at NEOCC that prompted the current review.

Improper inmate classification, or failure to attempt classification, contributed substantially to many of the problems that surfaced quickly at NEOCC - disturbances, violence, homicides, and the escape of six inmates, four of whom were serving sentences for murder. These events came as a shock to local community residents, who had been led to believe from the start that the facility would house only medium security inmates.

Jasper R. Clay, Jr. was requested to lead the Team's review of case selection and classification for this report. Mr. Clay has over 40 years of correctional management experience at both the state and federal levels, having recently retired as the distinguished Vice-Chairman of the United States Parole Commission, a position appointed by the President. Two other correctional professionals with many years of experience in inmate classification systems aided him, assisted by several other team members.

Mr. Clay and the entire Review Team soon understood that the management of both DOC and CCA were informed, willing and mutually responsible players in this transfer of large numbers of inmates to NEOCC who could not be considered medium security or high medium security under any reasonable correctional standard.

Because of the complexity of the issues and the history of case selection and classification at NEOCC, this report will give a detailed analysis of the Team's findings, beginning with some brief introductory comments on the concepts of interagency transfers of prisoners and inmate classification.

A. Interagency Transfer of Prisoners

Transfers of inmates between correctional agencies have long been a common practice. Such transfers have occurred for years between various states and also between many state or local governments and federal agencies such as the Bureau of Prisons, the U.S. Marshal Service or the Immigration and Naturalization Service.

More recently, it has become common for privately-operated prisons to accept inmates placed in their control under contract with distant local, state or federal agencies. Such transfers often involve difficult-to-manage inmate populations or populations requiring separation. The D.C. inmate population has long been considered very difficult to manage, and CCA officials were well aware of that fact.

It is the universal practice for a contract for inmate transfers to specify requirements on the types of cases to be transferred and the review process to be completed prior to the inmates being accepted. Well-managed correctional agencies insist on receiving and closely screening sufficient classification material prior to accepting inmates from any other agency or jurisdiction. Without sufficient material, cases would not be accepted. Control over the specific incoming cases is most important to assure that the transfer is consistent with the contract requirements and the capacities of the receiving agency's security and staff resources.

CCA is an experienced correctional agency that is larger than most state prison systems, operating over seventy prisons in this country and overseas. More than most prison systems, it is frequently involved in such contracts and in screening and accepting out-of-state cases from other agencies. It is a reasonable, but an erroneous, assumption that CCA would have in place adequate screening procedures on an system-wide basis that would accordingly apply to NEOCC, including a practice that no inmates would be accepted without sufficient classification material. As part of this process, CCA should have a trained case management staff to review closely all incoming cases. It is surprising that this did not occur at Youngstown.

The contract was clearly written and provides CCA the right to receive from DOC and to review full background classification information on all inmates and to reject unacceptable cases prior to transfer. Section H.8.1 of the contract states:

"The District shall only send, and the Contractor shall only be required to keep, medium and high medium inmates in accordance with DCDC's [DOC] classification system. DCDC shall at its own expense and within forty-five (45) calendar days, upon notice from the Contractor, take back an inmate if the Contractor determines and DCDC concurs that the inmate is no longer a medium and high medium inmate."

Section H.8.2 of the contract states:

"The District shall submit a pre-transfer application to the Contractor on each inmate proposed for confinement in the Contractor's facility. The application will be made available to the Contractor at least seven (7) days prior to the inmate's transfer. . . . Upon the receipt of the transfer package, the Contractor shall have five (5) days to review the transfer package. If the Contractor objects to the transfer of an inmate(s) the Contractor shall notify DCDC of its objection and the Contractor and DCDC shall attempt to resolve the objection within ten (10) days . . . ."

B. Principles of Inmate Classification and Screening

Inmate Classification is a two-part assessment process through which inmates are grouped together based upon their documented behavioral histories and current custodial requirements. The object is to house only those inmates together who pose similar risks to security, and who are most appropriate from a security standpoint for a particular facility in which they are housed. The total classification process consists of two phases: Initial classification and reclassification.

1. Initial Classification

Classification is not an exact science, and special attention must be given to predatory and escape-prone inmates. During the initial classification phase, inmates are differentiated by numerous factors such as their gender, age, length of sentence, severity of the offense for which they are confined, and history of escape or violence. For example, it would not be prudent to house a dangerous, escape-prone, multiple-offender in a minimum-security facility. It would be equally imprudent to house a first-time, white-collar offender in a maximum-security penitentiary.

Most correctional jurisdictions have some type of formal, objective system in place to accomplish this important task. The majority of systems are designed to predict behavior based primarily on an offender's history, present circumstances, and needs. These systems vary widely among different jurisdictions, but most use the same fundamental criteria to assign the level of risk each inmate may pose to society and/or the prison environment. While the nomenclature used vary widely, "minimum", "low", "medium", "close", "high" and "maximum" are common terms.

Prison facilities are also classified using terms similar to inmate classifications, based upon the architecture, design and security features. Institutions with walls, gun towers, and armed perimeter patrols are generally classified as maximum security, and house only those inmates who are deemed to require that level of constraint. At the other end of the spectrum, many minimum-security institutions do not have perimeter fences because inmates housed in them are not considered to be escape risks, and are not considered a threat to the community.

2. Reclassification

Reclassification, or the second phase, is an extension of the overall classification process. Initial classification serves as a tool used to determine the type of facility an inmate should be placed in from a security standpoint. After the inmate has been confined at an initial location for a prescribed period of time or following some significant event (i.e., serious misconduct or a sentence reduction, etc.), he or she should be reclassified, taking into account any new factors that have arisen. Reclassification is an ongoing process in which the initial classification data are augmented by the inmate's institutional adjustment, program efforts, conduct, changing release dates, etc. It is intended to reflect a more current picture of that particular inmate from a security, or custody-level perspective.

Reclassification often results in an inmate being moved to a more-secure or less-secure facility, or merely given more or less supervision at the same facility, depending upon the circumstances. Regardless of the system used, failure to classify and separate inmates properly can lead to homicides, assaults, escapes, predatory behavior, and other serious consequences.

C. Contract Stipulations

The NEOCC facility at Youngstown was planned by CCA as a medium security institution. This is how it was promoted initially to the citizens in the community and stipulated in the development agreement CCA signed with the City of Youngstown to construct and operate the facility.

Both the May and September 1997 contracts between DOC and CCA stipulated that the inmates were to be classified as "medium and high-medium" security.

Prior to NEOCC coming on line, the term "high-medium" security did not exist in the DOC inmate classification vernacular, at least not in a formal sense. It appears to have been developed as part of the contract solicitation process, and the inmates so described appear to be medium security inmates who, based on various reasons such as sentence length or institution misconduct, must be afforded closer supervision.

Apparently, from early on, the common working assumption on the part of both DOC and CCA was that this new category of high medium was a subset of the general category of medium. To them, this was an implicitly agreed upon method of "widening the net" from the traditional category of medium security without technically including maximum security inmates. Thus, CCA could technically be in compliance with the development agreement negotiated with the City of Youngstown, to which DOC had not been a party.

Both CCA and DOC entered the contract knowing that many of the inmates were not going to be purely medium security. From all indications, CCA was well aware of the problems DOC was experiencing in general, and the reputation of DOC inmates. This understanding had surfaced repeatedly during their contract negotiations with DOC from the fall of 1996 until the contract was signed in May 1997.

D. Role of the D.C. Department of Corrections

1. History of DOC Classification System

a. Origin of the System/Role of NCCD . DOC has had an objective inmate classification process in place since 1987, at least on paper. There is ample evidence, however, to suggest that it had not been used effectively over the years.

The National Council on Crime and Delinquency (NCCD) assisted DOC in developing its classification system under a grant from the National Institute of Corrections (NIC), a federal body with the mission of assisting state and local governments in corrections matters. The primary consultant on the project, Dr. James Austin, is the Executive Vice-President of NCCD. He is a recognized expert in inmate classification systems, with many years of experience in developing systems and training staff on how to manage them. He has worked intermittently under contract with DOC on inmate classification issues since the mid-1980s, including during the period NEOCC was activated and filled with inmates.

Since February 1998, Dr. Austin has also been employed by CCA as a consultant to assist in developing an inmate classification system at NEOCC, including a practice not to accept any inmates without the sufficient classification material. This association with NCCD apparently was prompted by the pressure on CCA from the class-action lawsuit filed by inmates at NEOCC.

Over the past 12 years, the DOC classification system has been modified internally, perhaps inappropriately, to make the inmate population more closely fit the bed space and architecture available. While the system remained more or less intact until earlier this year, from all indications, its integrity has been questionable.

b. NCCD Reviews in Intervening Years. In 1995, Congress authorized NIC, who again contracted with NCCD, to evaluate the operations and facilities at DOC, including an evaluation of its inmate classification procedures. In his final report, dated January 30, 1996, Dr. Austin identified the following five problem areas with the process:

Following these findings, NCCD and DOC collaborated to develop eleven tasks needed to remedy the problem areas. However, DOC never adopted the new classification forms and procedures or implemented any of the other recommendations.

Dr. Austin, in his capacity as a consultant for CCA, stated in a report dated July 2, 1998, for U.S. District Judge Sam H. Bell, Northern District of Ohio: "It is important to note that the DOC does not utilize an objective classification system that has been properly pilot tested. A number of studies by NCCD have documented the deficiencies associated with the DOC classification criteria and organizational structure. For these reasons, it is entirely possible that inmates who posed a threat to the safety of inmates and staff at NOCC [Northeast Ohio Correctional Center] were being transferred to NOCC."

c. Origin of Category of "High Medium". As stated earlier, DOC informally modified its inmate classification system to refer to inmates at the higher end of the medium range as "high mediums". This informal term was then apparently formalized so DOC could adhere roughly to its contract with CCA at Youngstown and, at the same time, move more inmates out of its overcrowded and rapidly deteriorating Occoquan facility.

Until the contract was negotiated, the "high medium" term had never been formalized in the DOC classification system, at least not in writing. It is not mentioned in the DOC classification manuals, nor is it shown on the various forms DOC uses. Although this term had not been formalized in the DOC system before, it had been a common term in daily operations. Even after DOC and CCA signed the contract, the category of high medium never was made a formal part of the DOC classification system. Later, in 1998, it did become a category in the new system CCA implemented based on the NCCD model. They converted the NCCD category of "close" to "high medium."

d. Decision to Adopt the BOP Model at DOC. In the Fall of 1997 and as a result of the future transfer of DOC felons to BOP under the Revitalization Act, DOC decided to adopt the BOP classification system rather than the NCCD model. This change would also make the transition of cases to BOP easier for both systems.

The BOP classification system has been operational since 1979. It has been tested and validated over the years, and is more restrictive than many similar systems. The Ohio classification system, which was modeled on the BOP system, is very similar and, because NEOCC is in an Ohio community, it is reasonable to compare the Ohio and BOP systems. This is outlined in Section F.3, below.

BOP staff provided extensive training for all case managers at DOC facilities, as well as for wardens and their management staff. In addition to the initial training, BOP staff also provided oversight and quality control as DOC staff systematically reclassified all inmates at DOC facilities over the winter and spring of 1998.

This process was progressing simultaneous with the events at Youngstown and at about the same time that the U.S. District Court had mandated use of the NCCD model at NEOCC. The DOC leadership, in consultation with NEOCC management, decided not to apply the BOP model to the NEOCC inmates. In addition to litigation issues, there also was a concern that the more restrictive BOP model, which does not have a high medium category, would classify a number of inmates above the medium level and result in their transfer back to Lorton.

In accordance with the Revitalization Act, within the next three years, all DOC felon inmates will eventually be housed in BOP facilities, or be placed in facilities that are contracted by the BOP. This also means that they are all to be classified under the BOP inmate classification system. The DOC inmates currently at NEOCC are no exception. Later, after the controversy surrounding the July escape, the decision was made to replace the NCCD model at NEOCC with the more-restrictive BOP model. Using the BOP classification instrument, DOC staff is now classifying all inmates scheduled to move to NEOCC before the move occurs.

Recently, in its FY 1999 Appropriation for the District, Congress effectively mandated that all DOC inmates be classified according to the BOP model and that any at NEOCC above the medium level must be moved by April 1, 1999. That decision and its impact are reviewed in more detail below in Section E. 4 of this chapter.

2. Selection of Inmates for Transfer to NEOCC by DOC

a. The First 200 Inmates to NEOCC. As detailed in Chapter III, in January 1997, after a series of serious, violent episodes between inmates, and between inmates and staff at the Occoquan facility, which functioned as the highest security open population prison in the DOC system, intelligence was received that a major inmate disturbance was imminent. The decision was made that the ringleaders, and other of the most-disruptive inmates, had to be moved out to other facilities virtually overnight. Several senior Lorton officials had an emergency meeting to determine which specific inmates were to be moved.

The plan was to identify 175 of the most problematic, violent, and disruptive inmates at Occoquan, without regard to classification or separation issues, and move them to NEOCC as soon as a contract was in place, and it was ready to accept inmates.

DOC decided to "send a message" to Lorton's problematic inmates, because NEOCC was viewed not only being 300 miles away form home, but also as a very secure and highly controlled facility. The issue of technical classification level does not appear to have been a significant factor for these officials who were trying to stay ahead of a crumbling, dangerous situation.

Due to procurement problems discussed in Chapter II of this report, NEOCC did not open until May 1997. This made it necessary for DOC to find temporary alternative housing for these violent and disruptive inmates. As detailed in Chapter III, DOC accomplished this initially by contracting for bed space at four county jails in Virginia. Later, as many of the inmates became disruptive in the Virginia jails, a number of them were sent to a local jail in Georgia and a CCA-operated jail in Bay County, Florida, where they continued their disruptive behavior. Additionally, some were placed temporarily with the Federal Bureau of Prisons.

In May 1997, NEOCC began accepting and receiving inmates, starting with these inmates, along with 26 additional inmates from the U.S. Marshals Service. They were the most disruptive group of DOC offenders to be transferred to the facility.

b. The Remaining 1500 Inmates. Immediately thereafter in May, DOC began filling the institution by sending the inmates slated for NEOCC as rapidly as possible. After the first 17 days, they sent 904 inmates to the facility. Later, in September, after the subsequent contract was signed, they sent another 800 inmates in rapid fashion.

These inmates were reportedly selected based on criteria spelled out by a DOC Deputy Director in a memorandum to DOC wardens at certain Lorton facilities. This memorandum did not mention security level or custody classification as criteria for selection. Instead, the emphasis was on the length of time the inmate had remaining to serve, and whether or not the inmate had to stay in the District for court proceedings, etc. Although there was some attempt to adhere to the selection criteria set forth, it is apparent that these instructions were generally disregarded.

A significant number of those inmates selected by DOC for transfer to NEOCC was either inappropriately classified, or not classified at all, prior to movement. Many appear to have been selected at random---others because they had been disruptive, or posed management problems for DOC. Consequently, depending upon the classification system used, many inmates sent to NEOCC were actually more appropriately housed in a higher-security facility. It is a matter of record that 274 inmates were transferred to NEOCC directly from the Maximum Facility at Lorton. This represented 40% of the DOC Maximum Facility's population. Conversely, and inexplicably, minimum security inmates were also transported to NEOCC.

The Review Team discovered that a number of DOC inmates being managed at its Lorton, Virginia facilities in 1997 as maximum security by the DOC, perhaps 300 or more, were transferred to Ohio. Although the specific number is in question, the fact that maximum security inmates were sent to NEOCC is not disputed by anyone who has provided the Review Team information on this issue, including several senior officials in DOC.

c. Judgmental "Overrides." In the cases where some type of classification was designated at DOC, a mechanism termed an "override" was often used to adjust the security level downward after point levels were completed. The override mechanism can be used to change an inmate's security level based on staff's professional judgment, and requires a supervisor's concurrence. This device is used in some form by most jurisdictions to allow for flexibility and use of professional judgment. In this instance, however, it appears to have been overused and/or misused in a substantial number of cases to qualify more inmates for transfer to NEOCC and assist DOC in simultaneously reducing its population at Lorton and moving some troublemakers out of its facilities.

d. Case Files on Transferred Inmates. To complicate matters further, DOC sent NEOCC incomplete and/or unreliable inmate records. DOC asserts it sent a file to NEOCC on every inmate, and it is difficult to reconstruct exactly what transpired. In a number of the files it did send, however, Pre-sentence Investigation Reports (offense and background data on the inmate), Face Sheets (sentencing data) and Separation Orders (documents that alert staff as to which inmates must be kept separated from others), were missing or incomplete. Where proper documentation did accompany the inmate, copies were often unintelligible. Senior officials at DOC have since acknowledged that, due to the rush to move inmates, this was entirely possible. DOC later did provide or replace the missing, incomplete, and/or unreadable documents after it obtained a request list from NEOCC.

3. Movement of Separation/Enemy Cases.

The Review Team found that DOC also transferred to NEOCC over 200 inmates who had to be kept separated from each other for various reasons, including, but not limited to, personal animosity and their inability to interact harmoniously with each other. Others had court-ordered separations because they had provided testimony against each other, or because they had been codefendants, and the court wanted to avoid collusion on their part.

Complete and reliable information was missing in many cases to document the basis for the separations, however. This not only placed some inmates in jeopardy and created a substantial amount of work for NEOCC staff, but it also has stymied efforts to determine whether or not the separations remain valid.

4. Impact of Transfers on DOC Operations.

The impact of moving the inmates out of DOC to NEOCC was immediately positive for DOC institution operations. This is particularly true at the Occoquan facility, where the inmate population was reduced from 1800 inmates to approximately 1200, partly as the result of a subsequent court order. Administrators also indicated that operations at the Lorton Maximum facility became less troublesome.

The DOC senior leadership did not hesitate to report this in various forums. In fact, the then-Director of DOC acknowledged in a recent meeting that one reason the assault rate had gone down in the D.C. system was because they had transferred many of their "problems" to NEOCC. She also made similar statements in an op-ed article she authored for The Washington Post.

5. Status of Current Case Selection and Transfer Process.

Since the initial activation of NEOCC, both the DOC and CCA/NEOCC leadership have instituted many improvements. The rate of inmate intake has dropped substantially. In fact, there have been few transfers in since last spring, and the inmate count has been reduced from 1700 to approximately 1300.

NEOCC now has an inmate classification process in place, so it has the ability to screen cases effectively prior to accepting them. Likewise, DOC has now committed to referring inmates to NEOCC on a case-by-case basis, sending a complete set of records on each inmate in advance. DOC staff now uses the more-restrictive BOP classification system to classify its inmates, and only true medium security inmates are referred for transfer.

E. Role of CCA/NEOCC

1. Role in Accepting Initial Cases from DOC.

DOC has innumerable problems, particularly with its inmate classification process, that have contributed substantially to the unfortunate events that occurred at Youngstown. Corporate CCA and local management, by not having a screening mechanism or an inmate classification process in place at the time of receiving inmates, were equally at fault for exacerbating the situation. NEOCC, after all, was about to receive many disruptive inmates from the DOC system.

Both CCA and NEOCC were fully aware of the type of inmate they were receiving from DOC and accepted these inmates. There were frequent communications at several levels between DOC and CCA/NEOCC, well in advance of the inmates' arrival. In support of this observation, the original NEOCC warden, a retired BOP warden, knew some of the inmates personally from federal facilities where they had been housed previously. He had full knowledge that these were difficult individuals in advance of opening.

For several months the CCA corporate offices also were well aware that these inmates were disruptive. Some of these inmates, in fact, were being moved directly from one CCA-operated facility in Panama City, Florida to another (NEOCC).

a. Involvement Prior to Opening. Before the facility opened, CCA sent a team of NEOCC administrators, including one of its assistant wardens and its chief of security, to Washington to review the files of the first inmates they were scheduled to receive. Also, at the warden's request, they toured the DOC Occoquan facility and met with staff to learn more about these inmates, and the institution from which they had been transferred.

Other NEOCC management and line staff worked on temporary duty status for a period of time at the CCA-operated Correctional Treatment Facility (CTF) in Washington prior to NEOCC opening to learn how to manage DOC offenders. The CTF houses DOC offenders exclusively.

Finally, during the training in preparation for receiving the first inmates, many NEOCC staff report being informed that they were to receive some of the worst inmates in DOC.

b. Lack of Any Classification Review Capacity at NEOCC. To come full circle with what amounts to a "blueprint for failure," NEOCC had no inmate classification review and screening process in place at all when the inmates arrived, nor was there even an attempt to train staff on the DOC classification system. The DOC classification system had been agreed to in the contract between DOC and CCA.

The case management counselors were in place, and technically had responsibility for classifying inmates, but they had very little training and still have no authority to make classification decisions. Some report becoming frustrated because they were performing other, more menial tasks. Of equal importance, there was no apparent training or emphasis on this highly critical process for mid-level and upper-level management.

For example, the classification supervisor position was not even established and filled until a substantial period of time after the first inmates had arrived. The classification supervisor, who transferred to NEOCC from another CCA facility after the majority of the inmates had already arrived, told members of the Review Team that she "was shocked" to learn there was no classification or screening process in place at NEOCC when she arrived. She said that she knew how to classify inmates, but when she proposed to develop a process at NEOCC, her immediate supervisor, an assistant warden rebuffed the proposal.

Moreover, it does not appear that for the first year NEOCC ever attempted to exercise its contractual options to reject a proposed inmate transfer or to return any inmate to DOC on the basis of custody classification. Without a sound classification and screening process in place, or training on the DOC system, when the inmates began arriving at NEOCC, there was little choice but to accept the classification DOC had assigned to each inmate. There was also no indication of any insistence by CCA on adequate case information from DOC prior to acceptance and transfer, nor were any inmates rejected by NEOCC. From all accounts, NEOCC took in any DOC inmate, without regard to classification.

2. Devastating Impact of Classification Failures on Operations.

In May 1997, NEOCC began accepting and receiving inmates, starting with 200 of the most disruptive DC offenders they could have gotten. Over a 17-day period, they received 904 inmates, and on one day alone, 156 inmates arrived. Serious problems began to surface almost immediately, as outlined in detail in other chapters of this report.

3. Classification and Case Management after Arrival of DOC Cases.

As has been established throughout this chapter, The Review Team found that during much of its first year of operation, as the NEOCC facility was quickly filled and serious problems began to occur, no real classification or case management functions were put in place by CCA.

a. Management of Separation/Enemy Cases. This has been one of the most major management and security problems facing NEOCC. It has had a profound effect, and it must be resolved. DOC should not have sent these inmates, and NEOCC should not have accepted them, or they should have returned them. A main point is that NEOCC had no policy or procedures in place to track and keep specific inmates separated. Moreover, after the scope of the separation problem became apparent, there still was no aggressive effort to establish an effective set of written policies and procedures.

Institution operations at NEOCC are severely hampered by this large number of inmates who must be kept separated from each other. During the Review Team's on-site visit in late September 1998, there were still 155 inmates at NEOCC who had to be separated from at least one other inmate there. This was down from the over 220 there previously. Nevertheless, this situation must be resolved so the institution can begin to operate with some semblance of a prison, instead of a jail. DOC and CCA must work closely together to get these separation cases out as soon as possible. This process is now well underway.

Unfortunately, NEOCC learned the hard way because information was missing from DOC in many cases. It is well documented that DOC sent some of these separation cases to NEOCC without conveying sufficient case information. The problem was compounded further by the fact that NEOCC did not have a viable screening system in place at the outset to ameliorate the negative impact on the institution, and reduce the risks to inmates. NEOCC also has not effectively managed the known separation cases at the institution. One of the homicides (Chisley) was between two inmates who should have been kept separated from each other. Specifically, they had stabbed each other three months earlier in a confrontation, and were supposed to have been kept apart henceforth. This homicide occurred in March 1998. However, during a review several weeks later in May 1998, NEOCC still did not have a full written policy in place to manage separation cases, and the procedures it had implemented were not well understood by line correctional officers.

b. Reaction to Incidents, Class Action Lawsuit. NEOCC received its first DOC inmates in May 1997, but it was not until February 1998 that CCA contacted the consultant, Dr. Austin, to assist them in developing and implementing an objective inmate classification system. This was finally done after a series of problems, and inmates had filed a civil suit in federal court protesting the conditions and operations at the facility.

c. Intervention of the Court. As part of the class-action lawsuit, and following the events listed above, U.S. District Judge Sam H. Bell of the Northern District of Ohio, consequently issued a preliminary injunction that prohibited DOC from transferring any more inmates to NEOCC until the inmates already there were properly classified. He ordered that this effort be headed by Dr. Austin, and gave him a deadline of 90 days. He also mandated that NEOCC remove all inmates with security classifications of higher than medium security from the facility .

d. Role of NCCD. From April through July 1998, Dr. Austin and NCCD worked as a CCA consultant with NEOCC establishing an inmate classification instrument, so staff could more accurately screen cases and decide which inmates to accept or reject. This instrument is similar in many respects to that used by DOC, with minor variations. Later in this report a comparison among the three systems used by DOC, NEOCC, and the BOP will be provided.

Along with the new classification instrument, NCCD developed a separate reclassification instrument to adjust security levels based upon an inmate's behavior subsequent to his arrival, and taking into account his institutional adjustment at NEOCC.

The case management counselor staff at NEOCC was trained on the new classification system by NCCD, small samples of inmates were classified, and accuracy audits were conducted. The stipulation was that if an inmate's file did not contain all the required information from DOC for classification, the inmate was to be considered "unclassified" until that information had arrived. The inmates in that status are kept separate from the general population until they can be classified.

In June 1998, NCCD also conducted on-site audits of DOC institutional files with the new NEOCC-completed classification forms to ensure reliability of file material being forwarded to NEOCC by DOC.

e. Identification and Transfer of Maximum Security Cases. In accordance with the court order, NCCD modified the classification instrument used previously with DOC and, working with NEOCC staff, screened the inmate population. As a result, 119 inmates out of the 1700 at NEOCC were identified as maximum security and moved out to either other CCA facilities or to the BOP.

f. Change to Stratified Housing. Beginning in the Spring of 1998, the NEOCC warden, who had recently replaced the original warden, put in place a system of "stratification", wherein they grouped the inmates together roughly by their security levels, using the modified NCCD classification instrument, and segregated them by housing areas. They were identified by the color of their jumpsuits (uniforms), and this system remains in place. It has proven to be an effective tool at restoring order and control in the facility, and inmates the Review Team interviewed have said this strategy has helped them feel safer as well.

4. More Recent Developments.

a. Actions in Response to July Escapes. After the escapes in July 1998, the institution was placed on lock-down status, and, based on agreements with local and state officials, staff identified inmates at the facility whose security levels were high medium on the NCCD scale. They were isolated from the general population and placed on a waiting list for transfer when space became available at other sites. During the week of October 26, 1998, the final group of high-medium inmates was removed from NEOCC and dispersed to various CCA and BOP facilities. In total, 326 inmates were transferred out of NEOCC at this point since the NCCD system was activated in February 1998.

Also after the July escapes and the focus on the lengthy sentences and violent offenses of the escapees, the then-Director of DOC assured the Ohio State Legislature that one of the steps she would take was to begin using the BOP model to classify NEOCC cases. Inmates scoring higher than medium on the BOP scale would be removed.

The reclassification of the NEOCC inmate population using the BOP model was performed by DOC staff under the direction and guidance of BOP staff, resulting in 521 cases being identified as high security. These inmates are now in the process of being removed, and all are to be placed in other facilities by April 1999.

Additionally, the decision was made that NEOCC would accept inmates from DOC only on a case-by-case basis, and after they had classified the inmate in advance, using the BOP classification system. Inmates with security point scores exceeding the BOP medium range would no longer be accepted, nor would inmates who had to be separated from others at NEOCC. The next step is to train NEOCC staff in the BOP system, and they have expressed an interest and willingness to receive this training, even though they have only recently completed training on the NCCD system.

b. Current Status. This is currently a transitional period for NEOCC staff. Prior to February 1998, the only classification model most of them had been exposed to was the DOC model, which was not very clear or applied reliably in many cases. Then after Dr. Austin was hired as a consultant by CCA, they had to learn the NCCD model. Now, through legislation and commitment on the part of DOC, they have to learn yet another model----the BOP model. Meanwhile, they are still using the NCCD model internally until they receive training on the BOP model.

Changing classification models so many times over the past 9 months has caused some problems for the staff at NEOCC. The application of the BOP model has served to identify even more inmates who must be removed from the facility, as noted above, and it has had the effect of forcing a number of housing changes at NEOCC until the high security inmates can be removed.

i. Management Review Panel for Incoming Cases. Over the past several months there have been several improvements to prevent the kinds of problems NEOCC has had since its opening. NEOCC came to an agreement with DOC on the security level of the inmates it would accept in the future, and what type of documentation was required for each inmate. No more high-medium level inmates will be accepted, and the more-restrictive BOP model is used to classify the inmates prior to them leaving the DOC.

It also established a review panel comprised of the warden, an assistant warden, the chief of security, and the classification supervisor, to ensure the referral process is working correctly. This high-level scrutiny had been much needed in the past.

Had such a mechanism been in place prior to its opening, as a good management practice, most of the problems NEOCC experienced might have been avoided. Both the leadership of DOC and CCA appear to be committed to responsibly handling the selection and transfer of inmates to NEOCC in the future, as well as other matters which should resolve many of the current problems.

ii. Assessment, Concerns, Transition to BOP Model. Although the institution has recently made good progress in the classification area, a number of issues remain to be addressed.

First, a major concern is that the classification issue has to be resolved quickly. The current confusion with the staff is understandable. They are now starting to learn their third inmate classification model in a short span of time. Many of the basic principles of these models are the same, but the details are very different.

Next, there must be strong management oversight to ensure this new process doesn't become another "paper program," and that staff learns to appreciate its value. Also, there still are some issues evident at NEOCC that continue to give the Review Team serious concern. For example, while the inmates have now been classified, and identified in accordance with their security requirements, our review revealed that there are still a significant number who are housed in quarters not commensurate with their security levels. As a consultant to CCA, Dr. Austin had similar concerns after he visited NEOCC in early September 1998 to conduct follow-up training with the case management counselors on the NCCD system.

In a memorandum dated September 21, 1998, to the NEOCC warden, Dr. Austin expressed his concern that while the reclassification forms were being completed with appropriate housing locations approved, inmates were not being moved accordingly. He went on to say that while the counselors at NEOCC appear to be making suitable recommendations, often no action was taken, primarily because they lack the authority to move inmates based on the classification instrument.

In the judgment of Dr. Austin (and the Review Team), there is an inherent organizational structure problem at NEOCC. Specifically, the counselors who conduct the classification assessments report directly to unit managers who are not familiar with, nor well versed in classification protocol or reclassification procedures. The counselors do not meet regularly and there is no system in place for meeting with the classification supervisor to ensure consistency.

In the same memorandum, Dr. Austin made four recommendations to the warden for institutionalizing and solidifying the classification process. The Review Team concurs with this assessment:

The goal is to incorporate consistency and accountability into the classification process, thereby enhancing internal security. The unit would have the authority to move an inmate to other quarters when it became apparent the inmate was inappropriately housed.

According to Dr. Austin, and confirmed at the time of our visit, NEOCC is grossly deficient in the area of automation. This is also discussed in this report in Chapter VI, "Management of Inmate Population."

Classification and reclassification forms are not entered into an automated, real time database that counselors, or anyone else, can access. There is a database reflecting housing, work assignments, etc., but nothing of any consequence regarding an inmate's custody level, except in the record office. An automated list of all the inmates the record office provided to the review team, however, contains only the following information:

-- Full name

- Facility ID number

-- Agency number

-- Date of birth

-- Housing assignment

-- Admission date

-- Sex

There is no mention of custody classification, whether they must be separated from other inmates, or job assignments.

There are not enough computer terminals for everyone to access, and most of the staff has not had adequate training in this regard. There is one FAX machine in the entire institution. Moreover, with the current population, all will be due reclassifications at approximately the same time. With no automated system in place, there is no way to determine when an inmate is due to be reclassified other than manually searching each inmate's file. This is a tedious, time-consuming task, thereby increasing the likelihood staff will not be conscientious about doing it consistently.

During Dr. Austin's visit, it became apparent that the counselors had never seen the policy and procedure manual that had been developed earlier to provide guidance on the new classification process at NEOCC. This lends some credibility to the concern that the classification process tends to be a "paper program" at this point.

One of the intrinsic problems with classification at NEOCC is that only line-staff is being trained in the process. It is important that there be an executive and managerial staff buy-in as well.

Specifically, the unit managers, who directly supervise the counselors, also need training in classification. Typically, they are unfamiliar with the scoring instrument, and do not appear to have a full appreciation for its value. The same holds true for upper level management, including the warden and assistant wardens.

.

As mentioned before, the NEOCC counselor staff is eager to learn and apply the BOP classification system as soon as possible.

F. Summary Comparison of Classification Models

1. Similarity of DOC and NCCD Models

It appears that the only substantive modification made by DOC to the NCCD model was a change in terminology for one of the security levels. What the NCCD model categorizes as "close" custody, DOC calls "medium" on a formal basis, and "high medium" on an informal basis. In the judgment of the Review Team, both these models place too much emphasis on an inmate's very recent adjustment behind the walls, and not enough on his history of behavior in the community. Both are seen as more lenient than the BOP model.

2. Contrast of BOP Model with DOC and NCCD Models

Because the DOC and NCCD models are so much alike, and the DOC model is no longer in use, they will be combined and contrasted to the BOP model as one process.

Although the NCCD and BOP models consider many of the same criteria, there are very substantive differences between them. The most significant ones are:

Criteria

NCCD

BOP

Offense behavior
Plea-bargaining can lower an inmate's score under the NCCD model, because only the official offenses are weighed. Not so with the BOP model, which measures the inmate's actual offense behavior.
Length of history Under the NCCD model, an inmate is held accountable for his behavior for only the past 10 years. The BOP model has no time limits.
Detainers The NCCD model blends detainers (pending sentences or charges) in with the current offense, and the inmate is held accountable for them only if they are more severe than the current offense. The BOP model holds inmates accountable for both, again, based on behavior.
Offender age The NCCD model subtracts points from an inmate who's 26 years old and above. The BOP model does not recognize age as a valid predictive criterion.
Projected release The NCCD model bases an inmate's projected release date as his Parole Eligibility Date. The BOP model bases this on a severity scale, which does not recognize parole, unless the inmate has already been granted a parole date.

In view of the above, the BOP model is considerably more restrictive than the NCCD model. This was recently illustrated dramatically when the NEOCC inmates were reclassified using both models. Under the NCCD model, approximately 210 of them were classified as higher than medium security. When the BOP model was applied to the same inmates, however, the number increased to 521 (more than double).

3. Comparison of BOP and Ohio Models

The Correctional Institution Inspection Committee of the Ohio General Assembly issued a report on October 7, 1998, on the NEOCC escapes and other problems. In its report, several recommendations were made to the Ohio General Assembly for existing and future contracts with private prison contractors. One of these recommendations would

"Require private contractors to assess, determine, and confirm the security level of each prospective out-of-state prisoner by using an inmate classification system that is identical in all material components to that used by Ohio DRC [Department of Rehabilitation and Correction]."

The BOP and Ohio models are materially similar to each other, in that they assign roughly the same weights to similar criteria. Therefore, they are almost identical as far as accountability and risk assessment are concerned. In the Summer 1997 issue of Corrections Management Quarterly, Dr. Austin is quoted as saying, "The DRC's (Ohio) classification system was originally adopted approximately 13 years ago and is directly modeled on the Federal Bureau of Prisons (BOP) system."

Both models are significantly more restrictive than the NCCD model, because they hold inmates accountable for their behavior over their entire histories, and they add security points for detainers.

With regards to criteria considered, the BOP and Ohio models differ in three notable ways:

Criteria

BOP Model

Ohio Model

Self surrender credit
The BOP model subtracts security points from low security inmates whom self-surrender with the court's permission. Ohio does not recognize pre-commitment status.
Offense behavior The BOP model bases its decisions on an inmate's actual offense behavior, not the charge, thereby negating the effects of plea-bargaining. The BOP model is significantly more restrictive than the Ohio model in this regard.
Projected release date The BOP model calculates an inmate's expected length of incarceration from a severity scale that does not take into account a speculative release date, such as parole. The Ohio model uses the inmate's earliest parole hearing date as its basis for this criterion.

The BOP model is more restrictive in this regard.

The security level designations between the two models differ somewhat in terminology, but they are comparable, primarily because the weights assigned, and the calculations used, to arrive at the point scores are very similar. Also, while the point score ranges are quite similar, there are some overlaps between the two models.

In the Ohio model, the security level terms are minimum, medium, close and maximum. The corresponding terms under the BOP model are minimum, low, medium and high.

One concern heard expressed is that the higher end of the BOP medium security point range overlaps to a degree with the Ohio model's close security range, and this is true. However, the BOP model holds inmates more accountable for their actions, in that actual behavior, not just charges, are considered when calculating the severity of their offense(s), thus a plea-bargain will not lessen an inmate's accountability. The BOP model also calculates the length of time an inmate is expected to serve in a more restrictive manner. Many inmates who score as Close security under the Ohio model would score as High security using the BOP model. Consequently, in the opinion of the Review Team, the BOP model is somewhat more restrictive than the Ohio model, and significantly more so than the NCCD model.

4. Potential Confusion of Moving to a Fourth Model at NEOCC: Ohio Model

The Review Team believes it is unnecessary for the NEOCC staff to now learn still another (fourth) classification model for several reasons:

G. Overall Findings and Recommendations

Findings of Major Concern

The Review Team concurs that there are three major findings in this chapter. They are:

F-3. DOC and CCA failed to perform rigorous case reviews and to carefully select the population for transfer, which contributed substantially to many of the problems that quickly surfaced at NEOCC. Managers of both organizations were informed, willing and mutually responsible players in the transfer of large numbers of inmates who could not be considered medium or high-medium under any reasonable correctional standard. DOC selected scores of inappropriate cases, all of which CCA uncritically accepted. Until recently, NEOCC never developed a capacity for inmate classification and screening.

F-4. DOC was irresponsible in sending over 200 inmates who required individual separation from other particular inmates at NEOCC, at times providing minimal file documentation. It is unacceptable correctional practice to house such separation cases in a general population facility. NEOCC accepted and kept these cases, without developing adequate procedures for managing their safety needs until after a homicide resulted from the poor procedures.

F-10. Procedures put in place to manage large numbers of separation cases constitute a major problem, severely limiting operations of the facility and aggravating idleness.

Major Recommendations

R-3. DOC should clearly define criteria for the selection of inmates for any future transfer to contract facilities. Sufficient time should be allowed for the DOC and the contract facility to screen referrals and determine if adequate information is available, and for the contractor to object to the transfer of any inmate not suitable under the terms of the contract.

R-4. DOC should ensure that future contract facilities have in place, before inmates arrive, a sound screening and classification capacity to use as a basis for assigning inmates to housing units, identifying individual security needs, and directing inmate involvement in work and program activities.

R-5. NEOCC should better emphasize the central importance of its inmate classification and the quality of its case management capacity. Additional classification training is important for not only the case management counselors and the classification supervisor, but also for upper management administrators who review the recommendations and decisions made by other staff.

R-6. The process of classifying inmates must be stabilized and confusion eliminated, after three different systems or models have been used in quick succession at NEOCC. Consistent with the direction of Congress in the 1999 District of Columbia Appropriations Act, the Federal Bureau of Prisons (BOP) model should be adopted as the permanent system, and staff should be well trained in its implementation.

R-7. DOC must immediately work with NEOCC to remove all existing separation cases from the facility and to ensure that no future known separation/enemy cases are sent to NEOCC. NEOCC must develop precise procedures for the management of any future separation cases which will occur from local incidents where a strong animosity arises. Staff and supervisors, should be thoroughly trained to carry out these sensitive procedures. In no instance should separation cases be allowed to be housed simultaneously in general population.

Additional Recommendations

AR-1. Unit management and security functions should be separated. Unit managers now report to the chief of security. This is not conducive to an atmosphere in which case management typically thrives. It sends a mixed message, and unit staff is prone to be less accessible to the inmates.

AR-2. The practice of having the Special Operations and Response Team continually visible in the halls in full riot gear should be discontinued.

Chapter V.

Security Issues

Introduction. A number of very serious and fundamental questions about security at NEOCC were raised because of the series of incidents which led to the commissioning of this review. The team reviewed the security management of the facility using two parallel processes:

It was concluded that there had been a pattern of flawed security attributable to both corporate and institutional management deficiencies, resulting in failures to meet the basic correctional mission of community, staff and inmate security. Most notably there were two homicides, a major escape, numerous stabbings, assaults against inmates and staff, and the widespread presence of dangerous weapons among inmates.

It is reasonable to conclude that certain of the most serious occurrences and problems were preventable or subject to significant mitigation. There is little indication that the local administration received significant guidance in this area from corporate management, except in reaction to major problems. To some extent, the serious security failures are also attributable to the inadequate oversight of the contract by DOC.

The Review Team and the security audit found that significant corrective steps have been taken and are ongoing by the current administration to rectify some of the fundamental breakdowns in earlier security procedures. They found some significant weaknesses and a number of areas needing attention. However, they did not find that the current technical security procedures are fundamentally flawed or particularly out of line with what might be found at most new comparable prisons should they be given a similarly intense audit.

In follow up to the security audit, it is of critical importance for its long term success and management that CCA/NEOCC take steps to implement the numerous recommendations contained in the report and to continually monitor itself in maintaining standards of acceptable security.

The Review Team spent considerable time reviewing the security aspects of the major incidents which have occurred in the year and a half since NEOCC opened. In this part of the security review, the team visited the facility and the local area during five different weeks to review records, perform interviews and conduct other fact finding activities.

1. Fundamental Security Breakdowns. The team found that in the first 15 months of operation there had been fundamental breakdowns by the institution and CCA corporate management in meeting their most basic correctional security missions: to protect the community from escape, to maintain order and control, and to protect the safety and lives of the institution's staff and inmates. Some examples of those major security breakdowns are:

The following analysis by the Review Team of the nature and causes of the security problems indicates serious failures at both the institutional and corporate levels, and to some extent with DOC due to its inadequate oversight.

2. NEOCC Operational Security Problems.

a. Impact of Broader NEOCC Operational Problems on Security. Before addressing some specific operational security problems, it must be pointed out that many broader areas of prison management beyond those strictly related to physical and procedural security have great impact on maintaining an overall safe and secure environment. In that regard, overall security at NEOCC has been severely hampered by other fundamental problems pointed out elsewhere in this report, such as:

The drastic pace of the rapid deployment of inmates in May of 1997 contributed to an initial state of disorganization and lack of control which long had an impact on many aspects of institution safety and security. A dysfunctional atmosphere developed from which it has been difficult to recover.

b. Summary of Incidents and Security Breakdowns. A detailed catalogue of incidents at NEOCC is attached as Appendix 4. Most of the more serious incidents, including the series of assaults and stabbings and the proliferation of weapons have been elaborated on elsewhere. Several bear expanded discussion.

c. Numerous Weapons Discovered. Almost immediately after the activation of the facility, contraband weapons began to be discovered, including 30 in just over the first two months of operation. Likewise, serious assaults and stabbings involving the use of some of these weapons quickly occurred. Over 110 such weapons have been discovered by staff since the opening of the facility. The weapons have been fashioned from a number of sources, primarily from such items as laundry carts, portable food carts, various trash and garbage containers and an assortment of other pieces of equipment used daily to move items about the facility.

Selection of proper, tamper-proof equipment during the activation of a secure prison is a critical aspect of good security management. Such compromise-free equipment is readily available throughout the industry.

In this case, not only were the pieces of equipment partially taken apart, with the carts at times being literally disassembled, but the 1/4 inch hardened steel rods and metal angle supports often clearly appeared to have been fashioned into weapons with the use of tools, indicating a lack of proper tool control policy and procedure. Only within recent months have staff identified the problem and are confident they have replaced all such vulnerable carts and equipment. Appendix 5 provides a list of the contraband discovered to date.

d. Derrick Davis Homicide. Derrick Davis was murdered early on the morning of February 22, 1998 in a general population unit. At a time during the feeding of breakfast when the floor officer apparently had been removed from the unit to cover other duties, Davis entered the cell of another inmate. By the time it came to the attention of staff that an incident had

occurred, Davis had been assaulted and stabbed about twelve times. He was taken to the local hospital where he was pronounced dead.

Other than the very problematic presence of the weapon and the lack of an officer on the floor of the unit, there are no unusual security and management concerns which have come to light in this incident. However, that observation may be partially based on the fact that, at least as far as the Review Team can determine, there were no After-Action reports completed by either the DOC or CCA as should have occurred routinely.

However, a major public concern has arisen recently regarding the botched handling by NEOCC staff of the follow-up to the murder. In spite of original assertions that CCA staff had not conducted an investigation parallel to that of police and prosecutors, it was surprisingly revealed to prosecutors only during the trial of two accused assailants that a NEOCC staff member did conduct a parallel investigation, including inappropriately making tape recordings of interviews. The result of this admission was that the two suspects were allowed to plead guilty to lesser charges and to receive relatively short, concurrent sentences.

e. Bryson Chisley Homicide. On March 11, 1998, in a devastating convergence of security lapses, inmate Bryson Chisley was murdered in the high security, long-term segregation unit. It is very reasonable to conclude that this incident was preventable and should never have occurred.

On December 21, 1997, Chisley had been in a knife fight in a general population unit with another inmate. The other inmate was seriously wounded with stomach wounds and transported to a local hospital where he was admitted for treatment. Chisley received stab wounds in the torso and was treated in the institution infirmary before being placed in segregation. The reason for the confrontation is not clear.

After the other inmate was returned to the facility, they should have been classified as separation cases and strict procedures should have been enforce to keep them from ever being in each other's presence, let alone housed in the same unit. However, they were placed in the same pod of the same segregation unit. Chisley apparently feared for his safety and repeatedly requested to be moved. His wife campaigned to have him moved away from the other inmate, including not only sending letters and speaking to NEOCC administrators, but also being interviewed in the local press.

On March 11, Chisley, the assailant, and three other inmates were being returned to their cells, shackled, from an outside recreation area where they were in separate, screened in areas. The assailant managed to remove his handcuffs and chased Chisley. He was assisted in the assault by one of the inmates who had just been identified as a principal assailant in the Davis murder three weeks earlier. Under any normal security precautions, he should not have been allowed near other inmates, coming out of his cell only alone and under heavy restraint and supervision. He helped pin Chisley while the other man repeatedly stabbed him. Chisley was transported to the local hospital where he died shortly after. Both inmates have pled guilty.

There were a number of major security lapses identified in this incident. Listed below are some of the key areas:

This incident clearly evidences a combination of major problems which had been allowed to take hold at NEOCC: (1.) lack of policy and procedure in critical security areas, (2.) inexperience and poor security training of supervisors and line staff , (3.) lack of any effective internal management controls at the local or corporate levels. In sum, the most basic security operations were seriously flawed. The After Action Report from the DOC's review of this incident is found in Appendix 6.

f. July 1998 Escape. On Saturday afternoon, July 25, 1998, six inmates serving long sentences for violent crimes escaped through the perimeter fence system of NEOCC, precipitating a major emergency for the local community and turning the intense scrutiny of media and public attention on the facility. Indeed, the incident led the Governor of Ohio and a broad array of elected officials to propose closure of the prison. The Governor requested the assistance of the Attorney General of the United States in sorting out the situation, a request which led directly to the initiation of this present review.

Another result was several days of hearings by a committee of the Ohio Legislature, the Correctional Institution Inspection Committee, which took testimony from a wide variety of witnesses and issued a report in October. That public report accurately and thoroughly outlined a number of failings in the security of the facility that led to the escape.

The escape is still in the process of investigation by the U.S. Marshal Service and criminal prosecution by the U.S. Attorney's Office, so that a number of relevant details are not available to this Review Team. However, the Review Team did have access to sufficient preliminary information, including some review documents of CCA and DOC, to outline the main issues involved.

The Incident

Shortly after noon on a clear, sunny day, 219 inmates from the Low Medium wing of the facility were moved to the largest of three recreation yards, Yard Three, for a routine period of summer recreation. Although all six escapees were serving very long sentences and five of the six were convicted murderers, they had not been disruptive and were assigned to the Low Medium security housing unit.

They were counted and processed to the recreation yard through a metal detector by five relatively inexperienced correctional officers. The audio alert on the metal detector was inoperable, and the staff did not use a hand-held detector to check inmates. Thus, it would not have been difficult to move a cutting tool through the area. It could not be determined how long the large metal detector had been inoperable or if any work order had been undertaken to repair it.

During the entire period of recreation, no supervisors visited the area, a customary correctional practice, nor were there any telephone checks. In fact, the shift commander, a captain, turned over command of the entire facility to a very inexperienced lieutenant. The captain's activities are mostly unaccounted for, as he reportedly completed paper work in an isolated office. The recreation area consisted of separate zones of coverage: the outside baseball field adjacent to the perimeter fence; a large gymnasium; and a paved area for basketball next to the gym. The five staff assigned may have been sufficient for coverage if they had remained on their assigned posts and if procedures for coordinated movement and rotation were established. However, there apparently was no planned coordination for movement.

After 45 minutes, at 1:00 p.m., one of the two officers assigned to the baseball field was reassigned to cover another indoor housing unit and did not return until 2:10 p.m., by which time the escape had apparently occurred. Reports show that other officers were allowed to leave their posts to use the rest room for unspecified periods. One staff member was playing ping pong in the gym with a group of inmates. It appears that the outside yard area was completely unsupervised for as long as 40 minutes. A large group of inmates may have been involved in distracting officers or in providing a human wall, thus shielding the view of staff.

Sometime during this period, the six inmates cut a four foot hole in the heavy gauge chain-link inner perimeter fence near the recreation yard. They then moved a distance along the fence to a less visible area and cut through the outer fence, managed to make their way through three rolls of razor ribbon and escape undetected. No alarm was activated in the electronic detection and motion alarm system. Apparently, there was a somewhat longstanding area of vulnerability in the system which the inmates had discovered but staff had not.

Staff in two vehicles assigned to continually patrol the perimeter did not detect the escape or the breach in the fence. Neither was there any special procedure for them to give special attention to the recreation yard. A common practice in many prisons would be for one vehicle to remain on moving patrol while the other maintained stationary supervision of the recreation area from the outside road.

The source of the cutting tool or how it was moved around by the inmates is not yet clear, although there was some early speculation that it had been provided by a staff member. That theory has not been substantiated by this Review Team. Neither could it be determined how the plan was put together, although there is an indication that some of the inmates were not in on the original plan, but only took advantage of the opportunity to escape when it arose. Fortunately, large numbers of inmates did not choose to take similar advantage and follow the route of these six.

In an unusual action out of the normal pattern, the remaining inmates asked to vacate the recreation yard early, at about 2:15PM, apparently to be out of the way in the event of any staff response. The staff who processed the inmates back in did not count them as was called for by procedure, or the escape might have been discovered considerably earlier. Likewise, no staff inspected the recreation yard after the close of the activity, as would be common practice. Had they done so, they may well have discovered the holes in the fence.

Staff only became aware of the escape after the inmates returned to the unit and a unit manager was informed of the problem by an inmate, at some time shortly before 2:40 p.m. Staff immediately found the hole in the fence and began a count procedure to determine how many inmates might be missing.

There is significant controversy and some confusion over the reporting of the escape to the local police. It was at least 30 minutes, and likely more, after initial discovery of the escape before a duty officer made an official call to the police. Several calls to 911 were made, with some confusing information given. After the arrival of law enforcement authorities, there was additional confusion and lack of coordination, due in considerable extent to the lack of a sufficient, pre-existent interagency emergency plan. This is a direct reflection on the poor state of relations with local law enforcement fostered by the NEOCC leadership.

There followed an extensive manhunt, as the six inmates were gradually apprehended. The last one was arrested in upstate New York several weeks later. Because most of the inmates were arrested in the immediate area, even very close to the prison, it appears there was no elaborate pre-planning and little or no outside assistance on their part.

Causes and Contributing Factors

Both DOC and CCA immediately sent ranking officials to lead After Action Reviews of the incident. Those reviews are attached as Appendices 7 and 8. Also as reported above, the Correctional Institution Inspection Committee of the Ohio Legislature reviewed and reported on the escape. The current Review Team relied on all those reports in addition to its own research to determine the causal factors listed below:

as reported. The routes, direction and predictability of the vehicles allowed the inmates to be well aware of their timing and presence.

inmates coming on and off the yard, this procedure was not properly followed. If it had been, the escape might have been discovered in a more timely fashion.

Remedial Actions to Strengthen Perimeter Security

A number of recommendations were made by both the DOC and CCA review teams. NEOCC kept the recreation yard closed for more than two months while they made significant upgrades to security and followed through on implementation of the recommendations. As part of the current review, the security audit team found in September that most of the required modifications had been made. In their reports contained later in this chapter, they identified additional physical and procedural requirements which the NEOCC administration agreed to implement,

Of greatest importance to this Review Team is the recommendation that attention to supervision and training of inexperienced staff and uniformed supervisors be closely monitored by the institution and corporate managers.

3. Corporate Management Failures. Of major concern to the Review Team was that fundamental security was repeatedly compromised. The apparent inability of the corporate office to assure the implementation of adequate security in a newly opened facility, and to learn from major security breakdowns at one facility, while correcting similar weaknesses and preventing similar problems at other secure facilities. This concern is directly related to the comments in Chapter VII about the lack of a sufficient capacity for self-assessment, including security audits.

While the commission of this review by the Attorney General included direction to look at certain problems at contract facilities beyond NEOCC which later housed DOC inmates, there were practical limits to the scope of the team's work. It was beyond the Review Team's capacity or intent to attempt an extensive review of incidents at a number of CCA

facilities. However, a few incidents which were recent or publicly known in the corrections field, including those with DOC inmates transferred to other CCA facilities from NEOCC, shed light on this concern.

a. Pattern of Escapes. Though the reviewers made no attempt to ascertain the record of all escapes from CCA facilities, there have been several which did come to the Review Team's attention which are directly relevant to this report because they seem to reflect on the capacity for self-assessment and improvement in security problems.

Escapes Through Perimeter Fences

Escapes Through Controlled Entrances

Several of these escapes, including those at Youngstown, might have been prevented had CCA implemented company-wide reviews along with preventive measures based on weaknesses found in earlier escapes or if it had in place effective internal controls and security audit processes.

b. Pattern of Failures in High Security Units. Likewise, after the major problems and breakdowns which were discovered in the procedures in the NEOCC high security segregation unit with the Chisley murder, similar serious incidents occurred with problematic DOC inmates transferred from NEOCC to two other CCA facilities. In both incidents, maximum security inmates slipped their handcuffs while being escorted by staff in the segregation units.

These incidents involved fundamental breakdowns in the most basic security procedures in the most critical unit of the prison. The inmates involved had previously proven to be dangerous and disruptive, meriting the highest degree of scrutiny and care.

Group Assault on Staff in High Security Unit Recreation Area

Recently, in CCA's Torrance County New Mexico facility in August, 1998, a DOC inmate being removed from a small, fenced recreation cage adjacent to the high security unit, managed to slip his handcuffs. He then assaulted the escort officer, took his keys, freed approximately ten other inmates from adjacent recreation cages who engaged in a serious brawl with a number of responding staff. At least five staff were injured and required hospital attention. The incident was only brought under control when security staff fired a warning shot. Had that action not been taken promptly, the incident might well have had a more serious or even tragic conclusion.

Homicide in High Security Unit

In an incident reminiscent of the March killing of Bryson Chisley at NEOCC, a homicide occurred at CCA's Mason, Tennessee facility on the evening of August 27, 1998. Two DOC inmates who had been transferred from NEOCC and who had animosity and had been involved in an incident two weeks before were somehow allowed out of their cells at the same time, the victim to make a phone call, and the assailant to take a shower. One slipped his handcuffs and assaulted the other with a sharpened weapon, although the victim, who was heavily shackled, also produced a weapon and defended himself. The victim was stabbed seven times and died a short while later.

According to an After-Action Report prepared by a DOC Deputy Director, a number of fundamental security procedures broke down. Some of the key findings follow:

In summary, once again there were multiple breakdowns in the most fundamental security procedures. The lack of proper supervision and staff training as well as adequate internal controls by management were evident. Appendix 9 contains DOC's After Action Report of this incident.

c. Lessons not Learned, Weaknesses not Corrected. In these various cases, had lessons been learned from the obvious breakdowns, they may have been prevented. Because of the previous incidents at other CCA facilities, especially those holding DOC inmates, security alerts should have been made by corporate headquarters in attempts to avoid serious or tragic disturbances.

For instance, after the Chisley homicide incident, CCA sent to NEOCC a high level management team led by a senior divisional director to conduct a review and take charge, as is described elsewhere in this report. Although that team made and implemented important changes at NEOCC, inexplicably it did not produce any written report or recommendations, nor is there any evidence that CCA communicated any of the lessons learned from that incident to its other institutions. Neither was any report done by the senior CCA administrator sent to New Mexico to review the disturbance involving DOC inmates there. Furthermore, no such reports were available to the District of Columbia government which pays the bills and which has a contractual right and responsibility to closely monitor problems with its inmates in such contract facilities.

4. Significant Recent Improvements in Security at NEOCC. Members of the Review Team, particularly the security auditors, were impressed by NEOCC's numerous improvements to policy and procedures in the area of security over recent months. There has been a complete turnover in the administration of the security chain of command, including a new warden, assistant warden, the chief of security and assistant chief of security, all of whom have apparently been hand-picked by CCA to come in and change the previous poor record in the security operations. Under Warden Turner's leadership, they seem to be knowledgeable and focused, committed to doing whatever it takes to make things right. Much of this progress is borne out in the results of the security audit below.

However, the progress must be considered fragile. The difficulty of the task should not be underestimated, particularly in light of the poor matching of staff inexperience with the sophistication of the inmates, compounded by such factors as inmate idleness and the poor pattern of inmate/staff relations.

5. DOC's Inadequate Oversight of Security Procedures. The monitoring of the NEOCC operations by the DOC is the subject of Chapter XI, but a few comments are in order here in relation to security. The DOC monitoring of security practices at NEOCC was sporadic for a lengthy period after the activation. Several visits were made and some reports with recommendations were written.

Once the consultant monitoring firm started its work, there was more consistency, but unfortunately they may not have possessed the necessary expertise specifically in security matters. There was little depth of focus on security issues and no significant problems were reported in the monthly monitoring reports. The major problems which were made evident by the series of breakdowns were never previously discovered by the monitors. The very basic problem of having no adequate written policy to keep the 200 separation cases under control was missed until after the Chisley murder in March.

Although there was no After-Action Review after the Davis homicide in February, excellent reviews with effective remedial recommendations were immediately performed following the Chisley incident and the July escape. Since late July there has been a full time, experienced monitor on-site, but he will need periodic assistance from DOC security specialists of the DOC.

Also, an excellent After-Action Report was completed by DOC after the homicide in August at CCA's facility in Mason, Tennessee. However, previous to that there had been little effective oversight by the DOC of security at the facilities in Tennessee and New Mexico,

nor is there any on-going presently. The same issue will be the case now that DOC inmates have been moved to the CCA facility in Florence, Arizona.

The nature of DOC operations have been drastically altered by the contracting out of a large portion of their inmates to remote sites. That pattern will increase next year. For DOC to effectively carry out its mission, it must recognize the need to create a full time oversight unit to monitor these various facilities.

B. Detailed Audit of Current Security Practices

Introduction. Because of the serious controversies surrounding the security of the facility, the Trustee's Office decided to commission a very detailed audit of the current state of institution security, engaging a team of independent experts which utilized a nationally accepted audit instrument and process. Assistance and direction in obtaining independent leadership for the team were sought from the National Institute of Corrections who provided a list of nationally recognized experts, including several who are used by the Institute to train state prison systems in security audits.

Based on the recommendation of the Institute, Stan W. Czerniak, Assistant Secretary for Security and Institutional Management, Florida Department of Corrections, was selected as the team leader. His recommendation to use James Upchurch, Statewide Security Administrator, Florida Department of Corrections, to assist in the task was readily accepted. Two other experienced correctional security experts rounded out the team.

1. Summary of Audit Findings. The audit team performed its comprehensive review from September 21-25 as part of the larger review team visit to NEOCC that week. It evaluated the current operations in some detail, not focusing on earlier operations or problems. The full audit report with recommendations prepared by the team is included below as Section C of this chapter. In summary, the Security Review Team found that over recent months major improvements had been made in a number of areas and that currently most technical security procedures were sound or in the process of being rectified.

They found some significant weaknesses and a number of areas needing attention. However, they did not find that the current technical security procedures are fundamentally flawed or particularly out of line with what might be found at most comparable prisons should they be given a similarly intense audit. They found the current warden and his administration to be eager to learn and to take corrective action when weaknesses were pointed out. Significant corrective steps have been taken and are ongoing to rectify some of the fundamental breakdowns in earlier security procedures outlined above.

Two remaining major areas of critical concern were pointed out:

2. Importance of Follow-up to Audit Findings. In follow up to the security audit, it is of critical importance for its long term success and management that CCA/NEOCC take steps to implement the numerous recommendations contained in the report and to continually monitor itself in maintaining standards of acceptable security. The old saying in corrections that "nothing stays fixed" is especially true in security matters. Development of a well-functioning security audit capacity by CCA is a fundamental step in the process.

Attached is a full copy of the Security Audit and Recommendations:

Findings of Major Concern

The Review Team concurs that there are two findings of major concern and two recommendations in this chapter. They are:

F-7. In a pattern of flawed security attributable to both corporate and institutional management deficiencies, NEOCC failed to accomplish the basic mission of correctional safety. Most notably, there were two homicides, a major escape, numerous stabbings, assaults against inmates and staff, and the widespread presence of dangerous weapons among inmates.

F-8. There is little indication that the local management received significant guidance in security procedures from corporate management, except in reaction to major problems. To a lesser extent, the serious security failures are also attributable to the inadequate oversight of the contract by the DOC.

Major Recommendations

R-8. CCA corporate headquarters must provide systematic direction and periodic oversight for NEOCC's operational security procedures, including regular, formal security audits performed by specialists coming from outside the local NEOCC management. Care should be taken to ensure that written plans of action are formulated and implemented to correct deficiencies and weaknesses.

R-9. CCA/NEOCC should implement the findings and recommendations of the security audit performed as part of this current review, as well as those made by DOC in the After-Action report following the July 1998 escapes and all DOC monitoring findings.

SECURITY AUDIT REPORT

NORTHEAST OHIO CORRECTIONAL CENTER (NEOCC)

CORRECTIONS CORPORATION OF AMERICA

Stan W. Czerniak, Corrections Consultant

Introduction

During the week of September 21-25, 1998, a team of corrections security consultants conducted a comprehensive security audit of the NEOCC. This audit was conducted on behalf of the District of Columbia, Office of the Corrections Trustee (OCT), in response to a request by the Attorney General for an intensive review of the facility.

The security audit team consisted of:

Team Leader: Stan W. Czerniak, Assistant Secretary

for Security and Institutional Management

Florida Department of Corrections.

Team Coordinator: Phil Armold, Program Manager, OCT

Steve Loudermilk, Security Consultant, OCT

James Upchurch, Statewide Security Administrator

Florida Department of Corrections

Scope of Review

During the course of this audit, the team toured a majority of the institution's areas, programs and services and directly viewed actual security practices. The areas toured included: housing units, academic, vocational, main control, maintenance, medical/dental, security HQ., armory, administration, warehouse, laundry, and all points of entrance/egress. Additionally, the team inspected the perimeter security system during daylight and nighttime conditions as well as viewed the out-of-door lighting system from inside and outside the perimeter.

In addition, visitation and transportation shakedown areas were visited and a transport vehicle was inspected. Officers and supervisors from two shifts were interviewed as well as key staff in all departments.

The team also reviewed company and institutional polices and operating procedures as well as pertinent documentation such as post orders, emergency plans, inventories, check-out logs for tools, weapons, security equipment, and sensitive items.

Actual security practices in the areas examined were observed by the team. Whenever possible, the audit was conducted by this team afford the members the opportunity to compare perceptions and discuss the practices being observed. At times, individual team members observed security practices at different parts of the institution, yet met frequently to discuss their findings/recommendations. The team debriefed daily with facility staff to discuss observations and recommendations.

The auditing instrument utilized was the National Institute of Corrections, (NIC): "A Model Security Audit Instrument" (Draft -- May 1998). Which contains over 500 recommended security standards. In conducting this audit, the team took an audit by exception approach. This is to say that only those practices that were seemingly below these standards are referenced in this report. By and large, NEOCC meets or exceeds a majority of NIC's standards. It is also recognized that the recommended "standards" contained in this instrument are not necessarily the same standards required by CCA or any other department of corrections for that matter. Rather, these recommended standards were used as a guide to complete this audit. To this end, it is important to note that the auditors did not utilize every recommended "standard" nor did they exclusively restrict themselves to this document. Instead, the auditors also drew from their considerable combined experiences to examine NEOCC's security operation from the viewpoint of a hypothetical inmate who was attempting to find defects and/or deficits in the institution's security.

At the end of the week, the team leader met with prison administrators to summarize and highlight the most pressing concerns of the team.

It is important to note that all of the issues and recommendations related in this report were the result of discussions and consensus by the individual team members.

The team agreed that NEOCC is in the process of developing and implementing a sound security program. The issues and recommendations identified in this report should not be construed as being unduly critical of the operation observed. Instead, it is our hope that these efforts will be of value to Warden Jimmy Turner and his staff to further strengthen what appears to be a security program that is developing in the right direction and, in fact, have recently accomplished a great deal.

The team was appreciative that Warden Turner allowed us to have totally unrestricted access to all areas of the prison. It should also be noted that the staff interviewed showed good professional bearing and were very polite and helpful

Finally, prior to reviewing the issues and recommendations reported by the team, it should be noted that the institution began to or already implemented several of our suggestions. Where we are aware of this, we will note same in the body of this report where appropriate.

As noted earlier, it is clear that NEOCC is in the process of developing and implementing what shows strong indications of becoming a sound security program. This effort appears to have been initiated in May 1998 with the development of improved security polices, procedures, and post orders.

The current administration of NEOCC is committed to the development of a security program that will be characterized by continuous process improvement. As evidence of this, the security audit team was impressed by the non-defensive posture of facility administrators when presented with issues and recommended changes to their current security program. They not only seemed genuinely interested in listening to our suggestions, but requested our opinions regarding several of their practices.

Especially significant is that we have indications that NEOCC has already adopted or plans to implement several of our recommendations.

Without question, the key to successfully protecting the public, staff, and inmates is the development and maintenance of sound security practices. Sound security practices are based on standards, training, supervision, and oversight or security auditing. Without each of these crucial components in place, there is often a tendency for new security enhancement procedural initiatives to be short lived or to be improperly implemented.

Security Practices

NEOCC's plan of security enhancement does not currently include a perpetual security auditing program that can provide an ongoing assessment of program effectiveness, identify deficiencies, and prescribe timely corrective action.

The primary purpose of conducting ongoing security audits is to identify weaknesses or deficiencies in a particular security operation so that self-corrective actions can be taken. Security auditing should therefore be viewed as a proactive rather than reactive approach to enhancing prison security; i.e., institutions identify their own weaknesses rather than waiting for the inmate population to show them (through serious incidents) where these deficiencies lie. Secondary reasons for conducting security audits include; determining if facility procedures and actual practices comply with established policy/procedures and assessing whether security resources are being used efficiently and effectively.

The five basic questions of a security audit include:

1) What are the current conditions? (Condition)

2) How should it be? (Criteria)

3) Why is this important? (Effect)

4) How did this come about? (Cause)

5) What will correct the problem? (Recommendation)

A good security auditing program will assist the institution to determine whether:

3) Institutional procedure provides ways to identify problems or breaches of security in a timely fashion.

4) Institutional procedure identifies ways to reduce/resolve problems (Emergency Plans).

5) Institutional procedure specifies accountability.

6) Institutional staff practices are in compliance with institutional procedures.

The most obvious benefits of implementing a comprehensive security auditing program is that deficiencies can be identified and corrected before becoming problematic.

In the case of external security audits, an independent review, focused strictly on security can often see or spot deficiencies that even good facility security staff, who are burdened with a myriad of day-to-day tasks and demands, often overlook.

In addition, external security auditors can be a valuable resource to supply technical assistance in helping to strengthen an institution's security program. This process can also help trace specific security program weaknesses to inadequacies in:

1) procedures,

2) staff performance,

3) facilities,

4) equipment,

5) training,

6) monitoring or internal auditing;

Noted deficiencies should be used to develop solution strategies and allocate or request company resources.

Finally, one of the most important benefits of security auditing is that the process itself heightens staff awareness of good security practice. This heightened awareness tends to diminish the likelihood of staff becoming complacent and taking security shortcuts

It is recommended that NEOCC establish its own internal auditing program and conduct comprehensive security audits twice a year. It is further recommended that CCA establish an external security auditing program to provide an independent review that works in partnership with the institutions to ensure continuous improvement in security programs.

Security Practices

In conjunction with implementing a security auditing program, it is very important that the company establish overall policy regarding what security standards will be followed throughout the organization. Of concern, is that the team was advised that there are no company standards regarding several crucial security functions such as tool control, communications, and administrative segregation.

Interestingly enough, NEOCC's policies/procedures in these areas were very strong and are a credit to the experience and skill levels of the administrators involved in their development and implementation. The development of good security standards; however, should not be left solely to the discretion of institution administrators. Instead, minimal standards should be required of all like institutions within a given correctional department or company.

Probably the most significant overall security issue at NEOCC has to do with the entrance/exit procedures and practices of this facility. Depending on the date and officers assigned to the front facility entrance, members of the team were required or not required to clear the scanner when it alerted. Practices such as emptying pockets and displaying or surrendering of ID cards was inconsistent. Several auditors were never asked if they had any guns, knives, explosives, or narcotics and one auditor was allowed to bring a cellular telephone into the institution. Sometimes members of the team were asked if they had over the $20 limit on their person, sometime they were not.

Of particular concern was that on two occasions auditors who were not required to surrender their ID cards upon entering the institution were later that day allowed to exit the facility without a positive identification check being performed at any point in the exiting process.

Also of concern is that the main control center allows individuals to exit the facility based on whether or not they recognize the person or if he/she is wearing a uniform. It is generally not a good idea to rely solely on recognition or apparel when deciding to allow individuals to exit a prison.

This is especially important when you have "tightened" all other aspects of facility procedures, such as NEOCC has recently done, to include adding razor wire, doubling perimeter patrols, implementing frequent fence/infrared checks, better tool control, etc. Under circumstances of heightened perimeter security, inmates will tend to examine egress practices for weaknesses for potential escape possibilities.

Nationally, several very high profile escapes have occurred from maximum security prisons where inmates have literally walked out of the front gate after being provided civilian or officer clothing through a variety of means; i.e., from officers, volunteers, or contractors or other staff; from visitors or received in packages. It is worth noting that inmates are already allowed to wear different colored sweat shirts under their uniforms in all areas of the prison, not just while engaged in outside recreation.

All this coupled with the fact that NEOCC currently has a large percentage of inexperienced security staff, makes it especially important that prior to exiting the grill gates controlled by the main control center, all individuals must present a valid ID card. Even better would be to explore the use of some of the technologies designed to enhance the identification process such as hand verifiers, iris-scans, etc.

It should be noted that NEOCC has indicated that it is implementing a positive ID check process for all individuals prior to allowing them to exit the institution. We strongly encourage that they make this a "top" priority.

It is also important to note that current emergency plans are being revised. The draft revision that we reviewed is extremely comprehensive and much improved over the plan presently in place. It is crucial that these plans be implemented and that staff be trained in their content as soon as possible.

The remainder of this report includes a listing of those NIC recommended standards that the audit team felt were not being followed by NEOCC, but if adopted could enhance institutional security. In addition, special security issues not referenced in the NIC document are also included as well as "special mentions" for particularly noteworthy practices.

Armory/Arsenal

Guideline:

The armorer and assistant armorer received training in all duties pertaining to the operation of the armory/arsenal and weapons maintenance.

Finding:

The armorer and assistant armorer have not received any training in the repair or maintenance of the firearms authorized for use at NEOCC. While obviously malfunctioning firearms are sent-out for repair, without the proper training less obvious malfunctions could go undetected. Also, without proper training for these staff, they are less likely to be able to perform crucial maintenance on these frequently checked-out firearms. Improperly maintained firearms are potentially dangerous for users and have a higher chance of malfunctioning when needed to protect the public (in the case of escape attempts) or by the officer in operation (during outside transports).

Recommendation:

The armorer and assistant armorer should receive certified training in the repair and maintenance of firearms authorized for use at NEOCC.

Special Finding #1:

The updated firearms qualification list was not readily available to the armory officer. Instead, he advised that he knew who was qualified to be issued a firearm. When tested on his knowledge of one officer's qualification status, the armory officer was incorrect. Something as crucial as the issuance of firearms should never be dependent upon anyone's memory. The list that was posted in the armory was only an example of how the list should look, but was not the actual updated firearms qualification list.

Special Finding #2:

The cutting of keys and cleaning of firearms are performed in the same room and on the same table. As a result, the small metal shavings from cutting keys can get into firearms while they are being cleaned. This can cause accelerated wear and malfunctioning of firearms. The malfunctions can be dangerous to the user or hamper efforts to prevent an escape or to protect an officer. The institution has advised that they have already separated these procedures.

Special Finding #3:

The facility does not require the use of Firearms Qualification Cards. These cards are worthwhile during emergency operations, in expediting the issuance of firearms, by placing the card on the weapon rack of the issued firearm. This would provide a rapid emergency response without losing accountability for weapons issued.

Communications

Guideline:

There is written policy that establishes responsibility for radio assignment for each person/post in the communication network and for supervision and maintenance of communication equipment and operations.

Findings:

Although there is no written policy, communications are currently very good with three alternatives readily available to most posts within the prison; i.e., two-way radios, telephones, and intercom systems.

Recommendation:

Written policy should be developed to meet guideline requirements. Doing so will help to ensure system wide consistency, continuity and accountability; that meets the security needs of this prison.

Guideline:

The use of personal communication equipment (radio, cell phone, etc.) is strictly prohibited.

Finding:

There is no written policy regarding the use of personal communications devices within the prison. During our visit to NEOCC, a member of the audit team was allowed to bring in his own cell phone. Also, the members of our team were never asked if they had any personal communications devices. Personal communications devices falling into the hands of the inmate population could be used for illicit activities that could jeopardize security or embarrass the facility.

Recommendation:

Policy should be written that strictly prohibits the introduction and use of personal communications equipment (radio, cell phone, etc.) within the prison.

Special Mention:

Communications within the facility are outstanding, as evidenced by an extensive institution-wide intercom system, telephones, and 101 two-way radios. Also, radios and panic alarms are tested prior to issuance. Panic alarms are available to non-uniformed staff and two-way radios have a "man-down" feature that is enunciated to the main control center.

Contraband Control Disposition of Property

Guideline:

A secure storage area is designated for use during referral of a contraband charge to disciplinary proceedings or outside court.

Finding:

Although a procedure was in place, the evidence safe contained a keyed locking system with keys being too readily available. Also, keys are subject to being lost and finding their way into the hands of unauthorized individuals.

Recommendation:

While on site, it was recommended that the safe be upgraded to include a combination lock and that the combination number be closely controlled. The evidence safe was upgraded during our visit and the combination will only be available to the facility inspector and key administrative staff.

Inmate Counts

Guideline:

Out-counts are approved by the shift commander in advance of count time.

Finding:

Out counts are called-in during the count and not brought to the attention of the shift commander until he/she approves out-counts after the count has been completed. This process could create a situation whereby the number of inmates allowed to be on out-count status could become excessive. Excessive numbers of inmates on out-count status could make it more difficult to account for inmates in a timely fashion.

Recommendation:

Out-counts should be approved by the shift commander in advance of count time.

Guideline:

There are at least six formal counts in a twenty-four hour period of which two counts are mandatory standing counts.

Finding:

Only two standing counts are scheduled per week. Under these circumstance, an inmate could be dead in his bunk or be very ill for three or four days before being discovered. This type of incident/situation has occurred in other jurisdictions and has resulted in major litigation.

Recommendation:

At least one, preferably two, standing counts should be held in any twenty-four hour period.

Guideline:

There are at least two staff counting the same group of inmates.

Finding:

While this occurs in actual practice, it is not required by company or NEOCC policy.

Recommendation:

Require that at least two staff count the same group of inmates in each count area.

Guideline:

It is required that all inmate movement cease from the time count is announced until the count is cleared.

Finding:

While this is required by policy, in actual practice, food service inmates are allowed, during count, to deliver food to the housing units. During this process, it was observed that housing staff were distracted from counting inmates by having to stop what they were doing to receive trays. Inmate movement during counts and distractions to the staff conducting counts can lead to inaccurate counting.

Recommendation:

Require that all inmate movement cease from the time count is announced until the count is cleared.

Guideline:

Industries, construction, and delivery vehicles that cannot be easily searched are required to be locked and remain in the institution until a count has cleared.

Finding:

This is not required by either company or NEOCC policy.

Recommendation:

Based on personal experience, we recommend that policy require that any vehicle inside the institution during count be secured and remain in the institution until count has cleared.

Guideline:

Staff conducting counts do not allow distractions while in the count process staff do not take phone calls during count. Inmates who distract staff during count activities are considered to have committed a major violation of institution order and are subject to major sanction.

Finding:

This is not required by either company or NEOCC policy.

Recommendation:

Based on personal experience, we recommend that policy require that any vehicle inside the institution during count be secured and remain in the institution until count has cleared.

Guideline:

Inmate participation in any portion of count activity is prohibited, including preparation, processing, delivery of count slips, or handling of count related documents.

Finding:

While this prohibition is not included in company of NEOCC written policy, staff advise that inmates are not allowed to participate in these activities.

Recommendation:

Official policy should spell out this prohibition.

Special Finding:

During a 4:00 PM count, it was observed that a group of contract staff were allowed to exit the institution. The practice could jeopardize the security of the institution especially considering some of the concerns with the exit process that were noted elsewhere in this report. Except for emergencies, there should be no movement into or out of the institution during the count process.

Control Centers

Guideline:

Control center staff are conversant with initial emergency response responsibilities, including response to electronic alarms, initial staff notification and call-back and issuing of emergency equipment.

Finding:

While staff are well-versed in their responsibilities, the Emergency Notification Roster lists 33 company executives and employees who are to be notified of escapes prior to notifying local law enforcement. This process could lead to delays in eliciting assistance from local law enforcement.

This could be advantageous to an escaping inmate(s) by providing more time for him to get further from the institution before an organized search by law enforcement is initiated.

Recommendation:

The Emergency Notification Roster for escapes should list, in priority order, minimal notification of company personnel before notifying local law enforcement personnel. Employees such as food service director and personnel director should not be notified of escapes prior to notifying local law enforcement.

Guideline:

Care is exercised to ensure identification of staff or inmates before access or exit is permitted through controlled doorways and gates.

Finding:

Currently there is no requirement that control center staff check identification of individuals who they allow to exit past the control center towards the main entrance. This is a crucial control point in the institution's overall security and once past this point, it is relatively easy to exit the prison. At least one member of the audit team was allowed to exit the prison on three different dates without being challenged to show any type of identification at either the main control center, the administrative area exit, or the main exit. Control center staff claim that they do not allow anyone to exit the facility that they do not recognize.

Many correctional jurisdictions have learned the hard way the perils of allowing staff to control prison egress on the basis of recognition, or for opening control points for individuals based solely upon their apparel, without requiring some form of positive identification checks. The possibility of an inmate obtaining civilian or officer clothing is quite real and has occurred in other jurisdictions.

Recommendation:

Require positive identification card to face checks prior to allowing crucial exit points to be opened. The facility may also wish to explore the use of special techniques such as "hand verification systems," to enhance the security at these points of egress. These types of systems have proven very effective.

Guideline:

There is written policy that limits access to the control room to authorized personnel. Unauthorized staff are not in the control room(s) at any time.

Finding:

Control center staff advised me that there is supposed to be a posted list of staff who are allowed in the control center. This list could not be found in the control center.

Recommendation:

Ensure that an updated list of persons authorized entry into the control center is posted in full view of the officer who controls the entrance to this highly sensitive area Unauthorized entry into the control center could jeopardize the security of the entire prison.

Special Finding:

Several members of the team expressed concerns that there may be too many functions expected from the control center staff. These functions include:

1. Controlling a large number of doors, grill gates, entrance/exits;

2. Monitoring the infrared perimeter system including clearing, resetting, etc.;

3. Answering telephones, especially inside and outside phones after hours;

4. Keys issued, received, and inventoried;

5. Restraints issued, received and inventoried;

6. Cameras monitored;

7. Radio traffic and intercom use.

Recommendation:

CCA should conduct an in-depth study to ensure that this arrangement results in a relatively error-free operation where work load requirements do not contribute to critical errors in any of the important security functions listed above.

Controlled Movement

Guideline:

All inmate movement documents are legible and bear the authorized signature of a staff member, and include the following information:

a) inmate's name and assigned number

b) department originating pass

c) name and signature of staff originating pass

d) time and date of pass

e) destination

f) time of arrival

g) signature of receiving staff.

Finding:

There is no formal pass system for inmate movement. Call-outs from individual departments are used.

Recommendation:

Keeping track of inmate movement and location and ensuring that they are where they are supposed to be is very important. Time specific passes issued and retrieved in accordance with a detailed procedure are very important and should be utilized. This is not necessary if staffing allows for all movement to be directly supervised.

Food Service

Guideline:

All knives and sharp implements (including meat hooks) are secured, inventoried, and accounted for at all times. Staff secure all knives and sharp implements prior to the serving of each meal.

Finding:

While the knife control procedure is very good, the knife cabinet is lightly constructed and could be easily compromised.

Recommendation:

Purchase a heavy duty knife cabinet for the storage of these dangerous tools.

Use of Force

Guideline:

Written policy provides protocol for the authorization of the use of chemical agents and maximum volume of use is established for all enclosed areas in which chemical agents could be required.

Finding:

Institutional policy does not describe a sequence-of-events that must normally occur before OC can be applied to an inmate. In addition, no guidance is provided regarding the amount of OC that may normally be utilized.

Recommendation:

NEOCC should consider providing guidelines regarding the sequence-of-events that must normally occur, and the amount that may normally be utilized in regards to the use of OC. An example of these guidelines would be:

Counsel inmate to cease his disruptive actions. If these efforts prove to be futile, the shift supervisor shall order the disorderly inmate to cease his actions and inform him that OC will be administered if he continues his disruptive behavior.

Any uninvolved inmate in the cell or immediate area should be given an opportunity to leave the potentially affected area.

Except in cases of extreme emergency, the shift supervisor should be present during the administering of the chemical agents.

Approximately three minutes after the order is given to cease the disruptive behavior, OC may be administered in the form of no more than three, one-second burst.

If, approximately five minutes after the initial administration of chemical agents, the inmate(s) still continues his disruptive behavior, chemical agents may again be administered in the form of no more than three, one-second bursts.

If this second administration of chemical agents fails to control the inmate's disruptive behavior, medical staff should be consulted to assist in determining the next course of action which may involve:

a) Medical/psychological intervention;

b) An additional administration of OC no more than three, one-second burst, or

c) Use of electronic restraining devices (for use in cell extractions or to gain control of an inmate so that restraints can be safely applied).

Guideline:

Written policy establishes specific criteria for use of electronic control devices.

Finding:

NEOCC written policy (9-1) states that electronic stun shields are justified "to enforce institutional regulations and/or orders." This statement appears to be too general and provides too much discretion in the use of these devices. Also policy that references the conditions that must exist prior to activating the electronic stun belt was non-existent

Recommendation:

Written policy should clearly indicate the types of situations on which electronic stun devices may be used.

Special Issue:

NEOCC has gone to great lengths to ensure the availability of fully charged video cameras throughout the institution for use in video-taping uses-of-force.

Hazardous Materials Management

Special Issue:

NEOCC policy 8-100 is comprehensive and specific in describing an effective hazardous materials management system. Clearly, this area has been emphasized by management. The distribution system for the chemicals utilized for living area sanitation featuring automatic dilution of non-poisonous, non-caustic substances is particularly impressive. Inventories inside hazardous materials storage areas were checked carefully and found to be meticulous and accurate. There were no substantial issues found in this area.

Mail

Guideline:

Incoming staff mail for distribution inside of the secure perimeter is inspected prior to distribution to the appropriate departments.

Finding:

Mailroom staff advised that incoming staff mail is not inspected for contraband. Experience shows that some staff have had contraband sent in by the mail to themselves. This contraband then ends up in the inmate population

Recommendation:

Incoming staff mail for distribution inside of the secure perimeter should be inspected for contraband prior to distribution.

Guideline:

All incoming and outgoing inmate mail is inspected for contraband.

Finding:

Mailroom staff advised that mail is only inspected for contraband if it appeared suspicious. The problem with this approach is that inmates and individuals sending mail to inmates become very good at hiding contraband in the mail.

Recommendation:

All incoming and outgoing inmate mail should be thoroughly inspected for contraband.

Guideline:

At high custody institutions, fluoroscopic examinations are conducted on all packages (for both staff and inmates) coming into the mailroom to locate contraband that otherwise might go undetected, or that might require dismantling or destruction to otherwise search thoroughly.

Finding:

Occasionally drug dogs are used to inspect packages. No other type of package scanning occurs.

Recommendation:

NEOCC should explore obtaining package scanning technology (Heiman x-ray, E-Scan, etc.) to ensure thorough and consistent scans of packages coming into the institution.

Special Issue:

NEOCC may wish to contract with the US Postal Service to train mailroom staff on how to handle suspicious looking mail/packages. Also, the institution may wish to consider obtaining "Clear Spray" which can make envelopes temporarily transparent allowing mailroom staff to visually detect small wires or components of letter bombs.

We understand that contact has already been made with the postal inspector's office to solicit the recommended training.

Inmate Visiting

Guideline:

When approved to visit, and before being permitted into the visiting areas, all visitors are subject to a "black light" or other equally effective identification process.

Finding:

Although the institution does utilize a "black light" procedure, at the time of our visit, they were completely out of the ink used in this process.

Recommendation:

Pay special attention to keeping a sufficient stock of this ink on hand.

Note:

If adopted as part of entry/exit identification for staff, etc., a hand verification system can be a very effective way to manage visitors' entry/exit.

Inmate Property

Guideline:

There is written policy establishing limitations on the amount of property an inmate may have in his/her possession, a listing of allowable items, and procedures for managing inmate property

Finding:

Recent change in policy has reduced level of inmate property to a more manageable level.

Special Recommendation:

It is recommended that dark blue and grey clothing be eliminated as these dark colors are difficult to see in reduced light and could assist an escaping inmate in evading his pursuers.

Inmate Work Assignments

Note: The area of Inmate Work Assignments was not covered by this review team.

Inmate Transportation

Guideline:

Written policy establishes minimum levels of training that must be provided to security staff who are assigned transportation responsibilities. Currently, assigned transportation staff have received the required training.

Finding:

If a transport officer is not issued a firearm (all transports require two officers, one is armed, one is not), then no additional training is required to be assigned to inmate transport duties. The transport officer that was interviewed, however, was extremely knowledgeable about the very comprehensive requirements outlined in the transport officer post order.

Recommendation:

Due to the sensitivity and vulnerability of the role of the transport officer, it is advisable that officers assigned to this post be required to successfully complete a specialized training program.

Guideline:

Written policy requires that the transportation officer have in his possession a removal order, signed by the warden/superintendent that provides authorization for the trip.

Finding:

Removal orders for medical trips are signed by medical personnel.

Recommendation:

While the need to take an inmate outside the institution for medical trips should be verified in writing by medical personnel, the actual authorization for the trip should be signed by administrative personnel of at least a rank of Chief-of-Security.

Guideline:

All high security transport officers are equipped with non-lethal control devices and body armor.

Finding:

Neither non-lethal control devices or body armor are provided for transport officers. In hospital settings, the officers cannot use their firearms and must rely on "bare-handed" self-defense control techniques to deal with assaultive inmates or attempted escapes. Electronic stun devices or pepper mace can be valuable to helping officers when faced with situations of this type. In addition, while on outside escorts, officers are extremely vulnerable to assaults with deadly weapons from outside individuals. Several jurisdictions provide their transport officers with body armor.

Recommendation:

Provide transport officers with non-lethal force alternatives, such as pepper mace or electronic stun devices (hand-held units). It is acknowledged that the facility does have a stun-belt for use on high risk transports. In addition, it is recommended that transport officers be provided with body armor that is at least rated at a threat-level II.

Key Control

Guideline:

A full-time locksmith is assigned responsibility for key control and maintenance.

Finding:

The assigned key control officer and/or the armory officer who provides assistance are not "locksmiths" and did not have expertise in lock maintenance or repair. Expertise appeared to be limited to the key control system and limited ability to cut from file keys and blanks a minimal number of low security keys.

Recommendation:

In the absence of any individual on the maintenance staff trained to properly inspect and perform preventative maintenance on locks and locking systems, a contract with a qualified locksmith should be initiated to ensure frequent periodic inspections and preventative maintenance. An alternative would be to have someone on staff trained appropriately to perform these tasks. It is preferable for the safety and security of the institution that facilities not only have provisions for locks and locking systems repair after they become broken, but also to inspect and identify problems proactively. Preventative maintenance programs performed by well trained individuals are essential in this effort.

Guideline:

There is a position description and current post orders that describe the duties and responsibilities of the locksmith and locksmith assistant.

Finding:

The NEOCC post orders 9-10-5 entitled "Armory/Key Control Officer" provide only limited, non-specific guidance to the assigned officer.

Recommendation:

This is a highly technical position with numerous very important responsibilities critical to the facility's security. This post order should be much more specific in spelling out the responsibilities and requirements of the assignment.

Guideline:

The post orders of issuing officers fully describe the responsibilities related to issuance and retrieval of keys/key rings and reporting loss, breakage, or failure to return keys.

Finding:

The NEOCC post orders 9-10-5 entitled "Armory/Key Control Officer" provide only limited, non-specific guidance to the assigned officer.

Recommendation:

This is a highly technical position with numerous very important responsibilities critical to the facility's security. This post order should be much more specific in spelling out the responsibilities and requirements of the assignment.

Guideline:

A security audit is conducted annually by person(s) from another institution or a central audit team.

Finding:

There is no annually conducted audit of this area by someone from another institution or a central audit unit.

Recommendation:

An outside audit can be invaluable in discovering deficiencies that those assigned may overlook.

Guideline:

Training is provided to the locksmith and locksmith assistant.

Finding:

No formal training has been received by the locksmith or the assistant.

Recommendation:

It is imperative the positions noted above receive formal training.

Guideline:

A perpetual inventory and cross-inventory of all keys, blanks, pattern keys, and locks is maintained. Documentation is current and accurately reflects what is actually on site.

Finding:

No perpetual inventory of key blanks was being kept. Cross-inventory of keys, blanks, pattern keys, and locks are not maintained.

Recommendation:

Initiate and maintain the appropriate perpetual inventories and cross-inventories.

Guideline:

All cut keys and key blanks are assigned a storage hook number and maintained in a storage cabinet(s) with a copy of the current inventory. A perpetual inventory is maintained.

Finding:

No perpetual inventory is kept.

Recommendation:

Initiate and maintain the appropriate perpetual inventory.

Guideline:

The number of copies and blanks for any given key in the storage area agrees with the documentation.

Finding:

Corbin L4-70 key blanks inventory listed 58 such blanks when in fact there were only 55.

Recommendation:

An accurate perpetual inventory is needed for all key blanks.

Guideline:

Key rings have been soldered or otherwise secured to prevent removal or loss of keys or identifying information.

Finding:

The key ring assigned to Unit Manager Maureen Dickson was not brazed or soldered. It should be noted that all other key rings inspected were soldered and the one in question was corrected prior to our departure.

Recommendation:

Ensure that all key rings are brazed or soldered each time keys are added or removed.

Guideline:

The permanent issue of keys controlled by institution policy and is limited to exceptional circumstances. A quarterly inventory is conducted of all permanent issued key rings.

Finding:

Policy 9-3 in paragraphs 3, F specifies 13 permanent issue keys rings/sets. The institution had 35 such permanent issue sets. There is no quarterly inventory of permanent issue keys being conducted.

Recommendation:

While is not necessary to limited permanent issue keys sets to the 13 specified when the keys are of a non-security type, institutional practice should agree with policy requirements. It is our understanding that this issue was being addressed prior to our departure from this facility. The quarterly inventories of permanent issue keys should occur.

Guideline:

There is documentation for each key cross-referenced by the following:

Finding:

Cross-referenced inventory documentation does not exist as specified.

Recommendation:

In order to provide for rapid, efficient determination of key assignment and utilization, the cross-referenced documents should be maintained as required.

Guideline:

Emergency keys are stored in a readily accessible place that is clearly separate from the standard key-issue board or cabinet. There is an alphabetical listing of the areas served by the various rings, each with the corresponding ring number, prominently posted.

Finding:

The legend for emergency keys to various areas was difficult to follow; i.e., wings denoted by letters while key rings were numbered; diagram of door and lock locations not readily related to key numbers or color code. The individual keys are not in the correct order on the rings.

Recommendation:

The legend for emergency keys should be simply related to the key identification system in the emergency key box. Keys on area emergency key rings should be ordered in such a manner as to provide sequential entry through all doors/locks in the area they are designed to access.

Guideline:

Emergency keys are rotated to equalize wear and all emergency keys/locks are tested at least quarterly by other than the institution locksmith. A ledger including documentation of such checks and the reported deficiencies is maintained on a permanent basis.

Finding:

The rotation and required quarterly testing of emergency keys is not occurring.

Recommendation:

Normal wear of locks from repeated use can cause unused emergency keys to function improperly. It is important that, at a minimum, emergency keys be tested quarterly to ensure that they work properly.

Guideline:

Emergency keys are included in the daily key count.

Finding:

Emergency keys are not included in the daily key count.

Recommendation:

Emergency keys must be verified as being present on a daily basis.

Guideline:

A record of the issuance of restricted keys is maintained bearing the key ring number, date, time of issue and return, the person to whom issued, the purpose of the issue, and the person authorizing the issue.

Finding:

Restricted key issue is not recorded separately or as suggested in this standard. As reported by the key control officer, all keys that are not "pass along" are considered restricted; however, the specific issue requirements are not being met.

Recommendation:

Account for restricted keys as suggested by the standard.

Guideline:

There are greater levels of restricted access maintained over some highly sensitive areas such as pharmacy, armory, lockshop, et., by use of glass door compartments, signature of the issuing officer and person to whom issued, written reports of issue, etc.

Finding:

There are no special issue requirements for these keys.

Recommendation:

Restricted keys should, at a minimum, be issued in accordance with these guidelines.

Note:

CCA Policy 9-3 in paragraphs 3, G and 5,B addresses restricted keys specifically. We were assured and witnessed work in progress to address the restricted key deficiencies.

Guideline:

The filing and storage of keys, pattern keys, blanks, chits, and other keying supplies suggests order and systematic, ongoing control of all key control processes.

Finding:

Deficiencies in documentation, record keeping and inventories were noted.

Recommendation:

Continued improvements in these areas by the current key control officer should result in all deficiencies being addressed.

Special Issue #1:

Manufacturer key code numbers should be removed and replaced with a non-duplicating local code number, cross-referenced to the manufacturer's code. Inmates reading the manufacturer's code may be able to obtain duplicate keys.

Special Issue #2:

Policy should specify how keys should be carried and secured by all assigned staff while in use in the facility: i.e., keys on person, conceal cuts as much as possible, avoid discussion of key access in presence of inmates.

Perimeter Security

Guideline:

The number of inner and outer razor rolls and the type of barb used (long or short) is appropriate for the perimeter security category of the institution being reviewed.

Finding:

The number of inner and outer rolls of razor wire is more than adequate. However, the manner in which this wire is secured to the fence and to other rolls of razor wire is not. Specifically, numerous fasteners were gaped so wide that they were very easy to remove.

Recommendation:

The use of more secure fasteners should be pursued.

Guideline:

The inner and outer concerted slabs at the fence base are appropriate for the perimeter security category of the institution being reviewed.

Finding:

Concrete slabs are not used on the exterior perimeter fence to prevent washouts and provide a secure anchoring point for the base rolls of razor wire. There is clear evidence of a progressive washout problem at several points on the outside perimeter fence. At some spots, because of washouts, the base of the fence was about 8 inches above the ground level.

Recommendation:

It is recommended that the institution consider installing a concrete apron for the outside perimeter fence. If this is not going to occur, it is recommended that a comprehensive approach be developed to prevent and address what appears to be a potential problem with washouts.

Guideline:

A crash barrier system is installed at every breach in the perimeter fence created for the purpose of vehicular access to the institution.

Finding:

There is no crash barrier at the vehicular gate.

Recommendation:

Install a crash barrier at the vehicular gate.

Guideline:

Perimeter staff demonstrate competence in response to helicopter or aircraft intrusion.

Finding:

Officers assigned to perimeter posts do not know how they are to respond to potential helicopter-assisted escapes. They were particularly unsure as to whether they were allowed to shoot into the compound to stop an inmate who is running towards a landed helicopter; or if they were allowed to shoot at the helicopter that was attempting to take off with an escaping inmate inside. The post orders for perimeter posts do not address the issue of helicopter assisted escapes.

Recommendation:

Post orders for the perimeter post should clearly provide company policy and instructions for how to deal with potential helicopter-assisted escapes.

Guideline:

The identification of all persons entering or exiting the institution is determined and verified by staff assigned and trained to control access and egress.

Finding:

The actual practices for entrance and egress were inconsistent throughout the week of this audit. For example, on some dates, some auditors were required to clear the metal detector, some were not, some were asked if they had any contraband, some were not, some had their wallets, coats and notebooks checked, some were not. In addition, on several occasions, some auditors had to give-up their ID cards prior to entering the institution, some did not. Upon leaving the institution on several occasions, the auditors who were allowed to enter the institution without first surrendering their ID cards were later allowed to exit the institution without any identification check being required.

Recommendation:

Additional training, supervision and monitoring would help to ensure greater consistency with NEOCC policy regarding entrance/egress practices. Also, as noted in other parts of this report, all individuals should be required to produce valid identification prior to being allowed to exit the prison.

Special Finding #1:

Additional razor wire in a "waterfall" pattern from the upright poles at the vehicle gates would help to enhance the security at these vulnerable points in the perimeter.

Special Finding #2:

The installation of heavy gauge "hog-wire" on the interior of the vehicle sally port would make this area less vulnerable to cutting.

Special Finding #3:

Post orders for perimeter officers prevent officers from using potentially deadly force until an escaping inmate (on foot or in a vehicle) breaches the outside fence. In the case of a vehicle assisted escape from the inside, this means that an escaping inmate is allowed to make a hole in both fences prior to using deadly force to try to stop this attempt.

In the case of an inmate on foot, this policy allows him to breach most of the perimeter security features prior to using deadly force. NEOCC may wish to rethink this policy to provide less likelihood that inmate could escape from this institution.

Special Mention:

All twenty infrared perimeter detection zones are checked three times per shift, at different distances (near the head and at varying distance from the head). This is an outstanding process to ensure the integrity of the infrared system.

Physical Plant

General Comment:

The facility is overall very well designed and constructed. The design features, visibility, types of security hardware, communications system and perimeter combine to make it more than adequate for the secure housing of high/medium custody inmates.

The facility may wish to explore the use of an additional camera or convex mirrors between the stairway and the inmate shower area in the housing units. This would provide for additional visibility from the officer's station to this fairly pronounced blind spot.

Post Orders

Guideline:

All post orders contain general instructions similar to the following, and others deemed important by the warden/superintendent: "Any employee taken hostage or otherwise under duress is without any authority, regardless of rank."

Finding:

None of the NEOCC post orders provide a hostage-related guideline for any of the officers. This type of guidance is particularly important for officers who control points of entrance/egress.

Recommendation:

All post orders should contain instructions regarding hostage situations that are similar to the above statement. We have been advised that NEOCC is making this addition to appropriate post orders at this time.

Guideline:

Post orders delineate in detail the expectation of the post assignment to include the following major categories: use of force (including helicopter escape).

Finding:

None of the post orders provide instructions regarding how to respond to helicopter escapes. Several officers on perimeter posts were questioned about "shoot/don't shoot" helicopter-assisted escape scenarios and were unsure as to what they were allowed or not allowed to do vis-a-vie, use of firearms. Aside from the security implications, there are potentially serious liability issues by not providing clear, written instructions regarding these types of escape possibilities.

Recommendation:

Post orders should provide very clear expectations and instructions for officers in regards to the use of potential deadly force for those officers assigned to perimeter posts. Again, we have been advised by NEOCC that this provision is being added to all appropriate post orders.

Admission and Discharge

Guideline:

Inmates are strip-searched upon admission and housed separately from others until precautions are taken to prevent contagion.

Finding:

Current policy require that inmates be "searched" not "strip-searched" upon admission. NEOCC's requirement does not provide for a thorough strip search to prevent the introduction of drugs, weapons, or other contraband that might not have been discovered by the sending jurisdiction. There are well documented institutional cases wherein inmates received from sheriff's departments or other correctional jurisdictions had major contraband on the person whey they arrived.

Recommendation:

Revise policy to require that inmates be strip-searched upon admission to NEOCC.

Searches

Guideline:

Written policy establishes responsibility for a system of searches and procedures for the search of all areas of the institution; staff; visitors, inmates, vehicles, mail, inmate property, warehouse goods, and other persons or commodities that may pose a threat through the introduction of contraband into the institution.

Finding:

Polices 3-16, 9-5, 9-110, 16-1, and 16-2 dated in May 1998 address search issues.

Guideline:

Written policy establishes requirements for the documentation of all searches to ensure that all areas of the institution are inspected within a reasonable time frame and to ensure the integrity of the search program.

Finding:

Searches are mandated by Policy 9-5; however, documentation is not required Documentation is not being done on cell searches.

Recommendation:

All cell searches should be documented, including those in which no contraband was found, to ensure that all areas of the institution are inspected within a reasonable time frame and to ensure the integrity of the search program.

Guideline:

All officer staff have received training in the conducting of cell searches in a manner that ensures the detection of all contraband.

Finding:

Some training is being provided but it does not contain all aspects of conducting a thorough, safe search.

Recommendation:

Increase level of cell search/general search training stressing thoroughness and staff safety.

Guideline:

Post orders require the search of all cell areas at least monthly.

Finding:

There is no requirement in the post orders for all cell areas to be searched monthly.

Recommendation:

Documentation should be included in the Post Orders to satisfy this guideline requirement.

Guideline:

All cell searches are documented and logged in an official search log with notation of the search date, cell searched, and contraband discovered.

Finding:

Cell shake-downs are not documented unless they find contraband. Also, there is no contraband shakedown log maintained on the housing units to inform staff of contraband found during preceding shifts.

Recommendation:

A contraband/shakedown log should be established and maintained in all housing units. This would provide on-coming shifts with valuable information in the event that dangerous contraband (weapons) is discovered during the preceding shifts. In addition, a contraband/shakedown log will help to ensure that all cells are searched within prescribed time frames.

Guideline:

Is the inmate, whose cell is being searched, present during cell search or a second officer present during the search?

Finding:

There is no requirement documented in policy(Policy 9-5)

Recommendation:

Inclusion of this requirement in the search procedures can provide protection for officers from allegations of impropriety and make the search process less antagonistic.

Guideline:

Each vacated cell is searched thoroughly before occupancy by another inmate to remove contraband and document damage to the cell interior and furnishings.

Finding:

Policy requires cell inspection upon its being vacated by the assigned inmate but there is no documentation to support that it is being done.

Recommendation:

This should be completed each time a cell is vacated and the results documented as well as the departing inmate being held accountable for any damage, etc.

Guideline:

Cells used for suicide watch are thoroughly searched before use.

Finding:

This requirement is not addressed in post orders or in policy 9-5.

Recommendation:

This is a critical issue and should be addressed specifically in both post orders and policy.

Guideline:

Random and routine frisk searches are conducted on inmates in all areas of institution and off institution grounds.

Finding:

Observation during our on-site visit did not support that random and/or routine pat-frisk searches are being conducted with any acceptable frequency. In fact, no member of the team observed any pat/frisk searches until the very last day of the audit.

Recommendation:

Random pat/frisk searches of inmates are essential to good security and the discovery of contraband and its movement within the institution. Frequent random pat/frisk searches should be required and monitored carefully for frequency by security supervisors.

Guideline:

Routine strip searches are conducted in a place and manner that affords a degree of privacy. Emergency strip searches are conducted in an area that affords privacy if conditions allow.

Finding:

Documentation and verbal reports indicate that strip searches conducted in March 1998 included inmates being stripped, cuffed, and maintained in this condition in a relatively open, non-private area for 30-45 minutes.

Recommendation:

Except in emergency situations, strip searches should be conducted in such a manner to allow for minimal privacy intrusion including observation by only those staff and other inmates absolutely necessary.

Guideline:

Documentation is maintained on all routine strip searches.

Finding:

Documentation on strip searches, as with all other search types, is lacking.

Recommendation:

Searches, particularly strip searches, should be carefully documented.

Guideline:

Thorough documentation is maintained of probable cause for search, the authorizing official, and the findings of the search.

Finding:

Thorough documentation is lacking.

Recommendation:

Searches, particularly strip searches, should be carefully documented.

Security Inspections

Guideline:

Each security inspection report is reviewed by the institution security chief and action taken as appropriate to the needs identified. Reports are maintained at least 30 days.

Finding:

All security inspection reports are not being signed indicating review by the chief correctional officer.

Recommendation:

Required review and documenting signature of the security chief should occur for each inspection report.

Guideline:

Each zone of electronic perimeter detection systems is tested daily in a manner consistent with the manufacturer's specifications.

Special Finding:

Each zone of the perimeter detection system is tested each shift. This exceeds standards requirement and is reflective of public safety commitment through escape prevention.

Guideline:

Emergency exit doors and keys are checked weekly to ensure they are in operating order. The physical check is logged.

Finding:

There is no documentation to substantiate that checks are occurring although reportedly they are.

Recommendation:

As per the standard, checks should be logged.

Guideline:

The visiting parking area is inspected before and after daily visitation?

Finding:

Although general parking lot checks are conducted, the visitor parking area is not checked per the standard.

Recommendation:

Perform checks of the visitors' parking area and log or otherwise document.

Segregation (Special Management)

General Comment:

Segregation area manager Captain Moses was extremely cooperative and knowledgeable. The units were clean and appeared relatively quiet. There were a minimal number of issues in this area.

Guideline:

Written policy clearly state criteria and procedures for placement and release from segregated housing areas, conditions of confinement, program components of the placement that pertain to eligibility for release, and review procedures.

Finding:

NEOCC Policy 10-100 does establish procedures for placement and release; however, it does not describe criteria for release eligibility.

Recommendation:

Criteria should describe the requirements that must be met prior to release from administrative segregation status.

This criteria should include the basis (i.e., behavioral) upon which the determination is made to determine when an inmate no longer poses a threat sufficient to merit segregation.

Guideline:

Written policy establishes requirement that the Security Major or Security Chief, Assistant Warden/Superintendent(s), and Warden/Superintendent visit special housing units at least weekly. Sign-in logs establish their visitation on a regular basis.

Finding:

Policy 9-7 does not require at least weekly visits by the Security Chief, Assistant Wardens, or the Warden.

Recommendation:

Segregation/special housing areas should be visited weekly by the above referenced administrators and these visits documented.

Guideline:

Regularly assigned staff are rotated from segregated special housing units at intervals specified by department policy.

Finding:

There is no established internal Policy 10-100 indicating the rotation of staff.

Recommendation:

Although the policy does reference an evaluation of assigned staff, the specific requirement for rotation is important due to the high stress associated with this assignment.

Guideline:

Documentation for each inmate includes, at minimum, the following information on each inmate assigned to segregation: movement in and out; visits to unit; cell assignments; unusual incidents; cell searches; inmate telephone calls; 30 minute checks; all meals, services, and activities deprived or not provided an inmate as required; exercise periods, and showers.

Special Finding:

Documentation maintained in the segregation units is very comprehensive and exceeds the standards requirement. Assigned officers are provided with all necessary information about the inmates to properly and safely manage and care for them.

Guideline:

All items entering the special housing units are searched; including food carts, clothing for exchange; property, linen, books/magazines.

Finding:

Policies 9-5, 10-100 do not specifically require searches before entering the segregation/special housing unit.

Recommendation:

Although observation and report by assigned staff indicates this is occurring, it should be required in policy.

Guideline:

When sufficient natural light is not available, interior lights are left on during daylight hours. Inmates are prohibited from obstructing windows or light fixtures.

Finding:

Some segregation cell lights were covered with toothpaste and paper thus diminishing light level in these cells.

Recommendation:

NEOCC management reports that this problem will be emphasized during cell inspections when inmates are out for recreation and showers. This should be checked routinely by supervisors and managers.

Tool Control

Guideline:

There is written policy that establishes procedures for the control of tools in each area of the institution. Class "A" tools are clearly defined, control procedures are specifically stated, and perpetual inventories are required.

Finding:

There is no CCA policy on tool control. There is however a comprehensive NEOCC policy.

Guideline:

Qualified security staff have been designated as tool control officer and assistant tool control officer.

Finding:

The maintenance supervisor serves as the primary tool control officer with oversight provided by the Chief of Security.

Recommendation:

Oversight provided by the security chief must be frequent and careful in that the maintenance supervisor may be influenced by objectives related to maintenance issues to subvert tool control issues in favor of more rapid and efficient accomplishment of maintenance projects.

Guideline:

All contractors working inside the institution receive written instructions outlining their responsibilities regarding tool and contraband control.

Finding:

Contractors working inside the institution do not receive written instructions regarding their tool control responsibilities.

Recommendation:

The chief of security reports that all outside contractors are escorted by security staff who are in turn responsible for the contractor's tools. This requirement should be spelled out specifically for assigned escort officers.

Guideline:

Designated security staff conduct tool area inspections at least monthly. And designated security staff conduct full tool control audits of all areas not less than every six (6) months.

Special Finding:

Tool area inspections are being conducted bi-weekly by Captain Medlin and frequent random spot checks are being performed by the chief of security. Full tool control audits are conducted monthly by the maintenance supervisor and reviewed by the security chief.

Guideline:

Hacksaw blades, hilti guns, torch heads/tips, etc., are stored in the control center where a perpetual inventory is maintained.

Finding:

The inventory of hacksaw blades, etc., stored in the armory/ready room was not current.

Recommendation:

These items must be carefully accounted for and the documentation of inventories must be current and accurate.

Guideline:

All Class "A" tools that cannot be marked are specifically logged and inventoried daily. All tools that can be marked without damage are etched with an ID code identifying the department, individual shop, and a separate tool number. All tools that cannot be marked without damage are kept in locked storage (not openly displayed as on a shadow board).

Special Finding:

The procedure in place for identifying and accounting for the dental tools is exceptional and illustrative of special attention to detail.

Guideline:

All tools that can be marked (with the exception of teachers' and secretaries' tools) are double color-coded by department and shop.

Finding:

In general, tools are not color-coded.

Recommendation:

Although all tools inspected were etched for identification, color-coding provides a quick, redundant, visual reference for tool identification. The justification is similar to that for shadow-boarding, in that a determination can be made visually almost at a glance as to what area a tool is assigned.

Guideline:

Hacksaw blades are mounted on rings and issued using a durable receipt system and only in amount necessary for one day's use.

Finding and Recommendation:

The inventory of hacksaw blades, etc., stored in the armory/ready room was not current.

These items must be carefully accounted for and the documentation of inventories must be current and accurate.

Chapter VI

Management of Inmate Population

Introduction. Inmate idleness undermines order and security in a prison. This chapter focuses on the opportunities for work and constructive activity available to inmates at NEOCC.

The pervasive idleness of most inmates has been one of the major shortcomings of NEOCC throughout its existence. While work and other activities are provided for a limited segment of the population, a significant number of inmates are not involved with these activities or are occupied for only a brief period each day. Idleness is aggravated by the NEOCC procedures for separation cases that prohibit inmates from separate wings from using recreation, educational and other program space simultaneously.

The nature of the communication and relations between inmates and the staff is another critical component of managing a safe, secure correctional setting. The Review Team found communication between inmates and staff to be poor, although the current warden has initiated improvement in this area.

These relations were severely harmed by a prolonged episode in the spring of 1998 during search procedures in all housing units instituted following the two murders. Unnecessarily harsh and humiliating procedures were employed, badly souring internal relations and any sense of trust. At a minimum, allowing or directing this procedure was a major mistake by corporate leadership and a serious lapse in judgement by the newly arrived warden.

A. Work and Program Opportunities

The lack of work and program opportunities is at variance with the provisions of the NEOCC contract, resulting in inmate boredom and negative inmate interactions. The DOC contract with CCA explicitly required that:

"C.1.2.1.1 The Contractor shall have sufficient programming to allow every general population inmate to participate in programs of occupational training and industrial or other work. . . ."

"C.1.2.4 The Contractor agrees to provide sufficient programs to allow every general population inmate to participate in meaningful educational, vocational, drug treatment or work programs. . . ."

1. Work Opportunities. During the Review Team's visit in late September 1998, a total of 736 inmate "jobs" were available at NEOCC, or enough to employ about 50% of the inmate population at the time. However, only 515 inmates, or approximately 33% of the inmates, were actually employed.

A closer inspection revealed that only 153 inmates worked outside their own housing wings. The primary "outside job" was in the kitchen, where 109 inmates were listed as employed. The other 44 inmates worked in the laundry, in maintenance, in the commissary, or for the education department (some as tutors). Moreover, the vast majority of the 362 inmates who were considered employed within their housing wings worked an average of a few minutes each day sweeping, mopping, handing out food trays, or picking up and distributing laundry.

There is no prison industry operating at NEOCC, resulting in the facility not being able to provide work opportunities for the inmate population. Some of the inmates interviewed stated that they cannot purchase from the commissary, buy stamps, or use the telephone because they cannot afford to pay for these services. The vast majority of the inmates interviewed wanted to work and earn money.

2. Educational/Vocational Programs. During several visits to the NEOCC before the housing stratification and controlled movement procedures were implemented in the spring of 1998, staff of the Trustee's Office observed that very few inmates were actually in classrooms, while space was available for educational and vocational programs. Inmates have consistently complained about the lack of programs or access to those programs that do exist.

This trend continued, and in late September 1998, NEOCC indicated that there were 780 "slots" available - 680 academic and 200 vocational - with 448 inmates (out of about 1,500) "enrolled." Unfortunately, these programs only briefly alleviate inmate idleness for about six to eight hours per week. Programs offered include:

Academic Adult Basic Education I, II, III, and IV
Vocational Building Maintenance

Commercial Cleaning

Computer Lab

Electrical/Mechanical

Interior Renovation

Horticulture

Life Skills (cognitive thinking, family relations, career planning, life management, substance abuse education, interpersonal and personal skills)

When the Review Team asked for lesson plans for the courses offered, NEOCC Education Department staff provided the lesson plans for the four levels of Adult Basic Education and for the Life Skills program. Each was a less-than-comprehensive one- or two-page outline.

a. Inmate Participation. The controlled movement of inmates according to their housing and custody levels automatically limits the access of inmates to educational and vocational programs. As noted above, Trustee's Office staff, as well as DOC review teams observed in 1997 and early 1998 that few inmates were actually in academic and vocational training classrooms.

The participation rate in programs between medium and minimum inmates is generally greater than high-medium inmates. During the week of the Team's major review, virtually all of the inmates in Wednesday and Thursday afternoon classes were in "Adult Basic Education" or "Life Skills" classes. However, very few inmates were in vocational classes, resulting in the closing of some of those classes for the day.

b. Accountability for Inmates. An NEOCC "Education Roster" dated August 26, 1998 indicated that 341 inmates were enrolled in morning or afternoon academic, "Life Skills," and vocational classes, but the Review Team observed that considerably fewer inmates are actually in those classes.

c. Eligibility for Educational/Vocational Programs. An NEOCC "Eligibility List for Education/Vocational Classes" dated September 1998 identified 119 inmates whose evaluation had been completed by the Education Department and were pending decision by the unit teams whether each of those inmates actually would be assigned to educational/vocational classes.

3. Drug Abuse Treatment. The drug abuse treatment program, through the Addictions Treatment Unit (ATU) is the only program in the facility where most of the inmates are consistently involved in constructive activities. It is a modified therapeutic community approach to drug and alcohol treatment aimed at changing an individual's lifestyle. With guidance from staff specifically trained in the CCA "Lifeline" program, inmates are involved in a variety of intensive group and other activities focusing on developing pro-social values, honesty, responsibility, and accountability.

The ATU program lasts a minimum of six months, and at the time of the Trustee's review, the program was expanding to add a new group of about 60 inmates in one "pod" to the 60 participants already in the program in another "pod." Some of the first group are expected to move to the "aftercare" phase of their treatment early in 1999, at which point a third "pod" will be devoted to the ATU. The September 1998 waiting list of inmates wanting to enter the ATU numbered:

54 Inmates with Court Orders for treatment

70 Inmates with Parole Orders for treatment

100 Inmate volunteers for treatment

224 Total

The Review Team made no effort to evaluate the therapeutic value or impact of the program. However, it was clear that the degree of constructive activity and inmate interest was quite good.

Compared with the lack of productive activity in most units, the ATU program activities start at 5:00 a.m. and lasts until 10:00 a.m. Part of the ATU program is built around the "Twelve-Step" program, which provides for continuity with programs in the outside community when inmates are released from prison. Participation in non-unit programs, like education, vocation training,

and recreation is also scheduled and encouraged, and the Review Team noted a high participation rate from ATU inmates.

4. Religious Programs. Religious programs are very limited at NEOCC, and were the source of complaints from many inmates. The only chaplain resigned some time before the Review Team's September 1998 visit, and although a replacement had been hired, he had not yet reported for work. As a result, religious services were either not held, or only held sporadically, with the assistance of volunteers. In addition, there is no chapel set up for religious services. Any religious service is conducted in small general-purpose rooms located in each housing wing or in the visiting room.

The stratified housing situation has had a severe impact on the religious program at NEOCC, as it has with virtually all the other institution operations. The Muslim inmates, of whom there are many at NEOCC, complained bitterly that they were not allowed to congregate due primarily to the stratified housing and the institution lockdown.

The newly hired chaplain (a Protestant minister) has recently reported for work at NEOCC. Hopefully he will have a positive impact on the religious services program, once the institution can normalize its operations.

5. Recreation Programs. The Recreation Department is staffed by one person. While a recurrent theme throughout this report, the institution lockdown and stratified management strategy has severely limited both the scope of recreation programs and the amount of time available to inmates to engage in them. Interviews with the inmates revealed that they typically get 2 to 3 hours a week of recreation outside the building, depending on their custody level.

Inmates are allowed recreation time in proportion to their custody levels. Minimum security inmates typically get more time in the recreation yards than those with medium custody. No two housing wings are allowed out simultaneously, and the maximum number of inmates allowed on the recreation yards at the same time is 125. There are two recreation yards, both minimally equipped with items such as basketball goals. A gymnasium exists, but during the Review Team's September 1998 visit, it had been closed for some time following the escape. During the Team's follow-up visit in October, it was being used to issue the inmates' personal property.

The recreation facilities for those in the Special Housing Units are ten fenced cages, with concrete floors, and surrounded by a wall. The cages are completely empty, without a bench or any equipment.

B. Segmenting the Inmate Population

1. Custody Levels. NEOCC's major tool for managing the inmate population is the housing stratification system, based on inmates' custody levels. As described in Chapter IV, inmates are classified as minimum, medium, high-medium, and maximum. Pursuant to the July 1998 Federal court order, the few remaining maximum custody inmates are housed in the administrative segregation awaiting transfer from the facility. Lower custody inmates are separated from the higher custody inmates by housing them in separate wings and then allowing only inmates from one wing at a time into the common areas (i.e., education, vocational training, medical services, etc.) This also necessitates bringing some services, such as commissary, legal mail, and medications, to the inmate housing units on a daily basis. The approach also serves to maintain the separation of specific inmates from other specific inmates ("separation orders").

2. Housing Stratification: Under housing stratification, which was instituted in the Spring of 1998, inmates are housing according to their custody levels:

West Wing Minimum

North West Wing Medium (lower)

North Wing Medium

North East Wing High-Medium* (1)

* Plus special needs, segregation, and protective custody.

Activities in the central common areas are scheduled so that only inmates from one wing are there at the same time, hindering access to activities by other inmates and resulting in increased idleness.

3. Separation Orders. In late September, 155 inmates required separation from at least one other inmate at NEOCC. The reasons for these separation orders vary, but a common example might be two inmates who were at some time in the past involved in a fight or assault on one another. At one point before some higher security inmates were transferred out of the NEOCC, the number of such separations was over 200. Procedures to keep inmates separated from each other have limited the movement of prisoners and the subsequent availability of activities.

a. Lack of Written Policy. While staff were somewhat familiar with the application of Separation Orders to operations, there is no formal written policy that specifically addresses separations. In May 1998 the NEOCC warden issued a memo of "temporary procedures for separation orders and handling inmates with separation issues," but it was designated to be temporary only until May 31, 1998, "pending approval of a formal facility policy."

b. Maintaining Information on Separation Orders. A database of inmates requiring separation is maintained by one of the unit managers, and a list of separatees is periodically generated from that database and distributed to, among others, the warden, assistant wardens, unit managers, shift captains, and staff at various common areas where inmates from more than one wing might go (education department, medical department, visiting room, etc.).

c. Usefulness of Separation Order Information. It is unclear how useful it is to distribute these lists. After a review of Segregation Unit procedures in April 1998, the DOC's Executive Compliance Officer reported that

A follow-up visit by the Review Team in September revealed some improvements.

d. Separation Database Not Automated. The separation computer database is not an automated "real time" one, and so its accuracy is limited to how often it is manually updated, which apparently is not more than monthly. To update an inmate's housing assignment on the list, staff must check each inmate on the separation list against the NEOCC's LAN-based database ("IMS") and manually update the separation database. The separation database is also not automatically cross-referenced, so, for a separated pair of inmates, a manual change has to be made to each inmate's record. Finally, the separation database is not available via the institution's LAN, unlike the IMIS database.

Because of all of the above vulnerabilities, the separation list is not and cannot be the key to manage the 155 separations. Again, the basic tool for maintaining separations is the housing stratification system, with its controlled inmate movements.

C. Unit Management

1. Introduction. The NEOCC is organized around the "unit management" system. This decentralized system, now common in prisons throughout the country, originated in the 1960s and 1970s and changed the traditional centralized model where top level managers (wardens, assistant wardens, and department heads) made many decisions about individual inmates. The unit management system introduced a new position, the unit manager, who supervised a unit team of specialists (for example, case managers, counselors, secretaries). Decisions about individual inmates were therefore made by unit managers and the unit teams.

2. Housing Unit Design. NEOCC is well designed for control purposes to divide the inmate population into 40- to 60-inmate segments, routinely. Unit management is significant because the only staff inmates have ongoing contact with are the correctional officers, who are often in control centers behind darkened glass. Such communication is very public (with other inmates present), distant, and impersonal. It limits the kind of communication and intelligence gathering that is routine when officers and inmates can speak face to face. However, the facility could be operated in a more open fashion than it has been but, with that stratification system in place, the current closed system does not readily lend itself to activities and programs for a population comprised primarily of long-term inmates.

3. Inmate Communication with Unit Staff. A unit management system in many correctional institutions allows inmates to have ready access to the decision-makers and permits staff and inmates to communicate better and get to know each other, far more than is possible under a more centralized system. For such reasons, institutions are often designed with unit management in mind, that is, offices are provided in the inmate housing units for unit managers and unit staff.

The NEOCC facility is not designed with unit staff offices in the living unit pods, although offices are provided just outside on each wing. Since inmates are generally confined to their pods, they do not have easy access to unit staff, especially since movement in the facility has become so closely controlled by the stratification system. Thus, the only staff inmates can readily see are the unit correctional officers -- staff who generally have limited expertise or authority. When the NEOCC warden recognized that unit staff were not in their units enough to talk with inmates, he initiated "contact sheets" for one group of key unit staff - the counselors (often known as "case managers" in other correctional systems). Counselors systematically log inmate contacts, and those logs and summary statistics are forwarded for the warden's review.

The Review Team examined four of those weekly summaries (July 23, August 19, August 31, and September 14) and noted that there were a sufficient number of counselor-inmate contacts among the sixteen counselors. While there is no way to compare the number of contacts before and after the contact sheets were initiated, this management tool seems to be having the desired effect. Inmates generally reported to the reviewers, through a structured interview process, that the inmates saw the counselors regularly (often daily) in their units. An inmate may put in a request form to see his counselor, and within a day or so the counselor comes to the unit. As time permits, the counselors will see other inmates, who did not make a formal request.

Inmates were not as complimentary about their unit managers, however, generally saying they do not come into the units often, do not take much time to talk with them, and do not respond to their concerns. Generally, unit managers are responsible for virtually all matters affecting their units (including the performance of the counselors), and inmate access to them could be a positive factor in communication, problem-solving, and inmate morale. This is especially important at NEOCC, since inmates are so restricted in their activities.

NEOCC's organizational structure poses another concern about Unit Management. Unit managers are under the chief of security, who reports to the assistant warden of operations. In many correctional agencies, unit managers are regarded as generalists who are concerned with virtually all aspects of their units. Their placement at the NEOCC under the chief of security implies that their main concern is security, which could focus their scope of responsibilities and duties too narrowly. This may contribute to the issue of the lack of inmate program participation addressed earlier in this chapter.

D. Inmate-Staff Communications and Relations

The Review Team found over the five weeks of visits to NEOCC that, in general, there is little communication and little rapport between staff and inmates. The observation was reinforced by daily observation of inmates and staff interaction, as well as structured interviews with inmates. Even though NEOCC is organized around a unit management system intended in part to foster good communication, the goal of good communication is not being achieved. This is due to the apparent lack of trust between inmates and staff. The mass search conducted in the spring of 1998 reinforced this mistrust of staff by the inmates. Months later, the Special Operations and Response Team still march daily through the corridors in full riot gear. This is indicative of management by intimidation, and, as observed by a high-level staff member of the Ohio Department of Rehabilitation and Corrections, it tells the inmates that the staff is frightened of them.

E. Spring 1998 Problematic Search Episode

In the spring of 1998, a prolonged episode occurred which has seriously marred the relationship and communications between the inmate population and the NEOCC staff, and which continues to have serious ramifications on the safe and secure management of the facility.

1. CCA/NEOCC Management Response to Events. In the wake of the second homicide in three weeks, CCA/NEOCC management reacted by instituting widespread search procedures in an unusual manner which could fairly be described as a reign of humiliation directed indiscriminately at the entire inmate population.

The administration's approach to management of the facility, which previously had been particularly lax and slow to respond, suddenly became harsh and reactive. Although such extreme procedures would be uncalled for in any circumstance, the vast majority of inmates were not uncooperative and had no involvement in the series of problems which led to the lockdown and searches.

On March 11, 1998, inmate Bryson Chisley was stabbed to death in an isolated unit of the facility, an incident which is described in Chapter V. The incident involved numerous procedural failures in the most secure unit of the institution and was the culmination of a series of stabbings and assaults, including the previous murder.

Both the local and corporate level management understandably were very concerned and took steps in response. After a short delay, the institution was locked down as a precaution. Corporate headquarters sent in a team of senior managers to assess the situation, including two experienced wardens and two senior executives from corporate headquarters. From all reports, this team took effective control of the operations of the facility and within a few days one of the visiting executives, Jimmy Turner, was named to replace the warden, Mr. Gibson. Several trained emergency Special Operations and Response Teams were also dispatched from other CCA prisons to Youngstown to assist local staff.

Very shortly after the arrival of the management team, a decision was made to perform a very thorough institution-wide search for weapons, also known as a shakedown. This procedure was referred to by management and staff there as an "Operation Clearout." As a result, a number of homemade weapons were found.

Up to this point all of these steps and management decisions, including the decision to search every area, were not uncommon and were consistent with good correctional management practice.

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2. Unusually Harsh, Degrading Methods. However, the manner and tactics of carrying out the searches over a period of weeks, as was consistently described by staff, managers and inmates, as well as by a visiting team of DOC administrators, went well beyond common or necessary practice. They were viewed as unprecedented for similar circumstances in the extensive correctional experience of a dozen Review Team members. The procedures were well organized and frequently observed by institutional and corporate management staff.

The procedures were also not consistent with the American Correctional Association's standard on control of contraband and searches. Standard 3-4184 from the Standards for Adult Correctional Institutions indicates in part that:

The institutions search plans and procedures should include the following:

In carrying out the searches while the prison remained locked down, SORT teams who were heavily outfitted in riot gear and helmets would enter housing units, usually accompanied by some NEOCC staff, often including female staff providing logistical and medical support. They announced to the prisoner population that the unit was to be searched and ordered that all prisoners were to stay away from their doors, apparently so as not to observe the process in the living unit. A team of at least four SORT members would approach each cell and order the one or two inmates to strip. They would enter the cell and search the inmate, then restrain him with leg irons and hands cuffed behind the back.

Frequently in the presence of female staff, the inmate would be led from the cell-- "paraded" was the descriptive term often used in interviews by inmates and occasionally by staff. While still naked, each man would be made to lie on the floor in the adjacent shower area or to kneel upright, leaning with his face against the wall. Inmates were instructed to remain in these uncomfortable positions and not to move or speak or watch what was occurring during the 30 to 60 minute period while cells were being searched.

It is long accepted, standard correctional practice to allow prisoners who have been strip-searched to at least put on undershorts to protect their privacy during the duration of subsequent procedures. Inmates are commonly locked into some adjacent secure area or cell, but in any case are allowed to stand or sit while waiting. Except in emergency situations, cross-gender strip searches are not practiced nor do members of the other gender observe such procedures. None of these practices was used.

3. Second Round of Searches. After the teams had completed their searches of all NEOCC housing wings over a period of about two weeks, the new warden and the senior managers made a decision to go back and perform a second round of searches, this time in an effort to remove excess personal property that inmates during the first ten months had been allowed by the NEOCC administration to accumulate.

During this round of searches, almost identical procedures to the first search were used, except that now it had been decided, after intervention by DOC upper management, to allow inmates to dress in shorts after the initial strip search. They were still made to lie on the floor or to kneel with their face against the wall.

There were other problems with the handling of this round of searches. First of all, inmates' cells were generally left in a very disorderly state by the search teams. Next, in spite of the organized, systematic approach taken with this search procedure, little effort was made to properly catalogue confiscated personal property and a great deal of it was lost, further antagonizing the inmate population. NEOCC staff report that two rooms were filled with confiscated property, the owners of which were often difficult to identify. NEOCC records show 733 filed "property claims," although a few of those may have been duplicates.

In any case, from March 1998 until very recently, the NEOCC staff has had the massive burden of trying to sort out inmate property. To their credit, the current warden and his administration have spent considerable time and paid out significant sums attempting to remedy these earlier mistakes. They have reconstructed property lists and reimbursed inmates for their lost property.

Had normal steps been taken by CCA administrators overseeing this second round of searches to document confiscated property properly, a great deal of subsequent effort by staff over a period of months would have been saved and the bitterness of the inmates over the manner of the searches would not have been so badly compounded.

4. Frequent Use of Force by Teams. Prison-wise, long-term inmates such as most of those at NEOCC are used to being searched and usually accept the necessity for administrators to perform systematic area shakedowns after serious incidents, though sometimes a few will resist.

In this case, many inmates objected to the manner of the searches, most verbally and others physically. As a result, numerous tactical uses of force were made by the SORT teams to physically restrain, shackle and move inmates, often using chemical agents or stun-shields in the process.

NEOCC records show that such calculated use of force by SORT teams was employed on 52 inmates during these several weeks in March and April. In most of the official reports, the descriptions of the use of force lack detail. In some cases there is enough detail to raise significant concerns regarding unnecessary use of force.

For example, in one case the official staff report indicates that after an inmate had been handcuffed behind his back and moved outside his cell, he did not obey an order to "keep his eyes and head looking forward and down towards the wall." The officer wrote: "Shortly after this, he began to look around again. I sprayed pepper spray on my glove and wiped it on his face." A review by the warden found that policy had not been followed and that the use of a chemical agent was not justified.

In another case, an inmate looked out of his cell window at the activity of the SORT team. After being told not to look out, he was later observed looking through his window. A seven-member team in riot gear was assembled at his door. The small slot for passing food was opened and the cell was sprayed with a pepper mace fogger. The SORT team then forcefully entered the cell, restrained the inmate and his cell mate, and removed them. In this case, the review by the warden found the use of the chemical agent to be justified.

These cases represent an over-reaction by staff. In neither case was the inmate presenting any physical threat, but only trying to observe the action of the SORT team. Although not documented in other official NEOCC reports, there were a number of complaints from inmates and some reports by staff that these type of inappropriate uses of force occurred.

It might be noted that the SORT team leader who directed these and several other incidents of use of force was soon promoted to become the chief of security at NEOCC.

It is now common practice to videotape all uses of force to later document that proper procedures were followed. Frankly, this practice also has the effect of discouraging any overzealous or uncalled for tactics by involved staff.

Such video cameras were in place at NEOCC during this period and available for use in just such occasions. However, in spite of the fact that these search procedures were well planned and were carried out daily over a period of weeks, inexplicably none of the incidents were videotaped. It is noted that more recently the NEOCC administration indicates it is committed to following prudent procedures by taping incidents whenever possible. During one recent visit of the Review Team, a somewhat minor assault unexpectedly occurred on two officers while one inmate was being moved between areas. Review Team staff observed that the response of NEOCC staff and the follow up procedures were filmed by two cameras for approximately 30 minutes. Unfortunately, the warden and his administration had chosen not to follow that practice previously.

5. Intervention of DOC's On-Site Review Team. The search procedures described above were observed by the on-site After-Action Review Team of administrators sent to NEOCC by DOC Director Moore to review events surrounding the Chisley homicide. The DOC Deputy Director leading the team found the procedures offensive and very inappropriate. After first observing what she considered extreme measures, she questioned supervisors at several levels and found some of the line supervisors open to modification, but concerned about making changes without direction from supervisors. She objected to the procedures to the first warden shortly before his removal, but found him unwilling to make any change.

She then proceeded to take a series of Polaroid photographs of the offensive procedures, including the movement of naked, shackled prisoners by heavily outfitted SORT team members. Another ranking executive in the DOC, who soon after reviewed the issue, described these photos to the Trustee's Review Team as shocking, saying they reminded him of pictures from third world war prisoner camps.

a. Abuse Complaints. The DOC's on-site reviewers received a number of complaints from prisoners of verbal abuse, physical abuse and excessive use of force by the search teams. Stun shields and chemical agents were reported to be used frequently and unnecessarily on prisoners who did not comply quickly or who raised verbal objections. There were also some complaints described as sexual abuse, where prisoners being strip-searched were improperly touched with implements in private areas by non-medical SORT team members.

Some staff members who had been offended by these procedures quietly approached the DOC review team members and made similar complaints of improprieties. The DOC's After Action Report outlined these complaints and recommended that they be investigated. It is attached as Appendix 6 . Some of its pertinent sections follow:

6. Issues Outside the Scope of the Current Review. Such complaints may raise serious issues of fact and law regarding the constitutionality or criminality of staff behavior, taken under cover of law. However, issues of compliance with the Constitution are already under review in a class action suit in Federal Court, while issues of criminality have previously been brought to the attention of the Federal Bureau of Investigation and the Department of Justice Civil Rights Division. On both of those levels, the matter is under review in the proper forums, and it is beyond the scope and competency of this current review to investigate or make judgements.

7. Correctional Management Concerns: Effect on Staff/Inmate Relations. Particularly in the difficult environment of a facility with long-term offenders, developing stable relations and communications between inmates and staff is a critical matter, and constitutes one of the major responsibilities of correctional administrators. This episode poisoned the well of relations between staff and inmates. Its strong negative impact at NEOCC remains.

Setting aside the most serious issues of alleged unlawful abuse which were not pursued in this review, the search procedures as described herein were consistently reported to this Review Team and were not disputed by the current warden when interviewed. He had initially been part of the team of senior managers sent in by CCA corporate headquarters, and was named warden during the time of the searches. Most of these events occurred while NEOCC was under his command.

The Review Team finds these procedures to be very unusual and problematic, apparently implemented for the purpose of intimidating the entire inmate population and to enforce a message of control by the uniformed staff. However, most of the inmate population had not been involved in any negative behavior. The harsh and unusual manner of these wide-spread, systematic searches left a deep scar of humiliation on the population, which is made up primarily of African Americans prisoners. Numerous inmates complained bitterly, often comparing their treatment to that recently dramatized of slaves on the ship Amistad.

Likewise, at least some of the female staff reported having been badly offended by the procedure and embarrassed for the prisoners with whom they work regularly.

Review Team members are particularly concerned that an impression was left on the many young staff at NEOCC, new to the corrections field, that such procedures are acceptable correctional practice. This is especially true since the activities were obviously witnessed and overseen by ranking corporate management staff and were carried out by specially trained CCA teams imported by corporate headquarters. This concern over the message portrayed to young staff is reinforced by the decision of CCA and the warden to quickly promote one of the visiting SORT team leaders to become the Chief of Security at NEOCC, the person in command of all uniformed staff.

On the contrary, this Review Team finds the unusual and degrading manner of the searches served no legitimate security or correctional purpose, nor could the current warden identify any such purpose in an interview with the Review Team. Rather, it is apparent that the searches had a profoundly negative effect on the operations and life of the facility.

8. DOC Management's Handling of the Episode. As reported above, an on-site After-Action Review Team of DOC administrators witnessed what they judged to be very inappropriate and objectionable procedures associated with the extensive search underway and unsuccessfully expressed their request for modification. They took several photographs. They did not keep records of the names of staff who reported abuse, as should have been done.

Upon returning to the District, they reported their concern to their supervisor, the Executive Deputy Director, who was second in command of the agency. He called the new NEOCC warden and insisted on modification, especially of the manner in which inmates were moved around living units naked and were forced to remain kneeling or prone for prolonged periods. In an apparent compromise, the warden thereafter allowed inmates to dress in shorts after being searched but still required them to lie or kneel as before.

The DOC team reported what they had observed and the information about possible abuse gathered from some NEOCC staff. They recommended that an investigation be conducted, however, no such review or investigation was ever undertaken by the DOC leadership.

Rather, the Director of the DOC contacted ranking corporate officials and, after discussions, allowed them the opportunity to internally investigate the complaints, forwarding the Polaroid photos by messenger to a corporate officer of CCA to be used in the investigation. Inexplicably, the Director did not put this request in writing nor were copies of the photos made in any form. No proper record of chain of custody of the photos was undertaken.

It was imprudent of the DOC Director not to have made copies and to have allowed a private company to investigate itself where some of the credible complaints describe actions bordering on being unconstitutional or even criminal. There should have been a serious concern with potential conflict of interest on the part of the corporate leadership, especially since the procedures were at least overseen but more likely instituted by ranking, on-site representatives of corporate management.

However, when the DOC Director received no response by CCA management, she appropriately reported the matter to the FBI for investigation.

9. Handling by CCA Corporate Management. First, there must be a concern that CCA management either planned and carried out this inappropriate episode which has done such damage to their operation at NEOCC, or that at a minimum they encouraged or condoned it through their on-site management team.

Moreover, CCA management has not provided any investigative report in response to the request of the DOC Director. Likewise, they have not responded to several oral requests and two written requests from the Trustee's Review Team for a written report. The photographs which could be relevant to civil court action or to the criminal investigation likewise have not been returned as requested by the DOC Director and the Trustee's Review Team. It has been reported by a CCA corporate officer that the photographs may have likely been misplaced or destroyed. These failures have hampered and obstructed important work of the DOC and of this Review Team.

One ranking member of CCA management reported to the Review Team that she had been assigned to perform an investigation of the complaints and had found them all to be unwarranted. However, she indicated she did not produce any kind of written report on advice of legal counsel. She also asserted that the manner and tactics of the searches, what she said the company calls an "Operation Clearout", were not unusual. She gave the clear impression such "Operation Clearout" procedures may well have been used elsewhere in the company's facilities.

This same individual was the highest ranking member of the CCA management team sent into the institution during the period in question. The team oversaw the search procedures and numerous other operational changes, including the replacement of the warden with one of their own members. On the face of it, she would seem to have a conflict of interest in performing any such investigation.

The Review Team is forced to conclude that either CCA as a correctional enterprise does not possess the capacity to perform an effective internal investigation, is unwilling in this case to perform such an important function, or at very least will not release the results of such a review to proper authorities.

F. Disciplinary and Grievance Procedures

1. Inmate Discipline. Inmate disciplinary procedures are governed by CCA Corporate policy 15-2, Disciplinary Procedures - Adult, as augmented by the NEOCC. Its purpose is to provide a safe and orderly environment; respond to inmate violations firmly, fairly, and consistently; and follow the requirements of "due process." "Minor" offenses and "major" offenses are defined in the NEOCC's policy 15-100, Offense and Penalty Code - Adult. Minor offenses include such offenses as disorderly conduct, failure to maintain personal hygiene, and use of vulgar, abusive, or obscene language. Major offenses include such offenses as assault, fighting, death, escape, and unauthorized use of drugs. Disciplinary hearings are to be held within seven days (excluding weekends and holidays), but may be postponed or continued for good cause. Inmates may appeal the decision within 15 days, and the warden is to respond in writing, affirming or reversing the decision, within 30 days.

If, at any point, a supervisor or hearing officer believes an inmate's conduct constitutes a crime, that person is required to notify the warden, who is to contact the appropriate law enforcement agency.

In March1998, the NEOCC contract monitor found that the system for inmate discipline required changes to policy, procedure, and practice to assure due process compliance on appeals, an unbiased disciplinary officer, disposition of individual charges, handling of minor offenses, and removal from disciplinary confinement when time was served. In April 1998, the contract monitor noted that the concerns had been resolved, in particular, by issuance of an inmate handbook. According to information the NEOCC provided to the DOC contract monitor, from October 1997 through August 1998:

858 hearings were held in a timely manner (94%)

56 hearings were postponed (6%)

888 written decisions were issued on time (97%)

146 appeals were submitted to the warden (16%)

125 appeals were responded to on time (86%)

2. Grievance Procedures. The Review Team found that inmate grievances are often handled at too low a level and that performance data about the grievance system generally provide an inadequate basis for internal assessments, particularly with respect to the compliance with policy-imposed time limits.

In any prison, a formal inmate grievance system is as important mechanism to monitor staff performance, to reconsider policy decisions, and, of course, to address individual inmates' grievances. Given the level of inmate dissatisfaction at the NEOCC, it is even more important.

It is NEOCC policy to encourage informal resolution of complaints at the lowest possible level through direct verbal contact between staff and inmates. There is also an Inmate Request Form that inmates can use to seek information from, or request appointments with, specific staff. Nonetheless, if an inmate wishes to file a formal grievance, Grievance Forms are available in each housing pod.

The inmate must file his grievance within seven days of the alleged incident (or when the inmate learned of it), and the Grievance Officer is to conduct an investigation and render a decision within 15 days. Within five days, the inmate may file an appeal with the warden, who is to inform the inmate of his decision within 15 days. The time limits may be extended to allow a more complete investigation, but the CCA policy indicates that the total time for the full grievance process may be no more than 90 days, except in unusual circumstances.

In practice, NEOCC's Grievance Officer sometimes sends an inmate's grievance to the appropriate department for an investigation and a draft response, but she also often responds based on her knowledge of what NEOCC policy requires in the situation presented.

A breakdown of the 2,680 grievances filed for the first eight months of 1998 is detailed in the Appendix 10 on the Inmate Grievance System.

a. Performance Data Inadequate to Assess the Grievance Program. The Trustee's review found it difficult to determine from the NEOCC's grievance database how well NEOCC is doing in meeting its own policy requirements to render a decision within 15 days, and then, if the inmate appeals, for the warden to render his decision within 15 days. The total time for the full grievance process may be no more than 90 days, except in unusual circumstances. May 1998 was chosen for a detailed review.

In a report from the grievance database dated September 1998, of nearly 400 grievances filed in May, over 100 had no "disposition date" recorded. It must be concluded, therefore, that either one-fourth of the grievances had not been answered, or that the data were incorrect. That same report indicated that 34 initial decisions were appealed to the warden, but only on 13 of those is there an "appeal decision" recorded. Again, it must be concluded that either two-thirds of the appeals went unanswered - or that the data were incorrect.

b. Problems with the Grievance System Previously Documented. In April 1998, the NEOCC contract monitor found that there were systemic problems with the grievance process, including inconsistencies in practice, inadequate staff responses, gaps in training, procedures, and compliance reports crucial for the grievance officer's resolution on issues, and inconsistencies between policy and the inmate handbook. Within a month, the contract monitor noted that those concerns were resolved. However, a subsequent review by the monitor revealed 59 grievances for April 1998 and 125 grievances for May 1998 were out of compliance with CCA's established 90-day resolution period.

c. Grievance Program Needs to be Monitored at a Higher Level. The grievance officer has to personally prepare the responses and send them under her signature. This procedure puts the grievance officer in the role of an ombudsman, as compared with grievance responses coming from a higher level official, like an assistant warden, as is common in other correctional systems. Reviews by higher level officials provide oversight of operations.

It would seem that the inmate grievance program, given its importance in monitoring operations and contributing to inmate morale, is one to which the NEOCC should devote sufficient resources for internal controls and self-assessment, as addressed earlier in this report. While the current (and relatively new) Grievance Officer impressed the reviewers as a very capable and conscientious employee, the grievance program is (and should be) a function of "top management."

The Grievance Officer should not have to fall back on answering grievances herself because other departments have not responded to her requests within her deadlines. Management at the level of assistant wardens should be interested in what inmates are grieving about, particularly any trends, and should be enforcing timely and thorough responses from the departments under their supervision. The grievance program should be independently reviewed at least quarterly to ensure it is being adequately supported and operated. As one basis for all of this internal control, the grievance database should be kept current.

G. Inmate Community and Family Ties

1. Visitation. There are a number of problems noted in the area of community and family ties. First, the inmates had been accustomed to receiving frequent visits in the past when they were housed at Lorton, they are now approximately 300 miles away from home. This makes it more difficult for them to maintain family ties. The great majority of them come from lower socioeconomic backgrounds and their families do not have the financial resources to make the trip to Youngstown very often. According to the Program Manager at NEOCC, only 20% of the inmates receive regular visits. This problem has been alleviated somewhat by D.C. CURE, a Washington-based group representing inmates' families. D.C. CURE assists by coordinating bus transportation to Youngstown for family members to visit. On Fathers Day 1998, CCA also chartered and paid for two buses to transport inmates' family members to NEOCC. Finally, NEOCC has been active in recruiting local volunteers to visit inmates who otherwise do not receive them.

The only issue regarding the visitation program that remains unresolved involves a visiting provision alluded to in the contract between CCA and DOC. The contract stipulates that an accommodation will be put in place to allow inmates to visit family members who do not have the financial means to travel to Youngstown. It is the understanding of the Review Team that this was to have been accomplished through the use of video conferencing. This has not yet been put in place, although NEOCC has plans to install it in the future.

2. Telephone Access. Although the Review Team got some complaints from inmates about the visitation program, the most pronounced complaints in this area involved access to the telephone. There were numerous complaints from inmates and family members about how expensive it was to make telephone calls, due primarily to the billing system. Additionally, inmates' families get billed once a quarter. Consequently, these bills can be quite substantial, and many of the families cannot afford them. A number of inmates said that they no longer had access to the phone because their families could not pay the bills. Legal calls are also billed to the inmates, and several complained that they no longer had access to the courts due to the expense involved.

3. Mail. Some inmates complained verbally to the reviewers about mail, but the Review Team found that NEOCC, overall, was handling mail appropriately and in a timely manner. This is an improvement, since an earlier review by DOC pointed out that mail delivery was slow, and that legal mail was sometimes being delivered opened.

4. Other Issues and Concerns. D.C. CURE brought a number of inmate complaints to the Review Team's attention as well. These include complaints of poor medical services delivery, lack of cultural diversity/sensitivity training for NEOCC staff, an unresponsive inmate grievance process, a lack of meaningful work and educational programs, inadequate religious diets, and inconsistencies with parole hearings and/or guidelines.

They also voiced serious concern with the perceived pattern of abuse of prisoners and excessive use of force during the Spring 1998 searches referenced above.

H. Overall Findings and Recommendations

Findings of Major Concern

The Review Team concurs that there are four findings of major concern in this chapter. They are as follows:

F-5. In the critical area of staff/ inmate relations, a poor level of communication and trust prevailed since the opening of the facility, although more recently there has been a significant effort toward improvement by management.

F-6. Staff/inmate relations were severely harmed by a prolonged episode in the spring of 1998 during which an extensive search of all housing units was instituted following the two murders. Unnecessarily harsh and humiliating procedures were systematically employed, souring internal relations. There were a number of allegations of excessive use of force by staff teams. This incident, which appeared to have been directed or tolerated by a corporate management team, continues to have serious negative ramifications on the safe and secure management of the facility. This event has never been adequately investigated and reported on by management of DOC or CCA.

F-9. A destructive pattern of extensive inmate idleness continues to prevail. There are few constructive work or program opportunities for most prisoners, which directly violates DOC's contract. Most inmates spend virtually all their time confined to small, noisy living units. This inmate idleness could become a permanent pattern if not soon corrected.

F-10. Procedures put in place to manage large numbers of separation cases constitute a major problem, severely limiting operations of the facility and aggravating idleness.

Major Recommendations

R-10. The highest priority must be given to reducing the longstanding issue of inmate idleness and providing daily activity outside the living units for all prisoners in order to meet the requirements of the contract and to establish sound correctional practice. Constructive work, training, educational and other program opportunities must be provided consistent with contract requirements, as well as significantly increased opportunities for off-unit recreation.

R-11. Until there are significant additional opportunities for constructive daily activities, the population of the facility should be reduced, preferably to 1,000 prisoners, since a greater number of idle prisoners invites many different serious problems, as has been experienced at NEOCC.

R-12. NEOCC management must prioritize efforts to improve staff-to-inmate relations and communications. Several measures toward this end would include increased accessibility of upper management staff and unit management staff, as well as the provision of various types of training for all staff in areas like interpersonal communications and cultural diversity, while at the same time eliminating unnecessary displays of force.

R-13. Search procedures, when deemed necessary, should be conducted in an accepted professional fashion, making full effort to respect the physical integrity and personal property of inmates.

Chapter VII

Operational Management and Controls

Introduction. The management and care of incarcerated individuals is a complex balance of protecting the public while maintaining high standards in a wide variety of diverse activities, among them, security, food services, social services, medical care, work, education, and training.

The management style at NEOCC, especially in the early days, was more reactive to events than proactive on a basis of good planning, sound correctional practices, supervision, training, ongoing self-assessment, and internal controls. Unfortunately, many of the events to which NEOCC management eventually reacted were dangerous both to the public and inmates and were "high profile" enough that the CCA's and NEOCC's credibility was badly damaged.

One of the most significant, albeit reactive, changes at NEOCC was a complete replacement of top level leadership over several months, after which many needed operational improvements were implemented. But there is no indication that - before those leadership changes -- CCA provided sufficient oversight and guidance during NEOCC's early planning and activation stages, nor insisted or even expected that NEOCC would build into its management structure a capability for meaningful, ongoing self-assessment and correction of deficiencies. Recent progress in self-assessment has been made, particularly in preparation for ACA accreditation, but it remains to be seen whether such internal controls will be ongoing in NEOCC's future.

The foundation for sound practices, operations, and programs is a comprehensive set of policies and procedures to direct, guide, and train managers, supervisors and staff and to inform inmates of their rights and responsibilities. While CCA's policy system is generally adequate, successful application of CCA's policy system at NEOCC was and is dependent on how extensively and skillfully these policies are supplemented and adapted for NEOCC's particular design and inmate population. A major concern -- one that contributed to the violence and escapes at NEOCC - was the lack of policy and procedures for consistently assessing and classifying individual inmates before accepting them from DOC and after their arrival, as addressed in Chapter III.

A. NEOCC's Reactive Mode of Management

1. Change and Upheaval Have Been Constant. Any number of top management, department heads, line staff, and inmates talk about the continuous pattern of change in so many aspects of the NEOCC operation since activation, including a complete turnover of top level managers. It is no overstatement to say that change has been the only constant - most staff seeing many of the recent changes as improvements - with inmates generally seeing them as a source of anxiety and frustration - of not knowing what to expect next.

2. Reaction to Events Rather than Proactive Innovation. The mode of management at NEOCC for much of its existence generally has either been one of passivity in the early days -- trying to get by with the hand dealt -- or later one of continually reacting to events generated by inmates or by the intervention of outside forces. Slower in coming was proactive management, which might include any internally driven innovation through self-assessment and good planning. Most often the actions taken in response to these intervening events have been positive, but at other times they seem ill-advised or excessive.

Numerous major changes in procedures, programs and leadership have been driven by a variety of intervening, high-profile events, such as the:

More recently, after all the previous problems and interventions and with the advent of new leadership, there seems to be a more internally driven form of management, more an attempt to get ahead of events and unwelcome outside scrutiny. One excellent example is the recent initiation of the process to seek accreditation of the facility through the American Correctional Association (ACA). This arduous process involves months of self-assessment and internal review, including in this case periodic assistance and review by accreditation specialists from corporate headquarters.

B. Internal Controls and Capacity for Self-Assessment

1. Limited Capacity for Self-assessment and Internal Improvement. This evidence of reactive management raises questions about CCA's and NEOCC's capabilities for ongoing internal controls, self-assessment, and internal audits. Effective management of a correctional institution requires a system of continual supervisory review, ongoing self-assessment, identification of weaknesses, and corrective actions, both internally at the institution level and externally from the agency level.

In response to two major incidents, the Chisley murder and the July escape, CCA sent in teams of senior managers to do targeted reviews. A useful report was done after the escapes, but the Trustee's Review Team has been repeatedly told that no report was generated by the management team after the murders. This failure results in no documentation of their findings and no written plan for future improvement at NEOCC. Of at least equal importance, there is no written analysis and recommendations that could be shared with managers at other CCA institutions, including those holding the difficult prisoners transferred from NEOCC. Unfortunately, similar security breakdowns occurred in at least two other CCA facilities as referenced in Chapter V.

As outlined above, little capacity at NEOCC for systematic internal assessment and improvement has been evidenced until recently. Except for pre-audit assistance done in preparation for the ACA audit, CCA had completed no other internal or external audits of NEOCC, at least none that the administration could produce for the reviewers.

In the face of repeated and dangerous breakdowns in security, no security audit had been performed or planned by CCA until that done by the Trustee's Review Team in late September 1998. Neither could it be determined whether such internal audits and self-assessments are an ongoing part of the corporation's management approach nor whether they are primarily used only after negative events have occurred.

2. Litigation Strategy Undercuts Public Accountability and Problem Resolution. On several occasions, Review Team staff were told by CCA administrators that written reports were not done after critical incidents on advice of legal counsel. It was apparent that more importance was given to concerns for documents turning up in subsequent litigation than with correcting past problems or with preventing future ones in various facilities.

If such a philosophy controls corporate administrative decisions, the Review Team finds it a short-sighted approach to correctional management and one which undercuts accountability for the public funds and the important societal mission which are entrusted to the company. The fact that there appears to be an organizational pattern of failure to rectify material weaknesses that led to serious breakdowns elsewhere begs the obvious question as to where might other similar security weaknesses and dangers still persist.

3. ACA Accreditation Process. As mentioned above, one very positive self-assessment step underway is NEOCC's application for ACA accreditation. This very excellent tool puts considerable emphasis on having sound written policies, procedures and documentation of practices. The standards are clear and the process rather resembles an open-book test. CCA seems to have thrown the full weight of its resources behind preparation for this audit.

In late July 1998, NEOCC received an "ACA mock audit" by the CCA Director of Quality Assurance. Though substantial weaknesses were found in several areas and additional documentation was required in others, generally the results were that most areas were "substantially in compliance." The auditor noted a "vast difference in overall staff attitude and morale" and that "it was apparent that a lot of hard work and long hours had been put in by staff to prepare" for the audit.

An "Internal ACA Audit" was scheduled and coordinated by the NEOCC Compliance Officer for the week of August 24-28, 1998, for which staff were assigned responsibility for reviewing 32 specific operational areas. This was followed by another "Corporate Pre-ACA Audit" in mid-September, which resulted in a number of noted deficiencies. This intense self-scrutiny is a by-product of the accreditation process and undoubtedly led to wide-spread improvements.

The actual ACA Accreditation audit was scheduled for late October, just as this report was being written. Based on the intense preparation and focused improvements, there is a strong likelihood of favorable results.

The concern of this Review Team is for sustainable progress. Once this particular impetus for internal auditing fades along with other intense outside scrutiny, CCA and NEOCC leadership must ensure that it has a formal, ongoing system for self-assessment that not only identifies deficiencies, but then corrects them. Particularly, with so many relatively new line staff and managers, it is likely that what gets audited and continually assessed will be what gets done.

C. Adequacy of the NEOCC's Policy System

1. CCA/NEOCC Policy System. As well as could be reconstructed, there were no adequate written policies in place for key operations during the first year of activation. Often those policies were not adapted from the generic CCA corporate format to meet the specific, detailed needs of the NEOCC operation. In reaction to a number of intervening events, a great deal of corporate and institutional effort has been directed at correcting these shortcomings. Virtually every policy in place has been finalized or reformulated in the past seven months. The result of these efforts is very encouraging, as the current set of operating policies is very functional.

A good policy system for a correctional agency should provide requirements and guidance for all major processes, programs, and procedures. Policies should be detailed enough for staff at all levels to be able to rely on them to accomplish the institution's mission. They should be kept current and be readily available to all staff who need to be familiar with them.

CCA's policy and procedures system consists of "Corporate and Facility" policies and "Facility" policies, organized into 22 chapters. For example, the first three chapters are on General Administration, Fiscal Management, and Personnel.

Corporate and Facility policies are often rather general, to accommodate the variety of jail, detention, and prison facility CCA operates, and it would seem that it is the responsibility of the local facility staff to customize those Corporate and Facility policies to meet the security, care, and programming needs of that facility's mission. At NEOCC, the policy system consists of about 73 CCA Corporate and Facility policies (some with local procedures inserted) and about 114 NEOCC Facility policies.

2. Post Order. At a level below "policies and procedures," it is a common practice for prisons to have "Post Orders" that specify how the general policies and procedures are to be applied to specific security posts throughout the facility. Reviewers generally found the current set of NEOCC Post Orders to be well written and specific in the guidance they provide to the staff who work those posts. Again, this appears to be the result of yeoman efforts on the part of local staff in recent months.

3. Policies in Place at the Time of Activation. The Trustee's review was not able to reconstruct a thorough historical account of what policies were in place at each interval from the opening of NEOCC to the present. Nor did the review attempt an exhaustive review of all of the some 187 policies in place; however, it did examine many of the most critical policies when focusing on specific program and procedural areas. Findings and comments on those policies are presented throughout this report. For example, the reviewers were surprised to find no Corporate policy on Control of Tools, which is vital in a secure correctional environment, as was reflected in the fact the July escapes were facilitated by use of a pair of wire cutters which have yet to be recovered. The NEOCC administration has recently developed its own very functional Facility policy on Control of Tools. By contrast, there is a Corporate policy on Key Control, another vital security concern in a prison.

Even without the benefit of a complete historical reconstruction, it is clear that a number of key policies and procedures in place when the institution opened were inadequate. This is further evidenced by the fact that the oldest policy at the NEOCC became effective in March 1998 and that all but five became effective in May 1998 or later. In fact, the NEOCC warden indicated to the Review Team his dissatisfaction with many of the policies in place when he arrived in March 1998.

In particular, reviewers found that the policies and procedures in a number of areas prior to the serious assaults, homicides, and escapes that prompted this review were inadequate for the DOC felon population the NEOCC began receiving in May 1997. Among those critical areas of weakness were policies and procedures for:

Particularly after the arrival of Warden Turner in March 1998, the facility did steadily develop better policies, particularly in the areas of security procedures and inmate classification, with the resultant housing stratification plan based on custody levels.

D. Use of Technology and Automation

1. Introduction. Another area of concern about operational management that emerged during the Trustee's review was NEOCC's limited use of technology. While some of the security measures are extremely dependent on technology, other key operations are impaired by inadequate equipment and resources, giving the impression of being "behind the times."

2. Inmate Information System. The primary inmate information system (IMS) is a Local-Area-Network (LAN)-based database that apparently is used in many CCA facilities. The databases in the various CCA facilities are not linked to the CCA corporate offices via any sort of Wide Area Network (WAN). The program's database includes such basic information as name, facility ID number, agency ID number, date of birth, housing assignment, admission date, sex, etc. Significantly, the program does not include a capability for tracking inmates who must be separated from each other. Neither does it automate information relative to an inmate's custody classification.

In regard to the latter, NCCD's 'final report" in July 1998 on custody classification included as one of its recommended actions that:

The [NEOCC] classification system should be fully automated including each scoring item, each over-ride factor cited, and accurate housing location of the inmate. Several management reports should also be developed that would ensure that inmates are being classified in a timely manner and that inmates are being properly housed.

Having custody classification information readily available (preferably "real time" via a network) is important in any correctional institution, but particularly so in one that relies so heavily on custody classifications for its housing stratification. At present, the only database for tracking custody classifications is at the NCCD offices in Washington, D.C.. Information must be mailed, faxed, or telephoned to NCCD so that it can update the database and return reports to NEOCC. This lack of automation about custody classification is also addressed in Section IV.

3. Separation Orders Database. Also, as detailed below, neither is the PC-based database used to track inmates at NEOCC who must be separated from each other an automated, "real time" one. To update an inmate's housing assignment, for example, staff must look up each inmate's current housing in the IMS database and then manually update the separation database. Separatees in the separation database are not automatically cross-referenced, so, for a separated pair of inmates, a manual change has to be made to each inmate's record. Finally, unlike the IMS database, which is available via the institution's LAN, the separation database is not.

The best way to integrate all of this information would be to include or link custody classification and separation data with the IMS database. Such integration is so important to correctional management that many modern "off-the-shelf" jail and prison management software packages include these capabilities.

4. Basic Office and Communications Technology. Finally, this review raised concerns that NEOCC basic office and communications capabilities are inadequate for a prison of its size and complexity. For example, one FAX machine for the whole institution is not enough, especially given NEOCC's need to exchange documents with its corporate headquarters and DOC. The inconvenience for staff having to go to a central point slows communication that is designed to be fast and easy.

Counselors, who are often the institution's primary contacts with inmates' families, law enforcement agencies, and community service agencies should have "outside" telephone lines.

Likewise, counselors and other staff who deal with individual inmates' case management should have computer terminals or regular access to them and be well trained in their use.

E. Leadership Change as Corrective Action

While there may have been other deficiencies in CCA's management approach, it did take decisive steps to turn around the situation at NEOCC by removing the entire top management of the facility, including replacing the warden, two assistant wardens and the chief of security over a period of months. This last position, in fact, has turned over twice. There has been an infusion of other new blood in certain other positions at the next level. Warden Turner had formerly been a warden elsewhere for CCA, but then had been promoted to a key position of executive leadership at corporate headquarters. Assigning him from there to the wardenship at NEOCC in its darkest days proved to be a bold and effective move.

This new leadership team, particularly Warden Turner, has had a very positive impact, as we have noted in a number of other sections of this report. Overall, it is widely agreed that there is a much greater sense of organization and of coherent progress toward goals. Staff have been observed to have improved morale, accompanied by greater loyalty and pride in the organization. By moving his office from the front administration area to the busy inner part of the facility, the warden has given a strong signal about the importance of communication with line staff and with inmates. A drastic turnaround has been made in the priority given relations with local leaders and law enforcement agencies.

Again, the primary concern of the reviewers has to do with how sustainable the progress will prove. Much of the change must be built into the fabric and structure of the operation, versus its being dependent on the strong personalities and experience of the new leaders who could be moved along at any time.

For now there is no question that significant progress has been made by the new leaders in overcoming the considerable problems of the first year of operation.

F. Lack of an Organized, Written Plan of Action

Although progress has been made by the current administration, the Review Team had a significant concern that, as with the administration of the first warden in the activation of the facility, there is no evidence of an organized, written plan of action that is guiding the management of the facility and which is available to staff at all levels. If the current progress is to take root and be sustained, it is important for major problems and priorities to be identified and for objectives to be identified, along with target dates for completion and persons and offices made responsible for meeting those objectives.

Such a plan should be developed. A major part of the plan should address the recommendations identified in this report and the plans for achieving them. There should be a mechanism for evaluating and measuring the progress toward achieving those priorities. In this way, the managers not only of the institution, but also at the corporate level and in the DOC can better know the progress being made toward overcoming the problems which have plagued the facility until now.

G. Overall Findings and Recommendations

The Review Team noted two major findings in this chapter. They are:

Findings of Major Concern

F-11. Until recently, NEOCC has not demonstrated the capability to identify and correct its own problems. Numerous major changes in procedures, programs and leadership have been spurred primarily in reaction to intervening negative events or external forces. CCA is reluctant or unable to perform internal audits or after-action reviews, with accompanying analytical reports following significant incidents of security breakdowns.

F-12. In response to the major problems and extensive public criticism, CCA management took a decisive step in March 1997 by bringing in a new warden and certain other upper management officials. While there were initial missteps, the new warden and his management team have had a positive impact, bringing a greater sense of organization and of coherent progress toward goals.

F-13. The management of NEOCC has not at any time developed an operational plan of action, including identification of such elements as the administration's major priorities for the facility, specific objectives, target dates or persons and offices responsible for achieving those objectives or solving critical problems. There is no mechanism for evaluating and measuring progress toward achieving those priorities and objectives.

Major Recommendations

R-14. CCA/NEOCC management should significantly increase its capacity for ongoing internal controls and operational self-assessment, including a process to identify problems and submission of written plans of action for implementation of solutions for deficiencies.

R-15. When serious incidents occur, CCA should conduct after-action reviews, prepare written analytical reports, and implement action plans to prevent such events in the future. All reports that pertain to NEOCC issues as well as those at similarly situated institutions should be readily available to DOC.

R-16. CCA/NEOCC should develop a detailed, written plan of action which identifies the facility's major priorities and problems, with objectives, target dates, and persons and offices responsible for implementation of each area. A major part of the plan should address the recommendations identified in this report and the plans for achieving them. Staff at all levels should be aware of this plan and of the major priorities of the facility and their role in achieving the objectives. There should be a mechanism for evaluating and measuring the progress toward meeting those priorities and objectives.

Additional Recommendations

AR-3. Significant improvements should be made in technology and automation, particularly in integrating basic inmate information with security/custody classification and separation orders (if any remain at the NEOCC).

AR-4. As decisions are made about changes in operations, care should be taken to keep the NEOCC's body of policy current, so that staff learn to rely upon and use those policies, as well as to maintain an authoritative history of policies that were in place.

Chapter VIII.

External Relations and Public Accountability

Introduction. The establishment of favorable, mutually trusting relations with the community is of major importance to all correctional systems. Through such arrangements, citizens gain better appreciation of the contributions of penal institutions as protectors of public safety and are more willing to accept correctional facilities as good neighbors. Such relations have direct operational benefits as well. Citizen involvement and volunteer services programs can offer a broad array of assistance to offenders both during and after confinement, thus decreasing inmate idleness while improving the rehabilitative and socialization opportunities available to them.

Poor external relations with the Youngstown community are among the principal problems now confronting NEOCC. While the facility initially received a favorable response from the political and lay structure of the city, public disapproval and suspicion have since added to the prison's difficulties. While the current warden has made significant recent efforts to improve this situation, ongoing progress is warranted to overcome the badly strained level of trust and credibility that now surrounds the prison.

A. Relations with Local Community

1. Prior to Contract, Opening. Prior to the opening of the facility, CCA officials eagerly sought and eventually achieved from city leaders ratification of the company's proposal to build a prison in Youngstown. Due to the region's history of declining economy and high unemployment, many in the area were encouraged by the benefits prison construction might bring to the vicinity. The city was therefore receptive to CCA's desire to establish a presence in their locality and officials of CCA cultivated local leaders in a number of ways during this period.

After a development agreement was signed in March of 1996 to operate a medium security prison and while construction was under way, CCA officials continued to communicate closely with city leaders as they sought out the District of Columbia as a source of inmates for the facility. In the winter of 1996-97, CCA twice facilitated trips for the Director of DOC to visit and tour the facility with CCA executives and meet or tour with local leaders. During the same period, it is now clear, CCA was moving forward with plans to accept and manage at NEOCC a group of the most difficult inmates from the troubled DOC Lorton complex.

2. After Activation. Once the prison was established, little material effort was made by NEOCC to maintain a partnership with citizens or public officials nor was there an attempt by prison authorities to create an open line of communication with area law enforcement agencies. Rather, isolationism, a posture of independence and inaccessibility characterized NEOCC's approach toward the local community.

As the frequency of adversities at the prison increased, both public and official concern rapidly became directed upon the internal operations of the facility. This concern appears to have escalated, in large part, due to the prison's ongoing failure to acquaint the residents of Youngstown and their political representatives with information regarding the nature of the facility and its many challenges. Moreover, separatism and non-responsiveness to public inquiry by CCA and NEOCC leadership significantly contributed to an environment of community mistrust of the corporation which quickly translated into fear for public safety.

Adding to this situation was the corporate policy of restricting the media from information regarding the negative occurrences at NEOCC. By assuming this position, CCA may have inadvertently worsened community trust by conveying the message that it did not consider itself to be accountable to the public.

B. Law Enforcement Agencies

1. General Relations. The relationship between NEOCC and local law enforcement agencies is seriously strained and constitutes a problem of major magnitude. Interviews with the Mahoning County Sheriff and Youngstown Chief of Police revealed a climate of tension and professional noncollegiality. While there have been recent signs suggesting improvement in their interactions, a rapprochement has only begun.

According to the Youngstown City Police Chief, a policy of self-sufficiency and insulation from public involvement was established at the prison by its first warden. At that time, the police department was advised that its presence would only be needed in the event of a serious fire. This attitude of independence by NEOCC has created feelings of disrespect and non-approval on the part of local public safety officials. Only recently have they been invited to tour the facility and at no time have they been involved in emergency planning exercises.

The lack of inter-agency coordination was made evident during the July 25, 1998 escape of six inmates. As reported by both the Sheriff and Police Chief, law enforcement personnel arrived at the prison only to find near chaos, an absence of organization, or an agreed upon, preplanned response. This situation caused a lapse in the conveyance of vital information and may have fostered undue delay in deploying an organized search for the escapees.

2. Mutual Assistance, Emergency Agreements. Although a mutual assistance emergency agreement existed at the time of the escapes, the document was fragmented and incomplete. Procedures for addressing hostage taking, inmate evacuation or mass disturbance were not sufficiently addressed. In addition, the emergency preparation plans had not been reviewed annually as standard correctional practice would dictate. As of the Review Team's visit on August 18, 1998, the facility's emergency plans had not been updated to include signatory approval of the current warden and existing Police Chief. Likewise, neither the Sheriff, Fire Department, Ambulance Rescue Services, State Police, nor the National Guard had signed the prison's emergency plans expressing their understanding and acceptance of its contents as mandated by the District of Columbia's contract with NEOCC and CCA.

During the Review Team's visit to NEOCC on September 21, 1998, reinspection of the prison's emergency plans revealed that they had been rewritten to correct many of the deficiencies of the earlier rendition. However, the current version had not been officially activated, as it had not been signed by any of the authorities who would be directly involved in its implementation.

As the existence of a properly formulated mutual assistance emergency plan is a requirement under its contract with the District of Columbia, it is not only incumbent upon NEOCC to at all times comply with this provision, but also for the District of Columbia to take firm measures to ensure that compliance.

3. Criminal Investigations. Serious concerns over the manner in which criminal investigations are processed at NEOCC have been expressed by local law enforcement officials. A review of police records has revealed that these authorities were not typically alerted when stabbings took place at the prison and only learned of their occurrence through notification by local hospital personnel. Furthermore, when victimized by inmate assaults, employees have often been left to seek criminal charges in their capacity as private citizens, receiving little support from NEOCC officials in the filing of their reports.

This situation can have far reaching negative ramifications in a penal setting. In expressing his dissatisfaction with this state of affairs, the Mahoning County Sheriff stated, "How can anyone expect inmates to respect prison authority when they are not held criminally accountable for attacking officers?"

Review of the prison's policies and procedures indicated that there are no stand alone, written procedures directing staff when, how, or under what circumstances they are to refer alleged criminal violations to the appropriate court(s) or law enforcement officials for investigation and possible prosecution. Rather, this matter is addressed secondarily as part of the prison's inmate disciplinary procedure. As such, the institution's investigator is responsible for determining whether a situation is referred to law enforcement authorities after an institutional infraction has been processed, often a matter of days. The lack of clarity and priority of this area was highlighted when the current warden could not cite the relevant policy nor identify who was responsible for reporting crimes to police when asked by the Review Team.

This lack of clear policy and management direction was brought into focus in the botched handling by NEOCC staff of the follow-up to the Derrick Davis murder. It is not appropriate for employees of a private company to perform an independent criminal investigation of a murder. In spite of original assertions that CCA staff had not conducted an investigation parallel to that of police and prosecutors, it was surprisingly revealed to prosecutors only well into the trial of two accused assailants that a NEOCC staff member did conduct a parallel investigation, including inappropriately making tape recordings of interviews. The result of this admission was that the two suspects were allowed to plead guilty to lesser charges and to receive relatively short concurrent sentences.

The absence of policies and procedures dealing with the investigation of criminal charges is of particular concern when one considers the importance of prosecutions in promoting institutional order, safety, and security. This is necessary and essential objectives of all correctional institutions. When offenders experience no legal consequences for criminal acts committed during their incarceration, it tends to jeopardize these fundamental requirements and contributes to an atmosphere where disregard for prison authority becomes prevalent.

4. Ohio Department of Rehabilitation and Corrections. In response to mounting public disapproval of the repeated mishaps taking place at NEOCC, legislation was enacted by the Ohio General Assembly in March 1998 to broaden the state's oversight of private correctional facilities. Among the provisions set into law were measures to reduce the seclusion and inaccessibility of facilities such as NEOCC to the public and government officials. Under the new legislation, the Ohio Department of Rehabilitation and Corrections (OHDRC) assumed increased involvement in the monitoring of the facility. Unlike the prior circumstances, NEOCC must now report all unusual incidents occurring at the prison to state correctional authorities and municipal officials. In addition, the prison must enter into a written agreement with the OHDRC that sets forth a plan for coordinating the activities of state and local law enforcement agencies in response to an emergency.

According to a high ranking OHDRC official, prior to the creation of these requirements, there was very little communication between NEOCC and state correctional officials. This situation existed even though the state's new "supermax" facility is located within five miles of NEOCC. This official recently reported that even with the March 1998 legislation, securing statutorily required reports from NEOCC can be extremely difficult, often "like pulling teeth."

In a further attempt to ensure that the standards under which NEOCC operated were consistent with those of state correctional institutions in Ohio, the Ohio legislature by passing House Bill 293 in March 1998, broadened the auspices of its Correctional Institution Inspection Committee (CIIC) to include private correctional facilities. Despite this measure, NEOCC refused to permit entry during an unannounced visit by the chair of this Committee, a State Senator, and other representatives and staff of the Committee. Staff of the Committee had previously put the administration of the facility on notice that such a visit was pending. This denial intensified the already problematic relations between NEOCC and government authorities.

The Correctional Institution Inspection Committee is charged by Ohio statue "to evaluate and assist in the development of programs to improve the condition or operation of correctional institutions." As the recent statutory amendment extends its scope and responsibilities to include private correctional facilities, the CIIC conducted public hearings and issued a report, limited in scope, following the July escapes from the prison.

While the expanded role of the CIIC is likely to yield favorable results, it is worth noting that certain provisions of the existing contract between CCA and the District of Columbia appear to inadvertently conflict with the CIIC's stated responsibilities. In this regard, Sections H.3.3 of the present contract establishes that all inmate records delivered by the District of Columbia are to be deemed confidential and privileged information. Moreover, Section I.1 of the agreement states: "No information regarding the contractor's performance of the contract shall be disclosed by the Contractor to anyone (emphasis added) unless written approval is obtained in advance from the Contracting Officer." Based on this conflict, the CCA/DOC contract may need to be modified to comply with Ohio law.

1. Citizens Advisory Committee. The recent creation of a Citizens' Advisory Committee by NEOCC is seen as a positive step toward community outreach and inclusion. Such organizations have traditionally proven to be major assets to penal institutions as they tend to increase the level of public knowledge of and involvement with correctional systems. While the development of the Citizens' Advisory Committee is considered to be favorable, its ability to reverse what appears to be deep-seated, public skepticism regarding NEOCC is uncertain.

Part of this skepticism is based on the perception that the establishment of this committee came about only very belatedly and half-heartedly, in response to the pressure of public and media attention. One local leader described a conversation with the first warden at the time of the opening of the prison. When he suggested to the warden that such a local advisory group be formed, the warden responded that he obtained all the advice he needed from CCA's board of directors.

Nevertheless, the first meeting of the group was held this fall and it has the potential to assist NEOCC in renewing its community relations.

2. Citizen Participation as Volunteers. The recruitment and orientation of volunteers at NEOCC are governed by Institutional Policy #22-100. This regulation indicates that "CCA encourages the use of volunteers to enhance and extend inmate programs which address the needs of the inmate(s)." The prison lists a cadre of 33 volunteers who assist in meeting the religious, drug treatment and visitation needs of its inmate population. Of these volunteers, 27 help in conducting various religious programs. There are presently no volunteers participating in the facility's education or vocational training efforts. The expansion of volunteer services to include these additionally important areas would help to expand the number of inmates engaged in rehabilitative activities and reduce the rate of inmate idleness.

Reportedly, community groups are becoming more interested in extending their services to NEOCC. This situation is seen as positive and suggests that the prison's external relations may be improving.

3. Family and Community Support. Affording inmates the means to maintain contact with their families and other sources within the community has long been recognized by prison managers as yielding mutually advantageous results. Not only do such contacts promote the rehabilitative goals of the corrections profession but they help to reduce tension within prison walls.

Several positive efforts have been made by CCA and NEOCC to assist relatives and concerned citizens wishing to visit DOC inmates housed in Youngstown. The first warden traveled to the District of Columbia to participate in a public meeting with DC Citizens United for Rehabilitation of Errants (CURE) and families of those incarcerated at NEOCC. In response to their concerns, NEOCC sponsored two special bus trips for family members. Such action has been well received by inmates and their relatives, at least as a beginning.

Another CCA corporate representative in the D.C. area has been helpful in serving as a conduit for concerns expressed by the families and representatives of the inmates to the institution administration.

There is a concern among a number of public officials and others interviewed by the Review Team that there is a very limited sense of public accountability evidenced by CCA. This view was summarized by one official who asserted that CCA seems to act as a rule unto themselves. This concern about lack of accountability cuts across several areas addressed throughout this report and is consistent with various findings of this review. Some examples of these concerns are as follows:

While it may be true that some could argue a different interpretation of some of these actions, it is also true that other examples could be added to the litany. In short, there exists a significant credibility gap in many quarters as to the commitment of CCA to be fully accountable, despite the fact that it is well reimbursed for carrying out a very sensitive societal mission on behalf of various governmental authorities.

F. Findings and Recommendations

Findings of Major Concern

The Review Team concurs that there are three findings of major concern in this chapter. They are:

F-14. External relations with the Youngstown community as well as law enforcement leaders have been severely damaged, adding to the prison's difficulties. There is a strong perception that after first winning the good will of the community prior to opening, CCA' s NEOCC leadership soon adopted a posture of independence and isolationism.

F-15. In the critical area of law enforcement procedures, NEOCC has shown disorganization and a lack of adequate coordination and cooperation with investigatory and prosecutorial agencies. The investigation of possible criminal behavior occurring at NEOCC has suffered from a lack of clear management policy and procedures, resulting in confusion and the mishandling of investigatory procedures. Joint interagency emergency assistance plans have not been adequately finalized and implemented nor have any joint emergency preparation exercises been planned or conducted.

F-16. A number of officials voiced a concern that CCA exhibits a limited sense of public accountability and responsiveness as it carries out a sensitive societal mission on behalf of governmental jurisdictions.

Major Recommendations

R-17. CCA/NEOCC should make a concerted effort to establish better relations with all elements of the local community and to allow itself to be held publicly accountable for the manner in which it carries out its sensitive and difficult public function.

R-18. It is of particular importance that NEOCC focus on improving its working relations with local, state and federal law enforcement and prosecutorial agencies. Priority must be given to establishing appropriate, agreed upon procedures and clear written policy for handling possible criminal behavior at NEOCC. Also of importance is finalizing and implementing joint, interagency emergency assistance plans and conducting joint emergency preparation exercises.

Chapter IX

Staffing/Human Resource Management

Introduction. The inspection and review of NEOCC included a comprehensive examination of the facility's human resources function. Unquestionably, sound security practices and effective operational policy are imperative to the successful management of a correctional facility. Well trained and experienced staff are equally essential to this mission.

In an effort to properly determine qualification/hiring requirements, staff experience levels, promotion practices and training mandates, the Review Team inspected numerous employee files and interviewed the facility's Personnel Coordinator and Training Manager. Contrary to CCA policy, the Review Team noted that many employee personnel files were incomplete. Several of the files reviewed did not contain complete application forms and other pre-employment documents. This was particularly true for employees who transferred to NEOCC from other CCA facilities. In addition, the Review Team conducted more than forty interviews with NEOCC staff at all levels.

Once this review process was completed, three major themes became apparent. Each of these themes will be discussed in turn.

In a correctional environment, mid-level supervisors are relied upon to set the tone of the facility. In other words, this group, more than any other, provides the example for new officers on how to respond to many daily problems and interactions. By their own actions, these supervisors demonstrate the control, confidence and organizational skills required to successfully manage an inmate population.

That success is dependent on effective interpersonal communication skills. It is imperative that staff know how to treat inmates fairly, consistently and with respect. Most correctional veterans agree that in addition to sound security practices, effective communication between staff and inmates is crucial to operating safe and secure facilities. Unfortunately, with a majority of the NEOCC staff being new to the field of corrections, this skill is clearly lacking. While it is acceptable and commonplace to hire a number of inexperienced staff for the activation of a new facility, the level of staff inexperience at NEOCC was ill advised. In most correctional systems, at the conclusion of formal training, new officers are guided and instructed in their daily duties by more experienced, seasoned senior correctional staff (i.e., sergeants, lieutenants, captains). However, at NEOCC many senior staff also lack the experience necessary to adequately perform this function. While some supervisors have prior law enforcement experience (i.e., military, or local police/Sheriff's departments), this background is not considered correctional in nature.

1. Levels of Experience. NEOCC has 30 senior correctional officers (sergeants), nine assistant shift supervisors (lieutenants), and nine shift supervisors (captains). Given the lack of experience among the newly hired line officers, NEOCC must rely on their sergeants, lieutenants and captains to provide the essential direction needed. This is particularly true in terms of the management problems associated with the inmate population at NEOCC. However, the relative inexperience among this mid-supervisory group calls that charge into question.

For example, among the 30 sergeants,16 had no prior correctional experience of any kind or only minimal experience as security guards. None of this group have ten years or more of experience, only one has between five and ten years, and 13 have less than five. Thus, the majority of the sergeants, those who provide the first line of direct supervision to new officers, are themselves new to the field.

A review of employee records revealed that among the nine lieutenants, two had no prior correctional experience, four have less than five years in the field, two have between five and ten years, and only one has ten years or more of experience.

Each of the six captains had prior experience, however, the problem that the Review Team noted was in the degree of prior experience. Among this group, four have less than five years in corrections and only two have ten years of experience or more. These captains are the most senior managers on duty at the institution during evening and weekend shifts. Notably, the July 25, 1998 escapes took place on a Saturday afternoon.

On that day, the captain in charge of the institution had effectively turned command over to a lieutenant, an individual with less than five years in corrections and less than one year as a supervisor. The captain's experience could not be ascertained as he had been terminated prior to the time of this review. It was determined that more than any other factor, the July escapes were due to staff inattention and poor supervision.

The absence of experience at the mid-level is apparent in other departments as well. For example, the majority of the medical staff had no prior experience in a prison environment, including the first health services administrator. The chief of nursing had only limited experience in local jails. Similarly, other professional staff (i.e., librarian, principal) had no correctional background.

2. Qualifications for Promotion. In part, this problem can be attributed to CCA's qualification requirements and promotion process. For example, pursuant to corporate policy, a sergeant must possess three years of experience in criminal justice which preferably includes one year in a supervisory position. However, CCA allows wardens to

waive any and all of these job requirements when making a selection. A review of the personnel files indicates that this discretionary option has been frequently utilized at NEOCC.

Similarly, CCA policy requires that an employee must be with the company for at least six months before becoming eligible for promotion, however, CCA waived this rule for all staff during the first six months of operation of NEOCC. In one of the files reviewed, one officer with two years of prior correctional experience at the county level was promoted to sergeant after only four months at NEOCC.

It was also noted that the qualifications for the lieutenant position are identical to those for the sergeant position. No additional training or experience is required. Captains are

required to possess four years of experience which includes three years in a supervisory position. All applicants may substitute education for experience.

Moreover, it does not appear that CCA has a policy governing promotions between positions once the six-month rule is satisfied. In fact, in many cases, it can be concluded

that the promotion process at NEOCC has been rushed. For example, a review of eleven (36%) of the current sergeant's personnel files revealed that the range of months between an individual's entry on-duty and promotion to sergeant was six months to one year. The range for promotion from lieutenant to captain was three months to five years. In one case, an individual was hired as an officer, then promoted to sergeant after six months, was then promoted to lieutenant two months later, and was made a captain three months after that.

Overall, the average time between date of hire and promotion was nine months for sergeants, 19 months for lieutenants, and 36 months for captains. It is important to note that these averages include staff who transferred to NEOCC from other CCA facilities with two or more years of experience. When these employees were excluded, the averages changed to 13 months for lieutenants and 15 months for captains. Among the sergeants, the two most experienced individuals had been with CCA for 18 and 20 months. Again, excluding these cases, the average time before promotion was reduced to seven months.

While it is true that some new employees may prove outstanding in a short time, the accelerated promotion practice has been overused at NEOCC.

Again, while it is not uncommon to hire a number of inexperienced staff for the activation of a new facility, the challenge is to ensure that a proper balance exists between and among staff experience levels throughout the institution. It is well known that CCA made a commitment to Youngstown officials to recruit heavily from the local community. Given the high rate of unemployment in the area, the promise of new jobs was a chief attraction to City officials and residents alike. An examination of the staff resident data confirms that both sides achieved the intended results.

Specifically, there are 518 authorized staff positions at NEOCC, 510 of which are currently filled. Contract staff (i.e., medical and food service personnel) comprise 15% of the workforce, and six percent transferred from other CCA facilities. This staffing level is adequate. Staffing reports reveal that of the 510 encumbered positions, 284 employees (57%) were recruited and hired from either the City of Youngstown (48%) or the neighboring Mahoning County (9%). Primarily entry- positions were filled locally, including most correctional officer positions. The overwhelming majority of these individuals did not have any prior correctional experience.

1. Hiring/Qualification Process. The personnel coordinator reported that the hiring process is completed as needed. Based on the current NEOCC attrition rate, hiring is typically conducted monthly. The screening process for new hires includes a statewide criminal record background check, motor vehicle check, fingerprints, medical screening and urinalysis. If a job candidate served in the military, a Department of Defense verification is made to confirm service record and discharge status. CCA policy requires that this process be conducted for all staff, including contract employees. Volunteers are subject to statewide criminal record and motor vehicle checks only. No national criminal record check is completed, no post employment background checks are conducted and subsequent drug testing is administered only in cases of reasonable suspicion.

Pursuant to CCA policy, the basic qualifications for a correctional officer position include a High School diploma or GED certification or equivalent, and a valid drivers license. Prior correctional, law enforcement or supervisory experience is not required.

As a result of these limited requirements and the emphasis on local hiring, the Review Team found that of the 318 correctional and senior officers currently on staff, only 63 individuals had prior correctional experience. As such, 80% of the correctional officers were new to the field of corrections. This fact is particularly alarming given the type of inmate population housed at the facility.

As detailed in Chapter IV, the inmates transferred from the District of Columbia were predominately repeat offenders with long histories of incarceration and records of violence. Thus, the inexperience and lack of confidence among the newly hired correctional staff were in sharp contrast to those over who they supervised. Since correctional officers have the most direct and continuous contact with inmates, this observation is all the more troubling.

In interviews conducted with first-line correctional officers, the majority revealed that they felt ill prepared to deal with the inmate population. In particular, they expressed concerns regarding the inmate classification. The resounding theme heard among these officers was that while the facility was designed to house medium-security inmates, they received maximum custody inmates. When asked how this affected their job performance, the officers indicated that they had not been properly trained or prepared to deal with the higher security inmate population.

Similarly, when senior officers were asked what impact, if any, this level of inexperience caused, they noted that newer officers tend to be less willing to respond directly to inmate misconduct and to write inmate incident reports. They further commented that some inmates take advantage of the inexperienced officers and, in turn, the officers tend to be afraid of the inmates and too easily intimated.

2. Staff Morale. Based on these comments and concerns, the Review Team was interested in the morale among the staff. In interviews, 41% rated morale as high, 37% believed it was neutral, and the remaining 22% rated morale as low. Without exception, the officers interviewed indicated that operational security had improved markedly since the arrival of Warden Turner in March 1998. Overall, 91% of the staff interviewed indicated that they felt safe on the job. Most freely acknowledged that this was not always the case. In addition, staff generally reported feeling less stressed on the job and attributed that to the new security operations and procedures in the facility.

Among those interviewed, 88% indicated that staff are in control of the facility. Nonetheless, several officers noted that the turnover among their ranks remain high. Again, some attributed this to officers being intimidated by the inmates and/or because they failed to adjust to correctional work.

3. Attrition/Demographic Data. A review of the facility's attrition data for both 1997 and 1998 was conducted. In 1997, a total of 71 officers were either voluntarily or involuntarily separated. Through the third quarter of 1998 ending in August, 63 officers had been separated. Of that number, 51 were terminated. Based on interviews with the personnel coordinator and a review of employee records, the primary reason given for resignation was a new job opportunity. The recent opening of a nearby OHDRC facility provided this motivation. On the other hand, policy violations (i.e., inappropriate relations with inmates, violation of post orders) and attendance problems were the most common reasons for officer terminations.

The Team also reviewed staff demographic data. Given that the NEOCC inmate population is predominately African-American, the racial composition of the workforce was of interest. It is well known that in a correctional setting, it is most preferable to maintain a balanced racial/ethnic mix among the staff. In this respect, staff diversity has oftentimes been directly linked to maintaining calm and order in a facility. Generally, NEOCC has succeeded in achieving this balance. Excluding the 74 contract employees, the racial/ethnic composition at the NEOCC includes 235 African-Americans (53%), 182 white employees (41%), 15 Hispanic staff (4%), one Asian employee (0.2%), and two Native Americans (0.4%). NEOCC does not collect race/ethnic data on contract staff.

While the ethnic mix among the line staff is good, minority representation is currently lacking in the top echelons. At the time of this review, NEOCC had one African-American in upper management. This individual has recently been transferred to another CCA facility, leaving NEOCC without minority presence at the managerial level.

During the interview process, employees were also questioned regarding their perception of staff interaction with inmates. Overall, 56% indicated that staff communicate effectively with inmates, 35% believed that the communication was average, while nine percent rated the interaction as ineffective.

When one considers the inexperience levels of the staff in contrast to the inmate population at NEOCC, the facility's troubled history is not at all surprising. It is, to many observers, a dangerous combination. In fact, one can arguably conclude that CCA officials have been very fortunate that the degree and extent of the documented problems have not been more severe than reported.

C. Insufficient Training of Personnel

CCA has a corporate policy governing staff development and training, however, no amount of pre-service training could have adequately compensated for the low level of experience among the line staff and supervisors at the time of the facility's activation. This is particularly true given the sophisticated inmate population transferred to Youngstown.

1. Pre-Service Training Requirements. Pre-service training for correctional officers is four weeks, which includes three weeks of classroom instruction and one week of on-the-job training. For non-correctional staff, there is a two-week training requirement which includes one week of pre-service orientation and an additional forty hours of combined classroom instruction and on-the-job training. Pursuant to corporate policy, training is required for all staff, including contract employees and volunteers. However, a random review of 15% of volunteer personnel files indicated that none had received the required training as outlined in CCA policy.

All lesson plans are developed at the corporate level. If a local training class is designed, corporate staff must approve the lesson plan before implementation. In June 1998, CCA approved Warden Turner's request for an expanded pre-service training program for correctional officers. The program is now five weeks. Classroom instruction was increased to 3 weeks and the on-the-job training component is now 56 hours. The pre-service training program is a pass/fail system. Employees who do not pass are typically terminated, however, with the warden's permission, an employee may receive remedial training and another opportunity to take the exam.

CCA's pre-service training requirements for correctional officers do not include a basic firearms course. As of the Review Team's September visit, 21 correctional officers had successfully completed firearms training. At NEOCC, typically only those officers who work armed posts (i.e., perimeter patrol, tower officers, escort officers) and members of the institution Special Operations and Response Team are required to complete this program. Most correctional systems require that all officers complete firearms training and require re-certification annually. This is a sound correctional practice and is clearly advantageous, particularly in emergency situations. Reportedly, NEOCC will train an additional 150 officers by mid-November 1998.

Interviews with officers support this effort. When asked what additional training, if any, they needed, many identified firearms. Staff also expressed a need for additional on-the-job training, improved communication techniques and inmate classification training.

2. In-Service Training Requirements. Pursuant to CCA policy, correctional officers, professional specialists and designated support personnel must complete a minimum of 40 hours of additional training each year. The training necessary to fulfill this requirement is not specifically stated in policy. In fact, guidance is limited to ". . . instruction designed to improve the employee's ability to understand and effectively manage inmate/resident behavior." CCA Policy 4-1, page 5, paragraph b.

In response to this in-service training mandate, NEOCC conducts a monthly warden's in-service training meeting. The two-hour meetings, which are mandatory for all staff, are conducted three times daily to allow staff on all shifts to attend. The meeting agenda for the past two months confirm that management staff, including the warden and assistant wardens, review a variety of topics, such as post orders and inmate restraint techniques.

The Review Team had an opportunity to observe one of these meetings and considered it both productive and effective. The meetings provide staff with updated information on new institution policies/procedures and a forum to raise issues of concern. The practice of using these meetings to fulfill in-service training is questionable however. For example, these monthly meetings also routinely include presentations of staff awards, such as letters of appreciation. Accordingly, using this forum to conduct training on essential correctional practices, such as shakedown techniques and shift change procedures, is not appropriate.

More importantly, with the inexperience levels among the correctional workforce, the Review Team considers in-service training to be a crucial element to ensure safe operational practices at NEOCC. Several of the topics covered during past warden's meetings, including chemical control, tool control and radio communication, would be more thoroughly presented in a formal training class. While these meetings may be useful, they are not acceptable substitutes for what arguably should be a more comprehensive, structured in-service training program that warrants the full attention of staff.

A review of employee training records further reveals that these monthly meetings are recorded on individual training records, along with warden's daily meetings, warden's weekly meetings, operations staff meetings, security supervisor staff meetings, and department head staff meetings, among others. Training credit was also given for attendance at ACA Audit Team meetings. The use of staff meetings as synonymous with training is not only inappropriate, it is also ill advised as it compromises the valid in-service training function necessary for essential staff development.

Interviews revealed that the training manager and the chief of security are in the process of preparing a field training manual for correctional staff. This joint effort is underway in response to a need for additional support for newly promoted and/or reassigned officers. Upon completion, the manual is intended to serve as a road map and essential resource for officers. Reportedly, the manual will include specific information on each post assignment in the facility. The Review Team fully supports this effort. Given the absence of a more formal in-service training component, this manual will undoubtedly provide much needed guidance and direction to NEOCC officers.

D. Findings and Recommendations

Findings of Major Concern

The Review Team concurs that there is one finding of major concern in this chapter. It is:

F-16. The lack of correctional experience on the part of almost all staff, especially supervisors, severely hampered NEOCC's attempts to manage a difficult inmate population. In spite of the commitment and enthusiasm of line staff as a group, they are not yet sufficiently experienced and trained for their duties.

Major Recommendations

R-19. CCA should transfer more experienced mid-level supervisors to NEOCC. These more seasoned correctional managers are essential to ensure that basic correctional and security techniques and practices are taught and enforced in daily operations.

R-20. Consistent with CCA policy and to increase the basic readiness of staff at all levels, NEOCC should design and implement a formal 40 hour annual in-service training program. The course curriculum should be designed with input from supervisors and managers to better target observed weaknesses and areas of poor performance.

R-21. NEOCC could benefit from increased ethnic diversity among its senior managers, especially in view of the make-up of the inmate population. While the ethnic mix among the line staff is good, a balanced minority representation is lacking in the top echelons after recent personnel changes. Given the current staff/inmate tensions at NEOCC, such increased diversity among the senior officials would be helpful.

Chapter X

Health Services Management

Introduction. There are few operations in a correctional environment which are as potentially contentious as inmate medical services. As detailed in Chapter III, the May

1997 opening of NEOCC was marked by the rapid influx of inmates. NEOCC staff throughout the facility were overwhelmed and unprepared for the level of activity. The health services department was no exception. As a result of the accelerated transfer rate, health services staff were incapable of keeping pace with the demands imposed. Additionally, interviews with both staff and inmates revealed that the medical operation during this time was chaotic and unorganized.

This concern was also evidenced by the July 1997 class action lawsuit filed by NEOCC inmates against CCA and DOC. In part, the suit charges that CCA provides inadequate medical care, including lack of access to health services staff and alleges a medical delivery system which is below community standards.

While these and other initial problems were well known, the Review Team was also aware of reported improvements in the medical operation. In an effort to provide a more comprehensive assessment, the Team utilized the same two-prong approach used in the security review. The Review Team concurrently:

Medical services at NEOCC are subcontracted by CCA to the Emergency Medical Services Association (EMSA), a private health services firm based in Ft. Lauderdale, Florida. At present, there are a total of 55 medical professionals on staff, including one full-time physician, one psychologist, one mental health clinician, eight registered nurses, thirteen licensed practical nurses and one dentist. In addition, EMSA utilizes the part-time contract services of one psychiatrist, one psychologist, one infectious disease physician to care for HIV-infected inmates, and additional nursing support.

While this current staffing level is adequate to serve the inmate population at NEOCC, it was not so at the time of activation. Nevertheless, even the present staff complement

would have been insufficient to handle the flow of inmates upon activation.

In addition, most of the health care providers had no prior experience in a prison setting, while a few others had experience only in a jail setting. This disadvantage was further compounded by inadequate assistance and training provided from EMSA corporate officials. EMSA was responsible for providing close oversight to the new operation and CCA should have properly monitored the contract to ensure that this requirement was met. Rather, NEOCC medical administrators reported being virtually left on their own following less than one week of training at EMSA headquarters. Notably, staff turnover in the medical department was commonplace during the early months of operation.

As referenced in Chapter III, most newly activated facilities will process 80 to 100 inmates per week. Conversely, NEOCC received over 400 inmates during the first week alone, followed by hundreds more within days. Clearly, this placed an enormous burden on the health services personnel who were charged with conducting medical assessments on each inmate upon arrival. This process includes a medical, dental and mental health assessment.

Based on common industry practice, and confirmed in interviews with NEOCC medical staff, the intake process should occur within 24 to 48 hours after transfer. However, as a result of the rapid transfer rate and ineffective intake procedures, the NEOCC medical department failed to meet this standard and became backlogged almost immediately. In equally short order, inmates began complaining that their medical requests were not being properly or expeditiously processed, and that their medical needs were being ignored. Interestingly, despite improvements in the medical department, inmate interviews reveal that this negative perception still exists.

Further complicating the activation process were incomplete and/or missing inmate medical records which caused continual delays during intake. NEOCC staff reported that DOC routinely failed to forward complete files. In many cases, this required staff to contact District officials for clarifying information, including confirmation of reported diagnoses and distribution of medications. On the occasions when DOC did not forward any medical files at all, NEOCC staff were forced to establish new records for the inmates. DOC officials were seriously at fault in this regard and in their failure to provide adequate oversight of the NEOCC medical department.

It must also be noted that NEOCC had a contractual prerogative to reject any inmate whose transfer was made without the proper paperwork. Nonetheless, despite the fact that these missing medical files were identified immediately as a problem area, NEOCC continued to accept every inmate without pause.

Another contributing factor was that many inmates arrived at NEOCC needing special medical attention. Records confirm that among the first group of 904 inmates, 250 were chronic care inmates with pre-existing conditions such as asthma, HIV, diabetes, high blood pressure and heart disease. Early audits conducted by both DOC and CCA officials

cited serious problems in the area of chronic care management. In fact, this area remained a significant problem for months. Cases requiring immediate need for vision and dental care were also prevalent.

The DOC audit, conducted in July 1997, also revealed inadequate staffing, a backlog of sick call requests, and incomplete physician notations in inmate medical records. The

auditor also reported that neither CCA nor EMSA had performed any on-site reviews of the medical department since the facility's activation. Given the size of the inmate population,

coupled with the inexperience levels among the medical personnel, the DOC auditor concluded that close over-site and monitoring by corporate officials was required.

Perhaps in response to these findings, CCA and EMSA conducted a joint medical audit in September 1997. The audit was similarly critical of deficiencies found in NEOCC sick call procedures and the staff physician's poor record keeping. In addition, the report revealed that only 50 of the 250 inmates with chronic care problems had been medically screened and that more than 400 inmate medical records had not been forwarded by DOC. Other findings included breaches in security in the medical department, such as a propped open pharmacy door, an unlocked supply room door, and scalpels stored on an open bookshelf. These practices, partially attributable to staff inexperience, were reportedly corrected immediately.

A more routine pattern of monitoring and evaluation of the medical department began in January 1998 following DOC's selection of Pulitzer/Bogard & Associates to provide contract monitoring services at NEOCC. The medical contractor conducted bimonthly

on-site reviews. Seven deficiencies were noted in the first monthly report. These included a four-week backlog for routine physician care, a six-week backlog for non-emergency eye care and dental treatment, and continuing problems treating chronic care cases.

Within one month, three of the seven deficiencies were resolved, including elimination of the four-week backlog for routine sick call. The other resolutions involved proper credentialing of medical staff files and obtaining corporate approval of the NEOCC policy/procedures manual. This improvement record was characteristic of the progress in the department. During the subsequent months, the backlog in eye care was eliminated and the delay for dental treatments has been reduced to three weeks.

By July 1998, the position of a full-time Contract Monitor was assumed. At the time of the current review, two deficiencies remained unresolved, including the three-week backlog for dental treatment. The other involved failure to establish mental heath criteria to determine which inmates required care beyond that offered by NEOCC. The other two deficiencies (i.e., development of a condom distribution policy and a Quality Improvement Program) were pending resolution.

B. Current Analysis of Health Services Management at NEOCC

The review of current medical operations at NEOCC was conducted by Review Team member Glen G. Johnson, M.D., former Medical Director, Texas Department of Corrections. Overall, he found the department had improved its operations and was functioning well.

In summary, the most serious concern noted was the management of inpatient beds. Several recommendations were made in this regard. In addition, Dr. Johnson cited unacceptable delays in performing laboratory tests, eye exams and dental exams. His findings also indicated that chronic care management has only recently improved and will require careful supervision to ensure continued compliance.

Dr. Johnson also noted that the medical department deserved special recognition for its management of HIV patients and for nursing care coordination. The Review Team agrees with his assessment that the current health services administrator is largely responsible for these and other improvements in the department. His complete findings and recommendations follow.

Major Recommendation

The Review Team concurs that there is one recommendation of major concern in this chapter. It is:

R-22. In the area of medical services, NEOCC should implement the recommendations of all DOC monitoring reports and of the findings of this current report.

HEALTH SERVICES AUDIT REPORT

NORTHEASTERN OHIO CORRECTIONAL FACILITY

Glenn G. Johnson, M.D.

In response to a request from John Clark, Corrections Trustee, District of Columbia, I joined a review team by the Office of Corrections Trustee during the week of September 21, 1998. Available for review prior to the on-site visit were four inmate death records and monthly audit reports completed by the contract monitor for 1998 up to, but not including, August 1998.

Discussions with the Corrections Trustee, Project Director, Project Coordinator and the team leader of the management oversight group were held the night prior to the site visit and the morning of the site visit. I commenced my review of the medical department on the morning of September 23, 1998.

The medical department is located in the central support building of the Northeast Ohio Correctional Center. There is a waiting room, a nursing station with an adjacent secure medical records room, two office/exam rooms, a large treatment/emergency room with a portable X-ray machine, an office for mental health shared by the two full-time mental health professionals, a two chair dental suite with lab work station, two large storage rooms for supplies, a secure pharmacy room, three offices for administration, 1 area for phlebotomy services, a storage room for hazardous waste, and four inpatient rooms (two of which have negative air flow for respiratory isolation). In general, the site was clean, well organized and the patient flow was good, with security control (to include pat searches) seemingly consistent and complete.

During my visit, I had interviews with representative medical personnel, all of whom were most professional and cooperative. Three inmates were interviewed during my visit to the special management unit within the administrative segregation unit.

I reviewed 47 active medical records, the majority chosen randomly from the past several month's sick call roster and from the lists of inmates with chronic medical conditions. Target reviews were done by referral from other site review team members with questions concerning medical conditions of inmates found during their individual interviews. The target reviews included 2 emergency room visits and 2 hospital admissions during the past month. All four records of patients currently in medical observation status were reviewed. In addition, four of six deaths during the past 10 months were reviewed.

While I did not review all aspects of medical/dental/mental health services, I do feel that the sample of medical records was large enough to determine the likelihood of a event within a statistically significant margin of certainty. Conclusions concerning the delivery of care, staff attitudes and morale, staff professionalism, and inmate concerns and perceptions of medical care are the result of consideration of all interviews and medical record reviews. The conclusions were presented to the Unit Health Administrator, and then in a group meeting to include the Warden prior to leaving the facility.

CONCLUSIONS

In general, the medical department was well functioning. All staff seen were most professional in their demeanor. Inmate patients were treated with respect. Patients were actively being seen by staff on both days during my on-site visit.

Several good programs deserve special mention. The care of HIV patients was well organized, treatment follow-up was appropriate, and "state of the art" medications were available and utilized by patients. There is an on-site contract infectious disease physician actively involved in the care of HIV infected patients. Nursing care coordination is good, and continuity is assured by the designated nurse. The mental health program is adequate, and while not offering services beyond crisis intervention and individual psychotherapy/psychopharmacology, there was no indication of patients lacking basic services, as well as no indication of over medication of patients.

Areas of major concern include the following:

1. Inpatient medical beds in the medical department--Currently these four beds are utilized as observation beds (the commonly accepted definition of an observation bed is observation by nursing staff for 24 hours or less). However, in reviewing the length of stay numbers for the past 8 months, it revealed a length of stay averaging approximately 3 days (range 1 to 28 days). In addition, it was learned that a common practice of placing overflow patients needing observation in administrative segregation was in place when there are no beds available in the medical department. When reviewing the documentation of the patients in the observation area, there was commonly no notation by the admitting/responsible physician throughout the stay. Nursing notes were scant, and limited to every 8 hour documentation, by in large. Documentation of patient access to other constitutionally mandated services (commissary, education, visitation, etc.) was not present. Mental health patients were placed under three separate levels of observation--observation, suicide precautions, suicide watch--each with its own level of one on one observation, and the amount and type of property provided. Mental health staff documented interviews with the patients consistently on a daily basis.

At best, it is my opinion that the four beds should be designated as infirmary beds--requiring admission, progress and discharge notes in a distinctly developed inpatient medical record by the responsible physician. A separate medical record should be maintained throughout the inpatient stay, and routine inpatient nursing admission assessments and progress notes completed. The facility medical staff, along with their company's support, should develop guidelines of services available in the facility, and make the difficult decisions as to the course of action to take when the acuity of the patient's needs are greater than what they can safety and reasonably provide. This should include mental health, with definite guidelines of treatment provided, and the course of action for patients exceeding the facility's capabilities. Placement of patients to be observed for medical or mental health reasons out of the medical department should be limited to conditions of very minor acuity, only after a reasonable medical assessments and approval by the responsible physician for limited periods of time.

I found no evidence of adverse outcomes for the past several months. However, I do feel that the current situation system is potentially dangerous. Review of the most recent inmate death in September revealed the use of an observation bed without a physician examination for 24 hours, and subsequent placement in the administrative segregation area for observation of his dietary intake--he died the next day. While better inpatient notes and care may not have anticipated this patient's death, there certainly was an opportunity to intervene more aggressively at an earlier time.

2. It was evidenced from my review of the medical records that many medical records were transferred from D.C. Department of Corrections in poor condition--if transferred at all. While the most recently received inmates uniformly have a pre-transfer screening form completed by the Department, the inmates transferred during the initial intake do not. It was reported by the facility health administrator, that oftentimes the medical records do not arrive with the inmate, and it is necessary for the facility to initiate a new record.

The medical department does a complete medical/dental/mental health assessment on intake. Because of this, many potential problems have been identified and addressed. Therefore, continuity of care between the DC. facility and this facility may be fractionated, but efforts on site attempt to alleviate the problems. Additionally, this further intensifies the potential for accusations between the facilities of transferring inmates inappropriately. Reviews of off site consultations during the fall and winter of 1997 did reveal many surgical conditions that were cared for at Northeast Ohio that were most definitely present prior to their transfer from D.C. Corrections. Efforts should be made to improve the transfer of medical information, as well as some attempts to assure the integrity of the pre-transfer screen by the D.C. Department of Corrections.

3. As reported in prior audits the contract monitor, there still exist backlogs in performing laboratory tests (the actual phlebotomy), eye exams and dental visits. The facility has taken admirable steps into improving the access to the eye exams--purchasing equipment and providing on site optometry services. The dental clinic is now under the supervision of a newly hired dentist, and conversations with her assure me that the delays are being addressed. A review of the backlog did note acceptable waits for routine conditions. I discussed with her other mechanisms to address the delays in acute pain conditions, to include the possibility of screening clinics by the dental assistant (if allowed by state law) or herself. The dentist is to be commended for her efforts, which include screening dental complaints in the administrative segregation area. Laboratory tests are still delayed--as witnessed by my review of medical records, and confirmed by interviews with medical staff. The health administrator relates the problem to nursing staff turnover, and assured me that staff has been hired, and the backlog delay has now decreased to 10 working days.

The delay in performing laboratory is still unacceptable, and should be more aggressively addressed. Further monitoring of the dental and eye clinics should be done on a routine basis to ensure compliance with acceptable delays.

Additional areas of concern are as follows:

1. Chronic disease clinics--These clinics manage the continuity of care of patients with chronic illnesses (diabetes, hypertension, heart disease, asthma/emphysema, HIV, seizure disorders, HIV disease/etc.). In normal practice, these clinics are held on a routine, scheduled basis, taking care of medications, laboratory and other tests to monitor the individual disease, diet, housing/living restrictions, and exercise. Normally, patients are seen in these clinics 3-4 times yearly, with a physician visit usually occurring 1-2 times and a designated nurse completing the other visits. In a prison environment, these clinics usually mirror the organization of the clinic, and its ability to cope with the divergent and complex medical needs of the patient population.

At this facility, chronic clinics have been in place for 3-4 months, as evidenced by my medical record review. While there is a responsible agent for the clinic (a designated nurse) and the form used during the clinical interventions seems adequate, there is insufficient evidence of a system that is functioning for a long term. Further monitoring of chronic disease clinics is warranted in the near future.

2. Tuberculosis Control Program--All inmates were tested for tuberculosis on transfer from the D.C. Department of Corrections. This was admirable, and would not have been absolutely necessary had medical records been complete on arrival at the

Northeast Ohio facility. However, now, many patients are due for their annual PPD or chest radiograph in August , September and October 1998. Those tests had not been

completed during this site visit. In addition, I suggested a modification in the manner in which all immunization and TB testing was recorded in the medical record. The facility health care administrator concurred with my suggestion, and was in the process of implementation before I left the facility.

Further monitoring of the TB Control Program will be necessary in the coming months to ensure compliance with facility policy and procedure.

3. Medical Records--Professional charting in the medical record is oftentimes minimal and signatures are difficult to discern. The charts contain a problem list, but it does not always reflect chronic or long term illnesses. Medical record entries do not detail the clinical (nurse, MD, mental health, walk-in, sick call, emergency) situation in which the intervention occurred. These deficiencies were brought to the attention of the health care administrator, who concurred.

Charting and completion of the medical record is essential for assessing care rendered, and ensuring continuity between care providers. These issues should be addressed in the medical department's quality assurance program. Inservicing of all health care professionals as to the proper contents, responsibility for completion, and legibility of notations should be instituted in the near future.

4. Physician--Physician notes are brief, and do not address issues of continuity of care--i.e., follow up, education, diet, exercise. All of these issues ensure a completeness of care--making the care rendered in the prison all encompassing, and not episodic, as found in many free world emergency rooms or walk in urgent care clinics. Prison affords the unique opportunity to diagnose, treat and follow up both acute and chronic medical conditions. The physician notes at this facility, as evidenced by chart review, did not address continuity of care.

Physician education, and monitoring by the corporate office is suggested, at a minimum. I was told, prior to my departure, that the contractor's regional physician was scheduled for an on site visit the week following my visit. I discussed these issues with the unit health care administrator, who promised to discuss them with the regional physician. I suggest continued monitoring for continuity of care by on site reviews, particularly targeted toward physician charting and interventions.

5. One particular case reviewed by me was bothersome. The case was of a patient with advanced rheumatoid arthritis, who needed further evaluation and treatment--to include, probably, intensive physical therapy and specialist consultations. Without further intensive intervention, preservation of mobility and function of his hands and legs will be

in jeopardy. I referred the case to the unit health administrator, who assured me that the case would be rapidly handled.

Interviews by me with inmates reveal a generally low opinion of medical services. I am unsure of how to completely explain their perceptions. While all interventions by medical staff that I witnessed were professional and respectful, I sense that was not always the case. Indeed, most staff interviewed agreed that the start up of the facility was chaotic, disorganized, and that there has been frequent staff turnover--which seems to have stabilized in the past 5 months. Since inmate movement has been fairly low, the inmates present now more than likely were present at the start up. Perhaps, most of their frustration is from early contact with the department. I discussed with health care staff ways in which to improve patient interventions, to increase patient contact, to offer patient education, and to be more pro-active with the inmates. The inmates not only need to have good services available, but also need to feel that their concerns will be addressed in a professional, non-judgmental manner.

Chapter XI

Contract Management and Oversight

Introduction. The effectiveness of any government contract for services is directly tied to the vigor and organization of the monitoring effort by the contracting agency. This principle is especially true in the case of a large prison holding difficult inmates.

It is vital to have at least one experienced, on-site monitor in order to ensure compliance with the contract and to fix problems. This individual must possess a broad range of experience and personal stature to be recognized as a professional by prison administrators. The monitor must also have access to the agency's subject matter experts when needed, such as experts in security, health services or classification.

Managing such a large, remote contract as that with NEOCC was a new dimension for DOC, and it adapted slowly and ineffectively to its responsibilities. DOC seemed relieved when the large group of problem inmates was transferred to NEOCC, but DOC was not prepared to take the next step of providing close oversight through an experienced, on-site monitoring staff, assisted by close coordination from the headquarter's office staff.

Although there were a few sporadic visits early on by DOC senior staff to make evaluations and recommendations, it was not until the serious operational problems were raised in the class action suit in U.S. District Court that DOC took the initiative to hire a consultant firm to provide oversight. While that firm was well organized, its range of expertise was limited and it did not identify and require remedial action on certain serious operational problems.

Later, DOC's prolonged efforts to hire a full-time employee as monitor were successful when it arranged for an experienced deputy warden to be on loan from the Ohio Department of Rehabilitation and Corrections (OHDRC), starting in July, 1998. He remains in place, though confronted by a very burdensome task. DOC needs to significantly expand and better organize its contract monitoring function as it continues to broaden the number of remote contract locations to which it transfers its inmates.

The NEOCC contract was the first large scale agreement issued by DOC outside of the Washington, D.C. area. As discussed in Chapter II of this report, the contract had a seriously flawed beginning.

1. Contract Administrator. Although this contract was not the first the District had with CCA, the monitoring provisions fell very short in terms of both preparation and definition. A review of the contract indicated that a single remote Contract Administrator was to be responsible for the day to day monitoring of the contract by the District of Columbia. As a result, a DOC Deputy Director was designated as the contract administrator. That official was stationed in the District of Columbia and made only brief, sporadic visits to NEOCC.

In addition, the contract stated that the contract administrator, "shall be required to certify receipt of satisfactory services prior to authorizing payments to Contractor." Although the intent of this provision was laudable, no details were specified in the contract or by the parties about how the administrator was to determine if the services were satisfactory. Also, no formula was provided specifying the appropriate penalties, i.e., reductions in the amount of remuneration due to CCA, if any particular service was found to be unsatisfactory.

Since fines for contract deficiencies were not spelled out, the sporadic appearance of the DOC contract administrator in the early stages of this contract had only a negligible impact on the entire operation. Without input from an "outside" correctional professional objectively observing and reporting on conditions, trends, and other perceived problems, there was little possibility that corrective changes could occur. As a result, when the large scale transfer of inmates to the institution overwhelmed the classification and separation systems that were not yet fully operational, the contract administrator was not around to identify and request immediate correction of the problems.

2. Initial Sporadic Audits. From the arrival of the first inmates at NEOCC, there had been critical concerns voiced by DOC officials that inmate work programs were inadequate, CCA Youngstown staff needed more training and experience, inmates were improperly classified, and DOC needed to establish an effective audit tool to assist in the monitoring of this facility. When the initial problems erupted, the DOC Director detailed other busy DOC officials, including another Deputy Director of Corrections and the Chief of the Warrant Squad, to audit the performance of the NEOCC. This audit required two trips to the facility and took place May 28-30, 1997 and August 11-14, 1997. The second trip also involved the DOC General Counsel.

The audits found a number of serious concerns that needed to be addressed. Some of those concerns identified at that point were factors in the serious incidents that followed. Those concerns included: ..."monitoring and control of inmates throughout the facility, inclusive of inmates shakedowns," ..."focus needs to be placed on responding and addressing inmate concerns in a timely manner," and ..."work programs appear to be inadequate for a soon to be population of 2000." Although there apparently were several conversations with inmates where they expressed their concerns about short-term inmates being mixed with long-term inmates, it was believed by the auditors that the classification

system addressed those issues. Unfortunately, it did not. The auditors further recommended that DOC send a team to the facility on a monthly basis to ensure compliance with the contract.

Since there was no full time monitor at NEOCC throughout this period, and because CCA was not independently reporting information about the difficulties it was experiencing unless a direct request came from DOC, it is not surprising that neither the contract administrator nor the audit team were fully briefed about the nature and extent of the problems at NEOCC. For example, other than being present at the institution on a constant basis, there was no effective way to see through the purported status presented to visitors in order to know the extent of the assaults on staff, stabbings, breakdowns in classification and separation procedures, and general state of disorganization.

The audit and recommendation of DOC senior officials was to increase NEOCC oversight by sending not just one individual, but a team from DOC on a monthly basis to review the ongoing operations at Youngstown.

In the meantime, the Chair of the D.C. City Council Judiciary Committee regularly and publicly encouraged the DOC Director to put a full-time monitor on site at NEOCC. This sentiment was echoed by other public advocates for the inmates and the inmates' families.

As a result, on November 7,1997, DOC began to advertise internally for a full-time, on-site monitor for NEOCC. As it turned out, DOC employees did not respond to the advertisement. Presumably, they did not find the transfer to Ohio and the position offered, a DS-14, sufficiently attractive.

The regimen of occasional brief visits by DOC contract administrator continued nearly seven months, i.e., from the time that DOC inmates first arrived at the Youngstown facility, in mid-May 1997, until November 1997, resulting in only a minimal amount of monitoring of the contract.

Finally, in November of 1997, the DOC located and hired the consultant firm of Pulitzer/Bogard & Associates to monitor the Youngstown contract on a less than full-time basis. Because these contract monitors were not on site, considerable time, money and effort were consumed by their constant travel.

By the time Pulitzer/Bogard mobilized to begin a part-time monitoring effort, the facility had been activated for seven months and good recommendations made by DOC staff were effectively lost in the process and received little or no reaction from CCA, DOC senior officials, or the new contracting staff. Pulitzer/Bogard mobilized its own team but, as with the previous arrangement, the monitoring would be done on a part-time basis. Also, at the outset, the team focused primarily on issues about which they had considerable expertise,

such as medical issues, which were deficient but had a relatively minor impact on the facility as a whole. They also established a tracking system to cover both the contract discrepancies they discovered and remedial follow-up actions that occurred. In addition, the reports they compiled after adverse incidents occurred, such as the murders and escapes, were comprehensive and well done. In other areas, however, their lack of experience was apparent.

Regular searches for contraband in inmate housing units are an absolute basic requirement of sound correctional practice. Nonetheless, concern about the absence of contraband searches at NEOCC was not voiced by the consultant monitors until after two homicides occurred at the facility, almost six months after the consultants had been on-site (in Pulitzer/Bogard Report No. 98-16 dated 3-25-98). In this same document, Pulitzer/Bogard gave NEOCC credit for enhancing programming and work opportunities. Unfortunately, as discussed elsewhere in this report, Pulitzer/Bogard looked at the numbers of inmates employed or in educational training, but overlooked the minimal time that these inmates were involved in these pursuits. For example, an inmate assigned the job of passing out food trays within a housing unit pod worked only fifteen to thirty minutes per day, but the consultants counted that as a job. The quality and amount of time an inmate is involved with education or work is far more important in reducing idleness than the mere number of inmates with "jobs." Again, this spoke to the need for full-time monitoring with monitoring staff that more quickly would recognize potentially serious situations. As stated earlier, after considerable urging from several prominent individuals, a full-time monitor was sought by DOC in November 1997.

The search for a full-time monitor was moved to Ohio in March of 1998 when the job was advertised in the Youngstown newspaper. The assistance of Ohio correctional authorities also was engaged. They assisted by agreeing to allow the DOC monitor position to be filled by an intergovernmental transfer of an Ohio Correctional employee, an Ohio resident with extensive correctional experience and contract oversight knowledge.

The monitor arrived at NEOCC in July 1998, while the Pulitzer/Bogard contract was still active, and he began to establish his role and presence. He took over complete control of the contract monitoring responsibilities on October 1, 1998. Appendix II contains his most recent monitor report. During that time, inmates categorized in the medium high range or above were transferred out of NEOCC, some to other CCA private prison facilities in Tennessee, New Mexico and Arizona. To date, no regular arrangements to monitor the ongoing performance of those private prison facilities has been put in place.

Findings of Major Concern

The Review Team concurs that there is one finding of major concern in this chapter. It is:

F-18. The DOC initially took little responsibility for its role of monitoring the operations at NEOCC, until confronted with major problems in Federal Court, public opinion and political scrutiny. Although DOC has appointed a Contract Monitor, it has not yet developed an adequate oversight management function at DOC headquarters.

Major Recommendations

R-23. DOC should supplement the current full-time contract monitor at NEOCC with additional professional and clerical assistance. Assistance should also be periodically provided to the local monitor by DOC headquarters subject matter experts, such as those from the areas of security, health services and case management.

R-24. DOC should establish a contract oversight unit in its headquarters that would have as its sole responsibility the monitoring of all contract facilities holding DOC inmates. The unit would develop and administer oversight guidelines, coordinate various forms of on-site monitoring, and ensure the proper implementation of plans of action or imposition of penalties for noncompliance.

Chapter XII.

Summary of Current Status of NEOCC

Introduction. While considerable progress has been made at NEOCC in recent months, the situation is still fragile and the jury is still out on the future of this project, which is so important for CCA and DOC as well as for the Youngstown community.

Under the pressure of devastating breakdowns in some of its most basic functions and the resultant intense public scrutiny, CCA has taken significant strides to improve its institutional operations and to begin to mend its relations with the community. DOC has likewise shown a serious commitment to improve its oversight of the NEOCC contract and to carefully screen transferring inmates. There is cause for guarded optimism that these improvements will be sustained and that progress will not be seriously undercut by unpredictable future incidents.

At the same time, the operation is quite vulnerable and the elements for slippage or even ultimate failure are still present. Significant problems remain, not the least of which are the extensive inmate idleness and the very low level of experience among line and mid-level supervisory staff. For long term success to be achieved, it will take a full commitment to progress, accountability and mutual cooperation on the part of both CCA and DOC, as well as persistent public scrutiny and a touch of luck.

A. Role of Current Warden, Administration

In response to the severe problems at NEOCC, CCA has replaced most of the leadership of the facility since last March, when it named Jimmy Turner as warden.

As reported, he initially made a critical lapse in judgement when he directed or tolerated the problematic episode of the searches described in Chapter VI, which left such a negative impact on the facility. More recently under his leadership, the facility seems to be beginning to jell. The progress they have made is delineated in various portions of this report:

1. Smaller Size and Lower Security Profile of Inmate Population. One of the most hopeful elements in the mix at NEOCC is the sharply altered profile of the inmate population. Extensive efforts have been made to identify and transfer out several hundred higher security inmates. When that process is complete, almost half of the population will have been removed and replaced by lower security inmates. The overall count of the institution has been reduced by several hundred, and the smaller size of the population has undoubtedly contributed to reducing the pressure on staff and to reducing the level of violence.

2. Growing Experience Level of Staff. Although the level of experience of the supervisory staff and the line staff is critically low, at least they are gaining seasoning as time goes by. If turnover can be kept to a minimum, the level of staff experience and the attendant growth in staff's self-confidence as a group will gradually increase.

3. Goodwill of Community Officials. Although there has been a great deal of anger, criticism, and concern by many citizens and public officials in Youngstown and the State of Ohio, there seems to be a genuine interest in seeing the facility succeed. The primary reason repeatedly cited is the same one which attracted the community originally: economic development and jobs in a hard hit area. While remaining skeptical and cautious, most leaders have expressed a strong willingness to work with CCA and the District of Columbia to correct past mistakes and to help the project succeed.

1. Progress not Deeply Rooted. Although several areas of progress are evident, most of these improvements have only begun in the past few months and are not deeply rooted or well entrenched. Sustaining this pattern of progress over the long haul will not be easy or guaranteed and will require a commitment by CCA to put in place systems of self-assessment and problem resolution.

Of particular concern and challenge is the area of security procedures. Until recently, a number of bad practices and habits were in place, and it is not difficult to envision the institution slipping back to such a pattern. The common human tendency to become complacent, to act in a hurry and cut corners, or to take short-cuts with daily procedures can quickly lead to severe problems in security operations. Close over-site and audits/assessments of this area are critical.

In a secure correctional environment such as NEOCC with inmates serving substantial sentences, other incidents and problems will likely occur to challenge the progress. How such events are handled will be a major factor in the long-term success of NEOCC. The longer the facility can go without any significant problems, the better its chance of success.

2. Persistent Inmate Idleness. In spite of other improvements to the operations, there remains pervasive idleness among the inmate population. On most days, the majority of inmates never leave the confines of their small living units. There are very few jobs off the units and those inmates in educational and training programs typically spend only three hours twice per week in them. All of this is bad practice, undesirable, and in violation of the contract with the District.

The longer this pattern of idleness persists, the greater the chances for continuing, even serious problems.

3. Staff Issues. Most staff and supervisors, while enthusiastic and committed, are still unseasoned and in many ways not yet a match for the prison-wise inmate population. Only time will gradually change that dimension. In the meantime, an almost inordinate responsibility rests on the shoulders of the few top staff with the background needed in this environment.

Related to that inexperience and to mistakes made in the first year of operation, the relations and communications of staff with inmates are simply not healthy and will only improve with sustained effort by the leadership of the facility.

4. Current Turnover in Inmate Population. During the current process of removing over 600 higher security inmates and replacing them with other true medium security cases, the staff will again face the task of integrating large numbers of new inmates into the population. Certainly, neither CCA nor DOC will want to repeat the rapid pace of the initial influx. The gradual and deliberate manner in which this turnover in population is handled will be critical to continued improvement in the operations.

Findings and Recommendations

Findings of Major Concern

The Review Team concurs that there is one finding of major concern in this chapter. It is:

F-19. There has been significant, though fragile, improvement at NEOCC in the past several months. In particular, there has been a marked reduction in reported violence and disruption, with most of the more troublesome inmates having recently been removed. The facility appears to be more organized and is working on solving many of its previous problems. The situation remains vulnerable and significant problems persist. Long-term success can be achieved only if there is a strong commitment to improvement and accountability by CCA and DOC, along with close public scrutiny in the District and Ohio.

1. The high-medium inmates, as classified using the NCCD model are either gone from NEOCC, or in the process of transferring out.