IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF iriE VIRGIN ISLANDS' D'*1*1'

UNITED STATES OF AMERICA,

)

Plaintiff,

)

v.

)

THE TERRITORY OF THE VIRGIN ISLANDS: )

JUAN LUIS, Governor, Virgin

)

Islands; BUREAU OF CORRECTIONS:

)

EDWIN POTTER, Director, ISIDORE BELL, )

Warden, Golden Grove Adult Correctional )

Facility;

)

Defendants.

)

COMPLAINT

,- - o ^

The UNITED STATES OF AMERICA, by and through.~l£&—» ^

Attorney General, Edwin Meese III, brings this act iori""^bursgan

to the Civil Rights of Institutionalized Persons Act of 1980,

42 U.S.C. §1997, to enjoin the named defendants from depriving

persons imprisoned at the Golden Grove Adult Correctional

Facility ("Golden Grove") of rights, privileges or immunities

secured or protected by the United States Constitution.

Attached hereto, and incorporated herein by reference, is the

Certificate of the Attorney General required by 42 U.S.C.

§1997b. In support of its Complaint in this action, the

United States alleges the following:

JURISDICTION, STANDING, AND VENUE

1. This Court has jurisdiction over this action under

28 U.S.C. §1345.

i mum

US'v' Vir9'n lslands

PC-VI-002-001

I ""I Illl HI!

2. The United States has standing to initiate this action pursuant to 42 U.S.C. §1997a.
3. Venue in the District of the Virgin Islands is proper pursuant to 28 U.S.C. §1391. The claims set forth in this Complaint all arose in said District/ and each of the named Defendants resides in said District.
4. Golden Grove is an "institution" within the meaning of 42 U.S.C. §1997(1).
PARTIES 5. Defendant TERRITORY OF THE VIRGIN ISLANDS (hereinafter "Virgin Islands") is an unincorporated territory of the United States and is a "state" within the meaning of 42 U.S.C. §1997. The Virgin Islands owns and operates Golden Grove which is an adult correctional facility. 6. Defendant JUAN LUIS is the Governor of the Virgin Islands, and, in this capacity, heads the executive branch of the territorial government. He appoints the Director of the Bureau of Corrections. 7. Defendant BUREAU OF CORRECTIONS is responsible for the administration and operation of Golden Grove. 8. Defendant EDWIN POTTER is the Director of the Bureau of Corrections, and, in this capacity, has responsibility for the operation of Golden Grove. He appoints and supervises the Warden of Golden Grove. 9. Defendant ISIDORE BELL is the Warden of Golden Grove and, in this capacity, is the chief administrator of
- 2-

Golden Grove and has responsibility for supervising the operations of Golden Grove.
10. The individual Defendants identified in paragraphs 6, 8, and 9 above are officers of the executive branch of the Virgin Islands and are sued in their official capacities.
FACTUAL ALLEGATIONS 11. Defendants are legally responsible, in whole or in part, for the operation of and the conditions at Golden Grove and the safety of persons imprisoned at that institution. 12. At all relevant times, the Defendants or their predecessors in office have acted or failed to act, as alleged herein, under color of state law. 13. Defendants are failing to provide persons imprisoned at Golden Grove with minimally adequate-'.medical care for their serious medical needs. 14. Defendants are failing to protect persons imprisoned at Golden Grove from unreasonable' fire safety frisks to their lives and safety. 15. Defendants are failing to provide such security and staff supervision to protect persons imprisoned at Golden Grove from wanton and reckless physical violence by other inmates or staff. 16. Defendants are failing to provide minimally adequate sanitation to protect inmates from unreasonable
risks to their physical health.
- 3-

17. The acts and omissions of Defendants alleged in each of paragraphs 11 through 16 constitute patterns or practices of resistance to the full enjoyment of rights, privileges and immunities secured or protected by the Constitution of the United States and deprives persons confined at Golden Grove of such rights,privileges and immunities.
"PRAYER FOR RELIEF 18. The Attorney General is not authorized to se3k any remedy at law and is authorized under 42 LJ.S.C. §1997 to seek only equitable relief. 19. Unless restrained by this Court, Defendants will continue to engage in the conduct and practices set forth in each of paragraphs 11 through 16 above that deprive persons imprisoned at Golden Grove of rights, privileges, or immunities secured or protected by the Constitution of the United States, and cause irreparable harm. WHEREFORE, the United States prays that this Court enter an order permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions and practices at Golden Grove set forth in each of paragraphs 11 through 16 above. The United States further prays that this Court grant such
- 4-

other and further equitable relief as it may deem just and proper.
Respectfully submitted,

_ )ate: /77/?d
IS W. DIEHM Jfiited States Attorney District of the Virgin
Islands

: 23 CU
EDWIN MEESE III Attorney General
of the^Um-tad States

Assistant Attorney General Civil Rights Division

/I

Date: >l /?1

ARTHUR E. PEAB0PY7 JR.

Chief

^"

Special Litigation Section

V. COLLEEN MILLER Attorney Special Litigation Section Civil Rights Division U.S. Department of Justice
Washington, D.C. 20530

nf tl|? Attorney
,!!- (0.2D530
CERTIFICATE OF THE ATTORNEY GENERAL I, Edwin Meese III, Attorney General of the United States, certify that with regard to the foregoing Complaint, I have complied with all subsections of 42 U.S.C. §1997b(a)(1). I certify as well that I have complied with all subsections of 42 U.S.C. §1997b(a)(2). I further certify pursuant to 42 U.S.C. §1997b(a)(3) my belief that this action by the United States, to be of general public importance and will materially further the vindication of rights, privileges, or immunities secured or protected by the Constitution of the United States. I finally certify that all prerequisites to the initiation of suit under 42 U.S.C. §1997 have been met. Pursuant to 42 U.S.C. §1997a(c), I have personally signed the foregoing Complaint. Pursuant to 42 U.S.C. §1997b(b), I am personally signing this Certificate. Signed this 23rd day of October > 1986, at Washington, D.C.
EDWIN MEESE III Attorney General of
the United States

 
 U.S. v. Virgin Islands
'I-
PC-VI-002-003 IN THE UNITED STATES DISTRICT COURT OF THE DISTRICT OF THE VIRGIN ISLANDS: DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

Plaintiff,

CIVIL ACTION: 86-265

v.
THE VIRGIN ISLANDS: JUAN LUIS, Governor, EDWIN POTTER, Director, Bureau of Corrections; ISIDORE BELL, Warden, Golden Grove Adult Correctional Facility,
Defendants.

oo -•'"> — O
' —(m
o o
~ m

AMENDED IMPLEMENTATION PLAN

,

i
I

The collective Defendants have had the benefit of Plaintiff's views and !

objections to the Implementation Plan originally filed on or about February

j

2, 1987. From Plaintiff's Objections to Implementation Plan, defendants gleaned;

Plaintiff's general objections to be the lack of detailed explanations of the

institutional procedures to be employed, the failure to establish (realistic)

deadlines and the unwarranted conclusion that the Plan includes provisions that

may increase the risk of harm to persons confined to the prison. Plaintiff has

also provided a series of specific objections that again substantially relate

to procedure while the immediate priority to Defendants was substance, the

prompt correction of identifiable problems.

It is not now submitted that these considerations are mutually exclusive

and the Consent Decree does indeed require a series of Plans to be fully im-

plemented by June of 1988. The defendants, however, have marshalled their ef-

forts toward the elimination of those things that diminish the prospects of

Constitutional conditions of confinement and the acquisition of items that pro-

mote its existance. To the extent that Plaintiff wishes to prioritize plans

and procedures that will facilitate the maintenance of a Constitutional system

once Defendants are reviewed and certified to have one, Defendants welcome the

expertise developed by Plaintiff in this area and would greatly appreciate

Plaintiff's recommendations and submissions of plans from other penal institu-

tions previously approved to determine whether those procedures could be inte-

grated into our system; this would expedite the objectives of all parties by

-2-

avoiding an extended "plan-objection" process. The Golden Grove Adult Correctional Facility operates on a series of daily ;
procedures that will be reduced to writing and submitted as plans to address the varied requirements delineated in Section III of the Consent Decree. These routines evolved from years of experience and practice; they will be more formally implemented and submitted to Plaintiff on or before November 1, 1987 in the plan format.

THE AMENDED IMPLEMENTATION PLAN
I. Purposes and Objectives:
Defendants believe they hcive complied or substantially complied with the
categorical goals listed under this section in the Consent Decree.
1. All obvious fire hazards have been identified and eliminated. Fire safety items have been obtained or ordered (Exhibit "B") ; an institutional fire team is now in place and fire service training is part of the curriculum for correctional officers (Exhibit " C " ) ;

2. The existing staff at the Golden Grove Adult Correctional Facility is

adequate in both number and training to provide inmates with protection from i

wanton and reckless physical violence from other inmates or staff, but Defendant*

continue to improve in both respects. The corrections budget submitted for the

approaching fiscal year (October 1st) included additional staff positions. The j

correctional officers are also required to regularly participate in training '

exercises that enhance their ability to provide the requirements of this sub- !

section (Exhibits "Di, D2").

'

3. The facility is cleaned six days a week by inmate crews under the

;

supervision of security officers. Inspections for purposes of sanitation and

maintenance are conducted at least four times a day and logged for corrections

and clean-up a minimum of twice a day with review at every shift change. Addi- j

tional equipment has been ordered and/or installed (Exhibits "E^, E 2 " ) .

j

i

4. Medical care is provided each day to all inmates requiring or re-

j

questing such assistance. A nurse is on duty Monday through Friday from 9:00AM

to 8:30 PM and weekends from 9:00 AM to 1:00 PM and 4:00 PM to 8:30 PM. A

doctor is on duty from 4:30 PM to 6:30PM, Monday through Friday and available

on the weekends. The public address system announces when the nurse and doctor

arrive and the general inmate population is free to go to them at any time.

Those inmates on restriction must request permission through the dormitory of-

ficer.

Mentally ill patients are initially screed by a professional counselor and then referred to a psychiatrist; extreme cases are further referred to the

f

-3-

Fredericksted Clinic which may result in commitment. The counselor is on duty Monday through Friday from 8:00 AM to 5:00 PM and the psychiatrist is available seven days a week.

II Conditions Requiring Immediate Correction:

As the Court may ascertain from the Compliance Report dated July 31, 1987,
the Conditions Requiring Immediate Correction outlined in Section II of the
Consent Decree have been eliminated already:
(1) All fire hazards have been removed from the inmate cells* and each cell is reviewed at each shift change to insure that no new hazard is introduced;

(2) At least one guard is on duty at all times and present in each inmate living unit; and

(3) All living units do have an adequate means to safely evacuate inmates

in case of emergency as evidenced by the attached Emergency Procedures Manual

(Exhibit " A " ) .

!

i

III Plans:

;

Defendants reiterate their request for Plaintiff's expertise and assistance!

in devising acceptable procedures for each subsection.

j

I

1. Defendants have an emergency evacuation plan exhibited herein at

|

A"; Defendants' institutional fire team will obtain and devise procedures for j

subsections l(b)(c) and (d) on or before October 15, 1987.

>

j

i

2. Defendants' Compliance Team** will draft procedures and identify equip-;

ment to be used to provide adequate security within Golden Grove on or before i

November 15, 1987.

[

3. Defendants' counsel, with the assistance of designated individuals from the Department of Health of the Government of the Virgin Islands, will develope procedures to provide adequate sanitary conditions in the food service area on or before November 1, 1987.

4. Defendants' Compliance Team will draft procedures to provide the medical care described in subsections 4(a) and (b) on or before November 15, 1987.

5. Defendant Edwin Potter will provide a written Memorandum of the staffing strategies to implement the plans envisioned above on or before December 1, 1987 and with due regard to budget contingencies.

• Counsel has information that all ninety fire retardant mattresses have beep received, but can only confirm that thirty are in place as of this writing.
** The Compliance Team is to include representatives from the Departments of Justice, Health and Fire Services together with a Corrections Supervisor and a Corrections Guard. This Team has never met to the best of Counsel's knowledge and belief nor have the individual members been designated.

-4-

IV Plaintiff's Specific Objections:
The majority of Plaintiff's objections to the Implementation Plan concern the lack of clearly defined procedures and concommitant deadlines for implementation, but two require directly responsive clarification.
The Defendants do not propose to remove guards from the living areas. Rather the proposal is to structurally join two dormitories, place two guards in that elevated structure, and encourage the guards to make rounds together. It is extremely difficult for one guard to break up a disturbance and call for help.
The Virgin Islands has no intention to use inmates in supervisory roles. V Governmental Considerations;
Departmental requisitions for this fiscal year concluded on September 18, 1987 and no further funds may be spent unless previously encumbered. Our new fiscal year begins October 1, 1987, but no budget has been submitted to and approved by the Legislature.
The timetable proposed should not be effected given its planning and policy objectives, but implementation by the Executive branch of the Virgin Islands Government may at some point hinge on whether the Legislature makes appropriate funds available.

CONCLUSION Defendants have demonstrated a willingness to comply with any and all measures that will insure adequate conditions of confinement at the Golden Grove Adult Correction Facility. Defendants welcome Plaintiff's proposal for a meeting in a good faith effort to resolve our differences.
Respectfully submitted,
GODFREY R. de CASTRO Attorney General

Dated:

TREST Principal Asst. Attorney General Department of Justice Attorneys for Defendants 46 Norre Gade St. Thomas, VI 00801 809/774-5666

c
-5-

CERTIFICATE OF SERVICE

IT IS HEREBY CERTIFIED that exact copies of the foregoing Amended Implementation Plan were served, as follows:

By Express Mail:

William Bradford Reynolds, Esq. Civil Rights Division U. S. Department of Justice P. 0. Box 37076 Washington, D.C. 20066

V. Colleen Miller, Esq. Civil Rights Division U. S. Department of Justice P. 0. Box 37076 Washington, D.C. 20066

By Regular Mail:

Edwin Potter, Director Bureau of Corrections P.O. Box 1100 Kingshill, St. Croix U.S. Virgin Islands 00850

Paul Samuel, Acting Warden Golden Grove Adult Correctional Facility P. 0. Box 1100 Kingshill, St. Croix U. S. Virgin Islands 00850

Postage prepaid, on this

•day of September, 1987.

 
 f

U.S. v. Virgin Islands
iiiiiiiiini

PC-VI-002-004

IN THE DISTRICT COURT OP THE VIRGIN ISLANDS

DIVISION OF S T . CROIX

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

v.

)

)

GOVT OF THE VIRGIN ISLANDS

)

et al

)

Defendants )

CIVIL NO. 1986/265

(\

MEMORANDUM OF COMPLIANCE CONFERENCE & ORDER

(O ^

THIS MATTER came on for a compliance conference on

-« o November 10, 19 87. A telephonic hearing was conducted.

J5 Gayle D. Fidler of the U.S. Dept. of Justice appeared for
•IJ
*-> the plaintiff and Treston E. Moore of the Virgin Islands
o
r Dept. of Justice appeared for the defendant. As a result of

c the conference, the following determinations were made.

1. A deadline of December 15, 1987 was set for

defendant, Government of the Virgin Islands, to submit

reports of the implementation by the compliance team of the

procedure required to satisfy the Consent Order.

2. The defendants will immediately submit any data

that they have available without waiting for the December

15, 1987 cutoff date.

3. On or before January 4, 1988, plaintiff will f i l e a

full response to a l l plans and procedures submitted,

excepting emergency evacuation plans.

U.S. V. V . I . "%•
Civil No. 86/*.o5 Page 2
4. On January 8, 1988, a conference will be held by telephone in an effort to resolve any outstanding issues regarding planning requirements.
5. It i s imperative that the above scheduling be complied with so t h a t the p l a i n t i f f ' s inspection team can come to St. Croix during the month of February to complete t h e i r inspection on the progress of the project.
DONE AND SO ORDERED November 12, 1987. ITER:

ATTEST OR INN ARN Clerk of/Court

JOH

L EN AH AN

U.S

ISTRATE

Deputy7 Clerk

Mailed on November 1 2 , 1987 t o i

V. Colleen Miller
Gayle D. F i d l e r U.S. Dept. of J u s t i c e Civil Rights Division Special Litigation Section P.O. Box 37076 Washington, DC 20066

Treston E. Moore Asst Attorney General V.I. Dept. of Justice 46 Nor re Gade St. Thomas, VI 00802

 
 U.S. v. Virgin Islands

m

PC-VI-002-005

o

IN THE UNITED STATES DISTRICT COURT «

FOR

THE DISTRICT OF THE VIRGIN DIVISION OF ST. CROIX

ISLANDSsfmTl

rn
• —\ m

•"" .0 ^

C3

" —* 0

~ 0 ~n

%.

n-t^orn

UNITED STATES OF AMERICA, )

Plaintiff,

)

)

) Civil Action No. 86-265

V.

)

)

THE VIRGIN ISLANDS, et al., )

Defendants.

~

)

MEMORANDUM IN SUPPORT OF MOTION FOR ORDER TO SHOW CAUSE

Plaintiff, the United States of America, submits this memorandum in support of its motion for order to show cause. The motion seeks an order of the Court to enforce compliance with the Courts "Memorandum of Compliance Conference and Order" entered November 12, 1987. The defendants, the Government of the Virgin Islands and certain government officials ("Virgin Islands"), have failed and refused to comply with this Court's lawful, unambiguous order.
STATEMENT OF FACTS This action was commenced pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. 1997, and concerns conditions at the Golden Grove Adult Correctional Facility ("Golden Grove"). On December 1, 1986, the District Court entered a Consent Decree which requires the Virgin Islands to maintain certain conditions at Golden Grove and to submit to the Court and the United States plans to ensure compliance with

r
- 2-
the Consent Decree. Under the terms of a joint stipulation of the parties, the Virgin Islcinds were to provide plans by February 2, 1987.
The Virgin Islands initially submitted plans which lacked sufficient specificity. In July, 1987, they promised to submit appropriate plans by August 31, 1987. This is reflected in an Order of the Court entered July 31, 1987. When the Virgin Islands failed to provide detailed plans by the August 31, 1987 deadline, the United States agreed to allow additional time for submission of the plans. The Court entered an Order on September 9, 1987, directing the Virgin Islands to submit plans no later than September 18, 1987. The amended plan, filed September 22, 1987, was again insufficient to comply with the Consent Decree.
On October 6, 1987, the Court entered an Order establishing a schedule of deadlines which would have resulted in all plans being submitted by December 1, 1987. By November, 1987, the Virgin Islands had again failed to submit plans and information in accordance with the court ordered schedule. In a telephone conference held November 10, 1987 counsel for the defendants represented that a number of materials were ready to be submitted and that all plans would be submitted by December 15, 1987. The Court entered an Order on November 12, 1987, setting a December 15, 1987 deadline for the submission of all plans and requiring the Virgin Islands to immediately submit the materials already available. The Virgin Islands have failed to submit any materials or any plans by the December 15, 1987 deadline.

c

- 3-

ARGUMENT

Disobedience of a Court order unequivocally merits

punishment save in instances in which compliance would

necessarily result in an irrevocable and permanent surrender of a

constitutional right. Kleiner v. First National Bank of Atlantar 751 F.2d 1193, 1208 (11th Cir. 1985). A court has inherent power

to enforce compliance with its lawful orders through civil

contempt. Shilletani v. United States. 384 U.S. 364, 370 (1966);

United States v. United Mine Workers. 330 U.S. 258 (1947).

Indeed, this power has been held to be essential to the

judiciary. Young v. United States ex rel. Vuitton et File S.A..

U.S.

, 107 S. Ct. 2124, 2131 (1987).

Where it appears, upon clear and convincing proof, that a

party has not complied with a court's order, the court may hold

that party in contempt of court. N.A. Sales Co.. Inc. v. Chapman

Industries Corp.. 736 F.2d 854, 857 (2d Cir. 1984). A party may

be held in civil contempt for failure to comply with an order of

the court if the order being enforced is clear and unambiguous,

the proof of noncompliance is clear and convincing, and the party

has not been reasonably diligent in attempting to accomplish what

was ordered. EEOC v. Local 638...Local 28 of Sheet Metal

Workers. 753 F.2d 1172, 1178 (2d Cir. 1985).

A party who disobeys a specific and definite court order may

properly be adjudged in contempt regardless of his intent when he

disobeyed the order. In re Crystal Gambling Hall. Inc.. 817 F.2d

r
- 41361, 1365 (9th Cir. 1987). Because intent is not an element of civil contempt, contempt may be established even though the failure to comply is unintentional. McComb v. Jacksonville Paper Co.. 336 U.S. 187, 191 (1949); General Signal Corp. v. Donallco. Inc.. 787 F.2d 1376, 1379 (9th Cir. 1986).
The failure of the Virgin Island to comply with the Court's order of November 12, 1987 meets the criteria necessary to hold a party in contempt. The order clearly and unambiguously required the defendants to submit plans by a specified date. Counsel for the defendants was given notice of that date, December 15, 1987, in the conference held November 10, 1987, as well as through the order entered November 12, 1987. The failure to file the required plans with the Court by December 15, 1987, is clear and convincing proof of the Virgin Islands' noncompliance with the Court•s order.
The pattern of noncompliance with the Consent Decree and the Virgin Islands' continual failure to meet increasingly lenient deadlines is proof of a lack of reasonable diligence in attempting to accomplish what the court has ordered. The mere fact that they may have taken steps toward achieving compliance with the Court's order is not a defense to a charge of contempt. Sizzler Family Steak Houses v. Western Sizzler Steak House. Inc.. 793 F.2d 1529, 1534 n.5, 1537, rehearing denied. 797 F.2d 982 (11th Cir. 1986). Although perfect compliance may not be required, the defendant's have failed or refused to exercise reasonable diligence in preparing and submitting plans to ensure

- 5that the inmates at Golden Grove are provided adequate living conditions. The Virgin Islands have neglected to marshal their own resources, assert their authority, and demand the results needed from subordinate persons in order to meet the Court's required deadline. They have allowed deadlines to pass without advance announcements or volunteered explanations, and have displayed an evident sense of nonurgency regarding the need to make plans and to improve conditions at Golden Grove. Accordingly, a finding of contempt is justified and appropriate.
CONCLUSION For the reasons set forth herein the United States respectfully prays that this Court enter an order directing the Virgin Islands to show cause why it should not be held in contempt.
Respectfully submitted,

Terry M. Halpern United States Attorney District of Virgin Islands

Wm. Bradford Reynolds Assistant Attorney General Civil Rights Division

V. colleen Miller Gayle D. Fidler Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section P.O. Box 37076 Washington, D.C. 20066

c

CERTIFICATE OF SERVICE
I certify that the foregoing Motion for Order to Show Cause
and the accompanying Memorandum in Support of the motion were
mailed first class, to the following counsel of record this
day of December, 1987:
Tristan Moore Virgin Islands Department of Justice #46 Norre Gade St. Thomas , VI 00801

/

'

•

'

V. Colleen Miller Gayle Fidler Attorneys U.S. Department of Justice Civil Rights Division P.O. Box 37076 Washington, D.C. 20066

 
 U.S. v. Virgin Islands

PC-V -002-006 IN THE DISTRICT COURT OF THE VIRGIN ISLANDS
DIVISION OF ST. CROIX

UNITED STATES OP AMERICA, ) Plaintiff )

v.

)

THE VIRGIN ISLANDS, et al., ) Defendants )

=° CO — o
o
CIVIL ACTION N^rj 86-2§£ n —

MOTION FOR CONTEMPT

Pursuant to this Court's order of March 2, 1988, the

defendants were directed to submit plans for compliance with

the consent decree on or before March 16, 1988. Defendants

have failed to comply with this order. Accordingly,

pursuant to the March 2, 1988 order, the United States

requests that the defendants be held in cotempt of court,

that the proceedings be reinstituted at an early date

certain, and that the Court take any other appropriate

action at this time.

Dated: March 18, 1988.

Respectfully submitted,

Wm. Bradford Reynolds Assistant Attorney General Civil Rights Division

TERRY M. HALPERN UNITED States ATTORNEY
By:

rim\u. Oliver, Jr. Gayle Dy Fiddler V. Ool^een Miller Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section P.O. Box 37076 Washington, D.C. 20066

r
CERTIFICATE OF SERVICE
I CERTIFY that the foregoing Motion For Contempt was mailed by regular mail, to the following counsel of record this 18th day of March, 1988 to :
Treston Moore, Esq. Virgin Islands Department of Justice 46 Norre Gade St. Thomas, Virgin Islands 00801
U. Oliver>J Jr. Colleen Miller le D. Fidler Attorneys U.S, Department of Justice Civil Rights Division Special Litigation Section Washington, D.C. 20530

 
 U.S. v. Virgin Islands

/"'"

II II II II I 11 I II II II I I II II I

PC-VI-002-007
IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF THE VIRGIN ISLANDS: DIVISION OF ST. CROIX

UNITED STATES OF AMERICA

:

Plaintiff,

:

v.
THE VIRGIN ISLANDS, ET AL. Defendants.

: CIVIL NO. 86-265
P a

: :

3? 5 3
* 8

OPPOSITION TO PLAINTIFF'S MOTION FOR

&

COMES

:
NOW Defendants

in Opposition to Plainr~t^rff^ Motion

for Contempt. In support of this Opposition Defendants

incorporate, by reference, the matter contemplated in the Second

Amended Implementation Plan and Defendants' Motion for

Enlargement of Time Within Which to File.

Respectfully submitted,

GODFREY R. de CASTRO Attorney^eneral

a Dated:

TRES1: Principal Vfistfl/Atty. G e n " V.I. Department of Justice 46 Norre Gade
St. Thomas, VI 00801

CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true copy of the foregoing Opposition to Plaintiff's Motion for Contempt was mailed, postage prepaid, to V. Colleen Miller, Esq., Civil Rights Division, U.S. Department of Justice, P.O. Box 37076, Washington, D.C. 20066, this flgfO day of TAjCUlQj^ , 1988.

GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES
o
DEPARTMENT OF JUSTICE
Ho'fGxJtHo 46 O»rlott» Am»ii». Si Thom«i. V.I. 00602
March 21, 1988

In rvphr plim i*w I FM«No

Gayle D. Fidler, Esq. Civil Rights Division U. S. Department of Justice Special Litigation Section P. 0. Box 37076 Washington, D.C. 20066

Re:

Certificates of Service

Dear Ms. Fidler:

Please be advised that the Second Amended Implementation Plan* which I "mailed" Thursday, March 17th, and the Motion to Permit Late Filing which I "mailed" Friday, March 18th were discovered with all other office mail for both days in our mail bin on Saturday, March 19th.

Although the delay seems to have been caused by the lack of petty cash and a broken postage meter, I express mailed your Plan out-of-pocket and sent your copies of my Motion by surface mail; I collected the Court and Chamber , copies and took a seaplane to St. Croix Saturday to drop them at the Clerk's office, but found no weekend mail slot or box available. Those packets were left with Assistant Attorney General Mitchell for morning hand delivery on this date.

Because I signed the Certificate of Service on both documents, something no attorney in my division is to do from this date until new mailing procedures are implemented, I owe you and the Court this explanation and assume full responsibility for any consequences.

Sin

fRESTON E./MOORE Principal Assistant Attorney General

Gayle D. Fidler, Esq. Civil Rights Division U. S. Department of Justice

CC:
:
...-.•

Hon. John E. Lanahan Attorney
Acting Managing n.v.^^i.^j,

-

•.••*••

: • ' •••*••• ''::;> \ ? - : r t

* Please correct "David v .'?•': Potter;:' "' F". 2 d ^ " {3d 0 1 ^ 2 / 8 8 ) ' " on '*^%' page 11, to read Frett v. GovernmenT of~The Virgin Islands^ -f '"•
F.2d , No. 86-3604 ( 3d, Cir. Feb. 17, 1988)^ .->, ../>;- '^-; ;. .' r

;W*

••

••••*/',*

...

 
 U.S. v. Virgin Islands

""

~ **- « • » • w w w * •••• • • • • • • Hm|| • • ! • • ! ! • !

PC-VI-002-008

IN THE DISTRICT COURT OF THE VIRGIN ISLANDS

DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

Plai nti ff , )

v.

) CIVIL NO. 8 6 - 2 6 5

)

FILED TtJ*?/T)AY OH

10

THE VIRGIN I S L A N D S , et al . ,

)

) Defendants. )

ORDER
For administrative convenience and in order t o provide more prompt payment ofthe experts who drafted the Flan of Compliance in accordance with this Court's Order ofOctober 7 , 1938, it is hereby ORDERED THAT:
1 . The United States snail pay the experts who prepared the Plan ofCompliance inaccordance with the bills submitted on ilarcn 2U , 1 9 8 4 : $ 3 2 4 7 . 0 0 t o >ir. C h a r l e s B r a s l o w and $4733 .76 t o M r . John Dahn.
2. The Order of this court ddted May 2 2 , 1989 is amended to state that the Viryin Islands government shall promptly r e i m b u r s e t h e U n i t e d S t a t e s f o r p a y m e n t of" t h e e x p e r t s upon submission ofastatement showing payment of the experts t o counsel for the Virgin Islands.
3. This Order does not constitute adecision on the United States' motion for contempt for failure to pay these experts nor does it constitute afinding that the United States is liable T o r t h e p a y m e n t o f t h e e x p e r t s .

DATED t h i s

day of November, 1 9 8 9 .
ENTEk :

ATTEST: URINN F. ARNOLD CLERK
Deputy Cleric//''

U.S.

TRICT

 
 IN THEUNITED STATES DISTRICT COURTED

FOR THE DISTRICT OF THEVIRGIN ISLANpS-]

DIVISION OF ST. CROIX

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UNITED STATES OF AMERICA, Plaintiff,

) )

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prj

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) Civil Action No. 86-265

)

)

THE VIRGIN ISLANDS, et al., )

Defendants.

'_

)

MOTION FOR ORDER TO SHOW CAUSE

Plaintiff, theUnited States of America, moves this Court to order defendants to show cause why thedefendants should not be held in contempt of this Court's order of November 12, 1987.
The grounds for this motion are that the defendants have failed to submit plans and data as required by sections one and two of the order, wherein the defendants were directed to immediately submit data already available to them and to submit plans for compliance with theConsent Decree by December 15, 1987. TheUnited States has received no such materials and none have been filed with theOffice of theClerk for theCourt. Where a party fails to comply with a lawful order of the court, a finding of contempt is justified.
WHEREFORE, theUnited States moves theCourt to issue to the defendants an order to show cause why they should notbe held in contempt of court for failing and refusing to comply with the Order of November 12, 1987.
U.S. v.Virgin Islands

PC-VI-002-016

J "

'!"ll'l " ""

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r

The United States moves the Court to grant the following relief, should it find the defendants in contempt of the order of November 12, 1987:
1. That the Court order the defendants to comply with the order of November 12, 1987;
2. That the Court fine, the defendants each day until the defendants comply with the terms of the order;
3. That the Court order the defendants to pay the costs that the United States incurs in this action;
4. That the United States be granted a reasonable amount of time after receipt of the plans to respond to them; and
5. That the Court order such other relief as it deems just and proper.
The United States refers the Court to the attached memorandum in support of this motion and incorporates it herein by reference.
Respectfully submitted,

United States Attorney District of Virgin Islands

Wm. Bradford Reynolds Assistant Attorney General Civil Rights Division
2>.
V. Cdlleen Miller Gayle D. Fidler Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section P.O. Box 37076 Washington, D.C. 20066

 
 IN THE DISTRICT COURT OF THE VIRGIN ISLANDS

DIVISION OF SAINT CROIX

UNITED STATES OF AMERICA,

)

Plaintiff,
vs. THE VIRGIN ISLANDS, et al,
Defendants.

)
) CIVIL NO. 1986/265 •- m

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)
J

ORDER

eenn

This cause coming before the Court on September 28, 1988,

and upon the oral motion of the United States to extend the

implementation date of the Consent Decree, and for good cause

shown, it is

ORDERED: That Section V, paragraph 1, of the Consent Decree

entered on December 1, 1986, is amended to extend the

implementation date of the decree from June 1, 1988, to two years

following the date this Court approves the firal plan to

implement the provisions of the Consent Decree.

DATED:

U.S. District Judge

U.S. v. Virgin Islands
PC-VI-002-018

 
 IN THE DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

Plaintiff )

v.

) CIVIL NO. 86-265

GOVERNMENT OF THE VIRGIN ISLANDS )

Defendant )

:

)

52
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ORDER

MS ^

THIS MATTER is before the Court on Motion of the United

States of America for Extension of Time to File its Response

to Defendant's Second Amended Implementation Plan. The

premises considered now therefore it is

ORDERED;

THAT the Motion of the United States of America For

Extension of Time to File Response to Defendant's Second

Amended Implementation Plan be and the same hereby is

GRANTED; and

THAT the time in which the United States has to file

its Response to Defendant's Second Amended Implementation

U.S. v. Virgin Islands PC-VI-002-019

Plan be extended until the close of business, Friday, May 27, 1988. DATED: May %S , 1988.
ENTER:

Orinn Arnold, ,£ler Deputy Clerk

DAVID V. O'BRIEN, Chief Judge

-mn

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 1 of 21

IN THE DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

PLAINTIFF,

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, et a!.; )

)

)

DEFENDANTS.

)

)

Civil No. _ _ __

SETTLEMENT AGREEMENT

I. PARTIES

This Settlement Agreement ("Agreement") is entered and between the United States of America ("United States"), acting through the United States Department of Justice, and the Territory of the Virgin Islands, et a!. ("Defendants").

II. INTRODUCTION

1. The purpose of this Agreement is to remedy the ongoing constitutional violations identified subsequent to the July 28,2011 filing of Defendants' Motion to Terminate pursuant to the Prison Litigation Reform Act, 18 U.S.C. § 3626(b) [Dkt. 565]. Through the provisions of this Agreement, the parties seek to ensure that the conditions at the Golden Grove Adult Correctional and Detention Facility ("Golden Grove") respect the rights of prisoners confined there. By ensuring that the conditions in Golden Grove are constitutional, Defendants also will provide for the safety of staff and promote public safety in the community.

2. Defendants consent to the entry of findings that the conditions at Golden Grove necessitate the remedial measures contained in this Agreement. The parties recognize that the conditions at Golden Grove and the treatment of prisoners confined tl1erein have an impact on whether prisoners will be successfully re-integrated on release, whether released prisoners will re-otTend, and public confidence in the criminal justice system.

3. The parties stipulate that this Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a). The parties further stipulate and agree and the Court finds that the prospective relief in this Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights agreed to by the parties, is the least intrusive means necessary to correct these violations, and will not have an adverse impact on

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 2 of 21
public safety or the operation of a criminal justice system. Accordingly, the parties agree and represent that the Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a).
III. DEFINITIONS
1. "DOJ" shall refer to the United States Department of Justice, which represents the United States in this matter.
2. "Compliance" is discussed throughout this Agreement in the following terms: substantial compliaJ1ce, partial compliance, and non-compliance. "Substantial Compliance" indicates that Defendants have achieved compliance with most or all components of the relevant provision of the Agreement. "Partial Compliance" indicates that Defendants achieved compliance on some of the components of the relevant provision of the Agreement, but significant work remains. "Non-compliance" indicates that Defendants have not met most or all of the components of the Agreement.
3. "Effective date" shall mean the date the Agreement is signed and entered by the Conrt.
4. "Defendants" refers to the Territory of the Virgin Islands aJ1d all of the agencies and individuals in their official capacities who will be involved in the implementation of remedial measures to address lmconstitutional conditions at Golden Grove.
5. "Facility" '01' "Golden Grove" refers to the Golden Grove Adult Correctional and Detention Facility, located in St. Croix, Territory ofthe U.S. Virgin Islands, and includes all buildings located on the Golden Grove campus and any building that may replace or supplement such buildings in the future.
6. To "Implement" a policy means: the policy has been drafted and disseminated to all staff responsible for following or applying the policy; all re\evaJ1t staff have been trained on the policy; compliance with the policy is monitored aJ1d tracked through audit tools; the policy is consistently applied, as demonstrated by audit tools approved by the Monitor; and there aJ'e corrective action measures to address lapses in application of the policy.
7. "Include" or "including" means "include, but not be limited to" or "including, but not limited to."
8. "Monitor" shall mean an individual selected to oversee implementation of the Agreement.
9. "Prisoners" or "Prisoner" shall be construed broadly to refer to one or more individuals detained at, or otherwise housed, held, in the custody of, or confined at either the existing facility or any institution that is built or used to replace or supplement the facility.
2

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 3 of 21
10. "Psychotropic medication" shall mean any substance used in the treatment of mental health problems or mental illness which exerts an effect on the mind and is capable of modifying mental activity or behavior.
11. "Qualified Medical Professional" shall mean a licensed physician, licensed physician assistant, or a licensed nurse practitioner, who is currently licensed to deliver those health care servi ces he or she has undeliaken to provide.
12. "Qualified Medical Staff" shall refer to Qualified Medical Professionals and Qualified Nursing Staff.
13. "Qualified Mental Health Professional" shall refer to an individual with a minimum of masters-level education and training in psychiatry, psychology, counseling, social work or psychiatric nursing, who is currently licensed to deliver those mental health services he or she has undertaken to provide.
14. "Qualified Mental Health Staff' shall refer to individuals with a minimum of a bachelor's degree and two years of experience providing mental health services who meets applicable Territory licensure and/or certification requirements and practices only within the scope of their training and licensure.
15. "Qualified Nursing Staff' means registered nurses and licensed practical nurses currently licensed to deliver those health care services he or she has undertaken to provide.
16. "Serious suicide attempt" means a suicide attempt that is considered to be either potentially life-threatening or that requires hospitalization for medical treatment.
17. "Special Management Housing Units" mean those housing units of the facility designated for prisoners in administrative or disciplinary segregation, in protective custody, on suicide precautions, or with mental illness.
18. "Staff' includes all persons who work at Golden Grove or provide services to prisoners at Golden Grove, including medical and mental health staff, whether employed by an agency of the Territory or any contractor, and including volunteers who provide services at the Facility without pay.
19. "Suicide Precautions" means any level of watch, observation, or measures to prevent suicide or harm from suicide attempts.
20. "Train" means to instruct in the skills addressed to a level at which the trainee has the demonstrated proficiency to implement those skills as, and when called for, in the training. "Trained" means a demonstration of staff proficiency.
21. "Use of force" means the application of physical or mechunicalmeasures to compel compliance by an unwilling subject. "Use of force" shall include all force except
3

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 4 of 21
complaints of minor discomfort from un-resisted handcuffing or un-resisted shackling of prisoners for movement purposes.
IV. SAFETY AND SUPERVISION
As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks, including development and implementation offacility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision
I. Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:
a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and I-lousing of Prisoners;
b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;
c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and
d. Supervision by corrections officers assigned to cellblocks, including any special management housing lmits (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including: (i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and (ii) conducting of adequate rOlmds by corrections officers and security supervisors in areas of the prison other than cellblocks.
B. Contraband
I. Defendants will develop and submit to USDO] and the Monitor for review and approval facility-speciiic policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:
a. Clear definitions of what items constitute contraband; b. Prevention of the introduction of contraband from anyone entering or leaving
Golden Grove, tl1tough processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison; c. Detection of contraband within Golden Grove, through processes including:
4

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 5 of 21
(i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinic, and other areas of Golden Grove to which prisoners may have access;
(ii) patdown, metal detector, and other appropriate searches of prisoners coming from areas where they may have had access to contraband, such as at intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic;
(iii) regular and random searches of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g., clinic, kitchen, dayrooms, storage areas, showers);
d. Confiscation and preservation as evidence/destruction of contraband; and e. Admission procedwes and escorts for visitors to the facility.
C. General Security
1. Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:
a. Clothing that prisoners and statT are required or permitted to wear and/or possess; b. Identification that prisoners, staff, and visitors are required to carry and/or
display; c. Requirements for locking and unlocking of exterior and interior gates and doors,
including doors to cells consistent with security. classification and fire safety needs; d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention.
D. Security Staffing
1. Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies and a staffing plan that provide for adequate statTto implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:
a. A security staffing analysis, incorporating a realistic shift factor, for all levels of security staff at Golden Grove;
b. A security stat1ing plan, with timetables, to implement the results of the security stat1ing ~ll1alysis; and
c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.
5

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 6 of 21
2. Defendants will implement the staffing plan developed pursuant to D.I.
E. Sexual Abuse of Prisoners.
I. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.
F. Classification and Housing of Prisoners
I. Defendants will develop and submit to USDOJ and the Monitor for review al1d approval facility-specific policies that will appropriately classify, house, and maintain sepal'ation ofprisoners based on a validated risk assessment instrument in order to prevent an u1l1'easonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective al1d allliually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
b. Housing and separation of prisoners in accordal1ce with their classification; c. Systems for preventing prisoners from obtaining unauthorized access to prisoners
in other units; d. The development and implementation of a system to re-classify prisoners, as
appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations; e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gal1g affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct; and f. Regular review of prisoners in segregation to minimize time in segregation, al1d provision of adequate opportunities for out-of-cell time for prisoners in segregation.
G. Incidents and Referrals
1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:
a. Reporting by staff of serious incidents, including (i) fights;
6

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 7 of 21
(ii) serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners; b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.); c. Requirements for preservation of evidence; 8l1d d. Central tracking of the above incidents.
2. The policy will provide that reports, reviews, and corrective action be made promptly 8l1d within a specified period.
H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that prohibit the use of Ulmecessary or excessive force on prisoners 8l1d provide adequate staff training, systems for use afforce supervisory review and investigation, and discipline and/or re-training of stafffound to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:
a. Permissible forms of physical force along a use of force continuum; b. CirctLl11st8l1ces Ul1der which the permissible forms of physical force may be used; c. Impermissible uses of force, including force against a restrained prisoner, force as
a response to verbal threats, and other Ulmecessary or excessive force; d. Pre-service training and annual competency-based and scenario-based training on
permitted/unauthorized uses offorce and de-escalation tactics; e. Training and certification required before being permitted to carry and use an
authorized weapon; f. Comprehensive and timely reporting of use of force by those who use or witness
it; g. Supervision and videotaping of planned uses of force; h. Appropriate oversight and processes for ilie selection and assignment of staff to
armory operations 8l1d to posts permitting the use of deadly force such as the perimeter towers; i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries; j. Prompt administrative review of usc of force reports for accuracy;
7

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 8 of 21
k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;
I. Administrative investigation of uses offorce; m. Central tracking of all uses of force that records: staff involved, prisoner injuries,
prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention; n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and o. Re-training and sanctions against staff for improper uses offorce.
I. Use of Physical Restraints on Prisoners
1. Defendants will develop and submit to USDO; and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:
a. Permissible and unauthorized types of use ofrestraints; b. Circumstances under which various types ofrestraint can be used; c. Duration of the use of permitted forms of restraints; d. Required observation of prisoners placed in restraints; e. Limitations on use of restraints on mentally ill prisoners, including appropriate
consultation with mental health staff; and 1'. Required termination of the use of restraints.
J. Prisoner Complaints
1. Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:
a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;
b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;
c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;
d. Centralized tracking of records of prisoner complaints, as well as their disposition; and
e. Periodic management review of prisoner complaints for trends and individual and systemic issues.
8

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 9 of 21
K. Administrative Investigations
1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:
1. Timely, documented interviews of all staff and prisoners involved in incidents; 2. Adequate investigatory reports that consider all relevant evidence (physical
evidence, interviews, recordings, docwnents, etc.) and attempt to resolve inconsistencies between witness statements; 3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required; 4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and 5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.
V. MEDICAL AND MENTAL HEALTH CARE
Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injnrious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
1. Accordingly, Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.
c. Prisoners' timely access to and provision of adequate medical and mental health caTe for seriolls chronic and acute conditions, including prenatal care for pregnant prisoners;
d. Continuity, administration, and management of medications, that address: (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices; (iii) review for known side effects of medications; and
9

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 10 of 21
(iv) sufficient supplies of medications upon discharge for prisoners with serious medical and mental health needs;
e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;
f. Prisoners' timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking, and timely responses to requests by qualified medical and mental health professionals; (ii) an adequate means to track, care for, and monitor prisoners identified with medical and mental health needs; (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care; (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises; (v) adequate aJ1d timely referral to specialty care; and (vi) adequate follow-up care aJ1d treatment after return from referral for outside diagnosis or treaiment;
g. Adequate care for intoxication and detoxification related to alcohol and/or drugs; h. Infection control, including guidelines and precautions and testing, monitoring,
and treatment programs; i. Adequate suicide prevention, including:
(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;
(ii) a protocol for constant observation of suicidal prisoners lmtil supervision needs are assessed by a qualified mental health professional;
(iii) timely suicide risk assessment instrument by a qualified mental­ health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;
(iv) readily available, safely secured, suicide cut-down tools; (v) instruction aJ1d scenario-based training of all staff in responding to
suicide attempts, including use of suicide cut-down tools; (vi) instruction and competency-based training of all staff in suicide
prevention, including the identiJ1cation of suicide risk factors; (vii) availability of suicide resistant cells; (viii) protocol for the constant supervision of actively suicidal prisoners
and close supervision of other prisoners at risk of suicide;
10

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 11 of 21
(ix) procedures to assure implementation of directives from a mentalhealth professional regarding: (1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
.I. Clinically adequate professional staffing of the medical and mental health treatment programs, as indicated by implementation of periodic staffing analyses and plans;
k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;
I. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;
m. Adequate dental care; n. Morbidity or mortality reviews of all prisoner deaths mld of all serious suicide
attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review; o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation; p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation; q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary smlctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;
r. Medical facilities, including the scheduling and availability of appropriate clinical
space with adequate privacy; s. Mental health care and treatment, including:
(i) timely, current, and adequate treatment plml development and implementation;
(ii) adequate mental health programs for all prisoners with serious mental illness;
(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;
(iv) comprehensive correctional and clinical staff training mld a mechmlism to identify signs and symptoms of mental health needs of prisoners notpreviously assigned to the mental health caseload; and
(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.
VI. FIRE AND LIFE SAFETY
11

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 12 of 21
Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshall;
b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire- and life-safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and s11)0ke detectors-in housing units;
c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;
d. Regular security inspections of all housing units that includes checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell; and (ii) that all facility remote locking cell mechanisms are functional;
e. Testing of all staff regarding fire- and-life safety procedures; f. Reporting and noti fication of fires, including audible fire alarms; g. Evacuation of prisoners threatened with harm resulting from a fire; h. Fire suppression; i. Medical treatment of persons injured as a result of a fire; and j. Control of highly flammable materials.
VII. ENVIRONMENTAL HEALTH AND SAFETY
Defendants will protect prisoners from environmental health hazards by providing constitutiorially adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDO] and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:
a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical iU'cas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;
b. Adequate ventilation throughout the facility; c. Adequate lighting in all prisoner housing and work areas; d. Adequate pest control for housing units, medical units, and food storage areas; e. Prisoner and clinic staff access to hygiene and cleaning supplies; f. Cleaning, handling, storing, and disposing ofbiohazardous materials; g. Mattress care and replacement;
12

Case: 1:86-cv-00265-WAL-GWC Document #: 689-1 Filed: 08/31/12 Page 13 of 21
h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;
1. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;
J. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food; and
k. Sanitary and adequate supplies of drinking water.
VIII. TRAINING
Defendants will take necessary steps to train staff so that they ,mderstand and implement the policies and procedures required by this Agreement, which are design_edJo provid" constitutional conditions.
1. Accordingly, Defendants will develop and submit to USDO.! and the Monitor for review and approval facility-specific policies regarding the following:
a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;
b. Pre-service training for all new employees; c. Periodic in-service training and retraining for all employees following their
completion of pre-service training; d. Documentation and accountability measures to ensure that staff complete all
required training as a condition of commencing/continuing employment.
IX. IMPLEMENTATION
1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Teclmical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.
2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.
3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United
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States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. Ifthe parties still cannot resolve a dispute, either party submit the dispute to the district court.
4. Defendants will conduct a semi-annual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.
5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still Calmot resolve a dispute, the parties agree to submit the dispute to the district court.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement. Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical andlor mental health reports and investigations as they become available.
8. Defendants shall maintain sufficient records to document that the requirements ofthis Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other docmnents over which Defendants may claim privilege.
9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and docurnents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ alld its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.
10. Excluding on-site tours, within 30 days ofreceipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.
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X. MONITORING
A. Selection of the Monitor
I. The parties will jointly select a person to serve as the Monitor to oversee the implementation of the Agreement. The selection of the Monitor will be conducted solely pursuant to the procedures set forth in this Agreement. The parties stipulate and ,upon presentation of this Settlement Agreement to the Court for its approval, will urge the Court to find that the appointment of a monitor in this case is a public exigency within the meaning of 31 V.I.C. §239(a)(2). The selection is subject to Court approval, and the Monitor will serve at the pleasure of the Court.
2. In selecting a Monitor who has the skill, background, and experience to perform the duties of the position, the parties will seek someone who:
a. is independent and can perform the duties of the Monitor free from undue influence;
b. has the confidence of the parties, the Court and the community; c. can perform the services in a cost effective manner; and d. has experience in: institutional reform, monitoJing, dispute resolution,
executive leadership, government service, or other relevant positions ..
USDOJ has expressed a preference for a monitor with experience in corrections. The Defendants have expressed a preference for a monitor ii'om the Virgin Islands. Each party will consider anyone nominated by the other party if the nominee otherwise meets the qualifications listed above. Ifthe monitor does not have corrections experience, he or she will engage a corrections expert for monitoring the provisions in Section IV,
3. The Monitor will be selected through the following process. Within 30 days ofthis Agreement being signed by the parties, each party will nominate up to three persons to serve as Monitor, and each party may strike one of the other party's nominees. Should the parties fail to reach agreement on a person to serve as Monitor within 30 days after exchanging nominations, the parties will recommend their remaining nominees to the Court and the Court will appoint the Monitor ii-om the names submitted by the parties. The same procedures will be followed ifthe position of Monitor later becomes vacant and the parties cannot agree on a replacement.
B. Termination of the Monitor
1. Neither party, nor any employee or agent of either party, will have ~U1y supervisory authority over the Monitor's activities or findings. The Monitor may be terminated only for good cause unrelated to the Monitor's findings and only with prior notice to, and approval of, the parties acting jointly or by the Court's order. Should all the parties agree that the Monitor is not fulfilling his or her duties in accordance with this Agreement, the parties may petition the Court for the Monitor's immediate removal and replacement.
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One party may unilaterally petition the Court for the Monitor's removal for good cause, and the other party will have the opportunity to respond to the petition.
C. Fees and Expenses of the Monitor
I. The cost for the Monitor's fees and expenses will be borne by Defendants. The parties recognize, however, that every effort should be made to control these fees and expenses in order to conserve funds for compliance. Therefore, the reasonableness of the fees and travel expenses of the Monitor will be considered in the choice of a person to serve. The Monitor will submit a proposed 12-month budget for the operation of the Monitorship, which will be subject to approval by the parties, and will identify any experts, consultants, and other individuals the monitor anticipates hiring. In the absence ofjoint approval, the proposed budget will be submitted to the Court for its review and approval. The Monitor will submit detailed monthly statements of fees 11l1d expenses to the parties, and either party may object to any statement the Monitor submits. In the absence of agreement, the Court will determine the appropriate amount to be paid.
2. Within the constraints set forth above in this section, Defendants will provide the Monitor with a budget sufficient to allow the Monitor to carry out the responsibilities described in this Agreement. In order to fulfill these responsibilities, it is foreseeable that the Monitor will be required to employ one or more subject matter experts. To the extent possible, the Monitor will rely for this purpose on appropriate agencies in the United States Virgin
Islands, e.g., local fire depmiment officials, sanitation inspectors, food service inspectors,
and other local entities with expertise in evaluating the sufficiency of the defendants' relevant compliance efforts. The Monitor may consult with or request the assistance of the Technical Compliance Consuitm1ts.
3. If the Monitor wishes to contract with or consult other persons or entities to assist in the evaluation of compliance, the Monitor must submit nominees and their qualifications to all parties for review and joint approval within 14 days; any disagreement between the parties on these persons or their proposed rate of compensation will be submitted to the Court for resolution. The Monitor will pay for the services out of his or her budget. Such persons or entities will be subject to all the same rights, limitations, and restrictions set forth in this Agreement as the Monitor. The parties reserve the right to object for good cause either to the necessity of the contract or consultation or to the person with whom the Monitor proposes to contract or consult.
D. Monitor's Access
1. Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.
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2. With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility aJ1d Detention Center, all facility non­ privileged records, prisoners' medical and mental health records, staff members, and prisoners. DefendaJ1ts will direct all employees to cooperate fully with the Monitor. Reasonable advance notice must be provided to the Bureau of Corrections prior to conducting anyon-site compliance reviews. Other than as expressly provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. Allnonpublic information obtained by the Monitor will be maintained in a confidential manner.
E, Limitations on Public Disclosures by the Mouitor
I. Except as required or authorized by the terms of this Agreement or as the parties may otherwise agree, the Monitor will not make any public statements except as specifically authorized in this Agreement with regaJ'd to any act or omission of Defendants or their agents, representatives, or employees. Any media statement made by the Monitor regarding the monitoring of this Agreement or his or her employment as Monitor must first be approved in writing by all parties. The Monitor will not testify in any other litigation 01' proceeding with regard to any act 01' omission of Defendants or any of their agents, representatives, or employees related to this Agreement, nor testify regarding aJ1y matter or subject that he or she may have leaJ'ned as a result of his or her performaJ1ce under this Agreement. Unless such conflict is waived by the parties, the Monitor will not accept employment or provide consulting services that would present a conflict of interest with the Monitor's responsibilities w1der this Agreement, including being retained (on a paid or unpaid basis) by any current 01' future litigaJ1t or claimaJ1t, or such litigant's or claimant's attorney, in connection with a claim or suit against Defendants, their departments, officers, agents or employees regarding the subject matter of this case. The Monitor is not a state, territorial, or local agency or an agent thereot: and accordingly the records maintained by the Monitor shall not be deemed publio records subject to public inspection. Neither the Monitor nor aJ1y person or entity employed or otherwise retained by the Monitor to assist in furthering any provision of this Agreement will be liable for any claim, lawsuit or demand arising out of the Monitor's performance pursuant to this Agreement. This provision does not apply to any proceeding before a court related to performance of contracts or subcontracts for monitoring this Agreement.
2. The Territory, the Government of the Virgin IslaJ1ds, and Defendants shall not be responsible for indemnification of the Monitor or any person or entity employed or otherwise retained by the Monitor to assist in furthering any provision of this Agreement and shall not bear responsibility for any attorney's fees 01' costs in cotn1ection with aJ1y suit or claim brought by a third party against the Monitor 01' any person or entity employed 01' otherwise retained by the Monitor to assist in furthering aJ1y provision of this Agreement.
F. Monitor's Reports
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1. The Monitor will issue an initial report to the parties within four months after the effective date of his or her appointment and then every four months thereafter until Defendants have reached at least partial compliance with every provision. At that point, the Monitor will issue reports every six months. These reports will be written with due regard for the privacy interests of individual prisoners and staff and for the interest of Defendants in protecting against disclosure of non-public information (e.g., security­ sensitive information). The Monitor's reports will indicate a compliance rating for each provision (both with regard to policy formulation and implementation) and may provide non-binding recommendations for achieving compliance with any provisions not in compliance at the time of the Report.
2. These reports will be filed in the record of this case under such conditions as the Court may order. The reports will be provided to counsel for comment in draft form at least two weeks prior to their filing, and the draft reports and any comments thereto shall be neither publicly disclosed nor filed on the record in this case.
3. Reports of the Monitor will be admissible in evidence to the extent permitted by the Federal Rules of Evidence.
G. Compliance Assessments
1. In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance. In order to assess compliance, the Monitor will review a suffIcient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.
H. Technical Assistance
1. The Monitor shall provide specific recommendations to the Defendants with regard to each substantive requirement of this Agreement, in order to assist Defendants in achieving and maintaining substantial compliance. Defendants also may consult with the Teclmical Compliance Consultants regarding the development of policies required by this Agreement. However, under no circumstances will any of them order or purport to order Defendants to take ~my specific step to achieve substantial compliance. The Monitor shall not, and is not intended to replace or take over the role and duties of the Governor of the Territory, the Director of the Bureau of Corrections, or the Warden of the Golden Grove Adult Correctional Facility and Detention Center.
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I. Monitor's Testimony

1. In accordance with the Federal Rules of Evidence, either party or the Court may call the Monitor to testify as a witness. Regardless of who calls the Monitor, each party may cross examine. The Monitor's testimony will be admissible as permitted by the Federal Rules of Evidence.

J.

Monitor's Ex Parte Communications

1. Absent agreement by both parties, the Monitor may not initiate nor receive ex parte commlmications with the Court. Either party may initiate or receive ex parte commlmications with the monitor. However, the Monitor may not initiate or receive ex parte communications with the_Defendallt Governor, Defendant Director, and officers and employees of ally Territorial agency or office other than Golden Grove, unless their counsel are afforded the right to be present.

XI. ENFORCEMENT AND TERMINATION

1. The District Court of the Virgin Islands will retain jurisdiction over this matter for the purposes of enforcing this Settlement Agreement.

2. This Agreement shall terminate when Defendants achieve compliance with the substantive provisions of this Agreement and maintain compliance for onc (1) year.

3. Failure by either party to enforce this entire Agreement or any provision thereof with respect to any deadline or ally other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreement.

4. If ally unforeseen circumstallce occurs that causes a failure to timely carry out any requirements of this Agreement, Defendants shall notify the Monitor and USDOJ in writing within 20 calendar days after Defendants become aware of the unforeseen circumstance and its impact on Defendants' ability to perform under the Agreement. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.

5. The Agreement shall be applicable to, and binding upon, all parties, elected officials al1d their respective officers, agents, employees, assigns, and their successors in office.

6. In the event that any provision of this Agreement is declared invalid for any reason by a court of competent jurisdiction, that finding shall not affect the remaining provisions of this Agreement.

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For the UNITED STATES OF AMERICA:

ERIC H. HOLDER, JR. Attorney General
THOMAS E. PEREZ Assistant Attorney General Civil Rights Division

RONALD W. SHARPE United States Attorney District of the Virgin Islands
ANGELA P. TYSON-FLOYD Assistant United States Attorney U.S. Attorney's Office 1108 King St., Ste. 201 Christiansted, U.S.V.I. 00841

JONATHAN M. SMITH Chief
LAURA L. COON Special Counsel EMILY A. GUNSTON ALYSSA C. LAREAU JUDEVOLEK Trial Attorneys United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW Washington, DC 20530 Tel. (202) 514-6255 Fax. (202) 514-4883

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For the TERRITORY OF THE VIRGIN ISLANDS:

I
!
I

-- ..-;~ :')«C

__

ZElle

. .

Attorney Gencl'!l

~£L USC. WILSON Director BUIl'eaauli of Corrections

SO ORDERED this ~ day of~_ _ _ _-" 2012, UNITED STATES DISmlCr JUDGE
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 Case: 1:86-cv-00265-WAL-GWC Document #: 689 Filed: 08/31/12 Page 1 of 10

IN THE DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA, Plaintiff,
v. TERRITORY OF THE VIRGIN ISLANDS et al.,
Defendants.

)

)

)

)

CIVIL NO. 86/265

)

)

)

)

)

)

JOINT MOTION TO ENTER CONSENT JUDGMENT Plaintiff, the United States of America, and Defendants, Territory of the Virgin Islands, et al., jointly move this honorable Court to enter the attached Settlement Agreement as an order of the Court to resolve the above-styled case. After engaging in extensive settlement negotiations, and to avoid the burdens of contested litigation, the Parties have agreed to jointly move the Court to enter the attached Settlement Agreement as an order of the Court. I. SCOPE OF PROPOSED SETTLEMENT The parties have reached the agreement through negotiation and consent. The parties intend through this Settlement Agreement to settle and compromise the claims and issues disputed between them. The Settlement Agreement is submitted to the Court for its approval as a fair, adequate, and reasonable agreement that obviates the need for the parties to litigate their claims and defenses. By consenting to the Court’s approval of the Settlement Agreement, the Defendants do not intend thereby to waive their right to contest or to preclude in litigation with any other person any of the claims and issues that were or could have been raised in this case. If the Court approves the Settlement Agreement, the parties jointly request that the Court:

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⋅ Deny the remainder of the relief that the Defendants requested in their Motion to Terminate Prospective Relief [ECF No. 565].
⋅ Order that all remaining, pending motions be deemed withdrawn without prejudice at the request of the movant.
II. LEGAL STANDARD “There is a strong judicial policy in favor of parties voluntarily settling lawsuits.”
Pennwalt Corp. v. Plough, Inc., 676 F.2d 77, 80 (3d Cir. 1982). This presumption in favor of settlements “is especially strong in ‘class actions and other complex cases where substantial judicial resources can be conserved by avoiding formal litigation.’” Ehrheart v. Verizon Wireless, 609 F.3d 590, 595 (3d Cir. 2010) (quoting In re Gen. Motors Corp., 55 F.3d 768, 784 (3d Cir. 1995)).
When presented with a consent decree, a court should ascertain that the decree is fair, adequate, and reasonable. See Binker v. Commonwealth of Pa., 977 F.2d 738, 747-48 (3d Cir. 1992) (noting that even non-class action settlement agreements “are agreed to be subject to a ‘universal’ standard, that of fairness, adequacy and reasonableness”); Stoetzner v. U.S. Steel Corp., 897 F.2d 115, 118 (3d Cir. 1990) (identifying relevant inquiry as whether agreement is “fair, reasonable, and adequate”). Additionally, a settlement will be invalidated when it is the product of fraud or collusion between the negotiating parties. Officers for Justice v. Civil Serv. Comm’n of City and Cnty. of San Francisco, 688 F.2d 615, 625 (3d Cir. 1982).
Because the Settlement Agreement constitutes prospective relief regarding prison conditions, the Court must also find that the Agreement complies with the Prison Litigation Reform Act (“PLRA”), 18 U.S.C. § 3626. The PLRA requires that the Court find the Settlement Agreement’s “relief is narrowly drawn, extends no further than necessary to correct the violation
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of the Federal right, and is the least intrusive means necessary to correct the violation of the Federal right.” 18 U.S.C. § 3626(a) & (c). Pursuant to the Court’s instruction that the parties propose a method that may enable the Court to make its required findings, the parties jointly recommend that the parties submit to the Court, within 45 days, memoranda of law in support of the joint motion and proposed findings of fact and conclusions of law. These submissions could be supported by sworn declarations of expert witnesses, deposition testimony, documents produced by the defendants, stipulations of fact that the parties may submit, and other evidence to support the PLRA findings as the Court deems necessary. These submissions will articulate why the parties believe this Settlement Agreement is uniquely tailored to effectively address the constitutional concerns remaining at Golden Grove and how the Agreement will bring this 25 year litigation to conclusion. III. DISCUSSION
This Court should approve the Settlement Agreement because the settlement is the result of months of arms-length negotiations by the Parties, and provides for relief that is fair, reasonable, and adequate, not the product of collusion, and narrowly tailored to remedy the ongoing Constitutional violations occurring at the Golden Grove Adult Correctional and Detention Facility (“Golden Grove”). The Agreement consists of eleven sections with comprehensive provisions on safety and supervision, medical and mental health care, fire and life safety, environmental health and safety, and training of Golden Grove staff and administrators. These comprehensive provisions establish benchmarks with regard to the safety and care of Golden Grove prisoners that directly coincide with the particular ongoing constitutional violations at Golden Grove. The Parties agree that the implementation of the Settlement Agreement will begin immediately upon the effective date and shall terminate when
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the Defendants have achieved substantial compliance with each provision of the Settlement Agreement and have sustained substantial compliance for a period of one year. The Settlement Agreement provides that, until such termination or termination under the PLRA, this Court shall retain jurisdiction over the implementation of the Agreement.
A. The Settlement Agreement is Fair, Reasonable, and Adequate and Not the Product of Fraud or Collusion 1. The Agreement is Fair, Reasonable, and Adequate
The Settlement Agreement is fair, reasonable and adequate to address the extensive, ongoing, and critical deficiencies at Golden Grove. In December 1986, the Court entered as an Order of the Court a Consent Decree executed by the United States and the Territory and other named Defendants, to address unconstitutional conditions at Golden Grove. [ECF No. 3]. In February 2012, the Court ruled that Consent Decree is unenforceable under the PLRA. Since that time, the parties negotiated at length to reach an agreed settlement that would, if approved by the Court, obviate the need for the Court to conduct a hearing and to make the findings required by 18 U.S.C. §3626(b)(3). With the proposed Settlement Agreement, the parties are taking a new approach. The parties agree that necessary reform must be grounded in the development of constitutionally adequate policies, training and implementation of those policies, and accountability for breach. The proposed agreement contains mechanisms to put in place this foundation.
This Agreement establishes benchmarks with regard to the safety and care of Golden Grove prisoners, but gives Defendants discretion in establishing the details of facility-specific policies designed to address constitutional infirmities. The United States and the jointly selected Independent Monitor then review, provide technical assistance, and then approve the policies designed by the Defendants. This process is designed to ensure that Defendants are invested in
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the success of the development and implementation of constitutionally adequate policies and procedures, formulated in cooperation with experts in the relevant fields. Finally, the Independent Monitor will report on compliance with the Settlement Agreement. The Monitor will report to the parties and the Court three times each year.
The substantive provisions of the Agreement are also fair, reasonable, and adequate to address unconstitutional conditions at Golden Grove. In order to protect prisoners from harm, including violence by other prisoners, Defendants have agreed to formulate and implement a multitude of policies to address and prevent harm from prisoner-on-prisoner assaults, excessive use of force by staff, inadequate medical care, inadequate mental health care and suicide prevention, and inadequate fire and life safety.
For each of the substantive sections of the Agreement, the parties wish to provide the Court proposed findings of fact and conclusions of law that identify current and ongoing unconstitutional conditions that necessitate such provisions in the Agreement. As noted above, the written submissions could be supported by sworn declarations of expert witnesses, deposition testimony, documents produced by the defendants, stipulations of fact that the parties may submit, and other evidence as the Court deems necessary.
2. The Agreement is Not the Product of Fraud or Collusion The Settlement Agreement is not the product of fraud or collusion. Both parties are intimately familiar with the conditions and practices at Golden Grove and spent long hours negotiating the Settlement Agreement during multiple in-person and telephonic negotiation sessions between September 2011 and August 2012. The Settlement Agreement’s specific provisions reflect the parties’ knowledge of the case from the past 26 years since the Court first ordered prospective relief to address unconstitutional conditions at Golden Grove, as well as
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recent facts gathered during the extensive discovery conducted by the parties since Defendants filed their Motion for Termination of Relief, including depositions, site visits, and the collection and review of thousands of pages of documents. This adversarial posture provides this Court with assurance that the Settlement Agreement is not a product of fraud or collusion.
B. The Agreement Provides for Prospective Relief that Complies With the Requirements of the PLRA
The adversarial nature of the extensive settlement negotiations has yielded a Settlement Agreement that provides for prospective relief that is narrowly tailored to correct the particular, ongoing constitutional violations at Golden Grove. Thus, the Parties stipulate that this Settlement Agreement complies in all respects with the provisions of the PLRA, 18 U.S.C. § 3626. The Parties further stipulate that the prospective relief in this Settlement Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights occurring at Golden Grove, is the least intrusive means necessary to correct these violations, and will not have an adverse impact on public safety or the operation of the criminal justice system. Accordingly, the Parties agree and represent that this Settlement Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a) & (c).
The Parties understand that the PLRA requires this Court to independently make findings that the prospective relief contained in this Settlement Agreement is “narrowly drawn, extends no further than necessary to correct the violation of the Federal right, and is the least intrusive means necessary to correct the violation of the Federal right.” 18 U.S.C. § 3626.
In an effort to address this concern, and to ensure that the Agreement is narrowly drawn, extends no further than necessary, and is the least intrusive means necessary to correct the constitutional violations at Golden Grove, this Agreement gives Defendants discretion in establishing the details of facility-specific policies designed to address constitutional infirmities.
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During negotiations, Defendants were careful to tie each requirement in the Agreement to specifically identified current and ongoing constitutional infirmities. That the requirements of the Agreement comply with the PLRA will also be made evident through the subsequent proposed submission to this Court described above.
C. The Appointment of a Monitor Constitutes a Public Exigency The Settlement Agreement contemplates that the Court will appoint a monitor to oversee the Defendants’ remedial efforts at Golden Grove. The parties agree that conditions at Golden Grove warrant the appointment of a monitor without delay. Therefore, the parties request that the Court find that the appointment of a monitor in this case is a public exigency within the meaning of 31 V.I.C. § 239(a)(2). IV. CONCLUSION For the reasons above, this Court should find that the Settlement Agreement is fair, adequate, and reasonable, and is not the product of collusion. Additionally, subsequent submissions will enable this Court to find that the Settlement Agreement is narrowly tailored to correct the particular constitutional violations ongoing at Golden Grove, and that the Agreement complies in all respects with the PLRA. The Parties respectfully jointly request that this Court approve the Settlement Agreement in its entirety, and enter it as an order of the Court.
Respectfully submitted, THE UNITED STATES OF AMERICA By: JONATHAN M. SMITH Chief LAURA L. COON
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Special Counsel
s/Alyssa C. Lareau ALYSSA C. LAREAU EMILY A. GUNSTON Senior Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202-514-6255 202-514-4883 (fax)
Angela P. Tyson-Floyd Assistant United States Attorney U.S. Attorney’s Office 1108 King St., Ste. 201 Christiansted, U.S.V.I. 00841 340-773-3920 340-773-1407 (fax)
VINCENT F. FRAZER, ESQ., ATTORNEY GENERAL
By:
s/ Richard Walinski RICHARD WALINSKI, ESQ. Counsel for Defendants Thacker Martinsek 3235 Levis Commons Blvd. Perrysburg, Ohio 43551 419-931-6936
s/ Nathan Oswald NATHAN T. OSWALD, ESQ. Counsel for Defendants Davies, Ruck & Speweik, Ltd. 427 W. College Ave, Box 412 Pemberville, Ohio 43450 419-287-3233 419-287-3215 (fax)
s/ Kenrick Robertson
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KENRICK ROBERTSON, ESQ. Assistant Attorney General Virgin Islands Department of Justice 1123 King Street Christiansted, VI 00820 340-773-6309 340-719-9762 (fax) s/ Aquannette Y. Chinnery AQUANNETTE Y. CHINNERY, ESQ. Assistant Attorney General Virgin Islands Department of Justice 34-38 Kronprindsens Gade GERS Complex, 2nd Floor St. Thomas, VI 00802 Phone: (340) 774-5666 Fax: (340) 776-3494 achinnery@doj.vi.gov
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CERTIFICATE OF SERVICE
I certify that on August 31, 2012, I electronically filed the foregoing with the Clerk of the Court using the CM/ECF system, which will send notification to the following:
Aquannette Y. Chinnery V.I. Department of Justice GERS Building 2nd FL 34-38 Kronprindsens Gade St Thomas, VI 00802 340-774-5666 X285 Fax: 340-776-3494 Email: achinnery@doj.vi.gov
Nathan T Oswald Davies, Ruck & Speweik, Ltd. 427 W. Collage Ave., Box 412 Pemberville, OH 43450 419-287-3233 Fax: 419-287-3215 Email: ntoswald@drslawyers.com
Richard S Walinski 900 Adams Street Toledo, OH 43604 419-349-2333 Fax: 419-720-34452 Email: rswalinski@gmail.com
Kenrick Robertson Assistant Attorney General Virgin Islands Department of Justice 1123 King Street Christiansted, VI 00820
/s ALYSSA C. LAREAU Alyssa C. Lareau Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202-514-6255
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 MRR-23-2006 17: 02 FROM:

13407763474

TO: 202 514 0212

MAR-23..,2006 TIlU 04:40 PM Judge Cannon

FAX 1';0. 3407735416

P.2
P. 01132.

UNITED STAT£S DISTRICT COURT FOR THE VIRGIN ISLANDS 
 DIVISION OF 51 CROIX 


)

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v,

)

)

TERRlTORY OF nrE VIRGIN IStANDS ) 


~~

) 


) 


Defendants. ) 

)

)

1986-CV..0265

TO: James Canoll, III, Esq., AUSA - Fax 776-3414 Ernest Batenga, ~sq., AlJSA:" Fax 773-1407 Kerry E. Drue, Esq., AG - Fax 774-9710 Aquanette Y. Chilmery, Esq., AAG - Fax 776M 3494 Richard Schrader, Esq., AAG - Fa~ 773-1425
QRDER GRANTING 'UNITED STATES.' MOTION TO FIND DEFENDANTS IN 
 CONTEMPT AND FOR APPOINTMENT Q.U SPECIA1 MASTER 

II-US 11ATTER is beforlil the Court upon Plaintiff United Sta~es of America's
("'United States") Motiqn for an Order to Show Cause Why Defendants Should Not Be
Held in Contempt (Dkt 154) (the "Contempt Monon"). A hearing upon the Court' 5 Order
to Show Cause was hel9, Febn.lary 8, 9, 10, and 13, Lpon completion of said hearing( the
Court ordered the parnes to 51.1 broit proposed Findings of Fact and Conclusions of law,

MRR-23-2006 17:02 FROM:

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TO:202 514 0212

MAR-23-2006 THU 04:40 PM Ju~~e Cannon

FAX NO. 3407735416

P.3 

P. U?/"Jc.

Ullitcrl Stat"s 'V, Territory of the ~'iJ'gil1 Islands 1O9r8d6,l!-rCGVr.:0m2~6l5ng United, States' Motion to ,Fil\cl Oefendan tin Conlempt Page 2
The Court has reviewed each party's Pl'OPOsed. Findlngs of. Fact and Conclusions of Law
and 'hereby adopts 2l,nd i.tllcorporat~s herein the FLndings of Fact ilnd Conclusions of Law
filed by Plairltiff United $tates. Based upon the 5aid Findings of 'Fact and Conclusi.ons of Law, the Court concludes
that there axe continuing and ongoing constitutional violations of the rights of indi.viduals held at the: Golden Grove Adult Correctional Facility and Detention Center ("Gold'en Grove"), and De£enciantsL are in contempt of the Court'9 Orders: th~ 1986 Consent Decree (Dkt. 3) ("Consent Decree"), the 1990 Plan of Compliance (DId. 5i) ("Plan of Compliance"'), and the 2003 Stipulated Agreement (Dkt. 146) ("Shpula,ted Agreement").
In addition, based upon the foregoing Find.ings of Fact and Conclusions of 'Law, the Court cond'L1.des that this CElse and the COl.ut's Orders are sufficiently .:::omplex ano., thus, that the appropriate rem.~dyfor Defendants' contemptand estiib1.1shed recordotresistan(l';l to the Court' F.i Orders is the appoin.trnertt of a Special Master to serve as an agent anc. officer of this Court to examiIle in detail and to assist the COU1't jn evaluating Defend~nts: compliance with the orders of this Court, inclucling th.e issues on which the Court found
IDefi.mcl2lnts are the 1erritot'y of thi! Virgin Islands, th0 Govt:mcr 01 the Virgin Islands, the Director of th~ Vi.rgjn rsl:mds Bureau of Conections, and the Wardell of thi:: Golden Grove Adult Con:ecticl't"l.:tlFacility and Detention Cl!:ntl:r (uGoiden Grove"), in St. Croix, Vb'gin 151~1:ids (c:ollt!ctiYcly t.I1C "Defe:nci:ll.1\t:;" or "USVI"),

MRR-23-2006 17:02 FROM:

13407763474

TO:202 514 0212

NAR-23-2006 THU 04: 40 PM JI,lqge Cannon

FAX NO, 3407735418

P.4
P. 03/32

Ullilcri States v. Tt:rritolY of ih~ YII',gilt IslOJ1ds 


1986-CV·0;265 
 Order Gral1ting

United

5tilte~~

Motion

to

Find

Defendant

i11

Contempt




Page 3 


D(~fendants in contempt ih the Court's Findings of Fact and ConclusioDS of Law, The Comt

fur.ther concludes th.at the relief in this Ol:der is narr.owly dravv'lll extends no further than

necessary to correct the violations offederal rights of inclividuals held at Golden Grove and thl2 Cour t's Ol:d~rs, is the .least :intrusive means necessary to remedy Defendants' contempt,

and will not have an adV1erse impact on public safety or the operation of a criminal justice

system. TheSpeck,\lMaster shall be chosen in ~lccordance with this Order a.':i set forth below
and shall have the Iespo~lsibilities, duties, and powers s.et forth in this Order.
A, Selection of Special Mastel' 1. . W'lthin tWenty (20) days of the issuanc«; o,~ this Order,the parties shall confer
to jointly agree upon a proposed Special Master and shall jointly or, if unabl~ to agree, se\)~raLlYI subrrrit their recommendation(s) for appoii1.tment oS a SpeciCll Mas. t,e
r according to the procedures set fo:rth in this Section, 

2. If the partles al'e unable to agree upon a proposed Special Master, pursLlant to the Pl'ison Litigation Reform Act ("PLRAIt), 18 U.S.c. § 3626(£)(2), Defendants and the
U:1ited States each shal~ file c:md serve a. recommendation s;;bmission thOlt lists not more
than. five (5) candidates to serve as Special )..1aster.

MAR-23-2006 17:03 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 DIU 04:40 PM Judge Cannon

FAX NO. 3407735416

P.5
P. O~/3?

United Stl1,:es '(]. Tern'eory of lh.e Vitgin I~lclrlru;
19S6·CV -U265 
 Order G1:.111tl:1.g United States! Motion to Find Defendant In Contelnpt 
 Page 4 

3. Whetherjo~tly or severCllly submitted, s\,Lch recommendatic;m 3ubm.ission(s) shall inchlde the parties' re~sons for each l'ecol1'lmendatioD (including the proposed candidate's curriculum. vit<:le and information 'regarding the candidate's previous experience as a Special. Master or other form of ~ompliance mOl'litor and previous qUc'\liflcation(s) as an expert in territorial, state, or fedel'tU courts) and. shall comply with Fed. R. Civ. P. S3(b)(:;). .
4. In determining whether to select DJ. candidate as the Special M~ster; the Court
shall consider whethe.r a candidate for Special Master generally has experience and education or training relevant to the operations and managemen.t of correctional c.nd detention facilities with the approximate inmate and detainee capacity of G,olden Grove (cunently approximately 570 inmates and detainees). The Court ~\lso shall consider
whether the candidate h~s experience and education or trairung in the field~ of penology,
correctional facility man~gement,correctiona1 m.~dical and mental health ctlre, flre safety and envi.ronm~ntal health and s"nitanon, and systems of accountability such ~s quality assurance, auditing, 01' i.hterC'\alreview and investigations. Candidates also shall be able to prepan: detailed wri~ten :re?OL'ts to tJ.'\e Court, retain and manage a team of experts, consultants, and staff as~sting the Special Master pt.1l·S1.1aJ."l.t to this Ord.er, and provide, in

MAR-23-2005 17:03 FROM:

13407753474

TO:202 514 0212

MAR-23-2006 THU 04:40 PM Jud~~ Cannon

FAX NO. 3407735418

P.5/33
P• .l).t)'/J~'2..

lJllite:d 5!CI t~r. t), Territory of ~}tc Virgi1l1:51ands 
 19S6-CV-02.65 
 Order Granting United States' Motion to Find Defendant lI1 Contempt 
 PageS 

addiLi.on to and in conjl.inction with retained experts, consuJtClnts, and staft technical
assistance to Defendants pursuant to this Order. 5. Where the parties are unable to' agree upon a pxoposed Special Master and
file and serve separate recclmmend'llion submissions, Withlll. ten (10) days of tiling, each
party shall have the op~Ol·t1.\nily to l'emove up to thr.~c (3) persons from the opposing
party's list:, 6. The Cou:rt·sha.ll make the final detennination and selection of tl,e Special
\
Master based upon either the parties' joint recornmendatjon submission or from the list of
remaining persons after th.e operation of Section A(5), above.
B. Appoilltment and Ma.ndate 1. The person selected by the Court as the Special Master is appointed effectivt:!
I
the d.ate o£the Cou.d;s Order selecting the Special Master. The Special Master'~ ~ppointment shall terrni~iC1te onlyby order of the COUl't after notice and Op'portunity for. the
parties to be heal:d. 2. The Special Master and any experts, consultants, or staff :retamed by the '
Special Master pm·s1.lant to l:his Order shall act in a professionall:apacity as an agent and
officer of this Cuurt and, sha11serve the C01..1.rt and the il"1.ter~sts of jus-lice. In the interest of selecling and ,T'i.ltairdng the Special Master, and C\.ny experts, consultants, or staff ret~inGd

MAR-23-2005 17:03 FROM:

13407763474

TO:202 514 0212

YAR-23-2008 THU 04:40 PM Judge C~nnon

FAX NO. 3407735416

P.7/33 

P. 06/3?

United Sttll:CS v. "f~rritDry of I.he !Yi"gin Islands 1986·CV-0265 
 OdeI' Granting United States' Motion to Fmd Defendant in Cont(!;mpt 
 P<lBe 6
by the Spedal Ylastel.' o:n an expe.dited basis, these individuals shaH be appointed (md retair'led by the Comt pwsuant to the procedmes SeC forth in. this Order and the o:rders of the Court. Neither the Special Master, nor any experts, consulta.l'l.'ts, or staff retained by the Special Master, shall be considered tenitorial or local ernployees and shall be e:xemptfroJ].'\ l:et':'itoriZll o:-locCll budgetary, budget allocation, or procurement Tecluirements.
3. Except as U!mil"ed by this Order, the Spt;)dal Master shall exercise all the powe! and authority granted under the PLRA a.nd Federal Rule of Ovi1 Procedure 53, and s/he
shalt t~ke an approp.riate actions to fulfill the orders of the COl.ltt to monitor, reviev,i, and
reporl on compliance with the Consent Decree, the Pl...n of Compliru'Lce, and the Sti.pulated Agreement, and any flL~ure orders of this Court O:1'2r01naiter collectively II orders of the Court") regarding the conditio:C1:) of confinement at Golden Grove.
4. 111e Special Master's authority shall not in,elude the autl"l.ority to condw.:t evidenti.ary heal'lngspl.tfSuant toPed. R. Civ. P. 53(d) and18 U.S.c. §3626(f)(1)(A) & (6)(A) or to iss'ue fmal orders pursuant to Ft:d. R. Civ. P. 53(e). The Court shall nt all times ret;;lln the authority, uponnoti.ce to the parties and opportunity to be heard, to reject or adopt in wholl; or in part, the Sp:ecial. Mastel·'s reports and prol?os~d orders.
5. This appointment i9 made pursuant. to the il.lherent powers of the Court. the PLRAJ Rule 53 of the Federal Rules of Civil Procedure, al:.d the orders of the Court.

MAR-23-2005 17:03 FROM:

13407753474

TO:202 514 0212

_ YtAR-23-2006 THU 04:40 PM Ju~ge Cannon

FAX NO, 3407735416

P.8/33
p, :J Inti

Ul'lit~d Sf.t1.t.es u, Tc:rritory of :llc Virgin I~l,)!ds
1986·CV-0265 
 Orcier Grantil"lg-United St::ltes'iMotloli to Find Defendllnt in Contempt 
 PZlge 7
P:urS\.1Z\:n~ tQ Rul.e 53 of the 'Federal Rules of Civil Procl2dure, the Special
Mastel' shall proceed with a111'easonable diligence, 7, p"L.u'suant to the PLRA, 18 U.s.c. §3626(£)(6), and Rule 530.£ the Federal Rules
of Civil Procedure, with !;he exceptio,n ofmini.steri~l:r.on-sub.5tantivemattersre]ated to, for
example, scheduling joint meet1l."lgs or telephone calls, obtaining contact information, Ot' providin.g for schedul:ing changes, the partil2s shall nor contact the Special Master OIl an~ t;:!arte basis, and the Spe~ial Master shall not contact the parties on an ~ parte basis.
8. Witb, respect to a.'1Y joint meeting conducted by the Spt:cial Maste'!' with the parties, a party may 't"aive it$ right '~o appeal: 01' may appear telephonically rathE!! than in person. In the'event a party :l.'ef1.1.ses or fails to appear upon reasonable notice to the party. the Special Master and any parties that do appear shall make note of the parties who did
not appeal'.
9. Pursuant ro R\,lle 53(g) of the Fed~l'nll{1.l1es of Civil Procedure, the Special
Master's recor.n.mendatlbnsand propo:)ed orders shan be reviewed by the Courtbased. on ~ clearly l€ 'roneO\lS stan~ard and shall be determined by ashowing of clear and convinc:ing
evidence.

MRR-23-2006 17:04 FROM:

13407763474

TO:202 514 0212

MAR-23-2008 TKU 04: 40 PM Jud!ge Cannon

FAX NO. 3407735416

P.9/33 
 II, UtI/.iiI

IJllited S/ClL'es v. Tel'l'irory af th~ Virgin I:;!,mcis 


1986-CV·026S 
 Order Gr:lnting

United

Statc~

Motion

to

Find

D(!·fe.nd:t.nt

in

Contl!'mpt




'P:Il~e E 


10. Pursua.l'l.ttothePLRA 18 U.s.c. 93616(£)(5), eveJ:Y sixmonthE, the Court shall j
conduct a review of the ~ppointnlent of the Special Master to determine whether his/hex

services con.tinue to be required,
11. Tile Sped2l;1 Master may be removed on. a basis unrelated to 18 U.S.c. §
3626(£)(3) &. (6)(D) orJy for good cause lmrelated to the Special Master's findings or rp.commendatiol'lS. Unless the Special Master i.s terminated pursuant to 18 U.s.c. § 3626(£)(5) &; (6)(D) or purStlant to Defendants' achieV0ment of sustained substantial compliance with each provision. of the orders of the C01.1.rt, terminali.on of the Special Master shallre5ult in re+il'l.itiation of the appointment pl:ocess d(:!scribed in this Order.
12. As used in this Order, substantial complia.nce means Ddendants; puxsu;mt to this Order and the or¢lel'5 of U1e COttrt, have consis tently complied 'v,Jith this Order and the ordel:s 0.£ the CO\.lrt and properly operated and will continue to opel'ate Golden Grove p1.1IS'lUmt to this Order, the ol'ders of the Court, and constitutional and federal sta.tutory
requirements such tha.t the Court does no t l'e~sonably fOl.'esee th2l.t temunatiorL of oversight:
y.,'m result in the disl11aJ.1tlement of tb.e changes at Golden Grovel any actionby De£endants to tmderm:ine improvements made at Golden Grove, or a hindrance to Defend ants' future
$\.tbstantial compliance with this Orchar and the orders of ~he Court. ~oncumphance witl·'. mere t~chnicali ties Oi' l't$mpOl.'al·Y £aih,'r~ to comp!y dtlring a perlod of otherwise sustained

MRR-23-2006 17:04 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04:40 PM J~dge Cannon

F~X NO, 3407735416

P.10<33 

p, 08h2

United States v, TCl1~to''!I of the Vil'gm Islands 1936·CV-0265 
 Order Gr<lnting United St21trd Motion to Find Defendant in contempt 
 L~age 9
substantial compliance "rill not constitute failure to maintain substantial com.pliance. At the same time, telnpO'fary compliance during a penod o.f noncompliance shall not constitute substantial cot,npliancQ, Defendants' unilateral implementation of best practices
will not Inadify the mean.ing of substantial c;ompliance. 13. Failure by' the Court the Special Master, ex-perts, consultants. and staff
retained by the Special lyfa5ter, or the United States to act upon or enforce any PaIt of this Order or the orders of the Court or any provision thereat with re5pect to any deadline or
any provision hel'ein shall n()t be constrw~d as a wai ve( of the right to enforce or right to
recoml"l'1.el"'.d that the Court enforce deadlines and provisions in this Order or orders of the
Court. C. Duties 

In addition to the duties described ClboYl:, the SpeciGll Master shan: 
 1. Within siXty (60) days of tlle appointl11ent of a Specitll Master, promptly
or conduct a thorough initial review and assessment of all aspects Defendants' compliance
with the orders af the Cow:t. This initial review sr.all inchlde a tour and inspection of Golden Grove wit:.1-t experts in conectional management/penology, correctional medical CElr~, :forensic psychiat11y, and fire s~.r:€.ty ::u"td environmente\l sanitation. This tour shaD include a review and assessment of securiLyI correctional, penological, medical and mental

MAR-23-2006 17:04 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04: 40 PM Juci!sc Cannon

FAX NO. 3407735416

P.11/33 
 P. lU/~c

Uni"f.ed StaCCS '0. Ttn'l'itil1"Y of Ihe Vi-rgiJ1 J$IClJld.~
'1986-CV-0265 Order Granting United States' Motioll to Fmd Defcndnnt in Contempt Pug;c '\0
h~alth c~re, and fixe safety arl.d environmental sanitation conditions at Golden Grove. The
Special Master shall be preseat at, take pent in, and give reasonable notice, to the parti88 of
this initial t01.tt and inspection. 2.. Cond'uct fUture t01..11'S and inspections of Gold8:ri Grove with experts in
correctional n'lanagement/penology, co:r.:t:G!ctional med.ical care, fOl.'ensic psy duatry, and fire
safety and envi.ronmental sanitation, not less than six (6) ,:months from the conclusion of the
initi?l review a.nd a9seS3ment descrIbed in Section C(l), and every six (6) months ther~after. The Special Master shall be present atl take part in, and giVe:! reasonClble nolice -to fhe partiC:'s
or eac:h tOt.11' and inspec.t'ion.
3. Wlthil1 ni~ety (90) days of the con1pletion of each tour and inspection
conducted pursuant to Sections C(l) and (2) of tills Section, the Special Master hirnJheJ:seIf
shall conduct a tOl.l! and inspection of Golden Grove to review and assess the conditions <It Golden Grove and determtne, if Dei0ndants are in. compliance with any of the provisions
(If the:: orders of the CoLirt. Prim to ~ach tour and :iJ.'tspection pursuant to this subsection,
the Spedal1vfaster sha.l;l (after giving the parties a rC!asonable opportunity to meet and
consult with the Special Muster) detennine which of the expeJts described inSections e(l) and (2) of thiS Sectio.n shall accompany the Special Master on each tour and inspectiOli
cond"'lcted pursuant to Fhis subsection. In addiLion to the 0tJpommity to meet cmd consuJ,t
,

MRR-23-2005 17:04 FROM:

13407753474

TO:202 514 0212

MAR-23-2D06 THU 04:41 PM Jucl~c Cannon

FAX NO, 3407735416

Ull'itccl St"l~ v. Territory of the Vitgin. J:olmuls
1986-CV·0265 Ol'd8r Gr'lntlng United States' Motion La find Ddendant in Contempt Page 11
as described inthis 5'\.lbse¢tiDn, the Special Master shall give reasonable 110tice to the parties
of each tour and i!lspectipn,
4. In ordeJ: to $.ssess compliz,nce, the revlew of a sLlfficient number of documents
and ma.terials to assess a~curately CLll'l'ent conditions shall include the following (by way
of example and wi.thout limitation on. the Court, th~ Speci~.l MasteL' and e):perts, )
consultants, and staif ;retained by the Special Mastel', or the pmties): dOC1.tmentsi
rriemOl~andai logbooks; reportsi inm,atc and staH files; incident re.ports; investigation
rep01'tsi sll.akedo'Vv:n/contraband reports and logbooks; st?£fing schedules, mstersr an.d
records; tl'aining Ncords and cl'u'ricula; medical ['epoIt~; medicaJ and/or mental health care
charts rE.'Col'ds, and files; intake and assessment forms; chronic care documentation and
j
logbooks; medical refenal and transport forms, logbooks, reports, and records; mental 

health care 9Cfeening, assessment cmd referral forms, logbooks, l"eports, a.nd records; 
 j
inn"late death., suicide,. suicide. attempt.. and sl1icide. monitoring and watch policies, 

procedur.es, log'books, files, records, and repol'ts; mall1.tenance, repair and replacem.ent 

records, for.ms, and documen.tation for fire, a.larm, safety, seemi ty, plumbin~ e1eclrical, and 

stru.cturalsystems; major repair and improvement plansj docuroentsj and :reco:rdSi policies, 

procedures, document~, and forms :related to development aDd implementation of pOlici(!$ 


~_MAR~23-2006 17: 05 FROM:

13407763474

MAR-?3-2008 THU 04:41 PM J~Jge Cannon

IU:i::I::li:: :;,lQ 1::10=10=
FAX NO, 3407735416

1""' • .L")' ..)..)
p. 12/31­

Unitt;d StMes v. Trm'itfJl'}J of the Vi'l'gil'l /sJnTlds 

1986-CV-0205 

Order Grilnting 'l':nited States"Mo t!on to Pind Defendant in Contempt 

Pilg~ 12 

and procedures; complialnce, quality aSsurance, investigatory, Zludit documents, Elnd any other documents or mat¢rials relevant to the operation of Golclen Grove.
5. Based upon each review Zlnd, ass~!lsment in conjunctio::l with the e;.cperts
retained by the Speclal Mastet, recorru:nend to the Court, in the forn:t or 3 report as described i:n this Orde.r, findings of non-compliance, p3rLi.al cornpHance, and/or sustali1ed substantial compliance,?s the recornmendation(s) may be, with all or part of the ordel:s of
the Court. 6. RecoD1rneild to tb.e Court, i.n the form. of reports as described in this Order,
the $p~cific remedial It1easures that tbe Court 11"\USt order Defendants to implement to
ensure sustained substantial compliance \.vith ~he orders of the Court. 7. Provide techrucal assistance (in conj1..1.rcction wlth retained experts) to
Defendants and their ag,encies, officials, and employees responsible for implementation and compliance with the orders of the Court. Provision of tedtrt.i.cal assistance shall not preclude the Special Master's or a Special Ma.9ter's expert, consultant, or sla.ffperson's determination th"t adqJ.tional remedial meaS'LlreS are necessary to comply with the orders
of. thl!! Court or that Defendants have dCli.'\onstrated s\.l~tained Sl.lhstanl'ial complian~e wi,lob.
the oIders of the Cour,t. When the Special Master o.t the experts retained by tlle Speci.:U

MAR-23-2006 17:05 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 1HU 04:41 PM Jud~e Cannon

FAX NO. 3407735418

P.1W33 
 Po Li/.Ji:

lfllired StoleS v. Teil-irory oftr.e Virgin j'sin.",a. 1O9l8d6~·rCVG.r.aQl"2l6ti5n
g UJ1iled St::ll;eS' :v1otion to Find Ddendant h\ Conrcmpt 

Pag~ 1:)
Master provide technica.~ assistance, such technical assistance shall be described mthe
Special Master's or experts' reports as further described in tlils Order 8. Conduct a D.1onthly meeting of the p'lrties to discuss the status at
proceedings, outstanding matters{ a.nd 1..1pcomil1g even.ts. The Special Master and the
parties m.ay conduct the monthly meetings il'l."person at a mutually agreeable 1oc:ation or
telephonically and the Special. Master or a party may appear telephonically loathe.r than iI'l

per.son, 9.

Prepare sti.ch reports as dl'L'ected ¥-L this OJ:del' and other orders ill the Court.

D. Powers of the Speci~ Master
J~.lJ actions of the Special Master and the Special Master's consultants, experts, r.ll1d

assistants will be under. thE direct control and supervision of this Court pursuant to Ute
orders of the Court. Specifically, and not by way of limitation, the SpeciFl..l Master and '~he

Special Master's consultants, experts, and assistants shall, without iurther orders o£ r.ll<?

Court/have:
1. Complete and unrestricted acclZ!ss: (a) to visit, to\.l:(, and insped the faciHtl~s
at Golden Grove; tb) to management, staff, and personnel (whether party or non-p<!ll'ty,
employee, contractor, qr affiliated person. or agenty) of Defendants and Golden GI'vve; (c) to any inmate, detall'lee, or other illdividu.al held at Golden Grove; and (d) ail documents,

MAR-23-200617:05 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04:41 PM JL.idge Cannon

FAX NO. 3407735418

Ultit.:d. Slates v. TL1'ritory oft/w Virgin Isltmds

19S6-CV-0265 
 Ol'deI Gran ling

Umted

S~il

ccs'"

Motion

to

Find

J)e[enoOlJ'it

in

Contempt




PGlgc:: 14:

records, files, reports, memoranda, correspondenc0, plans, notices, budgets, compl.13l1.ce, q\lality aSS1.1ran:ce, investigator), reviews. and documents and matena1s described in Section
C(5) of this Order and any other documents relevant to the operation of Golden Grove and

the Special Master's dut~es, 2. Authority to attend meetings or pl·oceedin,g[. regard.ing subject matters

relevant to Defendants' complia,ncc!:' conducted by, at the diredion of, or attended by management staff, al."td ;personnel (whether party or non-party, employee, contractor" or

affiliated persO.tl. or agericy) of Ddendants.
3, At any tinie plior to, during, or after c.onducting a review and assessment,
m.t:thority to rec~ive and review Defendants' and Golden Grove facility docume1'l.ts rmm
counsel for. mal'l.agemeJ;lt.. st~f, and personnel (whether party or non-parly! €mploye~,
con-h.-actor, or affiliated persan or agency) of Defendnnts or Golde:n Grove. \Vhenever such
docum~nts or other materials are produced 01." delivered to the Special Master nnd the
expe.'ts consultants, tltid staff ret(\ined by the Spedal Master (and the parties as set forth l
in Secti(.;m 1(8) of fhis Order), the Defendants and thei~ compliance coordinator (as
described in Section 1($) or this Order) shall produce documents or materials as they are
k~pt in the ordinm'Y COI..1fse of bUsoless and shall identify ~ach document (by sequcl\LtG\l numerical stamping) to ens~tl'e the C01.lItl the Special Master, the experts, consultants, and

MAR-23-2006 17:05 FROM:

13407763474

TO:202 514 0212

MAR-23-200B THU 04:4i p~ Judge Cannon

FAX Na 3407735418

P.16/33
P 1 , r.,);j".j;..i..

UJ1itca 5~(llc,: u. TmiJorJ oft'r.e Virgil11s[r.nd::
1986·CV·0265
Orr,j,:t Granting ~nitecl Stat(:s': Motion to Fll1d De[ino,mt in Contempt Pag()'lS
staff retained by the Spec;,al Master, and the parties a.re able to readily identify each 

t:locLUnent without f:€ gard to the information conl'i:lined therejI'l.. 
 (1. According .to th~ procedures set forth in this Order and the orders of '1i1~ 

Court the Special Master shall l't!tainj at Defendants' expense, consultants, experts, and 
 sLaff to assist the Special Master to cc\l'ry out the powers, duties, and responsibilities of this 

Order and other orders of the COl1rt. 

E. ConsuJ.t.mts, Experts and Staff
1. The Special Master shall retain consultants, experts, or staff after joi.,."'\tly 

confen"i.ng 'INi.ch the parties regarding the proposed consultant, expert, or staffpcrson. 
 2, While joiliHy conferring, t.~e parties and the Special Master shall include in 

their disc\.tSS10llS the approximate total fee9 ,n"td expenses to be paid by Ddendants. 1112 
 " 

paxties :md the Special ~astcr also shall consider infom1~ti.01i. rega,rding the candidate's 

previous experience working with C\ court, other governmental agencies, and a Special 
 J:..1aster, or other form of compliance moni.tor, The Sp~cial Master and the parties also shall 
 consider previous q1.1(l4fication(s) as an expert in territori~l, :>tate, or federal courts. 

3. A proposed expert generCl.lly shall 11 ~ve cxpe.ri~nce and ed u.ca tion OJ: training 

ot reI~vant to th~ir field <i.'Xper tise W'ithparticular emphasls on correctional and/or detention 

facilities 'With the approximate .inmate and detainee capacity of Golden. Grove and also shall 


MAR-23-2006 17:06 FROM:

13407763474

TO:202 514 0212

-----,
MAR-2'3-2006 THU 04:4i PM Judge Cannon

FAX NO, 3407735416

t-'.1(/")")
p, 16/:1:::

!.171i1.ea SI:ales v. 'ferriti3ry ojtlte Yh'giJl Is/antis

:I. 9 S6·CV -0265 Ordel. Gr3nling

United

Stat~"

Mo

hot'

to

Find

Defend;mt

In

Contempt

Page 16

be a.bl~ to prepare detaiJ,ed written reports to the Special Master, work with a team. of

experts, consultants, ancl staff, and provide, in addition to and in conjunction 'With the

Special Maste'r and other retained experts, consultants, and staff, technical ass'ist;;u:tce to

Defendants pursuant to 'this Order. 4. Within 10 q,ays of l:he Special Master's request that the parties jointly confer.,
the pc:t1"ties and I:he Speci~ Maste:- shull jointly, 01' if tmable to agree, severally, submit their
recommendation(s) to the Court for a proposed. consultant, expert, or staffpel'son in the forrn of a proposed order directing, at a minimum, the Special Master to retain such consultant, expert. 01· sta£fperson atDefendal"lts' expense and the fees, costs, ali.d expenses
of to be l?aid pursuant to Secti.on}{ this Order.
5. An ~:xpert, C011S1.1ltan.t, or staifperson may be termi.nated if the Speci,<ll Master and the parties agree anp. '.lpon good cause shown. Good cause shall include any violation of federal, territorial, or loc<lllaw, this Order or t.1rte orders of the Court, thClt reasonably calls into quesdon th.': expert's, consultant'5, OJ." staffperson's fimess to contU.m.e to se.rve the SpecialMaster, In the e'Vent the parties do not agree upon the need for termination, a party

may move for termination. 6. 1£ an expert, consultant, orstaffperso:n. is terminated pursuant to Section 8(.5)
of th.is Order or becomes unavailable,the Spec.iCll M~ster and the parties shall determine

~R~23-2005 17:05 FROM:

13407753474

TO:202 514 0212

MAR-23-2006 THU 04:41 PM Judie Cannon

FAX NO, 34077354iG

P.18/33
P. 17/32

United. 5trrws v, Terti!ory of th~ Virgm lsl.and,.

1986~CV -0265 
 Ol'cier Gr:loung

UnIted

State~/Moticn

to

find

Ddcndant

in

Contempt




P<lg~ 17

jointly Vlfhe~her a teplacement is needed, and 1£ sp, jointly select a replacement within

fifteen (15) days of the expert's, consultan::'5, or sti:l££perSOll's unavailabilily, In the event

that the parties do not a;gree 'upon the need for or id.entityoi a replacement, the parti.t::s
agree to utilize the selaction. proce:ssfor e~pertsJ COI1S1.litants, and staff as detailed in this

Order. 7.

If an expert, CQrlS'UHCU1t, or staffpersoI\ is termi:nated pursuant to Section E(5)

of this Order or b~comes unavailable, the applicable provlsions of this Order shall be toll~d

or for. any period time greater than the fifteen (15) days that itta}(es {01' the Special Master

and the parties jointly to select a replacem~nt to begin p~dorl1l.ance of the expert's,

consultant's, or. stafiperson's obligations pursuant to this Order, Anytime tolled pursuant to this subsection shall notred'..l.Ce the number of tours and inspections required under and

r.:ondLlcted pursuant to ;Sectiol"l C of this Orde.l'.

F. Reporting and Recommendations 1. Following each rQview and assessment conducted pUJ:Sl.lMt to Section C(1)­
(3), the Spedal Master ~'1d the Special Master's expeds, consultants, and staf.f shall prepme
a corr'lprehensive writt~n repol't for the parties and the Comt.
2. Within si~ty (60) days of the conel", si~m of any 'tOl.ll'l:ind :inspection conducted P1.1rSUeU'Lt to Section C(i)-(3) of this Ol'del~ the Special Master shall file his report (mcluding

----M-.AR-23-2006 17:06 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04:41 PM JI.:c1ge Oannon

FAX NO, 3407735418

P.19/33 P. 1I:V::V

Ullited StIUr:S v. Tt'/'J'itory ofthe 1/ir:ifJ Isla.nd:;
J.986-CV-0265 
 O]:ci.;r Cr<111tU\g Uni!l.':ci States' :Motion t4.l Find D~(~ndant in Contempt 

POlS!: Hi 

the G)xpert repoL'ts descri\;led herem) with the Court and serve copies oE his l'eport and the expert reports UpOl'l. the pGlrties, The experts) consultants, and staff retained pursuant to thi~ Order arc directed to prepare their expert report.s to ensure the Spedal Master's compHance with this subsecdon and Sections F(7) and F(8) of this Order. In the event the Special Matlter or the Special Master's experts,_ consultants, or staff, reqUE!st the duplication and productioll o,f dO'Ct.unents during a. tour and inspection and Defendants fail to deliver such docum.ents within l1iteen (15) dClyS of said tOi.tr and inspection, the Speciall1.1.astet, and the releva'!1t requesting ~xpert, consultant, or staffpersonJ shall note in their report{s) the Defendants' delay and, may determine, based on t~,~ failure to timely deliver s'Llm documents, t!:\at Defenc1ru1ts are not in sustained substantial compliance with the orders of the Court,
3. Where it is the recomm~I"\dation of the Special Master that th,e Court issue
certain ordel'(s), the report shaH il'lclLlde a proposed order.
\
4,. Consuitattts, experts/ and staff also shall prepare written reports ("expert reports") to the Special Ma...:;ter to assist the Special Master to carry out the powers, dutid, and responsibilities of this Order and other orders of the Court and to assist the Spt!cial Master in preparing the Speci.al Master's report. The Special Master shall include the

MAR-23-2006 17:07 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04:41 PM Jud~e Cannon

FAX NO. 3407735416

P.20/33
p, 18/j(!

LImt~d Statcsp. Territory of the Yi,'g:n Is1:r11:i~ 


1986·CV-0265 

Order GI<lr,l'ing

Unlte,d

St;l.t~·'

Motion

to

Find

Defendant

in

Conte;npt




p;tge 19 


expert l'eports as part oflilS repo1't and ['he ~xpert reports sha.ll be considered illCorp01'ated

by l'eierence into the Spe.cial Mastel"S report. 5, Each of the SpecialMaster's repcJlts and expert reports shan describe ill detml:
(a) the work periormed; (b) tours C1nd inspections c;onducted; (c) m.eetings attended; (d) perso'l'iS il'Lterviewec and those personS met with pl.!rsuant to Section C(4) of this Orderi (e)
documents requested, received, and l'~viewed (including a d.escription of the number,
types, identifying infot'l'l1ation, and date ranges of d6cuments S1.lch a.s: [number] ofincident
reports from [date] to [9,1l.re] l:evi~wed, patient charts of [patients A.B., c.,[)., E.F., etc-J, [number] of inn,,1 Ie files out of a pOp Lllation of [t.o tal population of facility], maintenance
records from [date] to [date) for [machine/area/system], policies and procedures for [area of operation], trairung records of officers [U.V" vV'x', Y.Z" etc.], [subject area/office/officer's] log"book); (f) the steps tal<enpursua:n.t to Section!) C(4)-(5) o£this Orde.:' :in order to aSsess com;pliance; (g) the subjective and objective criteria used to make reCOIDlnendations and findhlgs; propose remedial measures and ordersi and rlssess and determine substantial compliance, non--cornpliance, or partial compliancej (h) the steps taken to analyze conditions and assess compljance and the factual basis for each findrng;
(i) any other a.dditional assessment crir.eri~l used i.n lhe expert's, consultant's, and
5t~ffp(!rson's area of expertise where, pur.suant to Secti.on C(4) of tb,is Order, arl. experl:.

MRR-23-2005 17:07 FROM:
-----,

13407763474

TO:202 514 0212

MAR-23-2006 THU 04:41 PM Judge Cannon

FAX NO, 34071254i8

P.2V33
p, 20/32

Unitt:!! Stales v. -territory of the Virgin I,]allas
1986-CY -02 65 Order Granting United States! MOlLen to Fi11ct Defendant in Contempt Page 20
cO:1Eultant, 01' staffpersol1 retalned by the Special Master used such additional assessment criteria; (j) any technical ~S5ist~nce provided to Defendmts; (k) steps tak~n by Defendan8 to implement the ordetslDf the Court and comply wi.th any remediCll measures ordered by the Conrt; (1) specific reference to the provisions of this Order EUl.d the ordersof the Court ill'.plem~nted or not implemented by Defendantsi (m) tiLe Special Ma.s"tet.'s ox expert's evaluation of the extent to which Defendants have complied with 03Ch substru.i.tive remediaL measure or provision of the orders of the Court.
6. If the Spe~al MCl.ste.r or 4.'Ui expert, consultant, or sWifpC!50n ret<llned by the
Special Master det~l·mines th~,t Defendants are in sustain.ed substantial compliance with
any provlsions of I:his Ordel' or the orders of the Coul't, the Special Master, expert,
consultant, or staffp;;rs~m shaU so state in his written :r;eport and provide the factu.al baSIS ror the .findings, includij'\g, as appropricltc, identifica.tion of the details genetally described ill Section F(5) of this Order and any o·th@l" information, details, documents, or evidence which supports the Special Master's determination that the Defendants are in sustained substanl'fal compliance. Upon notice to the parties, 0ppOl'tLtIuty to be heard, a..l1d order of
the COllrt, review and assessment of th::lt provision of the orders of the Court shall be. S1.tspended pending .aitherthe motion of CI party for reinstaten1.ent of review and assessment or the abrogation of this Order.

MAR-23-2006 17:07 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04:42 PM Judge Cannon

FAX NO. 3407735416

P.22/33
P. 21/32

United Stlltes v. Territory oj the Virgin 18umds

1O~r8d6~·rCGV-l"0a2n6tl5n.g United States' MotiOn to Find Defendant in ConLempc 


Page 21

. 


7. Pdor to the Special Master' 5filing ofthe Pl"oposed report.. expert :reports, and
any proposed order(s) witli. th~ Court, the Sp<=cial Master shall provide copies of th~
pl'OpoSd€ repOlt, expert repOl."tS, and. any proposed orde:r(s) to the parties for l'eview and comment. The Special Masttl' snaU allow no more than ten. (10) days for review and

con'tment p=-ior to filing y,rith the Court. 8, Within ten (10) days of filing of the Special Master's proposed repol·tand any
proposed order(s), the pal'ties shall submit to the Court any agreement tvich or objecbons to the Special Master's report and/or proposed order$. Upon review and consideration of
any submissions by the parties, the Court shall d~tefmil"le whether to adopt 'the Special
Master's repoJ:t, in who)e or in part, and whether to issue any proposed order(s). 1111? failure of 3. party -to file any objection(s) to the Special Master's repor.t shan constitute agreement with ilie l'cport '\lId, if the Special Master has submitted a proposed order(s), consent to issuance of tk'le proposed order(s) as an ordcr(s) of the Court.
9. Prior to d~termining whether to adopt the Special Master's report, in whole:

or il1 part, and whether: to lS5ue any proposed order(s), the Court may, upon request or
when deemed appl:'opri;at~ hold a hearing at the earliest convenient time after no tiCI:! tel a.E
parties. Such hearing s):l<ul be condncted as the Court deems appropriate;,

MRR-23-2005 17:07 FROM:

13407763474

TO:202 514 0212

_--i
I1AR-23-20o.6 THU 04:42 PM Judge Cannon

FAX NO, 3407735418

P.23/33
t', (./1.=-(

UJlU:di 5tMe:; v. Territory of tho Vil'gi'/l [~lartcl$ 
 lSl86-CV-D?65 
 Old,,! Granting United 5l£ites' Motion to Find Defendant in Contcrnpt
Page 22
10. The Spl:..'Cial Master's report and any expert reports 6hall, as needed, "be writtel't with due regard f.o! the privacy interests of individual inmatt!5 and staff. AD nO1"\.­ public information obtai-ned. by the Special Master and the Special Mastees experL1:i,
consultants. and staff shall be maintained in a confi den.tial ma..rmer. 11. Once issued as orders of the COUl't, the Special Mastl2r'S repol't (together with
ro\y expert reports) shall be ente1'ed into the Court's docket. 

G, CONFLICTS AND DISCLOSURE 

1. Nothing herein shall prevent either Defendants Dr the United States from
retaining consultants, experts, and staff to aS5ist in their defense or prosecution of this ca~\~ or in t:l"leir efforts to achieve DefeI'l.dants' co!npliance "vith the orders of the Cot.1rt and
evaluate such compliance, 2. "Ex:~ept a.c: permitted p"..1tsuantto Section G(4) of this Order, no party, nor any
employee or agent of ahy party, sbClJl have any supervisory authority over the Special Master or the Special Mastt:I's experts, consultants, or staff's activities, reports, findings, Of recommendations aI)d in no eve.nt shall any party, nor any employee or agt:nt of 2(ny party, have any superVisory autl:lority over t11e .special Master OT the Special Mastt::r's expl£!rts, consultants, o:r staff's ~ ctiv.i ties, l"epcll'ts, find:iJ.'\.gs, or recommendations regarding

MRR-23-2006 17:08 FROM:

13407763474

TO:202 514 0212

MAR-23-200B THU 04:42 PM Judge Cannon

FAX NU. 3~O,(,(3b41b

P.24/33 
 r'. :';,j/ .:.~

Unitad States v. Tcrritetnj of the Vil'gm I~iJmds 


1986·CV-0265 
 Order Gl'm"ltLnS

United

Stat:esl

MotiCt'.

to

Find

D~fendzmt

i,"\

contempt




Page 23 


the subject mattel' of thi$ l~:wsuit or review and assessment o.f the conditions at Gold~n

Grove. 3. UnleE:s such conflict is waived by the parties and ordered by the Court, the
Special Master and the Special Master's experts, consultant~, and staa shall not accept employment or provl.de ~ervices for any matter relating to the subject matter of this lawsuit or the conditions at Goiq.en Grove, including being retain(;:d (on c'l, paid or unpaid basis) by any (\.u'tent or future ]~tigant or claimant, or such litigant's or claim.anL's attorney, in connectionwith a claim 01' suit against Defendants or the Virgin Islands or its departments, officP,rsr agents, or empioyecs regarding the s1.1bject matter of this lawsuit or. review and
ass.essment of the conditions at Golden Grove. 4. Neither the Special Ma.&terl nor the Special Mastel" 5 experts, consultants ar
staff, Cl..l'e bal'red from acc;epting em.ploy.aent or pro'V'iciiIlg eXPGl't or consulting services for matters tl;.at are not l"l~kited to the subject n"l.atter of this laws(.tit 01' review and assessment
of the conditions at Golden Grove. 5. Except as required or authorlzed by the orders of t1.l.~ Court, the SpeclAl
M::tster and the SpecialMaster'~ exp~ds, consultants, and staff shall not, with ~e exception o.f filing5 with the Court and gtMements in open Court, ,mC:Lke any public statements Ot stuter.!'le.n'ls lo the press regardjlig this matter, the work perfolmed pursuant to 6~ orders

MRR-23-2006 17:08 FROM:

1340( (b..:S4 (4

l'lAR-23-2006 THV 04:42 PM Judge Cannon

FAX NO. 3407725416

p, 241:32

United StMes 'V. Tr.r7'iIOrd of the Vil"gm ls14nds 
 1966-CV-0:265 
 Ol'der Cr::mti!1g United States' Molion to Find ])¢fr:ndant in. Contempt l)age 24
of the Court regarding this matter, or any observ()tions, statements, conclusions, recommendations, or fil\cHngs iI", connection wlth this mal:t:T€ or disclose any :iJ.uormation to anyone othel' than the COt1L't, the parties, or othel.' exper ts, consultants, and sta.ff wol'ldng with the Special Mastel: pursuant 'to U'\e orders of the Court.
6. Other tl1Clp this lawsuit and only as between the United States and 
 Defendants, the Special Master and the Sp~ciaIMastel" s experts, consultants, and staff sb.a.ll 
 not testify regarding .~l'ly matl-er or subject tha.t h.e or she may ha.ve leamed as:l result of 
 his 01' her performance pursuant to the ordEll:s of the Cou.rt. In this l..:1wsuit and only :1.S
 bebvcen the United States and the Defendants, either party may call tIi.e Special Master or 
 the Special Master's experts, cOllsultartts, and staff as a witness. In connection with the 
 lawsuit, neither party will call the Speci~l Ma.s:er or the Special Master's exp~rls, 
 consultants, and staH a$ their own expert or d.esignate such person as their own ex.p01t 
 pursuant to t'b.e Federal R1.11es ot Civil Procedure. TI:le scope and puiJ'ose of the Special 

Master or the Special Master's experts, consultants, and staff testimony shall be left to the 

discretion of !:he Court. 
 7. Other than in this l<1.wsuit and only ~s between. ·the United Sta~s 2mJ 

Defendants, reports iSS\led by the Special Master, inc11.1ding exper: !€ports J shall not be 
 adm.issible AgainstDefendants in any proceeding fol' any reason.. In this lawsuit as betwt.~eL'l 


MAR-23-2006 17:08 FROM:

13407763474

TO:202 514 0212 


MAR-23-2006 THU 04:42 PM Judie Cannon

FAX NO, 3407735416

P.26/33 I), cb/:';I

Unitt'a St([t~ v. Tc'1'/'itory 0/ the V{rgin l'slnnrls

1986.CY"[]2.65
 Order Granting

United

Stat<::s~

Motion

to

Find

Defendant

in.

Contt!l1"tpt 


Page2S

thE:! United States and Defendants, the admissibility il"lto evidence of the Special Mast:€ /:> reports, including expett reports, or portions thereof, shall be Governed by the Federal Rules of Evidence, and the pm·tics reserve all rights e.ither to 5€ek Z1dn1lssibmry 01" object to

admlssioility of those reports, 8. the Special Master and the Special MasteJ's experts, COl1St.l1tants, and staffare
appoir.ted pursuant to the ordel's of the Court and a.rc not a federat territorial, state, or local agency or an ~gent thereof, and G1ccordingly, with the exception of filings with the Court mid records introduced in open Court, the records maintained by the Special Mas ter and the Special Mas ter's expel' ts, consultants, and staff shall not be deemed public record.s

subject to pubUc inspection. H. Costs & Expense,s
1. PurSUa:!1t ~o the PLRA, 18 U.S.c. § 3626(£)(4), and as described in Tnore detail

. below, the Court shall pay the Special >.1aster's fees, plus reasonably incurred costs cmd

exper.ges, as described ii1l'l'lOre deta.il below. 2. Defendants shall pay each of the Special Master's retained consulwnts,
expel'tS, 01" ::>taff a daily ~ee, plus reasonably incurr.ed costs and expenses, as de!:icribed in

more detail 'below.

MRR-23-2006 17:08 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THU 04: 42 PM Jlldge Cannon

FAX NO, 3407735418

P.27/33 

r. 2tl13i

Ur.ited St~ltes tI. Tel1';~orll of the Virgi)l :s/((17.d; 1Or\:dl8~6l'-CGVra-[0\2t6ll5"t~ Umted St~tt:$' Motion ro Find Defendant in Contempt 
 Page 26 

3. In. addition to the abovementioned fees, Defendrults also shall pay reasOi"table
trat\Sportation, travel, lo:dging, meals, a.nd incidental expenses for the Special Mast~r'::; consultants, expel'ts, 01' $taff as well a5 reason~.ble: mai1jng, facsiro:ile, and photocopying expenses. In determirung ~'easonable expens~$J the Court will consider prevailing
commercially av<rilable costs for travel to, lodging in, and wod< in the Virgin Islands, as
weD as United States Government and Virgin Islands Govemment cune:n.t per diem, meal,
and. inddental expense rates.
4. 01\ a quarterly basis, the Special Master, (jonsulta.nts, experts, tll'ld staff !Jhall
$\.~bmit SepOll'Mely a stat~ment to the Courtfor approval of each person's fees ano expenses
with copies to counsel for all par.ties. The statement shall contain 2t signahue line for the
Court accornpa!1i~clby the statement JJ Approved for Di,~bursement./I Objections·to the statetl.'l(~nt shall be filed within ten (10) days of filing of the s~atement. Heal1.ngs thereon
shall be at the sale discretion of the Court. Any sum approved by the Court shr.ll be paid
within fifteen (15) days unless ordel'ed or agre€d upon.
m.e 5. Within t\A?enty (20) days of dzlte of this Order, Def€ndants shall depo~jt.
with the Clerk of Courti, United States District Court for the District of the ViJ:gm Islands,
Division of St. Croix, to the Clerk's Registry Account, a sum in the amount of $100,000.00
(one hUJ:\d):"t!d~thousand c1.o11clrs), and Defendants shru.l, as ordered by the COlU·t deposit

MRR-23-2006 17:09 FROM:

13407763474

TO:202 514 0212

MAR-23-200B THU 04:42 PM Ju~ge Cannon

FAX NO. 34cr('(3b41~

P.28/33
1". r.:. (/ Jc.

Um~!er.l States v. Tdti~Qry of Htr: Vtl'gin island.$

1.9S6-CV-0265 
 Order Granti.ng

'Cnit~cl

Stntesi.

Motion

to

Find

Defen.dant

ill

Contempt




.Page 27

or 51:1.(.1.1. additional monjes \lS require.d fOl' payment o:f the statements the Special Ma.ster,

consultants. experts, and, :>taff.
6. Money deposited in the Clerk's Registry Account shall not b~ subject to any

Court s1.ll:'cb.arge.s. 7. Money deposited in the Clerk'5 Registry Account sh.all be paid a.ccording to
this Order and the Ol'ders of the Court and shall be subjt:ct only to the budgetary, allocation, spending, ilnd payment decisions made by this COUl't, pursu.ant to the orders

o! the COl.1It.
8. Witl1 the e~ceptlon of the costs and expenses described he:L'e:in, each patty is

L'O bear its 0'\11111 costs. I. Defendants' Sta;tus Reports, Record Keeping, and Other Duties and Parties'
Coope:ration and Access
Inaddii.ion to the: responsibilities and duties of the parties detailed in this Order and th~ orders of the Court the Court Orders the following:
1. All par.tie~ shall cooperate fully with the Speci::l.l Master. Defendants shall
direct all current and future management, staff, and persoI:U'l.el (whether pal'ty or 11011.­
party, employee, contractor, or affiliated person or agency) oE Defendants and. Golden

MAR-23-2006 17:09 FROM:

13407763474

TO:202 514 0212

MAR-23-2006 THIJ 04:~2 PM Jlld~e Cannon

FAX NO. 3407735416

r-'. c:~:v..:s..:s
t', ("lUi::

United Stales v. Tel'J·irory of the: Virgin fl;ltllld. 

1986-CV·0265 
 Order Granting Unite:t Slates' ,Molion to Find Defend;!f\L in Contempt 
 Page 26 

Grove to cooperate fully with the Special Master cmd the Special Master's experts,
consL1ltants, and stCiff. 2. The Defendants shall ensure that all current and future management. staff,
and persoIU1.el (whe.thel' party or l1on~party, employee, C01\tractor, or affiliated person or agency) of Defendants arj.d Golden Grove 'Lmderstand a.nd foUow the term.s of this Order and the orders of the COUlt (to the extent necessary) to carry out their job dutil:s and
respol1::;ibiHties and to implement the tel1'l1S of this Order and the orders of the Court.
3. Wjth:in ten (10) da.ys of the appointml'nt of a Special Master, Defendants shall designate, in writing, to the Courl:, the Special Master, ond the United States, an individual '.IS a compliance coordiIl.(tol'for the Special Master who shall: (a) accept document requests
from the Special Master on behalf of all Defendant.s; (b) on behalf of all Defendants, bt!
responsible for delivery or docl.m'.ent9 to the Sp~cial Master (as the Special :Master di.reds
ei.ther to the Special Mas't~l· and/or the Special Master's exper:.S, consultants, Dr staff) and to th~ United States; (q) disttibute documents a.nd meeting and tour and inspection schedules issued by the Special Mastel: to c:ach Defendant; and (d) ensure Defenda,nl:J
comply with the Sec.tioIiS P(2) and 1(6) of this Order and the orde,rs of the Court. 4. Defendants shall trtalntain sufficient records to document compliance wi l:h
all of th€ l-equirements of tl"lis Order and the o~ders of the Court and to der.nc.JIl.5trate

------MRR-23-2005 17:09 FROM:

13407753474

TO:202 514 ~clc

MAR-23-200B THU 04:42 PM Jud~e Cannon

FRX NO, 3~07735416

t-'.,j~/,j,j
~. ~~/ ;;I~

L1rlit~d SWt'.S v. Trm'itD'Yy uf the Vll'gil11slllnds 


19S6-CV·0265 
 Ordt!t Gr;mting

L"nited

States'

~otiol1

to

Find

Defendant

il~

Conternpt

Pag~29

sustained substantial compliance with the orders at the Court. Defend.a11ts also shall

maintron (a.s long; as the ol:ders of the Court remaiI"l in effect) any and all.records: (a) l:d

document compliance with all of the requirements of this Order all.d th.e orders of the Court
and to d~monstrate sustained substantial COlll.pli"ncewith the orders of the Court; and (b)

required by the SpedalMaster and the Special Master's experts, co.nsulta.nts, Ot staff or

prodLlced to the Special Master and the Spedal Master's expert9, consultants, 01' sta.£1. The
C01..l1't hereby finds that ~ve:l1 the approximately twenty (20) year h.istory ot this litigation

and the requh'ement that Defel'l.dants demonstrate sustained ':'-Ubstruitial. compliance, the
records desCl'ibed in this sl.lbsection sh~)ll not be subject to Virgu1 Islands' territorial, local,

or othel' !'erord and doc\..\Inent retCl1tion laws, tegulations, requirements, and/or

procedures.
5. Within thirty days (30) days o.f the appointment of a Special Master"
Defendants shalliilc with the Court and serve on the Special Master and the UnHed States
a stal:t.l$ report inclLld~g any supporting documentation, s1.l.ch as p01kies, procedures,
protocols, and tnti.lling m.aterials, delin.eating all steps taken 01' piarmed in the current
reporting period to comply with each sub$t~J'l.tive provision of tb.e Consent Decree, Pl.dll of Compliance, Stipcllated Ag~'eement, and the ord~rs of the Court. Thereafter, Detend.l.lnts

MRR-23-2005 17:10 FROM:

13407753474

TD:202 514 0212

MAR-23-200B THU 04:42 PM Ju4ge Cannon

FAX NO, 34Q7735~IB

r' . ..:51"..:5..:5
p,jUI"1?

United Stotes v. Tdrito)"Y ufthe Vil'gin Isla1'lds 1986-CV-0265 
 Order Granting ULlite.d.5tate1/Moti01'1. to Find Deknd:mt in Cuntenpt 
 Page 30
will file with tiLe Court. ~lid si.t!l've on the Special Ma.ster 1:l.l\d the United States a status
report and supporting d9Cu.mentation. every thi:rty (30) days, 6. v\rhile on.site in t11e United States Virgi:n. Islands, Defendants shalJ. provide
the S?edal Master and his c.onsul tants, experts, and staff w.i th s'ltch ofEce space, equipment
(~ comp"lter, intemet access, copier, local and long distance tcalephone and facsimile access), and support serv~ces tba.t the Spedal Master and his consultruLts, experts, a.nd staff
may reasonably require, 7. When~vel' the Special Master conduds a. tour or inspection of Golden Grove
P1..u's·J.ant to the orders pf the Court, the 'United States and. Ddendants shall have tJ:te opporrunity to participate in S"..lch tot.tr or inspection with the same level of acce<'..>S as th(! Special Master. A party's decision to waive its right to take part in all or part of a t01..1r or inspection shail not preclude future p~.L"ticipatiOl"l i.n any tour or inspection and shall:noL be
used against any party during futtu'e proceedings. 8. Whenever the Special Master or tlt~ Special Master's expertsl consl1ltants, OJ:'
staff receives 01: reviews documents or oth.er materjals pUr9tH1l1HO this Order or the orders of tl,e Court (i:ncll1d:ing. without limitationl dOCl.~ments received or reviewed during the course of any to\.U' and irivestigCltion. pms\..l:;ll.,t to Section C of this Order)r the United States

MRR-23-2006 17:10 FROM:

13407763474

TO:202 514 0212 


MAR-23-2006 THU 04:43 PM Judge Cannon

FAX KO. 3407735416

P.32/33 P. Jl/J2

U/lilt:d States v. Territory pf thtl YiJ'Sill Monds

1986-CV-U265 Order Cranting

United

States'

Motiol'lto

l~lnd

Defendant

in

Contempt




Page 3J 


and Defend.ants 5h,111 receive such dOC'L.lmenls 01' other materials contempuraneously wi~h

delive.ry to the Special MastE:r. 9. If'any unfotieseen cirClItl."tstance occurs which causes a failure to carry out any
pro"\}i~:io:n of th;is Order or the orders of the Court. in a timely fashion, Defendants shall no tiEy th~ Court, the Special Master, the Special Masler's experts, CODSi.t1tants, and staff,
and the United States in ~vriting within a reasonable time ~Ifter Defendants becon'lc aware of the unforeseen CLl'CUmstEll1ce and its impact on Defendants' ability to comply Vvith this
i
Order and the orders of the COL1rt. The notice shall describe the cause of the failure to perform and the lneasL.1~es taken to prevent or minimize the failure, Defendants shall
implement aU i:easonabl~ measures to avoid or miJ.1itnize any such £ailu.r.e. WHEREFORE, it is hereby ORDERED th<lt the United States' Contempt Motil')l\

(Dkt. 154) is hel'cby GRANTED, and Defendants are hereby held in CON1EMPTi the Court hereby ORDERS the appoin.tr.ne:nt of CI Special Master with the responsi.bilities,
duties, Clnd powers set forth in this Ol'der and her0by ORDERS the fur ther relief descl'ib~c1

in this Order. 
 Dated: March 23, 2006

ENTER: 


~~~ ~ .:-"

. .~~

-GEORGw:cANNON,JR.

1).s. MAGISTRATIL JUDGE

'i1/l .
V

- -MAR-23-2005 17:10 FROM:

13407753474

TO:c=i6c= :'lQ i6clc

MAR-23-2006 THU 04:43 PM Judge Cannon

FAX NO, 3407135416

t-'.':'':''"':'':'
f', J'c/:Jf!.

Urllrcd Sfl1l:t!S o. T~n·it.ol'Y ofihe v'il'gi111;.lcmds 


1986..cV-0265 
 Ordmr Gl'anl'ing

Uni~(,:d

States'

Motion

to

Find

DQf0l1dant

il.

CofltempC

P~ge32

ATTEST: WILFREDO F. MORALES 
 Clerk of Court 

'By:
Deputy Clerk

 
 Case: 1:86-cv-00265-RLF -GWC Document #: 541 Filed: 06/09/11 Page 1 of 3

IN THE DISTRICT COURT OF THE VIRGIN ISLANDS
 DIVISION OF ST. CROIX 


UNITED STATES OF AMERICA, Plaintiff,
v. TERRITORY OF THE VIRGIN ISLANDS et al.,
Defendants.

)

)

)

)

CIVIL NO. 86/265

)




)




) 


)




)




) 


MOTION FOR APPOINTMENT OF A RECEIVER Plaintiff United States of America respectfully moves this Court for entry of an Order, pursuant to the Court’s equity jurisdiction and Fed. R. Civ. P. 66, appointing a receiver to execute the terms of the Consent Decree and subsequent remedial orders regarding the Golden Grove Adult Correctional and Detention Facility. A Memorandum in Support of the Appointment of a Receiver is filed herewith. In addition, the United States seeks limited discovery in connection with this motion.
Respectfully submitted,

JONATHAN M. SMITH Chief
LAURA L. COON Special Counsel
s/ EMILY A. GUNSTON ANDREW J. BARRICK EMILY A. GUNSTON Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section

Case: 1:86-cv-00265-RLF -GWC Document #: 541 Filed: 06/09/11 Page 2 of 3
950 Pennsylvania Ave., NW Washington, DC 20530 (202) 514-6255 202-514-4883 (fax)
Angela P. Tyson-Floyd Assistant United States Attorney U.S. Attorney’s Office 1108 King St., Ste. 201 Christiansted, U.S.V.I. 00841 340-773-3920 340-773-1407 (fax)

Case: 1:86-cv-00265-RLF -GWC Document #: 541 Filed: 06/09/11 Page 3 of 3
CERTIFICATE OF SERVICE
I certify that on June 9, 2011, I electronically filed the United States’ Motion for Appointment of a Receiver with the Clerk of the Court using the CM/ECF system, which will send notification to the following:
Aquannette Y. Chinnery V.I. Department of Justice GERS Building 2nd FL 34-38 Kronprindsens Gade St. Thomas, VI 00802 340-774-5666 X285 Fax: 340-776-3494 Email: achinnery@doj.vi.gov
Carol Thomas-Jacobs Department of Justice 8050 Kronprindsens Gade St. Thomas, VI 00802-0000 340-774-5666 Fax: 340-776-3494 Email: cjacobs@doj.vi.gov
Respectfully submitted,
/s ANDREW J. BARRICK ANDREW J. BARRICK Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 (202) 514-6255 202-514-4883 (fax)

 
 Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 1 of 26

IN THE DISTRICT COURT OF THE VIRGIN ISLANDS
 DIVISION OF ST. CROIX 


UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS et al., )

)

Defendants.

)

)

)

)

)

CIVIL NO. 86/265
MEMORANDUM OF POINTS AND AUTHORITIES IN SUPPORT OF UNITED STATES’ MOTION FOR APPOINTMENT OF A RECEIVER PURSUANT TO FED. R. CIV. P. 66 AND THIS COURT’S EQUITY JURISDICTION

I. INTRODUCTION For 25 years, prisoners in the Golden Grove Adult Correctional and Detention Facility (“Golden Grove”) have been suffering in dangerous and unsanitary conditions. For those 25 years, this Court has attempted to remediate these unconstitutional conditions using every tool available to it but one -- receivership. The Territory of the Virgin Islands (“Territory”) and the Bureau of Corrections (“BOC”) have resisted the Court at every turn. Because the Territory and BOC lack the leadership to comply with more than a handful of provisions in the five remedial orders in this case, this Court should place Golden Grove in receivership. Until this is done, prisoners will continue to suffer serious harm from a lack of security, denial of medical and mental health care, and filthy and hazardous living conditions. Significantly, stabbings and other prisoner-on-prisoner violence have dangerously increased in recent months. The Court must take action now to prevent additional serious harm to prisoners confined at Golden Grove. The appointment of a receiver is the only remaining viable option. A qualified receiver will assure that leadership is competent and qualified to implement basic correctional

Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 2 of 26
practices and address institutional conditions that have been lacking for many years. Moreover, the receiver will bypass the bureaucratic morass that has prevented reforms. A receiver will solve this crisis by creating sound policies, procedures, and practices assuring accountability and by addressing staffing and physical plant concerns, to bring Golden Grove into compliance with the Court’s Orders and prisoners’ constitutional rights.
The United States recognizes that a receivership is an extraordinary remedy and is authorized only upon a showing that Defendants are unwilling or unable to comply with the Court’s Orders. The 25-year record of defiance of Court Orders in this case unequivocally establishes the need for this measure.
II. FACTUAL BACKGROUND AND STATEMENT OF THE CASE In December 1986, the Court entered as an Order of the Court a Consent Decree (“C.D.”) executed by the United States and the Territory and other named Defendants (“Defendants”), to address unconstitutional conditions at Golden Grove. [Dkt. 3]. Twenty-five years later, Defendants still are not in compliance with fundamental provisions of the Consent Decree, subsequent Orders of the Court, or the Constitution. The Court tried for almost two decades to enforce the Consent Decree by issuing increasingly specific orders, including a 1990 Plan of Compliance [Dkt. 57] and a 2003 Stipulated Agreement [Dkt. 146]. After 20 years of noncompliance with the Court’s Orders and constitutional minima, on March 23, 2006 the Court held Defendants in contempt, and appointed a Special Master. [Dkt. 224, as amended by Dkt. 231]. Since that time, the Court has continued to work with the Parties and with the Special Master to improve conditions at Golden Grove. In 2007, the Court issued a Remedial Order “to implement specific compliance recommendations of the Special Master and the United States” to
2 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 3 of 26
“address some of the current and ongoing conditions at Golden Grove that contribute to the continued inability of Golden Grove authorities to remedy the findings of contempt entered by th[e] Court on March 23, 2006.” [Dkt. 304 at 3]. The Remedial Order was “intended to provide Defendants a structure with measurable and clearly defined short term goals to urgently address certain of the deficiencies previously identified in this case.” Id. at 3. In 2010, the Court imposed an additional order establishing “one final set of extended compliance deadlines.” [Dkt. 457 at 4]. In this Order, the Court stated that the deadlines and requirements therein would “provide a clear foundation for extraordinary relief, as appropriate,” in the event that Defendants did not comply with it. Id. at 4.
The Special Master has endeavored to assist Defendants to achieve compliance. With input from Defendants, she drafted a Compliance Matrix with due dates for each task to be completed. The Compliance Matrix was accompanied by specific compliance measures. The Parties agreed to the substance and format of monthly compliance reports that Defendants are required to submit. The Special Master communicated with the parties to achieve clarifications of outstanding matters as they occurred. She has conducted frequent on-site visits to the facility, trained Golden Grove officials and provided expert consultation regarding policies and procedures. The Special Master has prepared eight comprehensive semi-annual compliance reports. She has testified regarding her report findings,1 and has taken an active role in inchambers negotiations with the Parties to set compliance plans. In short, for five years she has closely counseled Golden Grove leadership to adopt and sustain basic correctional management policies to try to achieve protection of prisoners from harm, institutional security, appropriate
1 On March 8, 2011, the Special Master testified about her most recent findings set out in Compliance Status Report #8, and the Court adopted her findings as findings of this Court. Transcript of March 8, 2011, 21:8-11 (hereinafter “Tr.”).
3 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 4 of 26
prisoner healthcare, and sufficient environmental sanitation to protect against disease and inhumane conditions. Yet prisoners continue to lack basic safety and humane conditions, in violation of all aspects of the Court’s Orders and constitutional minima. A. Defendants Have Failed to Protect Golden Grove Prisoners from Serious Harm.
The 1986 Consent Decree requires Defendants to “provide such security and staff to protect inmates from wanton and reckless violence by other inmates or staff.” C.D. § I.2. [Dkt. 3]. This provision has not been met, and Defendants are incapable of meeting it. Despite numerous attempts to improve security and correctional officer staffing, Golden Grove is becoming a markedly more violent facility. Tr. 13:9-10.
There have been six stabbings at Golden Grove since July 2010. Special Master Report, March 5, 2011 (“S.M. Rpt.”) at 11-12; Defendants’ Golden Grove Court Report, May 10, 2011 (“Defs. Rpt.”) [Dkt. 535-1] at 1. The level of violence may be greater than known, because corrections officials do not have an adequate system for reporting serious incidents, and the leadership does not consistently report serious incidents of violence to the Special Master. S.M. Rpt. at 21, 29. Nonetheless, the Special Master’s review of facility records revealed sufficient evidence that the level of prisoner-on-prisoner and detainee-on-detainee violence is “disturbing.” S.M. Rpt. at 22.
In response to the first four stabbings, the Special Master convened a conference call in February 2011 to determine BOC’s planned response. At the time of the call, BOC had no plan, but soon after organized a facility-wide lockdown and search. S.M. Rpt. at 13; Tr. 14:7-10. While this “security drill” was poorly executed, it revealed much about the facility’s failings. S.M. Rpt. at 14. It netted an astonishing amount of contraband, including weapons, illegal drugs, street clothing, key-like devices, and electronics. S.M. Rpt. at 15. The Special Master reported
4 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 5 of 26
that the amount and type of contraband found “provide an extremely disturbing look at a facility out of control.” S.M. Rpt. at 14.
The violence is a direct result of Defendants’ failure to implement the Consent Decree and subsequent Orders. For example, Defendants have not:
 developed a comprehensive correctional policies and procedures manual;  trained staff on policies and procedures;  developed or implemented a comprehensive prisoner and detainee classification system;  implemented a proactive and regularized system of conducting shakedowns and prisoner
patdowns to limit contraband;  developed a system of tool control;  conducted sufficient disciplinary hearings to assure that charges of prisoner and detainee
misconduct are heard and resolved;  developed or implemented an employee recruitment plan; or  implemented other measures to hire sufficient numbers of qualified personnel and
supervisors as set out in approved hiring plans. The Special Master summed up current conditions in her recent report, which the Court adopted (Tr. 21:8-11): “Golden Grove is a violent place. The contraband that flows into the prison is evidence of corruption. There is no reason to think that the current BOC leadership is capable of addressing basic security and waiting any longer to act places lives in danger.” S.M. Rpt. at 44 (emphasis added). 1. Defendants Have Failed to Produce an Adequate Set of Policies and Procedures. Defendants’ failure to develop facility-wide correctional policies and procedures exemplifies their long-standing inability to even begin to implement Court-ordered requirements.
5 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 6 of 26
After it became apparent that the original Consent Decree and the 1990 Plan of Compliance would not be implemented, the United States negotiated a Stipulated Agreement [Dkt. 146], which the Court entered as an Order. [Dkt. 148]. Among other things, the Stipulated Agreement required Defendants to develop a comprehensive policy and procedures manual, disseminate it to all correctional staff, and keep a copy at every post. Stipulated Agreement, Attachment A, § I. A. [Dkt. 146]. The Court’s Order of May 15, 2007 again required Defendants to develop a comprehensive policy manual and to train staff on the policies. [Dkt. 304 at 7].
Despite these repeated orders, Defendants have not developed acceptable and comprehensive correctional policies and procedures. To assist the Defendants, the Special Master retained a corrections expert to draft model policies that would serve as a guide for Defendants’ work. But Defendants lost these policies three times, and the expert gave up on any further efforts.2 Tr. 24:3-12. The Special Master also provided Defendants with sample policies and provided comments to the few draft policies provided to her by Golden Grove. Tr. 24:13-23. Beginning in late 2010, the Special Master twice brought an expert to train Golden Grove employees to write correctional policies. Tr. 25:3-10. In January 2010, nine Golden Grove officers visited the Miami-Dade Department of Corrections and received extensive training on generally accepted correctional practices. S.M. Rpt. at 8. Notwithstanding these extraordinary efforts, Defendants have failed to produce a comprehensive set of policies and procedures. Tr. 25:11-23.
2 Corrections expert Darnley Hodge provided defendants with multiple copies of the drafts over a two year period, but Defendants lost each one. S.M. Rpt. at 42, 43.
6 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 7 of 26
2. Defendants Lack an Adequate Prisoner and Detainee Classification System. This Court’s Orders require Defendants to “provide such security … to protect inmates
from wanton and reckless physical violence by other inmates…” C.D. § I.2. [Dkt. 3]. Basic correctional practices require a system of inmate and detainee classification to keep inmates safe from violence. Tr. 15:14-16; 16:11-22. Defendants’ classification system for both sentenced prisoners and detainees is inadequate. The instrument being used to classify sentenced prisoners is designed to evaluate pre-trial detainees, and it has not been validated for Golden Grove. Tr. 16:6-10. Moreover, only one of the four employees tasked with classifying sentenced prisoners has ever received training on the instrument or process. Tr. 16:1-3.
Similarly, there are serious deficiencies in the classification system for pre-trial detainees. At the time of the status conference on March 8, 2011, Defendants were not classifying detainees at all. S.M. Rpt. at 17. Defendants had previously classified detainees, but that practice had ceased. S.M. Rpt. at 16. Thus, all detainees -- regardless of history of violence, gang affiliation, or mental health status -- were housed together. Defendants stopped classifying detainees about two years earlier as a “pilot project,” due in part to limited cell assignment availability. S.M. Rpt. at 17.
In her most recent report to the Court, the Special Master concluded that “the level of violence in the detainee housing areas is directly related to the lack of a classification interview, housing of mentally ill detainees without appropriate services, and a total absence of understanding about how to develop a housing plan . . . to meet security needs of arrestees.” S.M. Rpt. at 19. Still, at the March 8 hearing, the Director of the BOC testified that he believes a formal classification of detainees is unnecessary. Tr. 39:8-18.
7 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 8 of 26
Defendants now claim that they once again are classifying detainees. Defs. Rpt. May 10, 2011 [Dkt. 535-1] at 2. The Defendants’ failure to grasp the importance of classifying detainees, in spite of the Special Master’s warnings and a recent stabbing in the detainee housing area, and their failure to sustain prior reforms, exemplify a failure of leadership and an inability to implement and sustain minimally adequate correctional practices.
3. Defendants Are Unable to Stop Contraband From Entering the Facility. An alarming amount of contraband finds its way into Golden Grove. Weapons, cell
phones, street clothing, handkerchiefs, drugs, alcohol, and knives have been found. S.M. Rpt. at 13-14, 15. Defendants have failed to perform security cell shakedowns on a regular basis to respond to the introduction of contraband [Dkt. 304 at 9], in defiance of this Court’s May 15, 2007 Order. S.M. Rpt. at 15. Even after the spate of recent stabbings, it was only in response to the demands of the Special Master that Defendants conducted a “security drill,” which unearthed a significant cache of contraband. Tr.14:6-10. The type and amount of contraband found during this security drill led the Special Master to conclude that Golden Grove employees must have been complicit in the introduction of contraband to the facility. S.M. Rpt. at 25. The leadership’s inability to adequately address the contraband problem is also, according to the Special Master, evidence of incompetence. S.M. Rpt. at 25.
The presence of a large number of weapons speaks to the level of violence in the facility, and the terror that prisoners must feel at the prospect of violence from other prisoners. The discovery of this contraband has caused the Special Master to doubt whether the leadership of Golden Grove has the ability to “handle the everyday functions that are the core function of the prison and jail.” Tr. 14:18-20.
8 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 9 of 26
4. Defendants Do Not Have a Functioning Discipline System. A dysfunctional disciplinary system interferes with the Defendants’ requirement to
protect inmates from violence. C.D. § I.2. [Dkt. 3]. Golden Grove lacks adequate staff to hold disciplinary hearings. As a result, a large number of allegations against prisoners, including serious incidents of violence, are dismissed. Consequently, prisoners are able to assault each other with impunity, and correctional officers have become frustrated by the number of cases dismissed and the arbitrary removal of prisoners from lockdown before their sentenced time is concluded. S.M. Rpt. at 22-23.
5. Defendants Fail in the Most Basic Security Tasks. Defendants do not follow even the most basic tenets of accepted corrections practice,
which contributes to violation of the Court’s Orders that are designed to ensure that prisoners are protected from harm. Aside from having a completely inadequate classification system, sentenced prisoners are able to move freely throughout the facility, except during lockdown, rendering any classification system completely useless. S.M. Rpt. at 26. Staff uniforms are located in an area accessible to prisoners, despite previous warnings from the Special Master that this is a dangerous practice. S.M. Rpt. at 26. There are some cameras in the facility, but not enough of them, and they are not monitored. S.M. Rpt. at 27. On top of all of this, a number of critical sally ports and locks within the facility do not work. S.M. Rpt. at 38. An interior gate leading from the “yard” directly into the administrative building is non-functional, so it simply is left open during the day. Consequently, only two glass doors at the front entry prevent prisoners from leaving the facility. S.M. Rpt. at 38.
6. Defendants Do Not Have an Adequate Recruitment and Hiring Plan The BOC is severely under-staffed, which directly contributes to the unconstitutionally 9 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 10 of 26
high level of violence in the facility. S.M. Rpt. at 30. In spite of this, Defendants have demonstrated an inability or unwillingness to comply with Orders of the Court and produce a recruitment and retention plan. In May 2007, the Court ordered Defendants to produce a recruitment plan by July 15, 2007. S.M. Rpt. at 32. Defendants did not comply with that Order. S.M. Rpt. at 32. The Court issued the Order again in February 2010, with a due date of March 2010. In response, Defendants produced an inadequate plan. S.M. Rpt. at 32. In December 2010, the Court ordered Defendants a third time to produce this plan, and gave them until January 2011 to comply. In response, Defendants requested even more time to comply. When Defendants finally submitted the plan, it was still inadequate. S.M. Rpt. at 32. To date, Defendants have not produced an adequate staffing and recruitment plan. S.M. Rpt. at 32. B. The Physical Conditions of Confinement of Prisoners in Golden Grove are Constitutionally
Inadequate. Conditions of confinement at Golden Grove are deplorable, with little improvement since
the appointment of the Special Master. S.M. Rpt. at 33. Inside the facility, it is hot; air is not circulated; there is mold; many sinks and showers do not work; and the kitchen is unsanitary. Id. at 33; Tr. 19:1-2. Windows have fallen out of frames, and the frames and glass provide materials for weapons. S.M. Rpt. at 34. The sanitation in housing areas is inadequate. Broken sandbags are used to control flooding. There are leaking pipes, ripped mattresses, and broken and rusted exhaust fan assemblies. Id. at 36. In addition to the overall appearance of decay, the broken assemblies prevent temperature control in the housing areas.
By Order of February 22, 2010, Defendants were to conduct a physical plant assessment of the facility, due to the Court in April 2010. S.M. Rpt. at 35. Defendants initially agreed to provide this assessment by November 3, 2009. The deadline then was extended to
10 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 11 of 26
January 20, 2010. These deadlines came and went without any communication to the Special Master or completion of plans. Order, February 22, 2010 [Dkt. 457] at 3-4. More than a year has passed since the most recent due date and Defendants have not even executed a contract with an engineer to do the work. On May 10, 2011, Defendants once again requested an extension of this critical deadline. Defs. Rpt., May 10, 2011 [Dkt. 535-1] at 30. C. Defendants Do Not Provide Minimally Adequate Medical Care and Dental Services Remain
Clearly Inadequate. Defendants do not provide minimally adequate medical care for the serious medical
needs of inmates. Defs. Rpt., May 10, 2011 [Dkt. 535-1] at 36. The Consent Decree required Defendants to file by November 1, 1986 a plan setting forth “[t]he steps to be taken to provide for adequate medical care in medical emergencies and . . . to provide medical care for the serious medical needs of inmates, including procedures to provide for appropriate storage and administration of medications.” C.D. § III.4. [Dkt. 3]. The Plan was to be fully implemented by June 1, 1988. Id.§ III. Defendants did not meet these deadlines, and they were extended numerous times. The Compliance Matrix called for the plan to be submitted by June 1, 2011. Defs. Rpt. May 10, 2011 at 37 [Dkt. 535-1]. On March 8, 2011 Defendants testified that they were on track to meet this deadline [Tr. 72:12-14], but soon after they requested yet another extension.3 Twenty-five years after the initial due date for this plan, Defendants still have not submitted one.
By their own admission, Defendants remain out of compliance with 24 provisions of the Court’s Orders pertaining to medical care, dating back to the 1986 Consent Decree, the 1990 Plan of Compliance, and the 2003 Stipulated Agreement. The Compliance Matrix called for
3 The Special Master agreed to the extension of deadlines regarding medical services, over the objection of the United States. Defendants’ Memorandum of Law in Support of the Motion for Enlargement of Time (“Defs. Ext. Mot.”) [Dkt. 538] at 2.
11 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 12 of 26
many of these provisions to be completed by March 1, 2011. On March 8, 2011 Defendants testified that they had met all of these deadlines [Tr. 70:9-10], but on April 15, 2011 admitted that they had not and asked for yet another extension of all deadlines related to medical care. Defs. Rpt., May 10, 2011 [Dkt. 535-1 at 36-51].
Dental services also remain wholly inadequate. S.M. Rpt. at 41. Dental complaints received by the Special Master are significant in severity and number. Tr. 22:1-2. For the last two years, Defendants have claimed that they will be able to open a dental operatory on-site, but that has not happened. Tr. 22:7-14. As another example of Territory bureaucracy reportedly delaying compliance, no dental assistant has been hired due to the Notices of Personnel Action (“NOPA”) process. S.M. Rpt. at 40. “The NOPA hiring process” continues to signify bureaucratic delays preventing Court Order compliance.
III. LEGAL STANDARDS The federal courts possess the authority to implement any remedies necessary to correct constitutional violations. Washington v. Washington State Commercial Passenger Fishing Vessel Assoc., 443 U.S. 658, 695-96 (1979). Pursuant to its equity jurisdiction, a federal court has power to take broad remedial action to effectuate compliance with its orders. Lewis v. Kugler, 446 F.2d 1343, 1351-52 (3rd Cir. 1971). This equitable power includes the power to appoint a receiver. Id. at 1351; see also Morgan v. McDonough, 540 F.2d 527, 533 (1st Cir. 1976) (approving temporary receivership of South Boston High School for purpose of desegregation); Plata v. Schwarzenegger, No. C01-1351, 2005 WL 2932253, at *1 (N.D. Cal. Oct. 3, 2005) (ordering receivership for the delivery of medical services to all California state prisoners); Dixon v. Barry, 967 F. Supp. 535, 550-52 (D.D.C. 1997) (upholding appointment of a receiver over the District of Columbia’s Commission on Mental Health Services); Shaw v. Allen,
12 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 13 of 26
771 F. Supp. 760, 762 (S.D. W. Va. 1990) (appointing a receiver over a jail, noting, “a court acting within its equitable powers is justified, particularly in aid of an outstanding injunction in implementing…a receivership so as to achieve compliance with a constitutional mandate”); Gary W. v. Louisiana, No. 74-2412, 1990 WL 17537, at *30-31 (E.D. La. Feb. 26, 1990) (appointing receiver to oversee state’s children’s services agencies); Reed v. Rhodes, 500 F. Supp. 363 (N.D. Ohio 1980), aff'd as to appointment of Administrator of Desegregation, rev'd on other grounds, 635 F.2d 559 (6th Cir. 1980); Newman v. Alabama, 466 F. Supp. 628 (M.D. Ala. 1979) (appointing receiver for Alabama State Prisons); Turner v. Goolsby, 255 F. Supp. 724 (S.D. Ga. 1966) (maintaining receivership in school desegregation context); Judge Rotenberg Educ. Ctr. Inc. v. Comm’r of the Dep’t of Mental Retardation, 677 N.E.2d 127, 149 (Mass. 1997) (appointing receiver of state Department of Mental Retardation); Crain v. Bordenkircher, 376 S.E.2d 140, 143 (W. Va. 1988) (holding that it “has authority to place the [West Virginia] penitentiary in receivership and appoint a receiver for the purpose of constructing a new facility”); Petitpren v. Taylor Sch. Dist., 293 N.W. 2d 553, 557 (Mich. Ct. App. 1981) (noting that a trial court “may appoint a receiver in the absence of a statute pursuant to its inherent equitable authority”); Perez v. Boston Hous. Auth., 400 N.E.2d 1231, 1254 (Mass. 1980) (imposing receivership to achieve restructuring of housing authority).
A court may appoint a receiver to force public officials to comply with court orders. Lewis, 446 F. Supp. at 1351-52; see also Dixon, 967 F. Supp. at 550 (citing Morgan, 540 F.2d at 534-35) (holding the district court’s supplantation of local decision making with a receiver was justified given the local authorities’ failure to comply with the court’s desegregation orders); Judge Rotenberg Educ. Ctr., Inc., 677 N.E.2d at 463 (“Public officials who fail to abide by legal standards are not immune to these remedies . . . . A court with equity jurisdiction has the
13 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 14 of 26
discretion to appoint a receiver to take over the main function of public officials.”) (citations omitted); Plata, 2005 WL 2932253, at *23 (“The use of receivers to reform public institutions has spread to analogous contexts in the civil rights arena, including prisons.”).
The decision whether to appoint a receiver is a function of the court’s discretion in evaluating what is reasonable under the particular circumstances of the case. See Dixon, 967 F. Supp. at 550. Courts have developed a multi-pronged test to guide this determination. The test includes the following elements, the first two of which are typically given predominant weight: (1) whether there is a grave and immediate threat or actuality of harm to plaintiffs; (2) whether the use of less extreme measures of remediation has been exhausted or proven futile; (3) whether continued insistence that compliance with the Court’s order would lead only to confrontation and delay; (4) whether there is a lack of leadership to turn the tide within a reasonable period time; (5) whether there is bad faith; (6) what resources are being wasted; and (7) whether a receiver is likely to provide a relatively quick and efficient remedy. Plata, 2005 WL 2932253, at *23; see also Dixon, 967 F. Supp. at 550 (citing Judge Rotenberg Educ. Ctr., Inc., 677 N.E.2d at 148-49; Morgan, 540 F.2d at 533).
In sum, this “Court is not required to restrict its powers to those means that have proven inadequate, or that show no promise of being fruitful . . . . ‘[F]ederal courts are not reduced to issuing injunctions against state officers and hoping for compliance. Once issued, an injunction may be enforced.’” Plata, 2005 WL 2932253, at *24 (quoting Hutto v. Finney 437 U.S. 678, 690 (1979)).
IV. ARGUMENT Each of the Plata factors regarding what a court should consider prior to imposing receivership weighs in favor of imposing receivership in this case. The Defendants’ history of
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Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 15 of 26
non-compliance with Orders of this Court spans two and a half decades and includes a finding of contempt and appointment of a Special Master. Since her appointment five years ago, the Special Master has worked tirelessly to help the Territory to improve conditions at Golden Grove. She has now reached the conclusion that the only means of bringing Golden Grove into compliance with constitutional mandates is through the appointment of a receiver. S.M. Rpt. at 45. Prisoners in Golden Grove are in grave danger. A receiver will provide competent leadership and bypass many of the bureaucratic obstacles that have stymied progress. A. Prisoners at Golden Grove Face Grave and Immediate Harm and Threat of Harm.
Golden Grove is a dangerous and violent facility and prisoners confined there are at serious risk of grave harm, including death. There have been six stabbings there since July 2010 and at least one serious assault. S.M. Rpt. at 11-12; Defs. Rpt. May 10, 2011 [Dkt. 535-1] at 1. The level of violence continues unabated and indeed appears to be increasing. Tr. 13:9-10. Defendants’ response to these disturbing incidents has been completely inadequate. S.M. Rpt. at 14. Defendants have failed to implement basic security measures to protect prisoners from serious harm, and this disturbing level of violence is directly attributable to their failings.
Contrary to basic correctional practice, Golden Grove until recently had no system of classifying detainees who are housed in the jail portion of the facility. 4 S.M. Rpt. at 17. As a result, violent and dangerous detainees and vulnerable detainees -- both of whom Golden Grove fails to identify through an adequate classification system -- had access to each other, resulting in actual serious harm.5 In addition, even prisoners whom Golden Grove claims to classify are able to move at will among other prisoners within the facility, Id. at 26, thus defeating the point of a
4 Defendants report they now are classifying detainees. Defs. Rpt., May 10, 2011 at 2[Dkt. 535-1]. The Special 
 Master has not yet confirmed this, nor assessed the adequacy of the classification system.
 5 On December 22, 2010, a detainee stabbed another detainee, and on May 1, 2011, a detainee was assaulted by 
 another detainee. S.M. Rpt. at 12; Defs. Rpt., May 10, 2011 at 1 [Dkt. 535-1].

15 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 16 of 26
classification system. Moreover, the facility is completely unable or unwilling to stop the river of contraband flowing into the facility. S.M. Rpt. at 14. Golden Grove does not conduct regular shakedowns in accordance with basic correctional practices; rather, the most recent significant shakedown in February 2011 was completed only after the Special Master pressed the jurisdiction to develop strategies to address the spate of stabbings since July 2010. During this shakedown, Golden Grove staff discovered weapons, clothing, electronics, cell phones, and keylike devices. This amount and type of contraband are evidence of the Facility’s incompetence and/or corruption. B. Less Extreme Remedial Measures Have Been Exhausted or Will Prove Futile.
The Court has given Defendants countless opportunities to comply with its Orders in this case and the Court has taken all reasonable steps to enforce its Orders. For the past 25 years, Defendants have consistently demonstrated they do not have the capacity, ability, or willingness to comply with the Orders of this Court.
Most recently, in 2006, the Court ordered a remedy one step shy of receivership: appointment of a Special Master who is a national expert on correctional practices with access to resources to guide Defendants toward compliance in all areas of the Court’s Orders. The Special Master has provided guidance, resources, technical assistance, and extensions of deadlines and yet, five years into her appointment, conditions at the facility remain virtually unchanged. S.M. Rpt. at 44. She now believes all measures have been exhausted and that additional efforts will prove futile. S.M. Rpt. at 45. She has recommended that the Court appoint a receiver. S.M. Rpt. at 45. The United States concurs with the Special Master’s assessment of the futility of continued compliance efforts short of receivership, as neither the past two and a half decades of attempting to work with Defendants, nor the past five years of close guidance by the Special
16 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 17 of 26
Master, has propelled Defendants any closer to compliance. Nothing short of receivership will move Defendants toward compliance without additional years of delay. C. Continued Insistence on Compliance with the Court’s Orders Would Lead only to
Confrontation and Delay. The Court can easily draw on its and the Special Master’s experiences to conclude that
maintaining the status quo will only result in more confrontation and delay. Defendants have an established history of noncompliance. They have not complied with any major substantive provisions of any of the Court Orders from the past 25 years, including Orders from 1986, 1990, 2003, 2007, and 2010. Instead, they have missed or requested extensions to the deadlines agreed upon (and already extended) by the parties. Given past performance, future missed deadlines are inevitable, and imposition of additional court orders would result only in additional findings of contempt and delay.
Defendants’ promises of future compliance and claims of recent progress cannot be relied upon. On March 8, 2011, Defendants testified that they had met all of the Compliance Matrix’s March 1, 2011 deadlines, and that they were confident that they would be able to meet all of its future deadlines. Tr. 72:12-14. In contrast, the Special Master testified that day that she believed some deadlines already had been missed and she did not believe Defendants would be able to meet upcoming deadlines, in part because of territorial bureaucratic hurdles. Tr. 26:1416; 28:2-6; 27:4-7. Sure enough, just over a month later, Defendants admitted they had not met the March 1, 2011 deadlines relating to medical care, and requested extensions of those and a number of other critical deadlines. Defs. Motion for Enlargement of Time (“Defs. Ext. Mot.”) [Dkt. 538] at 1-2. Included was a request to extend the deadline for completion of plans for an assessment of Golden Grove’s physical plant, which had originally been due to the Court in
17 


Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 18 of 26
November 2009, and then again in January 2010. Order of February 22, 2010 [Dkt. 457] at 3. In making the request, Defendants cited to delays in personnel processing procedures. Defs. Ext. Mot. at 5. In another request, they cited to delays with NOPAs and the need “to solidify NOPAs.” Id. As predicted by the Special Master, Defendants have not been able to meet deadlines because of the Territory’s bureaucratic hurdles.
A district court faced similar circumstances when it decided to appoint a receiver for the District of Columbia’s (“District’s”) Commission on Mental Health Services. Dixon v. Barry, 967 F. Supp. 535 (D.D.C. 1997). There, the District had entered into a Consent Order with the plaintiff class of mentally ill District residents to overhaul its delivery of community mental health services to those individuals. The Consent Order anticipated a completion date of 1985. By 1985, the District still was not in compliance, and the Court issued a series of additional orders between 1985 and 1992. The 1992 order set forth in detail various targets, along with a timetable for implementation. The District failed to meet these obligations and, in 1993, the Court appointed a Special Master to facilitate and oversee the District’s efforts to implement the various orders of the Court. Despite the assistance of the Special Master, the District failed to fulfill its obligations. Dixon, 967 F. Supp. at 540.
When the Dixon plaintiffs finally moved for appointment of a receiver, the District argued that it was beginning to make progress and that the appointment of a receiver was unnecessary, given its recent efforts. It cited to the appointment of a new commissioner, modifications to the structure of the relevant agency, creation of additional positions, and personnel and procurement modifications. The Court, however, refused to take the District on faith, and appointed the receiver, stating, “[t]he long and frustrated history of this litigation provides no basis upon which the Court can put much trust in the District . . . . The District
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Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 19 of 26
repeatedly has made promise after promise about what it would do, but has substantially failed to so do.” Id. at 553. Here, too, Defendants repeatedly make promises about what they will be able to accomplish. Defendants have not kept those promises in the past, and there is no evidence that this pattern will change. D. Defendants Lack Sufficient Leadership to Turn the Tide within a Reasonable Time.
The Territory may have made some progress in limited areas of the Court’s Orders since the Territory’s delayed appointment of a compliance coordinator and medical director, but it is far too limited relative to the enormity of the need. Minor improvements in medical care, for example, are insufficient to resolve ongoing dangerous conditions and contempt of court. Defendants’ leadership is incapable of successfully implementing systemic change or completing even minimal goals towards constitutional conditions of confinement at Golden Grove. Most recently, the Special Master testified that she now questions “the ability of Golden Grove leadership to handle this, to not only come into compliance, but to handle the everyday functions that are the core function of the prison and the jail.” Tr. 14:17-20. E. Defendants’ Continued Failure to Meet or Communicate regarding Deadlines Demonstrates
Bad Faith. Though Defendants’ repeated failures and misstatements over the last 25 years may show
bad faith, the Court need not make a finding of bad faith before it may appoint a receiver. Plata v. Schwarzenegger, No. C01-1351, 2005 WL 2932253, at *30 (N.D. Cal. Oct. 3, 2005). In Plata, the Court noted that, when dealing with governmental institutions, the question of motive is complicated. It found that a lack of will was a key factor contributing to the defendant’s failure to comply with court orders and appointed a receiver while declining to make a finding of bad faith. Id.
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However, this Court could infer bad faith from Defendants’ continuing record of missing deadlines established by the Court’s Orders or agreed to by the parties, their failure to communicate compliance delays, and their failure to notify the Special Master of sentinel events within the facility. S.M. Rpt. at 11; see also Dixon v. Barry, 967 F. Supp. 535, 554 (D.D.C. 1997). Defendants’ communications to the Court also have not realistically reflected the current state of non-compliance. For example, Defendants testified on March 8, 2011 that they had met all of the Compliance Matrix’s March 1, 2011 deadlines and would be able to meet all future deadlines, Tr. 72:12-14, despite the Special Master’s testimony that some deadlines already had been missed and others likely would be missed soon. Just over one month later Defendants admitted they had not met the March 1, 2011 deadlines relating to medical care, and requested extensions of those and a number of other critical deadlines. Tr. 26: 14-16; 28:2-6; 27:4-7; Defs. Ext. Mot. [Dkt. 538] at 1-2. Although bad faith is not needed to appoint a receiver, the Court could find it in this case. F. Defendants Continue to Waste Federal and Territory Resources by Failing to Prioritize and
Implement Pressing Requirements. Defendants’ lack of effective leadership has resulted in a waste of limited resources and
has contributed to their ongoing failure to comply with the Court’s Orders. According to the Special Master, the Territory appears to be providing adequate fiscal resources to the BOC, despite severe economic challenges. Yet Defendants are not using these resources to address the critical needs of the facility. Despite the obvious necessity for adequate staffing to address increased prisoner violence, the Division of Personnel and the BOC have done very little to address crucial staffing needs. For years, the Special Master has warned that that the lack of adequate correctional staff has contributed to the alarming level of violence at Golden Grove and
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Case: 1:86-cv-00265-RLF -GWC Document #: 541-1 Filed: 06/09/11 Page 21 of 26
has urged leadership to focus on hiring correctional officers. Despite these admonitions, Defendants have not allocated resources to this most pressing need, and failure to appoint a receiver will result in a continued waste of the Court’s, the United States’ and the Territory’s time and resources, while prisoners remain in grave danger. G. A Receiver Is Likely to Provide an Effective and Efficient Remedy.
The Court has taken steps in an effort to force Defendants to comply with its Orders, including general orders, specific implementation plans with numerical targets, the finding of contempt, formal and informal conferences with the Parties, warnings as to possible sanctions, and the appointment of a Special Master. Each of these less severe remedies has resulted in little if any sustained success. The fact that almost twenty-five years have passed without implementation of the Consent Decree is sufficient evidence that Defendants are unable or incapable of doing so. The appointment of a receiver is the only viable alternative left to the Court.
One of the reasons the appointment of a receiver would offer more efficient and effective relief than the current structure is that a receiver would be able to bypass the Territory’s complicated procurement procedures, which have contributed to the delays so far. The Court has the power to appoint a receiver, and to grant that receiver whatever authority is necessary to ensure implementation of remedial orders. Gary W. v. Louisiana, No. 74-2412, 1990 WL 17537, at *32 (E.D. La. Feb. 26, 1990); see also Washington v. Washington State Commercial Passenger Fishing Vessel Assoc., 443 U.S. 658, 695-96 (1979) (“The federal court unquestionably has the power to enter the various orders that state officials and private parties have chosen to ignore, and even to displace local enforcement of those orders if necessary to remedy the violation of federal law found by the Court.”).
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In Dixon, the court’s decision to appoint a receiver was based in part on a desire to avoid the strictures of the District’s procurement process. There, the court found that the necessary funding was present, but that the procurement processes hampered the defendant’s ability to use that funding. Dixon, 967 F. Supp. at 546. In appointing the receiver, the court cited to the Special Master’s testimony that her efforts at reform were confounded by the bureaucracy and politics of the District, as well as the increasingly diluted authority of the District’s mayor. Id. at 549. The court found that the Special Master’s limited powers inhibited her ability to effect change. Id. Accordingly, in the order appointing the receiver, the Court gave the receiver all the powers necessary to fulfill it, including, “[a]ll powers over the [Commission of Mental Health Services] currently exercised by the Commissioner of Mental Health Services, the Director of Human Services, and the Mayor of the District of Columbia.” Id. at 555.
The District Court of the District of Columbia also ordered that the District jail’s medical and mental health services be placed in receivership. Inmates of D.C. Jail v. Jackson, 158 F.3d. 1357 at 1359 (D.C. Cir. 1998). Once the receiver was appointed, he was able to improve conditions in a relatively short period of time, in part because he was able to bypass the District’s procurement process. See Liat Weingart, Receiverships in the Prison Litigation Context: Factors Necessary for an Effective Judicial Remedy of Last Resort, 9 Cardozo Pub. L. Pol’y & Ethics J. 193, 236 & n. 127 (2010) (identifying factors contributing to successful receiverships through comparison of multiple experiences.)
In Inmates of D.C. Jail, the court had found in 1975 that conditions at the jail violated the Constitution and issued an injunction ordering the District of Columbia to improve conditions. Over a period of nearly twenty years, the court issued a variety of increasingly specific orders attempting to improve conditions at the jail, including the appointment of a Special Master to
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coordinate with D.C. in an attempt to alleviate conditions. Finally, in 1995, two years after appointing the Special Master, the Court ordered receivership. Inmates of D.C. Jail, 158 F.3d. at 1358-59. In its order, the court granted the receiver “[a]ll powers currently held by the Mayor, City Administrator, Director of the Department of Corrections, Assistant Director for Health Services and Chief Medical Officer regarding the delivery of medical and mental health services at the District of Columbia Jail.” Inmates of D.C. Jail v. Jackson (Inmates of D.C. Jail Order Appointing Receiver), No. 75-1668, at 8. Five years later, the standards in D.C. jails improved to a constitutionally acceptable level, and the receivership ended. Weingart, Receiverships, supra, at 223.
A number of other factors were involved in the success of the receivership in the Inmates of D.C. Jail case, all of which exist here. First, by the time the receiver was appointed, the Court already had issued numerous orders, and a Special Master who was familiar with the issues already was in place. Id. at 330. The Special Master, together with the parties, had drafted a detailed plan of action, which the receiver simply had to implement upon his appointment. Id. The existence of this detailed plan of action upon appointment allowed to receiver to complete work within a relatively short period of time. Id. at 231. Similarly, here the Special Master has drafted a compliance matrix, and like in D.C., the existence of this concrete and specific plan will allow the receiver to begin work without delay.
The relative size of Golden Grove also is advantageous. In the D.C. jail case, the receiver only had to deal with one institution whose population was relatively small -- in that case, about 1675 prisoners. Id. at 227. Because Golden Grove also is a single institution and is small by any measure, the receiver -- like the Special Master -- will quickly be able to grasp the issues facing the facility and facilitate timely compliance.
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For twenty-five years this Court has struggled to bring Golden Grove into compliance with the law. Without doubt, limited progress toward that end has been made. The Court has availed itself of all tools short of receivership in an effort to protect Golden Grove prisoners from grave danger. Defendants’ management, or lack of management, has prevented compliance with the Court’s Orders. Receivership is the only remedy available that presents any real possibility of success without ongoing harm to prisoners and protracted waste of government resources. Experience in other jurisdictions, especially Washington, D.C., teaches that this is an appropriate case for receivership and, if implemented correctly, will work to resolve this crisis. “The responsibility of the Court is ‘clear and compelling: to use its broad equitable powers to implement a remedy that, while sensitive to the burdens that can result from a decree and the practical limitations involved, promises realistically to work now.’” Plata, 2005 WL 2932253 at *28 (quoting Gary W. Louisiana, 1990 WL 17537 at *17, *30) (citations omitted).
IV. CONCLUSION For the foregoing reasons, this Court should place Golden Grove into receivership, and through its Order, empower the receiver to implement the previous Court Orders in this case. The Court also should grant the United States’ request to conduct discovery regarding this motion, including party and non-party depositions, as necessary.
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Respectfully submitted,
JONATHAN M. SMITH Chief LAURA L. COON Special Counsel s/ EMILY A. GUNSTON ANDREW J. BARRICK EMILY A. GUNSTON Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 (202) 514-6255 202-514-4883 (fax) Angela P. Tyson-Floyd Assistant United States Attorney U.S. Attorney’s Office 1108 King St., Ste. 201 Christiansted, V.I. 00841 340-773-3920 340-773-1407 (fax)
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CERTIFICATE OF SERVICE
I certify that on June 9, 2011, I electronically filed the United States’ Memorandum of Points and Authorities in Support of the United States’ Motion for the Appointment of a Receiver, using the CM/ECF system, which will send notification to the following:
Aquannette Y. Chinnery V.I. Department of Justice GERS Building 2nd FL 34-38 Kronprindsens Gade St. Thomas, VI 00802 340-774-5666 X285 Fax: 340-776-3494 Email: achinnery@doj.vi.gov
Carol Thomas-Jacobs Department of Justice 8050 Kronprindsens Gade St. Thomas, VI 00802-0000 340-774-5666 Fax: 340-776-3494 Email: cjacobs@doj.vi.gov
Respectfully submitted,
/s ANDREW J. BARRICK ANDREW J. BARRICK Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 (202) 514-6255 202-514-4883 (fax)
26 


 
 Case: 1:86-cv-00265-WAL-GWC Document #: 742 Filed: 05/14/13 Page 1 of 3

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

)

v.

)

)

)

TERRITORY OF THE VIRGIN ISLANDS, )

et al.,

)

)

)

Defendants.

)

__________________________________________)

Civil Action No. 1986-265

Attorneys: Jonathan M. Smith, Esq., Laura L. Coon, Esq., Alyssa C. Lareau, Esq., Emily A. Gunston, Esq., Washington, D.C.
For the United States

Richard S. Walinski, Esq., Toledo, OH.
For the Defendants

Nathan T. Oswald, Esq., Pemberville, OH.
For the Defendants

Aquannette Y. Chinnery, Esq., Carol Thomas-Jacobs, Esq., St. Thomas, U.S.V.I.
For the Defendants

Kenrick E. Robertson, Esq. St. Croix, U.S.V.I.
For the Defendants

ORDER

THIS MATTER comes before the Court on: (1) the parties’ “Joint Motion to Enter

Consent Judgment” (Dkt. No. 689), requesting that the Court enter the parties’ Settlement

Case: 1:86-cv-00265-WAL-GWC Document #: 742 Filed: 05/14/13 Page 2 of 3
Agreement (Dkt. No. 689-1) as an Order of the Court; and (2) the “United States’ Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement” (Dkt. No. 716), which Defendants do not oppose (Dkt. No. 723).
UPON CONSIDERATION of the foregoing, and the entire record herein, it is hereby ORDERED that the “United States’ Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement” (Dkt. No. 716) are ADOPTED in their entirety by the Court and incorporated by reference as if fully stated herein. In adopting the Proposed Findings of Fact and Conclusions of Law, the Court finds, inter alia, as agreed by the parties for purposes of this litigation, that: (1) Defendants are violating the Eighth Amendment rights of prisoners at Golden Grove Adult Correctional and Detention Facility (“Golden Grove”) in the areas of: (a) Safety and Supervision, (b) Medical and Mental Health Care, (c) Fire and Life Safety, and (d) Environmental Health and Safety, as more fully set forth and described in the “United States’ Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement” (Dkt. No. 716); (2) Prospective relief is necessary to remedy the current and ongoing Eighth Amendment violations, as more fully set forth and described in the “United States’ Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement” (Dkt. No. 716); (3) The prospective relief set forth in the Settlement Agreement (Dkt. No. 689-1) is narrowly drawn, extends no further than necessary to correct the Eighth Amendment violations at Golden Grove, and is the least intrusive means necessary to correct the Eighth Amendment violations, as more fully set forth and described in the “United States’ Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement” (Dkt. No. 716); and
2

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(4) The Settlement Agreement (Dkt. No. 689-1) is fair, adequate, and reasonable, and is

not the product of fraud or collusion, as more fully set forth and described in the “United States’

Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement” (Dkt.

No. 716) and the parties “Joint Motion to Enter Consent Judgment” (Dkt. No. 689).

In view of the Court’s findings, it is hereby

ORDERED that the parties’ “Joint Motion to Enter Consent Judgment” (Dkt. No. 689) is

GRANTED; and it is further

ORDERED that the Settlement Agreement (Dkt. No. 689-1) is ACCEPTED by the

Court, and ENTERED as an Order of the Court.

SO ORDERED.

Date: May 14, 2013

_______/s/________ WILMA A. LEWIS District Judge

3

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 833 Filed: 08/13/14 Page 1 of 27

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA

)

Plaintiff,

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, et al. )

Defendants.

)

_________________________________________ )

Civil No. 86/265

UNITED STATES’ MOTION FOR AN ORDER TO SHOW CAUSE WHY DEFENDANTS SHOULD NOT BE HELD IN CIVIL CONTEMPT OF COURT AND
REQUEST FOR EXPEDITED BRIEFING I. PRELIMINARY STATEMENT
Despite nearly thirty years of litigation, multiple enforcement orders, and countless admonitions from this Court, the prisoners and staff at Golden Grove Adult Correctional and Detention Facility (“Golden Grove”), as well as people in the surrounding Virgin Islands community, continue to be at risk of serious harm from Defendants’ ongoing failure to comply with court-ordered measures remedying unconstitutional conditions at the facility. In March 2014, the United States filed an enforcement motion asking the Court to order strict deadlines for Defendants to comply with some of the Settlement Agreement’s substantive requirements. At that time, there was no comprehensive implementation schedule for the Settlement Agreement. Only when the United States filed its motion did Defendants propose meaningful deadlines via its “work plan,” or schedule of deadlines for producing and implementing the policies, procedures, plans, and training that the Settlement Agreement requires. In consideration of this comprehensive work plan and the handful of changes made at the United States’ request, the United States withdrew its enforcement motion.

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At the April 28, 2014 status conference, the Court accepted these deadlines and encouraged the Territory to move forward in accordance with the plan. Yet, during the three months following that discussion, the Territory either failed to submit anything at all for certain work plan deadlines, submitted material long after the due date, or has submitted materials so patently deficient that the Monitor, Kenneth Ray, rejected them outright. These failures have not been without consequence. There have been numerous incidents threatening the safety of prisoners, staff, and the Virgin Islands community since the work plan went into effect: (1) a prisoner escape and subsequent alleged rape of his prior victim in the community in May 2014; (2) at least three prisoner-on-prisoner stabbings (two in May and one in July of 2014); (3) the attempted escape of five prisoners—caught by the Virgin Islands Police Department, not Golden Grove officials—in June 2014; and (4) a prisoner-on-staff assault during the onsite monitoring visit in June 2014.
The United States engaged the Territory and the Monitor repeatedly to attempt resolution of the Territory’s non-compliance without seeking judicial intervention. After many letters, calls, emails, and meetings in which the United States attempted to pin down exact dates by which it could expect the submission of all past-due items, the Territory finally proposed certain new work plan deadlines.1 However, given the Territory’s continuing inability to follow its own deadlines, the United States is not confident that the Territory will adhere to these deadlines without an order from this Court to comply. In fact, the Territory proposed any new deadlines for overdue items until after the United States threatened to file this Motion.2
1 Notably, the Territory’s proposal fails to include any new deadlines for past due training and implementation work plan items associated with policies that the Monitor rejected wholesale for their patent deficiencies. 2 See Ex. 1, Correspondence between USDOJ, the Territory, and the Monitor (portions redacted subject to protective order), at 32-33, Letter from USDOJ to Nathan Oswald, July 11, 2014 (“Significantly, we still do not know when you plan to deliver all outstanding work plan items. . . .We attempted to clarify via email . . . whether and when we
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Judicial intervention is now necessary not only to ensure compliance with the Settlement
Agreement, but also to address the ongoing emergent and unconstitutional conditions that
continue to place those inside and outside Golden Grove at imminent risk of harm. For these
reasons, as explained in detail below, the United States, by and through undersigned counsel,
respectfully moves this court for: (1) an order directing Defendants to show cause why they
should not be held in contempt of the May 14, 2013 Order Adopting the Parties’ Settlement
Agreement; (2) an order for Defendants to comply with the new deadlines they proposed for
some of the past-due items; (3) an order directing Defendants to propose new deadlines for the
remaining past-due work plan items; and (4) an order directing Defendants to discuss the status
of compliance with those deadlines in their next status report to the Court, due September 15, 2014.3
II. BACKGROUND
The United States comes before the Court yet again seeking an order requiring the
Territory to comply with the Settlement Agreement. The implementation schedule, or “work
plan,” currently governing Defendants’ compliance includes deadlines—set by the Territory—
for implementing the substantive provisions of the Settlement Agreement. This implementation
schedule was put in place after the April 28, 2014 status conference. Despite its ongoing
should expect to receive dates by which overdue items will be complete. You did not respond to that email. We remain in the dark about when these items will be delivered, despite numerous requests for this information. We cannot continue to wait for a revised schedule – the Court will be notified of this if you do not provide revised dates by Wednesday, July 16, 2014.”). See also Ex. 1 at 37, Letter from Nathan Oswald to USDOJ, July 18, 2014 (providing a list of dates by which the Bureau of Corrections (“BOC”) will complete some past-due items, but noting, “[a] couple more items belong in this list, but BOC needs to confer internally this weekend before it can provide the remaining dates.”); id. at 42-45, Letter from Nathan Oswald to USDOJ, July 24, 2014 (attaching an Excel spreadsheet containing several newly proposed dates for some additional—though not all—past-due items and noting that “[t]his list does not include deadlines (namely training and implementation dates) associated with policies required under the Settlement Agreement.”). To date, USDOJ has not received a complete list of dates from the Territory for submitting all past-due items, despite these and other assurances from the Territory. 3 On July 11, 2014, Defendants requested to modify the work plan to extend all forthcoming deadlines by 90 days. Although the United States objects to this broad, across-the-board modification request, for the purposes of this motion only, “past-due” items refer to all work plan items due on or before July 11, 2014.
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reservations about the “pace of defendants’ efforts towards compliance,”4 the United States
accepted these work plan deadlines and, in exchange, withdrew its motion seeking immediate enforcement action.5 Notably, before allowing the United States to withdraw its motion, the
Court questioned counsel for the Territory, and after receiving adequate assurances of the
Territory’s ability to satisfy the work plan deadlines, the Court accepted “these deadlines as deadlines.”6
Although the Court recognized that “hiccups” might happen, the Court repeatedly told
the Territory that the deadlines are “not simply deadlines on paper with an expectation that the hiccups will happen.”7 Rather, the Court expected—and the Territory did not correct the Court’s
assumption—that “in putting these deadlines together, the parties, and in particular the Virgin
Islands Government, carefully considered what needs to be done in order to achieve the deadlines.”8 In light of the Court’s confirmation that the Territory’s proposed deadlines in the
work plan were well thought out and reflected the logistics necessary to accomplish them, the
Court reiterated its “expectation . . . that it will be the exception, rather than the rule, that these deadlines are not met. . . . [I]t will be the rare exception.”9 The United States left the status
conference with the understanding that the parties and the Monitor would be implementing the
Settlement Agreement pursuant to a work plan containing firm deadlines that the Territory
proposed and promised to keep.
4 Apr. 28, 2014 Hr’g. Tr. at 7:2–7. 5 Order Accepting the United States’ Withdrawal of its Motion for Enforcement without Prejudice, ECF No. 807. See also Apr. 28, 2014 Hr’g. Tr. at 6:3–7 (“Accordingly, the United States is willing to withdraw its motion asking for more specific orders given that the deadlines in the agreement [work plan] comport with what the United States was requesting.”). 6 April 28, 2014 Hr’g. Tr. at 15:16–17. 7 Hr’g Tr. at 15:18–19. 8 Hr’g Tr. at 15: 23–16:8. See also id. at 15:20–22 (Court expressing its expectation that any “hiccups will be anticipated in advance such that they don’t impact the deadlines”). 9 Hr’g Tr. at 17:9–13.
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The Territory did not heed the Court’s instructions. Beginning in May, work plan deadlines continued to pass with no word from the Territory about compliance or any indication of how it planned to meet the deadlines. Despite the Territory’s assurances at the last status conference that it is “committing resources in an aggressive way to getting done what needs to be done,”10 the Territory has only completed 1 of 50 items due prior to July 11, 2014 under the work plan, and it has failed to request modification of any of these deadlines in advance.
The parties are now three months into the work plan, with significant delays in the production of policies, procedures, and plans necessary to implement the Settlement Agreement. The Territory’s continued failure to implement the provisions of the Settlement Agreement jeopardizes the health and safety of prisoners, staff, and community members. Golden Grove remains plagued with violence and security risks. As noted above, since the April 28, 2014 status conference, the following serious incidents occurred: 1) at least three separate prisoneron-prisoner stabbings, all of which required emergency medical attention; 2) an escape from a housing unit that allegedly resulted in the sexual assault of a member of the community who was previously raped; 3) an attempted escape from a housing unit, where five prisoners were apprehended by Virgin Islands police just before breaching the perimeter gate; and 4) a prisoneron-staff assault that occurred while the monitoring team was conducting its onsite visit.
These incidents are directly attributable to faulty locks and other inoperable security equipment, inadequate security staffing, and the overall lack of policies and procedures governing Golden Grove. Each of these deficiencies can be remedied if the Territory timely follows the steps outlined in their work plan. These incidents demonstrate how important it is
10 Hr’g Tr. at 10:23–24.
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for the Territory to meet the agreed-upon work plan deadlines and proceed towards compliance with the Settlement Agreement in due haste.
The United States attempted to reach resolution of the Territory’s failure to meet its own deadlines via conference calls, in-person meetings, and multiple meet and confer letters and email exchanges. After nearly two months of such efforts, the United States finally received concrete deadlines for when most past-due items will be submitted for approval and when the Territory will revise and resubmit rejected items.11 Given that the Territory did not follow its own deadlines in the entire first three months they were in place, there is no evidence that the Territory will comply with these deadlines absent specific Court orders.12 Instead, the Territory continues to repeat its decades-long pattern of waiting until the eve of possible court intervention to produce a partial measure. This pattern cannot continue any longer, especially when lives are irrevocably damaged from the imminent harms existing at Golden Grove.
III. LEGAL STANDARD It is well-established that a court has the “inherent power to enforce compliance with [its] lawful orders through civil contempt.” Cooper v. Aaron, 358 U.S. 1 (1958). See also Shillitani v. United States, 384 U.S. 364, 370 (1966); Carty v. Schneider, 986 F. Supp. 933, 939 (D. VI. 1997). While the elements of a consent decree resemble both a contract and a judicial act, the decree is considered a lawful court order for the purposes of contempt. Local 93, Int’l Ass’n of Firefighters v. Cleveland, 478 U.S. 501, 519 (1986) (stating that consent decrees have attributes both of contracts and of judicial decrees, a dual character resulting in different treatment for
11 After a final conference call on this issue, when the United States expressed its intent to file a contempt motion, the Territory indicated that it would resubmit policies and procedures that the Monitor previously rejected for patent deficiencies one week after the conclusion of the Monitor’s planned September 2014 Technical Assistance visit, or by September 19, 2014. 12 See Hr’g Tr. at 8:4–5 (noting that, although the work plan sufficiently outlined the work going forward, the United States had “concerns regarding [the Territory’s] ability to meet the deadlines”).
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different purposes); Harris v. City of Philadelphia, 47 F.3d 1311, 1331 (3d Cir. 1995) (asserting contempt is an appropriate enforcement mechanism for jurisdictions subject to consent decrees).
To hold a party in civil contempt for violating a court order, a court must find that: 1) a valid court order existed; 2) defendants had knowledge of the order; and 3) defendants disobeyed the order. F.T.C. v. Lane Labs-USA, 624 F.3d 575, 582 (3d Cir. 2010); Marshak v. Treadwell, 595 F.3d 478, 485 (3d Cir. 2009); Roe v. Operation Rescue, 919 F.3d 857, 871 (3d Cir. 1990). The movant must prove the violation by presenting clear and convincing evidence, with any ambiguities construed in the favor of the non-moving party. John T. v. Del. Cnty. Intermediate Unit, 318 F.3d 545, 552 (3d Cir. 2003). The moving party is not required to prove that the alleged contemnor acted willfully or in bad faith in its disobedience, as “good faith is not a defense to civil contempt.” Robin Woods Inc. v. Woods, 28 F.3d 396, 399 (3d Cir. 1994).
IV. ARGUMENT A. The United States Has Exhausted Meet and Confer Efforts At the outset, the United States wishes to ensure the Court that it made all reasonable efforts to resolve this matter through the Monitor before seeking this Court’s intervention. The United States is mindful of the Court’s instructions that the United States “look to see what is the most appropriate, most expeditious, most economical, most effective way to achieve what needs to be achieved” under the Settlement Agreement before seeking Court intervention.13 Accordingly, as outlined below, during the last two months the United States wrote letters, requested and participated in conference calls, sent emails, and otherwise attempted to communicate with the Territory regarding the United States’ concerns about missed deadlines and reasonable replacement deadlines.
13 Hr’g Tr. at 20:13–16.
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After all of these efforts, the Territory finally produced a list of dates by which most of
the past due items will be developed or revised and re-submitted. The fact that the Territory
finally—after three months of effort—submitted a new schedule of dates does not absolve them
of the fact that they are in contempt of the Settlement Agreement. Moreover, the schedule
presented to the Court in April is now an inaccurate reflection of the Territory’s progress towards
compliance. Accordingly, the United States seeks a finding of contempt and urges the Court to
order the Territory’s newly-proposed deadlines for past-due items, to better ensure the Territory
actually meets these deadlines.
B. The Territory is Non-Compliant With Its Own Deadlines The Territory has failed to comply with the vast majority of the work plan deadlines (for
items due prior to the filing of this Motion), and this failure puts Defendants in contempt of the Settlement Agreement. Notably, these are deadlines that the Territory set for itself.14 Both the
Court and the United States presumed that the deadlines contained in the Territory’s work plan were the product of careful thought and planning.15 Unfortunately, numerous communications with the Territory since April have confirmed that this was not the case.16
The Territory developed a work plan that includes two different categories of deadlines.
The first category includes work plan items that require the submission of draft policies, plans, or
14 Hr’g Tr. at 10:6–9 (noting that the Monitor modified some of the deadlines in the work plan, “but in large part the plan that he adopted is the plan that the defendants submitted”). 15 See Hr’g Tr. at 15:23–16:5 (“My assumption – and if that is incorrect, then somebody needs to stand up and tell me – my assumption is that in putting these deadlines together, the parties, and in particular the Virgin Islands Government, carefully considered what needs to be done in order to achieve the deadlines.”). 16 During the June 2014 onsite monitoring tour, the Territory confirmed that it rushed to put many of the dates into the work plan because of the United States’ pending enforcement motion without considering all of the logistics required to accomplish each item. Subsequent meetings with staff revealed that none of the staff leadership, let alone individual staff members, even knew about the work plan and were not consulted at all in its development. This violates the Court’s instruction at the April 28th status conference that the Territory loop in all necessary agencies, officials, and staff to accomplish the work plan items. See Hr’g Tr. at 24:18–25:13 (“I know that there are different agencies that the Bureau of Corrections has to deal with . . . whether its contractors, or employees, et cetera. I encourage you to make sure, first of all, that those agencies are brought into the loop as soon as possible.”).
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other paperwork to the Monitor and the United States.17 These items include a date in the
“Target Date Draft to DOJ/Monitor Comments” column of the work plan.18 The second
category of deadlines is for work plan items that do not require submission of a draft. Thus,
these items do not list a “Target Date Draft to DOJ/Monitor Comments” date; they only include
“implementation” dates, listed in the “Target Implementation Date” column of the work plan.19
As the Monitor has explained and the parties have agreed, although these implementation-only
items do not require the submission of a draft, they still require submission of documentation, in
some form, demonstrating that the work plan item is complete.20
Prior to July 11, 2014, the Work Plan required the Territory to meet at least 50 different
provisions. The Territory also voluntarily produced two items intended to satisfy later deadlines
(IV.F #6 and V #27), meaning the completeness of 52 items was at stake by July 11, 2014.
Thirty of those items required submission of a draft document to the Monitor and the United
States. The remaining twenty-two items required production of documentation sufficient to
show that the item was complete. In both categories, the Territory entirely failed to meet certain
deadlines, and for most deadlines that they met in form, they did not meet in substance.
17 For these provisions, there is also a later deadline by which the policy must be fully implemented. Under the Settlement Agreement, a policy is “implemented” when it has been drafted and disseminated to all staff responsible for following or applying the policy; when all staff have been trained on the policy; compliance with the policy is monitored and audited; the policy is consistently applied; and corrective actions are taken when lapses in the application of the policy occur. ECF No. 689-1 at 2. 18 See ECF No. 818. 19 Id. 20 For example, during the June 2014 onsite monitoring tour, the Monitor outlined the following types of documentation that the Territory should submit to demonstrate compliance with stand-alone training requirements, such as the training required in work plan item V # 21:
(1) documentation showing how many people were trained (including numbers and percentages of staff); (2) documentation containing the subject matter of the training; (3) information on the instructor’s identity and qualifications; (4) documentation showing how the training requirement was met (demonstration of staff proficiency,
e.g., through pre and post tests); and (5) course materials.
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Category 1: Work Plan Items Requiring Draft Submissions Of the thirty provisions requiring submission of a draft document, the Territory satisfactorily completed only one: Work Plan Item IV.D #1, which required the Territory to “complete a comprehensive staffing analysis using the National Institute of Corrections process as a guideline.” This staffing analysis was due on May 31, 2014; it was submitted on July 21, 2014. For seven of the provisions in this category, the Territory submitted nothing. These items include IV.A #27, IV.B #8, IV.D #4,21 and V #4-7. The Territory submitted documents intended to satisfy twenty-two of the remaining twenty-nine provisions requiring production of a draft document. However, the Monitor rejected each of these drafts for failing to meet basic requirements. Some of these documents were impossible to comprehend due to formatting and spelling errors. Others lacked important definitions; failed to include all the relevant provisions from the Settlement Agreement; were internally inconsistent; and lacked organizational structure. The Monitor rejected all of the submitted policies via email on June 13, 2014, stating that “none of the policies/procedures submitted for approval contain all basic elements I previously email[ed] about.”22 The United States made several attempts to work with the Territory to develop a schedule of dates by which revised draft policies would be submitted for approval: first, via a conference call on June 5, 2014; and second, during an on-site meeting with the Warden, the Director, and the policy development consultant for the Territory; and finally through a series of letters, each asking the Territory to “provide (1) a schedule of dates by which it will submit revised draft policies reflecting the Monitor’s guidance and our own comments; and (2) an explanation of the
21 The Territory indicated via email that item IV.D #4 would be delayed pending completion of the staffing analysis, originally due on May 31, 2014. The Territory never followed up to provide an exact date by which this item would be complete. Finally, on July 24, 2014, the Territory stated it would complete this item by September 16, 2014. 22 Ex. 1 at 24, Email from Kenneth Ray to Nathan Oswald, June 13, 2014.
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process the Territory will be using to revise existing policies or write new ones, where necessary.”23 Each time, the Territory told the United States that it would respond with its plan shortly.
Finally, on July 7, 2014, more than a month after the United States attempted to resolve this issue, the Territory responded via counsel by describing a new process for policy development that would utilize small groups of key personnel, working collaboratively with consultants reportedly hired by the Territory.24 The Territory provided a schedule of when those meetings would take place, and noted that once the consultants “incorporate the product” of the meetings into the policies, the Bureau of Corrections (“BOC”) would conduct a review within three working days.25 The United States sent a follow-up letter, noting that despite its hope that the new process would lead to improved drafts, the Territory still failed to offer a schedule for when the new drafts would be produced.26 Although the Territory’s July 7th letter attached a list of policy review committee meeting dates, it remained unclear how long the policy consultants would take to incorporate information obtained during those meetings, create a new draft, submit that draft for BOC approval, and finally submit the new draft to the United States and the Monitor. The United States offered the Territory one final opportunity to identify dates certain by which it would produce new policy drafts, requesting a response by July 16, 2014. The Territory replied on July 18, 2014, changing the policy development plan so that the Monitor would come on site to help rewrite the policies. Instead of providing dates certain for resubmitting the new draft policies, this correspondence further stated that it “makes sense to
23 See Ex. 1 at 26, Letter from USDOJ to Nathan Oswald, June 30, 2014. 24 See Ex. 1 at 29, Letter from Nathan Oswald to USDOJ, July 7, 2014. 25 Id. 26 See Ex. 1 at 32, Letter from USDOJ to Nathan Oswald, July 11, 2014.
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discuss” the timeline for producing new drafts “after the Monitor’s visit.”27 After multiple attempts to finalize a schedule for policy revisions, the United States was told to wait and “discuss this issue again after the Monitor” arrives on site to help the Territory rewrite its policies, a visit that will not occur until September.28 After the United States indicated its intent to file this enforcement motion during a final conference call on this issue with the Territory and the Monitor on July 22, 2014, the Territory sent an email the next morning stating that it can now commit to submitting all revised policies and procedures within a week after the Monitor’s technical assistance visit, or by September 19, 2014.29
The Territory also argued that certain policies already submitted (and rejected) covered multiple work plan provisions. Although there is certainly some overlap among work plan items, the Territory can only satisfy a work plan item if the document submitted actually applies to that work plan item. On more than one occasion, the Territory stated that work plan item X was satisfied by previously submitted policy Y, but policy Y was either wholly irrelevant or incomplete with regards to X. For example, work plan item IV.A #22 requires the Territory to “create a plan to ensure special needs prisoners are monitored more frequently and by qualified health care staff.” This item was due on June 1, 2014. The Territory sent an email on June 6, 2014 submitting the Territory’s “SMU and Segregation Policy,” and stating that this policy “satisfies IV-A #22.” That policy, however, did not define “special needs prisoners,” nor did it contain any plan ensuring more frequent monitoring of that population by mental health staff. Instead, the policy covered disciplinary and administrative segregation housing units. When this issue was raised with the Territory, it did not submit any additional information or an actual plan;
27 Ex. 1 at 36, Letter from Nathan Oswald to USDOJ, July 18, 2014. 28 Id. 29 See Ex. 1 at 41, Email from Nathan Oswald to USDOJ, July 23, 2014.
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instead, the Territory indicated that the policy regarding segregation would be revised in the
coming weeks.30 Accordingly, Item IV.A # 22 is overdue.31
This open-ended and constantly shifting schedule is precisely what the work plan
deadlines were designed to prevent. The United States does not object to the Monitor helping
the Territory rewrite their policies.32 Yet this could have—and should have—happened months
before, and this process should have been built into the deadlines the Territory submitted to the
Court last April.33 It was not. Rather than reflecting the logistics necessary to complete the
work plan items, the deadlines appear to have been pulled out of thin air, with the result that
deadlines are consistently missed or blatantly deficient drafts are produced—leading to no
progress under the Settlement Agreement. This is precisely the type of foot dragging that has
plagued this case for years. Given how long it took to get the work plan in place, and the
Territory’s failure to abide by its own deadlines, the United States requests that the Court now
30 See Ex. 1 at 29-30, Letter from Nathan Oswald to USDOJ, July 7, 2014. 31 Notably, the United States used Item IV.A #22 as one example of many where the Territory submitted a document in satisfaction of a work plan item, but the document was not actually sufficient to satisfy that item. The United States clearly noted in its June 30, 2014 letter: “To date, we have not received a single plan or schedule required under the work plan.” See Ex. 1 at 26, id. 32 During the July 22, 2014 conference call, the Monitor explained that he would arrange a week-long site visit in September 2014, during which he and another corrections expert appointed to his monitoring team, would meet with key Golden Grove personnel and completely redraft all previously rejected policies. In light of this, the United States asked for the Territory’s assurance that the policies would be revised and resubmitted for approval within a week of the Monitor’s visit. The Territory would not commit to this or any date by which the policies would be resubmitted during the conference call. The United States indicated at the conclusion of the call its intent to file an enforcement motion on this basis, among others. The Territory subsequently emailed to state that it could now commit to submitting revised policies in accord with the United States’ proposal. 33 The Monitor had offered to provide this hands-on technical assistance on numerous occasions, including during the June 2014 onsite monitoring tour, yet the Territory did not accept this offer until now. Indeed, during the April 2014 status conference, the Monitor explained how he had already provided some technical assistance to the Territory by way of “[s]amples, lists . . . a plethora of information, references, materials, professional references, . . . [and] descriptions of what’s missing in [the Territory’s] own policies” to assist in policy development. Hr’g Tr. at 113:11–14. See also id. at 109 (where Mr. Ray explained his concerns with the Territory’s policy development and foreshadowing that, despite his provision of models and samples, the Territory would still submit drafts so devoid of “basic elements” that he “ship[s] them back. . . . [A]nd before we know it we’re right back in front of [the Court] because . . . they’ve missed deadlines”).
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order the specific deadlines by which the Territory must produce items that are already long overdue.
Category 2: Work Plan Items Requiring Verification of Implementation In addition to the overdue work plan items that require production of draft documents, the Territory has either failed to produce documentation, or produced insufficient documentation, to show that certain “implementation” dates were met. The Territory did not produce any verification documentation for twelve of the twentytwo items in this category.34 For the remaining items requiring verification of implementation, either the Territory submitted insufficient documentation or further analysis determined that implementation did not, in fact, occur as stated by Defendants. For four items – items IV.A #17, IV.A #26, IV.D #6, and IV.F #5 – the Territory submitted some documentation, but the documentation was outdated, irrelevant, or insufficient to satisfy the work plan item.35 A single document, entitled “Plan to Ensure Safety at Golden Grove,” was submitted for both IV.A #17 and IV.A #26. This “plan” appears to derive from notes from a meeting, or follow-up notes written by the Warden, reminding management-level staff of certain responsibilities. Item IV.A #17 required the Territory to develop a “plan to ensure supervisors/management follow through on log book reviews to ensure all personnel are appropriately informed of GGACF activities and that issues are handled in an efficient and timely manner.”36 The submitted “Plan to Ensure Safety” included a note that certain staff should review and initial log books, but it did not provide any additional detail, nor did it give
34 See Ex. 2, Chart Outlining Status of Work Plan Completion. The United States completed this document to demonstrate for the Court which work plan items that have not been submitted, are incomplete, or whose completion is in dispute. 35 See id. 36 ECF No. 818 at 4.
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direction to all supervisory-level staff on what to do with the information gleaned from the log book entries. Item IV.A #26 requires the development of a “schedule to ensure all staff have basic issued equipment within the scope of the GGACF P&Ps and ensure the equipment is maintained on the equipment inventory check out forms.”37 The “Plan to Ensure Safety” does not mention anything about equipment checks or equipment inventory forms, much less provide a schedule for ensuring such equipment is provided and maintained. When asked to provide a new date by which IV.A #17 and IV.A #26 would be produced, Defendants argued (despite the United States’ earlier letter stating that not a single satisfactory plan or schedule had been produced to date), that these items were already completed via the “Plan to Ensure Safety,” or, in the alternative, were not required under the Settlement Agreement.38
Similarly, the Territory submitted equally insufficient documentation showing that Item IV.F #5 was complete. Item IV.F #5 required the Territory to review post staffing needs and ensure that scheduling reflects requirements within current staffing availability. This showing was due on June 11, 2014. On June 30, 2014, the Territory submitted overtime rosters for three shifts and stated that the rosters satisfied this work plan item. The United States agrees with the Monitor that this is not sufficient to demonstrate a meaningful review of needs and optimal deployment. 39
Finally, in satisfaction of item IV.D #6, which requires analysis of staffing deficiencies and revising staffing to address gaps, the Territory submitted an outdated “Critical Hiring Plan,” which was previously provided in December 2013. This hiring plan, created before the work plan was in place, could not possibly satisfy the work plan provision, which mandates a new
37 ECF No. 818 at 6. 38 See Ex. 1 at 58, Email from Nathan Oswald to USDOJ, August 8, 2014. 39 See Ex. 1 at 60, Email from Kenneth Ray to Nathan Oswald, August 10, 2014 (stating that he cannot accept these documents as evidence of compliance with work plan item IV.F #5).
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review of staffing deficiencies. Defendants agreed to redo this plan based on their staffing
analysis after the Monitor brought this issue to their attention.
For three other items, the United States received an email that the item was complete; but
observation during the June onsite monitoring visit disproved this assertion. These items include
IV.A #13, IV.A #19, and IV.A #20.40
Finally, for all other items, the United States received an email indicating that each item
was complete, but with no verifying documentation. These items include IV.B #5, IV.B #7, and
V #21.41 The Territory’s failure to complete provision V #21 (requiring the Territory to train
correctional officers on how to identify, refer, and supervise prisoners with medical and mental
health needs) is particularly troubling. This item was to be completed by June 1, 2014. The
40 See Ex. 1 at 26, 30. Work plan item IV.A #13 mandates a review of all posts to ensure each post has a manual, including post orders. Counsel for the Territory indicated that the Warden conducted rounds and could confirm this item was met. However, a week after receiving that verification, the Monitor toured the facility and observed some posts without any manuals or post orders. Item IV.A #19 requires the Territory to replace or repair any malfunctioning radios. Counsel indicated that this item was complete, but again, the Monitor observed some staff with malfunctioning radios and other posts without any radio present. Finally, IV.A #20 requires repair and replacement of telephone equipment. On June 11, 2014, Counsel indicated that this item was complete. When it became clear during the Monitor’s tour that many phones were inoperable (and one physically broken), Counsel retracted his earlier statement. In a subsequent letter, Counsel stated
. . . the contractor installing the fiber optics at Golden Grove has requested an extension of his contract to the end of September. By the end of September, the fiber optics and the new phones will be installed. As I indicated in my letter of July 7, none of the current phones will operate on the fiber optics backbone and none of the new phones will operate on the current infrastructure. Therefore it would be inefficient to replace phones now given how soon they will be removed.
Id. at 37, Letter from Nathan Oswald to USDOJ, July 18, 2014. The United States does not understand why the Territory originally committed to complete item IV.A #20 by June 1, 2014 if the phones would not work until the new fiber optic system was completed. Moreover, the Territory is now providing only an estimate – sometime in September -- of when this critically important communication system will be up and running. This is even more troublesome given the fact that the fiber optic project was originally slated to finish in April. The United States is unsure whether the September completion date will hold. 41 The Territory’s claims that it submitted certain forms to satisfy IV.B #5 and IV.B #7, but after a conference call regarding the Territory’s failure to provide adequate documentation in general, the Territory stated that it had no other documents to verify that these items were complete. And, as with items IV. A #17 and IV.A #26 discussed above, the Territory later argued that its failure to complete items IV.B #5 and IV.B #7 is of no consequence because these items are not required under the Settlement Agreement.
16

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Territory’s counsel notified the United States on June 11, 2014, that, as per BOC Director Julius Wilson, all officers received this training. The United States asked for verification of that training, in the form of a curriculum, sign-in sheets, or other materials. The Territory would not provide that verification. During the June 2014 onsite monitoring visit, the United States once again asked for verification that the training required by work plan item V #21 occurred. During discussions with Territory officials, it became clear that the training never happened and that there was no clear plan for providing that training in the future. As a result, the Territory eventually retracted its earlier email confirmation that the item was complete. The Territory now represents that “Warden Redwood expects to complete the training within ten days following July 21” and that it “looks like Warden Redwood expects to complete the training by August 1st.”42
The United States is greatly concerned that this item remains overdue. This limited, emergency training was requested because numerous log book entries indicated that prisoners with serious medical and mental health needs were left unattended and untreated for long periods of time. The United States specifically requested this emergency training in its March 2014 enforcement motion, but agreed to withdraw that aspect of the motion on the Territory’s assurance that it would provide the requested training no later than June 1, 2014. Despite the Director’s assurance that the training was already complete, the Territory did not—and still has not—provided this required training, while prisoners with serious medical and mental health needs continue to languish at Golden Grove.
42 Ex. 1 at 36-37, Letter from Nathan Oswald to USDOJ, July 18, 2014.
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C. The Territory Should Be Held in Contempt for its Failure to Meet These Deadlines
Under Third Circuit law, a finding of civil contempt is appropriate when: 1) a valid court order exists; 2) the defendants had knowledge of that order; and 3) the defendants disobeyed that order. Lane Labs-USA, 624 F.3d at 575. The Territory’s actions over the last three months clearly satisfy each of these elements.
It is indisputable that a valid court order exists and that the Territory had knowledge of that order. The Court accepted and entered the Settlement Agreement as an order of this Court on May 14, 2013.43 This court-ordered Settlement Agreement requires the Territory to “develop and submit to USDOJ and the Monitor for review and approval facility-specific polices” to remedy numerous ongoing constitutional deficiencies at Golden Grove.44 The agreement also requires the Territory to “take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.”45 To accomplish this goal, the court-ordered agreement requires the Territory to create and follow “a schedule for policy development, training, and implementation of the substantive terms of this agreement.”46 Thus, the implementation schedule codified in the Territory’s work plan is a requirement of this Court’s order, and the substantive provisions of that plan are drawn from the requirements of the Settlement Agreement itself.
43 ECF No. 724. 44 See generally ECF 689-1. 45 Id. at 13. 46 Id. Per the deference embodied in the court-ordered agreement, the Territory itself created the vast majority of the deadlines contained in the work plan. Any changes to the work plan on the eve of the April 28, 2014 status conference were limited and agreed to by the Territory.
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The Court made this clear during the April 28, 2014 status conference, emphasizing that the work plan deadlines “are the deadlines that will be in the Court’s . . . frame of reference with respect to how progress is being made or to be made” under the Agreement.47 The Court also stated that “it will be the exception, rather than the rule, that these deadlines are not met. . . . And I trust it will be the rare exception.”48 The Territory was therefore on full notice that these deadlines were requirements of the Court in implementing the court-ordered Settlement Agreement. Accordingly, the first and second elements of contempt are indisputably satisfied.
It is equally clear that the Territory has disobeyed these deadlines. As noted above, for some items, absolutely nothing was submitted. When documents were submitted, they were woefully inadequate, incomplete, or unresponsive. Notably, the Territory did not ask for a modification under Section IX.2 of the Settlement Agreement before these deadlines passed. The Territory simply failed to meet these deadlines, by delivering absolutely nothing or by delivering a completely inadequate product. Accordingly, a finding of contempt is appropriate.
D. The Territory’s Excuses for Failing to Comply with the Work Plan Deadlines Are Unpersuasive
In response to the United States’ and the Monitor’s multiple inquiries about past due items, the Territory has vacillated between a handful of different excuses, including but not limited to: 1) the resignation of the former Warden of GGACF in May; 2) administrative problems including delays associated with the contract with the policy development consultant; and 3) other unidentified “unexpected events.”49
None of these excuses deserve merit, especially because they were offered after deadlines had already passed. During the April 28, 2014 status conference, the Court warned the Territory
47 Hr’g Tr. at 16:16–18. 48 Hr’g Tr. at 17:9–13. 49 See Ex. 1 at 6, 16, 30-31.
19

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that such excuses would be unacceptable: “My expectation certainly isn’t that . . . we’re going to

turn around and have a schedule, and by two weeks from now we have a different schedule, and three weeks from now we have a different schedule after that.”50 Rather, the Court instructed the

parties that any modifications to the schedule must be for good cause and anticipated in advance of the deadline.51 In many instances, absolutely no justification was put forth for missing a

deadline, and the Territory did not acknowledge that certain items were past due until the United

States raised the issue on a conference call.

E. In Addition to a Finding of Contempt, the Court Should Order New Deadlines, Including Those Proposed by the Territory, for All Incomplete or Outstanding Work Plan Items
After nearly two months of attempting to secure deadlines for overdue items and a

schedule for resubmission of draft policies and procedures previously rejected by the Monitor,

the United States believes the Court should order new deadlines that will put the work plan back

on track. Unfortunately, the Territory has demonstrated that it will not follow the deadlines it

sets for itself; Court-ordered deadlines are therefore necessary to prevent these delays from

occurring yet again.

New Deadlines Provided by the Territory

The Territory recently proposed new deadlines for seventeen overdue items. These

items, including their original due date, are stated below:

Work Plan Item#
1. IV-A #11 2. IV-A #12 3. IV-A #14

Work Plan Deadline 6/15/2014 6/15/2014 6/14/2014

VI’s Proposed New Due Date
9/4/2014 9/1/2014 8/29/2014

50 Hr’g Tr. at 27:20–25. 51 See Hr’g Tr. at 26:8–11 (“Do not wait until the last minute at status, and say we needed to have two months on
that, because you, you name the agency, well, we didn’t get it in time.”).
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Work Plan Item#
4. IV-A #15 5. IV-A #16 6. IV-A #20 7. IV-A #25 8. IV-A #27 9. IV-C #7 10. IV-D #4 11. IV-D #6 12. IV-F #10 13. IV-G #2 14. V #5 15. V #6 16. V #21 17. V #32

Work Plan Deadline 6/14/2014 6/30/2014 6/1/2014 7/1/2014 6/15/2014 7/1/2014 6/15/2014 6/11/2014 6/30/2014 7/1/2014 7/1/2014 7/1/2014 6/1/2014 6/15/2014

VI’s Proposed New Due Date
9/30/2014 10/1/2014 9/30/201452 8/29/2014 10/15/2014 9/1/2014 9/16/2014 9/18/201453 8/29/2014 10/1/2014 9/12/2014 9/12/2014 8/31/201454 9/15/2014

The Territory also agreed to submit revised versions of all the previously rejected policies and other draft documents not listed in the above chart by September 19, 2014. This new date will influence the training and implementation dates in the work plan for those items, and the Territory should provide such dates to ensure a complete, up-to-date work plan.
Items Past Due for which the Territory Did Not Provide New Deadlines For five items, the Territory has not proposed any new dates by which the items will be complete.55 These items include IV.A #17 (originally due 6/1/14); IV.A #26 (originally due

52 The Territory communicated via email that the fiber optic installation project would be complete by the end of September, and the phones would be functional at that time. See footnote 40, supra. The United States takes this representation to mean that the Territory will complete item IV-A #20 by the last day of that month, September 30, 2014. 53 The Monitor requested that this item be completed by 9/18/2014 and the Territory is apparently willing to accommodate that request. See Ex. 1 at 49, Email from Nathan Oswald to USDOJ, August 6, 2014. 54 The Territory represented that they expect to have the training required by this item completed by 8/1/14, but requested two additional weeks to ensure all officers receive the training. See Ex. 1 at 37, Letter from Nathan Oswald to USDOJ, July 18, 2014. The United States therefore requests that the Territory provide proof that this training was completed for all officers no later than 8/31/14. 55 For two other items, IV.A #13 and IV.A #19, the Territory disputes the United States’ assessment that these items were not completed, based on the Monitor’s on-site observations in June. See, e.g., Ex. 1 at 30. For these two items, the United States will re-check whether the implementation is complete during the September 22-25, 2014 compliance tour.
21

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5/30/14); IV.B #5 (originally due 5/1/14); IV.B #7 (originally due 6/1/14); and IV.F #5 (originally due 6/11/14).
For IV.F #5, the Territory did not respond to the Monitor’s email noting that the documents submitted for this item were insufficient. For IV.A #17, IV.A #26, IV.B #5 and IV.B #7, the Territory argues that the United States either did not timely dispute the adequacy of the materials submitted in support of these items, or, in the alternative, that the United States is not permitted to dispute the adequacy of the materials because the Settlement Agreement does not require those work plan items. The first argument is factually incorrect, as both the United States and the Monitor raised concerns regarding the adequacy of the documents submitted to satisfy IV.A #17 and #26. The Territory acknowledged that it did not submit any additional documents to verify IV.B # 5 and #7 aside from documents previously determined to be insufficient. The second argument contradicts the clear text of Section IX of the Settlement Agreement, requiring the Territory to “propose . . . a schedule for policy development, training, and implementation of the substantive terms of this agreement.”56 The Territory’s work plan is the required schedule: it was drafted entirely by the Territory, not the United States, for the purpose of satisfying the Settlement Agreement. New dates must be provided by the Territory for when these items will be complete.
The Territory also must provide a date by which they will hire a Medical Director that is medically licensed to supervise medical staff at Golden Grove. As noted above, the Monitor recently discovered that Dr. Burton does not have the proper licensure to serve as Medical Director. The Territory should therefore be ordered to provide a date by which a new Medical
56 Settlement Agreement, § IX.1, ECF No. 689-1.
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Director will be hired, as required by work plan item V #1, or, if possible, a date by which the deficiency in Dr. Burton’s licensure can be corrected.
In sum, the Territory must provide new dates by which the following items will be completed: IV.A #17, IV.A #26, IV.B #5, IV.B #7, IV.F #5, and V #1.
Reporting on Status of Compliance with New Deadlines Finally, to avoid unnecessary exchanges with the Court regarding the status of compliance with the new deadlines, the United States requests that this Court order the Territory to discuss the status of compliance with the above deadlines within their next status report, due to the Court on September 15, 2014. The United States hopes to avoid litigation on these issues going forward. Hopefully, by incorporating the new deadlines into the orders of the Court, and requiring the Territory to report on those deadlines in its next status report, the Territory will not miss the mark yet again.
V. REQUEST FOR EXPEDITED BRIEFING Given the extreme risk of harm facing prisoners and staff at Golden Grove, as well as community members, due to the Territory’s progress towards compliance with the Settlement Agreement, the United States respectfully requests expedited briefing on this issue. Many of the new deadlines proposed by the Territory are at the end of August and beginning of September. To allow the Court to rule on whether those deadlines should be entered as Orders of this Court in advance of the deadlines, the United States requests that the Territory be given one week from the date of this filing to file their response. The United States will then complete its reply briefing, if any, within three business days. Oral argument, if necessary, could be conducted via telephone or video conferencing at the Court’s earliest convenience.
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VI. CONCLUSION The Territory’s performance thus far indicates that it does not devote serious attention to its obligations under the Settlement Agreement and the work plan. Despite having created the vast majority of the deadlines in the work plan, the Territory has not stayed on track. As a result, the work plan submitted to the Court is now meaningless—deadlines have come and gone, and there is no set of future deadlines governing this case. There is no mechanism in the Settlement Agreement allowing the Territory to let deadlines pass without any action, and to ask for an extension only after deadlines have passed. If the United States allowed these delays to continue without notifying the Court, we would arrive at the September status conference with very little progress made. Meanwhile, Golden Grove prisoners and staff and the community at large continue to suffer serious harm and risk of harm from the lack of safety, security, and medical and mental health care at Golden Grove. Although the United States is mindful of the Territory’s need to focus on the task at hand, the Territory clearly cannot do so on its own. To ensure that this case moves forward at an appropriate pace and does not extend into another three decades, the United States respectfully requests that this Court hold the Territory in contempt of the Settlement Agreement; enter the new deadlines provided by the Territory, as noted in Section IV.E., supra, as an Order of this Court; order the Territory to provide new deadlines for the five remaining items; and require the Territory to report on the status of compliance with those deadlines in its official status reports.
Respectfully submitted, MOLLY J. MORAN Acting Assistant Attorney General Civil Rights Division 24

Case: 1:86-cv-00265-WAL-GWC Document #: 833 Filed: 08/13/14 Page 25 of 27
MARK J. KAPPELHOFF Deputy Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Chief
LAURA L. COON Special Counsel s/ SHARON BRETT SHARON BRETT MARLYSHA MYRTHIL Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202-353-1091 202-514-4883 (fax) Angela P. Tyson-Floyd Assistant United States Attorney U.S. Attorney’s Office 1108 King St., Ste. 201 Christiansted, V.I. 00841 340-773-3920 340-773-1407 (fax)
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CERTIFICATE OF SERVICE
I certify that on August 13, 2014, I electronically filed the foregoing using the CM/ECF system, which will send notification to the following:
Aquannette Y. Chinnery V.I. Department of Justice GERS Building 2nd Fl. 34–38 Kronprindsens Gade St. Thomas, V.I. 00802 Tel: 340-774-5666 X285 Email: achinnery@doj.vi.gov
Carol Thomas-Jacobs Department of Justice Office of the Attorney General 8050 Kronprindsen Gade St Thomas, VI 00802-0000 Tel: 340-774-5666 Email: cjacobs@doj.vi.gov
Kenrick E. Robertson Office of the Attorney General 6040 Estate Castle Coakley Christiansted, VI 00820 Tel: 340-773-6309 Email: kenrickr@gmail.com
Nathan T Oswald Thacker Martinsek, LLP 300 Madison Ave., 10th Floor Toledo, OH 43604 Tel: 419-931-6934 Email: noswald@tmlpa.com
Joseph A DiRuzzo , III Fuerst Ittleman David & Joseph, PL 1001 Brickell Bay Drive Suite 3200 Miami, FL 33131 Tel: 305-350-5690 Email: jdiruzzo@fuerstlaw.com
26

Case: 1:86-cv-00265-WAL-GWC Document #: 833 Filed: 08/13/14 Page 27 of 27
Respectfully submitted, /s Sharon Brett SHARON BRETT Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202-353-1091 202-514-4883 (fax)
27

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 853 Filed: 09/24/14 Page 1 of 4

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA

)

Plaintiff,

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, et al. )

Defendants.

)

_________________________________________ )

Civil No. 86/265

JOINT MOTION FOR ENTRY OF STIPULATED ORDER

Pending before the Court is the United States’ Motion for an Order to Show Cause Why

Defendants Should Not Be Held in Contempt [ECF No. 833]. Oral argument on this Motion is

currently scheduled for September 25, 2014. In the days leading up to oral argument, the parties

were able to reach agreement on the issues raised in the motion and the necessary relief to be

ordered by the Court.

The Territory has agreed to stipulate that it is in non-compliance with the Settlement Agreement, entered as an Order of this Court on May 14, 2014 [ECF No. 689-1]. The Territory also agreed to stipulate to the relief outlined in the attached Stipulated Order, as an appropriate remedy for their non-compliance with the Agreement. Finally, the Territory agreed to stipulate that the relief is compliant with the Prison Litigation Reform Act, 18 U.S.C. § 3626(a).

The United States maintains its position, outlined in its Motion and Reply brief, that the facts and law support a finding of contempt. The Territory maintains that it is not in contempt, but stipulates that it is not in compliance with the Agreement. Because the Territory will stipulate to a finding of non-compliance with the Agreement, and because the Territory will stipulate to the relief requested by the United States, the United States believes the entry of a

Case: 1:86-cv-00265-WAL-GWC Document #: 853 Filed: 09/24/14 Page 2 of 4
Stipulated Order is the most expeditious route to resolving the issue and moving the Territory
towards compliance with the Agreement.
Accordingly, the United States of America and the Territory of the Virgin Islands jointly
move this Court to enter a Stipulated Order, attached hereto as Exhibit 1. If the Court grants this
Joint Motion and enters the attached Stipulated Order, the United States will agree to withdraw
its original contempt motion without prejudice. The United States and the Territory also
recognize that the entry of a Stipulated Order will have no effect on the Court’s September 25,
2014 status conference and the Court’s ability to investigate the Territory’s efforts towards
compliance during that conference.
Respectfully submitted, FOR THE UNITED STATES MOLLY J. MORAN Acting Assistant Attorney General Civil Rights Division
MARK J. KAPPELHOFF Deputy Assistant Attorney General Civil Rights Division
JONATHAN M. SMITH Chief
LAURA L. COON Special Counsel
s/ SHARON BRETT SHARON BRETT MARLYSHA MYRTHIL Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 2

Case: 1:86-cv-00265-WAL-GWC Document #: 853 Filed: 09/24/14 Page 3 of 4
950 Pennsylvania Ave., NW Washington, DC 20530 202-353-1091 202-514-4883 (fax) Angela P. Tyson-Floyd Assistant United States Attorney U.S. Attorney’s Office 1108 King St., Ste. 201 Christiansted, V.I. 00841 340-773-3920 340-773-1407 (fax)
FOR THE TERRITORY OF THE VIRGIN ISLANDS
s/ KENRICK ROBERTSON Kenrick E. Robertson Office of the Attorney General 6040 Estate Castle Coakley Christiansted, VI 00820 Tel: 340-773-6309 Email: kenrickr@gmail.com
s/ AQUANNETTE CHINNERY Aquannette Y. Chinnery V.I. Department of Justice GERS Building 2nd Fl. 34–38 Kronprindsens Gade St. Thomas, V.I. 00802 Tel: 340-774-5666 X285 Email: achinnery@doj.vi.gov
3

Case: 1:86-cv-00265-WAL-GWC Document #: 853 Filed: 09/24/14 Page 4 of 4
CERTIFICATE OF SERVICE I certify that on September 24, 2014, I electronically filed the foregoing using the CM/ECF system, which will send notification to the following: Aquannette Y. Chinnery V.I. Department of Justice GERS Building 2nd Fl. 34–38 Kronprindsens Gade St. Thomas, V.I. 00802 Tel: 340-774-5666 X285 Email: achinnery@doj.vi.gov
Kenrick E. Robertson Office of the Attorney General 6040 Estate Castle Coakley Christiansted, VI 00820 Tel: 340-773-6309 Email: kenrickr@gmail.com
Respectfully submitted, /s Sharon Brett SHARON BRETT Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 202-353-1091 202-514-4883 (fax)
4

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 874 Filed: 12/30/14 Page 1 of 17

DISTRICT COURT OF THE VIRGIN ISLANDS
 DIVISION OF ST. CROIX


UNITED STATES OF AMERICA,

)

)

)

v.

)

)

)

TERRITORY OF THE VIRGIN ISLANDS, )

et al.,

)

)

)

Defendants.

)

__________________________________________)


Civil Action No. 1986-265

Attorneys:
 Jonathan M. Smith, Esq.,
 Laura L. Coon, Esq.,
 Rita K. Lomio, Esq.,
 Sharon I. Brett, Esq.,
 Marlysha Myrthil, Esq.,
 Washington, D.C. Angela Tyson-Floyd, Esq., St. Croix, U.S.V.I.
For the United States

Carol Thomas-Jacobs, Esq., Aquannette Y. Chinnery, Esq., St. Thomas, U.S.V.I. Kenrick E. Robertson, Esq., Shari N. D’Andrade, Esq., St. Croix, U.S.V.I.
For the Defendants

MEMORANDUM OPINION

THIS MATTER came before the Court for a Show Cause Hearing on December 10,

2014. The subject of the hearing was Defendants’ Response to an Order entered on November

13, 2014, in which the Court directed Defendants, inter alia, to show cause why they should not

be sanctioned for their failure—for the third time this year—to pay the Monitor in this matter in

a timely manner. (See Dkt. No. 866 at 2). The Show Cause Hearing was scheduled after the

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Court found that Defendants’ written response to the Court’s November 13, 2014, Order to Show

Cause (Dkt. No. 867), was “both factually and legally inadequate” (Dkt. No. 868 at 2).

For the reasons that follow, the Court finds Defendants in contempt of this Court’s June

6, 2014 Order requiring timely payment of the Monitor, and will impose a fine of $1,000.00 for

Defendants’ noncompliance. Further, because of Defendants’ repeated failure to timely pay the

Monitor, the Court—to coerce compliance—will order that any future noncompliance with this

Court’s June 6, 2014 Order, without good cause or other legally sufficient reason, will subject

Defendants to a fine of $250.00 per day for each day that Defendants are noncompliant, plus

payment to the Monitor of any reasonable fees and expenses incurred as a result of the untimely

payment.

I. BACKGROUND1

A. Overview

This litigation began in 1986 when the United States filed a Complaint seeking to enjoin

the Virgin Islands Government from depriving inmates at the Golden Grove Adult Correctional

Facility (“Golden Grove”) of the rights, privileges, and immunities provided and secured by the

United States Constitution. (See Dkt. No. 1). After decades of litigation, the Court, on May 14,

2013, accepted a Settlement Agreement executed by the parties (Dkt. No. 689-1), and entered it as an Order of the Court (Dkt. No. 742).2 In the Order, the Court adopted the United States’

1 The facts and procedural history pertaining to the untimely payment of the Monitor were previously chronicled in a Memorandum Opinion issued by this Court on June 6, 2014. See Dkt. No. 831, United States v. Terr. of the V.I., 2014 U.S. Dist. LEXIS 77204 (D.V.I. June 6, 2014). Although the previous opinion describes many of the facts relevant to the instant matter, the Court will again set forth the pertinent background because of its importance to the Court’s ruling herein.
2 During the course of the litigation, the parties had previously entered into a Consent Decree, a Plan of Compliance, and a Stipulated Agreement (all of which were entered as Orders of the Court) to remedy the constitutional violations at Golden Grove. In a Memorandum Opinion issued on February 8, 2012, this Court found that these Orders did not comply with the Prison Litigation Reform Act. (See Dkt. No. 630). The ensuing litigation resulted in the May 14, 2013 Order of the Court adopting the parties’ Settlement Agreement.
2


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Proposed Findings of Fact and Conclusions of Law (Dkt. No. 716), and found, as agreed by the
parties, that “Defendants are violating the Eighth Amendment rights of prisoners at Golden
Grove[.] ” (Dkt. No. 742 at 2).
In the Settlement Agreement, the parties agreed to a broad plan to “remedy the ongoing
constitutional violations” at Golden Grove. (Dkt. No. 689-1 at Part II.1). A key provision of the
Settlement Agreement was that the parties “jointly select a person to serve as the Monitor to
oversee the implementation of the Agreement.” (Dkt. No. 689-1 at Part X.A.1). By Order entered
on June 19, 2013, the Court approved the parties’ joint selection of Kenneth A. Ray and appointed him to serve as the Monitor in this matter. (Dkt. No. 750).3 Under the terms of the
Settlement Agreement, “[t]he cost for the Monitor’s fees and expenses [are to] be borne by Defendants.” (Dkt. No. 689-1 at Part X.C.1).4
As discussed further below, over the span of nine months in 2014, the United States, on
behalf of the Monitor, filed, on three occasions, a “Notice and Request for Emergency
Telephonic Status Conference” (“Notice”) related to Defendants’ untimely payment of the
Monitor’s monthly invoices. On the first two occasions, the Court ordered a response from
Defendants and held a status conference. At each of the hour-long status conferences, the Court,
the parties, and the Monitor discussed, in substantial detail, the causes of the delay in payment;
the adverse implications of Defendants’ failure to timely pay the Monitor’s invoices; the Court’s
3 By the terms of the Settlement Agreement, the Monitor’s duties include: reviewing, modifying, and approving Defendants’ implementation schedule and training procedures (Dkt. No. 689-1 at Parts VIII.1 and IX.2-5); advising Defendants regarding substantive requirements of the Settlement Agreement (id. at Part X.H); resolving disputes between the parties (id. at Part IX.2-3, 5); and comprehensively reporting to the Court on Defendants’ progress in implementing the substantive provisions of the Settlement Agreement (id. at Part X.F-G). 4 The Settlement Agreement states that Defendants are to “provide the Monitor with a budget sufficient to allow the Monitor to carry out the responsibilities described in [the] Agreement,” and the Monitor is to “submit detailed monthly [invoices] of fees and expenses to the parties[.]” (Dkt. No. 689-1 at Parts X.C.2 and X.C.1, respectively). In furtherance thereof, Defendants and the Monitor entered into a contract, which provides, in relevant part, that “[t]he Government shall, within THIRTY (30) DAYS of the receipt of an invoice, pay the invoice in full or, if it contests any charge or charges on the invoice and fails to resolve the dispute by agreement, submit the dispute to the Court and the Court will determine the appropriate amount to be paid.” (Dkt. No. 817-1 at 42).
3


Case: 1:86-cv-00265-WAL-GWC Document #: 874 Filed: 12/30/14 Page 4 of 17
expectations of Defendants regarding timely payment going forward; and Defendants’ assurances that untimely payments would not recur. Following the second status conference, the Court issued a Memorandum Opinion on June 6, 2014 detailing the relevant factual and legal issues that supported the accompanying Order. In the June 6 Order, the Court directed Defendants to “pay the Monitor’s monthly invoices within thirty days of receipt—in accordance with the Defendants’ contract with the Monitor, executed pursuant to the Court’s May 14, 2013 Order adopting the parties’ Settlement Agreement—or be subject to sanctions.” (Dkt. No. 830 at 2).5
Five months after the June 6, 2014 Order, the United States filed a third Notice regarding yet another untimely payment of the Monitor’s monthly invoice. That Notice led to the issuance of the Court’s November 13, 2014 Order to Show Cause, Defendants’ written response, and the December 10, 2014 Show Cause Hearing.
B. Factual and Procedural History 1. Defendants’ First Failure to Timely Pay the Monitor
On February 18, 2014, the United States filed a Notice advising the Court that Defendants had failed to pay the Monitor for any of the work he had completed, totaling over $80,000. (Dkt. No. 766 at 1). Because Defendants had not paid the Monitor—even after a reminder from the Monitor which contained a final deadline for payment—the Monitor suspended his services, including the March 2014 monitoring tour and the Second Compliance Report due to the Court on March 10, 2014. (Id. at 1-2).6 The United States requested an emergency telephonic status conference to address the issue. (Id. at 2).
5 For the relevant text of the contract, see note 4, supra.
 6 The Monitor performed both of these services once the payment issue was resolved.

4


Case: 1:86-cv-00265-WAL-GWC Document #: 874 Filed: 12/30/14 Page 5 of 17
In an Order entered on February 19, 2014, the Court granted the United States’ request for an emergency telephonic status conference; set a telephonic status conference for February 20, 2014; and ordered Defendants to file a response to the United States’ Notice. (Dkt. No. 767 at 2). As ordered, Defendants filed a “Response to Notice and Request for Emergency Telephonic Status Conference” on February 19, 2014. (Dkt. No. 768).
In their Response, Defendants acknowledged that they are “obligated to pay the fees and expenses of the Monitor and the Monitor’s consultants” under the terms of the Settlement Agreement, and explained that in “September 2013[,] the Monitor and the Defendants agreed to a monitoring budget for the first year of the monitorship.” (Id. at 1). Defendants further explained that they executed a contract with the Monitor on December 12, 2013 containing “terms . . . consistent with the provisions of the Settlement Agreement,” and that “[b]etween December 12, 2013 and February 13, 2014, the contract obtained the approval of different [Virgin Islands] agencies as required by law,” after “back-and-forth discussion to resolve concerns about the contract.” (Id.).
According to Defendants, the “contract was finally approved on February 13, 2014,” and a check was issued to the Monitor for his outstanding invoices on February 19, 2014—the same date that Defendants filed their Response to the United States’ Notice. (Id. at 2). Defendants stated that “the delay in making payment to the Monitor . . . was not because the Defendants disputed their obligation to pay the Monitor or the amounts claimed on the Monitor’s invoice. Rather, the Monitor’s contract took time to finalize and approve.” (Id.). Defendants concluded that they “do not anticipate this kind of delay in making payments going forward.” (Id.).
At the telephonic status conference held on February 20, 2014, the Monitor expressed his concern that the payment issue interfered with his business relationships with the two consultants
5


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who are part of the monitoring team, and that they had both informed him that unless they are consistently paid on time, they will not be able to continue being a part of the team. The Monitor explained that he and his consultants had spent money, out of pocket, to finance trips to the Virgin Islands for two site visits in September and December of 2013 and, further, that untimely payments interfere with their other business obligations.
Counsel for Defendants explained that the sole reason for the delay in payment of the Monitor’s invoice was the time necessary for the development and approval of the Monitor’s contract. The parties and the Monitor agreed that, under the terms of the contract, Defendants are to pay the Monitor within thirty days of receipt of an invoice.7 Counsel for Defendants assured the Court that the process for payment of invoices takes “no more than three days” and, thus, there would be no issue in the future with payments beyond the thirty-day period.
The Court emphasized that the Settlement Agreement was entered as an Order of the Court, and that the Court “does not view lightly the findings that were made in its Order.” The Court stressed the urgency of remedying the constitutional violations found to exist at Golden Grove, and expressed its expectation that the parties are “doing their utmost to ensure that the terms of the Settlement Agreement and, therefore, the Order entered by the Court are, in fact, fulfilled.” The Court emphasized that the Monitor, his consultants, and their work are “integral and essential” to the Settlement Agreement, and expressed its concern that delays in the contract process caused the Monitor to issue an ultimatum, and ultimately halt his monitoring services. The Court concluded by stating its expectation that counsel for Defendants would make clear to individuals involved in the implementation of the Settlement Agreement that the Court expects
7 Counsel for Defendants informed the Court that, under the terms of the contract, Defendants are permitted to raise objections to the invoice and to bring unresolved disputes to the Court. Both counsel for Defendants and the Monitor expressed the mutual understanding, however, that the contract requires the Monitor to be paid within thirty days of receipt of an invoice, even if a dispute is unresolved, and that the resolution of any dispute would lead to an adjustment of future invoices, as appropriate.
6


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them to “move with dispatch with regard to the activities that are necessary to implement the Agreement, and the Court’s Order in connection therewith.”
2. Defendants’ Second Failure to Timely Pay the Monitor Approximately two-and-a-half months later, on May 8, 2014, the United States filed a second Notice advising the Court that the Monitor had not received payment for his March 2014 invoice. (Dkt. No. 813). The United States explained that the Monitor sent the March invoice to the parties via e-mail on April 2, 2014, and that after not receiving payment, the Monitor emailed the parties on May 5, 2014, advising them that if he was not paid by May 7, 2014, “he would once again suspend monitoring and seek court involvement.” (Id. at 1). According to the Notice, “[a]s of close of business on May 7, 2014, Mr. Ray had still not received payment for the March invoice.” (Id.). The United States requested that the Court set an emergency telephonic status conference. (Id. at 2). By Order entered later that same day, the Court ordered Defendants to file a response to the United States’ Notice, “explain[ing] with specificity the reason for their failure to timely pay the Monitor . . ., including an identification of any agency or agencies, or any individual or individuals, that contributed to the delay of the payment.” (Dkt. No. 814 at 2). In their “Notice of Filing and Amended Response to Notice and Request for Emergency Telephonic Status Conference,” Defendants explained that “[t]here was an oversight regarding the payment of the March 2014 invoice”; that “the March 2014 invoice was sent both to Attorney Robertson and [Bureau of Corrections] Director Julius Wilson”; and that “Director Wilson takes responsibility for this oversight regarding the payment not having been made.” (Dkt. No. 817 at 2). According to Defendants, “[o]nce Director Wilson received the email dated May 5, 2014, from the Monitor . . . he took immediate steps to expedite the payment.” (Id.).
7


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Following the filing of Defendants’ Response, the Court issued an Order on May 12, 2014 that set a status conference for May 27, 2014. (Dkt. No. 819). At the conference, counsel for Defendants and Director Wilson stated that the failure to timely pay the Monitor’s March 2014 invoice was an “oversight” due, in part, to the emergency absence of Attorney Robertson from the office and Director Wilson’s misunderstanding of his role in the payment process. As with the first failure to timely pay the Monitor, there was no dispute regarding the amount of the invoice. Further, Director Wilson explained that the money to pay the Monitor was already in the Bureau of Corrections’ budget, and thus there was no issue regarding the availability of funds to pay the Monitor’s monthly invoices. Director Wilson acknowledged that the failure to timely process the March 2014 invoice was the mistake of the Bureau of Corrections, and stated that he would implement a process to ensure timely payment.
Once again, the Monitor expressed to the Court that late payment of his monthly invoices creates an issue of retaining his consultants. He explained that given the difficulty in recruiting consultants with their level of qualifications, he does not want to risk losing them. The Court then expressed its concern that only two-and-a-half months had passed since Defendants assured the Court that timely payment of the Monitor’s invoices would not be an issue, and, in fact, that payment could be made within three days. The Court further stated that, because the issue is not the availability of funds but rather the implementation of a process to ensure that the Monitor is paid on time, there is no reason that funds cannot be dispersed in a timely manner given that Director Wilson indicated he would put a system in place to address the issue. Nonetheless, unwilling to simply accept the assurances of Defendants’ counsel and Director Wilson for the second time, the Court concluded the status conference by discussing with and then advising the parties that an Order would be forthcoming requiring Defendants to pay the Monitor timely or be
8


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subject to sanctions.8 The Court further noted that it would not hesitate to impose sanctions if the untimely payment problem persisted.
Accordingly, the Court issued an Order on June 6, 2014 that requires Defendants to “pay the Monitor’s monthly invoices within thirty days of receipt—in accordance with the Defendants’ contract with the Monitor, executed pursuant to the Court’s May 14, 2013 Order adopting the parties’ Settlement Agreement—or be subject to sanctions.” (Dkt. No. 830 at 2). In an accompanying Memorandum Opinion, the Court noted that the Monitor’s work is “‘essential to remedy the [constitutional] violation[s]’ found to exist at Golden Grove, and is instrumental to ‘provid[ing] the parties with the relief originally bargained for in the consent order.’” (Dkt. No. 831 at 10, quoting Holland v. N.J. Dep’t of Corrections, 246 F.3d 267, 283 (3d Cir. 2001)). The Court concluded that:
Because the Monitor’s work is contingent upon Defendants paying him—as they are obligated to do under the Settlement Agreement—and because Defendants have now failed to timely pay the Monitor twice, the Court finds that entering an Order requiring Defendants to pay the Monitor within thirty days of receipt of an invoice—as required by the contract between Defendants and the Monitor—or be subject to sanctions, is a “reasonable action taken . . . to secure compliance” and “protect[ ] the integrity of . . . [the] [consent] decree[.]” (Id. at 10-11, quoting United States v. Local 359, United Seafood Workers, 55 F.3d 64, 69 (3d Cir. 1995)). The Court cautioned that it “hopes the threat of sanctions—which the Court will not hesitate to impose if the problem persists—will result in the appropriate degree of attention being paid by Defendants to the timely payment of the Monitor’s invoices.” (Id. at 10).
3. Defendants’ Third Failure to Timely Pay the Monitor Notwithstanding the Court’s warning to Defendants—both orally and in writing—that sanctions would be imposed for future untimely payments, the Court received a third Notice
8 Counsel for Defendants acknowledged that there was nothing that legally precluded the Court from entering such an Order. In fact, counsel for Defendants deemed such an Order preferable to the establishment of an escrow account as advocated by the Monitor.
9


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from the United States on November 13, 2014. In the Notice, the United States informed the Court that the September 2014 invoice, submitted by the Monitor on October 10, 2014, had not been timely paid by Defendants in accordance with this Court’s June 6, 2014 Order. (Dkt. No. 865 at 1). Once again, the United States requested an emergency telephonic status conference to address the issue. Later that same day, the Court issued an Order, which directed Defendants to file a response to the United States’ Notice and, if payment of the Monitor’s September 2014 invoice was not timely, to show cause why sanctions should not be imposed for failing to comply with the Court’s June 6, 2014 Order. (Dkt. No. 866 at 2).
On November 17, 2014, Defendants filed a “Response to Notice and Request for Emergency Telephonic Status Conference” (Dkt. No. 867), in which they claimed—without any details or support—that the Bureau of Corrections had “timely processed” the Monitor’s invoice, but that the check was delayed because the Department of Finance had “technical difficulties with its software program.” (Id. at 1). While acknowledging that payment of the Monitor’s September 2014 invoice was not timely, Defendants argued against the imposition of sanctions by noting that their payment was “merely four days tardy”; that they acted “[i]mmediately” and “promptly” after being informed that the Monitor had not received payment; that the Department of Finances’ technical difficulties were “unforeseen”; and that Defendants did not “willfully violate” the Court’s June 6, 2014 Order. (Id. at 2).
By Order entered on November 24, 2014, the Court scheduled a Show Cause Hearing for December 10, 2014, after finding that Defendants’ Response to the November 13, 2014 Order to Show Cause was “both factually and legally inadequate.” (Dkt. No. 868 at 2). As stated in the Order, the purpose of the Show Cause Hearing was for “the Court’s consideration of whether a finding of contempt should be entered and sanctions imposed[.]” (Id. at 3).
10


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At the hearing, Defendants retracted their Response in its entirety, disclaiming that the delay in payment was due to technical difficulties at the Department of Finance, and disclosing instead that it was due to a series of delays at the Bureau of Corrections. Defendants’ Response—including the representations that the Bureau of Corrections “timely processed” the Monitor’s September 2014 invoice and that the delay was due to “unforeseen” technical difficulties with the software program at the Department of Finance—was reportedly based on incorrect information received from Bureau of Corrections personnel.
In presenting Defendants’ newly-discovered explanation, counsel for Defendants stated that the invoice was received from the Monitor on October 9, 2014. On October 22, 2014— thirteen days later—Director Wilson approved the invoice and sent it to the Bureau of Corrections’ Business Office.9 Then, for some unexplained reason, the invoice remained in the Business Office for eight days—from October 22, 2014 until October 30, 2014—before it was sent to the Department of Property and Procurement.10
On November 3, 2014, the Department of Property and Procurement approved the invoice as a requisition and converted it to a purchase order. The purchase order was then sent to, and received by, the Bureau of Corrections on November 5, 2014. Counsel for Defendants stated that once a purchase order is received from the Department of Property and Procurement, the proper procedure is to enter it into the Bureau of Corrections system the same day for payment through the Department of Finance. However, it was not until eight days later—on November
9 According to Director Wilson, the invoice was not approved until October 22, 2014, because he was out of the country for a family emergency. Director Wilson informed the Court that there was no one at the Bureau of Corrections who could act in his stead in approving the invoice. 10 Counsel for Defendants could not provide a reason for the delay in the Business Office. Director Wilson surmised that the delay may have been due to the unavailability of funds to pay the Monitor at the end of the month.
11


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13, 2014—that the purchase order was entered in a queue for payment.11 The check was issued
by the Department of Finance the same day.
II. DISCUSSION
It is well-established that federal courts “have inherent power to enforce compliance with
their lawful orders through civil contempt.” Shillitani v. United States, 384 U.S. 364, 370 (1966);
see also United States v. Harris, 582 F.3d 512, 514 (3d Cir. 2009) (“It has long been recognized that courts possess the inherent authority to hold persons in contempt.”).12 “Civil contempt is
remedial in nature, serving to coerce compliance with a court order or to compensate the other
party for losses sustained due to noncompliance.” United States v. Pozsgai, 999 F.2d 719, 735
(3d Cir. 1993). Thus, courts are generally “afforded broad discretion to fashion a sanction that
will achieve full remedial relief.” John T. v. Delaware County Intermediate Unit, 318 F.3d 545,
554 (3d Cir. 2003).
To hold a party in civil contempt, three elements must be established by clear and
convincing evidence: “(1) that a valid order of the court existed, (2) that the defendant had
knowledge of the order, and (3) that the defendant disobeyed the order.” Berne Corp. v. Gov’t of
the V.I., 570 F.3d 130, 139, 51 V.I. 1253, 1265 (3d Cir. 2009) (quoting Roe v. Operation Rescue,
11 According to the Operations Director at the Bureau of Corrections, there was a scheduled upgrade to the “ERP system” from approximately November 6, 2014 to November 12, 2014, which prevented the Bureau of Corrections from entering payments. It was acknowledged, however, that the Business Office was aware in advance of the dates of the scheduled upgrade. In view of the impending shutdown of the system, there was an even more compelling need for the Bureau of Corrections to follow the proper procedure of entering the purchase order in the system on the day it was received—November 5, 2014. However, there was no indication from Defendants that any effort was made to enter the purchase order in the system for payment before the scheduled system shutdown. 12 This inherent contempt power is derived from Section 401 of the United States Code, which provides that:
A court of the United States shall have power to punish by fine or imprisonment, or both, at its discretion, such contempt of its authority, and none other, as-(1) Misbehavior of any person in its presence or so near thereto as to obstruct the administration of justice; (2) Misbehavior of any of its officers in their official transactions; (3) Disobedience or resistance to its lawful writ, process, order, rule, decree or command. 18 U.S.C. § 401.
12


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54 F.3d 133, 137 (3d Cir. 1995) (internal quotation marks omitted)). Each element of civil contempt is present here.
First, on June 6, 2014, the Court entered a valid Order warning Defendants that they would be “subject to sanctions” if they did not “pay the Monitor’s monthly invoices within thirty days of receipt[.]” (Dkt. No. 830 at 2). The Court’s Order was accompanied by a Memorandum Opinion which detailed the factual and legal bases for the Order. (Dkt. No. 831).13
Second, Defendants knew of the Order because it was discussed at the May 27, 2014 status conference prior to its issuance, and the Court stated at the status conference that it would enter the Order. Moreover, Defendants’ Response to this Court’s November 13, 2014 Order to Show Cause (Dkt. No. 867) further confirms their knowledge of the June 6 Order.
Third, Defendants’ acknowledgment in their Response that payment of the Monitor’s invoice was “merely four days tardy,” and that they did not violate the Court’s Order “willfully” (id. at 2), reflects Defendants’ knowledge that they had violated the Court’s Order.
Defendants’ assertion that they did not violate the Order “willfully” (id.) is unavailing because “[w]illfulness is not a necessary element of civil contempt.” John T., 318 F.3d at 552 (quoting Harley-Davidson, Inc. v. Morris, 19 F.3d 142, 148 (3d Cir. 1994) (internal quotation marks omitted)). Thus, even assuming that Defendants could demonstrate that they acted in good faith, such evidence “does not bar the conclusion . . . that [Defendants] acted in contempt.” Id. (quoting Harley Davidson, Inc., 19 F.3d at 149); see also Robin Woods, Inc. v. Woods, 28 F.3d 396, 399 (3d Cir. 1994) (“[G]ood faith is not a defense to civil contempt.”).
The Court is mindful that its contempt power is not “without limits, particularly when directed against governmental defendants.” Inmates of Allegheny County Jail v. Wecht, 901 F.2d
13 As noted earlier, when the then-proposed Order was discussed with the parties’ counsel at the second status conference on May 27, 2014, counsel for Defendants acknowledged that there was nothing that legally precluded the Court from entering such an Order.
13


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1191, 1198 (3d Cir. 1990). It also recognizes that “in selecting contempt sanctions, a court is obliged to use the least possible power adequate to the end proposed.” Spallone v. United States, 493 U.S. 265, 276 (1990) (internal citations and quotation marks omitted). With these principles in mind, the Court concludes that the monetary sanction that the Court will impose is amply warranted under the circumstances here.
As the Third Circuit has explained: Because a court would not be justified in holding a [party] in contempt until [it] demonstrated a refusal to comply with an order, prior instances of disobedience will almost always accompany an order of contempt. Thus, . . . a valid order of civil contempt . . . reacts to prior instances of disobedience by seeking to compel and coerce future obedience. Harris, 582 F.3d at 519 (citation omitted). Accordingly, the Court’s finding of contempt and decision to impose sanctions in response to Defendants’ violation of the Court’s June 6, 2014 Order cannot be divorced from the history that preceded it. As the record in this matter indicates, during the status conference following Defendants’ first failure to timely pay the Monitor, the Court clearly set the stage regarding its expectations for the timely payment of the Monitor. In this regard, the Court, among other things: (1) stressed the essential and integral role of the Monitor in the fulfillment of the terms of the parties’ Settlement Agreement; (2) emphasized the sense of urgency that needed to attach to actions by Defendants necessary to implement the Settlement Agreement, including timely payment of the Monitor; (3) expressed its concern that Defendants’ actions thus far suggested that Defendants did not share the same sense of urgency; and (4) expressed the need for Defendants’ counsel to advise the individuals who are necessary to the implementation of the Settlement Agreement of the Court’s expectation that they will proceed with dispatch with regard to the activities that are necessary to implement the Agreement. Attributing the delayed payment solely to the lengthy
14


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contracting process and emphasizing that the payment process for the Monitor should take only three days, Defendants responded with assurances that there would be no future problems with payment of the Monitor within thirty days. Relying on these assurances, the Court took no further action.
Notwithstanding counsel’s assurances, two-and-one-half months later, the Court was called upon once again to address Defendants’ failure to timely pay the Monitor. This time, the delay was attributed to an “oversight” by the Bureau of Corrections stemming, in part, from the emergency absence from the office of one of Defendants’ counsel, coupled with the Director’s misunderstanding of his role in processing the Monitor’s invoices. Finding the Monitor’s work “essential to remedy the [constitutional] violation[s] found to exist at Golden Grove” and the Defendants’ repeated failures to timely pay the Monitor an obvious impediment to that work, the Court deemed it necessary to enter an Order requiring Defendants to pay the Monitor within thirty days “to secure compliance” and “protect[ ] the integrity of . . . [the] [consent] decree[.]” (Dkt. No. 831 at 10-11 (citation and internal quotation marks omitted)).
Five months later, the same problem surfaced yet again, and the Court is now faced—for the third time this year—with addressing Defendants’ failure to timely pay the Monitor. Defendants’ explanation of its delay-ridden processing of the Monitor’s invoice reflects inexcusable, contumacious conduct. The Bureau of Corrections appears to be proceeding with utter disregard of, and completely unfazed by, the Court’s articulation of its expectations regarding the timely payment of the Monitor, the Court’s oral admonitions in connection therewith, and the Court’s June 6, 2014 Memorandum Opinion and Order, including the threat of sanctions contained therein. It is quite apparent that the Bureau of Corrections, its Director Julius
15


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Wilson, and its counsel are not attaching to the payment of the Monitor the sense of urgency that this Court has ordered and the circumstances here require.
In sum, in view of Defendants’ third failure to timely pay the Monitor within a short time span of only nine months—which occurred after two conferences on this issue, coupled with an Order threatening sanctions designed to secure compliance with the parties’ Settlement Agreement—the Court concludes that there is no other way to coerce Defendants into compliance than to impose monetary sanctions. See Inmates of Allegheny County Jail, 901 F.2d at 1198 (finding “monetary sanctions were warranted by the defendants’ continuing noncompliance with the district court’s remedial orders”). The Court further concludes that the sanctions must be designed to address Defendants’ most recent failure to timely pay, and to coerce Defendants’ future compliance. See Int’l Union v. Bagwell, 512 U.S. 821, 828 (1994) (“Most contempt sanctions . . . to some extent punish a prior offense as well as coerce an offender’s future obedience.”).
Accordingly, the Court will impose a sanction of $1,000.00 for Defendants’ noncompliance with the June 6, 2014 Order—$250.00 for each of the four days that Defendants acknowledge the payment was late. The Court will further order that any future noncompliance with this Court’s June 6, 2014 Order—without good cause or other legally sufficient reason— will subject Defendants to a fine of $250.00 per day for each day that the payment is late, plus payment to the Monitor of any fees and expenses reasonably incurred as a result of the untimely payment.
16


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III. CONCLUSION


For the foregoing reasons, the Court finds that Defendants are in contempt of the Court’s

June 6, 2014 Order, for failing to timely pay the Monitor’s September 2014 invoice, and

concludes that monetary sanctions are warranted. An appropriate Order accompanies this

Memorandum Opinion.

Date: December 30, 2014

_______/s/________ WILMA A. LEWIS Chief Judge

17


 
 Case: 1:86-cv-00265-WAL-GWC Document #: 875 Filed: 12/30/14 Page 1 of 2

DISTRICT COURT OF THE VIRGIN ISLANDS
 DIVISION OF ST. CROIX


UNITED STATES OF AMERICA,

)

)

)

v.

)

)

)

TERRITORY OF THE VIRGIN ISLANDS, )

et al.,

)

)

)

Defendants.

)

__________________________________________)


Civil Action No. 1986-265

Attorneys:
 Jonathan M. Smith, Esq.,
 Laura L. Coon, Esq.,
 Rita K. Lomio, Esq.,
 Sharon I. Brett, Esq.,
 Marlysha Myrthil, Esq.,
 Washington, D.C. Angela Tyson-Floyd, Esq., St. Croix, U.S.V.I.
For the United States

Carol Thomas-Jacobs, Esq., Aquannette Y. Chinnery, Esq., St. Thomas, U.S.V.I. Kenrick E. Robertson, Esq., Shari N. D’Andrade, Esq., St. Croix, U.S.V.I.
For the Defendants

ORDER

UPON CONSIDERATION of the United States’ “Notice and Request for Emergency

Telephonic Status Conference,” filed on November 13, 2014, (Dkt. No. 865), the Order to Show

Cause, entered later that same day, (Dkt. No. 866), the Show Cause Hearing held on December

10, 2014, the entire record herein, and for the reasons stated in the accompanying Memorandum

Opinion, filed contemporaneously herewith, the Court finds that Defendants are IN

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CONTEMPT of the Court’s June 6, 2014 Order because of their failure—without just cause—to

timely pay Monitor Kenneth A. Ray’s September 2014 invoice as required by that Order.

Accordingly, it is hereby

ORDERED that the Bureau of Corrections shall be fined the sum of $1,000.00, payable

to the Clerk of Court no later than 5:00 p.m. on January 31, 2015, as a sanction for failing to

timely pay the Monitor’s September 2014 invoice, as required by this Court’s June 6, 2014

Order; and it is further

ORDERED that any future noncompliance with this Court’s June 6, 2014 Order—

without good cause or other legally sufficient reason—will subject Defendants to a fine of

$250.00 per day for each day that the payment is late, plus payment to the Monitor of any fees

and expenses reasonably incurred as a result of the untimely payment.

SO ORDERED.

Date: December 30, 2014

_______/s/________ WILMA A. LEWIS Chief Judge

2


 
 Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 1 of 10

DISTRICT COURT OF THE VIRGIN ISLANDS 
 DIVISION OF ST. CROIX 


UNITED STATES OF AMERICA,

)

Plaintiff,

)

)

Civil No. 86/265

v.

)




)




TERRITORY OF THE VIRGIN ISLANDS, et al., ) 


Defendants.

)

_________________________________________ )

UNITED STATES’ NOTICE OF OBJECTIONS AND 
 REQUEST FOR EMERGENCY STATUS CONFERENCE
 The United States respectfully requests that this Court set an emergency status conference with the parties and the Monitor, Mr. Kenneth Ray, to address the issue of the Territory’s incomplete, inadequate, and untimely final policy submissions that were due on March 30, 2015, per this Court’s implementation schedule (Docs. 863-1, 873). Section IX.3 of the Settlement Agreement provides that the United States may “provide[] written objections” to the policies submitted by the Territory (Doc. 689-1 at 14). An emergency status conference is warranted because the serious deficiencies in the Territory’s policy submissions, outlined in more detail below, impede all remaining deadlines in the Court-ordered implementation schedule. Because the Attorneys for the United States will be present in St. Croix as part of the continued mental health and security onsite compliance review on April 20–23, 2015, the United States respectfully requests that, if the Court’s docket permits, a status conference be set for a date during that week.1

1

Mr. Ray is not scheduled to be present in St. Croix that week, but he has indicated his

availability to participate in a status conference telephonically any day that week.

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BACKGROUND 
 Pursuant to the Settlement Agreement, entered as an order of this Court on May 14, 2013 (Doc. 742), the Territory must develop and implement facility-specific policies and procedures consistent with the Constitution and the provisions of the Settlement Agreement (Doc. 689-1). The Court’s implementation schedule set March 30, 2015, as the date by which the Territory must have finalized all policies and procedures required by the Settlement Agreement (Doc. 8631), and submitted them to the Monitor and United States. The final policies would then be ready for implementation at the Golden Grove Adult Correctional Facility (“Golden Grove”). As described below, the Territory has failed to meet this critical deadline, thus placing the remainder of the Court’s implementation schedule in jeopardy of further delays. I. The Territory’s Failure to Submit Forty-Eight Policies and Procedures and Its Failure to Address the United States’ Comments on the Remaining Policies and Procedures On March 30, 2015, the Territory submitted, via email, seventeen policies and procedures and four classification forms.2 See Exhibits A-R (filed under seal).3 The Territory failed to

2

The policies and procedures submitted were (1) Administrative Investigations—Staff

Discipline; (2) Classification Housing and Review; (3) Contraband Control and Searches;

(4) Environmental Health and Safety; (5) Environmental Health and Safety—Control of

Chemicals, Flammables, Toxic and Caustic Materials; (6) Environmental Health and Safety—

Food Service Sanitation and Hygiene; (7) Environmental Health and Safety—Inmate/Detainee

Clothing, Bedding, and Linen Supplies; (8) Environmental Health and Safety—Vermin and Pest

Control; (9) Fire and Life Safety Plan; (10) Prisoner Complaints/Grievance Process;

(11) Reporting and Review of Serious and Emergent Incidents; (12) Security Staffing;

(13) Sexual Misconduct Policy—PREA; (14) Special Management Housing; (15) Supervision of

Prisoners; (16) Training (and Staff Development); and (17) Use of Force. The four forms

submitted were (1) Administrative Confinement Placement Form; (2) Protective Confinement

Placement Form; (3) Initial Custody Classification; and (4) Reclassification.

3

The policies submitted by the Territory are referenced as Exhibits A-R. Three versions

of each policy are provided, separated by a cover sheet: Version 1 is the version submitted with

comments by the U.S. Department of Justice to the Territory on March 4, 2015. Version 2 is the

version submitted by the Territory to the U.S. Department of Justice on March 30, 2015, and

April 8, 2015. Version 3 is a comparison between Versions 1 and 2, created through Microsoft

2


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 3 of 10

submit forty-eight policies and procedures. In particular, the Territory did not submit the Inmate Disciplinary Policy, and also did not submit any of the forty-seven medical or mental health policies. Instead, the Territory sent an email at 10:51 p.m. on March 30, 2015, requesting a twoweek extension:
With respect to the medical and mental health policies, as you all know Ms. Charles has been responsible for finalizing the policies. She has not yet completed them and therefore, the Territory requests an additional two weeks to submit those policies. Exhibit S. The Territory provided no further explanation for the requested extension or for why the extension was being requested at the eleventh hour on the day of the deadline. Upon review of what the Territory did submit on March 30th, it was evident that the policies and procedures were not in final form and failed to address most of the concerns that the United States raised in its written comments submitted on March 4th—well in advance of its March 16, 2015 deadline. Although the United States provided comprehensive comments and redline edits to the submitted policies and further discussed the comments during three teleconferences with the Territory during the week of March 9th, it appears that the majority of the comments and concerns went completely unaddressed.4 The United States has several concerns with the submitted policies and procedures, including: (1) procedures do not adequately and clearly detail the specifics of what staff must do and which staff members are responsible for completing the task, see, e.g., Exhibit A, USDOJ Comment 72; Exhibit B, USDOJ Comment 77; Exhibit E, USDOJ Comment 31; Exhibit F,

Word’s “compare” feature to identify the changes made by the Territory. The United States requests, by separate motion, to file these and other policy drafts under seal to protect against unwarranted disclosure of Golden Grove operations that could undermine the facility’s safety and security.

4

The United States also offered to review policies on a rolling basis before the March 30

deadline. The Territory did not submit any policies for review.

3


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 4 of 10

USDOJ Comment 23; Exhibit G, USDOJ Comment 11; Exhibit O, USDOJ Comment 18; Exhibit Q, USDOJ Comment 39; 5 (2) procedures contravene the Settlement Agreement and
Constitution, or do not implement all provisions of the Settlement Agreement, see, e.g., Exhibit
C, USDOJ Comment 82; Exhibit N, USDOJ Comment 18; Exhibit P, USDOJ Comments 1, 2;
Exhibit R, USDOJ Comments 1, 13, 42, 46; and (3) placeholders such as “[WHO?]” and
“XXXX” remain in documents the Territory submitted as “final” policies, see, e.g., Exhibit K,
USDOJ Comments 35, 53, 61; Exhibit O, USDOJ Comment 38; Exhibit P, USDOJ Comments
23, 36; Exhibit R, USDOJ Comment 113.
II. The United States’ Objections to the Territory’s Policy Submissions The United States sent a letter to the Territory on April 1, 2015, objecting to the
Territory’s policy submissions and its request for a two-week extension to submit the medical
and mental health policies. See Exhibit T. The United States sought Mr. Ray’s immediate
mediation of these issues per Section IX.2 of the Settlement Agreement, and requested the
Territory’s written response by April 8, 2015. See id. at 3. In its letter, the United States also
provided several examples of substantive concerns that were not addressed by the Territory’s
March 30th submissions:
• Use of Force: We have twice raised objections to Section IV, which describes the permissible uses of force [see Exhibit R, USDOJ Comment 10], on the basis that Section IV, as written, does not comport with constitutional limits on the use of force in correctional facilities. Nonetheless, the Territory does not appear to have made any changes to Section IV.
• Prisoner Complaints/Grievance Process: The grievance process remains insufficiently detailed and confusing. The policy continues to reference “informal resolution” [see, e.g., Exhibit K, USDOJ Comments 5, 32, 64], notwithstanding the fact that the Territory had previously deleted all description of informal resolution procedures on February 2, 2015.

5

“USDOJ Comment NN,” as used in this motion, refers to the NNth comment by the

United States in the third version of a policy—the “compare” version that identifies the changes

made by the Territory in response to the United States’ comments.

4


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• Special Housing Management: We have twice raised objections to the frequency of review for prisoners with mental illness, noting that the Settlement Agreement explicitly prohibits placing prisoners with serious mental illness in any form of isolation, and stating that there should be periodic medical and mental health assessments to monitor and physical and mental well-being of prisoners in segregation [see Exhibit O, USDOJ Comment 67]. Nonetheless, the Territory does not appear to have made any substantive changes to the policy.
• Supervision of Prisoners: We have requested clarification as to what procedures are in place to maintain the confidentiality of attorney-client communications during attorney visitation [see Exhibit P, USDOJ Comment 98]. The Territory responded, “No confidentiality is maintained.”
• Contraband: We have noted that the policy appears to be missing discussion of “[a]dmission procedures and escorts for visitors to the facility” [see Exhibit C, USDOJ Comment 82 (quoting Settlement Agreement § IV.B.1.e)]. Nonetheless, the Territory does not appear to have made any substantive changes or additions to the policy.
Id. at 2.
The United States concluded: “Although the monitoring team provided the Territory
with technical assistance in establishing the framework for many—if not all—of the Territory’s
policies and procedures using models from other jurisdictions, it is imperative that the Territory
independently utilize the expertise of someone well-versed in corrections to complete the
policies and tailor them to the Golden Grove Adult Correctional Facility.” Exhibit T at 2.
III. Mediation by the Monitor
In response to the United States’ April 1, 2015 letter requesting mediation by the
Monitor, Mr. Ray scheduled a telephone conference for April 8, 2015. Mr. Ray began by
seeking additional information from the Territory to justify the requested two-week extension to
submit the medical and mental health policies. The Territory again stated that Ms. Charles has
been in charge of working on the medical and mental health policies and that although she had
been provided with staff assistance with formatting, Ms. Charles was not able to complete the
revision process. The Territory added that Ms. Charles has recently had to appear in court for
5


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 6 of 10

two hearings on unrelated matters with little advance notice. The Territory explained that no advance notice was given to the United States or Monitor about the delay because the Territory attorneys only learned of the status of the policies on March 30th—the day they were due. The Territory was unable to respond to the United States’ repeated requests for an explanation as to how the additional two-week timeframe would in fact be sufficient. Given the Territory’s response, the United States renewed its objection to the Territory’s requested extension and noted that because the March 30th deadline is court-ordered, the Territory is now in violation of that order and must seek leave of the Court for any extension of time.6
The United States asked about the status of the appointment of a Bureau of Corrections (“BOC”) Director or Warden for Golden Grove, and whether these individuals would ensure that there is someone on staff with corrections expertise to finalize the policies and procedures. The Territory said that neither a BOC Director nor a new Warden for Golden Grove has been appointed, and the Territory could not give any information on a timeframe for selection. The Territory also could not identify anyone with the requisite corrections expertise who would be working directly on the policies and procedures to address the United States’ concerns and get the policies and procedures into final approval form. Instead, the Territory asked Mr. Ray if he would undertake the task of completing the remaining work on the policies and procedures. Mr. Ray stated that he would only consider doing this if the Territory committed to providing all staff necessary for that process. Mr. Ray also explained that, due to other work commitments, he and Mr. Manuel Romero would not be available to begin this task until July 2015 at the earliest— months after training on the policies and procedures is scheduled, by this Court’s order, to begin on May 29, 2015 (see Doc. 863-1).

6

As of this date, the Territory has not filed any motion to extend time.

6


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 7 of 10
The United States concluded the call by repeating its objection to any further delay of the Court’s implementation schedule, noting that any delays with the policies and procedures will set back the remainder of the Court-ordered deadlines, and stating its intent to seek judicial intervention. Mr. Ray concluded that he did not have authority to adjust the Court-ordered deadlines. Accordingly, the United States advised Mr. Ray and the Territory that it planned to file objections with the Court pursuant to Section IX.3 of the Settlement Agreement. IV. The Territory’s Written Response
The Territory emailed a letter to the United States at 9:07 p.m. on April 8th, confirming the Territory’s request for Mr. Ray to begin additional work on the policies in July and repeating its request for a two-week extension to submit the outstanding medical and mental health policies and procedures. See Exhibit U. The Territory also attached the outstanding Inmate Disciplinary Policy. See Exhibit J. Although the Territory stated this policy had been omitted from the March 30 submission “[t]hrough inadvertence,” see Exhibit U at 1, the policy included revisions made the evening of April 8th. On April 9, 2015, the Territory sent, via email, fifteen of the forty-seven medical policies and three medical forms. See Exhibit V.
RELIEF REQUESTED The United States seeks an emergency status conference to address the following issues: First, the United States maintains that the submitted policy documents, although sent electronically on March 30, 2015, fail to meet the implementation schedule’s deadline for submitting policies and procedures in “final approval” form (Doc. 863-1). Thus, the Territory is in violation of this Court’s order. Second, the United States objects, under Section IX.3 of the Settlement Agreement, to any of the submitted policies and procedures being promulgated until the Territory addresses the United States’ comments and develops the drafts into final form.
7


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 8 of 10
Third, the United States objects to the Territory’s request for a two-week extension to submit the outstanding medical and mental health policies and procedures. The Territory has not provided a valid reason for further delaying its development of critical policies and procedures.
Fourth, the United States objects to the Territory’s request that Mr. Ray and Mr. Romero undertake the work of finalizing its policies and procedures, as (a) this is work that must be done by the Territory itself to build a solid foundation to address serious and persistent constitutional violations at Golden Grove, and to ensure the Territory has the requisite personnel on staff to develop, implement, review, and revise policies and procedures as necessary; (b) having Mr. Ray and Mr. Romero finalize the policies and procedures removes them from their roles as independent monitors and places them in positions more akin to de facto receivers; and (c) even if this were an appropriate role for Mr. Ray and Mr. Romero to undertake, this work would not begin until July 2015, at the earliest, rendering the current Court-ordered implementation schedule impossible to meet.
The United States further requests that in ordering any status conference, the Court specifically order not only officials from the Virgin Islands Bureau of Corrections to appear, but also a Territorial official who has knowledge of the status of appointing a new BOC Director and Warden for Golden Grove.
DATED this 10th day of April, 2015 Washington, District of Columbia
Respectfully submitted, VANITA GUPTA Acting Assistant Attorney General Civil Rights Division MARK J. KAPPELHOFF 8


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 9 of 10
Deputy Assistant Attorney General Civil Rights Division JUDITH C. PRESTON Acting Chief LAURA L. COON Special Litigation Counsel s/ Marlysha Myrthil MARLYSHA MYRTHIL RITA K. LOMIO Trial Attorneys United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, D.C. 20530 (202) 305-3454 (202) 514-4883 (fax) ANGELA P. TYSON-FLOYD Assistant United States Attorney United States Attorney’s Office 1108 King Street, Suite 201 Christiansted, Virgin Islands 00841 (340) 773-3920 (340) 773-1407 (fax)
9


Case: 1:86-cv-00265-WAL-GWC Document #: 888 Filed: 04/10/15 Page 10 of 10

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that on April 10, 2015, I electronically filed the foregoing using

the CM/ECF system, which will send electronic notification to the following:

CAROL THOMAS-JACOBS Civil Division Chief V.I. Department of Justice Office of the Attorney General GERS Building, 2nd Floor 34-38 Kronprindensens Gade St. Thomas, VI 00802 Telephone: 340-774-5666 Email: cjacobs@doj.vi.gov
AQUANNETTE Y. CHINNERY Assistant Attorney General V.I. Department of Justice Office of the Attorney General GERS Building, 2nd Floor

34-38 Kronprindensens Gade St. Thomas, VI 00802 Telephone: (340) 774-5666 x285 Email: achinnery@doj.vi.gov
SHARI N. D’ANDRADE Assistant Attorney General V.I. Department of Justice Office of the Attorney General 6040 Estate Castle Coakley Christiansted, VI 00820 Telephone: (340) 773-0295 Fax: (340) 773-1425 Email: sdandrade@doj.vi.gov

Respectfully submitted,
/s Marlysha Myrthil
MARLYSHA MYRTHIL Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 (202) 305-3454 (202) 514-4883 (fax)

10


 
 Case: 1:86-cv-00265-WAL-GWC Document #: 899 Filed: 04/20/15 Page 1 of 7

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, )

et al.,

)

)

)

Defendants.

)

__________________________________________)

Civil Action No. 1986-0265

Attorneys: Jonathan M. Smith, Esq., Laura L. Coon, Esq., Rita K. Lomio, Esq., Sharon I. Brett, Esq., Marlysha Myrthil, Esq., Washington, D.C. Angela Tyson-Floyd, Esq., St. Croix, U.S.V.I.
For the United States

Aquannette Y. Chinnery, Esq., St. Thomas, U.S.V.I. Shari N. D’Andrade, Esq., St. Croix, U.S.V.I.
For the Defendants

ORDER

THIS MATTER comes before the Court on the United States’ “Notice of Objections and

Request for Emergency Status Conference” (Dkt. No. 888), Defendants’ Court-ordered Response

thereto (Dkt. No. 895), and the hearing held on April 17, 2015. In the Notice, the United States

advised the Court that Defendants had failed to comply with the March 30, 2015 deadline for the

submission of final policies and procedures, as set forth in the Monitoring Schedule (Dkt. No.

863-1) that was the subject of the parties’ “Joint Motion for Entry of Stipulated Order” (Dkt. No.

Case: 1:86-cv-00265-WAL-GWC Document #: 899 Filed: 04/20/15 Page 2 of 7
853) and entered as an Order of the Court—subject to judicial enforcement—on December 17, 2014 (Dkt. No. 873).1
This is the third time over the course of little more than a year that the Court has had to address Defendants’ failure to meet deadlines, to which they had previously agreed, for the development of policies and procedures. On the first occasion, the matter was brought to the Court’s attention on March 3, 2014, when the United States filed a “Motion for Enforcement of this Court’s May 14, 2013 Order Adopting the Parties’ Settlement Agreement and for More Specific Orders Implementing that Agreement,” in which the United States informed the Court that Defendants had failed to abide by a deadline which Defendants set, as required by the Settlement Agreement, for the submission of draft policies. (Dkt. No. 777). The issue was later resolved by agreement of the parties with the development of an implementation schedule that set forth deadlines for deliverables required under the Settlement Agreement. (See Dkt. No. 800 (“Monitor’s Adopted Implementation Schedule”)). The United States then withdrew its Motion for Enforcement and advised the Court that “the Monitor’s Adopted Implementation Schedule sufficiently addresse[d] the relief requested in the United States’ [Motion for Enforcement].” (Dkt. No. 801 at 2).
On the second occasion, the matter was brought to the Court’s attention on August 13, 2014, when the United States filed a “Motion for an Order to Show Cause Why Defendants Should Not Be Held in Civil Contempt of Court and Request for Expedited Briefing.” (Dkt. No. 833). In the Motion, the United States advised the Court that, during the three months following
1 At the hearing held on April 17, 2015, the United States informed the Court that, on the March 30, 2015 deadline, Defendants submitted seventeen (17) of the sixty-five (65) policies and procedures that were due. Then, on April 8, 2015, Defendants submitted one (1) of the forty-eight (48) outstanding policies and procedures (the Inmate Disciplinary Policy), and on April 9, 2015, submitted fourteen (14) of the forty-seven (47) outstanding medical and mental health policies and procedures. On April 13, 2015, Defendants submitted an additional twenty-eight (28) medical policies and procedures. However, twelve (12) of them were duplicates of the policies and procedures Defendants had submitted on April 9, 2015. At the hearing, the parties agreed that Defendants have five (5) or six (6) mental health policies and procedures, and related forms, that are still outstanding.
2

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the United States’ withdrawal of its Motion for Enforcement and the filing of the Monitor’s Adopted Implementation Schedule, Defendants had once again failed to meet deadlines they had agreed upon and had failed to request an extension of time in advance of the deadlines. (Id. at 5). The United States requested that the Court find Defendants in contempt of the Court’s May 14, 2013 Order Adopting the Parties’ Settlement Agreement (Dkt. No. 742), and enter as an Order of the Court all new deadlines. (Dkt. No. 833 at 3).
The Court scheduled a hearing on the United States’ Motion for an Order to Show Cause for September 25, 2014. (Dkt. No. 837).2 However, the day prior to the hearing, the parties reached an agreement on the issues raised in the United States’ Motion and filed a “Joint Motion for Entry of Stipulated Order.” (Dkt. No. 853). In the Joint Motion, Defendants stipulated that they were non-compliant with the Settlement Agreement, entered as an Order of the Court on May 14, 2013, and agreed that a new schedule for policy development, training, and implementation would be submitted to the Court on October 17, 2014 and entered as an Order of the Court, subject to judicial enforcement. (Dkt. No. 853-1). In consideration of the entry of the Stipulated Order, the United States agreed to withdraw, without prejudice, its Motion for an Order to Show Cause. (Dkt. No. 853 at 2).
Now, the Court is faced with yet a third instance where Defendants have failed to abide by an agreed-upon deadline for policy development. This time, at the behest of both the United States and Defendants, the deadline was specifically dictated by Court Order. Thus, Defendants’ failure to comply with the deadline constituted a direct violation of a specific Court Order.
Compounding Defendants’ failure to meet the above-referenced deadlines is an apparent lack of adequate oversight of Defendants’ compliance with the terms of the Settlement
2 A status conference, where all parties were scheduled to be physically present, had previously been set for September 25, 2014. Therefore, the Court ordered that the status conference be expanded to include a hearing on the United States’ Motion. (See Dkt. No. 837 at 2).
3

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Agreement and related Court Orders by the legal team representing Defendants. The Court has observed that in each instance where there is a compliance problem that is brought to the Court’s attention by the United States, counsel for Defendants seek—in effect—to divorce themselves from responsibility for the problem. In this latest instance, counsel for Defendants indicated that they were unaware—until the day that the policies and procedures were due—of the Bureau of Corrections’ inability to meet the deadline.3 At the hearing held on April 17, 2015, counsel stated that they had relied upon representations from Bureau of Corrections personnel that everything was on track for the March 30, 2015 deadline.4
Had this been the first time that Defendants’ counsel had given such an excuse, the Court may not have been quite as troubled. However, given the recent history of this case, the Court finds wholly unacceptable counsel’s purported “reliance,” without more, and their seeming obliviousness to the reality of what is occurring at the Bureau of Corrections. Not long ago, it was routine for Defendants’ counsel to be unaware that the Monitor was not being timely paid until after the deadline for payment had passed and a concern was raised. Then, in November of 2014, in reliance on representations from Bureau of Corrections personnel, Defendants’ counsel submitted to the Court a Response to an Order to Show Cause that contained a completely fictitious account of why the Monitor’s payment was delayed (Dkt. No. 867)—an explanation that the Court found “factually and legally inadequate” on its face and that was retracted by Defendants’ counsel in its entirety at the subsequent Show Cause Hearing (Dkt. No. 868 at 2), following a more in-depth review of the matter by Defendants’ counsel. Now, in the face of a
3 Such a revelation is not merely surprising, but rather, incomprehensible, given that what was at issue here was not one or two delayed policies and procedures but forty seven (47) of sixty five (65) such submissions. 4 The Court notes that Vernita Charles, Health Care Administrator at the Bureau of Corrections—the point person for the medical and mental health policies and procedures, who has consistently received accolades from the monitoring team for her diligence and productivity in the development of the medical and mental health policies and procedures—informed the Court at the hearing that she had repeatedly requested administrative assistance from the Bureau to help her complete the medical and mental health policies and procedures, but to no avail.
4

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deadline of major significance to the fulfillment of the terms of the Settlement Agreement, Defendants’ counsel again simply relied on representations, and then learned at the eleventh hour that the commitment would not be honored.5
In view of Defendants’ violation of the Court’s December 17, 2014 Order (Dkt. No. 873), the Court would be well within its power to pursue contempt proceedings against Defendants. However, the Court will not pursue such proceedings against Defendants at this time. Instead, the Court will do two things. First, the Court will initiate in this Order yet another schedule for Defendants to meet its policy, training, and implementation obligations under the Settlement Agreement. The dates reflected in this partial schedule of deadlines were suggested by the parties at the April 17, 2015 hearing and accepted by the Court. The Court will not look favorably on any failure to meet these deadlines.
Second, the Court notes that, in addition to the Director of the Bureau of Corrections and the Warden of Golden Grove, the Governor of the Virgin Islands and the Attorney General of the Virgin Islands are also signatories to the Settlement Agreement, and are thus also responsible for ensuring that its requirements are fulfilled. (See Dkt. No. 689-1 at 21). In view of what the Court has observed to be a lack of adequate oversight of this matter by counsel for Defendants, the Court will henceforth incorporate in its Orders—as it deems appropriate—the requirement that the Attorney General and Chief Legal Counsel to the Governor appear in person at status conferences and other proceedings scheduled by the Court.6
5 Defendants’ counsel then added “insult to injury” by not seeking an extension from the Court of the Court-ordered deadline until sixteen (16) days after the deadline had passed—in their Response to the United States’ Notice of Objections. 6 The Court anticipates that the Attorney General and Chief Legal Counsel to the Governor will be required to appear, at a minimum, at each quarterly status conference held in this matter.
5

Case: 1:86-cv-00265-WAL-GWC Document #: 899 Filed: 04/20/15 Page 6 of 7
A final issue raised in the parties’ respective filings with the Court and at the April 17,
2015 hearing was Defendants’ request that they be permitted to rely on the services of the
Monitor to help address the objections lodged by the United States to Defendants’ non-medical,
non-mental health policies and procedures and to assist Defendants in finalizing them. Consistent
with the Settlement Agreement, the Monitor and his team have already provided significant
“technical assistance” to Defendants in the development of their policies and procedures. (See
Dkt. No. 689-1 at Section X.H.1). The Court will not allow the Monitor to assist Defendants with
this final phase of the process because the Court finds that such assistance would conflict with
the appropriate degree of independence that the Monitor must maintain in order to properly
perform his general monitoring responsibilities. (See, e.g., Dkt. No. 689-1 at Sections IX.3 and
X.A.2.a). Accordingly, Defendants will be required to seek any necessary assistance in this regard from another source.7
UPON CONSIDERATION of the foregoing, it is hereby
ORDERED that the parties and the Monitor shall adhere to the following schedule:
1. Defendants shall submit to the United States and the Monitor all of the outstanding mental health policies and procedures, and related forms, no later than April 24, 2015.
2. The United States and the Monitor shall submit to Defendants their comments and/or objections to the medical policies and procedures, and related forms, no later than April 24, 2015.
7 At the April 17, 2015 hearing, the Monitor advised the Court of an ongoing issue regarding the production of documents by Defendants. Defendants have exhibited a pattern of not providing the Monitor with requested documents necessary for his monitoring activities on dates to which Defendants agreed. The Monitor requested that the Court enter an Order requiring Defendants to provide him with all requested documents by agreed-upon dates. Although the Court will not enter an Order at this time, the Court has orally explained its expectation that Acting Director Dwayne Benjamin will ensure that documents are provided to the Monitor in a timely fashion. The Court also expects that counsel for Defendants will ensure that Defendants are meeting this requirement of the Settlement Agreement. (See Dkt. No. 689-1 at Sections IX.8 and X.D.2). The Court notes that this is not the first time that the Monitor has raised this issue of the Bureau of Corrections’ failure to timely provide him with documents that are necessary for him to perform his ongoing monitoring responsibilities. The Court hopes that no further action will need to be taken by the Court.
6

Case: 1:86-cv-00265-WAL-GWC Document #: 899 Filed: 04/20/15 Page 7 of 7

3. The United States and the Monitor shall submit to Defendants their comments and/or objections to the mental health policies and procedures, and related forms, no later than May 8, 2015.

4. Defendants shall submit to the United States and the Monitor final versions of the medical policies and procedures, and related forms, no later than May 29, 2015.

5. Defendants shall submit to the United States and the Monitor final versions of the mental health policies and procedures, and related forms, no later than May 29, 2015.

6. The Monitor—in accordance with Section IX.3 of the Settlement Agreement—shall assist the parties with resolving any disputes regarding any of the policies and procedures, and related forms, between May 29, 2015 and June 15, 2015.

7. At the scheduled June 11, 2015 status conference, the parties shall be prepared to apprise the Court of whether they expect that any remaining disputes regarding policies and procedures, and related forms, will require Court intervention in accordance with Section IX.3 of the Settlement Agreement. If the need for Court intervention is not anticipated, the parties shall be prepared to discuss a proposed schedule for training and evaluation of implementation.

8. No later than May 1, 2015, Defendants shall file with the Court a Notice apprising the Court of their efforts to retain an expert to assist them with finalizing the nonmedical, non-mental health policies and procedures, and related forms.

A separate Amended Order regarding the June 11, 2015 status conference will follow, consistent with this Order, with the requirement that the Attorney General and Chief Legal Counsel to the Governor appear in person at the status conference.

SO ORDERED.

Date: April 20, 2015

_______/s/________ WILMA A. LEWIS Chief Judge

7

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 756-1 Filed: 12/04/13 Page 1 of 99
MONITOR’S !SELINE OMPLI!NE !SSESSMENT REPORT GOLDEN GROVE ADULT CORRECTIONS AND DETENTION FACILITY

St. Croix, Virgin Islands
 In Re:

UNITED STATES OF AMERICA v. THE TERRITORY OF THE VIRGIN ISLANDS
 (Case No. 86/26)

Settlement Agreement of December 3, 2013

Completed by:
 Kenneth A. Ray, M.Ed.
 Independent Monitor

December 3, 2013


Case: 1:86-cv-00265-WAL-GWC Document #: 756-1 Filed: 12/04/13 Page 2 of 99

Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S BASELINE ASSESSMENT REPORT

Page 1 of 98

Settlement Agreement

Kenneth A. Ray, M.Ed. Monitor

TABLE OF CONTENTS

Cover Table of Contents Purpose & Executive Summary Baseline Assessment Methodology Assessment of Compliance Section IV. Safety and Supervision Compliance Section V. Medical and Mental Health Care Compliance Section VI. Fire and Life Safety Section VII. Environmental Health and Safety Section VIII. Training Section IX. Implementation

NA 1 2 6 14-98 14 47 78 83 91 95

Case: 1:86-cv-00265-WAL-GWC Document #: 756-1 Filed: 12/04/13 Page 3 of 99

Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S BASELINE ASSESSMENT REPORT

Page 2 of 98

Settlement Agreement

PURPOSE

The Monitor intends this report to serve three primary goals: 1) a baseline from which to monitor Defendant’s compliance with the Settlement Agreement; 2) assess, measure, and determine progress toward partial and substantial compliance with all provisions of said Agreement; and, 3) as a tool to assist Defendants in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of defendants and offenders incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.

EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

Pursuant to Section X subsection D paragraph 1 of the Settlement Agreement, a first site visit (Baseline Assessment) was conducted September 9-13, 2013. The Monitor and Parties mutually agreed to delay the visit beyond the 30 days stated in the Agreement due to scheduling conflicts and to allow adequate time to prepare.

The monitoring team consisted of Mr. Kenneth A. Ray, Monitor and operations expert; Ronald Shansky, MD, correctional medicine expert; and Roberta Stellman, MD, correctional mental health and suicide prevention expert. The selection of Dr. Shansky and Dr. Stellman involved input and concurrence by the Parties as required in Section X subsection C paragraph 3 of the Agreement.

Prior to the site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite visit. Additionally, the Monitor provided to the Territory documents and information to assist them regarding implementation planning, policy and procedure development, as well as proposed itinerary and proposed outcomes for this visit.

The site visit included a startup meeting on the first day involving representatives from both Parties, onsite tours, staff interviews, various inspections, document reviews, meetings, and a culmination meeting during the morning of the last day. Participation and involvement by the Parties was cooperative and active. Additionally, the Monitor and the Parties reviewed a draft of the Monitor’s contract proposed by the Territory and worked toward mutually amicable contract provisions. Although we were unable to finalize the contract during this time, subsequent revisions have been provided and we continue to work toward resolution on matters of conflict. Furthermore, the Monitor provided the Parties with a first-year Monitoring Budget; the budget has been approved.

Case: 1:86-cv-00265-WAL-GWC Document #: 756-1 Filed: 12/04/13 Page 4 of 99

Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S BASELINE ASSESSMENT REPORT

Page 3 of 98

Settlement Agreement

Assessment Overview

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 129 provisions; 119 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance, In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy formulation, and 2) implementation. The Monitor and the monitoring experts provided non-binding recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing the final report.

The baseline assessment found 108 of the 119 provision in Noncompliance, seven (7) in Partial compliance, none in Substantial Compliance, and two (2) remain in a Pending status for review during the December 2013 site visit. Implementation provisions were not measured using these standards but a narrative description of compliance is provided at this time; the required evaluation standards may be applied in evaluating these provisions in future reports once the Monitor has more clarity about doing so from the Parties. Overall, 91% of the provisions remain in Noncompliance, 6% in Partial Compliance, 0% in Substantial Compliance, and two (2) in a Pending Status. The figure below illustrates these assessment evaluation ratings.

Each provision in this report is in bold print and shadowed for clarification purposes.

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GGACF Sept 2013 Baseline Compliance Assessment Ratings

Compliance Sections

Provisions

Non Compliance

Partial Compliance

Substantial Compliance

IV. Safety and Supervision

58

52

4

0

V. Medical and Mental Health Care

36

34

0

0

VI. Life and Fire Safety

10

10

0

0

VII. Environmental Health and Safety 11

8

3

0

VIII. Training

4

4

0

0

Totals 119

108

7

0

Compliance Percentages

91%

6%

0%

IX. Implementation (Narrative)

10

0

0

0

Pending
0 2 0 0 0 2 2% 0

It is the opinion of the Monitor and monitoring experts that very little has improved at GGACF since the issuance of Findings of Fact Report (filed on 02/08/13). GGACF remains a dangerous and violent environment and is inadequately staffed, equipped, funded, maintained, and operated to provide and consistently sustain environmental and operational conditions of inmate care and confinement that meet constitutional requirements. This will be further demonstrated in the assessment findings of this report.

Policies and procedures, in general, remain underdeveloped, incomplete, and/or nonexistent, much as described in the Findings of Fact report. The lack of adequate policies and procedures contributes, in part, to inconsistent and dangerous security practices and habits. This was evidenced by cells doors and housing unit access points being padlocked and chained, internal housing unit gates being left open, housing unit control room doors being left unlocked, nonfunctional security lighting throughout external and internal security perimeters, illmaintained security fencing, an inadequate number of and broken portable radios, nonfunctional security door control panels, nonfunctional camera system and control panels in the two operational towers, ill-maintained and broken cell door components and observation windows, and various other practices that allowed inmates to move about the campus without being searched. Exacerbating these conditions is a serious lack of adequately trained and supervised correctional staff, and an overarching common frustration among staff regarding leadership support and commitment to improve security and poor environmental conditions.

Access to and possession of dangerous contraband by inmates appears to be a pervasive and persistent problem at GGACF based on interviews, housing unit inspections, and examinations of incident reports and activity logs. The presence of knives, machetes, cell phones, and large amounts of illegal drugs, for example, continues within the facility. GGACF officials report that there has not been a facility-wide shakedown (comprehensive cell inspection and facility search) in more than two years. This is very troubling if only based on the facilities’ known history of contraband and violence. However, contraband report documents provided to the Monitor show that incidents of contraband and the volume of contraband confiscated has increased significantly since the approval of the Agreement.

There appears to be no adequate complaint system in place for inmates. Although forms exist that inmates can use to present complaints and grievances, access to and submission of forms is unpredictable. Many of the boxes located in the cells used for inmates to submit complaints

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and/or sick requests are broken and/or filled with garbage. It seems obvious that no systematic

process exists for this requirement.

Environmental conditions remain unsanitary and unhealthy throughout the facility. Housing unit temperatures are too high despite efforts using portable coolers. Cells emit the odor of mold and mildew and many flood during heavy rains. High housing unit temperatures create risks for dehydration and dangerous side effects from psychotropic medications. Mold and mildew remains a serious problem through the housing units, cells, recreation areas, ceilings, and shower areas. Lighting is broken and/or nonfunctional in some areas. Kitchen and food service areas are in serious ill repair and dirty. Cooking equipment is broken, some are dangerously located, broken floor tiles create serious trip hazards. Insects were found on food and in kitchen areas. Inmates have limited access to drinkable water; there are broken cell sinks, toilets, and showers that must be repaired. Environmental conditions, overall, remain poor and unhealthy.

Fire and life safety conditions remain inadequate to predictably protect inmates and staff from fire and/or smoke. Fire sprinkler systems are nonfunctional and inmates use the sprinkler heads in their cells as make-shift clothesline brackets. Cell doors are padlocked, a padlocked chain provides access into one entire housing unit. Many occupied cells had exposed and/or frayed electrical wires, some near water leaks, some electrical boxes showed evidence of burn marks where electrical shorting has occurred. Fire drills are not regularly conducted nor are staff adequately trained, equipped, or prepared to effectively respond to fire emergencies. There is no fire or master key control program whereby officers are routinely assessed to demonstrate competency with basic fire safety response measures. Inmate cells are cluttered with combustible items, i.e., empty commissary packaging and paper. Inmates interviewed reported having those items for more than a month. Staff do not have access to breathing equipment needed to respond safely to a fire incident. They would not be able to safely search for or rescue others from a smoke filled structure. It does appear, however, that GGACF possesses an experienced and competent fire safety coordinator who can provide expert guidance toward compliance in these areas.

Administrative investigation policies and practices are inadequate to ensure timely review, consistent tracking, or consistent resolution of facility mishaps and staff misconduct. There is no systematic process for initiating, investigating, or managing this administrative component of quality management and assurance. Supervisors do not regularly review housing unit logs or incident reports to proactively initiate administrative inquiry into real and/or potential problems. Administrative investigations are primarily reactive and there is little evidence of follow-up.

Medical, mental health, and suicide policies, procedures, and practices are inadequate to ensure timely delivery of these health care requirements. Policies and procedures, in general, are underdeveloped or nonexistent. Existing staffing levels cannot provide adequate level of required care and administrative staff are not sufficiently engaged in program management to ensure program or care continuity. Mentally ill inmates are not properly assessed and treated in many instances. There are no formal treatment plans, no basic counseling services, few treatment encounters with qualified providers or even enough qualified providers to deliver minimum levels of care if treatment programs were possible. There is little to no follow-up or monitoring of mentally ill inmates placed in segregation by qualified mental health providers. There is no formal or systematic medication management program in place to monitor medication assisted treatment regimes. The lack of an organized, systematic, and regularly reviewed health records

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system makes it very difficult to track patients or even develop any measurable health care

quality assurance program.

We were provided no evidence to assess compliance with use of force or restraints provisions in the Agreement.

The training program is in a state of significant change according to GGACF officials. It is their intention to rebuild the entire training program and to bring it onsite under direct control of the Warden, which is a positive sign. However, there was no evidence provided to determine the effectiveness of the existing training program. We were provided an outline of training topics but the current training curriculum was not available for examination to determine its efficacy relative to pre- and in-service training, or whether any training topics were changed or added to accommodate implementation of the Agreement.

Agreement implementation has not appeared to have yet gained much traction. We were provided no evidence of an implementation plan beyond a very basic policy and procedure implementation schedule. A planned and systematic process for Agreement implementation does not exist and current levels of information and data tracking are insufficient to support such a process.

Despite a lack of progress and noncompliance with virtually all of the provisions in this Agreement, Territory officials voiced a serious commitment to comply with the Agreement.

BASELINE ASSESSMENT METHODOLOGY

The Baseline Assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties. The team consists of Mr. Kenneth A. Ray, M.Ed., Monitor; Roberta Stellman, MD, Psychiatrist; and, Ronald Shansky, MD, Correctional Medicine.

Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for baseline assessment visit purposes and scheduling, and monitoring expectations in general.

Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.

1. Description of how the Monitor will assess compliance with each of the Compliance Measures.

In general, compliance assessment will include the following activities:

A. Discussions and meetings with facility officials, staff, providers, and inmates.

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B. Discussions and meetings with community agency officials providing inspection or other

regulatory oversight of GGACF.

C. Discussion and meetings with officials and staff of contract providers and community

agencies who provide services within and/or for GGACF and inmates held in its custody.

D. Discussions and meetings with other pertinent staff, personnel, and community members,

either as requested by the parties or who, in the determination of the Monitor, can provide

relevant information for the purposes of monitoring.

E. On-site tours of grounds, perimeter security barriers, perimeter access control and

entrance points, all external security technology and methods, building and structural

exteriors, roofs, and utility systems.

F. On-site tours of all buildings, housing units, special environments, health care facilities,

receiving and discharge areas, segregation units, all cell areas, food service and storage

areas, utility closets and chases, utility technology and systems, fire prevention and

suppression systems, life safety locations and equipment, other interior areas and location

relevant to determine compliance.

G. Examination of all security equipment and systems used for perimeter, external,

structural, internal, and special security operations purposes.

H. Examination of health care equipment, supplies, materials, technology and other material

methods and processes used for inmate health care assessment, diagnosis, treatment

planning, treatment (long and short-term), follow-up, and discharge planning.

I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other

motorized vehicle used for correctional operations purposes.

J. Examination of any and all records, data, and/or information relevant to compliance and

compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above will assist the Monitor to determine compliance and the degree to which each of the compliance ratings (non-compliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the

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parties to develop metrics and core measures for qualitative and quantitative measurement of

progress and compliance. Core measures and metrics should specifically pertain to the conditions

set forth in the Settlement Agreement, and generally consider accepted standards and

recommendations promulgated by the National Correctional Association, American Jail

Association, National Commission of Correctional Health Care, American Psychiatric

Association, American Nursing Association, ASIS International, National Fire Protection

Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other

nationally accepted standards for compliance assessment and management. Additionally, specific

measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall

be followed. The following compliance management terms are suggested for assessment and

compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject
 defective or deficient performance, processes, services, equipment, etc. when applied.

 Compliance Assurance: Implies activities designed and intended to identify performance
 and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.
 Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or consumer satisfaction).
 Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of consumer satisfaction, a performance indicator might be: “the percentage of consumers who state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)
  Online media information
  Online public records
  Electronic and standard mailing of information
  Email communication and phone consultations 


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3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. A monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for the baseline visit and monitoring includes the following: many of these documents were not provided as requested. Territory officials stated following the baseline visit that some of this information did not exist. We, therefore, again request all documents as required under Sections X.B paragraph 2 and IX paragraph 8 of the Agreement. The Monitor offered technical assistance to the Territory to develop necessary documents that currently do not exist.

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system.

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14. Documentation reflecting any training facility staff has received, including any corrections

officer training manuals, pre-service and in-service training completed by all staff over the

past 36 months.

15. Current staffing schedules for security positions and shifts.

16. Job descriptions for all non-health care staff.

17. Copies of any self-evaluation reports, grand jury reports, American Correctional

Association surveys, National Institute of Corrections reports/evaluations, National

Commission on Correctional Health Care reports/evaluations, or any other outside

consultant reports regarding the facility.

18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry

to the facility or during their stay in the facility.

19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which

ones are vacant.

20. Reports and data showing turnover information and statistics for security, medical, mental

health, and other staff positions budgeted and authorized for the previous 36 months.

21. Any staffing improvement plan, applications for technical assistance, and county budget

proposals/authorizations to address staffing shortfalls.

22. Facility maintenance requests and work orders for the past 12 months.

23. Records and/or lists of physical improvements, repairs, and renovation completed to

correct security problems and deficiencies over the past 36 months.

24. Past 36 months of agency budgets.

25. List and contact information for any and all community vendors who provide services of

any kind to GGACF and contracts or professional services agreement authorizing those

services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy
of their records. 31. To the extent not provided above, the policies and procedures governing medical
and mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers, including
on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to include
health care policies under which those persons and/or entities provide inmate health care.

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36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD

testing, health assessments, and inmates sent to the emergency room or off-site for

hospitalization listing where applicable name, date of service, diagnosis and service provided.

37. A list of all persons with chronic illness listing name, location, and name of chronic illness.

38. A schedule of all mental health groups offered.

39. Minutes of any meeting that has taken place between security and medical for the past year.

40. Quality assurance and Medical Administration Committee minutes and documents for the past

year.

41. A list of all emergency equipment at the facility.

42. A list of current medical diets.

43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to

include in the log presenting complaint, name, date of request, date triaged, and disposition)

and chronic illness appointments for the past two (2) months.

44. A copy of the nursing protocols.

45. To the extent not provided above, a copy of any training documentation for security and 


medical staff on policies and procedures and emergency equipment.


46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location.

47. To the extent not provided above, external and internal reviews or studies of medical or mental

health services including needs assessments and any American Correctional Association and

National Commission on Correctional Healthcare reports.

48. List of all inmates placed in restraints, and all inmates receiving mental health treatments,

under suicide watch, or taking psychotropic drugs. Current mental health case list including

inmate name, number, diagnosis, date of intake, last psychiatric appointment, next psychiatric

appointment, and any case lists of inmates followed only by counseling staff with last

appointment date and follow-up appointment.

49. Documentation reflecting any training that facility staff have received on suicide


prevention, including certificates and training materials.


50. All documents related to the any suicide occurring within the past year.

51. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

52. All policies and directives relevant to suicide prevention. 53. All intake screening, health evaluation, mental health assessment, and any other forms

utilized for the identification of suicide risk and mental illness.
 54. Any suicide prevention training curriculum regarding pre-service and in-service staff

training, as well as any handouts.
 55. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 56. The entire case files (institutional, medical and mental health), autopsy reports, and 

investigative reports of all inmate suicide victims within the past three years.
 57. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 58. List of names of all inmates on suicide precautions (watch) within the past year. 59. The suicide watch logs for the past year. 60. Clinical Seclusion logs for the past year. 61. Use of clinical restraint logs for the past three years. 62. Any descriptions of special mental health programs offered.

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63. A list of all uses of emergency and forced psychotropic medications in the past year

64. A list of any use of force associated with the administration of psychiatric medications for the

past year.

65. A description of medical and mental health’s involvement/input into the disciplinary process

and clearance for placement in segregation.

66. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

The Territory did not provide all of the documents prior to the baseline visit as requested (specifically requested items number 3, 17, 19, 22, 23, and 25-66), and as required in the Settlement Agreement (Section IX paragraph 8). This somewhat hampered preparation by the monitoring team; many, but not all, of those documents were provided during and following the visit. The Monitor was advised by Territory officials that other documents requested but were requested did not exist. We will discuss this and the matter of documents needed for periodic review during the December visit.

Documents and information provided did afford the monitoring team a reasonably basic understanding about GGACF operations and conditions from which to perform an adequate baseline assessment. However, the absence of requested documents and information did impair the monitoring teams’ pre-visit, onsite, and post assessment work somewhat. Going forward, it is important to reiterate that the effectiveness of the monitoring process and the Territory’s ultimate success in fulfilling its obligations with the Agreement are, in large part, products of the Monitor having timely access to requested documents. The Monitor will remain considerate of the Territory’s technological and resource limitation affecting the timely access to requested documents with the understanding that the information is ultimately needed to ensure accurate, complete, comprehensive, and objective monitoring of the Agreement.

It is important to note that the onsite baseline visit was very productive despite a lack of requested information. Territory officials and participants were exceptionally cooperative, involved, and supportive throughout this aspect of the monitoring process. The Territory’s repeated desire to fully comply with the Agreement was evidenced by its active cooperation and involvement in the onsite visit. Similarly, United States Department of Justice representatives participating in the onsite assessment were equally cooperative and involved, which helped to maximize visit efficiency and productively. The presence of both Parties during the onsite visit assisted assessment focus and allowed for collaborative and timely resolution of important matters of mutual interest. Therefore, the Monitor and monitoring team respectfully requests that these representatives from both Parties participate at all future assessment visits.

The monitoring team used three primary reference points from which to assess compliance and progress with Agreement. These included: 1) the agreed 2012 Findings of Fact document, 2) documents, information, and data provided prior to, during, and following the onsite assessment, and 3) the onsite visit, which included meetings, discussions, interviews, campus tours and inspections. Site inspections were conducted during daytime and nighttime hours to better understand operational functioning, strengths, and deficiencies.

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During this assessment, the monitoring team toured the campus, inmate housing units and cells,

dayrooms and program spaces, food service/kitchen areas, maintenance and workshops, the

armory, intake/booking area, control rooms and officer posts, outer perimeter and fencing,

medical and mental health areas, both active tower, and the animal pens. We talked with BOC

representatives and staff, and spoke with inmates.

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IV. SAFETY AND SUPERVISION

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in .a jail setting, Defendants will implement appropriate measures to minimize these risks, including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.

A. Supervision

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:

a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;

ASSESSMENT: Noncompliance

FINDINGS: While it is recognized that the requirement to develop and implement effective policies and procedures is clearly described and defined in this Agreement, doing so does not alone either fully meet its substance or intent. Well-researched, evidence-based, comprehensively implemented and regularly evaluated and updated policies are only one tool for providing constitutionally reliable protection and care of inmates at GGACF. The substantial intent of this Agreement is to ensure that GGACF provide consistent and deliberate safety, security, and care of all inmates at all times. This requirement extends to all substantive areas i.e. security, health care, suicide prevention, sanitation, the use of force, training of staff, inmate and staff supervision, etc. It is important, therefore, to remind the Parties that completion and implementation of effective policies does not, alone, provide sufficient evidence of compliance with provisions involving policy and procedure development. Partial and Substantial Compliance requires valid and reliable proof that conditions of confinement at GGACF meet minimum constitutional requirements and are likely to continue to do so beyond the life of this agreement.

Effective correctional security policies and procedures provide staff with clearly written and systematic work methods to ensure adequate protection and care of inmates. These documents explain all the “who, what’s, when’s, where’s, why’s, and how’s” while helping to ensure compliance and accountability in their implementation and efficacy.

An examination of incident reports, jail logs, and practices evidence a clear lack of adequate policies and procedures. Here are a few examples:

One September 4, 2013 an inmate was slashed in a housing unit. The records suggest that no officer was on I Unit when the attack began. One inmate pursued the inmate-victim from one housing unit to another without staff intervention and with the assistance of unlocked housing

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unit doors. Once the officer arrives to stop the assault, the reports indicate that the victim-

inmate spat at the officer. This officer then retreated to the office/control room. The inmate

was able to gain access into this office area and a fist fight ensured before backup officers

could arrive to stop the violence. The reports also indicate that during this event, many other

inmates were trying to get out of the housing unit gate. The existence of, and compliance with,

adequate policies and procedures could have easily prevented or mitigated this violence and

serious breach in facility security.

In another incident reported to occur on July 11, 2013, an inmate-on-inmate homicide was the direct result of failures in security policy, training, and the lack of adequate security policy and practices. In this case an inmate was able to obtain a large knife and fatally stab another inmate near the kitchen area. The knife was not “home-made” but appeared to be a professionally manufactured weapon that was brought into the facility and accessible to the offending-inmate. The suspect-inmate seems to have been inadequately supervised before this event, was able to enter the G housing unit and give the knife to another inmate. This and other serious threats to inmates and staff seem virtually unstoppable based on unlocked housing and control room doors observed during the baseline assessment.

Neither or the incident reports discussed above alluded to any remedial, preventive steps to be taken or what policies or procedures were violated and/or should be reviewed to prevent future violence. The absence of any administrative reports provided to the Monitor leads to a conclusion that no administrative investigation occurred and/or no action was taken to retrain or discipline staff whose noncompliance with policies and procedure may have contributed to these events.

Most policies are in need of significant reform. Policies and procedures provided are outdated, unsigned, and most not referenced to professional regulations or standards, inconsistent, and appear to not be followed by staff in many instances based on observations of campus, housing areas, and security control areas. There are no policies or procedures that specifically stratify the defendant and offender populations (jail or prison) according to risk and needs. The two operations (jail and prison) are essentially stratified by gender and conviction status. Although the Settlement Agreement does not specifically state a condition to meet any professional standards or regulations pertaining to the operations of a correctional facility, it is highly recommended that Defendant’s base policy development and implementation on professional corrections standards as they are well researched, evidence-based, and very useful in establishing and maintaining a constitutionally-sound correctional operation.

RECOMMENDATIONS:

1. Revise/develop housing classification policies based on a current validated intake and review classification instrument. Submit document drafts as indicated in the Agreement before implementation.
2. Timely complete and submit a policy development plan that includes, at a minimum, the following elements: A. Policy title with related procedure titles B. Primary policy references C. Person(s) responsible for document development

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D. Expected dates to be forwarded to the Monitor and USDOJ for review and approval,

date(s) of staff training, implementation date

3. Review current population to verify accurate risk/need classification levels and

housing, reclassify and appropriately house as indicated by review process findings.

4. Refer to IV.F. regarding specific classification and housing policy recommendations.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: Noncompliance

FINDINGS: Post orders for all posts are vital to effective and consistent correctional operations. Post orders should be well-researched and written, easy to interpret and apply, easily accessible by staff at their duty posts, and regularly evaluated and revised as needed to ensure consistent continuity of post and facility operations.

Documents titled “Specific” and “General” post orders were provided following the baseline visit. Specific Post Orders comprise 10 pages of specific post directives, General Post Orders comprise in excess of 200 pages of general directives ranging from specific post duties to operational functions. Specific Post Order pages are not numbered, General Post Order pages are numbered but it is difficult to determine between Post Order and regulations, as they appear to be blended. The two sets of documents are formatted quite differently, none are signed by approving authority, none are dated, and none have document review, revision, and/or dates established or issued, nor do any of these documents include professional or regulatory references as previously discussed A general examination of both sets of documents suggest that many of these directives are not followed by staff based on observations of practices, housing and cell conditions. The Orders are not numbered, making it impossible to accurately reference any Order, section or subsection. Some of these directives would be virtually impossible to apply and/or comply with simply due to inadequate security staffing levels, maland non-functioning security equipment, and poor cell lighting. I was unable to locate any Post Order (Specific or General) that established minimum staffing levels for any security post. I also found no specific Post Orders specifying supervisor-to-officer ratios.

A partial examination of officer logs for Units L, K, X, I, and 9A dated June to September 2013 clearly evidence Post Order deficiencies, inadequate staffing levels, and/or lack of supervision as discussed:

Month

Unit

June

L

July

K

August

9A

X

I

Sept

I

I

Staffing Deficiencies Reported By Officers No relief officer at shift change Only one (1) officer to two (2) office post No relief officer for break, unit officer leaves unit unattended for break Security check finds 13 female inmates unsupervised, unit rear doors not locked No officers in I/J unit at shift change No supervisor on duty, no unit relief officer No supervisor unit checks during 4-12 shift

It seems more likely than not that these seven log entries reflect a larger, undocumented, problem. All of these reports evidence serious, and likely persistent and pervasive, problems

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with inadequate staffing levels – though it takes no less than six to seven months to fully train


a corrections officer for service – supervision, and inmate and staff safety and security. 


These are only a few of many very troubling log entries written by officers. Many other entries 
 report real and significant health risks to the inmates as demonstrated by a few log entry
 examples below:


June 18, 2013 (L Unit)
 Basic health needs are at risk because inmates do not have access to water after nighttime lock
 down as stated in the log, “Last call for water at this time; slots are closed. IM DR complaining
 about urine bag being clogged up.


June 19, 2013 (L Unit)
 - An inmate complains of head pain and “passes out in his room”
 - “No staffing relief available…24-hr shift ensues”. In this entry, an inmate shows an officer

a blood-filled toilet after urinating.

July 18, 2013 (K Unit)
 There was only one officer present when normally two are assigned to the unit. The reporting 
 officer reports “this practice is hazardous to both officer and inmate safety due to the status of the unit.” Additionally, it was reported that the backup generator did not come on during a power outage.

August 4, 2013(K unit) The officer reports, “Major repairs are needed within the unit from lighting fixtures, missing ceiling tiles, faulty locks, cells, cracks, mold and mildew…Administration is fully aware of these safety and health hazard conditions in this facility, also discrepancies in security but blatantly refuses to rectify them!!!”

These few log entries represent only a small number of reports for only a few housing units and only over an approximate three-month period (June-early Sept) but clearly evidence serious security, safety, and health problem that appear persistent and pervasive. Additionally, it is very difficult to garner consistent compliance with policies and procedures by staff when they feel that their concerns are ignored by administrators.

RECOMMENDATIONS:

1. Subsequent to policy and procedure development and revisions, conduct a complete review of existing Specific and General Post Order to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible; E. regularly reviewed, revised, updated; F. consistently enforced; G. known to staff through pre-service, in-service, and ongoing training.

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2. Develop a plan that provides for regular review of all log books by supervisors to ensure

staffing and other unit safety and security issues to be known and resolved in a timely

manner.

3. Ensure that all posts are staffed according to post complexity and dynamics, risks and

needs.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and

ASSESSMENT: Noncompliance

FINDINGS: Each housing unit inspected was issued two radios and charges. However, radios were observed to be left in unit control rooms when officers were in the housing units or outside the control room with control room doors left unlocked. This practice presents an extreme staff and inmate safety and security risk without legitimate justification. Additionally, some officers interviewed complained about nonfunctioning radios and having to share one radio at times.

RECOMMENDATIONS:

1. Revise and/or develop, implement, and evaluate policies and procedures governing radio communication equipment, usage, repair and maintenance.
2. Ensure that all posts are equipped with functionally reliable communications equipment; it is recommended that reliable radios are issued to ALL officers and staff working with and/or around inmates.
3. Repair, replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
4. The Monitor will review radio equipment inventories and functionality during the next onsite assessment.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including: (i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and (ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.

ASSESSMENT: Noncompliance

FINDINGS: Based on onsite observations, interviews with staff and inmates, a review of unit and incident report logs, inmate supervision is inconsistent, unreliable, and ill-performed. Post order limitations discussed previously contribute to this problem. For example, the many of the screen mesh on the cell doors are damaged to point that they prevent clear viewing into the cell by officers and inmates were allowed to cover viewing ports to prevent the officers from performing scheduled or random security checks. This single deficiency can easily create conditions for inmates to prepare or cause serious harm to other inmates, to themselves,

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conceal and/or use contraband, or experience an undetected medical or mental health

emergency.

RECOMMENDATIONS:

1. Refer to recommendations regarding Post Orders. 2. Revise and/or develop policies and procedures to ensure consistent and reliable
monitoring of housing units and cell blocks as stated above. 3. Ensure housing units and cell blocks are consistently staffed at levels required to ensure
staff and inmate safety and security, and according to inmate risks and needs. 4. Ensure that special needs inmates (suicide, mentally ill, medical infirm, vulnerable,
etc.) are monitored more frequently and by qualified health care staff. 5. Ensure that supervisors routinely inspect general and special housing units to ensure
compliance staffing requirements, policy and procedures, and to interview inmates to presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. 6. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, repair all broken cell doors, keep all housing unit doors locked, repair broken control panels to improve unit security.

B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: Partial Compliance

FINDINGS: Although current policies and regulations list what constitutes contraband, these policies are outdated, some are underdeveloped, and some are incomplete.

During the first day onsite, the Warden advised the monitoring team that a “shakedown” of the entire facility had not occurred in two years. This is clearly an unacceptable policy and/or practice as it creates an incarceration culture that promotes and encourages the introduction, use, and easy movement of contraband throughout the entire facility.

Additionally, at no time did I observe any inmates being searched as they entered or exited a housing unit, kitchen or shop areas, but did observe inmates entering and leaving those areas. This further encourages contraband movement throughout the campus.

RECOMMENDATIONS:

1. Review, revise, and develop contraband policies to include all forms of contraband, consequences for its introduction and possession, and actions staff are to take in its collection and disposition.

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b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: Noncompliance

FINDINGS: A review of housing unit logs (June-Sept, 2013) and Incident Log (October 2012 – September 2013) reflect a serious, dangerous, chronic, and pervasive contraband problem exists throughout the facility.

There were approximately 407 incidents reported on the Incident Log for the period examined. Almost one-third (125 /407) involved discovery of contraband and/or the likely presence of contraband (e.g., “intoxicated inmate”). The risks presented to staff, other inmates, and facility security, based on descriptions of seized contraband, ranged from minor to serious physical security breaches, to potentially deadly as shown in the table below listing items reported.

Incidents Logged
Incident Reported All Incidents Contraband

2012 (3mos) 99 42

2013 (8mos) 308 83

Combined (11mos) 407 125 (est.).

Contraband Found
Contraband Found
Not Identified Cell Phones CD/DVD Players Weapons/Sharps Illegal Drugs Intoxication Drug Paraphernalia Money

2012
16 18 0 2 4 0 1 2

2013
38 28 2 7 6 2 2 2

Total (11mos) 54 46 2 9 10 2 3 4

Contraband reporting data should be viewed as 1) positive efforts being made by GGACF officials and many staff to improve facility safety and security, and 2) as clear and convincing evidence that the facility is a dangerous environment for inmates and staff. These data also seem to support implications resulting from staffing level deficiencies, inadequate inmate and housing unit supervision, staff supervision, and the ease to which inmates can obtain contraband as evidenced by a 2013 inmate assault involving serious physical injury caused by manufactured machete, a reported removal of 73 bags of marijuana from Unit 9A in May 2013, and an inmate-on-inmate homicide occurring earlier this summer. Further analysis of contraband reports and the number of items confiscated following approval of the Order on May 14, 2013 demonstrates significant increases in these incidents and volume of most contraband-types.

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A cursory analysis of contraband incident reports for 3.5 months (approximate) before and following approval of the Settlement Agreement found the following changes in reported incidents and items confiscated:

 Reported contraband incidence increased 76 percent (25/44);  Number of unidentified items increased 50 percent (14/21);  Number of cell phones increased 215 percent (6/19);  Number of CD/DVD/Players decreased 100% (1/0);  Number of Weapons/Sharps/ increased from 0 to 9 in comparison;  Illegal drugs decreased from 3 to 1 seizures.

GGACF Contraband Reports &
Confiscations Before and After Approved
Settlement Agreement

Before SA Feb

Mar Apr

May 13th

After SA May
14th

Jun

Jul

Aug

3.5 Mos Before Agreement

3.5 Mos After
Agreement

Contraband Reports 3

12 10 2

2

16 9 15

25

44

Not Identified 1

5 8

0

86 7

14

21

Cell Phones 1

5 01

4

62 6

6

19

CD/DVD Players 1

0 00

0

00 0

1

0

Weapons/Sharps 0

0 00

3

31 2

0

9

Illegal Drugs 1

0 20

1

00 0

3

1

Intoxication 0

2 00

0

00 0

2

0

Drug Paraphernalia 0

0 00

0

00 0

0

0

Facility Property 0

0

1 0

0

00 0

1

0

Money 0

0 00

0

00 2

0

2

Totals

4

12 11 1

8

17 9 17

27

52

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Golden Grove Adult Correctional Facility Contrand Reports and Items Confiscated Comparison Before Settlement Agreement (Feb-May 13th) and After (May 14-August 31, 2013)

60

Not Identified

Cell Phones 50
CD/DVD Players

40

Weapons/Sharps

30

Illegal Drugs

Intoxication

20

Drug Paraphernalia

10

Facility Property

0 3.5 Mos Before Agreement

3.5 Mos After Agreement

Money Contraband Reports

The reports do not clarify whether these increases resulted from increased attention to this issue, increased volume of contraband, or both. These findings clearly demonstrate the presence of pervasive and persistent dangers to staff and inmate safety, security, and welfare of staff and inmates that can be mitigated and better controlled via effective policies, and staff and inmate supervision.
Additionally, an inspection of the medical unit found open cabinets containing scalpels and other dangerous medical devices. Leaving exam rooms cabinets and exam rooms unlocked and unattended provides no help in preventing access to contraband and exposes inmates and staff to very serious personal safety risks.
RECOMMENDATIONS:
1. Review, revise, develop, train, implement, evaluate contraband control policies that contain, at a minimum, the following elements: A. The purposes for contraband control; B. Safe methods and tactics for identification, seizure, recovery, and disposition; C. All locations where contraband can be hidden and disguised; D. Methods and points of delivery and access; E. Unannounced and irregularly time searches of cells, inmates, and inmate program; recreation and work areas; F. Keep all cabinets and doors locked at all times to prevent access to contraband; G. Use of metal detection equipment; H. Use of other mechanical devices for detection and recovery; I. Respect of inmates’ rights to authorized personal property J. Clearly articulate differences in inmate property allowed according to gender, religion, health conditions, conviction status, etc.

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2. Review, revise, develop, implement, train, and evaluate training policies, procedures,

methods, and demonstration of staff proficiency in the prevention, detection,

recognition, recovery, and disposition of contraband.

3. Ensure that all posts and high-risk contraband access points are properly secured at all times, adequately staffed, equipped with reliable video surveillance devices, and consistently enforce contraband rules and laws involving inmate, staff, contractors, volunteers, the public, etc.

4. Develop a uniformed incident tracking/reporting system using standardized contraband titles and locations; implement a continuous quality improvement program to ensure the accuracy and completeness of incident reports.

5. The Monitor requests electronic submission of the current Incident Log each month for review and analysis purposes, and to provide technical assistance as indicated.

c. Detection of contraband within Golden Grove, through processes including:

(i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinic, and other areas of Golden Grove to which prisoners may have access;
(ii) pat-down, metal detector, and other appropriate searches of prisoners coming from areas where they may have had access to contraband, such as at intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic;
(iii) regular and random searches of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g., clinic, kitchen, dayrooms, storage areas, showers);

ASSESSMENT: Noncompliance

FINDINGS: Refer to 1B above.

RECOMMENDATIONS: Refer to 1B above, expand application of recommendations to provision c (i-iii) above.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: Partial Compliance

FINDINGS: Examination of contraband incident data, current policies and procedures, and staff interviews suggest the presence of a basic confiscation and preservation practices.

RECOMMENDATIONS:

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1. Review, revise, develop, train, and implement, evaluate policies and procedures

involving confiscation and preservation of contraband as evidence for administrative

and legal enforcement purposes.

2. Ensure staff access to appropriate equipment and supplies needed to safely collect and

preserve contraband while maintaining evidentiary integrity.

3. Ensure adequacy of chain-of-custody methods and procedures.

4. Review, revise, develop, implement, train, and evaluate training policies, procedures,

methods, and demonstration of staff proficiency in the proper collection/confiscation

and disposition of contraband.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: Partial Compliance

FINDINGS: Similar to above.

RECOMMENDATIONS: Similar to above specific to admissions policies and procedures, internal and external escorts for visitors to the facility.

C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: Noncompliance
FINDINGS: Many inmates were observed wearing personal “street clothes” and not standardissue correctional uniforms. This practice creates substantial risk of escape and potential conflict among inmates.
RECOMMENDATIONS:
1. Review, revise, develop, implement, train, and evaluate policies and procedures requiring all inmates to wear standard-issue correctional uniforms.
2. Consider acquiring correctional apparel that provides obvious recognition of the inmates’ classification/status.
3. Ensure there is a consistently sufficient supply of uniforms to regular laundry exchanges and changes in an inmate’s classification and/or status.
4. Consider developing a correctional industry for making uniforms onsite. 5. Select/make uniforms specifically designed to reduce/eliminate places to hide
contraband and weapons. 6. Mark all uniforms with highly visible letters/numbers.

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b. Identification that prisoners, staff, and visitors are required to carry

and/or display;

ASSESSMENT: Noncompliance

FINDINGS: None of the inmates were observed wearing correctional identification. However, the Warden has developed an inmate identification card that he showed the Monitor during this assessment and intends to implement it soon. Not all non-uniformed staff wore official identification but should. The monitoring team was provided official identification upon entry into the facility each day; the identification cards were numbered, recorded by the officer, and collected each day before our departure.

RECOMMENDATIONS:

1. Ensure staff compliance with this provision. 2. Ensure appropriate policies and procedures are in place and made available to staff. 3. Ensure adequate supplies for making identification cards. 4. Regularly audit identification card inventory and maintain proper controls to prevent
inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories. 5. Consistently enforce identification card policies and procedures.

c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;

ASSESSMENT: Noncompliance

FINDINGS: Perimeter security gates were locked during this assessment except for a few instances when entering the facility at the beginning of the assessment. Some internal campus gates stood open providing access between buildings and recreation areas. Although this can be considered efficient for certain inmate movement purposes, the practice is more likely a convenience resulting from inadequate staffing levels. Internal gates leading into housing units were unlocked as were the doors into and between unit control rooms. Unit pipe chase/electrical doors were unlocked, which provided easy access to these areas by inmates. Many cell door locks were broken, many lockable cell doors had inmate-made devices attached to them to prevent them from locking. Most of the cell doors require manual locking and unlocking due to control panel designs and some inoperability issues. Inmates have been known to exit their cells and units, allegedly undetected, access the yard or other housing and assault other inmates. It is imperative that all cell doors remain locked when locked, that inmates are prohibited from, and sanctioned for, manipulating cell or other locking devices, and staff are required to adhere at all times to basic security locking protocols.

The inmate slashing and homicide events previously discussed are two very real examples of why it is important to enforce security locking-control policies and the dangerous and deadly consequences of those policies not being consistently practiced.

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RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluation policies and procedures related to facility security pertaining to locking and unlocking access points, units and cell doors, and other locations requiring consistent access controls.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable
functionality, detection of tampering, and timely repair/replacement. 5. Ensure staff are adequately trained in the proper use of mechanical and/or electronic
locking systems according to their post assignments. 6. Consistently sanction inmates for attempting or manipulating any security locking
system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked! 9. Consider replacing or upgrading existing unit control panels to provide for remote
electronic locking and unlocking of unit and cell doors. 10. Increase video surveillance of internal and external access points to ensure rapid
detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking
devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for
investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations. 13. Consistently enforce security locking policies and procedures with staff and inmates.

d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and

ASSESSMENT: Noncompliance

FINDINGS: The facility is currently understaffed with maintenance personnel to keep up with lock repairs and/or replacement. Unit logs examined show that staff do report unit and cell door lock problems. Otherwise refer to previous provision.

RECOMMENDATIONS:

1. Develop an “all-locks” maintenance plan for review with the Monitor during the December 2013 assessment. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken off line.

e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,

ASSESSMENT: Noncompliance

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FINDINGS: According to the training assistant interview, a background and criminal history check is performed on all uniformed and civilian applicants. However, a review of a few staff personnel folders did not find documents to verify this practice, nor did the folders contain supervisory review documents. Territory officials state that these documents are on file at the BOC central office and are available for review during the next visit. It is, however, important to state that the personnel/training program is currently under redevelopment and the records filing process has not been completed.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate policies and procedures for the applicant and staff records process as indicated by the training assistant.
2. Ensure access to applicant and staff records is adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
3. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.

D. Security Staffing

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor, for all levels of security staff at Golden Grove;

ASSESSMENT: Noncompliance

FINDINGS: A comprehensive staffing analysis has not yet been initiated, though the parties and monitor discussed and agreed to delaying the analysis until potential operational efficiencies could be evaluated. Observations during this assessment, staff interviews, and examinations of unit and incident log strongly suggest the facility is significantly understaffed. Only two of three security towers are operational due to staffing limitations and there seems to be a chronic shortage of relief staff. Inadequate staffing levels, combined with inadequate physical security controls (e.g. functional locks, control panels, cameras, lighting, etc.), and inconsistent security practices significantly increase safety and security risks to staff, inmates, and visitors.

RECOMMENDATIONS:

1. Complete a comprehensive staffing study using the Staffing Analysis process of the National Institute of Corrections.
2. Appropriate funding to hire sufficient numbers of staff to establish and maintain adequate levels of facility safety and security in accordance with staffing analysis results.

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b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and

ASSESSMENT: Noncompliance.

FINDINGS: The Monitor was not provided with an existing staffing plan. Security staffing schedules provided during this assessment did not provide adequate information to accurately determine authorized and actual staffing levels, or whether current security staff deployment practices met operational needs considering facility/campus design and layout, scheduled and unscheduled activities and events, population factors, etc. In the absence of those documents, I can only conclude that no standard staffing plan exists and that a policy of staffing deployment does not exist and/or is not followed, and/or is not routinely managed.

GGAF cannot effectively protect inmates and staff from harm, provide constitutional conditions of confinement, or provide adequate health care services in the absence of adequate staffing levels and plans. Staffing plans help correctional managers and supervisors devise effective staff deployment strategies, maximize and prioritize use of staffing resources, and help to ensure that staff are where they need to be, when they need to be there, doing what they need to do.

RECOMMENDATIONS:

1. Update existing security staffing plans for review with the Monitor during the December site visit.
2. Identify current and anticipated security staffing deficiencies. 3. Be prepared to discuss the staffing and analysis issues in more depth, and Plan
provisions during the December visit.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

ASSESSMENT: Noncompliance

FINDINGS: Refer to above findings.

RECOMMENDATIONS: Review, revise, develop, train, implement, evaluate policies and procedures related to facility staffing with particular focus on staffing levels, deployment, recruitment, selection, training, promotion, development, attrition, maintenance of staffing levels, etc.

2. Defendants will implement the staffing plan developed pursuant to D.1.

ASSESSMENT: Noncompliance

FINDINGS: Refer to previous findings.

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RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: Noncompliance

FINDINGS: Documents provided to the Monitor by GGACF include a general PREA policy. This policy is not dated, signed, or numbered. It is unknown if staff are aware of the policy or have completed training on PREA or this policy. The policy does not explain PREA and does not include all PREA definitions. The current policy also does not include all PREA requirements according to PREA standards. Additionally, inmate handbooks do not include PREA topics, their rights within PREA and methods for reporting violations, nor are PREA information documents provided to inmates upon admission.

RECOMMENDATIONS:

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements.
3. Appoint a PREA Compliance Coordinator as soon as possible. 4. Complete the PREA Self-Audit. 5. Review, revise, develop, train, evaluate policies and procedures that include, at a
minimum, the following PREA topics:

Policy Organization Definitions Inmate Reporting Staff and Agency Reporting Protection from Retaliation
Hiring and Staffing Viewing and Searches

Staff, Volunteer, and Contractor Training Inmate Education
Inmate Intake and Classification Agency and Staff Response to Inmate Reports Investigations Staff and Inmate Discipline Medical and Mental Health Care Monitoring

F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake

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as security-needs and available information permit, and no later than 24-48

hours after intake, considering the prisoner's charge, prior commitments, age,

suicide risk, history of escape, history of violence, gang affiliations, history of

victimization, and special needs such as mental, physical, or developmental

disability;

ASSESSMENT: Noncompliance

FINDINGS: Current classification policies and procedures are found in Section 3 of GGACF Policy and Procedure for Inmate Records, Booking and Inmate Processing, and Inmate Classification (pp.47-55, dated July 1, 1993). According to Territory Officials, the classification process was developed with the assistance of Dr. Jim Austin, classification expert, and the National Institute of Corrections. However, it is unknown whether facilityspecific classification protocol was put into place. No additional or new classification policies or procedures consistent with the elements of F.1.a above were provided to the Monitor. Additionally, current policy Table of Contents shows classification procedures on pp. 47-55; Section 3 is paged 49-50 and appears to be missing several pages.

The current admission and review classification instruments are outdated and cannot, therefore, reliably reflect actual classification levels and housing decisions. The current classification is inadequate because: 1) classification decision making is not based on a current and empiricallyvalidated classification tool, and 2) the high levels of institutional violence and contraband reporting in incident logs strongly are indicative of the absence of a valid and reliable classification system.

RECOMMENDATIONS:
1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that
provide more accurate and complete guidance for a valid and reliable classification system for non-convicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system.
b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: Noncompliance
FINDINGS: Detainees and convicted offenders are generally held in separate buildings except for female inmates who cohabitate in the same building. Inmates are generally housed according to their security level based on behavioral history and whether their background includes violent criminal acts. According to Territory Officials, inmates are also housed and/or separated for administrative, disciplinary, special needs, and/or work assignments. This is a very basic and unreliable practice for managing inmates and is not based on a reliable classification system. Such a practice is known to facilitate violence against inmates and staff,

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the introduction of contraband, and can create substantial barriers to inmate health and

wellbeing.

RECOMMENDATIONS:

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report to target population cohorts for housing and separation that is more consistent with behavioral risks, and needs.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: Noncompliance

FINDINGS: This practice is as much a classification issue as it is a security management issue. As previously discussed, security locking and unit supervision issues are inadequate and deficient based on an examination of the Incident Report and Unit logs. It is imperative that previously discussed security control deficiencies are addressed and corrected without delay. However, even the best classification tool and system is defeated when security and inmate supervisions policies and procedures are not followed consistently as observed during this assessment and evidenced in incident logs, reports, and housing unit logs.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

ASSESSMENT: Partial Compliance

FINDINGS: There is a current practice and general policy for reclassifying inmates following incidents involving violence and disciplinary events. However, this process, as previously stated, should be empirically validated.

RECOMMENDATIONS:

1. Refer to previous classification findings and recommendations.

e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct; and..(f).

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ASSESSMENT: Partial Compliance
FINDINGS: The newly implemented Incident Log Report is a good step in this direction as is the activation of the GGACF Gang Intelligence Unit. Additional improvements to information and data collection and analysis are warranted.
RECOMMENDATIONS:
1. Develop policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.
ASSESSMENT: Noncompliance
FINDINGS: There is currently no formal mechanism or process for regularly reviewing status and conditions of inmates housed in segregation. Several inmates housed in segregation presented with very poor hygiene and appeared to be seriously mentally ill. Some inmates interviewed indicated that they did not know how long they were to remain in segregation and several of those with apparent mental illness stated they had not seen a health care professional in weeks. There is clearly no formal monitoring process in place.
RECOMMENDATIONS:
1. Review, revise, develop, train, implement, evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or as a treatment for inmates who are mentally ill.
G. Incidents and Referrals

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1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

a. Reporting by staff of serious incidents, including (i) fights; serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENT: Noncompliance

FINDINGS: No such policy has been issued as of yet; this indicates that such reporting does not occur. This seems further evidenced by previous discussion involving Unit Logs wherein officers report serious security and facility deficiencies that seem to go unresolved. This lack of policy, procedure, systematic resolution and quality management appears to not only be discouraging and frustrating to correctional staff, but can promote noncompliance to policies and procedures in general, and provides management no reliable tools for effective staff deployment or security/safety hazard mitigation.

RECOMMENDATIONS:

1. Complete and submit policies as indicated. 2. Integrate the Incident Tracking system into this policy. 3. Develop protocols for current tracking system to improve data validity and reliability;
this document is replete with duplication and misleading entries. 4. Develop a unified incident coding system for valid and reliable information and data
collection, reporting, and analysis. 5. Establish regular monthly quality assurance meeting process involving all major
department team leaders to review serious incident reports and recommend evidencebased remedial measures for eliminating/mitigating incident frequency and severity.

b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: Noncompliance

FINDINGS: Gang/incident intelligence team meetings are regularly held but do not include, as a rule, senior management (team leaders) as discussed above.

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RECOMMENDATIONS:

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: Noncompliance

FINDINGS: Refer to previous section on contraband control as it also pertains to confiscation 
 and preservation of evidence.


RECOMMENDATIONS:


1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: Noncompliance


FINDINGS: Refer to previous findings regarding incident reporting and tracking.


RECOMMENDATIONS:


1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.

ASSESSMENT: Noncompliance


FINDINGS: Refer to previous findings regarding incident reporting and tracking.


RECOMMENDATIONS:


1. Include this element in the required policy and procedure. 2. Establish reasonable time frames as indicated.

H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force, Such policies, training, and systems will include the following:

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a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: Noncompliance

FINDINGS: Documents provided show that GGACF rules and regulations pertaining to staff use of force are scattered throughout these documents and not located in a unified Use for Force Policy and Procedure document, which is considered a standard method for maintaining policies. As such, it was very difficult to locate, accurately interpret, and/or reconcile similarities and conflicts between these regulations. In some cases, the regulations conflicted making it impossible to determine what and when force is authorized and used. I was unable to identify a standard Force Continuum document although Use of Force, Firearms, and Use of Chemical Agents is listed in the Pre-Service Training outline provided. I not did find use of impact weapons (batons) listed in the training outline but did observe them present in control rooms and possessed by the segregation housing officer.

RECOMMENDATIONS:

1. Review, revise, develop, train, evaluate use of force policies as indicated and include, at a minimum the following policy elements: A. Mission and purpose statement B. Legal authority for use of force C. Definitions: of force, conditions, applications, non-physical and physical force, authorized weapons, deadly force, necessary and unnecessary force, etc.; D. Pre-service staff proficiency training, qualifications, certification, and regular inservice training; E. Use of deadly force; F. Use of any weapon authorized for use; G. Reporting requirements; H. Force event quality control and assurance program and methods; I. Self-defense; J. Impermissible force; K. Staff noncompliance corrective measures; L. Medical/mental health involvement in use of force events; M. Force against special populations, e.g., mentally ill, frail, medically ill, aged; N. Planned and unplanned force; O. Special force operations and equipment; P. Officer safety and protection; Q. Emergency first aid; R. Administrative reviews; S. Use of restraints; T. Centralized incident, training, and qualification record keeping; U. Armory operations and instructor training and certification; V. Photographing, videotaping, recording of planned force events; W. Other.

2. No incident report involving use of force were provided to the Monitor to determine the existence of unnecessary or excessive force. The Monitor again specifically

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requests to be provided ALL documents involving incidents where force is used by

staff against inmates.

b. Circumstances under which the permissible forms of physical force may be used;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

e. Training and certification required before being permitted to carry and use an authorized weapon;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

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1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above. Additionally, an interview with one tower officer revealed that they are not trained or qualified in the use of a firearm from a tower location. It is extremely important that firearms training and regular re-qualification policies mandate training and demonstration of proficiency in the use of a firearm under all conditions and circumstances in which it is authorized for use. No officer should ever be authorized to carry a firearm unless and until fully training, tested, and qualified to do so and then only under the conditions and circumstance for which they were trained to do so.

RECOMMENDATIONS:
1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

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i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;
ASSESSMENT: Noncompliance
FINDINGS: Refer to findings in H.a. above
RECOMMENDATIONS:
1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
1. Administrative investigation of uses of force;
m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;
ASSESSMENT: Noncompliance

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FINDINGS: Refer to findings in H.a. above. Also refer to findings regarding incident

reporting, tracking, and quality assurance.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

o. Re-training and sanctions against staff for improper uses of force.

I. Use of Physical Restraints on Prisoners

1. Defendants will develop and submit to USD0J and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above. Additionally, and as previously stated, no reports involving the use of restraints were provide to the monitoring team. The absence of such reports makes it impossible to determine whether the use of restraints was reasonable, necessary, and/or permissible.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

b. Circumstances under which various types of restraint can be used;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

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RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Duration of the use of permitted forms of restraints;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Required observation of prisoners placed in restraints;

ASSESSMENT: Noncompliance

FINDINGS: Refer to findings in H.a. above

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See below.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

ASSESSMENT: Noncompliance

FINDINGS: No specific policy or procedure currently exists regarding use of physical restraints on inmates with suspected or known mental illness, or that involve appropriate consultation with either medical or mental health staff.

Well researched, clear, and comprehensive policies and procedures for this aspect of force/restraints/restraint chair is critical for ensuring appropriate use of restraints involving inmates with mental illness and/or who suffer from medical conditions that could be exacerbated from restraint use. Medical and mental health staff must be involved in decisions to use and terminate use of restraints on this population.

Therefore, decision making in the use of restraints on this population must include a multidisciplinary process involving custody, medical, and mental health staff and professionals to ensure the utmost care and monitoring is taken to protect this population from psychoemotional and/or physical harm.

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It is important that all restraint devices function properly according to manufacturer specifications, are routinely inspected for functional reliability and, are applied properly and in a manner that reduces harm risks. Inmates should only be restrained if and when less restrictive alternatives have failed to ensure inmate and staff safety and/or when those alternatives are determined by the multidisciplinary process as likely ineffective.

Inmates under restraint should be regularly monitored for circulation and potential physical harm by qualified medical staff, and for psycho-emotional harm by qualified mental health staff. Restraints use should not exceed four (4) hours in duration without authorization by licensed qualified medical and mental health professionals in consultation with custody management.

RECOMMENDATIONS:

1. Develop, train, implement, and evaluate well-researched, well-written, clear, and complete policies and procedures to managing the use of restraints process.
2. Involve a multidisciplinary process in decision making to use, monitor, and terminate restraint use.
3. Train all staff in this process and the proper use of restraints and less restrictive alternatives.
4. Develop training lesson plans for this process that ensure staff competency in both knowledge and application of the restrain policies and procedures. Always train using the actual restraint devices authorized.
5. Develop and implement a reporting and tracking system for restraint use. Leadership should review all restraint use on a monthly basis to ensure policy compliance and take remedial/corrective actions, whether to policy, procedure, or staff noncompliance, in a timely manner. All remedial/corrective actions should be documented and maintained.

f. Required termination of the use of restraints.

ASSESSMENT: Noncompliance

FINDINGS: Same as above

RECOMMENDATIONS:

1. Same as above. 2. Ensure the policy includes restrictions on restraint use duration and termination
requirements.

J. Prisoner Complaints
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

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a. A prisoner complaint system with confidential access and reporting,

including assistance to prisoners with cognitive difficulties;

ASSESSMENT: Noncompliance

FINDINGS: There are no clearly written policies and procedures for ensuring confidential access for reporting complaints or that includes assistance to inmates with cognitive and/or communication (verbal/written/auditory) impairments. Although the incident log notes “confidential” in certain cases, this practice is informal and discretionarily determined according to specific circumstances. Discussions with the Warden about this issue revealed that both confidentiality and communication impairment issues are dealt with on a case-bycase basis, but no formal policies and procedures exists. Those discussions also suggest that management is aware of these needs, takes appropriate steps to meet those needs, but does so in the absence of written guidelines.

It is also important that policies and procedures direct under what conditions housing unit officers are authorized to resolve complaints. This issue must be studied carefully with specific written controls when promulgating policies and procedures. It is important for the protection of staff and inmates that inmates have timely access to a complaint/grievance process that is unfettered by unauthorized resolution by correctional staff. Such controls and guidelines will also facilitate inmate access to their rights, care and alert facility officials (administration, security, medical, mental health) to ongoing risks to inmates and staff.

There is no formal inmate complaint/grievance tracking system currently in place. Although complaint forms are available to inmates, there is no system established to ensure that complaints are resolved, followed-up, and/or monitored. Current practices also differ among unit officers, according to inmate and staff interviews. Some officers allow free access to complaint forms, others state they attempt to resolve matters informally before issuing a form, still others require all completed complaint forms to be submitted by the inmate to the officers for further processing. Inconsistencies in the complaint process exposes staff and inmates to erroneous allegations of misconduct, increases risks of inmate abuse by staff, places inmate health care and rehabilitation at risk, and thwarts development of a valid and reliable complaint reporting and tracking system. However, even the best inmate complaint system is rendered ineffective if inmates do not have the means to ensure complaints are reliably collected and reviewed. Many of the boxes used to collect complaints and sick requests at the housing units were found unlocked and/or broken. Some of these boxes were filled with trash, which clearly evidences ineffective management oversight by housing unit officers, supervisors, and management.

RECOMMENDATIONS:

1. Review, revise, develop, train, and implement inmate complaint policies and procedures.
2. Develop and implement a valid a reliable complaint reporting and tracking system. 3. Conduct monthly administrative reviews of the inmate complaint reporting and
tracking process to measure and verify program compliance, take timely and appropriate remedial and correction action.

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b. Timely investigation of prisoners' complaints, prioritizing those relating to

safety, medical and/or mental health care;

ASSESSMENT: Noncompliance

FINDINGS: Same as above

RECOMMENDATIONS:

1. Same as above. 2. Include policy and provisions for timely investigations of complaints, prioritization of
complaints related to risks of harm and safety, medical and/or medical care.

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: Noncompliance


FINDINGS: Again, there is no formal policy on this subject matter.


RECOMMENDATIONS:


1. Complete required policies and procedures. 2. Include specific policy and procedural provisions requiring corrective action for staff
noncompliance, and that ensures timely, consistent, and appropriate disciplinary action against staff who violate the policy.

d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: Noncompliance.


FINDINGS: Same as above, and with previous discussions about records and tracking systems.


RECOMMENDATIONS:


1. Develop and implement a formal centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: Noncompliance

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FINDINGS: Currently, there is no formal process or policy for periodic management review

of inmate complaints. Reviews are performed on a case-by-case basis.

RECOMMENDATIONS:

1. See previous recommendations related to reporting and tracking complaints. 2. Conduct monthly administrative reviews of inmate complaint/grievance tracking
reports and data to identify patterns of individual staff, inmate, and/or systemic problems and issues.

K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;

ASSESSMENT: Noncompliance

FINDINGS: These policies and procedures have not been submitted as stated above, have not been submitted to the Monitor for review and comment.

RECOMMENDATIONS:

1. Submit administrative investigation policies and procedures per this provision as indicated.
2. Ensure the policies and procedures clearly describe investigative timelines, officials responsible who are authorized to conduct interviews, methods and locations of interviews, and other relevant topics that maintain the integrity and legality of the investigative review process and determinations.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: Noncompliance

FINDINGS: Same finding as above

RECOMMENDATIONS:

1. Same as above.

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2. Develop, as part of these, methods for adequate collection, recording, handling,

labeling, preserving, and maintaining administrative investigation evidence,

information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

ASSESSMENT: Noncompliance

FINDINGS: Same findings as above.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: Noncompliance

FINDINGS: Same findings as above

RECOMMENDATIONS:

1. There is no formal pre- or in-service training program to train staff who are involved in initial and/or administrative investigation.
2. Provide adequate training of staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
3. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management.
4. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

ASSESSMENT: Partial Compliance

FINDINGS: Although the policies and procedures required under this provision have not been submitted as discussed, current GGACF regulations establish written penalties for staff misconduct. Discussions with the Warden indicate that corrective action against staff involved

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in any misconduct does and will occur when supported by evidence. It is also important,

however, to use a similar investigative/corrective action process for maintaining compliance

with policies and procedures in general, e.g., following security policies, etc.

RECOMMENDATIONS:

1. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.
2. Integrate the information in the above into the administrative policies and procedures previously discussed.
3. Record and maintain onsite records of staff misconduct investigative reports and determinations.
4. Protect the integrity and confidentiality of these staff records; control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
5. Provide training to supervision staff in the appropriate use of this information for staff supervision, counseling, discipline, promotion, etc. purposes.
6. As with all training, especially training required for and, that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:

a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: At the time of our visit, we were informed that medical staff coverage was 8:00 a.m. to 8:00 p.m. seven days per week, which meant that non-qualified medical and mental health staffs, i.e., correctional officer staff, were in fact conducting the intake screens during this period. In addition, the process itself, including the policies, does not require that the qualified health care staff develop a disposition in order to facilitate continuity of care at the completion of the intake screen. As an example, a patient entered with diabetes, receiving insulin twice per day. During the intake screen, the health care person did not ascertain when the patient had received her last insulin dose and, in fact, there were no orders written to facilitate insulin dose continuity until 48 hours after intake. Clearly, this creates liability for the patient, which, with a well-designed process, would be avoidable. In addition, the intake screen lacks details with regard to a number of items related to chronic diseases, infection control matters, such as TB symptom questions, substance use details that facilitate the development of an understanding of the liability for withdrawal problems, and other items. We look forward to working with the Golden Grove staff to develop an improved process, including an improved screening tool. We were notified that in the budget to be implemented 10/1/2013, are resources to insure health care staff presence for expanded hours between 8:00 a.m. and midnight seven days per week. This would be an improvement. We also looked at the volume of detainees received between the hours of midnight and 8:00 a.m. during the three-month period of June, July, and August 2013. What we found was, of 151 intakes totally within the three-month period, 24 were admitted between midnight and 8:00 a.m. However, of those 24, 14 arrived after midnight but were released the same day. Therefore, during a three-month period, only 10 inmates arrived after midnight and stayed more than a day. We discussed with the health care leadership strategies to insure that even after midnight, if there is no health care staff person on site, the intake screen could in fact be performed by an on-call health care staff member who could do the screen via video technology from home while the patient was in the intake area. The initial screen would not include vital signs unless an officer could utilize automated equipment to collect that information. Either way, health care staff will be on site in less than eight hours and at that point, vital signs certainly could be completed. Although the current process is fraught with problems that interfere with the ability of the program to substantially comply with the Agreement, we did discuss an approach that would clearly meet the intent of the Agreement. The Golden Grove staff seemed extremely receptive to

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the approach. What follows is an outline for this approach, which should ultimately be

promulgated into a policy and procedure.

1. All intake health care screens are performed by qualified health care staff, mostly onsite, but during off hours, potentially via video technology while the health care staff member is at home.
2. The use of an expanded screening tool that captures significantly more relevant health care data that enables the health care staff screener to develop a plan for disposition to facilitate care continuity.
3. Training of the health care staff on the use of the new tool. 4. The development of acuity indicators that direct the health care staff screener on the
urgency of scheduling the health assessment (1-3 days), a sick call visit, or a chronic care clinic visit as well as mental health follow-up, including suicide precautions. 5. The daily review of the screens and the dispositions to provide feedback to the screening staff so that their performance continually improves. 6. Included in the acuity measures are indications of when the physician must be contacted immediately based on the need for medical orders or input from the physician with regard to the appropriate steps for a given patient. 7. A tracking system for all intakes so that every intake that has been identified with some medical problems or mental health problems and who receives a plan with a specific disposition in fact has that plan carried out. This would be in the form of an intake-tracking log that includes the date that the follow-up is to occur.

RECOMMENDATIONS:

1. Out of the seven elements listed in the findings, develop a draft policy and procedure along with a new intake screening form for submission to the Monitor.
2. Feel free to solicit input and/or consultation through the Monitor for the development of this policy and procedure.

MENTAL HEALTH FINDINGS:

The intake process is flawed, and even when incoming inmates are identified through the screening tool or the officer's observations as having mental health problems referrals often do not occur, resulting in misidentification and lack of services for those individuals. The facility currently has underdeveloped, non-implemented, and non-practiced medical policies. As a result, there is not a standardized system of mental health intake assessments within the facility. Staffing is inadequate in quantity and composition to meet the needs of the seriously mentally ill housed at GGACF.

Many of the policies are well written and comprehensive but not applicable to this facility. Policies may describe an ideal vision but the procedures should always reflect the actual practice including whatever constraints exist within the facility.

RECOMMENDATIONS:

1. The nurse intake screen needs to contain all relevant data elements for both mental health history and symptoms as well as suicide screening.

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2. Policies and procedures should be revised and/or developed that are consistent with

number one above.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: The policy reviewed by us requires the health assessment to be completed within three days and in fact, several records we reviewed did not have a health assessment completed within the obligatory three days. In addition, the health assessments did not always conclude with an initial problem list and plan as is appropriate in order to initiate ongoing care. Additionally, the intake screen data did not seem to impact the urgency of the completion of the health assessment. It is obvious that based on patients’ acute or chronic problems, the initial health assessment is more or less urgent. A type 1 diabetic must have their health assessment performed the same day that they enter; on the other hand, a patient with good blood pressure control may have their health assessment delayed until the third day so that in the meantime the blood pressure is monitored and the clinician performing the health assessment has multiple data elements to utilize for the plan of treatment for the hypertension. It is important for the clinicians performing the health assessments to appreciate that these assessments are being completed in order to develop an initial problem list and plan for each problem, as opposed to exclusively being performed in order to document a history and physical exam. The following elements should become part of the health assessment policy.

1. Based on criteria provided to the health screener, the health assessment must be performed by an advanced level provider (MD, DO, ARNP, PA, etc.) based on medical need, on either day 1, day 2 or day 3.
2. The health assessment, when conducted for a patient with a chronic disease, should include chronic disease specific history elements in order to determine, at the time of the health assessment, an appropriate plan.
3. The health assessment for patients at risk of withdrawal problems must include relevant history and physical assessment in order to determine whether a withdrawal monitoring protocol and treatment plan needs to be implemented. Where the screening history suggests the possibility of withdrawal problems, the physician should be contacted to determine the need for withdrawal monitoring.
4. The health assessment plan for patients with chronic diseases must include referral for chronic disease follow-up.
5. Plans must include diagnostic monitoring as well as indicated therapeutic interventions. 6. An intake log should be used to track the occurrence of health assessments to determine the
timeliness of necessary services. 7. The Medical Director should review each health assessment for feedback to the clinicians
regarding the quality of the professional performance.

RECOMMENDATIONS:

1. Utilize the elements listed under “Findings” to promulgate a new policy and procedure for the performance of health assessments.

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2. Utilize the Monitor and his team for any consultation or technical assistance.

MENTAL HEALTH FINDINGS:

The mental health assessment requirements is for an appropriately credentialed Mental Health Professional to perform a comprehensive mental health assessment for those inmates whose intake screens contain positive response for either mental health history questions and/or suicide screening. Currently the only staff person having those requirements is the psychiatrist but this person is rarely onsite and does not conduct most of these assessments.

Medical and mental health assessments are currently performed by a licensed practical nurse and licensed master in social work intern, respectively. In addition, the licensed practical nurse informed me that she has had no training specific to mental health, which is a requirement for the NCCHC intake assessment standard. Appropriately credentialed clinicians who may perform a comprehensive mental health assessment include Qualified Mental Health Professionals as defined but his agreement. These include independently licensed medical and mental health professionals with appropriate training and experience.

I spoke with the licensed practical nurse that completes all of the initial health assessments. The team was initially informed that inmates are escorted to medical as soon as they are processed at intake during the day and the next morning if the inmate comes in overnight. However, in actual practice the nurse informed me that the intake can take days to complete and sometimes even a week.

Medical staff has to obtain an escort in order to go across the compound to the intake or detainee area. However, once someone is identified by the intake nurse as having a mental health issue, the mental health counselor sees them, usually within a day. She documents a comprehensive biopsychosocial assessment in a traditional format. Unfortunately, the mental health counselor is not independently licensed as required by this standard. She currently has a license as a Master Level Social Worker Intern in Florida and an Addictions and Substance Abuse Certification. While these qualifications enable her to work effectively in providing counseling services, comprehensive psychological evaluation and treatment plans should be developed by an independently licensed mental health professional.

We also requested copies of the health services clinical staff credentials while onsite. We were told that licenses and credentials are maintained in the Bureau office and copies were not available on site for our inspection. Mrs. Jennifer Charles, the mental health coordinator, did provide me with copies of her credentials, which indicate that she is a licensed Master Social Work Intern in the State of Florida as well as a Certified Addictions Counselor.

Copies of the officers’ screening are not filed in the medical record.

RECOMMENDATIONS:

1. Comprehensive mental health assessments should be performed by practitioners who are licensed to practice independently and reach diagnostic conclusions on all intakes with positive response to mental health and/or suicide question on the intake screen. It is recommended that GGACF hire an independently licensed mental health professional to

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complete all initial assessments and provide services for complicated cases as well as suicide

prevention monitoring.

2. Suggest the following template for comprehensive mental health assessment:

THE INITIAL MENTAL HEALTH ASSESSMENTS

SUBJECTIVE/ OBJECTIVE  The subjective portion of the entry shall contain critical elements required by the DSM (current version) to support the differential diagnosis and global assessment of function.  Past history will note pertinent findings such as prior hospitalizations, commitments, periods of outpatient psychiatric treatment and substance abuse treatment, any episodes a self-injury, suicidal ideation are intent and/or significant aggression. In addition, a history of victimization or perpetration of abuse should be noted. Significant medical illnesses and history of traumatic brain injury should be listed.  Inquiry into previous work history, military history, prior incarceration, and other significant psychosocial information should be provided.  Family history should include any history of psychiatric or substance abuse disorders as well as suicidal behavior in close family members.  Substance abuse history including current use and previous symptoms when withdrawing should be entered in the chart.  Current medications as well as response to prior treatment regimens should be listed.  The mental status examination will contain appropriate corroboration in a narrative form to the symptom checklist. Thus, should the clinician check a box indicating hallucinations, it is appropriate to describe the content and nature of the reported symptom(s).

ASSESSMENT  All assessments completed by psychiatrists, independently licensed mental health professionals, or qualified psychiatric/mental health nurse practitioners shall contain a full five axis diagnosis based on the American Psychiatric Association's DSM (current version) unless a template form does not require this information.

PLAN  The plan will include medications (or referral for a medication evaluation) if indicated.  Referrals for appropriate psychosocial interventions, comments on discharge planning, and a follow-up for general health needs will also be indicated in the plan.  In addition, a risk assessment, if indicated, as well as the clinician’s professional opinion as to the degree of risk will be entered.  All records will indicate the date (or approximate date (e.g., return in 3 weeks) of the next clinically appropriate follow-up visit.

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 Primary Axis I and Axis II diagnoses should be entered on the master problem

list by a Qualified Medical or Mental Health Professional as defined by the

Agreement.

 Other disciplines may initially list the symptom deficits such as cognitive

deficits and thereafter defer to the diagnosis provided by the above specified

disciplines.

3. Suggest the following template for progress note monitoring/follow-up documentation:

THE PSYCHIATRIC PROGRESS NOTE

SUBJECTIVE/OBJECTIVE  Comments should be entered concerning any reports of side effects or relevant clinical symptoms presented by the patient.  Describe patient’s report of changing in symptom control and overall functioning.  The clinician should comment on any recent PAC admissions, or transfers to segregation and the impact of those status changes as reported by the inmate.  The clinician should indicate the clinical response by the patient to the current treatment plan and the presence of medication side effects.  Significant additions and deletions in diagnostic categories should be substantiated by DSM (current version) criteria recorded in the subjective portion of the note.  The reasons prompting significant changes in medications or the patient’s treatment plan should be explained by history or findings

ASSESSMENT  Provide an assessment pertinent to the data documented.

PLAN  The appointment designated as the return to clinic time should be clinically appropriate.  Laboratory studies should be ordered as clinically appropriate.  Any planned interventions are documented

4. As part of the required Staffing analysis, GGACF should complete a detailed staffing analysis to determine the number of qualified mental health professionals required to deliver adequate services to detainees and prisoners.

c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners; (this report will focus on sick call under this section)

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: Although the draft policy with regard to both acute and chronic medical conditions has some useful elements within, there are not only many things missing, but also the

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practice as evidenced in the records does not conform to the draft policy. We also have not seen

any policy that deals with prenatal care for pregnant prisoners. With regard to acute conditions,

the policy must articulate the goal that access must be provided through processes that insure

confidentiality of request as well as actual clinical service. In addition, access for acute conditions

must be both timely and predictable; thus, if an inmate requests service for an acute problem, they

must have a reasonable expectation that they will receive that service within two days. In reviewing

the housing units, we identified damaged or inoperable sick call slip collection boxes, thus

resulting in requests probably going through custody staff. In addition, in reviewing medical

records from a recent few days in the past month, we identified several records in which the nurse

never performed an assessment, presumably because they were going to refer to the physician, but

several days after the request, the patient had been seen neither by a nurse nor by a physician. This

is a process that is neither timely nor predictable. With regard to the sick call process, the following

elements should be integrated into the draft policy.

1. General population inmates place their requests in a locked box in their housing unit to which only health care staff has access to retrieve the slips. Slips are retrieved daily.
2. Patients in lockdown have their requests retrieved directly by health care staff on a daily basis as opposed to collection on a daily basis from a box. Slips are retrieved daily.
3. On the same day the slip is collected, it is triaged by a nurse for acuity and urgency. Those determined to be urgent or emergent must be seen that same day. Most will be seen as routine and should be seen by nursing staff within one day.
4. When a nurse determines from the paper triage that the patient will need to be seen by a clinician, they must still perform an assessment within one day.
5. Referrals to clinicians after nurse face-to face-assessment can be made on the basis of the assessed severity of the presenting symptoms, but all must be seen by a clinician within five days.
6. A sick call log must be utilized which begins with the triaging nurse entering patient identification data along with presenting complaint and the date the patient is seen for a nursing assessment. After the nursing assessment is completed, if the patient is referred on to a clinician, the date of that visit should also be tracked.
7. On a weekly basis, the head nurse should review the nursing progress notes with the respective nurses who performed the service with an eye toward identifying opportunities for improvement.
8. On a monthly basis, the Medical Director should review clinician notes with an eye toward identifying opportunities for improvement.

RECOMMENDATIONS:

1. The elements in the above findings should be used to promulgate a policy and procedure related to access to care and sick call.
2. The Monitor’s team should be utilized for consultation and/or technical assistance.

MENTAL HEALTH FINDINGS:

The limited and unpredictable hours of psychiatric service are not conducive to the scheduling needs of the service. The mental health coordinator is currently performing biopsychosocial assessments independently and without review by the psychiatrist. Her credentials allow her to adequately provide counseling services, implement components of a treatment plan, conduct

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group therapy, and discharge planning; however, a fully licensed master’s level mental health

professional should be added to the service to perform these assessment functions. In addition

monitoring of individuals on suicide watch, making determinations whether to change the level

of watch, following people removed from suicide watch, and development of treatment plans

should be performed by a fully licensed independent master’s level mental health professional.

Despite several requests, we were never provided with a staffing schedule or matrix. GGACF

currently has a full-time master level social worker and a part-time psychiatrist for a few hours

per week. In the past, the facility contracted with a counseling service to provide group and

individual counseling (The Village) but that contract ended due to nonpayment and subsequent

failure to reach an agreement with this care provider. There has been no staffing increase to

compensate for the loss of that service. As a result, the two staff members are providing only

the minimum service consisting of assessments of referrals, counseling follow-ups for some of

those people assigned to the caseload, and infrequent psychiatric visits. The counselor will

expedite visits to the psychiatrist for inmates with acute problems, but the common result is a

delay in the management of those inmates on the chronic care caseload because there are

insufficient hours of psychiatric time to allow for scheduling of urgent and routine visits in the

clinic.

The psychiatrist is currently partially retired but continues to be available to the facility. In general, it appears that he will be on site for part of Tuesday and may return on Thursdays if notified in advance by the mental health professional. Due to the sparse number of psychiatric hours currently available, some patients may be rescheduled to return to clinic in six months to a year.

In the course of our visit, we discovered one of the few female detainees who were identified as having thoughts of self-harm on intake but never received any referral to mental health. This woman identified herself to us during our tour of the facility and was obviously identifiable as a person with mental illness. Yet, she was never scheduled with mental health even though medical had filed an order from the court for a competency evaluation in her medical record. The mental health caseload represents a lower than expected percentage of inmates in treatment. The question as to whether there is under-identification of mental illness during the intake process and difficulties with that process needs to be explored through a quality improvement process.

RECOMMENDATIONS:

1. Sick requests containing mental health complaints, needs, and/or symptoms should be referred by the medical department to qualified mental health staff for review and resolution.

2. The facility needs to define by policy the qualifications required for each clinical process as well as time frames to complete these processes and provide the clinically necessary followup.

3. Again, a staffing analysis needs to be completed to determine the required minimum number of psychiatric hours and counseling hours needed.

4. The Bureau may wish to consider implementing tele-psychiatry to enhance the availability of psychiatry hours on an island that currently only has one psychiatrist.

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5. Mental health staff should perform, at a minimum, weekly segregation rounds and monthly well-being checks on all sentenced inmates on the mental health caseload.

d. Continuity, administration, and management of medications that address:

(i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and
clinical practices; (iii) review for known side effects of medications; and (iv) sufficient supplies of medications upon discharge for prisoners
with serious medical and mental health needs;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We have not been provided with any policy or procedures regarding medication management. The findings section, therefore, will contain elements that can be used to promulgate a policy and procedure. Medication management seems to involve a haphazard process that includes unlocked, open, and unattended pharmacy room, open medication bottles, and an overall unsecure process. This must be corrected immediately.

1. Medication management must be conducted in a manner that is consistent with professional guidelines as well as territory nursing and pharmacy practice statutes.
2. Only appropriately credentialed clinician staff may write orders for medication. 3. The goal for timeliness of patient receipt of routine medications is within 24 hours of receipt
of clinician order. 4. For critical medications, defined as insulin, anticoagulants, seizure medications and other
specific medications such as Plavix, along with HIV medications, an effort should be made to prevent dose discontinuity. That is, based on the community order, patients should not be allowed to miss a single dose if at all possible. 5. With few exceptions, clinicians should strive to order medications on a frequency of no more than twice per day. 6. For patients on a twice a day regimen, medication administration should occur roughly 12 hours apart. 7. A limited set of stock medication should be available onsite to be administered in order to facilitate medication continuity. 8. The stock medications onsite should ordinarily include at least one medication in every common chronic disease class. 9. Medications must be stored under lock and key with controlled substances under double lock and key. 10. Only designated staff should have access to the keys. 11. All controlled substances must be administered on a dose-by-dose basis with a record of dosages utilized, including the name of the patient who received the dosage. 12. At the end of each shift, two staff people should be present for counting the available controlled substances. 13. When medications are administered, nurses should conduct the administration according to the five rights.

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14. Patients for whom medication is administered should appear with an ID card and a container

of water so that they can ingest the medication with water.

15. Post-ingestion, the officers should be responsible for a mouth check to insure there is no

contraband.

16. As soon after administration as possible, nurses should document on a medication

administration record the receipt or the refusal of the medication.

17. On a monthly basis, the Medical Director must review the appropriateness of clinical

prescribing.

18. A policy should be drafted that insures that patients about to be released to the community

are provided with at least a two-week supply of any chronic medications. The policy must

build in required health care reentry planning by the health care program.

RECOMMENDATIONS:

1. The above elements should be included in a draft policy and procedure dealing with medication management.
2. The Monitor staff should be sought for consultation or technical assistance in the drafting of this policy and procedure.

MENTAL HEALTH FINDINGS:

Medications are currently provided by a local Diamond pharmacy. Psychotropic medications are purchased in bulk bottles and dispensed by a licensed practical nurse on the units. An inspection of the environment revealed current stock bottles of Haldol, Stelazine, Risperdal, Zyprexa, Haldol Decanoate and Abilify. Antidepressant stock consisted of Celexa, sertraline, and Wellbutrin. Ziprisidone and benztropine are also available. No expired medications were identified. The registered nurse informed me that medications are packaged in labeled envelopes and carried to the units. However, the envelopes are simply labeled with the inmate’s name. There are no other identifiers including the name of neither the medication nor the Sig. Without being knowledgeable of the US Virgin Islands Board of Pharmacy requirements I cannot comment as to whether this practice is below the local standard. Medications are administered BID.

The door to the clinic pharmacy was never observed to be locked throughout our entire period of inspection. The controlled substance key ring was noted to either be placed on the lockbox or on the desk near the door of the room even when there was no medical staff present. On the afternoon of September 10, 2013 a nonmedical staff member was observed leaning against the controlled substance cabinet in the pharmacy while speaking with a nurse. We were told that the narcotics/controlled substance count is only performed weekly. The staff has just begun a log list for sharps control but the registered nurse did not know the frequency with which these items are logged at this moment in time. This list must be properly managed and inspected into help reduce contraband within the facility and to reduce risk of serious harm to inmates and staff.

Oftentimes documentation demonstrates transcribed orders but it is unclear what time the order was written and then what time the order was actually taken off.

Almost all records reviewed on site showed no routine monitoring for psychotropic side effects including a baseline and follow-up AIMS examination on those persons receiving neuroleptic medications. This further demonstrates deficiencies involving a lack of monitoring of mentally

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ill inmates housed in segregation and dangers of serious physical illness or death due to

excessive exposure to heat by inmates on certain psychotropic medications.

Medication administration records do not indicate a start date, stop date, name of prescribing clinician. Some lacked frequency of administration as well. The medical records do not consistently demonstrate monitoring for side effects from medication or consent by the inmate to accept a particular medication and their awareness of the potential side effects and risks.

There are no formal systems in place for the notification of health services by classification of upcoming releases and by health services to provide discharge medications. Staff informed us that the current time there is no discharge planning process to ensure aftercare follow-up and medication continuity.

RECOMMENDATIONS: GGACF officials must take timely action to correct the deficiencies identified in this findings section above.

e.

Maintenance of adequate medical and mental health records, including

records, results, and orders received from off-site consultations and treatment

conducted while the prisoner or detainee is in Golden Grove custody;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We received a policy approved in May 2010 titled “Confidentiality of Medical, Mental Health, Dental and Recovery Services Information.” This policy describes procedures for maintenance of medical, mental health, dental and recovery service files. However, the policy requires that every inmate entering a BOC facility will have a mental health file that is separate from the medical file. This particular provision is wrong. It is important that all clinical care is integrated into a single file. There may be a dental section within the medical file and a mental health section within the medical file, but the file itself must be a unitary file. The procedure indicates that the medical file must contain all medical information and that this should be maintained separate from the inmate’s master file. This is appropriate. However, there are a variety of staff including a CNA or nursing staff that ultimately has a hand in medical file maintenance as an added part of their other duties. The end result is medical files that are not well maintained and therefore there is information that should be accessible timely which in fact is not. The following are some basic principles and guidelines for an effective adequate health records management system:

1. The health administrator is responsible for overseeing medical records management. 2. Medical records will be managed in a way that insures and protects patient confidentiality. 3. The record will contain a problem list that allows access to it immediately upon opening
the medical record file. 4. Clinicians and only clinicians are responsible for updating the problem list with any new or
additional problems. 5. Documents obtained from the provision of offsite services, such as consultations or
procedures or emergency room visits or discharge summaries, must be filed only after reviewed by a clinician, who documents their name and the date of the review on the document.

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6. Dental and mental health records are filed in reverse chronology, generally within their own

sections.

7. The medical record program should maintain data on the percentage of records available at

the time of appointments as well as the timeliness within which offsite service documents

are filed within the record after receipt and review by clinicians from the offsite service.

8. This service needs a policy on medical records documentation that would include required

elements in each different type of documentation. For example, a standardized progress

note for psychiatry that routinely assessed for medication side effects would ensure better

compliance in monitoring for these common problems and allow for quality assurance

chart review.

9. GUIDELINES APPLICABLE TO ALL MEDICAL RECORD ENTRIES:  All entries shall be legible  Each entry shall list the inmate’s name and MDC number  Each entry shall be signed by the clinician and indicate their professional degree  All entries shall be dated and timed  Current housing location, such as special housing or isolation, should be apparent by reading the chart  Every assessment and clinical visit notation shall follow the SOAP format (unless the documentation is on a required template that is structured differently) and make every effort to provide the narrative information necessary for another clinician to understand the writer’s assessment.

RECOMMENDATIONS:

1. The above elements should be utilized to draft a more detailed medical record policy. 2. The Monitor’s staff should be utilized as resources to facilitate development of the policy
and procedure.

MENTAL HEALTH FINDINGS:

Medical records are stored in a separate room. They are alphabetized and do not have a Bureau of Corrections number. Name alerts are utilized when necessary.

There are no medical records personnel to organize and maintain the medical files. As a result, the records are disorganized. The mental health professional reported she was told not to file records in the charts until they were reorganized.

Medication administration records show orders transcribed but lack essential components such as a start date, stop date, and the name of the ordering clinician. The administration records may demonstrate significant medication noncompliance, yet there is no system of written notification to the clinician and no evidence in the records reviewed that medication compliance is taken into consideration at the time of the visit. More often than not, MARs are missing from the medical record.

The medical records are not in chronological order and records are not always filed in the correct section of the chart. Chart sections are not labeled. Some charts are combined medical and

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mental health records while others are separated and the facility should consistently do one or

the other.

There is no policy that drives the organization and quality of the medical record. Medication administration records were frequently absent for months at a time. Entries are not routinely timed and often the signature is illegible and lacks credentials. The quality of the documentation is poor and often insufficient to support a diagnosis and treatment plan.

The only documents that contain a current and past history consistently are the biopsychosocial assessments completed by the mental health coordinator. However, many of the charts reviewed did not contain this document and therefore, more often than not, lack of a past and present history.

RECOMMENDATIONS:

1. One chart per inmate, combining medical and mental health documentation for an integrated record.
2. I have recommended that the mental health professional immediately file her notes in the medical record so they are available for the psychiatrist to review.
3. A policy needs to be developed with documentation guidelines and instructions for organizing and maintaining the medical record.
4. Quality improvement effort should be undertaken to track compliance with policy once implemented.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: This items was dealt with under letter (c), including recommendations for the policies. Although logging was occurring, it was not performed conscientiously and there were inconsistencies between the logging and what was found in the medical records.

RECOMMENDATIONS: See letter (c) findings and recommendations.

MENTAL HEALTH FINDINGS: The current sick call process is not confidential because inmates must hand their requests to an officer. Sick call request boxes on the units were served be either broken, used to store other equipment, or unlocked and therefore useless. At the current time, the facility has not implemented a sick call log that would enable demonstrating compliance with all of the above requirements.

RECOMMENDATIONS:

1. A confidential process needs to be established that enables:

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 monitoring of the timeliness of retrieval of sick call requests

 appropriate triaging by a registered nurse or mental health professional (in the case

of mental health requests)

 timeliness of response by the appropriate qualified health professional

 appropriateness and effectiveness of the treatment plan generated.

f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;

ASSESSMENT: Noncompliance

MEDICAL FINDINGS: Tracking of care and monitoring of these services was found to be either non-existent, incomplete, inconsistent, and/or not routinely reviewed and utilized as indicated. We have described in each required service area how tracking of care and monitoring should be performed.

MENTAL HEALTH FINDINGS: Same as above.

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: Some work has been completed, starting with the creation of a chronic care policy as well as chronic disease guidelines based on material prepared by the National Commission on Correctional Health Care. In addition, an internist who is a cardiologist has been hired to see chronic care patients onsite weekly. All of this is very encouraging. However, what needs to be done is the completion of the chronic care policy and the training of the onsite consultant so that he is familiar with both the chronic disease guidelines and the policy. At this point, that familiarity does not exist. In addition, clarity needs to be developed with regard to how to insure continuity of care from the moment patients with chronic diseases enter the facility. Under (a) we described an example of a recently entering detainee with type 2 diabetes maintained on insulin for whom orders were not written, including for the insulin, until about 48 hours after she entered. The chronic disease policy must describe a method for approaching these diseases from the point of identification on entry and be designed in a way that is consistent with the urgency of the medical need. This begins with the screen, is succeeded by the health assessment and then the initial chronic disease visit. The following elements are critical to a well-run chronic disease program.

1. The model that is utilized must be based on the concept of disease control with (for common diseases) standard definitions of good, fair and poor control. The NCCHC chronic disease guidelines utilize this format.
2. The clinical practice must be consistent with the chronic disease guidelines. 3. The policy must address patients who enter with critical needs, such as insulin. An example
would be for patients with type 1 diabetes or whose disease is poorly controlled, such as a patient with extremely elevated blood pressure. Patients whose disease is poorly controlled should be seen as soon as possible, with at minimum a call to the on-call physician. Based

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on the patient’s medication and other needs and degree of control, the health assessment may

take place in a range of from 1-3 days, based on clinical need.

4. The program must require an initial chronic disease visit during which substantial disease

specific history is obtained, identifying symptoms and organ damage and current disease

control. The NCCHC website has both initial chronic disease visit forms and a form for

follow-up visits. These were discussed with the internist consultant, who appeared quite

interested in utilizing them for documentation. These forms require specific questions based

on each specific common disease be asked during the history.

5. The guidelines should describe what the baseline diagnostic assessment must include and

these should be followed by the clinician.

6. Patients should be followed at a frequency dictated by disease control. In general, patients in

good control may only need to be seen every three months; those in poor control must be

seen in no more than four weeks.

7. At the visits, the medication regimen should be reviewed and orders written that insure that

the patient does not run out of medication prior to the next visit.

8. At the first clinician visit, the chronic disease problem must be entered on the problem list

and the patient referred to the internist and enrolled in the chronic care program. The program

must maintain a chronic disease registry, which indicates which patients have one or more

specific chronic diseases. This registry is dynamic, as people are entering weekly and being

released weekly. A nurse may be assigned to maintain the chronic disease registry.

9. The Medical Director should review the chronic disease records on a regular basis for both

compliance with the chronic disease guidelines as well as determining whether the clinician

took appropriate action when the degree of control was either fair or poor.

RECOMMENDATIONS:

1. Utilize the above nine elements to expand your chronic disease policy and the guidelines as well as the forms.
2. Contact the Monitor and his staff for consultation and/or technical assistance.

MENTAL HEALTH FINDINGS:

Currently, the mental health professional maintains the case list that identifies those inmates followed both on the detainee and the sentence side of the facility by the psychiatrist. The psychiatrist informed me that inmates prescribed medications for a temporary problem will not be included in the caseload. The list contains the inmates name, diagnosis, medication regimen, BOC number, and date of birth. The list is lacking the date for the next psychiatric and counseling visit. In reviewing the medical records it is clear that people are not scheduled for follow-up as medically necessary or in a timely manner.

RECOMMENDATIONS:

1. A minor modification to the current case list log as recommended above would improve the tracking capabilities of the facility.

2. The list should contain both the BOC number and the inmates’ date of birth.

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3. Any inmate followed by mental health should be captured on a log, perhaps one for

psychiatry and one for counseling.

ASSESSMENT: Noncompliance

MEDICAL FINDINGS:

RECOMMENDATIONS:

MENTAL HEALTH FINDINGS:

Patients are scheduled in chronic care mental health clinic in unpredictable and inconsistent fashions. Frequently people appear to be lost to follow-up and may be seen every 5 to 12 months despite a diagnosis of a serious mental illness.

Chart review uncovered examples of inmates decompensating during a long hiatus between 
 visits, which may have been prevented had they been followed more frequently. 
 Inmates who presented with acute symptomatology were not scheduled for an earlier follow-up, 
 but again may have been seen months later, which may result in prolonged housing in isolation,
 or deterioration in the person's condition.


RECOMMENDATIONS:

1. As mentioned previously, a policy that would dictate required time frames for follow-up of people in the chronic care mental health clinic may improve the timeliness of return visits and allow for tracking when looking for quality outcomes.
2. All prison inmates on a mental health caseload should have at a minimum a monthly wellbeing check by a mental health professional. Minimum frequency of psychiatric visits should be outlined by policy.

See related findings by Dr. Shansky for items v, vi, g. and h.

f. (iv) adequate measures for providing emergency care, including training of staff:
(1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-
threatening conditions; (3) to recognize and timely respond to emergency medical and
mental-health crises; ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We have been provided neither complete training materials nor documentation of staff who have completed the required training. We are also aware that there have been difficulties communicating with the on-call physician. The line staff expressed frustration about being able to access a clinician timely during an urgent or emergent problem. This issue must be resolved. We understand that there is a plan to have a full-time Medical Director responsible for both St. Croix and St. Thomas. That person needs to own the clinical outcomes of the patient population. One will not be able to expect that type of ownership and accessibility unless the territory makes a

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commitment both financially and otherwise to the proposed Medical Director. The prognosis for the

medical program hinges in our opinion on the territory’s ability to make a satisfactory commitment

to their Medical Director, who must then make a commitment to the patients and staff. The Medical

Director must not only be accessible by phone but also be involved in training staff and seeing

patients onsite. This will be discussed in greater detail under letter (j) that addresses staffing. The

emergency care urgent/emergent policy must address the following items:

1. Urgency is based exclusively on patient perception. 2. When a patient notifies a custody officer that they have an urgent problem, the custody
officer is required to contact medical without exception and medical is obligated to perform an assessment, preferably in the clinic but possibly in the housing unit, also without exception. 3. Based on that assessment, the patient’s problem can be addressed definitively or an advanced level clinician must be contacted for further direction. An advanced level clinician may need to come in or the nurse may place the patient on the phone with the advanced level clinician who can perform part of the assessment telephonically. 4. All urgent care calls must be logged into an urgent care log that contains patient identifiers, date, time, presenting complaint and disposition. Where the disposition requires sending the patient offsite to an emergency room, when the patient returns the patient must be returned through the medical unit, a nurse must review the offsite service paperwork and where indicated, contact the advanced level clinician. If the offsite service paperwork is not available, the nurse should contact the emergency room and have that documentation faxed or scanned and sent by e-mail. 5. Based on the patient’s condition on return, the patient may be held for observation or returned to his housing unit. In any event, there must be a primary care clinician follow-up visit with the patient as soon as possible but in no more than three days. At that visit, the primary care clinician must document a discussion with the patient regarding the offsite service findings and any plans. 6. The emergency response policy should include requirements for training and certification in basic like support and first aid, documentation of such training as well as requirements for emergency drills.

RECOMMENDATIONS:

1. The above elements should be utilized in drafting the urgent/emergent care policy and in constructing the urgent/emergent care log.
2. The Monitor and his team should be contacted for any consultation or technical assistance.

MENTAL HEALTH FINDINGS: The island hospital has closed their psychiatric unit. When patients have acute situations that cannot be managed within the facility they can be sent to the emergency room. That department can maintain the individual for up to 48 hours while attempting to medicate them for stabilization. Once the patient is compliant with medications they are returned to GGACF. If needed they are placed in isolation until they are able to take their medications, eat, and follow commands. If necessary, the facility will have to locate an off-island psychiatric hospital.

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There were no current cases to review that required such placement. The facility currently does

not have a log of inmates sent to the emergency departments and therefore retrospective review

for quality purposes cannot be done.

The facility is currently not staffed adequately and designed physically to accept and monitor acutely ill persons with a mental illness once the emergency room releases them after 48 hours if they remain acutely ill.

There are communication issues between security and medical at the facility. When someone is sent on an emergency basis to the hospital after hours that information is not relayed in a timely fashion to the medical department. In addition, the list of who was sent out from the facility is not accurate according to the medical director. The medical service must depend on the log from transportation, which currently is being provided at the end of each month by security.

Currently, emergency requests are completed within 24 hours and routine within 48 hours. Access is dependent on the availability of patrol rovers. When there is an urgent need the staff can call the warden to obtain a rover.

RECOMMENDATIONS:

1. Suggest a policy that is highly detailed and provides a well delineated list of staff responsibilities to emergency response.
2. Facilitate an emergency transportation system. 3. Train staff in CPR and schedule CPR-certified staff during hours when medical staff is
unavailable. 4. Stock the following essential equipment in a secure location and train staff on use:
respiratory barriers, Ambu bags, and defibrillators. 5. Schedule accordingly so there is Correctional staff available to provide non-ambulance
transportation to an off-site healthcare facility.

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: Noncompliance

MEDICAL FINDINGS: With regard to the timely referral for specialty care and procedures, the following elements should be utilized to promulgate the policy and procedure.

1. Prior to an order for a specialty consultation or procedure, there should be a progress note in the record indicating the basis for the need for such services.
2. Once the order is written, it should be received by a scheduler who schedules the appointment within 30 days or less.
3. The day before the appointment is to occur, custody must be informed so that they can prepare the escort resources necessary for the service to be obtained.
4. If the service is cancelled by the offsite service, or because of lack of custody, it must be rescheduled as soon as possible.
5. At the time of the progress note, the clinician should be describing the service to the patient in order to avoid ordering something that would later be refused.

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6. When the patient returns from the offsite, custody must bring the patient to the medical

staff, who can determine whether the offsite service report is available. If it is not, they

must contact the offsite service and have it faxed or scanned and sent.

7. When the nurse reviews the report, they must determine whether there may be any urgent

orders, in which case the physician must be contacted for such orders.

8. Once the report is available, the patient should be scheduled to be seen by the Medical

Director or designee so that there can be documentation of a discussion with the patient

regarding the findings and plan. All of these elements must be part of the policy and

procedure.

RECOMMENDATIONS:

1. Use the above elements to construct an offsite service policy and procedure. 2. Contact the Monitor or his team if any technical assistance or consultation is needed.

f.(vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above

ASSESSMENT: Noncompliance

MEDICAL FINDINGS: Overall, follow-up care was found inconsistent or non-existent. Followup requirements are described in each service area.

RECOMMENDATIONS: See above

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We have not been provided documents regarding the intoxication and detoxification policies and procedures and/or guidelines. The intake screen is the place where the program makes its initial determination about the liability related to whether either intoxication or detoxification are relevant issues. This requires that a more detailed substance history is obtained. We will work with the staff to enhance the intake medical screen so that critical information is obtained at the time of the intake screen. Critical information includes the duration and volume of substance use, the most recent use, any history of withdrawal symptoms or hospitalizations, all of which can be utilized to determine the risk. In addition, the Medical Director must develop protocols at a minimum for alcohol, benzodiazepines and opiates that include both monitoring, usually performed by nurse staffing, as well as treatment. The monitoring by the nurses should include a scoring methodology, above which requires contact with the physician. We will work with the Medical Director and nursing staff to insure these elements are created.

RECOMMENDATIONS:

1. Develop policy and procedure and guidelines beginning with intake screening and leading to protocols for monitoring and treating each of the major common substances.
2. Contact the Monitor or his staff for consultation and/or technical assistance.

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h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We reviewed two documents, one labeled “Infection Control Activities,” and the other labeled “Infectious Disease Management.” The first document, Infection Control Activities, begins with a description of universal precautions. However, it does not provide the basis for the universal precautions. The basis of universal precautions is the assumption that all bodily fluids are potentially infected and therefore precautions have to be utilized when dealing with them. The infection control activities policy should begin with that statement, and then the application of the policy flows logically. The infection control activities policy also describes training of inmates to perform cleanup activities when bodily fluids soil items, and yet we have not seen any training materials that would suggest the inmates are adequately trained. There is a section that deals with post-exposure prophylaxis that appears to be consistent with Centers for Disease Control recommendations. There is also a section on surveillance activities, which should be reported on a quarterly basis to the quality improvement committee. Such a report should include not only the incidence of sexually transmitted diseases, HIV infections, hepatitis and MRSA and food poisoning but also sanitation and sterilization activities in the dental program along with post-op infection rates in the dental program. The infectious disease management program and policy need some adjustment, particularly with regard to tuberculosis testing and treatment. As an example, under tuberculosis testing and treatment, number 3 states, “Inmates with signs and symptoms of potential infections will be placed on respiratory isolation until his or her PPD is read.” If patients have signs and symptoms of active tuberculosis, they must have a chest x-ray as soon as possible to rule out active disease. This is independent of the skin test result. In addition, it indicates that patients with a history of prior positive skin test will obtain a chest x-ray and will remain in respiratory isolation and protective mask until the x-ray results are available. This is not necessary. Patients with a prior history of positive PPD should be queried regarding TB symptoms. If in fact the query is completely negative, there is no need for isolation until the chest x-ray is completed. Therefore, the infectious disease management policy does require some additional modifications.

RECOMMENDATIONS:

1. Work through the Monitor and his staff for consultation and/or technical assistance.

i. Adequate suicide prevention, including:

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: The facility practice regarding suicide watch does not comply with the policy presented for review. The mental health staff is unaware of any suicide watch in the facility since March 2013. Yet, in reviewing the officers’ log for L unit, an individual was

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identified as being on suicide watch on June 24, 2013. This person was never referred to mental

health by a behavioral checklist. No suicide risk assessment tool has been implemented.

RECOMMENDATIONS:

GGACF needs to develop a communication system that is timely and reliable for notification regarding inmates placed on suicide watch, behavioral referral requests, and intake referrals.

(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: As mentioned elsewhere in the body of this report, despite a policy outlining how suicide watch should be documented and at what frequency, the officer logs in no way reflect that practice The facility currently is thinking of retrofitting a smaller group holding cell into a suicide prevention cell because there are no cells within the housing units that would meet qualifications as a suicide resistant cell. We were told that when somebody is on suicide watch they are kept in their cell under constant observation. However, review of security logs did not support that information.

RECOMMENDATIONS:

While the current policy does define the frequency of watch, it has not been approved and implemented. The policy needs to be put into effect.

(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: There is no suicide risk assessment instrument available. Mental health is not always notified of the suicide watch and therefore a 24-hour time frame cannot be met.

RECOMMENDATIONS:

1. A practical policy and procedure needs to be implemented and monitored for compliance. 2. It is suggested that the service considered developing a standardized progress note that would
include a suicide risk assessment and a suicide watch treatment plan.

(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: Pending next inspection

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MENTAL HEALTH FINDINGS: We were told that cut down tools are located in the officers

control center. The monitoring team did not inspect for cut down tools, however.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: Noncompliance


MENTAL HEALTH FINDINGS: See the report of findings by Mr. Ray.


(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: Noncompliance


MENTAL HEALTH FINDINGS: See the report of findings by Mr. Ray.


(vii) availability of suicide resistant cells;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: Currently there are no suicide-resistant cells within the facility. The warden is considering converting a holding cell in the intake area into a suicide resistant cell.

RECOMMENDATIONS:

1. Given the difficulty expressed by medical staff in obtaining the patrol officer to escort them to the intake area, it is unlikely this location would facilitate compliance with the proposed policy that requires daily assessment by mental health.

2. In addition, most policies will require nursing rounds each shift as well as administration of medication as ordered.

3. Retrofit cells designated for suicidal inmates to be suicide proof. Consult with Mr. Ray about retrofit options and specifications as needed.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: We were informed that the facility places all inmates on suicide watch on constant observation due to the absence of the suicide resistant cell. However, the one log entry indicating an inmate was placed on suicide watch by security not only failed to document the watch every 15 min., but the only entries in the log for the entire unit’s activities was recorded by the unit officer. In addition, the log is maintained in the officers’ bubble, which

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would mean that constant observation would have to be broken for the second officer to enter

the bubble and make an entry every 15 min.

Inmates are currently housed on L-unit for monitoring. Our observation of the cells on that unit indicated very impaired visibility through a small window screen in the door that would make it unlikely an officer could conduct an adequate constant observation of a person in that cell. The height of the window and the food port are such that to carry out constant observation would require a person to either stand constantly or sit in a very crouched position in order to attempt the observation. Neither is desirable and nor likely to occur as required by the current policy draft.

RECOMMENDATIONS:

1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
2. Renovation of an intake cell may be the only immediate alternative. If this environment is utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.
3. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15 minute watches.

(ix) procedures to assure implementation of directives from a mental health professional regarding: (1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: Cells used for suicide prevention are in the segregation unit and are at best hazardous due to poor visibility, lack of suicide resistant measures, inadequate security staffing to provide the necessary observation, no evidence of nursing involvement in the monitoring of individuals on the high level of watch, and no evidence of mental health intervention while on watch.

Staff informed me that when they are notified of someone being placed on suicide watch the mental health counselor will arrange to see the patient. There is no written communication from mental health back to security regarding what property the inmate can have and the frequency of observation required. No suicide risk assessment tool has been implemented. The mental health staff are not following any formal guidelines for suicide watch follow-up. There is no systemized involvement of mental health in evaluating inmates prior to placement in segregation, assessing whether there are mitigating circumstances secondary to the presence of a serious mental illness, enhanced support by mental health while people with serious mental illness are housed in segregation, no systemized review of competence to refuse treatments by the most seriously mentally ill inmates, and no programming available to aid the inmate in advancing off of segregation into general housing.

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In reviewing the only case of someone placed on watch in the past nine months, it is obvious

that there was no medical or mental health involvement in the case. Mental health was not

notified of a person being placed on watch and therefore was unavailable to assess them and

determine whether Cells used for suicide prevention are in the segregation unit and are at best

hazardous due to poor visibility, lack of suicide resistant measures, inadequate security staffing

to provide the necessary observation, no evidence of nursing involvement in the monitoring of

individuals on the high level of watch, and no evidence of mental health intervention while on

watch, they could be removed from watch. The officer that initiated the watch only conducted

30 min. checks during their shift. On the following shift no safety checks were performed. In

addition, on the following shift safety checks were documented once every hour. There after no

further checks were done. The current method of managing someone on suicide watch seems

chaotic and idiosyncratic.

RECOMMENDATIONS:

1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.

2. Renovation of an intake cell may be the only immediate alternative.

3. If this environment is utilized then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.

j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We have requested a copy of the staffing plan to be implemented on October 1, 2013, which has not been provided. Under the current arrangement, there is supposed to be a Medical Director onsite at least two days per week, but staff indicates that this is not usually happening. In fact, they also have difficulty accessing the Medical Director for urgent/emergent problems. It is a requirement that we have to know what staffing is available onsite. We believe that the Medical Director should be seeing patients at least two days per week. We are aware that a physician assistant sees patients on Saturday and Sunday and an internist/cardiologist is seeing patients on Fridays. If the Medical Director saw patients Tuesdays and Thursdays, there would never be two days in a row without an onsite clinician. We are also aware that the plan is to have nursing staff available from 8:00 a.m. to midnight, seven days per week. It is our belief that if that coverage is made available, and a nurse on call could perform midnight to 8:00 a.m. intake screens, which seem to occur about four times per month, the intake process would be completely based on health care staff screening. If that screening results in a disposition that resulted in a plan for patients to be seen based on urgency, then no patient would go without being seen for more than a day. We would like to see the staffing plan that has been proposed in the current budget request and we would like to see the plan to utilize those resources. It is our belief that the staffing for medical services may be close to where it needs to be. However, that cannot be ascertained without the necessary documents. We would be happy to help with an initial staffing analysis.

RECOMMENDATIONS:

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1. Provide the staffing document to the Monitor along with the duties assigned to each staff member.

MENTAL HEALTH FINDINGS: This document was not provided to the Monitor or the team.

RECOMMEDATIONS: Refer to Mr. Ray’s assessment, findings and recommendations pertaining to staffing analysis recommendations.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

MENTAL HEALTH FINDINGS: Refer to Mr. Ray’s assessment, findings and recommendations pertaining to staffing analysis recommendations.

RECOMMEDATIONS:

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: This element is probably intended to describe a quality improvement program. We were not provided evidence of any policy and/or quality improvement activities. We will work with local staff to develop a policy and program that facilitates improvement and meets NCCHC requirements.

RECOMMENDATIONS: TBD

MENTAL HEALTH FINDINGS: There is not an operative quality improvement committee and no quality improvement activities at the time of this to work.

RECOMMENDATIONS: GGACF Mental Health Department, under the supervision of the Medical Director needs to develop a schedule of quality improvement activities and systems to measure the clinical processes and their outcomes. Currently there is a monthly report, which was not provided for our review, to the Health Services Administrator. From speaking with the Mental Health Coordinator, it appears that certain quality assurance activities may be occurring that track some of the statistics monitored through logs and case lists. We were provided no document evidence supporting this claim. This will be more closely assessed during the Dec 2013 visit.

m. Adequate dental care;

ASSESSMENT: Not assessed. However, Mr. Ray found the dental exam room in disarray, unsanitary, and unsecure with cabinets open exposing medications and dental instruments that could easily be converted to contraband by inmates.

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FINDINGS: To be assessed at next visit.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We have not been provided any policy or procedure dealing with morbidity or mortality reviews. Until the issue of clinical ownership of the program is solved, this element cannot be addressed. In a morbidity or mortality review, the first step would be to construct a care chronology based on the patient’s interactions with the health care program, starting with intake. This chronology is designed to be purely descriptive of the sequence of health care occurrences that are documented in the health care records. After that chronology is constructed, it would behoove the territory to utilize an external reviewer to review and critique the care provided. It is counterproductive to have clinicians review their own work. Utilizing both the chronology of care and the medical record and discussing the case with staff should allow the external reviewer to construct a final clinical summary.

RECOMMENDATIONS:

1. Utilize the above to construct a mortality and morbidity policy. 2. Contact the Monitor and his staff for any consultation or technical assistance.

MENTAL HEALTH FINDINGS: There is currently no Morbidity and Mortality Committee. The Health Services Administrator is trying to address this but has found it difficult to identify times during which the medical director is available. As of now there is no mortality review and no mortality report generated by the medical services.

RECOMMENDATIONS:

Policy and procedure modeled from national standards should be developed and implemented at the facility.

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: Noncompliance.

MEDICAL FINDINGS: We saw no policy on this nor were we provided any evidence of it or of reasonable practices that ensure such rounding takes place. It does not appear, however, possible simply due to mental health staffing levels. We would strongly encourage drafting the policy based on NCCHC standards utilizing the compliance indicators and discussion sections.

RECOMMENDATIONS: TBD

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MENTAL HEALTH FINDINGS: that no mental health isolation/segregation rounds are

conducted at the facility.

RECOMMENDATIONS:

It is recommended that a policy be developed that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: No policy and procedure exists addressing a review process for mental health and medical clearance of inmates with serious mental illness being placed in isolation. There are no policies regulating the amount of out-of-cell time provided to special needs prisoners in segregation. Mental health staff does not perform segregation rounds. Despite the absence of policies and procedure, this practice actively violates the Agreement and any reasonable standard of care.

RECOMMENDATIONS:

1. It is recommended that a detailed policy be developed to address this issue that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: There is no policy or procedure requiring participation of mental health staff in the disciplinary process and as a result there currently is no input. Regarding placement in segregated environments, it is unclear whether a medical and mental health clearance is done for such a housing assignment. We were also told in a meeting with the Health Services Administrator and Medical Director that medical sees everyone when there has been a use of force, and if severe enough, after hours the inmate will go to the emergency department. The medical department has to rely on the security emergency department log to determine if anyone has been taken to the hospital.

RECOMMENDATIONS:

1. A policy and procedure should be established to allow for an assessment by mental health of incidents potentially resulting in disciplinary sanctions in those inmates on the mental health caseload.

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2. Input into the disciplinary process should be written and periodically monitored through a

quality improvement process to determine if the disciplinary officer is collaborating with

mental health staff in adjusting their sanctions when there are mitigating circumstances

secondary to the person's illness.

3. Currently, there is no retrospective of use of force as part of the medical quality improvement

process but such a process should be put in place.

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;

ASSESSMENT: Noncompliance

MEDICAL FINDINGS: There are plans to create new space, which we have walked through. The new space will allow for so-called inpatient beds for monitoring patients as well as an outpatient area for both medical and dental patients. The new space is a substantial improvement over the existing available space, which because of the design makes it more difficult to efficiently utilize while insuring adequate privacy. We have not yet seen specific architectural drawings, but our discussions with leadership staff suggest that the conceptual plans could be a significant advancement. We certainly remain available to offer any assistance in redoing the clinical space.

RECOMMENDATIONS:

1. Send the Monitor the plans as soon as a draft has been developed.

MENTAL HEALTH FINDINGS: Both the mental health coordinator and the psychiatrist see patients in the medical clinic in sound private settings. There are no private interviewing spaces on the segregation units or in the female housing units, which may create barriers to access since the entire compound would need to be shut down to enable movement of these persons.

RECOMMENDATIONS:

1. The facility needs to explore what barriers may exist to providing frequent and adequate services to inmates in special housing in sound private settings.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan development and implementation;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: Medical services and mental health services at the current time lack any continuous quality improvement program, which greatly impedes their ability to self-monitor, develop, and implement effective corrective action plans or program development.

Treatment plans were only found in a few records. In most circumstances the plans were unrealistic in that they assigned activities such as educational classes and mental health groups that were not provided at the facility. The plans also recommended certain frequency of followup by mental health or psychiatry, which was not even approximated in the actual practice.

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RECOMMENDATIONS:

1. Treatment plans should reflect the actual services rendered as opposed to idealistic suggestions.
2. Suggest the following template for crafting the inmate’s plan of care:

THE INDIVIDUALIZED TREATMENT PLAN:  Treatment plans should follow a problem-oriented format.  Problems listed should be descriptive and meaningful with measurable goals.  The plan should indicate time frames to complete the above goals.  Planned interventions are documented  A date of the scheduled review of the individual treatment plan will be listed on the chart.  All members of the treatment team in attendance shall sign the treatment plan and indicate their professional degree.  A notation by the team will also indicate progress made towards previous goals.  The patient shall also sign the treatment plan indicating participation and awareness of the established goals.

(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: Currently there are no programs in mental health for prisoners with serious mental illnesses. The only services currently provided are occasional contacts with the Mental Health Coordinator and infrequent visits with the psychiatrist with lapses between visits of up to a year.

RECOMMENDATIONS:

1. GGACF Mental Health Department should conduct a needs analysis and make recommendations to the Health Services Administrator, Medical Director, and Bureau of Corrections regarding required staff and other resources necessary to provide adequate services in both general population and segregated areas.
2. Comparable programming should be provided for female inmates and detainees as well.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: Noncompliance

MENTAL HEALTH FINDINGS: GGACF lacks sufficient psychiatry hours to provide adequate oversight of this requirement (although we were not provided with the staffing schedule, it appears that GGACF has fewer than eight hours per week of psychiatric time) to perform comprehensive initial psychiatric assessments and chronic care follow-ups at clinically

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necessary frequencies. There was a surprising underrepresentation of the treatment of mood

disorders on the caseload and women.

A continued finding of dependence on long acting injectable neuroleptics rather than oral agents seems a variance from customary practice. This may be a clinical choice designed to increase medication compliance. There was no evidence of a policy that addresses the use of emergency and involuntary medication.

RECOMMENDATIONS:

1. Improved methods of practice and a staffing and programs analysis needs to be completed.

2. GGACF may wish to consider adding telepsychiatry to increase the availability of psychiatric resources by contracting with psychiatrists on the mainland who obtain licenses in the USVI. Of course, the latter would require capital investment in equipment and the development of a policy and procedures that would structure this type of service.

3. A reasonable informed consent form should be developed and patient education documented.

4. A policy addressing the use of emergency and involuntary medication should be developed.

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

ASSESSMENT: Noncompliance
 FINDINGS: See assessment of findings of Mr. Ray regarding training provision below.
 RECOMMENDATIONS:


(v) ceasing to place seriously mentally ill prisoners in segregated housing or lockdown as a substitute for mental health treatment.

ASSESSMENT: Non-Compliance

FINDINGS: Currently, seriously mentally ill inmates are housed in segregation and by policy may be placed there until their conditions are stabilized. However, the decreased capacity for observation, lack of availability of potable water in their cells, hot conditions with poor ventilation, absence of mental health rounds, absence of any structured therapeutic programming places these individuals at risk for serious life threatening physical illness and behavioral decompensation.

RECOMMENDATIONS:

1. GGACF should consider alternative housing and as recommended above, develop a plan to introduce adequate programming for this population.
2. Increased out-of-cell-time and life skills activities should be considered.

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3. It is also recommended that all inmates with a serious mental illness should be seen in a

confidential setting at a minimum of at least monthly by a psychiatrist and monthly by a

mental health counselor.

4. Weekly mental health rounds are also required for this population.

5. Suggest the following template for progress monitoring of inmates in segregation (may also

be used for general population):

THE GENERAL POPULATION AND SEGREGATION MENTAL HEALTH PROGRESS NOTE

SUBJECTIVE/OBJECTIVE  The subjective portion of the note should contain descriptions of any current problems, the inmate's level of activity and function, programs participation, job assignments, family issues, and any other pertinent information.  Documentation of any reports of medication issues or side effects  A brief mental status examination unless the template does not require that information.

ASSESSMENT  A DSM (current version) diagnostic list as well as an estimate of the current global assessment of function  An assessment pertinent to the data documented

PLAN  A clinically appropriate follow-up appointment  A description of the recommended, if any, appropriate psychosocial intervention and an estimate of the timeframe to complete such treatment. For example, "The inmate will be seen weekly for four visits focusing on cognitive behavioral therapy for bereavement counseling."

ENVIRONMENT OF CARE  As a general rule, all psychiatric and counseling encounters, including face to face
encounters in response to a sick call request and pre-segregation interviews, should be conducted in an area guaranteeing sound privacy.  Only segregation rounds may routinely be conducted at the cell front or in a day room area.  Variance may be permissible during extended states of lock down, if the inmate is deemed to lack behavioral control, and other crisis situations.

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VI. FIRE AND LIFE SAFETY

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:

a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;

ASSESSMENT: Noncompliance

FINDINGS: General Emergency Plans and Procedures were provided following the onsite assessment. However, an examination of these documents found no life-fire safety program, policies or procedures as indicated in VI.1 above. Therefore, no written life-fire safety program has been reviewed by the local Fire Marshal.

This assessment process involved inspection of inmate housing, medical, kitchen, storage areas, workshops, and administrative areas. A lengthy interview was also conducted with GGACF fire safety officer, who seemed well-qualified and committed to an effective fire safety program.

Officials report that two (2) fire emergencies occurred in the past 12 months. GGACF does not have a functional fire detection or suppression system in place at this time. The fire suppression system (sprinklers) in the housing area is inoperable; inmates are allowed to use the sprinkler heads to anchor clotheslines for drying apparel and linens. Access to certain living units (X Pod) cell doors were padlocked i.e., X pod. Comprehensive fire drills for housing units or other occupied structures are not conducted; quarterly fire drills must be conducted of all facility areas and on all shifts.

Additionally, housing unit and cell inspections revealed exposed electrical wiring, some showing burn traces on receptacles indicating electrical shorting and fires occur and standing water near shower areas and in certain cells. Many inmate cells presented with clutter of combustible materials, which should be removed. Interviews with housing unit staff revealed that they do not know how to operate fire control panels and would not know how to effectively respond under fire or emergency conditions. The fire control panels show no test/maintenance logs, which is required for consistent inspection of operability. The workshop and kitchen areas were inspected for fire safety conditions. There appears to be adequate operable fire extinguishers located strategically. All extinguishers inspected show current inspection tags and pressures. However, the woodshop presented with a considerable amount of combustible wood bi-products that should be kept clear from ignition sources. There appears to be a lack of breathing devices (SCBA, etc.) for staff to safely and expeditiously respond to fire events. Although the kitchen is scheduled for renovation and new equipment, I found exposed electrical connections for some equipment, and potentially serious burn hazard related to the height of an open-flame stove. This stove was boiling a 5-gallon pot of liquid on an open flame;

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the position and height of the stove would make it very difficult to remove the pot safely and

should be corrected.

Overall, the fire safety official I interviewed seemed to be a well-qualified expert in fire safety. He seemed cognizant of related provisions in the Agreement, how to comply with all requirements, and fully intends to do so. It is, therefore, essential that Territory and GGACF officials provide the necessary support and resources needed to comply with this provision.

RECOMMENDATIONS:

1. Develop, train, implement, and evaluate a comprehensive life-fire safety program that includes all policy, procedure, resources, equipment, training, monitoring, and system/programming testing components.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install SCBAs or an appropriate alternatives at all locations where staff would need to
search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate
supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security. 7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program. 8. Supervisors should conduct routine, schedule and unscheduled physical inspections of occupied structures taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action. 9. The fire inspection program must be clearly detailed in fire safety policies and procedures, and become a fundamental element of pre-and in-service training.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: Noncompliance

FINDINGS: Refer to previous findings.

RECOMMENDATIONS:

1. Refer to previous recommendations. 2. Consider purchasing fire safety program software from NFPA and/or the American
Correctional Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

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c. Comprehensive and documented fire drills in which staff manually unlock

all doors and demonstrate competency in the use of fire and life safety

equipment and emergency keys that are appropriately marked and

identifiable by touch;

ASSESSMENT: Noncompliance

FINDINGS: Refer to previous findings for this provision. Additionally, there are no formal policies or procedures regarding an emergency key system, which is a critical component of any credible correctional fire safety program. An effective emergency key system ensures rapid access to emergency keys to evacuate people from structures where fire threats are present or expected.

Padlocks continue to be used to secure inmates in some cells and housing units. For example, the door to the women’s dorm was chained shut and secured with a padlock. The women there told us they are often left unattended. According to them, one night there was a storm and the cells were flooding. One woman had exposed wiring in her cell and there were sparks flying. The women were screaming for someone to help them. One of the women finally got the attention of a prisoner worker, who ran and got help. This is an extremely dangerous practice and places inmates and staff risk of harm.

Staff must be well-trained and drilled on the use of emergency keys use to ensure they are consistently ready and able to manually unlock all doors under any circumstance involving real or potential threats to life safety. All staff must be competent and proficient in performing these functions. Additionally, all locking mechanisms, manual and electronic must be regularly inspected and tested to ensure reliable operability. All inspections and testing must be documented, recorded, and records maintained. Timely repair and/or replacement of keys/panels/electronics must occur.

I found no evidence of an onsite, competency-based fire safety training or testing program. Competency-based training and testing must be provided within the environments where the life-safety response actions will or may occur. This means that staff must be trained on campus and under simulated emergency response conditions involving realistic scenarios, conditions, actual equipment, etc. The fire safety officers should oversee this process and involved community responders as needed to ensure comprehensive coordination of life safety events.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above.
Train and drill staff as discussed on system use. 3. Develop emergency key and locking mechanism inspection and reporting system as
discussed above. 4. Implement competency-based staff training as discussed above. 5. Exercise fire safety program using onsite, scenario-based drills; include community
responders in exercise planning and exercise events. 6. Send the training officer and part-time fire safety officers to the National Fire Institute,
National Emergency Training Center, Emmetsburg, MD for additional training.

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d. Regular security inspections of all housing units that includes checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell; and (ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: Noncompliance

FINDINGS: As previously stated.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems.

e. Testing of all staff regarding fire and life safety procedures;

ASSESSMENT: Noncompliance.

FINDINGS: As previously stated.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision.

f. Reporting and notification of fires, including audible fire alarms;

ASSESSMENT: Noncompliance.

FINDINGS: As previously stated.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision.

g. Evacuation of prisoners threatened with harm resulting from a fire;

ASSESSMENT: Noncompliance.

FINDINGS: As previously stated.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: Noncompliance.

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FINDINGS: As previously stated.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: Noncompliance

FINDINGS: As previously stated, and as indicated in current medical/mental health program deficiencies in resource levels, policies and procedures.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 5. Qualified medical staff should participate in the development of fire program training topic that involved burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.

j. Control of highly flammable materials.

ASSESSMENT: Noncompliance

FINDINGS: Refer to previous findings regarding contraband, clutter, combustible materials near fire ignition sources, wiring, water, etc.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. Develop a formal writing “Combustion Control and Prevention Plan” component to the comprehensive fire safety program that includes regular and documented inspections combustible materials (solids, liquids, gases) for all areas and structures. Maintain a current inventory and tracking report of materials and locations, corrective actions and mitigation efforts.

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VII. ENVIRONMENTAL HEALTH AND SAFETY


Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

GENERAL COMMENT: The following is a list of specific findings during this assessment.

1. There is no hot water in the housing units, which creates serious health and sanitation risks for staff and inmates.
2. Many sinks in the cells were inoperable. 3. Some of the toilets did not flush properly. 4. Inmates are allowed to wash their clothes and linens in the toilets and/or sinks, then hang
them to dry on clothes lines anchored to inoperable fire sprinklers in their cells. 5. Standing water was found in housing units and cells. Inmates and staff state that housing
units will flood during heavy rains. 6. Several shower heads were broken, shower stalls were covered with mold, as were
ceilings and cell-block walls. 7. Mold was thriving on ceilings, maintenance closets, pipe chases, recreation areas, areas
in the kitchen. 8. Housing unit temperatures were very high, which, combined with high humidity can
promote and spread infectious diseases, exacerbate certain chronic medical and mental illness, promote inmate frustration and violence, and dissuade correctional staff from leaving air-conditioned control rooms to conduct housing unit inspections, rounds, and security checks. High temperatures also pose very serious health risks to inmates on certain psychotropic medications current being administered to inmates. 9. Food trays being filled in the kitchen with food were still drying after being washed. Overall sanitation in the kitchen was poor and in need of regular deep cleaning. 10. Housing unit water is essentially undrinkable and inmates are unable to access water when locked in their cells without the assistance of the housing unit officer. I was told by inmates that there are times when officers will not respond to requests for water or are away from control rooms for extended periods. This is evidenced by officer logs where officers have recorded leaving their units completely unattended to take breaks and/or where no relief officer was available. Unit logs also report a practice of “last call for water”. This practice evidences that inmates do not have consistent access to potable drinking water. 11. Many of the inmate mattresses appeared old, tattered, and filthy. Inmates and staff stated that mattresses are not routinely cleaned or disinfected during and between uses. Linens are allowed to be washed in toilets and hung to dry as previously described. 12. There is no written formal sanitation inspection and/or infection control program. 13. Medical and dental exam rooms were filthy with what appeared to be dried bodily fluids on pans that held equipment for procedures. Trash cans were full. Sharps containers were full. This environment, overall, was in serious need of deep cleaning and maintenance.

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14. The facility appears inadequately staffed to provide adequate monitoring, oversight, and

response to routine or emergency sanitation conditions or maintenance issues.

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;

ASSESSMENT: Noncompliance

FINDINGS: There is no formal written facility sanitation, housekeeping, and/or hygiene plan or program. Policies and procedures related to this provision are incomplete, difficult to find, and scattered illogically throughout inmate handbooks, rules, and regulations.

RECOMMENDATIONS:

1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.

b. Adequate ventilation throughout the facility;

ASSESSMENT: Noncompliance

FINDINGS: GGACF officials have placed “swamp coolers” in housing units for cooling and ventilation, which is a positive effort but ineffective in controlling high temperatures, high humidity, and preventing transmission of allergens and infectious pathogens. The cells remain very hot and stuffy despite access to outside air though broken windows and/or other wall penetrations. Several inmates, included those with serious and chronic medical and mental health problems, described the heat and airflow as “inescapable”, “can’t breathe”, or “torturous.” Several inmates locked in segregation cells appeared to be very lethargic, which is symptomatic of heat exhaustion and/or dehydration. These temperature levels combined with limited access to water can result in serious harm or even death and must be mitigated without delay.

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RECOMMENDATIONS:

1. Timely complete an air quality assessment performed by a qualified provider. Implement necessary improvements that reduce housing area temperatures and increase air flow.
2. Ensure inmates have constant access to drinkable water. 3. Medical and mental health staff should monitor all inmates for heat and airflow-related
health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions. 4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors. 5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions. 6. Ensure that adequate amounts of drinkable water is always available to inmates. 7. Medical and mental health professionals should closely monitor inmates being administered medications that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: Noncompliance

FINDINGS: Lighting throughout the external and internal security perimeter, housing units and cells, and other buildings need repair. Some simply need bulbs replaced, others require electrical work. In general, the poor lighting conditions on this campus and within buildings, especially housing units, creates serious safety and security risks for staff and inmates and must be addressed immediately and consistently.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and
internal illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance.

d. Adequate pest control for housing units, medical units, and food storage areas;

ASSESSMENT: Partial Compliance

FINDINGS: There is no formal written pest control/mitigation plan currently. Environmental sanitation and air conditions are conducive to insect problems and infestations. Athough I did

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not observe any pest infestation problems during this assessment, medical staff did report and

showed a photograph of a “bug in a meal tray.” I will reassess this condition at the December

assessment.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. This provision will be assessed more closely during the December assessment.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: Partial Compliance

FINDINGS: Several housing units/cells and staff washrooms did not have hand soap and/or hand sanitizers. I did observe some cleaning supplies in housing units being used by inmates engaged in cleaning floors and shower areas. However, it is unknown whether inmates are trained in the proper use and storage of those chemicals. Based on bacterial odors emitting throughout housing unit areas, the high presence of mold and mildew, and grime on cell doors and walls, deep and more regular cleaning is required to improve unsanitary conditions.

Not all inmates had personal hygiene products in their possession and some stated that they were not provided any. Consultation with housing unit staff indicated that inmates have ready access to personal hygiene supplies upon request..

RECOMMENDATIONS:

1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Maintain an adequate supply of these personal care items in control pods or housing
units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in
their cells and living areas.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: Noncompliance

FINDINGS: There is no formal infection control plan or biohazard control plan. There are no specific comprehensive written policies or procedures addressing the topic. This is further evidenced by a foul odor of bio waste emitting from certain cells and trash receptacles in the medical clinic. Additionally, medical/dental clinic exam rooms had used syringes setting on counters, blood-stained gauze in trash cans, and full sharps containers. I observed no presence of designated biohazard refuse bags or educational posters providing safety/heath information for staff or inmates about this topic.

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RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for bio-hazard safety and exposure control; B. Written and enforced procedures and protocols for bio-hazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all bio-waste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a bio-hazardous control program that involves regular inspections of all potential contamination areas.
2. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.

g. Mattress care and replacement;

ASSESSMENT: Noncompliance

FINDINGS: As previously stated.

RECOMMENDATIONS:

1. Refer to previously discussed sanitation recommendations. 2. Consider replacing all mattresses with those that are more bacteria-resistant. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and
contraband, cleaned and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance
requirements.

h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;

ASSESSMENT: Partial Compliance

FINDINGS: Bulk cleaning supplies and chemicals are stored in the maintenance building and warehouse. An inspection of the maintenance buildings found this stock to be well organized with MSDS posted. Additionally, these areas are typically locked but I observed no inventory logs in each room storing chemicals. Additionally, there is no documented formal training

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program for inmates in the proper use of these supplies or chemicals. I found no incidents

involving inmate misuse in handling of cleaning chemicals in the Unit or Incident logs

examined. Maintenance supervision staff appeared attentive to inmate workers, which suggests

that supervision is likely adequate. However, storage spaces were not vented and may need to

be.

RECOMMENDATIONS:

1. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
2. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: Noncompliance

FINDINGS: Refer to previously discussed issues involving sanitation, clothing, and linens. I will closely assess the laundry area during the December assessment.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.
2. Develop specific policies and procedures for handling, containing, and washing contaminated clothing, linens, and mattresses.
3. Consider replacing all wood laundry carts made of non-absorbing materials that can be sanitized and completely cleaned. Discontinue the practice of moving laundry on carts that have not been cleaned and sanitized.
4. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing should be exchanged with clean items twice per week at minimum, sheets and towels once per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health.
5. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets.
6. Staff and inmates involved in the laundry work progress should be properly training and supervised.
7. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food; and

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ASSESSMENT: Noncompliance

FINDINGS: I inspected the kitchen areas, food preparation process and methods, and interviewed the food service supervisor. I was advised that kitchen flooring and an oven were scheduled for replacement. The food service supervisor stated that she specifically came to the facility that day for this inspection but was suffering from “pneumonia.” I found that very strange and quite unsettling considering the need to protect the kitchen environment, other staff and inmates from infectious pathogen exposure.

The kitchen, in general, seemed unsanitary and in need of deep cleaning and repair. It was reported that only one of four ovens operate, hood vents have occasional electrical problems, bathrooms were unsanitary and without toilet paper, and the soap or water for hand washing. The utensils room was unlocked with removed items but there were no “chits” replacing taken items to track their whereabouts. Major cooking equipment, functional or not, seemed greasy and vent hoods appeared to have long standing layers of grease and dust on tops and underneath. One of the two freezer/coolers is not operating and the cooler that is operational registered an internal temperature of 48 degrees Fahrenheit. Inmates were busy preparing food and several filled food trays recently washed had not completely dried. Although not an infestation, several flies were observed on recently cooked food and filled food trays. None of the inmates or staff seemed to notice the insects and/or give their presence much concern. Additionally, there are no temperature logs maintained for the dishwasher, cooking, food distribution, or refrigeration, all of which are expected and standard correctional food service program practices. There is no system in place for conducting regular health screening of inmates and staff assigned to the food service program. There is no formal inmate kitchen worker training program nor any comprehensive food service program policies and procedures manual to govern the program.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with nationally recommended allowance for basic nutrition; F. Prohibitions of using food as a disciplinary measure; G. Involvement of independent outside sources to verify food service facilities and equipment meet government safety codes; H. Prescribes regular cleaning schedules including routine deep cleaning; I. Provide written utensil control methods similar to those used by the tool shop; J. Accident prevention program; K. Personal and environmental sanitation requirements;

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L. Food temperature monitoring and records keeping;

M. Adequate health protections for all staff and inmates including health screens and

prohibitions against working in the kitchen when ill;

N. Requirements for daily monitoring of staff and inmate cleanliness practices, and

that all bathrooms and wash basin are consistently supplied with antibacterial soap

and hot water;

O. All areas and equipment related to food preparation, distribution, and storage

require frequent inspection to ensure they are sanitary, operational, and safe;

P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit;

between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the

final rinse. The person conducting inspections should be a qualified food service

inspector;

Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit,

refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees

Fahrenheit or below, unless national or state codes specify otherwise;

R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit

and cold foods at approximately 41 degrees Fahrenheit;

S. Supervisory food service staff should monitor food service operations to ensure that

that cooking, cooling, and food temperatures and delivery meet established

requirements;

3. GGACF officials should review food service requirements promulgated by the

National Correctional Association and National Commission on Correctional Health

Care.

4. Develop a food service training program that includes inmate and staff training records

and ensure that all training is well-documented.

5. Policies and procedures developed should include controls for the use of caustic, toxic,

and hazardous materials used in the kitchen. Material Safety Data Sheets should be

posted conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: Noncompliance

FINDINGS: Refer to previous findings regarding sanitation and this provision.

RECOMMENDATIONS:

1. Refer to recommendations regarding sanitation and this provision. 2. Develop and implement a corrective action plan for that ensures inmates have
consistent and reliable access to safe drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;

ASSESSMENT: Noncompliance

FINDINGS: A formal training program appears to be under development, though formal written training policies and procedures regarding implementation of this Agreement either do not exist and/or were not provided. The Monitor met with a training program assistant and was provided a three-page document outline pre-service and in-service training provided to correctional officers as shown below:

PRE-SERVICE TRAINING Introduction to Law Enforcement (22 hrs.)
Rules, Protocols, and Administrative Duties (17hrs) Criminal Investigation (11hrs) Facility Procedures and Protocol (247hrs) Juvenile Procedure (4hrs) Officer Mental Health & Well Being (30hrs) General Topics (40hrs) Emergency Procedures (18hrs), note, Suicide Prevention is for 1hr Equipment Use (16hrs)

IN-SERVICE TRAINING No Hours Listed Policies and Procedures First Aid/CPR Sexual Harassment Suicide Prevention Gang Prevention Unarmed Self Defense

According to the training assistant providing information about the training program, preservice training is provided by a qualified local contractor. However, the assistant was unable to verify trainer credentials or produce training agreements between the Territory and the training organization. No curriculum was available for review at the time of this assessment but an officer “training manual” was provided and included several basic training topics appropriate for pre-service correctional staff, but much of the narrative was underdeveloped and spoke mostly to agency General Orders and Rules, Standard Operating Procedures – Employee Rules of Conduct, Code of Ethics, Dress Code, and Inmate Rules of Conduct.

RECOMMENDATIONS:

1. Written training policies and procedures should be developed and implemented to govern pre-service, in-service, and ongoing training or corrections and civilian staff.

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The following are a few recommended elements for training program policies and

procedures:

A. Training program mission statement, goals, objectives, and operating procedures; B. Written, understandable, and measurable; C. A training program written code of professional standards and ethics; D. Employees participate in formulation of policies, procedures, and practices; E. The training program is adequately staffed with qualified training and support
staff; F. There is a written organizational plan that depicts training program structure, lines
of communication and authority; G. Training records management and control; H. Descriptions and roles of agency, public, and private training agencies and/or
organizations involved in training development and implementation; I. Authorization and description of off-site training facilities; J. Regularly scheduled meetings between training leadership and agency leaders for
program coordination and management purposes; K. A system for monitoring training program methods, content, and outcomes; L. Training program funding and space; M. Training program role in staff recruitment, selection, training, re-training,
promotion, dismissal; N. Prohibitions against and consequences resulting from staff and student
misconduct related to training functions and activities; O. Adequate equipment and supplies are available to develop, prepare, administer,
and evaluate training program and services; P. Appropriate accommodations are available for disabled and/or impaired students; Q. Training curricula and plans are developed, evaluated, and updated based on a
valid assessment of staff performance that identifies current job-related training needs; R. Ongoing formal evaluation of pre-service, in-service, and specialized training program conducted and/or sanctioned by the agency; S. Adequate reference materials are available to program staff and learners; T. All courses provided include attendance records, lesson plans, instructor name, course evaluations, methods for demonstrating topic proficiency and test results; records of certificates or completion verification; U. Methods that protect the integrity of testing and assessment processes; V. Courses are based on competency-based curriculum supported by appropriate materials and course resources; W. All instructors are qualified to teach course topics; instructors teaching uses of force, first aid, weapons use, etc. are currently certified to instruct such courses; X. Use of force training includes non-physical, physical, and appropriate use of authorized weapons, force levels, justification, etc.; Y. Training topics, content, proficiency, and hours/weeks of training is established for pre-service, in-service, and specialized training; Z. Firearms training covers use, safety, and care of firearms and the legal and ethical constraints on their use. Training includes knowledge and performance, and is assignment specific (e.g. use of weapon in various settings, conditions, areas);

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AA. Chemical agent training covers the use and handling of chemical agents, as

well as the treatment of persons exposed to a chemical agent;

BB. Emergency responders are available to timely respond to training incidents

involving injury.

2. Training plans should be developed for all revised and new policies and procedures required under this Agreement. These plans should include methods for determining content proficiency as defined in this agreement. The use of pre and post tests and visual demonstration of applied topics should be used in measuring topic competency.

b. Pre-service training for all new employees;

ASSESSMENT: Noncompliance

FINDINGS: No pre-service training curricula or lesson plans were provided as requested. Preservice training has been provided by a third party contractor, but BOC is in the process of working to develop its own training program. I am unable to accurately assess compliance.

RECOMMENDATIONS:

1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.

c. Periodic in-service training and retraining for all employees following their completion of pre-service training;

ASSESSMENT: Noncompliance

FINDINGS: No training curricula or lesson plans were provided as requested. I am unable to 
 accurately assess compliance.


RECOMMENDATIONS:


1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.

ASSESSMENT: Noncompliance

FINDINGS: Training program policies and procedures were not provided to the Monitor as requested. Also no logs or programs were evidenced that would track who took training and no competency based assessments were provided.

RECOMMENDATIONS:

1. Provide the Monitor all training program policies and procedures.

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2. In the absence of training program policies and procedures, develop such policies and

procedures.

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IX. IMPLEMENTATION


1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.

FINDINGS: Little tangible evidence was provided before, during, or following the baseline assessment that clarified if or what steps have been taken to implement the requirements of this Agreement. However, Territory officials voice a serious commitment to comply with the Agreement and did provide on June 20, 2013 the outline exactly as shown below for when they intend to have policies and procedures developed, training, and implemented.

Golden Grove Adult Correction Facility

Drafting of Policies

120 days

Training on Approved

180 days after the

Policies

policies are drafted.

Implementation

One year after training

is complete.

The above implementations schedule, in general, is inadequate for several reasons. First, the implementation of this Agreement requires much more systematic planning and roll out. All staff should be aware of the Agreement and possess a working understanding about its content, expectations, purposes, intended outcomes, etc. This did not seem to exist during our baseline visit. Line staff interviewed stated that they had not been apprised of Agreement contents nor had they seen the Agreement. The successful implementation of this Agreement will benefit tremendously by making staff explicitly aware of the Agreement, its content and the role they play in meeting all substantive provisions. Another reason that this implementation schedule seems anemic is that it does not present more specifically what will be done, how it will be done, when it will be done, and who will do what by when. A more detailed and specific implementation plan/schedule is required to ensure systematic planning, execution, and evaluation of Agreement implementation and whether compliance actions 1) comply with the Agreement, and 2) cause improvements that eliminate unconstitutional conditions, care, and custody for inmates. Thirdly, the proposed implementation is unrealistic for the scope and breath of this Agreement. Institutional reform of this type and size necessitates careful and deliberate planning and execution. It is the opinion of this Monitor, based on over 30 years of experience in organizational change, policy and program development implementation, and evaluation, that it is impossible to meet the timelines presented here without additional resources that would far exceed what Territory officials report are available for this work. The Monitor provided feedback about this schedule and gained agreement that we would discuss this schedule and planning process further but that the Territory should move forward to the extent possible to implement the schedule provided. Additionally, the Monitor offered technical assistance in the development of a realistic implementation plan and schedule.

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2. Upon appointment, the Monitor will adopt the schedule as proposed or as

amended by the Monitor after consultation with the parties and the TCCs.

Either party may seek a modification to the schedule by making a request to the

Monitor, or the Monitor may modify the schedule as necessary. If the parties

disagree with each other or with the Monitor and cannot resolve it with the

Monitor, either party may submit the dispute to the district court.

FINDINGS: Please refer the findings discussed above. The Monitor has not agreed to the Territory’s implementation plan or schedule. However, it is my belief, based on verbal and written communications with Territory officials, that a more explicit, specific, and detailed implementation plan is underway. Therefore, I believe it is important to consider these stated positive efforts and review progress toward this requirement in more detail at the December 2013 visit. Again, the Monitor will provide any requested technical assistance to the Territory in this matter.

3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

FINDINGS: As discussed throughout this assessment report, the Territory provided no evidence that any policies or procedures are in revision. No new policies or procedures or revisions have been provided to the Monitor or DOJ for review and approval as required. My only conclusion, based on this, is that there have been no new polices and/or procedures developed and/or new regulations have been developed and/or implemented but were not submitted for review and approval as required.

4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.

FINDINGS: Prior to the baseline assessment visit the Monitor provided Parties with documents intended to assist the Territory in developing means and measures for evaluating progress and compliance and offered technical assistance is developing a quality assurance management process. Accordingly, there has been no further communications from Territory officials about this requirement and the first impact evaluation study is due by the end of January 2014. Furthermore, the Monitor provided a basic illustration of how to descriptively measure contraband control compliance in this report when discussing contraband control provisions. Territory officials should review that section from both compliance and

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compliance evaluation contexts. The Monitor again offers technical assistance with this

requirement.

5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.

FINDINGS: The Territory has submitted no requests, proposals or recommendations to modify policies, procedures or the plan. The Monitor looks forward to reviewing proposed changes and provided requested technical assistance if requested. It is believed, however, that the creation of a better development implementation plan will greatly facilitate the Territories compliance with this requirement.

6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.

FINDINGS: The Monitor has received no status reports or any communication from Territory about this requirement. To reiterate, the development and a more systematic planning process will afford Territory officials evidenced-based tools and documentation for complete quarterly status reports. These reports should be very detailed, specific, fact-based, and apply qualitative and quantitate principles for evidencing progress with all provisions and requirements of the Agreement. Below is a basic format this Monitor has found very practical and useful in other large Settlement Agreements he monitors:

Section/Subsection
Shows Agreement Section and wording

Provision
Specific provision wording

Accomplishment/Progress
Succinct description of what has been accomplished, can include what actions are underway.

Proof of Accomplishment, Progress, Practice Comprehensive description using qualitative, quantitative, and narrative information, specific reference documents or other evidence

Comments
As needed to clarify information provided previously, challenges, barriers, opportunities, etc.

7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.

FINDINGS: At least one incident involving inmate violence were not reported in a timely manner. The first incident involved an inmate-on-inmate homicide that occurred on 07/12/13, the Monitor and DOJ were notified of this event via email on 07/15/13. This delay in reporting the event

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timelier prompted DOJ to issue a complaint Territory officials reminding them of this reporting

requirement. Territory officials responded with a commitment to comply with this requirement but

stated that the circumstances surrounding the event made it unreasonable to provide more timely

notification.

Another event involving violence and serious physical injuring to an inmate on 09/05/13. The Monitor and DOJ were notified within 45 minutes of the event. This action evidences the Territories intent to comply with this requirement.

During the December 2013 site visit the Monitor will review all incident reports and logs to determine the degree to which this requirement is being met.

8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.

FINDINGS: Documents provided before, during, and following the baseline visit are not sufficient to document that requirements of the Agreement are being properly implemented or met as previously discussed. Although Territory officials did provide many of the requested documents, the quality and content of those documents provided little or no evidence of compliance with the Agreement. It is therefore, incumbent upon the Territory to make identification and/or development and maintenance of such records a top priority throughout the life of this Agreement.

9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.

FINDINGS: Territory officials provided reasonable access to the facility and staff during the baseline visit.

10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.

FINDINGS: Territory responses to specific questions regarding compliance with the Agreement have complied with this requirement according to the Monitor’s best estimate.

 
 Golden Grove Adult Corrections & Detention Facility U.S. Virgin Island Bureau of Corrections St. Croix, VI
2013 Federal Court Settlement Agreement
In re: United States of America v. The Territory of the Virgin Islands (86/265)
Second Compliance Monitoring Report
Completed by: Kenneth A. Ray, M.Ed., Monitor
March 17, 2014

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Kenneth A. Ray, M.Ed. Monitor

TABLE OF CONTENTS

Topic

Page

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

1

Purpose & Executive Summary ………………………………………………… 2-13

Compliance Assessment Methodology ………………………………………….

14

Assessment of Compliance ……………………………………………………… 21-116

Section IV. Safety and Supervision Compliance ………………………………

21

Section V. Medical and Mental Health Care Compliance …………………….

60

Section VI. Fire and Life Safety …………………………………………………

96

Section VII. Environmental Health and Safety ………………………………… 101

Section VIII. Training ……………………………………………………………. 110

Section IX. Implementation ……………………………………………………… 113

EXHIBIT 1. Monitor’s Jan 28, 2014 Emergent Conditions of Confinement

NA

Letter to the Territory

EXHIBIT 2. Descriptive Narrative of Facility Assessment Findings

NA

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PURPOSE

The Monitor intends this Second Compliance Monitoring Report to serve three primary goals: 1) a baseline from which to monitor Defendant’s compliance with the Settlement Agreement; 2) assess, measure, and determine progress toward partial and substantial compliance with all provisions of said Agreement; and, 3) as a tool to assist Defendants in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of defendants and offenders incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.

EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

This onsite compliance monitoring assessment was conducted by the Monitoring Team December 9-12, 2013. The monitoring team consisted of Mr. Kenneth A. Ray, Monitor and operations expert; Ronald Shansky, MD, correctional medicine expert; and Roberta Stellman, MD, correctional mental health and suicide prevention expert. The selection of Dr. Shansky and Dr. Stellman involved input and concurrence by the Parties as required in Section X subsection C paragraph 3 of the Agreement. Prior to the site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite visit.

The site visit included a startup meeting on the first day involving representatives from the United States Department of Justice and the U.S Virgin Islands. The assessment consisted of onsite tours, staff interviews, various inspections, document reviews, meetings, and a culmination meeting during the morning of the last day. Participation and involvement by the Parties was cooperative and active.

Assessment Overview

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 129 provisions; 119 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance, In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying

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representations from Defendants regarding progress toward

compliance and for examining supporting documentation, where

applicable. Each Monitor's report will describe the steps taken to

analyze conditions and assess compliance, including documents

reviewed, individuals interviewed, and the factual basis for each of the

Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy formulation, and 2) implementation. The Monitor and the monitoring experts provided non-binding recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing the final report.

The baseline assessment found 108 of the 119 provision in Noncompliance, seven (7) in Partial compliance, none in Substantial Compliance, and two (2) remain in a Pending status for review during the December 2013 site visit. Implementation provisions were not measured using these standards but a narrative description of compliance is provided at this time; the required evaluation standards may be applied in evaluating these provisions in future reports once the Monitor has more clarity about doing so from the Parties. Overall, 91% of the provisions remain in Noncompliance, 6% in Partial Compliance, 0% in Substantial Compliance, and two (2) in a Pending Status. The figure below illustrates these assessment evaluation ratings.

Each provision in this report is in bold print and shadowed for clarification purposes. Based on this assessment, there were no changes in compliance rates from the Baseline Report as shown below:

Compliance Sections

Provisions

Non Compliance

Partial Compliance

Substantial Compliance

IV. Safety and Supervision

58

52

4

0

V. Medical and Mental Health Care

36

34

0

0

VI. Life and Fire Safety

10

10

0

0

VII. Environmental Health and Safety 11

8

3

0

VIII. Training

4

4

0

0

Totals 119

108

7

0

Compliance Percentages

91%

6%

0%

IX. Implementation (Narrative)

10

0

0

0

Pending
0 2 0 0 0 2 2% 0

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Based on this assessment, it is the opinion of the Monitor and monitoring experts that very little

has improved at GGACF since the September 2013 Baseline Assessment or Findings of Fact

Report (filed on 02/08/13). GGACF continues to be a dangerous and violent environment that is

inadequately staffed, equipped, funded, maintained, and operated to provide and consistently

sustain environmental and operational conditions of inmate care and confinement that meet

constitutional requirements. This will be further demonstrated in the assessment findings of this

report.

This assessment finds no basis to significantly re-write the Baseline Report Executive Summary:

“[Overall], policies and procedures, in general, remain underdeveloped, incomplete, and/or nonexistent, much as described in the Baseline Report and Findings of Fact report. The lack of adequate policies and procedures contributes, in part, to inconsistent and dangerous security practices and habits. This was evidenced by cells doors and housing unit access points being padlocked, internal housing unit gates being left open, housing unit control room doors being left unlocked, nonfunctional security lighting throughout external and internal security perimeters, ill- maintained security fencing, an inadequate number of and broken portable radios, nonfunctional security door control panels, nonfunctional camera system and control panels in the two operational towers, ill-maintained and broken cell door components and observation windows, and various other practices that allowed inmates to move about the campus without being searched. Exacerbating these conditions is a serious lack of adequately trained and supervised correctional staff, and an overarching common frustration among staff regarding leadership support and commitment to improve security and poor environmental conditions.

Access to and possession of dangerous contraband by inmates appears to be a pervasive and persistent problem at GGACF based on interviews, housing unit inspections, and examinations of incident reports and activity logs. The presence of knives, machetes, cell phones, and large amounts of illegal drugs, for example, continues within the facility. GGACF officials report that there has not been a facility-wide shakedown (comprehensive cell inspection and facility search) in more than two years. This is very troubling if only based on the facilities’ known history of contraband and violence. However, contraband report documents provided to the Monitor show that incidents of contraband and the volume of contraband confiscated has increased significantly since the approval of the Agreement.

There appears to be no adequate complaint system in place for inmates. Although forms exist that inmates can use to present complaints and grievances, access to and submission of forms is unpredictable. Many of the boxes located in the cells used for inmates to submit complaints and/or sick requests are broken and/or filled with garbage. It seems obvious that no systematic process exists for this requirement.

Environmental conditions remain unsanitary and unhealthy throughout the facility. Housing unit temperatures are too high despite efforts using portable coolers. Cells emit the odor of mold and mildew and many flood during heavy rains. High housing unit temperatures create risks for dehydration and dangerous side effects from psychotropic medications. Mold and mildew remains a serious problem through the housing units, cells, recreation areas, ceilings, and shower areas. Lighting is broken and/or nonfunctional in some areas. Kitchen and food service areas are in serious ill repair and dirty. Cooking equipment is broken, some are dangerously

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located, broken floor tiles create serious trip hazards. Insects were found on food and in kitchen

areas. Inmates have limited access to drinkable water; there are broken cell sinks, toilets, and

showers that must be repaired. Environmental conditions, overall, remain poor and unhealthy.

Fire and life safety conditions remain inadequate to predictably protect inmates and staff from fire and/or smoke. Fire sprinkler systems are nonfunctional and inmates use the sprinkler heads in their cells as make-shift clothesline brackets. Cell doors are padlocked, a padlocked chain provides access into one entire housing unit. Many occupied cells had exposed and/or frayed electrical wires, some near water leaks, some electrical boxes showed evidence of burn marks where electrical shorting has occurred. Fire drills are not regularly conducted nor are staff adequately trained, equipped, or prepared to effectively respond to fire emergencies. There is no fire or master key control program whereby officers are routinely assessed to demonstrate competency with basic fire safety response measures. Inmate cells are cluttered with combustible items, i.e., empty commissary packaging and paper. Inmates interviewed reported having those items for more than a month. Staff do not have access to breathing equipment needed to respond safely to a fire incident. They would not be able to safely search for or rescue others from a smoke filled structure. It does appear, however, that GGACF possesses an experienced and competent fire safety coordinator who can provide expert guidance toward compliance in these areas.

Administrative investigation policies and practices are inadequate to ensure timely review, consistent tracking, or consistent resolution of facility mishaps and staff misconduct. There is no systematic process for initiating, investigating, or managing this administrative component of quality management and assurance. Supervisors do not regularly review housing unit logs or incident reports to proactively initiate administrative inquiry into real and/or potential problems. Administrative investigations are primarily reactive and there is little evidence of follow-up.

Medical, mental health, and suicide policies, procedures, and practices are inadequate to ensure timely delivery of these health care requirements. Policies and procedures, in general, are underdeveloped or nonexistent. Existing staffing levels cannot provide adequate level of required care and administrative staff are not sufficiently engaged in program management to ensure program or care continuity. Mentally ill inmates are not properly assessed and treated in many instances. There are no formal treatment plans, no basic counseling services, few treatment encounters with qualified providers or even enough qualified providers to deliver minimum levels of care if treatment programs were possible. There is little to no follow-up or monitoring of mentally ill inmates placed in segregation by qualified mental health providers. There is no formal or systematic medication management program in place to monitor medication assisted treatment regimes. The lack of an organized, systematic, and regularly reviewed health records system makes it very difficult to track patients or even develop any measurable health care quality assurance program.

We were provided no evidence to assess compliance with use of force or restraints provisions in the Agreement.

The training program is in a state of significant change according to GGACF officials. It is their intention to rebuild the entire training program and to bring it onsite under direct control of the Warden, which is a positive sign. However, there was no evidence provided to determine the

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effectiveness of the existing training program. We were provided an outline of training topics

[and training invoices] but the current training curriculum was not available for examination

to determine its efficacy relative to pre- and in-service training, or whether any training topics

were changed or added to accommodate implementation of the Agreement.

Agreement implementation has not appeared to have yet gained much traction. We were provided no evidence of an implementation plan beyond a very basic policy and procedure implementation schedule. A planned and systematic process for Agreement implementation does not exist and current levels of information and data tracking are insufficient to support such a process.

Despite a lack of progress and noncompliance with virtually all of the provisions in this Agreement, Territory officials voiced a serious commitment to comply with the Agreement.”

This assessment found conditions and practices involving healthcare, safety, and security
conditions so concerning to the Monitor and monitoring team that the Monitor submitted to Territory officials the following 2nd Monitoring Assessment Emergent Conditions of
Confinement letter on January 28, 2014 (see Exhibit 1):

Director Wilson, Mr. Robertson, Mr. Oswald,
This revises the January 6th, 2014 2nd Monitoring Assessment Emergent Conditions of Confinement letter following your review and comment period as required under the Agreement and subsequent to your initial response dated January 14, 2014. Revisions include:
1) Removal of the requested sentence regarding environmental conditions 2) Numbers all bullets for better clarity
3) Clarifies the first sentence of section I. Staffing, A. 15, regarding the relationship
between staff, inmates, and contraband
4) Removes the unreferenced foot note as indicated
Your January 21, 2014 response is appreciated and evidences commendable and valuable efforts ultimately relevant to prospective compliance and progress. However, and until these and other improvements are fully implemented, I strongly urge and encourage the Territory to timely take any and all appropriate steps to ameliorate and/or mitigate real and potential risks and harm otherwise discussed in the letter. One such step could include issuing directives requiring GGACF officers to maintain locked housing units; to search all inmates before leaving and entering housing units; to ensure all cells are inspected during each shift; and, to require all supervisors to conduct quality assurance inspections of all housing units during their shifts and to take immediate corrective action where non-compliance and/or deficiencies exist.
The second onsite monitoring assessment of GGACF was conducted December 9-12, 2013. The assessment was performed by the monitoring team including, Drs. Shansky and Stellman, and

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myself. Representatives from the Virgin Islands and U.S. Department of Justice participating in

this assessment.

As stated in our meetings during the course of this assessment, the monitoring team found conditions of confinement at GGACF virtually unchanged from the September 2013 assessment. Additionally, we expressed our serious concern about several specific unchanged conditions that we believe require expedited remedial action to ensure the safety and welfare of inmates and staff.

These risks involve issues related to 1) staffing levels and staff supervision, 2) security practices and systems, 3) life and fire safety conditions, and 4) medical and mental health assessment and care. I encouraged Territory officials during the onsite assessment to take immediate steps to remove and/or reduce these risks and advised you that I would provide you with more specific details about these findings before submission of the second compliance report to assist in developing and prioritizing an emergency action plan for that purpose. That information is provided herein.

In closing, I want to reiterate that the monitoring team will continue to provide requested technical assistance to the Territory in its efforts to comply with the Settlement Agreement.

Respectfully,

Kenneth A. Ray, M.Ed., Monitor PSCC: Roberta Stellman, MD, Correctional Mental Health Expert
Ronald Shansky, MD, Correctional Medical Expert

The Monitor also included in that letter the following recommendations for correcting the reported deficiencies (see Exhibit 1):
Golden Grove Adult Correctional Facility 2nd Monitoring Assessment December 9-12, 2013
Urgent Conditions of Confinement Concerns at GGACF Kenneth A. Ray, Monitor January 28, 2014
The following articulates certain findings by the monitoring team during the second onsite assessment of GGACF that necessitate emergency action to eliminate and/or reduce safety and welfare risks to inmates and staff. Territory officials are encouraged to take immediate steps to ameliorate these conditions due to their critical nature, real and potential imminent harm these conditions pose to facility security, inmate and staff well-being.
I. Staffing:
A. Correctional Staffing and Inmate Supervision

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The serious safety and security risk reported in the Findings of Fact Report and the First

Monitoring Report were found to be unchanged. Inadequate staffing levels and staff supervision

continue to create dangerous safety and security practices and conditions that expose staff and

inmates to actual and potential risk of harm throughout the facility. Some of the most urgent and

pervasive examples once again found during the second site assessment include:

1. Chronic staffing shortages resulting in housing units operating with one or no officers.

2. Officers not showing up for work when scheduled and/or refusing to work assigned areas.

3. Officers refusing to work certain housing areas due to fear of inmates and unsafe conditions.

4. Housing unit sally port entrance doors, internal security gates, and control room doors remaining unlocked.

5. Security gates throughout the campus being left unlocked and/or standing open.

6. Officers leaving housing units unattended.

7. Officers being afraid to enter the housing unit alone and/or with no back-up officer to conduct cell inspections and/or security checks; they remain in the unit control room.

8. Officers being required to work extensive overtime that can cause mental fatigue and impair their alertness and awareness to safety and security threats.

9. Access gates leading into housing units are routinely left opened and/or unlocked when officers enter the housing units.

10. Lack of officers contributes to lax security practices and sound inmate supervision as evidenced by inmates being allowed to obstruct visibility into their cells using blankets, towels, cardboard, and/or paper products. Officers cannot see into many prison and detention unit cells due to these obstructions and do not open cell doors for security inspections as a general rule.

11. Inadequate staffing and security practices, for example, impair timely and effective response to security incidents as observed while touring unit 9A, the isolation unit of the detention center. An inmate was able to breach the lock on his cell and access the pod day room. An officer then locked the housing unit gate and the inmate eventually returned to his cell. This inmate could have just as easily bolted out of the building and/or gained access to the officer.

12. Lack of adequate inmate body searches. For example, an inmate was not properly searched before leaving his housing unit or entering the medical facility for services. While receiving medical services from health care staff this inmate produced a shank in the form of a metal coat hanger that he indicated was needed for his protection against other inmates. This device could have easily been used by this inmate to cause serious physical injury to health care staff.

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13. In one medical event, a female inmate in X-dorm went into a diabetic coma when no security

officers were on the unit. The other female inmates had to scream through the unit windows

until another officer who was passing by the building responded and the inmate was

subsequently transported to the hospital for care.

14. In another security event in the prison lockdown unit, a handcuffed inmate being escorted by two officers was able to break away from the officers and exit the building before being caught because the pod security gate and housing unit sally port doors were unsecured.

15. Inadequate staffing levels, undertrained and under-supervised staff, under-monitored and under-supervised inmates contribute to the presence of dangerous contraband in housing units. For example, while touring 9B, this Monitor found a 4-inch knife blade openly sitting on the top bunk of an inmate’s cell. This clearly suggests this inmate had little or no concern of this weapon being detected by security staff. Upon my notifying security staff of this weapon, the knife was removed and the inmate was locked in his cell before the cell was searched for more contraband or weapons. During the shakedown, other contraband, including screws, frayed bits of cell phone chargers, a cell phone battery, seeds (potentially of marijuana) and “dime bags” (typically used to store drugs) were also recovered. Per the above incident, the presence of contraband in plain view in a cell indicates that the inmates are confident that security staff will never conduct rounds or enter the prisoners’ cells to conduct a contraband check. This is a very unsafe security practice because it allows the inmate to obtain other possible weapons in preparation for officers to return and search his cell.

16. During our tour of the juvenile unit, the single unit officer was observed sleeping when we entered the unit. This officer made no attempt to interact with the inmates during our visit, and one juvenile inmate stated that the officers seldom enter the housing area. The two juvenile prisoners were essentially left locked in the housing unit without supervision, having full run of the unit and easy access to broken broom handles. These potential weapons were found covered by a very large mound of trash in one unoccupied cell. This trash pile, which consisted of a large quantity of combustible refuse, appeared to have been there for a long time based on the presence of some decayed food products found.

17. Regarding unlocked security gates and housing units, the Warden stated that many officers do not lock them and/or leave them open for their own safety when entering the units. He stated that officers do not want to be locked in the units with inmates with only one set of keys, especially when there is only one officer on the unit and/or when they do not have radios to summon for assistance if the inmates attempt to take the officer hostage and overrun the unit. This situation is made even more dangerous because the unit officers are not issued weapons they can easily access for self or inmate protection. Officers are, thereby, in extreme danger each time they enter a housing unit.

18. Unit and supervisor log books are filled with examples of the emergency nature of GGACF staffing levels. Unit officers write such entries as “this unit is unmanned,” “radios are nonfunctional,” “no supervisor came on the unit,” “no relief officer,” and, “I will not be responsible if anything goes wrong….” Supervisor log books verify that there are times when units are not staffed and inmates are not supervised. The women’s unit frequently goes

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without any officer on duty, especially during overnight shifts while inmates are locked in

their cells.

19. It was also learned that there are times when only one of three security towers are operational due to staffing shortages. This is a serious problem, as it leaves internal and external security perimeters completely unmonitored where unstaffed towers are located. This condition is worsened due to several nonworking perimeter lights.

B. Medical and Mental Health Staffing

Inadequate medical and mental health staffing levels continue to prevent Golden Grove from providing constitutionally adequate care.
1. The logbook entries are replete with examples of medical and mental health care issues being flagged by security staff, along with a note that “no doctor is available” or “no one present in medical.” When the woman in the diabetic coma, discussed above, was transported to the hospital, for example, there was no medical staff on duty. As a result, there was no documentation in the prisoner’s medical record regarding the prisoner’s hospitalization, her return, or any follow-up treatment. But for the log book entries recording this event, it was as if it never happened.

2. The intake health screening requirements of the agreement cannot be met until there is 24hour medical care available. The monitoring team was advised by Territory officials that the “paperwork had been submitted for night nurses” but nothing was finalized yet. According to the HSA, she had never been shown the resumes submitted for those positions. However, during a meeting with the director, this monitor was shown a resume packet of nursing applicants and was advised that several applicants were approved for hire but no start dates were provided.

3. While on-site, we observed how the lack of coordination between security staff in intake and medical staff leads to a high risk of harm to prisoners. On Monday morning (December 9, 2013), intake forms were obtained by Medical for prisoners who came in at 8:35 pm Friday and 6:09 pm Sunday. Both forms indicated numerous positive responses to questions related to chronic medical needs (diabetes), potential withdrawal (alcohol), and mental health risks (“talks and answers himself, appears to be delusional”). These positive responses should have led to immediate notification to medical/mental health staff, due to the risk the prisoners so obviously faced.

4. In addition to identifying urgent nursing needs, the HSA also requested a medical records assistant and recommended a candidate. However, BOC leadership has not acted on her request and recommendation at this time. The HSA indicated that she does not have time to begin to write the policies required by the Agreement, as she is overburdened with administrative duties that could be handled by an assistant. Even without an assistant, the medical records reviewed were disorganized and missing key information. There were no appointment logs and thus there was no way of knowing whether a prisoner with urgent medical or mental health needs was being seen as needed.

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5. The current psychiatrist on-site planned to retire by the end of 2013. Although a

replacement, Dr. Sang, was reportedly hired, telephone conversations with Dr. Sang caused

concern that she had not been contacted about a start date. Even with the current psychiatrist,

there are very few hours of mental health care being provided every week.

6. The one unlicensed mental health counselor on-site tries, but oftentimes prisoners are not transported to their appointments due to a lack of security staff available to transport. As a result of the lack of mental health staff, there are no real suicide prevention or mental health care programs in place. For the second time, we were told that no suicide watches had been initiated in the previous three month period, only to discover through logbook entries that security staff had initiated a watch on their own and had decided when to discontinue the watch, all without notifying mental health staff. Staff are clearly acting without the benefit of clear policies, procedures, supervision, and/or management communication. There was no corresponding documentation of a watch in the medical file. Furthermore, our tour of both detention and prison segregation units found mentally ill inmates, some presenting with paranoid and/or symptom deterioration who stated that they had not seen a mental health staff person in weeks. This is very troubling considering that these inmates were allowed to maintain obstructed view into their cells and/or their cells were so dark that I was unable to see into the living area. These conditions severely impair adequate security supervision of these inmates, and such sensory deprivation can exacerbate psychiatric pathologies causing more severe and prolonged psycho-emotional suffering.

7. With regard to medical staff, while on-site we were informed that the medical director for BOC had only been to the facility six times since our last visit. After bringing this to the attention of BOC leadership, the Director was removed from her position during the week. Another candidate was approached, but given the delays and difficulties getting contracts finalized, it is unclear when and if he will actually start his duties.

8. As noted above, during the week I was told about various medical and mental health hires. However, the HSA and candidates seemed unsure as to whether this staff would ever actually start. At a mid-week meeting, the Director told the HSA that she should begin selecting candidates for the nursing positions, but she was unable to access resumes that had been submitted months ago. When we left, she was still working on gathering this information.

9. With regard to security staff, at the very end of the week a meeting was arranged between the Monitor and the Director of the Bureau of Corrections. At that meeting, the Director indicated that he has approval to hire 30 new corrections officers and that 14 will be entering the academy “sometime before the end of the month.” However, as of the end of the visit, no academy start date had been scheduled. It is now the beginning of January 2014, and we have not received any confirmation that these new hires were brought on board and that a new academy class began. It is also unclear why these plans were not revealed to us at the beginning of the visit. One possible explanation was that BOC’s human resources director (also training director and director of administration) was on leave during our visit, as she was during our last visit, and other BOC personnel did not have ready access to her files.

II. Inadequate Safety Equipment and Inadequate Training on Use of Equipment In addition to the staffing shortage, the logbooks also highlighted the lack of working
safety equipment in many of the units.

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1. Equipment lists on different units often noted that the unit was without a working radio, empty first-aid boxes, and/or no suicide cut down tools. In some instances, particularly in the X-Dorm, the units went without a working radio or phone for weeks at a time. The absence of reliable communication devices presents extreme risk to staff and inmate safety, especially if there is only one officer assigned to each housing unit. If an incident were to occur, the officer would have no way of calling for help. The fact that many of the male units are staffed by one female officer makes this threat even more real and present.

2. We also observed that not every unit had a cut down tool or a working flashlight. And, in at least one instance, the officer on duty did not believe there was a cut down tool available, when in fact one was located at the back of a locked box. It was clear to me that, even where equipment is available, the officers are unaware and therefore unable to use that equipment in an emergency. In one unit where there was a cut down tool, the tool was locked on a wallmounted cabinet that was too high for the officer to reach.

3. Housing unit equipment logs are not maintained consistently. Logs were found incomplete with some logs missing equipment verification entries for several days at a time. It is clear that these logs are not consistently monitored for quality assurance by supervisor staff.

III. Physical Plant Issues

Numerous environmental hazards were observed during the compliance monitoring tour. Golden Grove’s facility is old and in need of much repair.

1. It rained off and on during our visit, creating significant flooding in most of the housing units. Standing water on the floor of the units creates numerous safety risks. Exposed electrical wiring near dripping water was also found.

2. Mold remains prolific throughout the housing units. All of the housing units have a large level of mildew and mold throughout. Some inmates complained that their health is deteriorating as a result of these conditions. One inmate complained that mold in his cell is exacerbating his chronic asthma and he is having difficulty breathing

3. The kitchen remains filthy with rotting food bi-products under sinks, stoves, and between broken floor tiles. Additionally, there appears to be no effective control over cooking instruments such as knives, large metal spoons, etc. During our tour we found the kitchen tool room door unlocked and standing open, the tool cage open and unlocked, several tools, including knives and large metal spoons, missing. No security officers were present on the floor at this time and the two civilian kitchen staff were both sitting in the office socializing with an officer while several inmates cleaned the kitchen area unsupervised.

4. The lack of a working fire safety system is also a very serious concern. The cell fire sprinklers are used by virtually every inmate to anchor homemade clotheslines. It is unclear whether or when the facility plans to fix the sprinkler system so that it is fully operational.

Conclusion and Recommendations:

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As previously stated, this is a non-exclusive list of specific serious issues found during the

second monitoring site visit that beg for urgent attention and resolution. Considering the

potentially life threating nature of many of these findings, Territory officials are encouraged to

immediately take the following action:

1. Expedite the hiring and adequate training of all open staff positions – corrections, medical, and mental health. Develop an emergency hire plan that includes deadlines for having all positions trained and working.

2. Stop the practice of allowing inmate housing units to go unstaffed, inmates unsupervised.

3. Stop the practice of leaving housing unit sally port doors, internal security gates, and officer control room doors open and/or unlocked. These doors should remain closed and locked at all times except for authorized movement.

4. Ensure that all housing units are consistently supplied with reliably functioning radios for all officers assigned to the unit, and with all other equipment needed to provide safe and secure supervision of the unit and inmates, i.e. cut down tools, flashlights, etc.

5. Do not allow officers to enter housing units with security keys and without the presence of another officer who can rapidly respond if needed.

6. Ensure adequate, proper, and active management of the juvenile unit and supervision of juvenile inmates.

7. Increase supervisor presence in housing units to perform quality assurance functions and staff supervision.

8. Remove all coverings from cell door windows and cell areas that block clear and complete view inside cells. Also, inmates, especially mentally ill inmates, should not be allowed to live in dark cells as previously discussed.

9. Ensure inmates are properly searched for contraband when leaving and returning to their units, when entering and leaving other facility buildings.

10. Develop a comprehensive plan for repair and/or replacement of all non-functioning security mechanisms, equipment, systems, and lighting. Include a comprehensive plan for repair or replacement of the fire suppression system. These plans should include completion deadlines.

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SECOND ASSESSMENT METHODOLOGY

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties. The team consists of Mr. Kenneth A. Ray, M.Ed., Monitor; Roberta Stellman, MD, Psychiatrist; and, Ronald Shansky, MD, Correctional Medicine.

Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for baseline assessment visit purposes and scheduling, and monitoring expectations in general.

Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.

1. Description of how the Monitor will assess compliance with each of the Compliance Measures.

In general, compliance assessment will include the following activities:

A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning. I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.

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J. Examination of any and all records, data, and/or information relevant to compliance and

compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (non-compliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
 Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.

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 Domain: A core aspect of the organization’s performance, such as access to care, costs of

care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates,

or consumer satisfaction).

 Performance Indicator: A defined, objectively measurable variable that can be used to

assess an organization’s performance within a given domain. For example, within the

domain of consumer satisfaction, a performance indicator might be: “the percentage of

consumers who state that they received the types and amounts of services that they felt they

needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)  Online media information  Online public records  Electronic and standard mailing of information  Email communication and phone consultations
3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. A monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for the baseline visit and monitoring includes the following: many of these documents were not provided as requested but more was provided during the Second visit that for the Baseline visit, and Territory officials stated that they intend to continue

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to general and provide the requested documents. It is important to reiterate the need for the

documents listed below. Considering the size of this list, and GGACF’s limit staff and technical

resources, the Monitor intends to assist the Territory in narrowing this list to the most salient

items.

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and county budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months. 23. Records and/or lists of physical improvements, repairs, and renovation completed to correct security problems and deficiencies over the past 36 months. 24. Past 36 months of agency budgets.

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25. List and contact information for any and all community vendors who provide services of

any kind to GGACF and contracts or professional services agreement authorizing those

services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy
of their records. 31. To the extent not provided above, the policies and procedures governing medical
and mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers, including
on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to include
health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD
testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment. 46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location. 47. To the extent not provided above, external and internal reviews or studies of medical or mental health services including needs assessments and any American Correctional Association and National Commission on Correctional Healthcare reports. 48. List of all inmates placed in restraints, and all inmates receiving mental health treatments, under suicide watch, or taking psychotropic drugs. Current mental health case list including inmate name, number, diagnosis, date of intake, last psychiatric appointment, next psychiatric

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appointment, and any case lists of inmates followed only by counseling staff with last

appointment date and follow-up appointment.

49. Documentation reflecting any training that facility staff have received on suicide

prevention, including certificates and training materials.

50. All documents related to the any suicide occurring within the past year.

51. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

52. All policies and directives relevant to suicide prevention. 53. All intake screening, health evaluation, mental health assessment, and any other forms
utilized for the identification of suicide risk and mental illness. 54. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 55. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 56. The entire case files (institutional, medical and mental health), autopsy reports, and
investigative reports of all inmate suicide victims within the past three years. 57. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 58. List of names of all inmates on suicide precautions (watch) within the past year. 59. The suicide watch logs for the past year. 60. Clinical Seclusion logs for the past year. 61. Use of clinical restraint logs for the past three years. 62. Any descriptions of special mental health programs offered. 63. A list of all uses of emergency and forced psychotropic medications in the past year 64. A list of any use of force associated with the administration of psychiatric medications for the
past year. 65. A description of medical and mental health’s involvement/input into the disciplinary process
and clearance for placement in segregation. 66. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

It is important to note that this assessment visit was very productive despite a lack of requested information. Territory officials and participants were exceptionally cooperative, involved, and supportive throughout this aspect of the monitoring process. The Territory’s repeated desire to fully comply with the Agreement was evidenced by its active cooperation and involvement in the onsite visit. Similarly, United States Department of Justice representatives participating in the onsite assessment were equally cooperative and involved, which helped to maximize visit efficiency and productively. The presence of both Parties during the onsite visit assisted assessment focus and allowed for collaborative and timely resolution of important matters of mutual interest. Therefore, the Monitor and monitoring team respectfully requests that these representatives from both Parties continue participate at all future assessment visits.

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The monitoring team used four primary reference points from which to assess compliance and

progress with Agreement. These included: 1) the agreed 2012 Findings of Fact document, 2)

documents, information, and data provided prior to, during, and following the onsite assessment,

3) the onsite visit, which included meetings, discussions, interviews, campus tours and

inspections, and 4) the Baseline Assessment Report.

During this assessment, the monitoring team toured the campus, inmate housing units and cells, dayrooms and program spaces, food service/kitchen areas, maintenance and workshops, the armory, intake/booking area, control rooms and officer posts, outer perimeter and fencing, and medical and mental health areas. We talked with BOC representatives and staff, and spoke with inmates.

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IV. SAFETY AND SUPERVISION
As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in .a jail setting, Defendants will implement appropriate measures to minimize these risks, including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:
a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No measurable changes were apparent regarding stratification of inmate housing for institutional classification, housing, policy or procedure. Recommendations provided in the Baseline Report remain appropriate.
While it is recognized that the requirement to develop and implement effective policies and procedures is clearly described and defined in this Agreement, doing so does not alone either fully meet its substance or intent. Well-researched, evidence-based, comprehensively implemented and regularly evaluated and updated policies are only one tool for providing constitutionally reliable protection and care of inmates at GGACF. The substantial intent of this Agreement is to ensure that GGACF provide consistent and deliberate safety, security, and care of all inmates at all times. This requirement extends to all substantive areas i.e. security, health care, suicide prevention, sanitation, the use of force, training of staff, inmate and staff supervision, etc. It is important, therefore, to remind the Parties that completion and implementation of effective policies does not, alone, provide sufficient evidence of compliance with provisions involving policy and procedure development. Partial and Substantial Compliance requires valid and reliable proof that conditions of confinement at GGACF meet minimum constitutional requirements and are likely to continue to do so beyond the life of this agreement.
Effective correctional security policies and procedures provide staff with clearly written and systematic work methods to ensure adequate protection and care of inmates. These documents explain all the “who, what’s, when’s, where’s, why’s, and how’s” while helping to ensure compliance and accountability in their implementation and efficacy.

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An examination of incident reports, jail logs, and practices evidence a clear lack of adequate

policies and procedures. Here are a few examples:

One September 4, 2013 an inmate was slashed in a housing unit. The records suggest that no officer was on I Unit when the attack began. One inmate pursued the inmate-victim from one housing unit to another without staff intervention and with the assistance of unlocked housing unit doors. Once the officer arrives to stop the assault, the reports indicate that the victiminmate spat at the officer. This officer then retreated to the office/control room. The inmate was able to gain access into this office area and a fist fight ensured before backup officers could arrive to stop the violence. The reports also indicate that during this event, many other inmates were trying to get out of the housing unit gate. The existence of, and compliance with, adequate policies and procedures could have easily prevented or mitigated this violence and serious breach in facility security.

In another incident reported to occur on July 11, 2013, an inmate-on-inmate homicide was the direct result of failures in security policy, training, and the lack of adequate security policy and practices. In this case an inmate was able to obtain a large knife and fatally stab another inmate near the kitchen area. The knife was not “home-made” but appeared to be a professionally manufactured weapon that was brought into the facility and accessible to the offending-inmate. The suspect-inmate seems to have been inadequately supervised before this event, was able to enter the G housing unit and give the knife to another inmate. This and other serious threats to inmates and staff seem virtually unstoppable based on unlocked housing and control room doors observed during the baseline assessment.

Neither or the incident reports discussed above alluded to any remedial, preventive steps to be taken or what policies or procedures were violated and/or should be reviewed to prevent future violence. The absence of any administrative reports provided to the Monitor leads to a conclusion that no administrative investigation occurred and/or no action was taken to retrain or discipline staff whose noncompliance with policies and procedure may have contributed to these events.

Most policies are in need of significant reform. Policies and procedures provided are outdated, unsigned, and most not referenced to professional regulations or standards, inconsistent, and appear to not be followed by staff in many instances based on observations of campus, housing areas, and security control areas. There are no policies or procedures that specifically stratify the defendant and offender populations (jail or prison) according to risk and needs. The two operations (jail and prison) are essentially stratified by gender and conviction status. Although the Settlement Agreement does not specifically state a condition to meet any professional standards or regulations pertaining to the operations of a correctional facility, it is highly recommended that Defendant’s base policy development and implementation on professional corrections standards as they are well researched, evidence-based, and very useful in establishing and maintaining a constitutionally-sound correctional operation.

RECOMMENDATIONS:

1. Revise/develop housing classification policies based on a current validated intake and review classification instrument. Submit document drafts as indicated in the Agreement before implementation.

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2. Timely complete and submit a policy development plan that includes, at a minimum,

the following elements:

A. Policy title with related procedure titles

B. Primary policy references

C. Person(s) responsible for document development

D. Expected dates to be forwarded to the Monitor and USDOJ for review and approval,

date(s) of staff training, implementation date

3. Review current population to verify accurate risk/need classification levels and

housing, reclassify and appropriately house as indicated by review process findings.

4. Refer to IV.F. Regarding specific classification and housing policy recommendations.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No new Post Orders were provided for review during this inspection with regard to Housing Unit Supervision or staffing. Additionally, Housing Unit and Supervisor logs report several instances of staff shortages and absences similar to what was reported in the Baseline Report. These logs indicate that some housing units are left unmanned for long periods of time and inmates are left not supervised. The lack of current post orders and chronic correctional staffing shortages create very unsafe conditions of staff attempting to enter housing units and conduct security / safety checks. Post Orders must clearly and specifically articulate when and how officers are to conduct these checks and include safe options for managing the inmate population while conduction checks. Additionally, lack of adequate levels of correctional officer supervision continues to cause officers to ignore and/or tolerate contraband rule violations. As discussed in Exhibit B, a majority of the occupied cells were either cluttered with various personal items and/or were allowed various items, whether legally considered contraband or not, such as fans with exposed electrical parts and wires, clotheslines tethered to broken fire sprinkler heads, empty food containers that are fire hazards, and other dangerous devices. These findings further emphasis the need for effective Post Orders and staff supervision, and timely completion of the required staffing analysis.

Post orders for all posts are vital to effective and consistent correctional operations. Post orders should be well-researched and written, easy to interpret and apply, easily accessible by staff at their duty posts, and regularly evaluated and revised as needed to ensure consistent continuity of post and facility operations.

Documents titled “Specific” and “General” post orders were provided following the baseline visit. Specific Post Orders comprise 10 pages of specific post directives, General Post Orders comprise in excess of 200 pages of general directives ranging from specific post duties to operational functions. Specific Post Order pages are not numbered, General Post Order pages are numbered but it is difficult to determine between Post Order and regulations, as they appear to be blended. The two sets of documents are formatted quite differently, none are signed by approving authority, none are dated, and none have document review, revision, and/or dates established or issued, nor do any of these documents include professional or regulatory references previously discussed A general examination of both sets of documents suggest that many of these directives are not followed by staff based on observations of

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practices, housing and cell conditions. The Orders are not numbered, making it impossible to

accurately reference any Order, section or subsection. Some of these directives would be

virtually impossible to apply and/or comply with simply due to inadequate security staffing

levels, mal-and non-functioning security equipment, and poor cell lighting. I was unable to

locate any Post Order (Specific or General) that established minimum staffing levels for any

security post. I also found no specific Post Orders specifying supervisor-to-officer ratios.

A partial examination of officer logs for Units L, K, X, I, and 9A dated June to September 2013 clearly evidence Post Order deficiencies, inadequate staffing levels, and/or lack of supervision as discussed:

Month

Unit

Staffing Deficiencies Reported By Officers

June

L

No relief officer at shift change

July

K

Only one (1) officer to two (2) office post

August

9A

No relief officer for break, unit officer leaves unit unattended for break

X

Security check finds 13 female inmates unsupervised, unit rear doors not locked

I

No officers in I/J unit at shift change

Sept

I

No supervisor on duty, no unit relief officer

I

No supervisor unit checks during 4-12 shift

It seems more likely than not that these seven log entries reflect a larger, undocumented, problem. All of these reports evidence serious, and likely persistent and pervasive, problems with inadequate staffing levels – though it takes no less than six to seven months to fully train a corrections officer for service – supervision, and inmate and staff safety and security.

These are only a few of many very troubling log entries written by officers. Many other entries report real and significant health risks to the inmates as demonstrated by a few log entry examples below:

June 18, 2013 (L Unit) Basic health needs are at risk because inmates do not have access to water after nighttime lock down as stated in the log, “Last call for water at this time; slots are closed. IM DR complaining about urine bag being clogged up.

June 19, 2013 (L Unit) - An inmate complains of head pain and “passes out in his room” - “No staffing relief available…24-hr shift ensues”. In this entry, an inmate shows an officer
a blood-filled toilet after urinating.

July 18, 2013 (K Unit) There was only one officer present when normally two are assigned to the unit. The reporting officer reports “this practice is hazardous to both officer and inmate safety due to the status of the unit.” Additionally, it was reported that the backup generator did not come on during a power outage.

August 4, 2013(K unit) The officer reports, “Major repairs are needed within the unit from lighting fixtures, missing ceiling tiles, faulty locks, cells, cracks, mold and mildew…Administration is fully aware of

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these safety and health hazard conditions in this facility, also discrepancies in security but

blatantly refuses to rectify them!!!”

These few log entries represent only a small number of reports for only a few housing units and only over an approximate three-month period (June-early Sept) but clearly evidence serious security, safety, and health problem that appear persistent and pervasive. Additionally, it is very difficult to garner consistent compliance with policies and procedures by staff when they feel that their concerns are ignored by administrators.

Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Subsequent to policy and procedure development and revisions, conduct a complete review of existing Specific and General Post Order to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible; E. regularly reviewed, revised, updated; F. consistently enforced; G. known to staff through pre-service, in-service, and ongoing training.
2. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues to be known and resolved in a timely manner.
3. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Access to an adequate supply of reliable portable radios for all housing areas remains problematic. A review of housing unit logs and inventory sheets indicate a lack of reliable radios and power charges. In some instances, officers who are managing two housing units must share a single radio. For example, the J unit log reported only one working radio for two housing units, and the X (female Detention and Sentenced unit) log reported not having a functioning radio or telephone for days. The lack of such basic communication equipment makes it virtually impossible for staff to summon help if needed in an emergency. Maintaining radio and telephone communications in housing units at all times is critical to staff and inmate safety and security and must be corrected without delay.

Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

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1. Revise and/or develop, implement, and evaluate policies and procedures governing radio communication equipment, usage, repair and maintenance.
2. Ensure that all posts are equipped with functionally reliable communications equipment; it is recommended that reliable radios are issued to ALL officers and staff working with and/or around inmates.
3. Repair, replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
4. The Monitor will review radio equipment inventories and functionality during the next onsite assessment.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including: (i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and (ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously described, there has been no detectable improvement since the Baseline Report. Cell conditions indicate that adequate and frequent rounds of cell block are not being conducted by officers or supervisors. As previously stated (refer to Exhibit B) most of the cells were found to be cluttered and inmates were still allowed to keep contraband and/or items that can be used to harm officers and other inmates. Many cells had sheets and/or towels draped across and over cell doors and/or hanging from the previously described clotheslines that fully or partially blocked viewing inside the cell. Many of the occupied cells were very dark making it impossible to perform inmate security / safety checks. The Juvenile unit contained a, unlocked cell that was littered with a large pile of trash, old food items, broken broom handles, etc. and appeared to have been left in this conditions of weeks. It was obvious that staff paid little or no attention to this sanitation problem and that the two juvenile inmates were provide little or no monitoring or supervision.

All cells must be kept reasonably lighted at all times and all visual obstructions into the cells must be removed.

Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Refer to recommendations regarding Post Orders. 2. Revise and/or develop policies and procedures to ensure consistent and reliable
monitoring of housing units and cell blocks as stated above. 3. Ensure housing units and cell blocks are consistently staffed at levels required to ensure
staff and inmate safety and security, and according to inmate risks and needs.

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4. Ensure that special needs inmates (suicide, mentally ill, medical infirm, vulnerable,

etc.) are monitored more frequently and by qualified health care staff.

5. Ensure that supervisors routinely inspect general and special housing units to ensure

compliance staffing requirements, policy and procedures, and to interview inmates to

presenting problem conditions. Supervisors should also ensure that all safety and

security equipment is present and functional during these inspections and immediately

replace any nonfunctional equipment.

6. Repair all broken lights in housing units and cells, issue flashlights to staff for cell

inspections, repair all broken cell doors, keep all housing unit doors locked, repair

broken control panels to improve unit security.

B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: These policies, as stated in the Baseline Report, remain outdated, underdeveloped, and incomplete. There was no appreciable improvement determined during this assessment. However, there has been an appreciable increase in contraband recovery as indicated in incident reports and contraband logs. GGACF are commended for this additional attention to controlling contraband but dangerous items, such as the knife blade found on an inmate bunk and the wooden stick found in the juvenile housing area are clear and dangerous indications of chronic inattention to basic security conditions. Another example is an incident involving an inmate who entered the Medical unit with an undetected piece of wire and made a threatening statement to medical staff. The nurse who wrote the incident report referred to the piece of wire as a “shank” but later changed the report stating that it was not a shank. This is a good example how the lack of clear definitions one what constitutes contraband creates security risks for staff.

Although current policies and regulations list what constitutes contraband, these policies are outdated, some are underdeveloped, and some are incomplete.

During the first day onsite, the Warden advised the monitoring team that a “shakedown” of the entire facility had not occurred in two years. This is clearly an unacceptable policy and/or practice as it creates an incarceration culture that promotes and encourages the introduction, use, and easy movement of contraband throughout the entire facility.

Additionally, at no time did I observe any inmates being searched as they entered or exited a housing unit, kitchen or shop areas, but did observe inmates entering and leaving those areas. This further encourages contraband movement throughout the campus.

Recommendations provided in the Baseline Report remain appropriate.

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RECOMMENDATIONS:

1. Review, revise, and develop contraband policies to include all forms of contraband, consequences for its introduction and possession, and actions staff are to take in its collection and disposition.

b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As discussed above and previously described, there is no appreciable improvement in the contraband policies or procedures; inmate access to contraband remains dangerously unfettered as evidence below by an examination of contraband seizures reported after the Baseline Assessment for September thru December 2013.

Contraband Seized Sept - Dec 2013 Cell Phone Phone Charger Other Electronic Device Currency Knife Shank Machete Cutting Device Tools Marijuana / Leafy Subs Tobacco / Papers Toxic Chemical Drugs Contraband ( as stated in the log) Jewelry Bottles ETC
Total Items
Phones Sharp Weapons Intoxicants / Drugs

Count 23 5 2 6 4 7 3 3 2 19 5 1 1 2 8 2 1
94 23 17 26

The Baseline Assessment findings reiterated below for the purposes of showing that the high level of contraband in the facility continues:

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A review of housing unit logs (June-Sept, 2013) and Incident Log (October 2012 – September 2013) reflect a serious, dangerous, chronic, and pervasive contraband problem exists throughout the facility.

There were approximately 407 incidents reported on the Incident Log for the period examined. Almost one-third (125 /407) involved discovery of contraband and/or the likely presence of contraband (e.g., “intoxicated inmate”). The risks presented to staff, other inmates, and facility security, based on descriptions of seized contraband, ranged from minor to serious physical security breaches, to potentially deadly as shown in the table below listing items reported.

Baseline Assessment Data Previously Reported

Incidents Logged
Incident Reported All Incidents Contraband

2012 (3mos) 99 42

2013 (8mos) 308 83

Combined (11mos) 407 125 (est.).

Contraband Found
Contraband Found
Not Identified Cell Phones CD/DVD Players Weapons/Sharps Illegal Drugs Intoxication Drug Paraphernalia Money

2012
16 18 0 2 4 0 1 2

2013
38 28 2 7 6 2 2 2

Total (11mos) 54 46 2 9 10 2 3 4

Contraband reporting data should be viewed as 1) positive efforts being made by GGACF officials and many staff to improve facility safety and security, and 2) as clear and convincing evidence that the facility is a dangerous environment for inmates and staff. These data also seem to support implications resulting from staffing level deficiencies, inadequate inmate and housing unit supervision, staff supervision, and the ease to which inmates can obtain contraband as evidenced by a 2013 inmate assault involving serious physical injury caused by manufactured machete, a reported removal of 73 bags of marijuana from Unit 9A in May 2013, and an inmate-on-inmate homicide occurring earlier this summer. Further analysis of contraband reports and the number of items confiscated following approval of the Order on May 14, 2013 demonstrates significant increases in these incidents and volume of most contraband-types.

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A cursory analysis of contraband incident reports for 3.5 months (approximate) before and

following approval of the Settlement Agreement found the following changes in reported

incidents and items confiscated:

 Reported contraband incidence increased 76 percent (25/44);  Number of unidentified items increased 50 percent (14/21);  Number of cell phones increased 215 percent (6/19);  Number of CD/DVD/Players decreased 100% (1/0);  Number of Weapons/Sharps/ increased from 0 to 9 in comparison;  Illegal drugs decreased from 3 to 1 seizures.

GGACF Contraband Reports &
Confiscations Before and After Approved
Settlement Agreement

Before SA Feb

Mar Apr

May 13th

After SA May
14th

Jun

Jul

Aug

3.5 Mos. Before Agreement

3.5 Mos. After
Agreement

Contraband Reports 3

12 10 2

2 16 9 15

25

44

Not Identified 1

5 8

0

86 7

14

21

Cell Phones 1

5 01

4

62 6

6

19

CD/DVD Players 1

0 00

0

00 0

1

0

Weapons/Sharps 0

0 00

3

31 2

0

9

Illegal Drugs 1

0 20

1

00 0

3

1

Intoxication 0

2 00

0

00 0

2

0

Drug Paraphernalia 0

0 00

0

00 0

0

0

Facility Property 0

0

1 0

0

00 0

1

0

Money 0

0 00

0

00 2

0

2

Totals

4

12 11 1

8 17 9 17

27

52

Golden Grove Adult Correctional Facility Contrand Reports and Items Confiscated Comparison Before Settlement Agreement (Feb-May 13th) and After (May 14-August 31, 2013)

60

Not Identified

Cell Phones 50
CD/DVD Players

40

Weapons/Sharps

30

Illegal Drugs

Intoxication

20

Drug Paraphernalia

10
0 3.5 Mos Before Agreement

3.5 Mos After Agreement

Facility Property Money Contraband Reports

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The reports do not clarify whether these increases resulted from increased attention to this

issue, increased volume of contraband, or both. These findings clearly demonstrate the

presence of pervasive and persistent dangers to staff and inmate safety, security, and welfare

of staff and inmates that can be mitigated and better controlled via effective policies, and staff

and inmate supervision.

Additionally, an inspection of the medical unit found open cabinets containing scalpels and other dangerous medical devices. Leaving exam rooms cabinets and exam rooms unlocked and unattended provides no help in preventing access to contraband and exposes inmates and staff to very serious personal safety risks.

GGACF officials are encouraged to continue with improvements to policies and procedures. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate contraband control policies that contain, at a minimum, the following elements: A. The purposes for contraband control; B. Safe methods and tactics for identification, seizure, recovery, and disposition; C. All locations where contraband can be hidden and disguised; D. Methods and points of delivery and access; E. Unannounced and irregularly time searches of cells, inmates, and inmate program; recreation and work areas; F. Keep all cabinets and doors locked at all times to prevent access to contraband; G. Use of metal detection equipment; H. Use of other mechanical devices for detection and recovery; I. Respect of inmates’ rights to authorized personal property J. Clearly articulate differences in inmate property allowed according to gender, religion, health conditions, conviction status, etc.

2. Review, revise, develop, implement, train, and evaluate training policies, procedures, methods, and demonstration of staff proficiency in the prevention, detection, recognition, recovery, and disposition of contraband.

3. Ensure that all posts and high-risk contraband access points are properly secured at all times, adequately staffed, equipped with reliable video surveillance devices, and consistently enforce contraband rules and laws involving inmate, staff, contractors, volunteers, the public, etc.

4. Develop a uniformed incident tracking/reporting system using standardized contraband titles and locations; implement a continuous quality improvement program to ensure the accuracy and completeness of incident reports.

5. The Monitor requests electronic submission of the current Incident Log each month for review and analysis purposes, and to provide technical assistance as indicated.

c. Detection of contraband within Golden Grove, through processes including:

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(i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinic, and other areas of Golden Grove to which prisoners may have access;
(ii) pat-down, metal detector, and other appropriate searches of prisoners coming from areas where they may have had access to contraband, such as at intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic;
(iii) regular and random searches of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g., clinic, kitchen, dayrooms, storage areas, showers);

ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to 1B above. Additionally, it is important to note that the Gang Intelligence and Search Team (GIST) has made some progress in seizing contraband but their search activity does not occur with sufficient regularity to effectively control the high levels of contraband. It is very important that the GIST increase frequency and regularity of cell searches.
RECOMMENDATIONS: Refer to above, expand application of recommendations to provision c (i-iii) above.
d. Confiscation and preservation as evidence/destruction of contraband; and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: An examination of Evidence Collection Logs indicate that GGACF officials and staff continue to confiscate and preserve contraband and other evidence when found. This log appears to well organized and complete. However, although the evidence collection log is filled out, it does not appear that all contraband collected during cell searches is being properly recorded. For example, after discovering the 3-4 inch blade on and inmate’s cell-bunk, a shakedown of the cell was conducted that revealed several other pieces of contraband, including pieces of wire, cell phone battery, and small plastic baggies useful in storing drugs. The Warden completed an incident report for that event but only the blade was reported as “contraband seized.” This may have due to the fact that the Warden was not present in the cell when the remaining contraband was confiscated. Regardless, this example demonstrates that a complete log is not necessarily an accurate.
RECOMMENDATIONS:
1. Review, revise, develop, train, and implement, evaluate policies and procedures involving confiscation and preservation of contraband as evidence for administrative and legal enforcement purposes.
2. Ensure staff access to appropriate equipment and supplies needed to safely collect and preserve contraband while maintaining evidentiary integrity.

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3. Ensure adequacy of chain-of-custody methods and procedures.

4. Review, revise, develop, implement, train, and evaluate training policies, procedures,

methods, and demonstration of staff proficiency in the proper collection/confiscation

and disposition of contraband.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: PARTIAL COMPLIANCE (Based on Baseline Report only)

FINDINGS: Not assessed during this visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS: Similar to above specific to admissions policies and procedures, internal and external escorts for visitors to the facility.

C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously described, several inmates continue to wear and possess personal clothing items. This was observed on the yard and in the housing areas. There has been no change since the Baseline assessment. Recommendations provided in the Baseline Report remain appropriate.

None of the inmates were observed wearing correctional identification. However, the Warden has developed an inmate identification card that he showed the Monitor during this assessment and intends to implement it soon. Not all non-uniformed staff wore official identification but should. The monitoring team was provided official identification upon entry into the facility each day; the identification cards were numbered, recorded by the officer, and collected each day before our departure.

RECOMMENDATIONS:

1. Review, revise, develop, implement, train, and evaluate policies and procedures requiring all inmates to wear standard-issue correctional uniforms.
2. Consider acquiring correctional apparel that provides obvious recognition of the inmates’ classification/status.
3. Ensure there is a consistently sufficient supply of uniforms to regular laundry exchanges and changes in an inmate’s classification and/or status.
4. Consider developing a correctional industry for making uniforms onsite.

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5. Select/make uniforms specifically designed to reduce/eliminate places to hide

contraband and weapons.

6. Mark all uniforms with highly visible letters/numbers.

b. Identification that prisoners, staff, and visitors are required to carry and/or display;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As reported in the Baseline Report, none of the inmates were observed wearing correctional identification that was to be implemented. The inmate identification card provided by the Warden during the Baseline Assessment has not been implemented. Additionally, there were not enough visitor badges available for the monitoring team or DOJ representatives this visit. We were told that badge-clips were misplaced or taken.

However, the Warden reiterated that he has developed an inmate identification card system that should be fully implemented before the next assessment visit. Additionally, and as stated in the Baseline Report, not all non-uniformed staff wore official identification but should. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Ensure staff compliance with this provision. 2. Ensure appropriate policies and procedures are in place and made available to staff. 3. Ensure adequate supplies for making identification cards. 4. Regularly audit identification card inventory and maintain proper controls to prevent
inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories. 5. Consistently enforce identification card policies and procedures.

c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously described, there has been no appreciable improvement in keeping perimeter access gates secured as was found at the facility entrance; GGACF officials reported this was due to a recent lightning strike that disabled locking electronics. Additionally, many internal yard gates were unlocked and open as were many housing unit entrance doors, their internal gates and control room doors. This remains very problematic and dangerous for inmates and staff.

The Warden state that leaving housing unit gates unlock was for officer safety due to staffing shortages. This is a very dangerous situation as leaving housing unit doors and gates unlocked and/or open when officers are in the housing units creates imminent opportunities for escape and violence.

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Perimeter security gates were locked during this assessment except for a few instances when

entering the facility at the beginning of the assessment. Some internal campus gates stood open

providing access between buildings and recreation areas. Although this can be considered

efficient for certain inmate movement purposes, the practice is more likely a convenience

resulting from inadequate staffing levels. Internal gates leading into housing units were

unlocked as were the doors into and between unit control rooms. Unit pipe chase/electrical

doors were unlocked, which provided easy access to these areas by inmates. Many cell door

locks were broken, many lockable cell doors had inmate-made devices attached to them to

prevent them from locking. Most of the cell doors require manual locking and unlocking due

to control panel designs and some inoperability issues. Inmates have been known to exit their

cells and units, allegedly undetected, access the yard or other housing and assault other

inmates. It is imperative that all cell doors remain locked when locked, that inmates are

prohibited from, and sanctioned for, manipulating cell or other locking devices, and staff are

required to adhere at all times to basic security locking protocols.

The inmate slashing and homicide events previously discussed are two very real examples of why it is important to enforce security locking-control policies and the dangerous and deadly consequences of those policies not being consistently practiced.

Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluation policies and procedures related to facility security pertaining to locking and unlocking access points, units and cell doors, and other locations requiring consistent access controls.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable
functionality, detection of tampering, and timely repair/replacement. 5. Ensure staff are adequately trained in the proper use of mechanical and/or electronic
locking systems according to their post assignments. 6. Consistently sanction inmates for attempting or manipulating any security locking
system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked! 9. Consider replacing or upgrading existing unit control panels to provide for remote
electronic locking and unlocking of unit and cell doors. 10. Increase video surveillance of internal and external access points to ensure rapid
detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking
devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for
investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations. 13. Consistently enforce security locking policies and procedures with staff and inmates.

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d. Procedures for the inspection and maintenance of operational cell and other

locks in Golden Grove to ensure locks are operational and not compromised

by tampering; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There has been no appreciable improvement since the Baseline Report. The facility remains understaffed with maintenance employees. Additionally, a review of housing officer logs indicate continued problems with non-functional cell door locks and emergency exit doors. This issue remains problematic and poses clear and present safety and security risk to inmates and staff. This is evidenced by reports of inmates being able to get out of their locked cell and attacking other prisoners; in some cases, inmates were able to access other housing units because adjacent housing unit gates were unlocked. This condition is exacerbated when only one or no officer is working the housing units, as has also been reported.

Additionally, housing unit emergency exit door locks are often reported as “nonfunctional.” This condition creates serious risks to life and safety when inmates must be evacuation in cases of emergencies.

An “all locks” maintenance policy and Plan as previously recommended was not provided during this visit.

The facility is currently understaffed with maintenance personnel to keep up with lock repairs and/or replacement. Unit logs examined show that staff do report unit and cell door lock problems. Otherwise refer to previous provision.

Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Develop an “all-locks” maintenance plan for review with the Monitor during the December 2013 assessment. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken off line.

e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documents provided during this assessment by Territory officials indicate that the staff recruitment and selection process involves the processes listed above. Documents were provided by the Director that included an Employment Background Screening. However, no documents were provided to verify consistency between policy and practice. The GGACF HR person was not available during this assessment and should be interviewed during the next visit and a sample of personnel files should be reviewed. Recommendations provided in the Baseline Report remain appropriate.

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According to the training assistant interview, a background and criminal history check is performed on all uniformed and civilian applicants. However, a review of a few staff personnel folders did not find documents to verify this practice, nor did the folders contain supervisory review documents. Territory officials state that these documents are on file at the BOC central office and are available for review during the next visit. It is, however, important to state that the personnel/training program is currently under redevelopment and the records filing process has not been completed.
RECOMMENDATIONS:
1. Review, revise, develop, train, implement, evaluate policies and procedures for the applicant and staff records process as indicated by the training assistant.
2. Ensure access to applicant and staff records is adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
3. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.
D. Security Staffing
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:
a. A security staffing analysis, incorporating a realistic shift factor, for all levels of security staff at Golden Grove;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Security staffing levels remain inadequate and dangerously low. Officer and supervisor logs frequently report staff shortages and absences. Housing areas requiring two offices are reported having only one officer working, and there are occasions when housing areas are completely unattended by officers. Despite the fact that VIBOC officials state an additional 14 officers will soon begin the academy, this issue remains very problematic and requires immediate attention to ensure that all posts are consistently staffed with adequate numbers of officers. A comprehensive NIC staffing analysis has not been engaged as of this assessment but is required in the Order.
A comprehensive staffing analysis has not yet been initiated, though the parties and monitor discussed and agreed to delaying the analysis until potential operational efficiencies could be evaluated. Observations during this assessment, staff interviews, and examinations of unit and incident log strongly suggest the facility is significantly understaffed. Only two of three security

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towers are operational due to staffing limitations and there seems to be a chronic shortage of

relief staff. Inadequate staffing levels, combined with inadequate physical security controls

(e.g. functional locks, control panels, cameras, lighting, etc.), and inconsistent security

practices significantly increase safety and security risks to staff, inmates, and visitors.

Recommendations provided in the Baseline Report remain appropriate.
RECOMMENDATIONS:
1. Complete a comprehensive staffing study using the Staffing Analysis process of the National Institute of Corrections.
2. Appropriate funding to hire sufficient numbers of staff to establish and maintain adequate levels of facility safety and security in accordance with staffing analysis results.
b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: An Emergency Staffing Plan was developed by the Director and apparently approved. It was reported that an additional 14 officers have been employed and are attending the training academy. However, this Plan is not based on the results of the required staffing analysis but GGACF officials are commended for these efforts.
The Monitor was not provided with an existing staffing plan. Security staffing schedules provided during this assessment did not provide adequate information to accurately determine authorized and actual staffing levels, or whether current security staff deployment practices met operational needs considering facility/campus design and layout, scheduled and unscheduled activities and events, population factors, etc. In the absence of those documents, I can only conclude that no standard staffing plan exists and that a policy of staffing deployment does not exist and/or is not followed, and/or is not routinely managed.
GGAF cannot effectively protect inmates and staff from harm, provide constitutional conditions of confinement, or provide adequate health care services in the absence of adequate staffing levels and plans. Staffing plans help correctional managers and supervisors devise effective staff deployment strategies, maximize and prioritize use of staffing resources, and help to ensure that staff are where they need to be, when they need to be there, doing what they need to do.
Recommendations provided in the Baseline Report remain appropriate.
RECOMMENDATIONS:
1. Update existing security staffing plans for review with the Monitor during the December site visit.
2. Identify current and anticipated security staffing deficiencies.

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3. Be prepared to discuss the staffing and analysis issues in more depth, and Plan

provisions during the March 2014 visit.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to the above findings. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS: Review, revise, develop, train, implement, evaluate policies and procedures related to facility staffing with particular focus on staffing levels, deployment, recruitment, selection, training, promotion, development, attrition, maintenance of staffing levels, etc.

2. Defendants will implement the staffing plan developed pursuant to D.1.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous findings related to staffing analysis and planning.

RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated in the Baseline Report, documents provided to the Monitor by GGACF include a general PREA policy. This policy is not dated, signed, or numbered. It is unknown if staff are aware of the policy or have completed training on PREA or this policy. The policy does not explain PREA and does not include all PREA definitions. The current policy also does not include all PREA requirements according to PREA standards. Additionally, inmate handbooks do not include PREA topics, their rights within PREA and methods for reporting violations, nor are PREA information documents provided to inmates upon admission.

Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at

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http://nicic.gov/ for qualified information about PREA compliance, training, and other

related resources.

2. Review PREA and develop an action plan for the implementation of PREA

requirements.

3. Appoint a PREA Compliance Coordinator as soon as possible.

4. Complete the PREA Self-Audit.

5. Review, revise, develop, train, evaluate policies and procedures that include, at a

minimum, the following PREA topics:

Policy Organization Definitions Inmate Reporting Staff and Agency Reporting Protection from Retaliation
Hiring and Staffing Viewing and Searches

Staff, Volunteer, and Contractor Training Inmate Education
Inmate Intake and Classification Agency and Staff Response to Inmate Reports Investigations Staff and Inmate Discipline Medical and Mental Health Care Monitoring

F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: There has been no change since the Baseline Report. No revised policy and procedure drafts have been provided to the Monitor for review as of yet. Compliance with this Provision requires a high level of technical expertise and qualification; it is likely that GGACF officials will required outside technical assistance to comply with this Provision are encouraged to contact the USDOJ NIC for this assistance. Recommendations provided in the Baseline Report remain appropriate.
Current classification policies and procedures are found in Section 3 of GGACF Policy and Procedure for Inmate Records, Booking and Inmate Processing, and Inmate Classification (pp.47-55, dated July 1, 1993). According to Territory Officials, the classification process was developed with the assistance of Dr. Jim Austin, classification expert, and the National Institute of Corrections. However, it is unknown whether facility-specific classification protocol was put into place. No additional or new classification policies or procedures consistent with the elements of F.1.a above were provided to the Monitor. Additionally, current

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policy Table of Contents shows classification procedures on pp. 47-55; Section 3 is paged 49-

50 and appears to be missing several pages.

The current admission and review classification instruments are outdated and cannot, therefore, reliably reflect actual classification levels and housing decisions. The current classification is inadequate because: 1) classification decision making is not based on a current and empirically-validated classification tool, and 2) the high levels of institutional violence and contraband reporting in incident logs strongly are indicative of the absence of a valid and reliable classification system.

RECOMMENDATIONS:

1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that
provide more accurate and complete guidance for a valid and reliable classification system for non-convicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance.

b. Housing and separation of prisoners in accordance with their classification;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As found in the Baseline Report, detainees and convicted offenders are generally held in separate buildings except for sentenced and un-sentenced female inmates who are separated in the same building. Inmates are generally housed according to their security level based on behavioral history and whether their background includes violent criminal acts. Inmates are also housed according to administrative, disciplinary, special needs, and/or work assignments. This is a very basic and unreliable practice for managing inmates and is not based on a reliable classification system. Such a practice is known to facilitate violence against inmates and staff, the introduction of contraband, and can create substantial barriers to inmate health and wellbeing. For example, some inmates with serious mental illness (SMI) are being housed in segregation / lockdown unit for lack of an effective and valid classification system. This practice can exacerbate inmate behavior management problems, their mental illness, and specifically prohibited by the Order per Provision V.1.p:

“A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;”

Recommendations provided in the Baseline Report remain appropriate. This issue will remain problematic and contribute to continued introduction of contraband and violence until a valid and reliable classification system is developed, implemented, and evaluated. Refer to previous recommendations.

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Detainees and convicted offenders are generally held in separate buildings except for female

inmates who cohabitate in the same building. Inmates are generally housed according to their

security level based on behavioral history and whether their background includes violent

criminal acts. According to Territory Officials, inmates are also housed and/or separated for

administrative, disciplinary, special needs, and/or work assignments. This is a very basic and

unreliable practice for managing inmates and is not based on a reliable classification system.

Such a practice is known to facilitate violence against inmates and staff, the introduction of

contraband, and can create substantial barriers to inmate health and wellbeing.

RECOMMENDATIONS:

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report to target population cohorts for housing and separation that is more consistent with behavioral risks, and needs.
3. Comply with the Order’s prohibition against housing mentally ill inmates in an isolation cell or housing unit.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: This issue remains problematic and is exacerbated by poor security practices previously described regarding open and unlocked yard gates, housing unit entrance doors and gates, and officer station doors leading between housing units. This issue remains problematic and will continue to pose real and potential risk of harm to staff and inmates. Refer to previous recommendations.

This practice is as much a classification issue as it is a security management issue. As previously discussed, security locking and unit supervision issues are inadequate and deficient based on an examination of the Incident Report and Unit logs. It is imperative that previously discussed security control deficiencies are addressed and corrected without delay. However, even the best classification tool and system is defeated when security and inmate supervisions policies and procedures are not followed consistently as observed during this assessment and evidenced in incident logs, reports, and housing unit logs.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

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ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: As stated in the Baseline Report, there is current practice and general policy for reclassifying inmates following incidents involving violence and disciplinary events. However, this process, as previously stated, should be empirically validated.

Additionally, an examination of Grievance and Discipline Logs show they are incomplete. The Grievance Log is missing several important entries indicating that some important grievances go unanswered. The Discipline Log and disciplinary documents provided evidence that many disciplinary cases are dismissed because timely due process was not provided to the inmate. The accuracy and completeness of these records are very important for making consistent and reliable re-classification decisions. Otherwise, as is indicated in the disciplinary reports, inmates under disciplinary action are given “time served” and release from restrictions without being afforded their right to due process.

There is a current practice and general policy for reclassifying inmates following incidents involving violence and disciplinary events. However, this process, as previously stated, should be empirically validated.

RECOMMENDATIONS:

1. Refer to previous classification findings and recommendations. 2. Refer to recommends related to grievance and disciplinary policies and procedures.

e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct; and..(f).

ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Implementation of a new Incident Reporting Log was described in the Baseline Report and remains in effect. However, a review of this log shows it is often incomplete and illegible. Additionally, the creation of the Gang Intelligence Search Team (GIST) is a positive improvement to comply with this provision, assist in controlling contraband, and reducing the high incidence of violence. The team’s scope of responsibility should be expanded to cover all aspects of this provision and participate in regular meetings review incident reports, data, and outcomes resulting from their efforts. Additionally, specific policies and procedures should be developed to guide in this process. Otherwise, recommendations provided in the Baseline Report remain appropriate.
RECOMMENDATIONS:
1. Develop policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.

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3. Revise incident report forms to include all essential elements to track incident data in

a systematic and unified manner.

4. Establish an incident tracking database to produce and regularly review valid and

reliable incident information and data.

f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There continues to be no formal mechanism or process for regularly reviewing status and conditions of inmates housed in segregation. As reported in the Baseline Report, several inmates housed in segregation presented with very poor hygiene and some appeared to be seriously mentally ill. Some inmates interviewed indicated that they did not know how long they were to remain in segregation and several of those with apparent mental illness stated they had not seen a health care professional.

As an example, the mental health case planner described to Dr. Stellman a prisoner who became “increasingly agitated that I had not ‘come to see’ him during his time in lockdown.” (August 14, 2013 Incident Report). The case planner reported that:

“I explained most times Case Management Planners are not aware of who is in lockdown . . . I explained with my caseload this is not realistic [to seek the prisoner out while in lockdown]. I requested [help from management] take the responsibility to request help whenever he needs it.”

There remains no formal monitoring process in place. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or as a treatment for inmates who are mentally ill.

G. Incidents and Referrals

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1. Defendants will develop and submit to USDOJ for review and approval facility-specific

policies to alert facility management of serious incidents at Golden Grove so they can take

corrective, preventive, individual, and systemic action. Such policies will include the

following:

a. Reporting by staff of serious incidents, including (i) fights; serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There has been no change since the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

No such policy has been issued as of yet; this indicates that such reporting does not occur. This seems further evidenced by previous discussion involving Unit Logs wherein officers report serious security and facility deficiencies that seem to go unresolved. This lack of policy, procedure, systematic resolution and quality management appears to not only be discouraging and frustrating to correctional staff, but can promote noncompliance to policies and procedures in general, and provides management no reliable tools for effective staff deployment or security/safety hazard mitigation.

RECOMMENDATIONS:

1. Complete and submit policies as indicated. 2. Integrate the Incident Tracking system into this policy. 3. Develop protocols for current tracking system to improve data validity and reliability;
this document is replete with duplication and misleading entries. 4. Develop a unified incident coding system for valid and reliable information and data
collection, reporting, and analysis. 5. Establish regular monthly quality assurance meeting process involving all major
department team leaders to review serious incident reports and recommend evidencebased remedial measures for eliminating/mitigating incident frequency and severity.

b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: PARTIAL COMPLIANCE

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FINDINGS: Senior staff now participate in GIST meetings to review incident activity, which

is an improvement since the Baseline visit but additional work is needed for compliance.

For example, the lack of administrative staff severely restricts and limits the level of criminal or administrative investigations from taking place, and that incident reports are not consistently reviewed for accuracy or completeness. Participation in GIST meetings, while important, does not necessarily result in meaningful or comprehensive review of incidents. It also does not suggest that staff are identifying trends, and using the information obtained to inform security decisions.

RECOMMENDATIONS:

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous section on contraband control as it also pertains to confiscation and preservation of evidence

RECOMMENDATIONS:

1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous findings regarding incident reporting and tracking. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous findings regarding incident reporting and tracking. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

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1. Include this element in the required policy and procedure.

2. Establish reasonable time frames as indicated.

H. Use of Force by Staff on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force, Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There has been no change since the Baseline visit. No policy or procedure revisions have been provided to the Monitor for review. A review of reports involving use of force made it virtually impossible to determine whether force and/or the levels of force used were appropriate under the circumstances. Recommendations provided in the Baseline Report remain appropriate.

Documents provided show that GGACF rules and regulations pertaining to staff use of force are scattered throughout these documents and not located in a unified Use for Force Policy and Procedure document, which is considered a standard method for maintaining policies. As such, it was very difficult to locate, accurately interpret, and/or reconcile similarities and conflicts between these regulations. In some cases, the regulations conflicted making it impossible to determine what and when force is authorized and used. I was unable to identify a standard Force Continuum document although Use of Force, Firearms, and Use of Chemical Agents is listed in the Pre-Service Training outline provided. I not did find use of impact weapons (batons) listed in the training outline but did observe them present in control rooms and possessed by the segregation housing officer.

RECOMMENDATIONS:

1. Review, revise, develop, train, evaluate use of force policies as indicated and include, at a minimum the following policy elements: A. Mission and purpose statement B. Legal authority for use of force C. Definitions: of force, conditions, applications, non-physical and physical force, authorized weapons, deadly force, necessary and unnecessary force, etc.; D. Pre-service staff proficiency training, qualifications, certification, and regular inservice training; E. Use of deadly force; F. Use of any weapon authorized for use; G. Reporting requirements; H. Force event quality control and assurance program and methods; I. Self-defense;

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J. Impermissible force;

K. Staff noncompliance corrective measures;

L. Medical/mental health involvement in use of force events;

M. Force against special populations, e.g., mentally ill, frail, medically ill, aged;

N. Planned and unplanned force;

O. Special force operations and equipment;

P. Officer safety and protection;

Q. Emergency first aid;

R. Administrative reviews;

S. Use of restraints;

T. Centralized incident, training, and qualification record keeping;

U. Armory operations and instructor training and certification;

V. Photographing, videotaping, recording of planned force events;

W. Other.

b. Circumstances under which the permissible forms of physical force may be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings. No change. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Refer to findings in H.a. above. Recommendations provided in the Baseline

Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

e. Training and certification required before being permitted to carry and use an authorized weapon;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No documents were provided to support improvements in this area. As previously stated, the HR/Training person was again not available during this assessment. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Despite the lack of revised related policies and procedures, incident reports examined during this assessment indicate that force incidents are relatively low and that staff are reporting the incidents. However, GGACF official are encourage to include a use of force review process at the management level to collect relevant data and regularly verify consistent reporting of force events. Otherwise, recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

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1. Include this requirement in policy, procedures, and training as discussed in

recommendations H.a. (1A-W) above.

h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since Baseline visit. Furthermore, the frequency with which the towers are not operational due to staffing problems renders them a consistently unreliable security control post. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The Warden stated that, although there are few incidents of force being used against inmates, that all incidents and reports are reviewed for accuracy and justification in a timely manner by supervisors and management officials. However, a review of reports indicated that some remain incomplete and/or do effectively articulate what is being reported. No revised policy or procedure has been provided to the Monitor for review as indicated in the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

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k. Timely referral for criminal and/or administrative investigation based on

review of clear criteria, including prisoner injuries, report inconsistencies,

and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit. Additionally, the Warden reported that the Investigator position has not yet been filled. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

l. Administrative investigation of uses of force;

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit. No policy or procedure revision was provided to the Monitor for review. Additionally, a review of the Inmate Grievance and Disciplinary Logs indicates that these documents are often incomplete and do not follow acceptable timeframes for resolution. Additionally, there is no specific mechanism for reviewing grievance or disciplinary events for use of force involvement. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. No policy or procedure revisions were provided to the Monitor for review. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

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1. Include this requirement in policy, procedures, and training as discussed in

recommendations H.a. (1A-W) above.

o. Re-training and sanctions against staff for improper uses of force.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Training records were not provided to the Monitor at this or the Baseline visit and the Training Director was not available for either assessments. No policies or procedures were provided that articulate such a process.

RECOMMENDATIONS:

1. Refer to previous list of Use of Force policy and procedure topics related to this provision for inclusion in those documents.

I. Use of Physical Restraints on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:
a. Permissible and unauthorized types of use of restraints;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No records, policies, or procedure were provided to prove compliance with this provision. Additionally, as previously stated, the HR/Training person was not available during this assessment and those records are apparently not kept onsite. Recommendations provided in the Baseline Report remain appropriate.
RECOMMENDATIONS:
1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
b. Circumstances under which various types of restraint can be used;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same findings and recommendation as above. Recommendations provided in the Baseline Report remain appropriate.
RECOMMENDATIONS:

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1. Include this requirement in policy, procedures, and training as discussed in

recommendations H.a. (1A-W) above.

c. Duration of the use of permitted forms of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Required observation of prisoners placed in restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See below.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Develop, train, implement, and evaluate well-researched, well-written, clear, and complete policies and procedures to managing the use of restraints process.
2. Involve a multidisciplinary process in decision making to use, monitor, and terminate restraint use.
3. Train all staff in this process and the proper use of restraints and less restrictive alternatives.
4. Develop training lesson plans for this process that ensure staff competency in both knowledge and application of the restrain policies and procedures. Always train using the actual restraint devices authorized.

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5. Develop and implement a reporting and tracking system for restraint use. Leadership

should review all restraint use on a monthly basis to ensure policy compliance and take

remedial/corrective actions, whether to policy, procedure, or staff noncompliance, in a

timely manner. All remedial/corrective actions should be documented and maintained.

f. Required termination of the use of restraints.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Same as above. 2. Ensure the policy includes restrictions on restraint use duration and termination
requirements.

J. Prisoner Complaints

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

Additionally, a review of the Inmate/Detainee Grievance Log Sheet indicates that this process is not consistently maintained. Much of the information required by the Log is missing and incomplete. Several dates are missing, which makes it impossible to determine whether responses to inmates were timely. The “Chief’s Response” column frequently states “no answer” or is empty. This is problematic as several of the inmates’ complaints involved medical issues, officer misconduct, rights violation allegations, request for hygiene products, attorney access, food, assaults by officers, missing eye-wear and personal property, and dietary meals, for example.

There are no clearly written policies and procedures for ensuring confidential access for reporting complaints or that includes assistance to inmates with cognitive and/or communication (verbal/written/auditory) impairments. Although the incident log notes “confidential” in certain cases, this practice is informal and discretionarily determined according to specific circumstances. Discussions with the Warden about this issue revealed that both confidentiality and communication impairment issues are dealt with on a case-by-

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case basis, but no formal policies and procedures exists. Those discussions also suggest that

management is aware of these needs, takes appropriate steps to meet those needs, but does so

in the absence of written guidelines.

It is also important that policies and procedures direct under what conditions housing unit officers are authorized to resolve complaints. This issue must be studied carefully with specific written controls when promulgating policies and procedures. It is important for the protection of staff and inmates that inmates have timely access to a complaint/grievance process that is unfettered by unauthorized resolution by correctional staff. Such controls and guidelines will also facilitate inmate access to their rights, care and alert facility officials (administration, security, medical, mental health) to ongoing risks to inmates and staff.

There is no formal inmate complaint/grievance tracking system currently in place. Although complaint forms are available to inmates, there is no system established to ensure that complaints are resolved, followed-up, and/or monitored. Current practices also differ among unit officers, according to inmate and staff interviews. Some officers allow free access to complaint forms, others state they attempt to resolve matters informally before issuing a form, still others require all completed complaint forms to be submitted by the inmate to the officers for further processing. Inconsistencies in the complaint process exposes staff and inmates to erroneous allegations of misconduct, increases risks of inmate abuse by staff, places inmate health care and rehabilitation at risk, and thwarts development of a valid and reliable complaint reporting and tracking system. However, even the best inmate complaint system is rendered ineffective if inmates do not have the means to ensure complaints are reliably collected and reviewed. Many of the boxes used to collect complaints and sick requests at the housing units were found unlocked and/or broken. Some of these boxes were filled with trash, which clearly evidences ineffective management oversight by housing unit officers, supervisors, and management.

RECOMMENDATIONS:

1. Review, revise, develop, train, and implement inmate complaint policies and procedures.
2. Develop and implement a valid a reliable complaint reporting and tracking system. 3. Conduct monthly administrative reviews of the inmate complaint reporting and
tracking process to measure and verify program compliance, take timely and appropriate remedial and correction action.

b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate. Additionally, the development and implementation of a consistent process for timely investigating inmate complaints is thwarted by inmate grievance process discussed above.

RECOMMENDATIONS:

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1. Same as above. 2. Include policy and provisions for timely investigations of complaints, prioritization of
complaints related to risks of harm and safety, and medical and/or medical care.

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit; there is no formal policy or procedure on this subject matter. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Complete required policies and procedures. 2. Include specific policy and procedural provisions requiring corrective action for staff
noncompliance, and that ensures timely, consistent, and appropriate disciplinary action against staff who violate the policy. 3. Also consider Inmate Grievance Log issues described above in developing these policies and procedures. 4. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate. Same issues described above regarding the Grievance Log.

RECOMMENDATIONS:

1. Develop and implement a formal centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

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Additionally, the Inmate Grievance Log clearly suggest the absence of a systematic and

reliable process for reviewing prisoner complaints, trends, or individual and systemic issue.

RECOMMENDATIONS:

1. See previous recommendations related to reporting and tracking complaints. 2. Conduct monthly administrative reviews of inmate complaint/grievance tracking
reports and data to identify patterns of individual staff, inmate, and/or systemic problems and issues.

K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate. No policy or procedure revisions have been submitted to the Monitor for review.

RECOMMENDATIONS:

1. Submit administrative investigation policies and procedures per this provision as indicated.
2. Ensure the policies and procedures clearly describe investigative timelines, officials responsible who are authorized to conduct interviews, methods and locations of interviews, and other relevant topics that maintain the integrity and legality of the investigative review process and determinations.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

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1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling,
labeling, preserving, and maintaining administrative investigation evidence, information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Additionally as previously discussed, even if an investigation determines that an inmate deserves some form of punishment for a disciplinary infraction, that punishment is often not determined or enforced because due process proceedings often do not occur. A review of prisoner disciplinary files from the last three months shows that no prisoner had disciplinary action taken against him or her; disciplinary charges were dismissed because there were not enough staff to conduct the due process hearings. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate. As previously stated, the HR/Training person was not available during this visit.

RECOMMENDATIONS:

1. There is no formal pre- or in-service training program to train staff who are involved in initial and/or administrative investigation.
2. Provide adequate training of staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
3. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management.

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4. Develop and implement, as an adjunct to these policies and procedures, an

“Investigators Manual” that provides guidance to staff responsible for oversight and

investigative activities.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change regarding policy and procedure requirement since the Baseline visit.

RECOMMENDATIONS:

1. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.
2. Integrate the information in the above into the administrative policies and procedures previously discussed.
3. Record and maintain onsite records of staff misconduct investigative reports and determinations.
4. Protect the integrity and confidentiality of these staff records; control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
5. Provide training to supervision staff in the appropriate use of this information for staff supervision, counseling, discipline, promotion, etc. purposes.
6. As with all training, especially training required for and, that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE
Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: At the time of this second visit, we were provided with a draft of the screening policy which does contain several of the elements that would, if implemented, bring the facility into compliance. We appreciate the work performed by the Golden Grove staff to draft this policy. The draft presumes the ongoing involvement of correctional officers performing the screenings during the off hours. Having reviewed numerous records during this visit, we have concluded that commonly the officer health care screen does not lead to, in most circumstances, appropriate follow-up by health care staff. In fact, the majority of the records we reviewed did not contain appropriate follow-up, which may include contacting the on call physician or at a minimum, an early health assessment by an advanced level clinician. We were also provided with a newly developed screening tool to be used by health care staff which does contain many of the elements which should be present as part of an intake screen. However, the screening tool relies on the use of an acuity scale in order to determine the appropriate disposition, including the urgency with which a physician is called as well as the timing of the health assessment. What is missing is the acuity scale to be developed by the Medical Director. This tool presumes only health care staff are performing the intake screens. We have been told that the budget that took effect October 1, 2013 does contain positions for three additional registered nurses and three additional licensed practical nurses. With these positions in place, the facility should be able to guarantee that only licensed health care staff in fact perform the intake screens 24 hours per day, seven days per week. During our visit, the leadership staff were informed that they should review the applications for nursing staff for these positions. However, they were blocked from doing this when the person in charge of human resources was unavailable and these applications were inaccessible. A responsible leader of human resources would have made arrangements for these applications to be available. It is quite discouraging that the leadership of such an important position within the organization is entrusted to a person who demonstrates such an absence of professionalism. We are quite encouraged by the submission of both the draft policy and the draft intake screen. However, we must also see the draft acuity scale, including the definitions of the type of identified conditions that warrant either an immediate call to the physician or health assessments to be performed on Day 1, Day 2, Day 3, or in some instances based on the need for finger stick or blood pressure monitoring, Day 7. We appreciate that the Health Administrator has

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in fact utilized many of the elements that we provided in our initial report. Besides removing the

use of correctional officers in the intake health care screening process, the draft policy should

specify the tracking of the elements of the intake process, including a completion of the screen,

the completion of the TB screen, the completion of the health assessment by dates, and the

scheduling of any follow-p, including mental health, dental, chronic care and sick call visits, along

with any other required follow-up.

RECOMMENDATIONS:

1. Out of the seven elements listed in the findings, develop a draft policy and procedure along with a new intake screening form for submission to the Monitor.
2. Feel free to solicit input and/or consultation through the Monitor for the development of this policy and procedure.
3. Continue the excellent work on the intake policy, including the provision of an acuity scale and the log tracking system.
4. Solicit input and/or consultation through the monitor for the development of this policy and procedure.
5. Proceed with the hiring process of the RNs and LPNs. 6. The priority policies for development should include: (1) intake screening, (2) health
assessment, (3) sick call, (4) chronic care, (5) urgent/emergent services, (6) continuity, (7) discharge planning, (8) intoxication/detoxification, (9) quality improvement, (10) transfer screening, (11) clinical performance enhancement, (12) medication management.

MENTAL HEALTH FINDINGS: The intake process remains flawed with no change in the process or tools. As noted in September 2013 "even when incoming inmates are identified through the screening tool or the officer's observations as having mental health problems, referrals often do not occur, resulting in misidentification and lack of services for those individuals." Medical screenings are frequently delayed significantly and at least in one case, medications have been administered to an inmate for several months with no clinicians order or follow-up visit.

Regarding the development of mental health policies and procedures specific to the facility, no new policies have been developed since the time of our initial visit. Staffing remains unchanged and is still considered inadequate in quantity and composition to meet the needs of those seriously mentally ill and acutely symptomatic inmates housed at GGACF.

RECOMMENDATIONS:

1. A more effective intake process should be developed so that medical staff has access to new detainees and prisoners within 24 hours. The initial security screening tool is not robust enough to provide good identification of medically and psychiatrically ill people. Security staff conducting these interviews will require additional training by health services (medical and mental health) and a quality assurance tool should be developed to monitor the completeness of their documentation and the accuracy of their triage two medical and mental health staff.
2. Medication bridging is problematic with evidence of medications being prescribed and administered but not ordered by a clinician. A review method needs to be developed to oversee the reliability of this process.

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3. All of the medical policies need to be reviewed and modified as applicable to this facility.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have not yet seen the revisions to the health assessment policy that we reviewed after our first visit. In particular, the health assessments policy did not require the development of an initial problem list and plan and should be utilized to insure appropriate continuity of services. Since the acuity scale for performing the health assessments was not available, it is not likely that the timing of the health assessments would always be appropriate. Finally, we are well aware that there have been serious problems with the predictability of the availability of onsite physician or other advanced level practitioner services. Compliance will not be achievable until there is a dependable schedule for onsite advanced level provider services. In particular, there have been serious and prolonged absences with regard to the Medical Director’s presence. It is our understanding that efforts are being made to address this problem. Successful implementation of the intake process is dependent on the availability and active participation of the Medical Director. Many of the records we reviewed either lacked a health assessment or contained a health assessment that was greatly delayed. Examples are a patient with a seizure disorder entered in December 2012 who had a screen by an officer but no health assessment or adequate follow-up. In addition, a patient with HIV disease had a physical exam in January 2012 but no listing of HIV on the problem list. This patient, by the way, has not seen an HIV specialist for a year and lacks a recent viral load within the last six months. Our last report contained many of the elements that should be present within the health assessment policy. We look forward to working with the leadership team in the completion of the health assessment policy.

RECOMMENDATIONS:

1. Utilize the elements listed under “Findings” to promulgate a new policy and procedure for the performance of health assessments.
2. Utilize the Monitor and his team for any consultation or technical assistance.

MENTAL HEALTH FINDINGS: Intake medical screenings are often delayed by nearly a week following booking. All too frequently there is evidence of the failure to complete a 14 day history and physical assessment by medical staff. This is an essential process designed to allow the inmate a second opportunity to report signs and symptoms that he/she may have not wish to share with the security officer at the time of intake or he/she may have been impaired at that time and not interested in participating in the process. In addition, failure to complete both of these steps in a timely manner delays or fails completely to provide for mental health referrals. These inmates then become lost to follow-up and current preadmission medications are abruptly discontinued.

Both juvenile males were interviewed on tour and their medical records were then examined which verified their reports.

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Findings Case #1

Deficiencies/ Areas of Potential Harm

The inmate was recently released from rehabilitation services on Prilosec and Remeron. Intake was performed 8/7/13 and medications were noted. The medical intake was 8/8/13 and a weight but no height was obtained. There has been no 14 day history and physical, has never been seen by a clinician. Inmate is currently on Prilosec without a prescription from an M.D. Psychiatric medication was never administered; inmate has never been referred to mental health, and reports never having been seen. Inmate did not, fortunately, report difficulties off his antidepressant.

1. Failure to refer for psychiatric evaluation
2. Failure to bridge his antidepressant medication
3. Continuation of Prilosec without a clinicians order
4. Failure to perform a 14 day history and physical assessment
5. Incomplete vital signs on intake

An intake was performed on 8/16/13 and the review of systems area on the officers screening is completely blank. A medical screen was performed 8/25/13 with no recorded height. The PPD was placed and read within a reasonable timeframe. Inmate has had no clinical contact since the time of his medical screening.

1. Incomplete intake screening 2. Incomplete vital signs on
medical screening 3. Significantly delayed
medical screening 4. No 14 day history and
physical ever performed

The parties have agreed to amend the definition of a qualified mental health professional to include an unlicensed master level provider. This is in part because the US Virgin Islands does not have a licensure process for social workers or counselors at this time. Instead, the parties have agreed that a qualified professional based on education, training, and experience will satisfy the current settlement agreement. Therefore, the Mental Health Coordinator has sufficient qualifications to perform and complete a comprehensive mental health assessment and deliver psychological services at the facility. The facility is in compliance regarding the qualifications of staff conducting the initial comprehensive mental health/biopsychosocial assessment following referral from the screening staff.

However, there has been no change in the screening tool or process, as well as, 14 day history and physicals. Security intake screening forms are often unsigned and incomplete particularly marked by the failure to document responses to the review of systems questions.

Most significantly, regarding mental health care, is the fact that sentenced inmates do not routinely receive comprehensive mental health assessment unless they are referred to mental health. It is generally a standard throughout the United States that prison inmates all receive an initial evaluation by a qualified mental health professional within the same time frames as the completion of the 14 day history and physical by medical.

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RECOMMENDATIONS:

1. Again, GGACF should complete a detailed staffing and programs need analyses to determine the number of qualified mental health professionals required to deliver adequate services to detainees and prisoners.
2. Intake screening tools, as recommended before, should be improved in their comprehensiveness, quality of documentation, legibility, signature, date and time.
3. A quality improvement process should be developed to monitor the quality and timeliness of intake screenings as well as 14 day history and physicals and comprehensive mental health assessments for all prison inmates and the latter for any detainee with a positive mental health screen.

c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have not seen the revised policy that addresses sick call or access to primary care health services. We also have not seen a policy that addresses prenatal care for pregnant prisoners. During this visit, we continued to find sick call boxes that were broken and therefore not usable. We were told that in housing units with broken boxes, medication nurses collect the slips. We were also told that the slips are then brought back to the nurse and stamped received and placed in a sick call tray for the head nurse to review. In reviewing the current sick call log, we observed that most patients were seen by a nurse or an advanced level clinician within two days. However, some were not seen for up to a week. We were informed that this was usually due to the absence of an onsite physician. An example is a patient with HIV, diabetes, and hypertension who submitted a slip on November 26 and was not seen until December 2. A second example is a patient who submitted a slip on November 14, complaining of side pain. The inmate was not scheduled for a physician assessment until November 21. When this inmate was seen, labs and x-rays were ordered; however, these were never performed. We were informed that these were not performed because of problems with lack of officers and lack of a transport van to take the patient to the hospital for the tests. Another case was a patient who arrived in March of this year, was screened by an officer but has never had a health assessment. This inmate submitted a slip requesting services for a head infection on November 12, but was not seen until November 27. Finally, there is an example of a middle-aged patient who submitted a slip on 11/13 for knee pain and was not seen until 11/22. An x-ray was ordered but this was never done, we were told, because the transport van to take the patient to the hospital for the x-ray was out of service.

RECOMMENDATIONS:

1. Use the eight elements in our initial report listed under findings of small letter ‘c’ to develop your sick call policy and procedure.
2. The policy should insure that there is an assessment by either a registered nurse or advanced level clinician within two days of receipt of the request. For referrals to an advanced level provider, there should be a registered nurse assessment within two days

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unless there is certainty that the advanced level provider will be onsite within the required

two days.

3. The administration must address the escort officer and transport van problems creating

delays in access.

4. Utilize the monitor’s team for consultation and/or technical assistance.

MENTAL HEALTH FINDINGS: The continued limited and unpredictable hours of psychiatric service are not conducive to the scheduling needs of the service. In addition, the lack of security support hampers the team's ability to deliver timely and predictable services because inmates cannot be brought to the clinic as scheduled. In the past, the facility contracted with a counseling service to provide group and individual counseling (The Village) but that contract ended due to nonpayment and the inability to reach a contract with the facility. There has been no staffing increase to compensate for the loss of that service and no further group therapies provided. As a result, the two staff members are providing less than the minimum service consisting of assessments of referrals, counseling follow-ups for only some of those people assigned to the caseload, and infrequent psychiatric visits. The counselor will expedite visits to the psychiatrist for inmates with acute problems, but the common result is a delay in the management of those inmates on the chronic care caseload because there are insufficient hours of psychiatric time to allow for scheduling of urgent and routine visits in the clinic.

At the time of our visit the psychiatrist was still partially retired but continues to be available to the facility. In general, it appears that he will be on site for part of Tuesday and may return on Thursdays if notified in advance by the mental health professional. Due to the sparse number of psychiatric hours currently available, some patients may be rescheduled to return to clinic in six months to a year.

The mental health caseload continues to represent a lower than expected percentage of inmates in treatment. The question as to whether there is under-identification of mental illness during the intake process and difficulties with that process needs to be explored through a quality improvement process.

Access to care continues to be significantly restricted due to the lack of security staff available to transport inmates to and from the clinic. We again observed many instances of delayed or untimely follow-up appointments which are at least partially attributable to the lack of escort officers.

Our findings are supported by case reviews as follows:

Case # 8
27

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Findings Case

Deficiencies/ Areas of Potential Harm

Review of this record indicated a psychiatrist order instructing follow-up on the laboratory study the doctor had ordered four months before. There is no mental health initial comprehensive assessment or progress notes from the mental health counselor in this record. The last orders for multiple medications including Haldol and Depakote were written May 7, 2013. This inmate has not been seen by psychiatry since May 2013

1. Delay in carrying out laboratory orders
2. Inadequate psychiatric follow-up
3. Missing mental health documentation from the record

The Depakote level was ordered on 10/11/13 and no results are found in the medical record. On 10/31/13 the physician noted that his entry was a second order for valproic acid level. He also noted for the nurses that there was an active order for Cogentin which apparently had not been transcribed and initiated.

1. Nursing transcription omissions for medication and laboratory studies

RECOMMENDATIONS:

1. The elements in the above findings should be used to promulgate a policy and procedure related to access to care and sick call. A system for a confidential retrieval of sick call request by medical staff should be implemented and codified in policy.
2. The Monitor’s team should be utilized for consultation and/or technical assistance. 3. The facility needs to define by policy the qualifications required for each clinical process as
well as time frames to complete these processes and provide the clinically necessary followup. 4. Again, a staffing analysis needs to be completed to determine the required minimum number of psychiatric hours and counseling hours needed. 5. Mental health staff should perform, at a minimum, weekly segregation rounds and monthly well-being checks on all sentenced inmates on the mental health caseload. 6. Nursing transcription omissions should be addressed through education, supervision, and monitored by a Quality Assurance process.

d. Continuity, administration, and management of medications that address:
(i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and
clinical practices; (iii) review for known side effects of medications; and (iv) sufficient supplies of medications upon discharge for prisoners
with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE

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MEDICAL FINDINGS: We still have not been provided with any policy or procedures regarding medication management. We have in our last report provided 18 points which can be utilized with regard to various aspects of the policy as well as the medication program. During this visit, we also observed a medication administration by the nurse who performed this for a morning medication pass. The nurse had excellent rapport with the inmates and interacted with them quite constructively. She also had good rapport with the correctional officers. However, there were basic elements that were either never adhered to or not consistently adhered to. The first element requires that the inmate presenting to the nurse demonstrate, by the presence of an ID card or wristband, that he is who he presents himself to be. This was never done. The second element requires that the inmate present with a container of water with which to ingest the medication. We in fact saw one or two inmates ingest the medication without any water and walk away. This is the perfect strategy if one is going to cheek the medications for use later. Finally, there should be a mouth check conducted by a correctional officer after medication ingestion. This was never done. Finally, the documentation of the administration does not occur until the entire medication process has been completed. Delaying the documentation is known to increase documentation errors. We also reviewed a report prepared by the pharmacist titled, “Assessment of Medication Management Processes,” and submitted by the pharmacist in October of 2013. This consultation report documents that the current process is not consistent with Virgin Islands statutes and does not maintain the appropriate controls that would insure protection of the medications. We understand that there is a possibility of a pharmacist being granted a contract to manage the medications. We believe this is an excellent step forward and would strongly endorse it. In order for the medication processes to substantially improve, there has to be education of the patients as well as education of the officers regarding their role as team members in facilitating the provision of medications.

RECOMMENDATIONS:

1. The above elements should be included in a draft policy and procedure dealing with medication management.
2. The Monitor staff should be sought for consultation or technical assistance in the drafting of this policy and procedure.
3. Proceed with the effort to contract with a pharmacist to improve the management of pharmacy services.
4. Modify the post orders of housing unit officers to include their participation in assisting the nurse in the medication process. This assistance should include insuring that the appropriate inmates are made available to the nurse in an orderly fashion and that immediately after ingestion, the officer conducts a visual inspection of the mouth to insure that there is no contraband.
5. When this is in place, the inmates should be informed that in order to receive medications they must present their ID to the nurse as well as bring a container of water to the nurse. Finally, in order for them to receive the medications, they must facilitate a visual inspection of their mouth after ingestion.
6. Continue drafting both medication administration policies and medication management policies, including the 18 elements listed in the findings of our first report.
7. Develop a strategy that allows more timely documentation of the administration in relationship to the actual administration.

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8. Develop your policy and procedures regarding making available discharge medications,

understanding that the process and procedures are likely to be different for sentenced inmates

whose release is planned versus un-sentenced inmates whose release may be unplanned.

MENTAL HEALTH FINDINGS: GGACF has made strides to improve medication management. A consulting pharmacist has been hired and construction to create improved pharmacy facilities and security are underway. The pharmacist is also working with the territories Board of Pharmacy to obtain a facility pharmacy license.

During an interview with a female diabetic inmate (case # 1) we observed two insulin syringes on her person. She reported that the nurse comes once a day with two syringes filled with insulin. These syringes of insulin are left with her for self-administration. She usually keeps her syringes in her cell and the nurse will pick them up the following morning. In reviewing her medical record her medication administration records indicated that in August of 2013 she was dispensed a vial of Novolin. There were no MARs for October or November and her December MARS shows no administration entries. This report raises serious concerns regarding sharps control as well as the dispensing of enough insulin to represent a potential harm to self or others.

Another concern was raised by an interview with a female inmate who reported that she is on to hypertensive medications but half the time she does not receive one or the other medication. She also reported that at one point she had missed almost an entire week of medication. However inspection of the medication administration records demonstrated 100% administration of Procardia, and hydrochlorothiazide. Indeed review of every MAR showed excellent medication administration with sparse refusals.

The psychiatrist reported concerns about the reliability of transcription and implementation of both his medication and laboratory orders and this was substantiated in review of some medical records. Psychiatry does not utilize informed consent forms and there is no routine documentation regarding education about medication side effects and inmate consent. Medication review often is not performed within customary timeframes, with some inmates lost to follow up and psychiatric chronic care review or not seen for 6 months.

See case # 8 cited under 1.c.

RECOMMENDATIONS: defer to Dr. Shansky's report

e.

Maintenance of adequate medical and mental health records, including

records, results, and orders received from off-site consultations and treatment

conducted while the prisoner or detainee is in Golden Grove custody;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have not yet received a medical records policy that deals directly with the procedures required to insure timely accessibility of the medical records to the professional staff. In our first report, we provided some basic elements that should be considered when developing the medical record policies. During this visit, we continued to find records in which documents had not been filed as well as documents filed in the wrong section or not filed chronologically. We also found documents in the records, such as offsite service reports, which had

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not been initialed and dated by the responsible clinician. These are all elements that must be

addressed in the new policy. It is important that there be a single medical record and that that record

contain not only all medical documents but also all dental and mental health documents. This

method provides for more timely assessment and care, especially in emergent situations, while also

providing for adequate continuity of care. It would be a significant improvement were there to be a

dedicated medical record clerk responsible for filing as well as pulling for use the medical records.

RECOMMENDATIONS:

1. The above elements should be utilized to draft a more detailed medical record policy. 2. Consider providing a position for a staff person completely dedicated to the maintenance and
timely provision of medical records. 3. Develop policies and procedures requiring the timely review, initialing and dating of all offsite
service documents, including procedure reports, consultation reports, emergency room reports and discharge summaries. 4. The Monitor’s staff should be utilized as resources to facilitate development of the policy and procedure.

MENTAL HEALTH FINDINGS: Medical records are stored in a separate room. They are alphabetized and do not have a Bureau of Corrections number. Name alerts are utilized when necessary. As noted in the Baseline Report:

There are no medical records personnel to organize and maintain the medical files. As a result, the records are disorganized. The mental health professional reported she was told not to file records in the charts until they were reorganized.

We again noted that the mental health counseling notes were still being retained in the Mental Health Coordinator's office.

One significant improvement was the development and implementation of the psychiatric progress note. As a result of the use of this form, the psychiatrist’s documentation was better, organized, detailed, and easy to read and navigate through.

There continue to be significant problems with documentation in the medication administration record. Our prior notations from September 2013 still hold true:

Medication administration records show orders transcribed but lack essential components such as a start date, stop date, and the name of the ordering clinician. The administration records may demonstrate significant medication noncompliance, yet there is no system of written notification to the clinician and no evidence in the records reviewed that medication compliance is taken into consideration at the time of the visit. More often than not, MARs are missing from the medical record.

The medical records are not in chronological order and records are not always filed in the correct section of the chart. Chart sections are not labeled. Some charts are combined medical and mental health records while others are separated and the facility should consistently do one or the other.

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There is no policy that drives the organization and quality of the medical record. Medication

administration records were frequently absent for months at a time. Entries are not routinely

timed and often the signature is illegible and lacks credentials.

The only documents that contain a current and past history consistently are the bio psychosocial assessments completed by the Mental Health Coordinator. However, many of the charts reviewed did not contain this document and therefore, more often than not, lack of past and present history.

RECOMMENDATIONS: Unchanged since the baseline visit

1. There is a need to draft a more detailed medical record policy. 2. The Monitor’s staff should be utilized as resources to facilitate development of the policy
and procedure. 3. One chart per inmate, combining medical and mental health documentation for an
integrated record. 4. It is recommended that the mental health professional immediately file her notes in the
medical record so they are available for the psychiatrist to review. 5. A policy needs to be developed with documentation guidelines and instructions for
organizing and maintaining the medical record. 6. Quality improvement effort should be undertaken to track compliance with policy once
implemented.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for the policies.

RECOMMENDATIONS: See letter (c) findings and recommendations.

MENTAL HEALTH FINDINGS: Female inmates, by consensus, reported that the most effective system they have been able to develop in order for medical to receive their sick call requests is to hand their requests to male trustees through the gate of their unit. They reported that using sick call boxes or handing their sick call requests to the security officer both failed as reliable methods of communicating with the medical department. They all reported that they were told they were supposed to hand sick call requests to security staff. Even though the nurse is on the unit twice a day that staff member apparently does not request or collect sick call requests.

The most worrisome finding are the reports, both in September and now, December, of frequent lack of security officers on the units at night when women are locked in their cells. The danger of this practice is highlighted by the following:

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Findings Case # 5
This woman recently went into a diabetic coma approximately 2 months ago while locked in her cell during the night. Her blood glucose level was critically low. There was no officer on the unit and she reports that an officer was going off duty and had a feeling that she needed to go to the female dormitory. The inmate has been on insulin for 22 years and has never had an insulin induced coma before. As a result of this episode the dose of her insulin was lowered. The medical record validates her reports.

Serious Deficiencies that could result in

death

1. It is only by serendipity that an

officer decided to check on the unit

when going off duty. Had she not

this woman would likely have had

serious

life

threatening

consequences or died had this

officer not performed an unassigned

check outside of her post.

2. The other inmates report they were

screaming and banging on the walls

to attract attention and were

frightened by their powerlessness to

aid the ill woman.

Additionally, segregation sick call rounds by mental health staff on a weekly basis for both detainees and sentenced inmates is not occurring.
RECOMMENDATIONS: Similar to those of the September 2013 report as follows:
1. A confidential process needs to be established that enables:  monitoring of the timeliness of retrieval of sick call requests  appropriate triaging by a registered nurse or mental health professional (in the case of mental health requests)  timeliness of response by the appropriate qualified health professional  appropriateness and effectiveness of the treatment plan generated.
f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: Tracking of care has begun with regard to sick call but has not been fully implemented with regard to intake processing, chronic care, unscheduled offsite services and scheduled offsite services. There are Excel sheets for the unscheduled offsite services but they lack documentation of the presence of the required offsite service report as well as the required follow up visit with the clinician. The same problem is also true for the scheduled offsite services.
RECOMMENDATIONS:
1. Develop tracking logs for the intake process as well as for scheduled and unscheduled offsite services that include the tracking of required follow up services.
2. Utilize the resource of the monitor to assist in developing this process.

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MENTAL HEALTH FINDINGS: See above.

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have worked with the GGACF leadership team with regard to a chronic care policy, chronic care clinical guidelines, and forms have been borrowed from materials available through the National Commission on Correctional Health Care. We are also pleased that an internist has been contracted with to provide chronic care services onsite weekly. We believe that the chronic care program structure is near completion. What remains is submission of the policy for final review, along with the disease specific guidelines and any tracking materials. Also, all clinician and nurse staff have to become familiar with both the policy and the guidelines as well as the encounter forms and flow sheets. This particular service could easily move into partial compliance at the next visit. The piece that is missing is the active involvement of the Medical Director in not only helping develop the remaining elements but also in overseeing and performing the training of the staff.

With regard to acute care guidelines, policies and procedures do not exist for assessing and treating acute medical events.

RECOMMENDATIONS: Utilize the above nine elements to expand your chronic disease policy and the guidelines as well as the forms. 1. Continue to develop the structural elements for this program and send out for review any related
materials. 2. Continue to contact the monitor and his staff for any technical assistance.

MENTAL HEALTH FINDINGS: unchanged since the baseline assessment as follows:

Currently, the mental health professional maintains the case list that identifies those inmates followed both on the detainee and the sentence side of the facility by the psychiatrist. The psychiatrist stated that inmates prescribed medications for a temporary problem will not be included in the caseload. The list contains the inmates name, diagnosis, medication regimen, BOC number, and date of birth. The list is lacking the date for the next psychiatric and counseling visit and should include the names of every inmate currently receiving any psychiatric medications and who is actively engaged in mental health treatment and follow up. In reviewing the medical records it is clear that people are not scheduled for follow-up as medically necessary or in a timely manner.

Patients are scheduled in chronic care mental health clinic in unpredictable and inconsistent fashions. Frequently people appear to be lost to follow-up despite a diagnosis of a serious mental illness.

It should also be noted that a couple of progress notes by the psychiatrist contain notations that an inmate was unable to be seen due to a lack of an escort officer.

RECOMMENDATIONS: Similar to those of the September 2013 report as follows:

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1. Contact the Monitor and his staff for consultation and/or technical assistance.

2. A minor modification to the current case list log as recommended above would improve the

tracking capabilities of the facility.

3. The list should contain both the BOC number and the inmates’ date of birth.

4. Any inmate followed by mental health should be captured on a log, perhaps one for

psychiatry and one for counseling.

5. As mentioned previously, a policy that would dictate required time frames for follow-up of

people in the chronic care mental health clinic may improve the timeliness of return visits

and allow for tracking when looking for quality outcomes.

6. All prison inmates on a mental health caseload should have at a minimum a monthly well-

being check by a mental health professional. Minimum frequency of psychiatric visits should

be outlined by policy.

7. The mental health caseload should be modified to track the date of the follow-up visit for

easy identification of overlooked appointments.

See related findings by Dr. Shansky for items v, vi, g. and h.

f. (iv) adequate measures for providing emergency care, including training of staff:
(1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-
threatening conditions; (3) to recognize and timely respond to emergency medical and
mental-health crises;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have not yet seen either the policy and procedures or the training material or the record of who has been trained and who remains to be trained. In addition, we continue to be aware of the frustration of staff in accessing the on-call Medical Director. Log books also revealed a consistent frustration among housing unit officers regarding their inability to contact and/or access medical staff when needed. We have heard that there may be some changes made in the near future that will create a dependable and timely availability of clinical resources. We hope that this change is made prior to our next visit. In our first report, we provided elements that should form the basis of the urgent care part of the urgent/emergent policy and procedures. We would encourage either the development of two separate policies, which may in fact be easier to comprehend, or a single policy that has both the urgent and emergency elements included in it.

We reviewed five records specifically with regard to emergency send outs and found the following problems. In none of the records was the emergency room report available. Instead, the only documentation from the hospital was patient discharge instructions. A meeting with emergency room leadership should occur in which it is made clear that your physician needs the emergency room reports in order to insure appropriate continuity. We also did not consistently find a nurse note with vitals upon return and we did not consistently see a timely follow up visit with the onsite clinician which should occur within two to three days after the emergency room trip. The requirement for these elements should be found in the urgent/emergent policies, including the requirement that at the follow up visit onsite, the clinician documents a discussion with the patient of the findings and plan. A review of these required elements should become part of your quality improvement monitoring.

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RECOMMENDATIONS:

1. The above elements should be utilized in drafting the urgent/emergent care policy and in constructing the urgent/emergent care log.
2. The Monitor and his team should be contacted for any consultation or technical assistance. 3. Use the elements listed in our first report to develop your urgent care policy along with your
emergency care policy. 4. The emergency care policy should include requirements for training and certification in basic
life support and first aid as well as the documentation of critiques of quarterly emergency drills. 5. Nurses should be trained that when patients return from unscheduled offsite services they should
document a note that describes the patient’s condition and a set of vitals, and insure that appropriate paperwork, including the emergency room report, are available and where indicated, a physician contacted for any recommended orders. 6. Your QI program should monitor the presence of the report and the timeliness and appropriateness of the follow up visit by the clinician. 7. Correctional staff, and any staff having contact with inmates should be trained to recognize health care emergencies and qualified health care staff should be consistently available to respond where a qualified medical person can address that emergency.

MENTAL HEALTH FINDINGS: In November 2013 a security log entry notes that an inmate (#9) complained of chest pain and not feeling right. Security notified the treatment building and the nurse responded that there was no doctor present at the time. Examination of the medical record indicated no medical entries for this date and no evaluation by the physician assistant who should have been on site at that time. Such lack of documentation is not only unprofessional but creates and incomplete medical record that exposes the inmate to delay in care and/or incomplete care.

Similar to those of the September 2013 report as follows:

The island hospital has closed their psychiatric unit. When patients have acute situations that cannot be managed within the facility they can be sent to the emergency room. That department can maintain the individual for up to 48 hours while attempting to medicate them for stabilization. Once the patient is compliant with medications they are returned to GGACC. If needed they are placed in isolation until they are able to take their medications, eat, and follow commands. If necessary, the facility will have to locate an off-island psychiatric hospital.

The facility is currently not staffed adequately and designed physically to accept and monitor acutely ill persons with a mental illness once the emergency room releases them after 48 hours if they remain acutely ill.

We have been provided neither training materials nor documentation of staff who have completed the required training as of the training officer has been on vacation during both of the site visits. We were told that no one else has access to her records.

RECOMMENDATIONS: Similar to those of the September 2013 report as follows:

1. The above elements should be utilized in drafting the urgent/emergent care policy and in constructing the urgent/emergent care log.

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2. The sick call request form needs to include triage status.

3. Suggest a policy that is highly detailed and provides a well delineated list of staff

responsibilities to emergency response.

4. Facilitate an emergency transportation system.

5. Train staff in CPR and schedule CPR-certified staff during hours when medical staff is

unavailable.

6. Stock the following essential equipment in a secure location and train staff on use:

respiratory barriers, Ambu bags, and defibrillators.

7. Schedule accordingly so there is Correctional staff available to provide non-ambulance

transportation to an off-site healthcare facility.

8. The Monitor and his team should be contacted for any consultation or technical assistance.

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have not yet reviewed the policy and procedure regarding specialty care or scheduled offsite services, which includes both specialty care and procedures. In our first report, we listed eight elements that should become part of the policy and procedure. These should be utilized in the drafting of the policy and procedure.

During this visit, we found the following problems in records we reviewed. We found some records in which there was no initial progress note describing why the consultation was requested. In addition, we found records in which the consultation report was missing and we also found records in which no follow up visit with a clinician or documented discussion of the findings and plan had occurred.

RECOMMENDATIONS:

1. Use the above elements to construct an offsite service policy and procedure. 2. Contact the Monitor or his team if any technical assistance or consultation is needed. 3. Send us the draft policy and procedure that utilizes the guidance from the first report. 4. Continue to utilize the monitor’s team for any technical assistance.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This has been discussed under number v.

RECOMMENDATIONS: See number v.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

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RECOMMENDATIONS: defer to Dr. Shansky’s report

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have not yet been provided documents regarding the intoxication and detoxification policies and procedures and/or guidelines. We indicated in the first report that the intake screen is the place where the program makes its initial determination about the liability related to either intoxication or detoxification issues. We saw that the draft intake screen tool does address these issues. We are encouraged by this progress. However, even and effective intake health screening tool is rendered meaningless if it is not being completed by qualified health care staff. We would also like to see protocols developed by the Medical Director for alcohol, benzodiazepine and opiates that include both monitoring performed by nursing staff as well as treatment.

RECOMMENDATIONS:

1. Develop policy and procedure and guidelines beginning with intake screening and leading to protocols for monitoring and treating each of the major common substances.
2. Contact the Monitor or his staff for consultation and/or technical assistance. 3. Develop the policies, procedures and guidelines utilizing information from our first report.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

Mr. Massey, the Substance Abuse counselor reported that GGACF has no detoxification program and that people are detoxifying while housed in a cell in the booking area.

h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This facility does not yet have an organized infection control program, and requires a nurse, preferably a registered nurse, to assume responsibility on a part-time basis for coordinating the infection control program. The intake screen should contain the TB symptom questions that begin the process of determining risk for tuberculosis. An infection control coordinator coordinates not just the TB control program, which includes the screening on intake and the follow up, in addition to responding to potential new cases, but also the handling of skin infections because of potential MRSA as well as the identification and reporting of sexually transmitted diseases. It would be useful to review an effective jail and/or prison infection control program and obtain policies and procedures and guidelines from existing programs. A place to start would be the Federal Bureau of Prisons policies and guidelines which are available on the

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internet. The program should initially focus on the TB control aspects, including the screening on

intake.

RECOMMENDATIONS:

1. Work through the Monitor and his staff for consultation and/or technical assistance.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

i. Adequate suicide prevention, including:
The best way of describing this section’s findings is to summarize a case that will highlight all the deficiencies cited below and the assessment for each section:

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Findings Case # 9

Serious Deficiencies that could result in death

Security log from November 5, 2013 indicated this inmate complained of chest pain and was not feeling right. The treatment building was notified and the nurse stated there was no doctor at that time. Examination of the medical record indicated no entry for this date and no evaluation by the physician’s assistant who should have been on site at that time. The second log entry on that day at four o'clock in the afternoon again notes that the inmate was not feeling well. The supervising officer supposedly said the inmate would need to wait until the doctor arrives. At 4:15 PM he was escorted to the treatment building. Later that evening at 10:36 PM it is noted that the inmate is in the multipurpose room trying to commit suicide. He was cutting his wrist. The sergeant was notified and security removed all of his personal possessions. There are two notations the following day shift that a check was made on the detainee. No checks were made on the evening shift. There is one notation at 11:10 PM that the inmate wanted his personal belongings back but the sergeant rejected that privilege. On November 7 at 9:16 AM there is a notation that the inmate was now placed on lockdown per the chief. The next notation that indicates any sort of well-being check appears on November 8 at 8:40 AM and 2:57 PM. The next notation concerning this inmate’s status occurs on November 11 when it is noted that he is on lockdown. The next day on November 12 at 2:23 PM the officer notes that per the chief the detainee is no longer on lockdown. The note reads "he checked with the medical staff about said detainee lockdown status and there is nothing to refer to".

1. Failure to provide necessary access to emergency medical evaluation and care
2. The inmate was placed on what appears to be a suicide watch on November 5 in his own cell (not a suicide resistant room) and was not released from lockdown status until November 12. There is a notation that his personal belongings were removed but no mention of whether his linens and uniform (the two most common tools in successful hangings) were removed. It appears that mental health and medical staff were never notified of this lockdown status and never evaluated or followed the inmate. The officers failed to conduct and document, at a minimum per policy, 15 min. checks on the inmate. The inmate was not seen by mental health until 11/15/13 after security had released him from lockdown. This case demonstrates unpredictable and unreliable observation of inmates at imminent or active risk of selfharm and fails to rise to the national minimum guidelines for suicide prevention.

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On October 28 a behavioral checklist by security to

3. There was no response by

Health Services was initiated on this inmate stating he

Mental Health/Medical to a

had an unusual loss of memory and was depressed. A

Behavioral checklist referral

similar checklist was initiated on November 11 checking radical changes in behavior, expressing a desire to commit suicide, inflicting bodily harm, keep

from security issued on October 28, 2013 (a Monday). The request on Nov. 11th (a

complaining of ailments that are nonexistent,

Monday) did not elicit a

expressing the belief that there are plots are plans

response from Mental Health

against personal safety, and showing poor personal

services until 11/15/13. There

hygiene.

is an undue delay or no

The inmate was last seen on August 2, 2013 by mental

response by Health Services to

health counselor and was only seen by the psychiatrist

urgent/emergent security

on November 15, 2013 who notes that the inmate was

referrals.

referred by a behavioral checklist.

4. This case demonstrates a

Inmate denied signs or symptoms of the mental illness.

complete disconnection

He recently met with his attorney said he would be

between security and health

released from prison next week. The detainee appeared

services and also suggests staff

happy and denied suicidal ideation. Discharge planning

has little awareness or no

was done.

training on the suicide

prevention policy.

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Mental Health staff did not report placing anyone on suicide watch this last quarter. However, the security logs demonstrated an inmate placed on observation without his possessions for attempting to cut himself and being suicidal. Mental health was not notified and this was not called a suicide watch.
RECOMMENDATIONS:
1. GGACF needs to develop a communication system that is timely and reliable for notification regarding inmates placed on suicide watch, behavioral referral requests, and intake referrals.
2. Inmates attempting self-harm should be immediately reported to the medical staff on duty that shift or the next business day.
(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;

ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: The decision to remove the person from watch in the case discussed was made by security not a psychiatrist or a mental health professional in consultation with a psychiatrist. Grossly inadequate levels of observation are documented in the security logs during the time this person was on lockdown.

Therefore, when medical informs the auditing team that there have been no instances of suicide watch in the facility their data and reports are unintentionally inaccurate.

RECOMMENDATIONS: Until a qualified mental health professional assesses the inmate they should be placed on suicide precaution under direct observation.

1. Therefore, when medical informs the auditing team that there have been no instances of suicide watch in the facility their data and reports are unintentionally inaccurate.

2. While the current policy does define the frequency of watch, it has not been approved and implemented. The policy needs to be put into effect.

(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: No suicide assessment was performed until after security returned all of the inmate’s possessions in the case listed above.

RECOMMENDATIONS: Unchanged from the last report. GGACF needs to implement a policy that requires notification of nursing staff when anyone is placed on observation immediately when staff is on site. An after hour protocol should be considered as well to allow for notification of mental health staff by the next morning

1. A practical policy and procedure needs to be implemented and monitored for compliance. 2. It is suggested that the service considered developing a standardized progress note that would
include a suicide risk assessment and a suicide watch treatment plan.

(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: As indicated in the Monitor’s previously discussed review, there is a lack of cut-down tools throughout the facility. Additionally, and as reported by the Monitor, some staff are not aware of the location of existing tools, tools are commonly reported as missing on the Officer’s Log, and emergency drill training in the use of these tools is not regularly conducted.

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RECOMMENDATIONS:

1. Cut down tools should be available in all housing areas, and areas where inmates could have an opportunity to harm themselves i.e. kitchen, medical building, etc.
2. All staff required to use this tool should be well trained and emergency drills demonstrating proficient use of the tool should be conducted on a regular basis.
3. Supervisors should regularly inventor and audit tool location and make immediate provisions to replace missing or non-function tools when found.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: During both site visits, September and December 2013, the training officer was unavailable and no one had access to her files. No proof of in-service training nor disaster drills have been made available to the monitoring team.

RECOMMENDATIONS: Develop and implement scenario-based suicide prevention, response, and recovery training program that requires application of policy and procedure, and that topic competence is proven by both written test and demonstration by staff. Adequate initial and annual trainings should be documented and maintained.

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: During both site visits, September and December 2013, the training officer was unavailable and no one had access to her files. No proof of in-service training has been made available to the monitoring team.

RECOMMENDATIONS: Annual disaster drills should include scenarios with response to a mental health emergency/suicide and be documented in a file maintained by the training supervisor.

(vii) availability of suicide resistant cells;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: There are no suicide resistant (safety) cells at GGACF. This was further verified in consultation with the Monitor.

RECOMMENDATIONS:

1. Retrofit cells designated suicide precautions to be suicide proof.

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2. Renovation of an intake cell may be the only immediate alternative. If this environment is

utilized, then the facility needs to carefully monitor how readily medical and mental health

staff can maintain daily contact with the inmates.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: The facility needs to develop, train to, and implement a policy for suicide prevention. In addition, there does not appear to be any system by which security implements and maintains an adequate watch.

RECOMMENDATIONS:

1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
2. Renovation of an intake cell may be the only immediate alternative. If this environment is utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.
3. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15 minute watches.

(ix) procedures to assure implementation of directives from a mental health professional regarding: (1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: There have been no improvements regarding suicide prevention. Security does initiate Behavioral Referrals but these are not always responded to by Health Services/Mental Health Services as promptly as is necessary. It is unclear if the delay is due to delayed arrival of the referral to the clinic, a shortage of security staff to escort the inmate, a shortage of mental health staff, or all of the above plus other obstacles the facility may be aware of.

The provision of adequate suicide prevention and programming remains a grave concern as evidenced by the case reviewed during this visit which fails to meet all nine of the above requirements. Fortunately, no harm befell this individual.

Security places people on lockdown status for self-injurious behavior without notifying mental health services. As a result there is absolutely no mental health review of the inmate. The decision to remove the person from watch is made by security not a psychiatrist or a mental health professional in consultation with a psychiatrist. Grossly inadequate levels of observation are documented in the security logs during the time this person was on lockdown.

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Therefore, when medical informs the auditing team that there have been no instances of suicide watch in the facility their data and reports are unintentionally inaccurate.

RECOMMENDATIONS:

1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
2. Renovation of an intake cell may be the only immediate alternative. 3. If this environment is utilized then the facility needs to carefully monitor how readily
medical and mental health staff can maintain daily contact with the inmates.

j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have indicated previously the problem with availability of the Medical Director onsite as well as on-call. In addition, we indicated that the plans to hire three registered nurses and three licensed practical nurses were subverted by a non-cooperative Director of Human Resources. The need for 24/7 nursing coverage remains urgent and requires immediate attention. We have also referred to the need for a clerical person dedicated to the maintenance of the medical records. We believe that addressing these medical staffing needs is likely to suffice for the ability of the program to achieve substantial compliance with regard to medical services.

RECOMMENDATIONS:

1. Provide the staffing document to the Monitor along with the duties assigned to each staff member.
2. Based on the October 2013 budget, provide the staffing positions allocated for Golden Grove for medical services to the monitor.
3. Complete the task of filling the three registered nurse and LPN positions. 4. Identify a Medical Director who will insure both onsite presence as well as on-call timely
availability. 5. Address the medical records component.

MENTAL HEALTH FINDINGS: No staffing analysis was presented to the monitor. Mental health staffing levels remain unchanged from the time of our last visit. Delays in follow-up care continue and are frequently related to the lack of escort officers; however, if security staff was increased it is unlikely that the current mental health staff hours would be sufficient to meet the needs of the facility, particularly if sufficient services were provided to the seriously mentally ill inmates. Additionally, the retirement of the psychiatrist is especially troubling as this will increase and prolong gap is care and medication reviews.

1. RECOMMEDATIONS: Refer to the Monitor’s assessment, findings and recommendations pertaining to staffing analysis recommendations. Provide the staffing document to the Monitor along with the duties assigned to each staff member.
2. A replacement for the retiring psychiatrist must be employed immediately.

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k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Clearly, the consistent availability of offsite officers as well as a transport van has interfered with the ability to provide follow up ordered lab and x-ray services. In addition, we are aware of access onsite that was either delayed or unavailable due to officer staffing.

RECOMMENDATIONS:

1. Determine the officer staffing needed (a) for offsite services and (b) for onsite services to insure that access is neither delayed nor denied.

MENTAL HEALTH FINDINGS: No change from baseline assessment report as follows:

Correctional staffing documents provided were inadequate to determine existing levels of authorized staff, work shifts, work locations, duty assignments, and shortages.

RECOMMENDATIONS: No change from baseline assessment per port as follows:

1. Develop staffing policies and procedures that reflect facility and population needs. 2. Develop staffing documents that allow for accurate and timely tracking of staffing levels,
shift and duty assignments, work locations, and shortages. 3. Prepare for performing a comprehensive staffing analysis to determine require staffing levels
using NIC Net Annual Work Hour methodology. 4. Ensure staff members are properly trained in all aspects of their respective duty assignments
working with special needs and mentally ill inmates. 5. Provide Monitor with accurate, complete, and up-to-date staffing schedules as described
above.

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Until the policies and procedures have been implemented, it is difficult for an organized quality improvement program to effectively monitor for either process performance or professional performance. Until an actively involved Medical Director is in place, the professional performance aspects will not be addressed, certainly with regard to the clinicians. There is a chief nurse, but until there is clarity with regard to the expectations of the nursing staff performance, there cannot be accountability expected.

RECOMMENDATIONS:

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1. As the policies and procedures are finalized, staff are trained and the policies implemented, begin the monitoring of process performance with regard to intake, health assessments, TB screening, sick call, unscheduled onsite and offsite services, scheduled onsite and offsite services as well as chronic disease management and medication management.
2. Work with the monitor and his staff, who can provide technical assistance.

MENTAL HEALTH FINDINGS: See case #9 cited under section 1. I, adequate suicide prevention.

There is not an operative quality improvement committee and no quality improvement activities at the time of this to work. This element is probably intended to describe a quality improvement program. We are unaware of any policy and/or quality improvement activities. We will work with local staff to develop a policy and program that facilitates improvement and meets NCCHC requirements.

The health services administrator informed us that they are scheduled to begin a quality improvement committee but are having difficulty finding a time when the medical director can attend.

GGACF Mental Health Department, under the supervisions of the Medical Director needs to develop a schedule of quality improvement activities and systems to measure the clinical processes and their outcomes. Currently there is a monthly report, which was not provided for our review, to the Health Services Administrator. From speaking with the Mental Health Coordinator it appears that certain quality assurance activities may be occurring that track some of the statistics monitored through logs and case lists.

RECOMMENDATIONS: GGACF Mental Health Department, under the supervision of the Medical Director needs to develop a schedule of quality improvement activities and systems to measure the clinical processes and their outcomes. Currently there is a monthly report, which was not provided for our review, to the Health Services Administrator. From speaking with the Mental Health Coordinator, it appears that certain quality assurance activities may be occurring that track some of the statistics monitored through logs and case lists. We were provided no document evidence supporting this claim. This will be more closely assessed during the March 2013 visit.

m. Adequate dental care;

ASSESSMENT: NOT ASSESSED

MEDICAL FINDINGS: The dentist was not available during this trip, which suggests that the dentist’s presence may not be predictable and dependable. Insure that there is a predictable and dependable dental presence.

RECOMMENDATIONS:

1. Insure that there is weekly predictable and dependable dentist presence onsite. 2. Begin tracking the weekly frequency of both restorations and extractions.

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MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report.

RECOMMENDATIONS: defer to Dr. Shansky’s report.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We still have not seen any policy or procedure with regard to this. Until the Medical Director involvement is improved, we cannot expect any progress on this issue. With each mortality review there must be a medical chronology as well as a mortality review that describes both the things done well as well as opportunities for improvement.

RECOMMENDATIONS:

1. Utilize the above to construct a mortality and morbidity policy. 2. Construct a mortality and morbidity policy with input from the Medical Director. 3. Contact the Monitor and his staff for any consultation or technical assistance.

MENTAL HEALTH FINDINGS: There have been no deaths or significant morbidity reported for the mental health caseload since the time of our last visit.

RECOMMENDATIONS: defer to Dr. Shansky's report

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We discussed with the leadership team how this could be accomplished and therefore what the policy should contain. We will await the drafting of such policy.

RECOMMENDATION:

1. Utilize the monitor and his staff for technical assistance.

MENTAL HEALTH FINDINGS: Similar to the baseline assessment as follows:

We saw no policy on this. We would strongly encourage drafting the policy based on NCCHC standards utilizing the compliance indicators and discussion sections. Both the prisoners and mental health staff reported that no mental health isolation/segregation rounds are conducted at the facility.

RECOMMENDATIONS: Similar to the baseline assessment as follows:

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It is recommended that a policy be developed that incorporates the requirements of national

accrediting bodies such as the NCCHC or the ACA.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Mental health staff provide no structured out of cell therapeutic programming for seriously mentally ill inmates in administrative segregation or the special needs housing unit adjacent to segregation. In general, it is recommended that the former, should they require a residential level of care, receive at least 10 hours per week of unstructured out of cell time and 10 hours of structured out of cell encounters per week (individual or group therapy) driven by their individual treatment needs. Those requiring only outpatient care should have more than five hours per week of unstructured out of cell time and increased private contact with a counselor and a psychiatrist while housed in isolation.

Findings also remain the same as the baseline assessment as follows:

No policy and procedure exists addressing a review process for mental health and medical clearance of inmates with serious mental illness being placed in isolation. There are no policies regulating the amount of out-of-cell time provided to special needs prisoners in segregation. Mental health staff does not perform segregation rounds.

RECOMMENDATIONS: Similar to the baseline assessment as follows:

1. It is recommended that a detailed policy be developed to address this issue that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA.
2. The facility should develop an outline for therapeutic residential level of treatment on these units, identify the staffing needs and coordinate with security to effectively initiated enhanced treatment designed to stabilize and improve inmate function with the goal of possibly moving some of these men into general population and an outpatient level of care.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Currently there is no formalized process by which a qualified mental health provider performs a pre-segregation assessment to determine whether the person is at risk of self-injury if placed in isolation and is at risk of an intensification of their mental illness if placed in isolation. Mental health also has no formalized process to determine if there are mitigating factors that would lessen or eliminate the disciplinary sanction.

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Similar to the baseline assessment as follows:

There is no policy or procedure requiring participation of mental health staff in the disciplinary process and as a result there currently is no input.

Regarding placement in segregated environments, it is unclear whether a medical and mental health clearance is done for such a housing assignment. We were also told in a meeting with the Health Services Administrator and Medical Director that medical sees everyone when there has been a use of force, and if severe enough, after hours the inmate will go to the emergency department. The medical department has to rely on the security emergency department log to determine if anyone has been taken to the hospital.
RECOMMENDATIONS: Similar to the baseline assessment as follows:

1. A policy and procedure should be established to allow for an assessment by mental health of incidents potentially resulting in disciplinary sanctions in those inmates on the mental health caseload.
2. Input into the disciplinary process should be written and periodically monitored through a quality improvement process to determine if the disciplinary officer is collaborating with mental health staff in adjusting their sanctions when there are mitigating circumstances secondary to the person's illness.
3. Currently, there is no retrospective of use of force as part of the medical quality improvement process but such a process should be put in place.

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: No change from previous report.

RECOMMENDATIONS:

1. Send the Monitor the plans as soon as a draft has been developed.
MENTAL HEALTH FINDINGS: The physical plant regarding the delivery of mental health services has not altered since our last visit. We did observe some confidential log material displayed in a manner that would have been readily visible to inmates being treated within that office space. The staff member was informed that this was a poor practice and immediately removed the materials.
Currently the Mental Health Coordinator is conducting 1 group therapy in an office that would not comfortably hold more than 4 inmates. The physical limitations, in addition to the shortage of escort officers and mental health staff, severely limit any additional programming opportunities at this time. No adequate programming space exists in or near the special needs

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unit or segregation for the programming of the seriously mentally ill inmates in these housing

units. There is a small satellite medical clinic space that could be used for individual mental

health encounters on the segregation pod.

Both the Mental Health Coordinator and the psychiatrist see patients in the medical clinic in sound private settings. There are no private interviewing spaces on the segregation units or in the female housing units, which may create barriers to access since the entire compound would need to be shut down to enable movement of these persons.

RECOMMENDATIONS:

1. The facility needs to explore what barriers may exist to providing frequent and adequate services to inmates in special housing in sound private settings.
2. Send the Monitor the plans as soon as a draft has been developed.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan development and implementation;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: During this visit we again found examples of inmates with delayed or absent psychiatric follow-up.

Case # 10
11

Findings Case
This inmate is still listed on the psychiatric caseload. His intake was done on June 23, 2013 and was positive for thoughts of hurting himself or others, a history of mental health treatment, drug withdrawal, auditory hallucinations, mood changes and medications including Risperdal, Seroquel, and Zoloft. His medical screen occurred two days later and it is noted that psychiatric medications were ordered. He was seen by the psychiatrist for the first time on July 18, 2013 who assigned the diagnosis of psychosis NOS and was referred to the mental health counselor. He was never seen again by the psychiatrist and was noted to have been released from the facility on September 18, 2013
The inmate was booked on May 9, 2009. He was originally placed on Haldol in March of 2013. On April 24, 2013 a behavioral referral was sent from security to medical notifying them of a radical change in behavior, and inability to sleep, outbursts and constant hostility. This form was received one day later. He was seen the next day by the mental health social worker who noted that he was taken to a treatment building by four officers and had to be restrained with racing thoughts, pressured speech, and flight of ideas. The psychiatrist was called and ordered intramuscular injections of an antipsychotic agent and that

Deficiencies/ Areas of Potential Harm
1. Delayed initial psychiatric assessment which should be performed within 10 business days of referral.
2. At least two months between his initial review and any attempt at followup, if any may have been in the works prior to his release.
1. Despite an episode of extreme agitation requiring injectable medication, is inmate was not scheduled for psychiatric reevaluation for more than three months following the episode. 2. Medication noncompliance was repeatedly noted by the mental health counselor with

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he be returned to his cell once stable. His next encounter with the psychiatrist occurred on May 2, 2013 with no further follow-up appointments documented in the record. He was seen again on 5/13/13, 7/30/13, by the mental health counselor who documented medication noncompliance at both visits. On 8/6/13 the counselor noted that the clinic attempted to reevaluate the inmate by the psychiatrist for noncompliance but there was no patrol officer to escort the inmate.

no expedited appointment with the psychiatrist.

12 This gentleman was screened 5/18/12 and noted to have a 1. At best inadequate

serious mental illness. He is currently on injectable Haldol documentation or poor

and Cogentin but there were no documented psychiatric medical record management

records for the year 2013 in the chart.

and at worst a complete

absence of psychiatric

management of this person's

medication regimen.

15 The inmate was readmitted to the facility on 5/23/13 and 1. Psychiatric follow-up is

was noted to be incoherent. The psychiatrist was familiar grossly inadequate. At a

with the inmate and had treated him for schizophrenia in minimum this inmate should

the past. He noted the man was disoriented to time and

be followed by the

place, grandiose and had poor hygiene. The inmate needed psychiatrist at least monthly

to be redirected constantly. The psychiatrist started him on given his serious mental

injectable Haldol. His next follow-up was not until six

illness diagnosis and acute

months later, 11/26/13. The inmate stated he was doing symptomatology. It is also

"very good" but was noted to be grandiose, delusional,

unclear why this man was

inappropriate affect, poor eye contact, poor hygiene,

initially not considered for

malodorous, and appear to have intellectual disabilities. placement in the acute care

His medication was continued and he was diagnosed with unit on St. Thomas.

chronic schizophrenia.

2. At the time of his follow-

up six months later there is

little evidence of any

significant improvement in his

symptomatology which may

be related to the sparse

services provided to him

during that period of time.

18 This inmate is not on the psychiatric case list. On intake he 1. There appears to be a lack

was noted to be depressed and have a history of seizures of coordination of care

and high blood pressure. He was observed to have seizure between medical and mental

like behavior on the unit in June 2013 and inmate July

health for inmates with dual

there is a notation in the record that medical questioned diagnoses. In July 2013 when

whether his seizures might be psychosomatic. In

there was a question of

September 2013 he was seen by a registered nurse

psychosomatic etiology for

complaining of anxiety and frustration. 12/6/13 he

his seizures one would expect

removed a sling from his right shoulder and tried to hang an initiation of a referral to

himself with it. His affect was noted to be sad and he was psychiatry for evaluation.

presently being interviewed by the mental health social

This did not occur.

worker. He was seen by the psychiatrist on 12/10/13 who

noted that the individual was no longer suicidal and did not

have the psychiatric disorder.

19 Seen at intake 4/3/13 and was noted to have auditory hallucinations. Medical screening was delayed and

1. Delayed medical intake

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occurred on day 8 of incarceration. The inmate was not seen by psychiatry until April 23, 2013 when the psychiatrist began him on a low dose of Risperdal. He returned four months later. This second follow-up is documented on an undated note on the newly implemented psychiatric progress note form and there is a medication order on 10/28/13 which appears to be at the same time the note was generated. The plan was for him to return to the clinic in two weeks. This has not occurred.

2. Delayed initial psychiatric evaluation 3. Delayed psychiatric follow-up

22 On 10/8/13 there is a psychiatric note that he allegedly

1. Psychiatric medications

stabbed a detainee. He refused mental health services and continued without follow-up

his appointment. The plan was to order urine drug screen and despite repeated

which he refused on 10/10/13. He has not been seen since. documentation of complete

His last mental health counseling note was 8/14/13 with a noncompliance.

plan that he attends weekly counseling. He refuses

medication and his MAR indicates that he has been 100%

noncompliant with Haldol/Cogentin on his December

record.

25 A short form intake was done on 5/1/12. A bio

1. Six months return

psychosocial assessment was performed 3/20/13. He was psychiatric appointments

admitted to this facility on 3/12/13. His first psychiatric exceeds the generally

assessment was on 3/21/13 were no symptoms were noted recommended standard of

and he was to return in one month. Follow-up was on

chronic care visits occurring

5/7/13 and he was noted to be slow in his response time. at least every 90 days.

Follow-up was set at 6 months later. On 11/7/13 he was 2. No medication

noted to be intellectually deficient with an IQ of 56 and the administration records were

plan was to continue medications. The day prior he had filed in the chart.

been seen by the social worker who noted that he was very

explosive.

Similar to the baseline assessment as follows:

Medical services and mental health services at the current time lack any continuous quality improvement program, which greatly impedes their ability to self-monitor, develop, and implement effective corrective action plans or program development. Treatment plans were only found in a few records. In most circumstances the plans were unrealistic in that they assigned activities such as educational classes and mental health groups which were not provided at the facility. The plans also recommended certain frequency of follow-up by mental health or psychiatry which was not even approximated in the actual practice.

RECOMMENDATIONS: One observation from this audit is that the mental health clinic logs do not show a return to clinic date as well as the last completed visit. Thus, there is no concrete tool to track if someone has actually fallen off the radar and needs to be seen in follow-up. It is recommended that the clinic logs the modified and, perhaps organized on a spreadsheet so that it can be easily sorted for the convenience of the staff to ensure timely follow up appointments based on clinical necessity with an upper limit of time between visits set at 90 days.

Similar to the baseline assessment as follows:

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1. Treatment plans should reflect the actual services rendered as opposed to

idealistic suggestions.

2. Suggest the following template for crafting the inmate’s plan of care:

THE INDIVIDUALIZED TREATMENT PLAN:  Treatment plans should follow a problem-oriented format.  Problems listed should be descriptive and meaningful with measurable goals.  The plan should indicate time frames to complete the above goals.  Planned interventions are documented  A date of the scheduled review of the individual treatment plan will be listed on the chart.  All members of the treatment team in attendance shall sign the treatment plan and indicate their professional degree.  A notation by the team will also indicate progress made towards previous goals.  The patient shall also sign the treatment plan indicating participation and awareness of the established goals.

(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Similar to the baseline assessment as follows:

Currently there are no programs in mental health for prisoners with serious mental illnesses. The only services currently provided are occasional contacts with the Mental Health Coordinator and often infrequent visits with the psychiatrist with lapses between visits of up to a year.

As mentioned earlier the Mental Health Coordinator has begun one general population group with four or five inmates. There is no mental health programming for segregated or special needs inmates.

While on site I also had the opportunity to meet with Mr. Massey who educated me regarding the substance abuse programming available at the facility. In the past there had been a residential treatment program but this no longer exists. Currently they have a 90 day outpatient program. He provides programming on a voluntary basis. He has an elders program for inmates over the age of 57 who can act as mentors. There are currently eight men in this category that he supervises and meets with them weekly. Each coordinator receives 160 hours of training from him. Approximately 2 years ago the substance abuse program was dismantled and Mr. Massey was laid off from his full-time position. He was hired back part time. Mr. Massey reported that GGACF has no detoxification program and that people are detoxifying while housed in a cell in the booking area. Recruiting inmates to participate in substance abuse programming has been difficult. He reported the units all have crack cocaine, marijuana, cocaine, and alcohol illicitly available to inmates most of whom are unwilling to consider being substance free. In 2013 he has received a total of 10 referrals of dual diagnosed inmates from the mental health service.

RECOMMENDATIONS: Unchanged from the Baseline Assessment as follows:

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1. GGACF Mental Health Department should conduct a needs analysis and make

recommendations to the Health Services Administrator, Medical Director, and Bureau of

Corrections regarding required staff and other resources necessary to provide adequate

services in both general population and segregated areas.

2. Comparable programming should be provided for female inmates and detainees as well.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Unchanged since the Baseline Assessment based on chart review.

GGACC lacks sufficient psychiatry hours (although we were not provided with the staffing schedule, it appears that GGACC has fewer than eight hours per week of psychiatric time) to perform comprehensive initial psychiatric assessments and chronic care follow-ups at clinically necessary frequencies.

There was a surprising underrepresentation of the treatment of mood disorders on the caseload and women.

A continued finding of dependence on long acting injectable neuroleptics rather than oral agents seems a variance from customary practice. This may be a clinical choice designed to increase medication compliance.

There is no policy that addresses the use of emergency and involuntary medication.

RECOMMENDATIONS:

1. Improved methods of practice and a staffing and programs analysis needs to be completed. 2. GGACC may wish to consider adding telepsychiatry to increase the availability of
psychiatric resources by contracting with psychiatrists on the mainland who obtain licenses in the USVI. Of course, the latter would require capital investment in equipment and the development of a policy and procedures that would structure this type of service. 3. A reasonable informed consent form should be developed and patient education documented. 4. A policy addressing the use of emergency and involuntary medication should be developed.

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: As mentioned previously, the training officer has not been available during our two site visits and no one else has access to her training records. Therefore there is no ability for the monitoring team to make any determinations regarding a level of

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compliance with this requirement. In addition case #9, indicates that security staff including

supervisory level staff have little awareness and or training in the suicide prevention policy. This

is demonstrated by security placing an inmate who was self-injurious on lockdown, failing to

notify medical services and mental health services of that status, and failing to implement and

document the watch requirements of the policy. In addition, security staff terminated the watch

without any review by mental health.

RECOMMENDATIONS: GGACF should ensure the training officer or her records are available at the time of the next site visit for review by the monitoring team.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lockdown as a substitute for mental health treatment.

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Unchanged from the Baseline Assessment as follows:

Currently, seriously mentally ill inmates are housed in segregation and by policy may be placed there until their conditions are stabilized. However, the decreased capacity for observation, lack of availability of potable water in their cells, hot conditions with poor ventilation, absence of mental health rounds, absence of any structured therapeutic programming places these individuals at risk for serious life threatening physical illness and behavioral decompensation.

RECOMMENDATIONS: Unchanged from the Baseline Assessment as follows:

1. GGACC should consider alternative housing and as recommended above, develop a plan to introduce adequate programming for this population.

2. Increased out-of-cell-time and life skills activities should be considered.

3. It is also recommended that all inmates with a serious mental illness should be seen in a confidential setting at a minimum of at least monthly by a psychiatrist and monthly by a mental health counselor.

4. Weekly mental health rounds are also required for this population.

5. Suggest the following template for progress monitoring of inmates in segregation (may also be used for general population):

THE GENERAL POPULATION AND SEGREGATION MENTAL HEALTH PROGRESS NOTE
SUBJECTIVE/OBJECTIVE  The subjective portion of the note should contain descriptions of any current problems, the inmate's level of
activity and function, programs participation, job assignments, family issues, and any other pertinent information.
 Documentation of any reports of medication issues or side effects  A brief mental status examination unless the template does not require that information.

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ASSESSMENT

 A DSM (current version) diagnostic list as well as an estimate of the current global assessment of

function

 An assessment pertinent to the data documented

PLAN  

A clinically appropriate follow-up appointment A description of the recommended, if any, appropriate psychosocial intervention and an estimate of the timeframe to complete such treatment. For example, "The inmate will be seen weekly for four visits focusing on cognitive behavioral therapy for bereavement counseling."

ENVIRONMENT OF CARE  As a general rule, all psychiatric and counseling encounters, including face to face encounters in response to a sick call request and pre-segregation interviews, should be conducted in an area guaranteeing sound privacy.  Only segregation rounds may routinely be conducted at the cell front or in a day room area.  Variance may be permissible during extended states of lock down, if the inmate is deemed to lack behavioral control, and other crisis situations.

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VI. FIRE AND LIFE SAFETY

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:

a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Develop, train, implement, and evaluate a comprehensive life-fire safety program that includes all policy, procedure, resources, equipment, training, monitoring, and system/programming testing components.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install SCBAs or an appropriate alternatives at all locations where staff would need to
search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate
supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security. 7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program. 8. Supervisors should conduct routine, schedule and unscheduled physical inspections of occupied structures taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action. 9. The fire inspection program must be clearly detailed in fire safety policies and procedures, and become a fundamental element of pre-and in-service training.

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b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations. 2. Consider purchasing fire safety program software from NFPA and/or the American
Correctional Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above.
Train and drill staff as discussed on system use. 3. Develop emergency key and locking mechanism inspection and reporting system as
discussed above. 4. Implement competency-based staff training as discussed above. 5. Exercise fire safety program using onsite, scenario-based drills; include community
responders in exercise planning and exercise events. 6. Send the training officer and part-time fire safety officers to the National Fire Institute,
National Emergency Training Center, Emmetsburg, MD for additional training.

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d. Regular security inspections of all housing units that includes checking:

(i) that cell locks are functional and are not jammed from the inside

or outside of the cell; and

(ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. During this inspection, and as previously described some of the Housing Unit locks are found non-functional.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems.

e. Testing of all staff regarding fire and life safety procedures;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision.

f. Reporting and notification of fires, including audible fire alarms;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision.

g. Evacuation of prisoners threatened with harm resulting from a fire;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

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RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. There remains no functional fire suppression system in the Housing Units other than fire extinguishers. This system must be made fully operational, regularly tested and maintained.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders. 3. Ensure that the fire suppression system is fully operational, regularly tested, and
maintained.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 5. Qualified medical staff should participate in the development of fire program training topic that involved burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.

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j. Control of highly flammable materials.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. Additionally, and as described throughout Exhibit B, inmates are allowed to keep large amounts of combustible items in their cells. The large amount of combustible trash foundin the juvenile unit evidences a lack of adequate concern for this issue.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. Develop a formal writing “Combustion Control and Prevention Plan” component to the comprehensive fire safety program that includes regular and documented inspections and removal of combustible materials (solids, liquids, gases) from all areas and structures. Maintain a current inventory and tracking report of materials and locations, corrective actions and mitigation efforts.

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VII. ENVIRONMENTAL HEALTH AND SAFETY
Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:
GENERAL COMMENT: The following was provided in the Baseline Report and remains consistent with narrative discussion provided at the beginning of this report.
1. There is no hot water in the housing units, which creates serious health and sanitation risks for staff and inmates.
2. Many sinks in the cells were inoperable. 3. Some of the toilets did not flush properly. 4. Inmates are allowed to wash their clothes and linens in the toilets and/or sinks, then hang
them to dry on clothes lines anchored to inoperable fire sprinklers in their cells. 5. Standing water was found in housing units and cells. Inmates and staff state that housing
units will flood during heavy rains. 6. Several shower heads were broken, shower stalls were covered with mold, as were
ceilings and cell-block walls. 7. Mold was thriving on ceilings, maintenance closets, pipe chases, recreation areas, areas
in the kitchen. 8. Housing unit temperatures were very high, which, combined with high humidity can
promote and spread infectious diseases, exacerbate certain chronic medical and mental illness, promote inmate frustration and violence, and dissuade correctional staff from leaving air-conditioned control rooms to conduct housing unit inspections, rounds, and security checks. High temperatures also pose very serious health risks to inmates on certain psychotropic medications current being administered to inmates. 9. Food trays being filled in the kitchen with food were still drying after being washed. Overall sanitation in the kitchen was poor and in need of regular deep cleaning. 10. Housing unit water is essentially undrinkable and inmates are unable to access water when locked in their cells without the assistance of the housing unit officer. I was told by inmates that there are times when officers will not respond to requests for water or are away from control rooms for extended periods. This is evidenced by officer logs where officers have recorded leaving their units completely unattended to take breaks and/or where no relief officer was available. Unit logs also report a practice of “last call for water”. This practice evidences that inmates do not have consistent access to potable drinking water. 11. Many of the inmate mattresses appeared old, tattered, and filthy. Inmates and staff stated that mattresses are not routinely cleaned or disinfected during and between uses. Linens are allowed to be washed in toilets and hung to dry as previously described. 12. There is no written formal sanitation inspection and/or infection control program.

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13. Medical and dental exam rooms were filthy with what appeared to be dried bodily fluids

on pans that held equipment for procedures. Trash cans were full. Sharps containers were

full. This environment, overall, was in serious need of deep cleaning and maintenance.

14. The facility appears inadequately staffed to provide adequate monitoring, oversight, and

response to routine or emergency sanitation conditions or maintenance issues.

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. As described in Exhibit B, conditions remain unsanitary throughout the facility i.e. extensive mold, lack of drinking water in cells, dirty showers, etc.

RECOMMENDATIONS:

1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.

b. Adequate ventilation throughout the facility;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

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1. Timely complete an air quality assessment performed by a qualified provider.

Implement necessary improvements that reduce housing area temperatures and

increase air flow.

2. Ensure inmates have constant access to drinkable water.

3. Medical and mental health staff should monitor all inmates for heat and airflow-related

health risks. All inmates in segregation or who are locked in their cells should be

monitored by medical and mental health staff for signs of health conditions.

4. Train all staff in detecting and responding to health conditions related to heat and air

circulation contributors.

5. Install environmental health condition monitoring devices, e.g., temperature, humidity,

and air quality readers. Require regular monitoring and recording of readings and take

timely action to mitigate environmental conditions that create health risks caused by

those conditions.

6. Ensure that adequate amounts of drinkable water is always available to inmates.

7. Medical and mental health professionals should closely monitor inmates being

administered medications that are adversely affected by high body temperatures and

take appropriate steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and
internal illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance.

d. Adequate pest control for housing units, medical units, and food storage areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.

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2. Ensure that inmates involved in pest control activities are properly trained, equipped,

and clothed for requirements of those activities.

3. This provision will be assessed more closely during the December assessment.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. However, most of the cells inspected appear to have an adequate supply of personal hygiene products.

RECOMMENDATIONS:

1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Maintain an adequate supply of these personal care items in control pods or housing
units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in
their cells and living areas.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for bio-hazard safety and exposure control; B. Written and enforced procedures and protocols for bio-hazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all bio-waste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a bio-hazardous control program that involves regular inspections of all potential contamination areas.

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2. GGACF officials should consult an environmental specialist to assess these conditions

and assist them in developing appropriate mitigation plans and policies.

g. Mattress care and replacement;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previously discussed sanitation recommendations. 2. Consider replacing all mattresses with those that are more bacteria-resistant. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and
contraband, cleaned and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance
requirements.

h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
2. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.

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2. Develop specific policies and procedures for handling, containing, and washing

contaminated clothing, linens, and mattresses.

3. Consider replacing all wood laundry carts made of non-absorbing materials that can be

sanitized and completely cleaned. Discontinue the practice of moving laundry on carts

that have not been cleaned and sanitized.

4. The initial issue of inmate supplies should include, at minimum: one (1) corrections

issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket.

Clothing should be exchanged with clean items twice per week at minimum, sheets and

towels once per week at minimum. Blankets should be exchanged monthly at

minimum. Any clothing, linens or bedding should be changed immediately if they

appear damaged and/or unsanitary, or appear to present a risk to health.

5. Ensure that inmate handbooks provide clear rules and information about the laundry

program, how to access clothing, linens, and bedding. Cease the practice of allowing

inmates to wash clothing in housing unit or cell sinks and toilets.

6. Staff and inmates involved in the laundry work progress should be properly training

and supervised.

7. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. The following observations were found during this inspection of the kitchen:

1. The main kitchen door from the work side has water dripping from the ceiling. There are exposed electrical wires and some standing water. It appears they have been cleaning in in this area but standing water remains on the floor and there are no warning signs or placards. There is a service sink separating the entrance to the male and female bathroom.

2. Entering the women’s bathroom, there is full container of hand sanitizer on the sink. The sink is operational but there is no hot water. The bathroom floor is filthy and requires a deep cleaning.

3. The male bathroom is in similar condition as the female bathroom and requires a deep cleaning. There is a dirty wall urinal, the light does not work, and there is cold water but no hot water. The frame separating the toilet areas is rotting at the base. I could find no toilet paper in this bathroom.

4. In the kitchen area, there are large stainless steel sinks back-to-back near the cooking area. The tile under the sinks is damaged and needs to be repaired or replace. The plumbing is exposed. There are rotting food products under the sink. The sinks are both clogged with what appears to be corn or some other food products. There is also a 12 inch knife in the sink attached to a metal cord that is padlocked to the faucets.

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5. An inspection of the kitchen tool/utensil found it unlocked and unattended by staff. Light

is on and both the tool cage gates are unlocked are wide open. Although a “shadow board”

is in place for tool management, there does not appear to be any equipment inventory logs.

There does not appear to be a chit system in use for tool tracking and inventor management.

It appears that several tools are missing, including knives, ladles, large spoons, etc.

6. The kitchen has two large internal cooler/freezers; one of them is operational and one appears to be broken. The broken cooler has no external temperature gauge and appears to be used for storage.
7. The working cooler has an external temperature gauge showing a temperature of about 47 degrees, and contains various properly stored food products.

8. There is a large iron cook stove here and needs to be replaced. The nearby deep fryer contains used oil. There is also a pan sitting on a cart next to it with some old oil. The second deep fryer appears to be clean and covered by a stainless steel pan.

9. To the opposite side of that group of kitchen equipment is a 12 burner cast iron stove and ovens that are currently being used. This was the oven that was reported in the Baseline Report as positioned too high for safety reasons.

10. There is also a prep area for food distribution. This is the cafeteria are where inmates come here to collect their food. This is a decent size room for distributing food from the kitchen through large food ports. There are additional food service areas nearby, as well as a fairly large stainless steel dish sink. The inmates are busy cleaning this area. There is a single fire extinguisher mounted on the wall as you enter the kitchen area with brief instructions on use that appears recently inspected.

11. In general, the kitchen area remains in the poor condition as it was found at the Baseline visit with broken tiles, leaking ceilings and mold, insects, and equipment that needs to be replaced.

12. Outside of the kitchen building is another freezer with a temperature reading of 21-22 degrees, which is adequate for frozen products. It is locked and we will not enter it.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with nationally recommended allowance for basic nutrition;

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F. Prohibitions of using food as a disciplinary measure;

G. Involvement of independent outside sources to verify food service facilities and

equipment meet government safety codes;

H. Prescribes regular cleaning schedules including routine deep cleaning;

I. Provide written utensil control methods similar to those used by the tool shop;

J. Accident prevention program;

K. Personal and environmental sanitation requirements;

L. Food temperature monitoring and records keeping;

M. Adequate health protections for all staff and inmates including health screens and

prohibitions against working in the kitchen when ill;

N. Requirements for daily monitoring of staff and inmate cleanliness practices, and

that all bathrooms and wash basin are consistently supplied with antibacterial soap

and hot water;

O. All areas and equipment related to food preparation, distribution, and storage

require frequent inspection to ensure they are sanitary, operational, and safe;

P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit;

between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the

final rinse. The person conducting inspections should be a qualified food service

inspector;

Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit,

refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees

Fahrenheit or below, unless national or state codes specify otherwise;

R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit

and cold foods at approximately 41 degrees Fahrenheit;

S. Supervisory food service staff should monitor food service operations to ensure that

that cooking, cooling, and food temperatures and delivery meet established

requirements;

3. GGACF officials should review food service requirements promulgated by the

National Correctional Association and National Commission on Correctional Health

Care.

4. Develop a food service training program that includes inmate and staff training records

and ensure that all training is well-documented.

5. Policies and procedures developed should include controls for the use of caustic, toxic,

and hazardous materials used in the kitchen. Material Safety Data Sheets should be

posted conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to recommendations regarding sanitation and this provision. 2. Develop and implement a corrective action plan for that ensures inmates have
consistent and reliable access to safe drinking water.

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3. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate.

Additionally, the Monitor was provided several official documents that listed current training topics, invoices for training, and staff attendance. No curricula documents were provided for review, nor any documents indicating that staff have been trained on policies pursuant to this order. Again, the HR/Training person was not available during this assessment.

RECOMMENDATIONS:

1. Written training policies and procedures should be developed and implemented to govern pre-service, in-service, and ongoing training or corrections and civilian staff. The following are a few recommended elements for training program policies and procedures:

A. Training program mission statement, goals, objectives, and operating procedures; B. Written, understandable, and measurable; C. A training program written code of professional standards and ethics; D. Employees participate in formulation of policies, procedures, and practices; E. The training program is adequately staffed with qualified training and support
staff; F. There is a written organizational plan that depicts training program structure, lines
of communication and authority; G. Training records management and control; H. Descriptions and roles of agency, public, and private training agencies and/or
organizations involved in training development and implementation; I. Authorization and description of off-site training facilities; J. Regularly scheduled meetings between training leadership and agency leaders for
program coordination and management purposes; K. A system for monitoring training program methods, content, and outcomes; L. Training program funding and space;

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M. Training program role in staff recruitment, selection, training, re-training,

promotion, dismissal;

N. Prohibitions against and consequences resulting from staff and student

misconduct related to training functions and activities;

O. Adequate equipment and supplies are available to develop, prepare, administer,

and evaluate training program and services;

P. Appropriate accommodations are available for disabled and/or impaired students;

Q. Training curricula and plans are developed, evaluated, and updated based on a

valid assessment of staff performance that identifies current job-related training

needs;

R. Ongoing formal evaluation of pre-service, in-service, and specialized training

program conducted and/or sanctioned by the agency;

S. Adequate reference materials are available to program staff and learners;

T. All courses provided include attendance records, lesson plans, instructor name,

course evaluations, methods for demonstrating topic proficiency and test results;

records of certificates or completion verification;

U. Methods that protect the integrity of testing and assessment processes;

V. Courses are based on competency-based curriculum supported by appropriate

materials and course resources;

W. All instructors are qualified to teach course topics; instructors teaching uses of

force, first aid, weapons use, etc. are currently certified to instruct such courses;

X. Use of force training includes non-physical, physical, and appropriate use of

authorized weapons, force levels, justification, etc.;

Y. Training topics, content, proficiency, and hours/weeks of training is established

for pre-service, in-service, and specialized training;

Z. Firearms training covers use, safety, and care of firearms and the legal and ethical

constraints on their use. Training includes knowledge and performance, and is

assignment specific (e.g. use of weapon in various settings, conditions, areas);

AA. Chemical agent training covers the use and handling of chemical agents, as

well as the treatment of persons exposed to a chemical agent;

BB. Emergency responders are available to timely respond to training incidents

involving injury.

2. Training plans should be developed for all revised and new policies and procedures required under this Agreement. These plans should include methods for determining content proficiency as defined in this agreement. The use of pre and post tests and visual demonstration of applied topics should be used in measuring topic competency.

b. Pre-service training for all new employees;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above. No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.

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c. Periodic in-service training and retraining for all employees following their completion of pre-service training;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above. No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above. No change since the Baseline visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Provide the Monitor all training program policies and procedures. 2. In the absence of training program policies and procedures, develop such policies and
procedures.

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IX. IMPLEMENTATION

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.

FINDINGS: Territory officials have completed and submitted to the Monitor and DOJ a more detailed plan and schedule for policy development, training, and implementation. However, this draft document omits several important dates, does not prioritize implementation activities according levels of importance, and appears to remain in draft form. The Monitor and DOJ will consult with Territory officials regarding necessary revisions, but Territory officials are to be commended for the effort displayed in working toward accomplishment of this requirement.

2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.

FINDINGS: Please refer the findings discussed above. The Monitor has not agreed to the Territory’s implementation plan or schedule.

3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

FINDINGS: As discussed throughout this assessment report, the Territory provided no evidence that any policies or procedures are in revision. No new policies or procedures or revisions have been provided to the Monitor or DOJ for review and approval as required.

4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.

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FINDINGS: This requirement has not been met. The Monitor remains available to assist the

Territory as described above.

5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.

FINDINGS: The Territory has submitted no requests, proposals or recommendations to modify policies, procedures or the plan. The Monitor looks forward to reviewing proposed changes and provided requested technical assistance if requested. It is believed, however, that the creation of a better development implementation plan will greatly facilitate the Territories compliance with this requirement.

6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.

FINDINGS: Not Assessed.

7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.

FINDINGS: To Be Assessed

8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.

FINDINGS: To Be Assessed

9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.

Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S SECOND ASSESSMENT REPORT

Page 115 of 116

Settlement Agreement

FINDINGS: Territory officials provided reasonable access to the facility and staff during the baseline visit. However, it would be helpful and most efficient to the onsite assessment process if requested logs and documents were readily available beginning the first day of each visit.

10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.

FINDINGS: Territory responses to specific questions regarding compliance with the Agreement have complied with this requirement according to the Monitor’s best estimate.

Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S SECOND ASSESSMENT REPORT

Page 116 of 116

Settlement Agreement

EXHIBITS 1 & 2

Criminal Justice Courts Law Enforcement Corrections Security Healthcare Institutional
Federal State County Municipal Communities
Research Analysis Assessment Development Implementation Evaluation
Facilitation Curricula Coordination Collaboration
Systems Technology Organizational Leadership
Recruitment Selection Staffing Training
Policy Procedure Risk Management Legal Litigation
Fiscal Management Budget Grants Procurement
Options Alternatives Strategy Sustainability
Professional Competent Confidential Ethics Integrity Performance
ASSESS ANALYZE ACTUALIZE

2nd Monitoring Report

Kenneth A. Ray

EXHIBIT 1

JUSTICE SERVICES, LLC
PO Box 1481 Ashland, KY 41105-1481 Phone: 606-694-3031 Email: ken@rjsjusticeservices.com
FEDERAL COURT APPOINTED INDEPENDENT MONITOR

January 28, 2014

Via Electronic Mail

To: For the Virgin Islands

CC: For the United States

Julius Wilson, Director, Virgin Islands Bureau of Corrections
Kenrick Robertson, Assistant Attorney General, Virgin Islands Department of Justice
Nathen Oswald, Special Assistant Attorney General, Virgin Islands

Allyssa Lareau, CRT, Trial Attorney Special Litigation Section Civil Rights Division United States Department of Justice
Sharon Brett, CRT, Trial Attorney Special Litigation Section Civil Rights Division United States Department of Justice

Re: United States v. Territory of the Virgin Islands, 86cv265, 2nd Monitoring Assessment Emergent Conditions of Confinement

Director Wilson, Mr. Robertson, Mr. Oswald,

This revises the January 6th, 2014 2nd Monitoring Assessment Emergent Conditions of Confinement letter following your review and comment period as required under the Agreement and subsequent to your initial response dated January 14, 2014. Revisions include:

1) Removal of the requested sentence regarding environmental conditions 2) Numbers all bullets for better clarity 3) Clarifies the first sentence of section I. Staffing, A. 15, regarding the relationship between
staff, inmates, and contraband 4) Removes the unreferenced foot note as indicated

Your January 21, 2014 response is appreciated and evidences commendable and valuable efforts ultimately relevant to prospective compliance and progress. However, and until these and other improvements are fully implemented, I strongly urge and encourage the Territory to timely take any and all appropriate steps to ameliorate and/or mitigate real and potential risks and harm otherwise discussed in the letter. One such step could include issuing directives requiring GGACF officers to maintain locked housing units; to search all inmates before leaving and entering housing units; to ensure all cells are inspected during each shift; and, to require all supervisors to conduct quality assurance inspections of all housing units during their shifts and to take immediate corrective action involving non-compliance and/or deficiencies exist.

The second onsite monitoring assessment of GGACF was conducted December 9-12, 2013. The assessment was performed by the monitoring team including, Drs. Shansky and Stellman, and myself. Representatives from the Virgin Islands and U.S. Department of Justice participating in this assessment.

“Dedicated to Public Safety, and to Community Wellness"
KENNETH A. RAY - RJS JUSTICE SERVICES PO BOX 1481 ASHLAND, KY 41105-1481 PHONE: 606.694.3031 EMAIL: ken@rjsjusticeservices.com

As stated in our meetings during the course of this assessment, the monitoring team found conditions of confinement at GGACF virtually unchanged from the September 2013 assessment. Additionally, we expressed our serious concern about several specific unchanged conditions that we believe require expedited remedial action to ensure the safety and welfare of inmates and staff.
These risks involve issues related to 1) staffing levels and staff supervision, 2) security practices and systems, 3) life and fire safety conditions, and 4) medical and mental health assessment and care. I encouraged Territory officials during the onsite assessment to take immediate steps to remove and/or reduce these risks and advised you that I would provide you with more specific details about these findings before submission of the second compliance report to assist in developing and prioritizing an emergency action plan for that purpose. That information is provided herein.
In closing, I want to reiterate that the monitoring team will continue to provide requested technical assistance to the Territory in its efforts to comply with the Settlement Agreement.
Respectfully,
Kenneth A. Ray, M.Ed., Monitor PSCC: Roberta Stellman, MD, Correctional Mental Health Expert
Ronald Shansky, MD, Correctional Medical Expert

Golden Grove Adult Correctional Facility 2nd Monitoring Assessment December 9-12, 2013
Urgent Conditions of Confinement Concerns at GGACF Kenneth A. Ray, Monitor January 28, 2014
The following articulates certain findings by the monitoring team during the second onsite assessment of GGACF that necessitate emergency action to eliminate and/or reduce safety and welfare risks to inmates and staff. Territory officials are encouraged to take immediate steps to ameliorate these conditions due to their critical nature, real and potential imminent harm these conditions pose to facility security, inmate and staff well-being.
I. Staffing:
A. Correctional Staffing and Inmate Supervision
The serious safety and security risk reported in the Findings of Fact Report and the First Monitoring Report were found to be unchanged. Inadequate staffing levels and staff supervision continue to create dangerous safety and security practices and conditions that expose staff and inmates to actual and potential risk of harm throughout the facility. Some of the most urgent and pervasive examples once again found during the second site assessment include:
1. Chronic staffing shortages resulting in housing units operating with one or no officers.
2. Officers not showing up for work when scheduled and/or refusing to work assigned areas.
3. Officers refusing to work certain housing areas due to fear of inmates and unsafe conditions.
4. Housing unit sally port entrance doors, internal security gates, and control room doors remaining unlocked.
5. Security gates throughout the campus being left unlocked and/or standing open.
6. Officers leaving housing units unattended.
7. Officers being afraid to enter the housing unit alone and/or with no back-up officer to conduct cell inspections and/or security checks; they remain in the unit control room.
8. Officers being required to work extensive overtime that can cause mental fatigue and impair their alertness and awareness to safety and security threats.
9. Access gates leading into housing units are routinely left opened and/or unlocked when officer s enter the housing units.
10. Lack of officers contributes to lax security practices and sound inmate supervision as evidenced by inmates being allowed to obstruct visibility into their cells using blankets, towels,

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cardboard, and/or paper products. Officers cannot see into many prison and detention unit cells due to these obstructions and do not open cell doors for security inspections as a general rule.
11. Inadequate staffing and security practices, for example, impair timely and effective response to security incidents as observed while touring unit 9A, the isolation unit of the detention center. An inmate was able to breach the lock on his cell and access the pod day room. An officer then locked the housing unit gate and the inmate eventually returned to his cell. This inmate could have just as easily bolted out of the building and/or gained access to the officer.
12. Lack of adequate inmate body searches. For example, an inmate was not properly searched before leaving his housing unit or entering the medical facility for services. While receiving medical services from health care staff this inmate produced a shank in the form of a metal coat hanger that he indicated was needed for his protection against other inmates. This device could have easily been used by this inmate to cause serious physical injury to health care staff.
13. In one medical event, a female inmate in X-dorm went into a diabetic coma when no security officers were on the unit. The other female inmates had to scream through the unit windows until another officer who was passing by the building responded and the inmate was subsequently transported to the hospital for care.
14. In another security event in the prison lockdown unit, a handcuffed inmate being escorted by two officers was able to break away from the officers and exit the building before being caught because the pod security gate and housing unit sally port doors were unsecured.
15. Inadequate staffing levels, undertrained and under-supervised staff, under-monitored and under-supervised inmates contribute to the presence of dangerous contraband in housing units. For example, while touring 9B, this Monitor found a 4-inch knife blade openly sitting on the top bunk of an inmate’s cell. This clearly suggests this inmate had little or no concern of this weapon being detected by security staff. Upon my notifying security staff of this weapon, the knife was removed and the inmate was locked in his cell before the cell was searched for more contraband or weapons. During the shakedown, other contraband, including screws, frayed bits of cell phone chargers, a cell phone battery, seeds (potentially of marijuana) and “dime bags” (typically used to store drugs) were also recovered. Per the above incident, the presence of contraband in plain view in a cell indicates that the inmates are confident that security staff will never conduct rounds or enter the prisoners’ cells to conduct a contraband check. This is a very unsafe security practice because it allows the inmate to obtain other possible weapons in preparation for officers to return and search his cell.
16. During our tour of the juvenile unit, the single unit officer was observed sleeping when we entered the unit. This officer made no attempt to interact with the inmates during our visit, and one juvenile inmate stated that the officers seldom enter the housing area. The two juvenile prisoners were essentially left locked in the housing unit without supervision, having full run of the unit and easy access to broken broom handles. These potential weapons were found covered by a very large mound of trash in one unoccupied cell. This trash pile, which consisted of a large quantity of combustible refuse, appeared to have been there for a long time based on the presence of some decayed food products found.

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17. Regarding unlocked security gates and housing units, the Warden stated that many officers do not lock them and/or leave them open for their own safety when entering the units. He stated that officers do not want to be locked in the units with inmates with only one set of keys, especially when there is only one officer on the unit and/or when they do not have radios to summon for assistance if the inmates attempt to take the officer hostage and overrun the unit. This situation is made even more dangerous because the unit officers are not issued weapons they can easily access for self or inmate protection. Officers are, thereby, in extreme danger each time they enter a housing unit.

18. Unit and supervisor log books are filled with examples of the emergency nature of GGACF staffing levels. Unit officers write such entries as “this unit is unmanned,” “radios are nonfunctional,” “no supervisor came on the unit,” “no relief officer,” and, “I will not be responsible if anything goes wrong….” Supervisor log books verify that there are times when units are not staffed and inmates are not supervised. The women’s unit frequently goes without any officer on duty, especially during overnight shifts while inmates are locked in their cells.

19. It was also learned that there are times when only one of three security towers are operational due to staffing shortages. This is a serious problem, as it leaves internal and external security perimeters completely unmonitored where unstaffed towers are located. This condition is worsened due to several nonworking perimeter lights.

B. Medical and Mental Health Staffing

Inadequate medical and mental health staffing levels continue to prevent Golden Grove from providing constitutionally adequate care.
1. The logbook entries are replete with examples of medical and mental health care issues being flagged by security staff, along with a note that “no doctor is available” or “no one present in medical.” When the woman in the diabetic coma, discussed above, was transported to the hospital, for example, there was no medical staff on duty. As a result, there was no documentation in the prisoner’s medical record regarding the prisoner’s hospitalization, her return, or any follow-up treatment. But for the log book entries recording this event, it was as if it never happened.

2. The intake health screening requirements of the agreement cannot be met until there is 24-hour medical care available. The monitoring team was advised by Territory officials that the “paperwork had been submitted for night nurses” but nothing was finalized yet. According to the HSA, she had never been shown the resumes submitted for those positions. However, during a meeting with the director, this monitor was shown a resume packet of nursing applicants and was advised that several applicants were approved for hire but no start dates were provided.

3. While on-site, we observed how the lack of coordination between security staff in intake and medical staff leads to a high risk of harm to prisoners. On Monday morning (December 9, 2013), intake forms were obtained by Medical for prisoners who came in at 8:35 pm Friday and 6:09 pm Sunday. Both forms indicated numerous positive responses to questions related

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Page 3 of 7

to chronic medical needs (diabetes), potential withdrawal (alcohol), and mental health risks (“talks and answers himself, appears to be delusional”). These positive responses should have led to immediate notification to medical/mental health staff, due to the risk the prisoners so obviously faced.
4. In addition to identifying urgent nursing needs, the HSA also requested a medical records assistant and recommended a candidate. However, BOC leadership has not acted on her request and recommendation at this time. The HSA indicated that she does not have time to begin to write the policies required by the Agreement, as she is overburdened with administrative duties that could be handled by an assistant. Even without an assistant, the medical records reviewed were disorganized and missing key information. There were no appointment logs and thus there was no way of knowing whether a prisoner with urgent medical or mental health needs was being seen as needed.
5. The current psychiatrist on-site planned to retire by the end of 2013. Although a replacement, Dr. Sang, was reportedly hired, telephone conversations with Dr. Sang caused concern that she had not been contacted about a start date. Even with the current psychiatrist, there are very few hours of mental health care being provided every week.
6. The one unlicensed mental health counselor on-site tries, but oftentimes prisoners are not transported to their appointments due to a lack of security staff available to transport. As a result of the lack of mental health staff, there are no real suicide prevention or mental health care programs in place. For the second time, we were told that no suicide watches had been initiated in the previous three month period, only to discover through logbook entries that security staff had initiated a watch on their own and had decided when to discontinue the watch, all without notifying mental health staff. Staff are clearly acting without the benefit of clear policies, procedures, supervision, and/or management communication. There was no corresponding documentation of a watch in the medical file. Furthermore, our tour of both detention and prison segregation units found mentally ill inmates, some presenting with paranoid and/or symptom deterioration who stated that they had not seen a mental health staff person in weeks. This is very troubling considering that these inmates were allowed to maintain obstructed view into their cells and/or their cells were so dark that I was unable to see into the living area. These conditions severely impair adequate security supervision of these inmates, and such sensory deprivation can exacerbate psychiatric pathologies causing more severe and prolonged psycho-emotional suffering.
7. With regard to medical staff, while on-site we were informed that the medical director for BOC had only been to the facility six times since our last visit. After bringing this to the attention of BOC leadership, the Director was removed from her position during the week. Another candidate was approached, but given the delays and difficulties getting contracts finalized, it is unclear when and if he will actually start his duties.
8. As noted above, during the week I was told about various medical and mental health hires. However, the HSA and candidates seemed unsure as to whether this staff would ever actually start. At a mid-week meeting, the Director told the HSA that she should begin selecting

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candidates for the nursing positions, but she was unable to access resumes that had been submitted months ago. When we left, she was still working on gathering this information.
9. With regard to security staff, at the very end of the week a meeting was arranged between the Monitor and the Director of the Bureau of Corrections. At that meeting, the Director indicated that he has approval to hire 30 new corrections officers and that 14 will be entering the academy “sometime before the end of the month.” However, as of the end of the visit, no academy start date had been scheduled. It is now the beginning of January 2014, and we have not received any confirmation that these new hires were brought on board and that a new academy class began. It is also unclear why these plans were not revealed to us at the beginning of the visit. One possible explanation was that BOC’s human resources director (also training director and director of administration) was on leave during our visit, as she was during our last visit, and other BOC personnel did not have ready access to her files.
II. Inadequate Safety Equipment and Inadequate Training on Use of Equipment
In addition to the staffing shortage, the logbooks also highlighted the lack of working safety equipment in many of the units.
1. Equipment lists on different units often noted that the unit was without a working radio, empty first-aid boxes, and/or no suicide cut down tools. In some instances, particularly in the XDorm, the units went without a working radio or phone for weeks at a time. The absence of reliable communication devices presents extreme risk to staff and inmate safety, especially if there is only one officer assigned to each housing unit. If an incident were to occur, the officer would have no way of calling for help. The fact that many of the male units are staffed by one female officer makes this threat even more real and present.
2. We also observed that not every unit had a cut down tool or a working flashlight. And, in at least one instance, the officer on duty did not believe there was a cut down tool available, when in fact one was located at the back of a locked box. It was clear to me that, even where equipment is available, the officers are unaware and therefore unable to use that equipment in an emergency. In one unit where there was a cut down tool, the tool was locked on a wallmounted cabinet that was too high for the officer to reach.
3. Housing unit equipment logs are not maintained consistently. Logs were found incomplete with some logs missing equipment verification entries for several days at a time. It is clear that these logs are not consistently monitored for quality assurance by supervisor staff.
III. Physical Plant Issues
Numerous environmental hazards were observed during the compliance monitoring tour. Golden Grove’s facility is old and in need of much repair.
1. It rained off and on during our visit, creating significant flooding in most of the housing units. Standing water on the floor of the units creates numerous safety risks. Exposed electrical wiring near dripping water was also found.

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2. Mold remains prolific throughout the housing units. All of the housing units have a large level of mildew and mold throughout. Some inmates complained that their health is deteriorating as a result of these conditions. One inmate complained that mold in his cell is exacerbating his chronic asthma and he is having difficulty breathing
3. The kitchen remains filthy with rotting food bi-products under sinks, stoves, and between broken floor tiles. Additionally, there appears to be no effective control over cooking instruments such as knives, large metal spoons, etc. During our tour we found the kitchen tool room door unlocked and standing open, the tool cage open and unlocked, several tools, including knives and large metal spoons, missing. No security officers were present on the floor at this time and the two civilian kitchen staff were both sitting in the office socializing with an officer while several inmates cleaned the kitchen area unsupervised.
4. The lack of a working fire safety system is also a very serious concern. The cell fire sprinklers are used by virtually every inmate to anchor homemade clotheslines. It is unclear whether or when the facility plans to fix the sprinkler system so that it is fully operational.
Conclusion and Recommendations:
As previously stated, this is a non-exclusive list of specific serious issues found during the second monitoring site visit that beg for urgent attention and resolution. Considering the potentially life threating nature of many of these findings, Territory officials are encouraged to immediately take the following action:
1. Expedite the hiring and adequate training of all open staff positions – corrections, medical, and mental health. Develop an emergency hire plan that includes deadlines for having all positions trained and working.
2. Stop the practice of allowing inmate housing units to go unstaffed, inmates unsupervised.
3. Stop the practice of leaving housing unit sally port doors, internal security gates, and officer control room doors open and/or unlocked. These doors should remain closed and locked at all times except for authorized movement.
4. Ensure that all housing units are consistently supplied with reliably functioning radios for all officers assigned to the unit, and with all other equipment needed to provide safe and secure supervision of the unit and inmates, i.e. cut down tools, flashlights, etc.
5. Do not allow officers to enter housing units with security keys and without the presence of another officer who can rapidly respond if needed.
6. Ensure adequate, proper, and active management of the juvenile unit and supervision of juvenile inmates.
7. Increase supervisor presence in housing units to perform quality assurance functions and staff supervision.

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8. Remove all coverings from cell door windows and cell areas that block clear and complete view inside cells. Also, inmates, especially mentally ill inmates, should not be allowed to live in dark cells as previously discussed.
9. Ensure inmates are properly searched for contraband when leaving and returning to their units, when entering and leaving other facility buildings.
10. Develop a comprehensive plan for repair and/or replacement of all non-functioning security mechanisms, equipment, systems, and lighting. Include a comprehensive plan for repair or replacement of the fire suppression system. These plans should include completion deadlines.
END REPORT

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Golden Grove Adult Correctional Facility 2nd Monitoring Assessment December 9-12, 2013
Urgent Conditions of Confinement Concerns at GGACF Kenneth A. Ray, Monitor January 28, 2014
The following articulates certain findings by the monitoring team during the second onsite assessment of GGACF that necessitate emergency action to eliminate and/or reduce safety and welfare risks to inmates and staff. Territory officials are encouraged to take immediate steps to ameliorate these conditions due to their critical nature, real and potential imminent harm these conditions pose to facility security, inmate and staff well-being.
I. Staffing:
A. Correctional Staffing and Inmate Supervision
The serious safety and security risk reported in the Findings of Fact Report and the First Monitoring Report were found to be unchanged. Inadequate staffing levels and staff supervision continue to create dangerous safety and security practices and conditions that expose staff and inmates to actual and potential risk of harm throughout the facility. Some of the most urgent and pervasive examples once again found during the second site assessment include:
1. Chronic staffing shortages resulting in housing units operating with one or no officers.
2. Officers not showing up for work when scheduled and/or refusing to work assigned areas.
3. Officers refusing to work certain housing areas due to fear of inmates and unsafe conditions.
4. Housing unit sally port entrance doors, internal security gates, and control room doors remaining unlocked.
5. Security gates throughout the campus being left unlocked and/or standing open.
6. Officers leaving housing units unattended.
7. Officers being afraid to enter the housing unit alone and/or with no back-up officer to conduct cell inspections and/or security checks; they remain in the unit control room.
8. Officers being required to work extensive overtime that can cause mental fatigue and impair their alertness and awareness to safety and security threats.
9. Access gates leading into housing units are routinely left opened and/or unlocked when officer s enter the housing units.
10. Lack of officers contributes to lax security practices and sound inmate supervision as evidenced by inmates being allowed to obstruct visibility into their cells using blankets, towels,

GGACF Conditions of Confinement Concerns of 121213

Page 1 of 7

cardboard, and/or paper products. Officers cannot see into many prison and detention unit cells due to these obstructions and do not open cell doors for security inspections as a general rule.
11. Inadequate staffing and security practices, for example, impair timely and effective response to security incidents as observed while touring unit 9A, the isolation unit of the detention center. An inmate was able to breach the lock on his cell and access the pod day room. An officer then locked the housing unit gate and the inmate eventually returned to his cell. This inmate could have just as easily bolted out of the building and/or gained access to the officer.
12. Lack of adequate inmate body searches. For example, an inmate was not properly searched before leaving his housing unit or entering the medical facility for services. While receiving medical services from health care staff this inmate produced a shank in the form of a metal coat hanger that he indicated was needed for his protection against other inmates. This device could have easily been used by this inmate to cause serious physical injury to health care staff.
13. In one medical event, a female inmate in X-dorm went into a diabetic coma when no security officers were on the unit. The other female inmates had to scream through the unit windows until another officer who was passing by the building responded and the inmate was subsequently transported to the hospital for care.
14. In another security event in the prison lockdown unit, a handcuffed inmate being escorted by two officers was able to break away from the officers and exit the building before being caught because the pod security gate and housing unit sally port doors were unsecured.
15. Inadequate staffing levels, undertrained and under-supervised staff, under-monitored and under-supervised inmates contribute to the presence of dangerous contraband in housing units. For example, while touring 9B, this Monitor found a 4-inch knife blade openly sitting on the top bunk of an inmate’s cell. This clearly suggests this inmate had little or no concern of this weapon being detected by security staff. Upon my notifying security staff of this weapon, the knife was removed and the inmate was locked in his cell before the cell was searched for more contraband or weapons. During the shakedown, other contraband, including screws, frayed bits of cell phone chargers, a cell phone battery, seeds (potentially of marijuana) and “dime bags” (typically used to store drugs) were also recovered. Per the above incident, the presence of contraband in plain view in a cell indicates that the inmates are confident that security staff will never conduct rounds or enter the prisoners’ cells to conduct a contraband check. This is a very unsafe security practice because it allows the inmate to obtain other possible weapons in preparation for officers to return and search his cell.
16. During our tour of the juvenile unit, the single unit officer was observed sleeping when we entered the unit. This officer made no attempt to interact with the inmates during our visit, and one juvenile inmate stated that the officers seldom enter the housing area. The two juvenile prisoners were essentially left locked in the housing unit without supervision, having full run of the unit and easy access to broken broom handles. These potential weapons were found covered by a very large mound of trash in one unoccupied cell. This trash pile, which consisted of a large quantity of combustible refuse, appeared to have been there for a long time based on the presence of some decayed food products found.

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Page 2 of 7

17. Regarding unlocked security gates and housing units, the Warden stated that many officers do not lock them and/or leave them open for their own safety when entering the units. He stated that officers do not want to be locked in the units with inmates with only one set of keys, especially when there is only one officer on the unit and/or when they do not have radios to summon for assistance if the inmates attempt to take the officer hostage and overrun the unit. This situation is made even more dangerous because the unit officers are not issued weapons they can easily access for self or inmate protection. Officers are, thereby, in extreme danger each time they enter a housing unit.

18. Unit and supervisor log books are filled with examples of the emergency nature of GGACF staffing levels. Unit officers write such entries as “this unit is unmanned,” “radios are nonfunctional,” “no supervisor came on the unit,” “no relief officer,” and, “I will not be responsible if anything goes wrong….” Supervisor log books verify that there are times when units are not staffed and inmates are not supervised. The women’s unit frequently goes without any officer on duty, especially during overnight shifts while inmates are locked in their cells.

19. It was also learned that there are times when only one of three security towers are operational due to staffing shortages. This is a serious problem, as it leaves internal and external security perimeters completely unmonitored where unstaffed towers are located. This condition is worsened due to several nonworking perimeter lights.

B. Medical and Mental Health Staffing

Inadequate medical and mental health staffing levels continue to prevent Golden Grove from providing constitutionally adequate care.
1. The logbook entries are replete with examples of medical and mental health care issues being flagged by security staff, along with a note that “no doctor is available” or “no one present in medical.” When the woman in the diabetic coma, discussed above, was transported to the hospital, for example, there was no medical staff on duty. As a result, there was no documentation in the prisoner’s medical record regarding the prisoner’s hospitalization, her return, or any follow-up treatment. But for the log book entries recording this event, it was as if it never happened.

2. The intake health screening requirements of the agreement cannot be met until there is 24-hour medical care available. The monitoring team was advised by Territory officials that the “paperwork had been submitted for night nurses” but nothing was finalized yet. According to the HSA, she had never been shown the resumes submitted for those positions. However, during a meeting with the director, this monitor was shown a resume packet of nursing applicants and was advised that several applicants were approved for hire but no start dates were provided.

3. While on-site, we observed how the lack of coordination between security staff in intake and medical staff leads to a high risk of harm to prisoners. On Monday morning (December 9, 2013), intake forms were obtained by Medical for prisoners who came in at 8:35 pm Friday and 6:09 pm Sunday. Both forms indicated numerous positive responses to questions related

GGACF Conditions of Confinement Concerns of 121213

Page 3 of 7

to chronic medical needs (diabetes), potential withdrawal (alcohol), and mental health risks (“talks and answers himself, appears to be delusional”). These positive responses should have led to immediate notification to medical/mental health staff, due to the risk the prisoners so obviously faced.
4. In addition to identifying urgent nursing needs, the HSA also requested a medical records assistant and recommended a candidate. However, BOC leadership has not acted on her request and recommendation at this time. The HSA indicated that she does not have time to begin to write the policies required by the Agreement, as she is overburdened with administrative duties that could be handled by an assistant. Even without an assistant, the medical records reviewed were disorganized and missing key information. There were no appointment logs and thus there was no way of knowing whether a prisoner with urgent medical or mental health needs was being seen as needed.
5. The current psychiatrist on-site planned to retire by the end of 2013. Although a replacement, Dr. Sang, was reportedly hired, telephone conversations with Dr. Sang caused concern that she had not been contacted about a start date. Even with the current psychiatrist, there are very few hours of mental health care being provided every week.
6. The one unlicensed mental health counselor on-site tries, but oftentimes prisoners are not transported to their appointments due to a lack of security staff available to transport. As a result of the lack of mental health staff, there are no real suicide prevention or mental health care programs in place. For the second time, we were told that no suicide watches had been initiated in the previous three month period, only to discover through logbook entries that security staff had initiated a watch on their own and had decided when to discontinue the watch, all without notifying mental health staff. Staff are clearly acting without the benefit of clear policies, procedures, supervision, and/or management communication. There was no corresponding documentation of a watch in the medical file. Furthermore, our tour of both detention and prison segregation units found mentally ill inmates, some presenting with paranoid and/or symptom deterioration who stated that they had not seen a mental health staff person in weeks. This is very troubling considering that these inmates were allowed to maintain obstructed view into their cells and/or their cells were so dark that I was unable to see into the living area. These conditions severely impair adequate security supervision of these inmates, and such sensory deprivation can exacerbate psychiatric pathologies causing more severe and prolonged psycho-emotional suffering.
7. With regard to medical staff, while on-site we were informed that the medical director for BOC had only been to the facility six times since our last visit. After bringing this to the attention of BOC leadership, the Director was removed from her position during the week. Another candidate was approached, but given the delays and difficulties getting contracts finalized, it is unclear when and if he will actually start his duties.
8. As noted above, during the week I was told about various medical and mental health hires. However, the HSA and candidates seemed unsure as to whether this staff would ever actually start. At a mid-week meeting, the Director told the HSA that she should begin selecting

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candidates for the nursing positions, but she was unable to access resumes that had been submitted months ago. When we left, she was still working on gathering this information.
9. With regard to security staff, at the very end of the week a meeting was arranged between the Monitor and the Director of the Bureau of Corrections. At that meeting, the Director indicated that he has approval to hire 30 new corrections officers and that 14 will be entering the academy “sometime before the end of the month.” However, as of the end of the visit, no academy start date had been scheduled. It is now the beginning of January 2014, and we have not received any confirmation that these new hires were brought on board and that a new academy class began. It is also unclear why these plans were not revealed to us at the beginning of the visit. One possible explanation was that BOC’s human resources director (also training director and director of administration) was on leave during our visit, as she was during our last visit, and other BOC personnel did not have ready access to her files.
II. Inadequate Safety Equipment and Inadequate Training on Use of Equipment
In addition to the staffing shortage, the logbooks also highlighted the lack of working safety equipment in many of the units.
1. Equipment lists on different units often noted that the unit was without a working radio, empty first-aid boxes, and/or no suicide cut down tools. In some instances, particularly in the XDorm, the units went without a working radio or phone for weeks at a time. The absence of reliable communication devices presents extreme risk to staff and inmate safety, especially if there is only one officer assigned to each housing unit. If an incident were to occur, the officer would have no way of calling for help. The fact that many of the male units are staffed by one female officer makes this threat even more real and present.
2. We also observed that not every unit had a cut down tool or a working flashlight. And, in at least one instance, the officer on duty did not believe there was a cut down tool available, when in fact one was located at the back of a locked box. It was clear to me that, even where equipment is available, the officers are unaware and therefore unable to use that equipment in an emergency. In one unit where there was a cut down tool, the tool was locked on a wallmounted cabinet that was too high for the officer to reach.
3. Housing unit equipment logs are not maintained consistently. Logs were found incomplete with some logs missing equipment verification entries for several days at a time. It is clear that these logs are not consistently monitored for quality assurance by supervisor staff.
III. Physical Plant Issues
Numerous environmental hazards were observed during the compliance monitoring tour. Golden Grove’s facility is old and in need of much repair.
1. It rained off and on during our visit, creating significant flooding in most of the housing units. Standing water on the floor of the units creates numerous safety risks. Exposed electrical wiring near dripping water was also found.

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2. Mold remains prolific throughout the housing units. All of the housing units have a large level of mildew and mold throughout. Some inmates complained that their health is deteriorating as a result of these conditions. One inmate complained that mold in his cell is exacerbating his chronic asthma and he is having difficulty breathing
3. The kitchen remains filthy with rotting food bi-products under sinks, stoves, and between broken floor tiles. Additionally, there appears to be no effective control over cooking instruments such as knives, large metal spoons, etc. During our tour we found the kitchen tool room door unlocked and standing open, the tool cage open and unlocked, several tools, including knives and large metal spoons, missing. No security officers were present on the floor at this time and the two civilian kitchen staff were both sitting in the office socializing with an officer while several inmates cleaned the kitchen area unsupervised.
4. The lack of a working fire safety system is also a very serious concern. The cell fire sprinklers are used by virtually every inmate to anchor homemade clotheslines. It is unclear whether or when the facility plans to fix the sprinkler system so that it is fully operational.
Conclusion and Recommendations:
As previously stated, this is a non-exclusive list of specific serious issues found during the second monitoring site visit that beg for urgent attention and resolution. Considering the potentially life threating nature of many of these findings, Territory officials are encouraged to immediately take the following action:
1. Expedite the hiring and adequate training of all open staff positions – corrections, medical, and mental health. Develop an emergency hire plan that includes deadlines for having all positions trained and working.
2. Stop the practice of allowing inmate housing units to go unstaffed, inmates unsupervised.
3. Stop the practice of leaving housing unit sally port doors, internal security gates, and officer control room doors open and/or unlocked. These doors should remain closed and locked at all times except for authorized movement.
4. Ensure that all housing units are consistently supplied with reliably functioning radios for all officers assigned to the unit, and with all other equipment needed to provide safe and secure supervision of the unit and inmates, i.e. cut down tools, flashlights, etc.
5. Do not allow officers to enter housing units with security keys and without the presence of another officer who can rapidly respond if needed.
6. Ensure adequate, proper, and active management of the juvenile unit and supervision of juvenile inmates.
7. Increase supervisor presence in housing units to perform quality assurance functions and staff supervision.

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8. Remove all coverings from cell door windows and cell areas that block clear and complete view inside cells. Also, inmates, especially mentally ill inmates, should not be allowed to live in dark cells as previously discussed.
9. Ensure inmates are properly searched for contraband when leaving and returning to their units, when entering and leaving other facility buildings.
10. Develop a comprehensive plan for repair and/or replacement of all non-functioning security mechanisms, equipment, systems, and lighting. Include a comprehensive plan for repair or replacement of the fire suppression system. These plans should include completion deadlines.
END REPORT

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EXHIBIT 2
2nd Compliance Monitoring Report DESCRIPTIVE NARRATIVE OF FACILITY ASSESSMENT FINDINGS
This descriptive narrative intends to provide a detailed overview of findings during this assessment, and to serve as a foundation for Compliance Ratings.
Conditions of Confinement, Safety and Security Overview
Upon entry to the facility, the entrance gate leading to the main electronic security gate was unsecured. A cursory inspection of the security mechanism indicates that the gate is out of alignment with the electronic latch, causing intermittent latch failure. This security problem was also found and discussed in the Baseline Report.
A reasonable search of persons and possessions was conducted by the entrance security officer but there were not enough visitor badges for the monitoring team and USDOJ officials. It was reported that all badges were currently in use.
The facility yard appeared recently mowed and clean with a few inmate workers tending to their work responsibilities under the general supervision of one officer. Two un-cuffed female inmates were being escorted toward us by an officer; one of these inmate wore proper inmate clothing, the other was out of uniform and wearing a New York Giants uniform jacket.
The yard security gates leading to building 9 were unlocked and the electronics appeared to be broken and inoperable. All three security gates on secured walkway to building 9 were unlocked and standing open.
Building 9 (Bravo): The security gate to 9-Bravo is secured, requiring key lock. However, the door to the officer’s station is unlocked. The housing unit Activity Room/Day Room ceiling is covered with mold. Eating tables on two surfaces are broken and need to be repaired. There is minor rubbish on the ground and standing water near the window. There are several exposed wires hanging from the ceiling and from electrical areas that power the TV. The ceiling going into this multi-purpose room is damaged. Due to recent heavy rain fall and roof problems, water is leaking from a corner down the wall onto the floor and into a bucket.
The swamp cooler is functioning and the air temperature feels reasonably comfortable. The medical exam room has been partially retiled. The sink is working because the water has been left running. There are broken and missing ceiling tiles. A plastic fork is jammed into the exam room entrance door preventing it from locking. The janitor’s closet door is open and propped open. There appears to be a cable wire loose and unconnected atop of a stainless steel shelf that is long enough to be used potential weapon, ligature, or whip. There are hoses connected the faucets, the sink appears reasonably clean, and the water is working.

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9 Bravo has four showers on the lower tier and upper tiers. The first lower tier shower floor has mold and broken concrete with exposed rocks. The plaster ceiling paint is peeling, there are soap stains and soap pieces lying on the ground, which are slip hazards. The second shower is similar to the first. It also appears to have a broken faucet. The water is running freely and the air vents appear to be somewhat plugged up. The third shower appears to be a bit cleaner; however, this shower is inoperable. The faucets are missing and the hot and cold water pipes are exposed. The fourth shower appears to be inoperable. The ceiling and paint are peeling, and the floor appears reasonably clean.

An inspection of ground level (lower tier) inmate cells found safety, security, and sanitation problems.

Cell 1-B was locked and unoccupied. However, the door window screen mesh is covered with a substance blocking the view.

Cell 2-B is unlocked. The steel window grate looks fairly new. There is one inmate lying down, apparently asleep. The room is reasonably clean but dark. The lights are off. There is a homemade clothesline tied from the sprinkler head over to the window. There is a plug-in fan. The sink does not work. The toilet is running. This is a 2-person cell with one person in it. The top bunk is being used for personal possessions, books, etc. An adequate supply of personal hygiene products appears to be present.

Cell 3-B is locked. It is a 2-person cell and appears unoccupied and appears clean; however, dark.

Cell 4-B is locked. This cell is unoccupied. The screen window mesh appears intact. It is dark, and I don’t know if the water is running or not because I was unable to enter the cell.

Cell 5-B has a towel hanging over the screen; however, it is open. This is an occupied cell, one person in this cell. It appears that this person has their own supply of ice in an ice cooler. The toilet flushes. The sink works. It appears reasonably clean and organized. There are two homemade ashtrays from a metal can that can also serve as a puncture weapon. The room appears organized with appropriate personal hygiene supplies. This cell has a homemade clothesline attached to the sprinkler head and the window.

Cell 6-B has a cover over the door window screen about halfway up from the inside. It is unlocked and occupied. There is a little bit of standing water on the floor. The toilet and sink are functional. There is an array of disorganized personal possessions on the top bunk as well as food products, empty water bottles, mail, clothing, and marked and unmarked medication bottles; the unmarked bottle is empty. The electrical power socket has a power surge protector; however, it is uncapped. There is a substantial amount of water running under the bottom bunk due to leaking from the rain.

Cell 7-B is a handicapped cell that appears unoccupied and is locked. The door window screen mesh has been pushed in and is rusted and dirty.

Cell 8-B is occupied and unlocked. The door window screen mesh is dirty with a dime-sized hole

in the mesh. The cell is dark. The sink works but the toilet does not flush. The floor appears dry;

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however, there is an unplugged electric fan with a damaged cord. The fan’s motor assembly is uncovered and exposed, which exposes its electrical functioning making it a safety hazard. There is also some sort of power plug plugged into the receptacle with the surge protector. The power plug is running under the bunk and connected to a DVD player. The top bunk is cluttered with an assortment of personal possessions, i.e., movies, clothing. There appears to be an adequate supply of personal hygiene products.
B-56 is a locked pass-through door to the adjacent Unit. The vestibule area floor has dirt, old batteries, old plastic sporks (plastic combination of spoon and fork), waste and some sort of electrical wire laying on it. These items should be completely removed to provide unobstructed movement of staff and inmates in the case of an emergency.
Cell 9-B is another handicapped cell. Again, I cannot see through, it is dark. The mesh is filthy with dust and something else.
Cell 10-B was closed but unlocked. This cell appears to be unoccupied. There is no bed in here. The sink is operable but the toilet is not operable. There appears to be waste in the toilet, i.e., a fork, some paper and some sort of powder substance covering the lip of the toilet. There also appears to be some sort of insulation stuffing, maybe out of a mattress that has been torn up. This cell is filthy, unoccupied, but accessible to inmates and it should not be accessible to inmates if it is unoccupied. Just about everything in here is combustible and a fire hazard, especially considering the fact that inmates are allow the use of tobacco and lighters.
Cell 11-B is a handicap cell that is locked, unoccupied, and reasonably clean.
Cell 12-B is locked, unoccupied, and appears to be clean.
Cell 13-B is occupied and locked. The cell appears to be clean and somewhat organized. The bed is made. There are personal belongings as well as empty paper cups and commissary product packages on the top bunk. There appears to be an adequate supply of personal hygiene. There is a fan, similar to the previous fan, plugged in and not running but the motor assembly is exposed, exposing the electrical components of the fan.
Cell 14-B is occupied and open. The toilet flushes and the sink works; however, the sink appears to have a homemade rubber faucet to direct the water. The cell is reasonably clean. There are several empty plastic bottles, i.e., juice bottles, personal hygiene bottles. The top bunk has personal clothing and personal possessions that look well organized and clothing folded. There is a homemade clothesline attached from the sprinkler head to the window as noted before. There is an unplugged electric fan with exposed electrical components and motor assembly. There is a red line tied to the inside of the door to allow the inmate to close the door at will. A wet towel is rolled up at the inside base of the door that inmate stated “is needed to keep the large centipedes out…”
Cell 15-B is a handicapped cell that has a fairly new metal mesh. It appears empty but I cannot see inside because it is dark.

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Cell 16-B is unlocked and occupied. The cell floor appears to be clean. There are wet T-shirts or some clothing at the cracks of the wall base to prevent water from coming in. Top bunk is cluttered with personal possessions, covered food products, water products, plastic forks, combustible products, personal hygiene products. The bed has no blanket.

An inspection of the upper tier of 9 Bravo found conditions similar to its lower tier. This tier also has four showers. Shower one is apparently broken and the floor area reasonably clean. The shower head is covered with plastic. Shower two has stains around the shower head but it is functional. The floor is reasonably clean. Shower three is functional with peeling paint. Floor appears to be reasonably clean. Shower four appears to be functional but the paint is peeling and there is a considerable amount of mold present.

An inspection of upper-tier inmate cells found similar safety, security, and sanitation problems.

Cell 17-B is locked, appears to be unoccupied, and the door window grate appears new.

Cell 18-B is locked, apparently occupied, and the screen mesh is torn at the base offering loose small wire shards that can be used for a weapon. It was difficult to see inside due to the damaged window mesh but the cell looks reasonable clean. There is a homemade clothesline attached to the sprinkler head running to the window. There appears to be an adequate supply of personal hygiene products.

Cell 19-B is locked and occupied; however, the fairly new door screen grate is covered by paper, preventing visibility to the inside. An internal inspection found two homemade clotheslines as previously described. The cell seems reasonably clean and organized. There appears to be a homemade ashtray on the top bunk, a bottle of “White Out” correction fluid, and a knife blade that is approximately four inches in length that will need to be removed immediately and conducted a contraband search. There is an electrical fan with frayed wires. There appears to be an adequate supply personal hygiene products. The presence the openly exposed knife blade in this unit is indicative of a lack of cell searches or attention to detail by operation staff running this unit.

Cell 20-B is locked with a fairly new door window metal grate; however, this window is covered by a cardboard that obscures internal visibility. Water appears to be working in this cell. As with other cells, this cell has makeshift clotheslines attached from the sprinkler head to the window and the sprinkler head to the upper bunk area. The table is reasonably organized with personal possessions and clothing. There appears to be an adequate hygiene products on the table. The top bunk is holding mostly books and papers. There is a small fan plugged in and attached to the top bunk. Motor assembly appears to be covered as manufactured.

Cell 21-B is locked and not occupied. It has rubbish, trash bags in it. It does not appear to have been cleaned in quite some time. The walls are covered with peeling paint. The locking mechanism appears to be broken with cellophane commissary product bags stuck in the locking mechanism.

Cell 22-B is locked with a fairly new metal grate on the door window that is unobstructed. There

is a clothesline attached from the sprinkler head to the window. The mattress consists of what

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appears to be stacked shards of torn insulation from a mattress that present a significant fire hazard. There does not appear to be a standard mattress in this cell. There are also trash bags and other personal effects lying about.
Cell 23-B is locked and appears occupied, the door window mesh is somewhat covered and damaged, and the room is dark with a homemade clothesline as previously described.
Cell 24-B is locked and appears occupied. The door window mesh is dirty but does not obstruct internal visibility. There is a plastic bag at the bottom, either to keep out the centipedes or water. The room’s floor appears to be clean. Bed is made and there appears to be and adequate supply of personal hygiene products.
Cell 25-B is locked and appears occupied. The door window mesh appears intact and does not obstruct internal visibility. There is a towel hanging over the top bunk that prevents viewing to the bottom bunk. There is also a smell of marijuana emitting from this cell. There is a plugged in DVD player, a fan, and an adequate supply of personal hygiene products.
Cell 26-B is locked and occupied with what appears to be a fairly new door grate that is unobstructed. It appears to be reasonably kept and what appears to be an adequate supply of personal hygiene products.
Cell 27-B is locked and appears to be unoccupied; however, it has not been cleaned out. There are old cellophane food wrappers scattered on the floor. There is a homemade rope tied to the bottom of the bench.
Cell 28-B is locked and occupied by an inmate who states he is in “lock-down for security reasons.” A towel is mounted to the top bunk that covers visibility into the bottom bunk. The cell, though dark, appears to have an adequate supply of personal hygiene products and is reasonably well kept.
Cell 29-B is occupied and locked. It is fairly sparse with personal belongings; however, this cell has a homemade curtain using a sheet that is anchored to the ceiling. This should be removed. Looks like a fairly new mattress but no bedding on the mattress. There appears to be an adequate supply of personal hygiene products.
Cell 30-B is locked and occupied. The door window mesh is in fair condition. There is a large fan inside. Again, there is a homemade clothesline attached to the sprinkler head to the window. This is fairly well kept and does not appear cluttered. The inmate appears to keep it fairly clean and organized. There appears to be an adequate supply of personal hygiene supplies.
Cell 31-B is locked and occupied. Screen mesh is hard to see through but I can see because of the natural light. It has a clothesline anchored from the sprinkler head to the window. It has full trash bags on the upper bunk. There is also a foot locker near the bottom bunk where the inmate sleeps, between the bed and table that has a DVD player on it. There appears to be a large can being used for an ashtray; there is a faint odor of burnt tobacco.

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Cell 32-B is unlocked and occupied. There is a towel draped over the top of the door that covers the inside of the metal grate. Again, the security visibility practices here reflect lack of attention to standard security policies and practices that are very dangerous for inmates and staff.

The Day Room environment of 9 Bravo is reasonably clean. Inmates are socializing and playing cards. Some of the inmates are wearing prison uniforms, others are wearing personal clothing such as personal shorts, personal T-shirts, personal tennis shoes, flip flops. The television appears to be gone. The swamp cooler is working and blowing air. The Grievance Form and Inmate Request Forms box, which would be for medical and inmate grievances, has a missing top and provides no protection for these documents.

The corrections officer came from the 9 Bravo control room into the housing unit, leaving the gate unlocked, which is a condition of the lack of staffing that requires them to carry security keys into it and leave the gate unlocked. Leaving the gate unlocked from the inside gives inmates access to the outside and to the control room. The control room for 9-Bravo is unlocked. The gate is unlocked and an inmate could easily enter this control room. Entering the control room, they would have direct access to the fire extinguisher that could be used as a weapon. There are chemicals setting on desks. This security deficiency gives inmates easy access to the lighting system, fire alarm systems. They would have access to coat hangers and areas in this control room. 9 Bravo control room does not have any security control systems in it. Ceiling panels are missing, exposing electrical wires that would be too high to reach without a ladder. Between the two control rooms (Alpha and Bravo) is the bathroom, which appears to be fairly clean with running water and a toilet. I see hand sanitizer and toilet paper and a can of comet or powdered detergent.

Building 9 (Alpha). Upon entering the Control Room there are no security control panels or any electrical security control systems. The red fire control system box does not appear operational. All of the ceiling panels are gone except those at the lights. There are electrical cords and what appears to be a computer cable running to the PC. This room contains a fire extinguisher with an updated pressure inspection. The officer in this control room states that there are no suicide cutdown tools in this control room or this unit. (The fact is there was a cut-down tool in there in a box locked but the officer was not aware of that fact). The Control Room door to the secured vestibule is unlocked. The security gate into the housing is unlocked – I just let myself in. It is unlocked on both sides allowing inmates direct access from the housing unit to this Control Room to Control Room B into housing 9 Bravo.

9 Alpha Multipurpose Room has standing water, apparently from the storms. The television has been taken out. The ceiling appears to have mold. There is a towel draped across one of the horizontal fire plumbing pipes.

Alpha recreation yard has a plastic baggie and small homemade twine tied to the steel grate. The door is unlocked allowing access to that rec area. The rec area appears to have been flooded during the storms this week but is drying. It appears the drain system is working fine.

The inmates in 9 Alpha are locked in their cells (security lock-down). The Grievance Box is locked

with a padlock securing confidentiality of documents. The swamp cooler is working. Some of the

lights are not working, either burned out or shut off. All lights should be on in this environment

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for security visibility purposes. The exam room door is standing open. The exam room sink plumbing drain pipe is disconnected. The janitor’s closet floor appears clean. The drain sink has mold, rust, macaroni, a plastic fork, and several washcloths hanging from the hanger. The sink itself is plastic and looks fairly clean. There is running water and bars of soap. There also appears to be plastic Tupperware and a plastic spoon in the sink. The floor is wet from recent cleaning.

9 Alpha has four shower stalls on the ground level (lower tier) and four on the top tier. The first shower stall on the lower tier is a handicapped shower with what appears to be appropriately positioned rails and seating. The floor is filthy and the shower appears functional. Shower two uses a large piece of plastic for privacy. This shower appears functional. The floor is much cleaner than the previous shower; however, there are soap stains and melted soap as well as old bars of soap that are laying on the ground presenting slip hazards. Lower tier shower three has the same plastic burlap mesh in front of the gate. There is an empty soap box and soap pieces that present slip hazard and needs to be cleaned. This shower does not appear to be functional. The shower head is missing but there is a cleaning product bottle on the floor.

An inspection of ground level (lower tier) inmate cells found safety, security, and sanitation problems. This is a high security housing unit so we will not enter any of the cells at this time.

Cell 1-A is padlocked and appears occupied, and it is very difficult to see inside. The officers do not regularly carry flashlights for visibility. This cell door window mesh has food products that need to be removed for sanitation and security reasons.

Cell 2-A is padlocked and appears occupied. Visibility is extremely low. The steel mesh has a cigarette in it.

Cell 3- is padlocked and appears occupied. The door window mesh is somewhat obstructed. It appears the inmate was able to slide paper between the wire mesh and metal grate to reduce visibility. Looking inside this cell, this inmate has homemade clotheslines that have towels, clothing and sheets draped over them preventing full visibility into the cell.

Cell 4-A: Cannot see inside.

Cell 5-A: Cannot see inside.

Cell 6-A is padlocked and cannot see inside. The inmate can control the hatch with a rope tied to it and has a towel draped over to prevent visibility from the inside.

Cell 7-A is padlocked. I cannot see inside. Lights are out and it is dark.

Cell 8-A is not padlocked but there is no visibility.

A-56 is an exit door leading to the outside. The outside door is open. The internal door is locked and vestibule area appears to be a staging area for some current electrical. This area contains electrical transformers and other metal products.

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Cell 9-A is dark, torn mesh, new grate and a homemade device to control the food-hatch.
Cell 10-A is padlocked. There is absolutely no visibility. This cell needs to be cleaned.
Cell 11-A has absolutely no visibility. The inmate has placed newspapers inside the door window to prevent internal visibility. This condition creates an extremely dangerous situation by forcing an officer to lean down to speak with the inmate and no visibility through this door.
Cell 12-A is padlocked with obscured visibility through the mesh. The mesh is covered and the inmate appears to be sitting on his bunk. There is a clothesline with a sheet draped over preventing full visibility into the cell.
Cell 13-A is padlocked with low visibility.
Cell 14-A is padlocked with no visibility.
Cell 15-A is padlocked with no visibility.
Cell 16-A appears unoccupied with very little visibility into the cell.
Inspecting the upper tier, there are four shower stalls as previously stated. Shower #1 appears functional and cleaner than the others. There is standing soap on the floor creating slip hazard. Shower #2 appears to be in the same condition as shower one. Shower #3, same condition as showers #1 and #2 but there is a lot of rust running down from the shower head cover plates. There also appears to be spider webs near the ceiling. Shower #4 appears to be operational; however, it is absolutely filthy.
Door A-62 is a pass-through door leading to door B-62 (9 Bravo housing). The vestibule space between doors A-62 to B-62 is absolutely filthy. The floor is covered with dirt, food products, plastic utensils and food bags. This are must be kept cleaned for inmate movement in case of emergencies.
Cell 17-A is unoccupied and locked. This cell appears to be reasonably clean.
Cell 18-A reveals the food hatch is closed and controlled by the inmate. There is absolutely no visibility through the door grate. There is a towel draped over it with newspapers stuffed in the grate.
Cell 19-A is the same condition as the previous cell. The food port is open, no padlock. It is occupied and fairly organized.
Cell 20-A has some visibility through the mesh, but very low. It is unoccupied.
Cell 21-A is unoccupied and needs to be cleaned

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Cell 22-A is appears to be occupied but there is no internal visibility. The food hatch is controlled by the inmate. There is a towel draped over the door from the inside preventing full visibility into the cell.

Cell 23-A is occupied is fairly organized and kept. There is standing water coming from cracks in the floor. There is also a towel draped over the door preventing full visibility.

Cell 24-A is unoccupied and locked.

Door A-61 is a service door that is closed and locked.

Cell 25-A is unoccupied. The cell appears reasonably clean.

Cell 26-A is unoccupied. The cell appears reasonably clean.

Cell 27-A is occupied but I cannot see inside because it is dark and the door window is cluttered.

Cell 28-A is unoccupied with paper between the door grate and the door mesh. The door mesh is torn.

Cell 29-A is unoccupied and appears reasonably clean.

Cell 30-A is occupied but visibility completely obscured by a towel of sheet.

Cell 31-A is occupied but visibility is completely obscured similar to the previous cell.

Cell 32-A has the same condition as the previous two.

The inmates in this unit are high security disciplinary inmates. Many complain of lack of hygiene products, lack of clothing products, and complain about commissary prices, lack of access to water in their cells.

Building 9 (Charlie). The rolling security door entering the building were unsecured. The door to the officer’s station was unsecured; however, the gate into the housing unit was secure. The Day Room is similar to those previously described and there is standing water on the floor due to the heavy rains. The Rec Yard appears to have flooded, but it is mostly clear of standing water. There is water dripping from the ceiling at the yard entrance door. There is standing water throughout the housing unit.

In general, this housing unit, similar to the previous housing units, has mold on the ceilings. There are leaks in the ceiling at the top tier and the bottom tier. The floor drains are not completely open and need to be cleaned. It is a brand new swamp cooler that is not operating. I am told by an officer that the cooler it is brand new. The date of issue shows 12/05/13.

The Control Room door in 9 Charlie is unlocked and the door from the housing unit and the gate

to the housing unit leading to this Control Room is unlocked.

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My review of the equipment log indicates there is no suicide prevention cut-down tool located in this unit. The officer stated that a tool was not provided to this Control Room.
The Control Room requires accounting for the following equipment, which also shows no cutdown tool listed.
 A/C unit  Air Horn  Baton  Cable Box  Cut Down Tool  Log Book  Microwave  Phone  Handcuff  First Aid Kit  Keys  Fire Extinguisher  Hand Radio  Garbage Bin  Water Cooler  Chairs  TV  DVD Player  Washer/Dryer  Standing Fan  Wall Fan  Computer  Caliper
This equipment inventory log shows no equipment entry verifications for December 1, 2, 6, 7, 8, 9, 10 and 11. This log appears to be incomplete and not regularly maintained.
An inspection of upper level inmate cells found safety, security, and sanitation problems similar to those previously described.
Cell 32-C appears to be occupied but visibility in the room is obscured through the door grate. There is a sheet blocking visibility in the room.
Cell 31-C appears to be occupied by two inmates with fair visibility. The cell is reasonably clean with an adequate supply of personal hygiene products.

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Cell 30-C appears to be occupied. Several personal belongings and an adequate supply of personal hygiene products. The room needs to be cleaned.

Cell 29-C appears similar to previous cells. There are three clotheslines hanging as previously described. There is no visibility of the bottom bunk due to a towel blocking draped over the top bunk. There appears to be an adequate supply personal hygiene products.

Cell 28-C is occupied. This cell has several towels, apparently serving as a carpet. There are homemade clotheslines as previously described, several personal belonging, several books, writing materials. There appears to be an adequate supply of personal hygiene products.

Cell 27-C: Similar to the previous cell described.

Cell 26-C is occupied with visibility mostly obscured by hanging sheets being used as room separators.

Cell 25-C is occupied with a towel blocking the view to the bottom bunk. There are numerous personal possessions and food products. It is reasonably organized and clean. There appears to be an adequate supply of personal hygiene products.

Cell 24-C is occupied with full view inside. There are clotheslines as previously described and what appears to be an adequate supply of personal hygiene products.

Cell 23-C appears to be occupied but visibility into the cell is completely obscured by towels hanging from a clothesline as previously described.

Cell 22-C is occupied. Towels are being using towels as a carpet, possibly to deal with rainwater entering the cell. There appears to be an adequate supply of personal hygiene products. There also appears to be a blunt force weapon that has been crafted out of tightly rolled newspaper, probably for exercise. Although this device appears to be used for exercise, it could easily be used to seriously assault other inmates and/or staff and should be removed.

Cell 21-C is occupied with a sparse amount of personal possessions but an adequate supply of personal hygiene products. This inmate reports health concerns about the mold and dust throughout his cell and housing unit.

Cell 20-C is occupied with clear visibility into the cell. The cell appears to be reasonably clean and organized with an adequate supply of personal hygiene products.

Cell 19-C is occupied but very dark inside. The view into the cell is partial obscured by sheets or towels hanging from a clothesline as previously described. The cell is disorganized and emits the order of smoke.

Cell 18-C is occupied but full view into the cell is obscured by a towel draped over the top bunk. There appears to be an adequate supply of personal hygiene products.

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Cell 17-C appears to be occupied but the door grate is completely blocked by cardboard with a small viewing port cut from inside. The cell is dark and disorganized.

Door C-62 is a pass-through door to D-62 similar to those previously described. The vestibule area needs to be cleaned, also as previously described and for the same emergency life-safety reasons.

Building 9 (Delta). The Control Room door is secured as is the gate to the housing unit. An inspection of the Officer Equipment log also shows no entries for December 1 or 2. Similar to the previous equipment log, this log is incomplete.

An inspection upper-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.

Cell 17-D is an occupied cell. There is standing water in the floor. The inmate states he has been mopping. There appears to be an adequate supply of personal hygiene products.

Cell 18-D is occupied but door window is almost completely covered by a cardboard commissary product.

Cell 19-D is occupied with good visibility that appears clean and organized. There is a clothesline anchored to the sprinkler head and window as previously discussed. There appears to be an adequate supply of personal hygiene products.

Cell 20-D is occupied and somewhat disheveled. The window and lighting above is covered by newspaper. The door window is covered by a black towel. There are clotheslines hanging from the door hinges to the bunks and from the sprinkler heads to the window and from the door hinges to the sprinkler head, all holding towels and clothing. Personal belongs and food products clutter the floor. This cell needs to be organized and cleaned. There appears to be an adequate supply of personal hygiene products. There are also several small trash bags that appear to be filled with garbage and need to be removed. Several paper items, torn cardboard lying around on the ground. This needs to be cleaned up. Plastic bottles. Toilet needs to be flushed. There are several boxes in here. This is a fire hazard.

Cell 21-D appears to be unoccupied and metal grate on the door window is blocked by paper. The cell needs to be cleaned.

Cell 22-D appears to be unoccupied. It needs to be cleaned as well as the clotheslines need to be removed from their anchors.

Cell 23-D appears to be occupied; however, there is a towel draped over preventing visibility into it from the door and (open the door).

Building K & L. The sliding security door into this Unit is unlocked and open. The security gate to L is open and the control room door is unlocked.

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L Control Room does have a functional security control panel. I am advised by officers that the control panel remains non-operational. These all need to be repaired and functional.

The Multi-Purpose Room is locked and appears to be nonfunctional. This room is filled with garbage bags and boxes, indicating that it is not being used by inmates. Again, as previously discussed, the unit has standing water on some areas of the floor. The Examination Room is locked and does not appear to be used. The Janitor’s Closet is locked.

Similar to those previously described, there are shower stalls located on the upper and lower levels. The doors to the lower tier showers are made of metal framed screening with locking mechanisms. Shower #1 is a handicap shower with what appears to be appropriately placed hand rails and seating, and appears to be in better condition than those previously described. This shower appears to be functional and reasonably clean. Shower #2 appears to be functional and reasonably clean. Showers #3 and #4 are similar to #2.

An inspection lower-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.

Door L-55 door is a pass-through door to Housing Unit K-55. The pass-through vestibule area has standing water and exposed electrical wires with the electrical connections taped with electrical tape. The wires need to be secured. The floor needs to be kept dry. This area should be well maintained for emergency movement of inmates as previously described.

Cell L-1 appears to be empty. The cell needs a deep cleaning.

The plumbing chaise door adjacent to this cell is unlocked and poorly lighted. This, and all similar doors should remain locked at all times.

Cell 2-L is unoccupied. Screen is torn but has a secured grate over it. It needs to be cleaned.

Cell 3-L has an intact screen and grate and is unoccupied.

Cell 4-L hatch is open. The room is dark and appears occupied and cannot see inside.

Cell 5-L appears to be occupied and is similar to the above.

Cell 6-L appears to be unoccupied and very dark inside.

Cell 7-L appears in the same condition as 6-L.

Cell 8-L appears in the same condition as 7-L.

Door L-56 door is a pass-through door to L-57. The floor appears to have been flooded, at least in the corners at the external walls. This room needs to be cleaned for emergency movement reasons previously discussed.

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Cell 9-L is unoccupied but needs to be cleaned. Mattresses and pillows need to be removed and sanitized.

Cell 10-L is occupied and the inmate is covered by a sheet. There appears to be standing water that needs to be removed. There appears to be an adequate supply of personal hygiene products. Visibility is fair.

Cell 11-L is occupied with the inmate standing at the door preventing my view into the cell area. This inmate does not respond to my questions.

Cell 12-L is unoccupied with standing water that needs to be completely cleaned.

Cell 13-L is unoccupied and in similar condition as 12-L.

Cell 14-L is occupied with fair visibility. However, the inmate has a plastic bag draped over his lighting preventing visibility at night except by a flashlight.

Cell 15-L is too dark to see inside. The door window screen is torn but the grate is intact.

Cell 16-L appears to be unoccupied, the door window screen is torn but the window grate is intact. There is standing water and rust on the metal bunk. This cell to be cleaned and dried.

An inspection upper-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.

Cell 32-L is occupied and there is standing water in front cell door. The door window grate is intact and there appears to be an adequate supply of personal hygiene products.

Cell 31-L is pitch black. The screen is torn but grate intact.

Cell 30-L is in similar condition as 31-L.

Cell 29-L is in similar condition as 32-L.

Cell 28-L is unoccupied and needs to be cleaned.

Cell 27-L is unoccupied, needs to be clean, and standing water removed.

Cell 26-L is in similar condition as 27-L.

Cell 25-L is too dark to inspect.

Cell 24-L is unoccupied and needs to be cleaned.

Cell 23-L is unoccupied and needs to be cleaned.

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Cell 22-L is unoccupied and needs to be cleaned.

Cell 21-L is too dark to inspect, the door window screen is dirty and obscures visibility.

Cell 20-L appears to be occupied but is too dark to inspect.

Cell 19-L appears to be occupied but is too dark to inspect.

Cell 18-L is occupied and the room is filthy.

Cell 17-L is occupied and the room is filthy.

Door L-62 leads K-62 pass through and is completely under standing water.

Top tier showers are in similar condition to the bottom tier showers. I do not see anything remarkably different from the bottom showers.

In general, the cell environments are in poor condition. The Day Room is clear of any tables or out time seating areas. The ceiling appears to have mold. There is standing water.

The K-side of the Control Room also has no functioning security control panel.

An Officer here showed me the cut-down tool and stated she received initial training on its use but there are no emergency drills using the cut-down tool. There should be tools on both sides that are easily accessible by officers.

Officers here appeared attentive to their work. They showed me a disorganized filing system for documenting cell checks on the lockdown side. I recommend they use a 3-ring binder with dividers for each inmate.

The K Multi-Purpose room door is empty and locked. Overall, this Unit is much cleaner and better kept than those previously inspected. The Janitor Closet appears clean with adequate supplies for cleaning that would be left available. The swamp cooler is not operating.

There are no doors on lower level showers in Unit K. Three of the showers stalls have transparent plastic strung-across drape about five feet high. Shower #1 is handicapped accessible and appears functional. Showers #2, #3, and #4 appear in fair condition and functional.

An inspection lower-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.

Cell 1-K is occupied and open. This cell appears clean, and well-kept. There is a clothesline as previously described. There appears to be an adequate supply of personal hygiene products.

Cell 2-K is locked and too dark to inspect.

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Cell 3-K is occupied and open. There is standing water on the floor. There appears to be an adequate supply of personal hygiene products. This cell is reasonably clean and organized.
Cell 4-K is similar to 3-K but there is no tooth paste.
Cell 5-K is similar to 3-K.
Cell 6-K is similar to 3-K.
Cell 7-K is similar to 3-K.
Cell 8-K is similar to 3-K.
Door K-56 is a pass-through door either to the outside, probably an outside door. However, it is too dark to inspect the vestibule area.

Cell 9-K is similar to 3-K but dark inside.

Cell 10-K is similar to 9-K.

Cell 11-K is occupied and open. The cell is sparse of personal belongings. The mattress is heavily damaged and without linens. The pillow is made of a foam product, is not covered, and is damaged. There appears to be an adequate supply of personal hygiene products.

Cell 12-K is unoccupied and needs to be cleaned.

Cell 13-K is occupied, clean and organized with a clothesline as previously described. There appears to be an adequate supply of personal hygiene products.

Cell 14-K is occupied, clean and organized with an adequate supply of personal hygiene products.

Cell 15-K is occupied and emits the odor of smoke. This call has no mattress or pillow, but there is a sheet blanketing the metal bunk. There appears to be an adequate personal hygiene products.

Cell 16-K appears to be unoccupied but is too dark inside to inspect.

There are four upper showers in this unit; three of them are functional but all appear to be reasonably clean and need of minor tile maintenance.

An inspection upper-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.

Cell 17-K is occupied and good visibility into the cell. The cell emits a pungent odor. There are

no bed linens on the mattress or pillow. There is an adequate supply of personal hygiene products.

The cell, overall, is reasonable clean and organized.

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Cell 18-K is occupied and disorganized. There appears to be an adequate supply of personal hygiene products.
Cell 19-K is occupied, clean, and organized.
Cell 20-K is occupied, very dark, and disorganized. There is a clothesline as previously discussed but no personal hygiene products are found.
Cell 21-K is occupied, clean, and organized. There appears to be an adequate supply of personal hygiene products.
Cell 22-K appears to be occupied, is disorganized but there appears to be an adequate supply of personal hygiene products.
Cell 23-K is occupied and reasonably kept. Adequate personal hygiene products.
Cell 24-K appears to be unoccupied but is locked and very dark inside. There is a clothesline as previously described but no personal items.
Cell 25-K: It is occupied but empty. There is a fan running and there appears to be an adequate personal hygiene products. The inmate appears to take good care of his environment.
Cell 26-K is occupied and open with few personal possessions. There appears to be an adequate personal hygiene products. The mattress and bed linens are present and appear to be reasonably clean. Clothing items are stuffed in the external window, probably to stop wind and rain. The cell is organized but should be cleaned.
Cell 27-K: is occupied and open. There appears to be an adequate personal hygiene products. The cell is reasonably clean and organized.
Cell 28-K: is similar to 27-K
Cell 29-K is occupied and probably the best kept cell in this entire facility. Well-organized, looks very clean. The inmate appears to take great pride in maintaining his cell. There appears to be an adequate supply of personal hygiene products.
Cell 30-K is similar in condition to 29-K.
Cell 31-K: Occupied and somewhat disorganized. There is a towel at the base of the cell door to control water, according to the inmate. There appears to be an adequate personal hygiene products.
Cell 32-K is occupied, reasonably clean and organized. There appears to be an adequate supply of personal hygiene products.

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K Unit is specialty housing unit for protective custody, mentally ill, medically infirm and other inmates requiring special housing separation. Inmates here, compared to other Units inspected, are very quiet, playing games, watching TV and appear to be socializing well.

The ceiling is similar to the previous housing units. There are large areas of mold on the ceilings and standing water near outer walls in some areas.

J-Unit the entrance door and locked and open upon entry. The vestibule doors to the security gates leading to the housing unit was standing wide open. Additionally, the door into the officer’s station is unlocked and open. The officers are both in the housing unit with the security keys.

The Equipment Log is incomplete. The log reports that there is no cut-down tool, although the officer says there is one “somewhere on the unit.” A closer review of the log indicates that there are consistently no cut-down tools, no microwave, no handcuffs, no water cooler, no TV, no DVD player, no washer/dryer, no standing fan, no wall fan, and no computer. Additionally, and similar to other logs, there is no column to verify the presence of a flashlight(s).

The December log also reports that there is only one radio for the two units. This is an extremely unsafe practice as it would only require an inmate to grab the radio, rendering staff unable to call for assistance in an emergency.

The Multi-Purpose Room appears clean and reasonably organized. There is no standing water and the floor looks clean. However, the rec yard appears to have flood as previously described in other housing areas and there are sandbags being used to stop water from entering the unit. The swamp cooler is operational.

Exam Room is open but it does not appear operational. There is no sink and the room needs to be clean and repaired. The janitor's closet has a broken tile at the base, the water is running and the room needs to be cleaned.

There are four showers on the lower level, similar to those previously discussed. All shower stalls have operating doors. Shower #1 is a handicap shower with appropriately placed rails and seating. The shower head is leaking but the shower is in fair condition and reasonably clean. Shower stalls #2, #3, and #4 four are in similar condition as #1 but #4 has no running water.

An inspection of lower-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.

Cell 1-J has its window covered preventing inspection.

The adjacent plumbing chaise door is unsecured, exposing electrical cable and plumbing systems. This door should remain secured at all times as previously discussed.

Cell 2-J is occupied but too dark to inspect.

Cell 3-J is too dark to inspect.
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Cell 4-J visibility is obstructed.

Cell 5-J is similar to 4-J.

The next plumbing chaise door is secured.

Cell 6-J window are covered.

Cell 7-J appears occupied, is locked but dark.

Cell 8-J is similar to 7-J.

Cell 9-J is occupied but door is locked. There are some plastic products on the window grate that obscure visibility into the cell.

Cell 10-J is similar to 7-J.

Cell 11-J has the door window grate completely blocked; there is no visibility into the cell.

The plumbing chaise door adjacent to 11-J is open and unlocked. Same concern and recommendation as previously discussed.

Cell 12-J is occupied, clean and reasonably organized. There appears to be an adequate supply of personal hygiene products.

Cell 13-J is similar to 11-J.

The plumbing chaise door adjacent to 13-J is unlocked. Same concern and recommendation as previously discussed.

Cell 14-J is occupied and locked. The internal view is blocked by a towel draped inside covering the door window.

Cell 15-J is occupied, reasonably clean and organized with an adequate supply of personal hygiene products.

The plumbing chaise door next to 15-J is unlocked. Same concern and recommendation as previously discussed.

Cell J-16 is occupied, reasonably clean and organized with an adequate supply of personal hygiene products.

The upper tier showers are currently being used by inmates and will not be inspected. They are apparently functional.

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An inspection of upper-tier inmate cells found similar safety, security, and sanitation problems as previously discussed.
Cell 17-J is too dark inside to inspect.
Cell 18-J is occupied and unlocked. This inmate reports being the victim of the machete attack in September. His wounds appear to be healing. He states he is being provided adequate medical care; however, his jaw appears to be wired shut. The cell is reasonably clean and organized. There appears to be an adequate supply of personal hygiene items.
Cell 19-J is occupied, locked, clean, and reasonably organized. There appears to be an adequate supply of personal hygiene items.

Cell 20-J is occupied, appears clean but dark. The inmate is not very responsive, somewhat paranoid.

Cell 21-J is occupied, appears clean and dark inside.

The plumbing chaise adjacent to Cell 21-J is unlocked and open. Same concern and recommendation as previously discussed.

Cell 22-J appears to be occupied. A towel draped over the top bunk prevents visibility to the bottom bunk. Room reasonably kept using a large towel or something as a carpet.

Cell 23-J is similar to 21-J.

The plumbing chaise door adjacent to 23-J is unlocked. Same concern and recommendation as previously discussed.

Cell 24-J is occupied. The inmate is standing in the door blocking intentionally blocking my view into the cell.

Cell 25-J is occupied but is a curtain blocking visibility to the bunks; however, it is fairly clean and organized.

Cell 26-J is similar to 25-J.

Cell 27-J is similar to 25-J.

Cell 28-J is similar to 25-J.

Cell 29-J is similar to 25-J.

Cell 30-J is similar to 25-J.

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Cell 31-J is too dark to inspect.

Cell 32-J is similar to 31-J.

A cursory inspection of I Unit found it to be in much the same condition as the J Unit with no remarkable distinctions.

Medical Building. The entrance gate and sliding glass doors into this Unit were unlocked, allowing easy access into these areas. The doors leading into the reception area and rear areas were also unlocked; there was no staff at the reception desk but charts were left sitting on the reception desk.

An inspection of the exam rooms found the cabinets unlocked but no scalpels were found in any cabinet as in the Baseline visit. However, there were several medical instruments setting about that could be used as a weapon or blunt instruments. The stainless steel instrument pans do not appear to have been cleaned since my last visit in September. There is a small bio hazard container with a foot pedal containing what appears to be bio-waste; however, it contains no liner. These garbage receptacles should contain red biohazard bags, regularly emptied and sanitized. Administrative offices seem to be clean and reasonably organized.

The medication room security gate and access door were unlocked, allowing direct access to medications. The padlock to the medications and narcotics is unlocked and the room was unattended by staff. The security gate, so to speak, to a small medications cabinet is unlocked and open. None of the cabinets or drawers have locks on them. This entire environment should be kept secured at all times and there should be no access into this environment without proper authority. There is no record system maintained to log staff access to this room.

X Dorm (Female Convicted Offenders Side). Access to X-Dorm is gained through a secured gate. The padlock and chain found during the previous inspection has been removed and replaced with a security padlock.

The Officer’s Station door is open to the inmate Day Room. The fire panel remains dysfunctional. There is an unlocked cabinet in this office that contains latex gloves, a small hand-held air horn, a large supply of feminine hygiene products, and a semi-stocked first-aid kit possessing a cut-down too. There is a fire extinguisher in this room that shows a maintenance inspection of June 13, 2013.

The sentenced side and detention side are separated by a shared dayroom. Currently, the sentenced inmates are out of their cells, most of whom are in the dayroom.

There are two shower stalls at the far end of the housing corridor. Shower #1 has a shower door frame but no door panel for privacy. The door panel was laying against the wall next to the shower stall. The door to shower stall #2 was intact. Both showers need to be cleaned and repainted. The faucets were dripping and appeared to be in need of minor repair.

Cell 1 is occupied. The cell appears to be reasonably tidy, clean and organized. A clothesline is

attached to the wall. There appeared to be an adequate supply of personal hygiene products.

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Cell 2 is a storage room that is padlocked containing assorted supply items.

Cell 3 is occupied and is reasonably well-kept and tidy with an adequate supply of personal hygiene products.

Cell 4 appears to be occupied but the door window grate is covered from the inside.

Cell 5 is occupied, reasonably tidy and clean.

Cell 6 appears to be occupied but the door window grate is covered from the inside.

Cell 7 is occupied, clean and very organized.

X Dorm (Female Detention Side). The general Day Room has an open door to the secured rec yard. There are a few seating areas, picnic benches, a cat wandering about. There is also a direct open area through the chain link fence into the visitation walkway. Additionally, the gate to that walkway is open, leaving direct visibility from this rec yard for these detention inmates to the outside visitation area as well as through the chain link fences into the public parking areas. This is a serious contraband risk. Undergarments are being dried in the sun on a clothesline stretched across vertical pipes.

The Day Room inside has an exercise bike, a large picnic bench, and bookshelf with books. There is a secured metal screen door between the Officer’s Station and this Day Room. The hot water closet was unlocked. Inside this closet was a hot water heater, several plastic bags, several sandbags, and a couple of mop-handles. The proximity of the plastic bags to the water heater electrical component present a potential fire hazard, and the unsecured mop-handles present an assault risk. All combustible items should be removed from this closet; it should be kept locked and not accessible to inmates.

These showers are similar to the sentenced side; however, both shower doors are intact. Showers appear to be fairly clean with some paint decay over the showerheads.

Cell 15 is occupied and has a concrete bunk and a small mattress. There is a bucket of food stuff on the floor. The cell is reasonably clean and organized. There appears to be an adequate supply of personal hygiene products. However, the door screen is damaged and needs to be replaced.

Cell 14 is occupied, the door view port is somewhat covered from the inside. The room appears reasonably clean and organized. This the inmate states she prefers to remain locked in her cell and to no socialize with other inmates. She seems lucid and communicative. There appears to be an adequate supply of personal hygiene products.

Cell 11 is not occupied and appears to be clean.

Cell 12 is occupied, is clean and organized with several personal hygiene products.

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Cell 10 is occupied, reasonably clean and organized.
Juvenile Housing Unit. The entrance door is unlocked and open. The officer, upon entering this housing area, appeared to be sleeping at the duty station. There are no video monitors to monitor the juveniles who are locked in the housing unit some distance from the duty station. There is a fire extinguisher mounted behind the Officer’s Station with a current inspection sticker and positive pressure. Officer assigned to this post states he has no cut-down tool.
Entering the living areas, there is a gang bathroom off the side with two showers; many of tiles are broken and in a state of disrepair. The showers apparently work but do not appear to provide adequate privacy required by PREA. An adjacent water closet floor is damaged and dirty but the cold water seems to be working.
The Unit currently housing two juvenile inmates. Both of them appear to have their door grates partially covered with cardboard.
Cell 20 is occupied and reasonably clean and organized. It has a bathroom, however the toilet is not flushed and there is a large plastic liquid dispenser sitting atop the sink. There appears to be adequate personal hygiene products.
Cell 21 is occupied and in similar condition as Cell 20.
Cell 19 is unoccupied and it is absolutely filthy with large pile of garbage, bags, rotting and old food containers, and other discarded items. A wooden stick, approximately three feet in length, is laying on the ground under some of the trash. This stick is a clear and present risk to the inmates and/or staff it used as a weapon. This cell must me completely cleaned, sanitized, and searched for all potential weapons and those items removed.
At the end of the hall is a large Multi-Purpose recreation area. It needs to be cleaned. There is a ping pong table, two (2) small picnic tables and a correctional grade chess table in here. There is also cat food, indicating that there is a cat in this area.
It seems clear that the juvenile inmates are simply placed in this living environment and fed. Both inmates report that they are not provided educational or counseling services. Both inmates state that they have not seen healthcare staff following the intake process, although neither report any medical problems.
Adult Male Special Housing. We will now enter a special detention unit near the administration access area from the yard. Access gate is locked. This is called the Intake Unit; however, it is the former booking area that has been converted into an 8-cell housing unit. There are three (3) inmates in there. None report on medications. It is calm and reasonably well-kept.
Kitchen Building. The yard gate leading to the kitchen is locked from the inside and requires staff to unlock to gain entry.

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Entering the kitchen, the main kitchen door from the work side has water dripping from the ceiling. There are exposed electrical wires and some standing water. It appears they have been cleaning in this area but standing water remains on the floor and there are no warning signs or placards. There is a service sink separating the entrance to the male and female bathroom.

Entering the women’s bathroom, there is full container of hand sanitizer on the sink. The sink is operational but there is no hot water. The bathroom floor is filthy and requires a deep cleaning.

The male bathroom is in similar condition as the female bathroom and requires a deep cleaning. There is a dirty wall urinal, the light does not work, and there is cold water but no hot water. The frame separating the toilet areas is rotting at the base. I could find no toilet paper in this bathroom.

In the kitchen area, there are large stainless steel sinks back-to-back near the cooking area. The tile under the sinks is damaged and needs to be repaired or replace. The plumbing is exposed. There are rotting food products under the sink. The sinks are both clogged with what appears to be corn or some other food products. There is also a 12 inch knife in the sink attached to a metal cord that is padlocked to the faucets.

An inspection of the kitchen tool/utensil found it unlocked and unattended by staff. Light is on and both the tool cage gates are unlocked and are wide open. Although a “shadow board” is in place for tool management, there does not appear to be any equipment inventory logs. There does not appear to be a chit system in use for tool tracking and inventor management. It appears that several tools are missing, including knives, ladles, large spoons, etc.

The kitchen has two large internal cooler/freezers; one of them is operational and one appears to be broken. The broken cooler has no external temperature gauge and appears to be used for storage. The working cooler has an external temperature gauge showing a temperature of about 47 degrees, and contains various properly stored food products.

There is a large iron cook stove here that needs to be replaced. The nearby deep fryer contains used oil. There is also a pan sitting on a cart next to it with some old oil. The second deep fryer appears to be cleaned and covered by a stainless steel pan.

To the opposite side of that group of kitchen equipment is a 12 burner cast iron stove and ovens that are currently being used. This was the oven that was reported in the Baseline Report as positioned too high for safety reasons.

There is also a prep area for food distribution. This is the cafeteria are where inmates come here to collect their food. This is a decent sized room for distributing food from the kitchen through large food ports. There are additional food service areas nearby, as well as a fairly large stainless steel dish sink. The inmates are busy cleaning this area. There is a single fire extinguisher mounted on the wall as you enter the kitchen area with brief instructions on use that appears recently inspected.

In general, the kitchen area remains in the poor condition as it was found at the Baseline visit with

broken tiles, leaking ceilings and mold, insects, and equipment that needs to be replaced.

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Outside of the kitchen building is another freezer with a temperature reading of 21-22 degrees, which is adequate for frozen products. It is locked and we will not enter it.
Carpentry Shop Building. The shop consists of various wood-working equipment and supplies including planers, saws, lathes, presses, etc. There is a fire extinguisher in a cabinet accessible with an inspection date of June 13, 2013. The pressure, like the others, appears to be positive. I see no MSDS signs. I see no work safety signs other than “Noisy Area Wear Protection” and “No Smoking” signs. This area should have work safety signs posted throughout. The room is otherwise reasonably kept and well-organized for the work performed.
An adjacent inmate break area contains wood rubbish, is very un-kept and filthy. There appears to be a partially functional refrigerator containing ice. This room, if used for breaks, food preparation, and/or eating should be kept well cleaned and sanitized.
Classroom Area. Now entering the classroom area (as it is called). It has a work room with a couple of absolutely beautiful table tops under construction by inmates. There is an inmate bathroom in this area with only cold sink water. The floor, walls, and toilets are filthy. This area requires a deep cleaning. Adjacent to this area is an unlocked storage room cluttered with cardboard and wood bi-products. These items present a fire hazard.
Car Repair Shop. The car repair shop appears to be reasonably clean and organized. The tool room is open. The tool supervisor is putting away the tools and appears that all the tools are accounted for, and as reported in the Baseline assessment. This tool area remains well managed and secured. An inspection of all tool rooms indicates an appropriate level of security in these areas.
Upholstery Shop. This area appears to be reasonably organized and relatively clean. Several inmates are busy working on projects. An inspection of cabinets finds no dangerous tools.

DESCRIPTIVE NARRATIVE OF FACILITY ASSESSMENT FINDINGS

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2013 Federal Court Settlement Agreement
In re: United States of America v. The Territory of the Virgin Islands (86/265)
Third Compliance Monitoring Report Golden Grove Adult Corrections & Detention Facility
U.S. Virgin Island Bureau of Corrections St. Croix, VI
Completed by: Kenneth A. Ray, M.Ed., Monitor
April 22, 2014

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Kenneth A. Ray, M.Ed. Monitor

TABLE OF CONTENTS Topic Cover ……………………………………………………………………………… Table of Contents ………………………………………………………………… Executive Summary & Overview………………………………………………… Purpose…………………………………………………………………………….. Compliance Assessment Methodology …………………………………………. Section IV. Safety and Supervision Compliance ……………………………… Section V. Medical and Mental Health Care Compliance ……………………. Section VI. Fire and Life Safety ………………………………………………… Section VII. Environmental Health and Safety ………………………………… Section VIII. Training ……………………………………………………………. Section IX. Implementation ………………………………………………………

Page NA 1 2 4 5 12 51 98 103 113 119

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EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

This onsite compliance monitoring assessment was conducted by the monitoring team March 4 thru 7, 2014. The monitoring team consisted of Mr. Kenneth A. Ray, Monitor and correctional administration and operations expert; Dr. Ronald Shansky, MD, correctional medical expert; and Dr. Roberta Stellman, MD, correctional mental health and suicide prevention expert. Prior to this site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite assessment.

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance, In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy and procedure formulation, and 2) implementation. The Monitor and the monitoring experts provided non-binding recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing the final report.

This assessment found 106 (88%) of the 120 substantive provisions (non X. Implementation) Noncompliance (second assessment: 108, 91%), 14 (12%) in Partial compliance (second assessment 7, 6%), none in Substantial Compliance. These compliance ratings show a slight improvement from the second assessment and two returned from Partial Compliance to NonCompliance..

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GGACF THIRD COMPLIANCE ASSESSMENT SCORE CARD

Agreement Compliance Provision Total

Non

Topic Areas

Provisions Compliance

IV. Safety & Supervision

59

51

V. Medical & Mental Health Care

36

36

VI. Fire & Life Safety

10

10

VII. Environmental Health & Safety

11

5

VIII. Training

4

4

Total Substantive Provisions

120

106

100%

88%

Partial Compliance
8 0 0
6 0 14 12%

Substantial Compliance
0 0 0
0 0 0 0%

Additional Partial Compliance (PC) progress was demonstrated in areas of IV. Safety and Supervision (4 to 8 PC), VII. Environmental Health and Safety (3 to 6 PC).
Implementation (Section X) provisions were not measured using these standards but a narrative description of compliance is provided at this time; the required evaluation standards may be applied in evaluating these provisions in future reports once the Monitor has more clarity about doing so from the Parties.
This assessment found a paucity of progress despite the commendable efforts to purchase new radios, engage a major facility clean-up effort, observing many of the housing and external gates locked, hiring the new psychiatrist, and repairing perimeter fence lighting since the Findings of Fact Report (filed on 02/08/13), the September 2013 Baseline Assessment, and December 2013 second assessment. As such, and based on staff and inmate interviews; reviews of various official logs and records, and direct observations, GGACF remains a very dangerous, violent, unhealthy, under-supervised, under-maintained, and deleteriously understaffed correctional environment. Inmates and staff are unnecessarily exposed to real and potential psycho-social and physical violence, inmates cannot receive adequate levels of medical or mental health services and care, and the lack of an adequate fire suppression system places everyone working and incarcerated at GGACF at constant substantial risk. Substandard and inconsistent security practices i.e. consistently closing and locking security doors and gates are exacerbated by inoperable locking mechanisms. Housing units continue to flood during heavy rains and mold remains profuse throughout most inmate housing areas. The training program, based on documents provided, requires significant overhaul with focus on promulgation and evaluation of standardized curricula that emphasizes contemporary pre and in-service correctional subjects and practices as its priority. GGACF remains very penetrable for dangerous contraband (knives, shanks, cutting devices, impact tools, etc.) as well as cell phones and drugs, and a variety of the kinds of contraband according to evidence logs and incident reports. The inmate grievance process is not consistently managed and adequately documented according to grievance records review, and the inmate disciplinary process appears to deliver inconsistent consequences and fails to consistently administer due process hearings due to staffing shortages. Inmates continue to be allowed to keep in their cells used prescription needles and unused syringes, which is an extremely hazardous practice, especially considering the regularity that housing units are left with no or inadequate staffing levels. Inmates with mental illness, some with serious mental illness, are housing in segregation or locked in their cells (segregated) for long periods of time and without ongoing assessment and monitoring by mental health professionals. Housing unit logs also report that

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inmates remain able to “pop” their cell door locks and gain unauthorized access to housing unit

areas. Suicidal inmates continue to be placed on suicide watch by correctional officers without

the knowledge or involvement by mental health staff, and housing unit logs report that officers

either have difficulty summoning medical staff when needed for inmate medical issues or decide

to respond to medical issues on their own without consulting medical staff. Events involving use

of force against inmates is not reported consistently, and there have been delays in reporting to

management potentially serious medical issues involving inmates assaulted by other inmates.

These and similar other concerns will be further discussed and described in this report.

Territory officials must re-double their efforts and seriously consider revising recruiting policies in order to expeditiously fill all correctional and health care vacancies, and to hire all additional staff required following completion of the staffing analysis. Regarding deficient correctional staffing, housing unit logs for September 2013 thru March 2014 reported approximately 275 instances involving officer and supervisor staffing shortages including: 1) housing units being left locked or unlocked and unattended by staff, 2) officers showing up to work to find no officer on post, 3) officers leaving work or their post without authorization, 4) late to work, 5) no supervisor on duty, and 6) one officer responsible for monitoring two housing units. An examination of supervisor logs for August 2013 thru February 2014 found over 100 instances involving no unit staff, no supervisor, “extremely short staffed”, staff call-offs, lateness, leaving work without authorization and refusing to work assignments as directed.

Equally vital is filling all health care vacancies including the medical director (MD) and nursing staff immediately. Until this is accomplished, inmate health services effectively functions without qualified leadership and clinical staffing levels necessary to provide and maintain constitutional levels of health care. Furthermore, the number of inmates with mental illness, many suffering from serious mental illness cannot be adequately assessed, treated, and monitored by a single mental health counselor and one psychiatrist; additional mental health staff is clearly warranted and necessary.

Finally, it is important to reiterate the need for the promulgation and implementation of adequate administrative and operational policies and procedures. Many of the problems and concerns discussed in this report are directly and in-directly related to a lack of effective and contemporary policies and procedures to govern facility leadership and staff duties and behavior. To date, the Monitor has not received any new or revised policies or procedures for review and approval.

PURPOSE

The Monitor intends this Third Compliance Monitoring Report to serve three primary goals: 1) assess compliance progress relative to previous assessments, 2) assess, measure, and determine progress toward partial and substantial compliance with all provisions of said Agreement; and, 3) as a tool to assist Defendants in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of defendants and offenders incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands

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THIRD ASSESSMENT METHODOLOGY

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.

Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.

Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.

1. Description of how the Monitor will assess compliance with each of the Compliance Measures.

In general, compliance assessment will include the following activities:

A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning. I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.

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J. Examination of any and all records, data, and/or information relevant to compliance and

compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (non-compliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
 Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.

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 Domain: A core aspect of the organization’s performance, such as access to care, costs of

care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or

consumer satisfaction).

 Performance Indicator: A defined, objectively measurable variable that can be used to assess

an organization’s performance within a given domain. For example, within the domain of

consumer satisfaction, a performance indicator might be: “the percentage of consumers who

state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)  Online media information  Online public records  Electronic and standard mailing of information  Email communication and phone consultations

3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for the Baseline and subsequent visits and monitoring includes the following. Many of these documents were not provided at the Baseline and second visit as requested but more were provided during the second and third visits. Territory officials stated that they intend to continue to generate and provide the requested documents. It is important

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to reiterate the need for the documents listed below. Considering the size of this list, and

GGACF’s limited staff and technical resources, the Monitor intends to assist the Territory in

narrowing this list to the most salient items. Documents in bold below have either not been

provided or have not been updated but are necessary for effective monitoring.

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months. 23. Records and/or lists of physical improvements, repairs, and renovation completed to correct security problems and deficiencies over the past 36 months.

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24. Past 36 months of agency budgets.

25. List and contact information for any and all community vendors who provide services

of any kind to GGACF and contracts or professional services agreement authorizing

those services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of
their records. 31. To the extent not provided above, the policies and procedures governing medical and
mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers,
including on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to
include health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment. 46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location.

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47. To the extent not provided above, external and internal reviews or studies of medical or mental

health services including needs assessments and any American Correctional Association and

National Commission on Correctional Healthcare reports.

48. List of all inmates placed in restraints, and all inmates receiving mental health

treatments, under suicide watch, or taking psychotropic drugs.

49. Current mental health case list including inmate name, number, diagnosis, date of intake, last

psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed

only by counseling staff with last appointment date and follow-up appointment.

50. Documentation reflecting any training that facility staff have received on suicide

prevention, including certificates and training materials.

51. All documents related to the any suicide occurring within the past year.

52. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms
utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and
investigative reports of all inmate suicide victims within the past three years. 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications
for the past year. 66. A description of medical and mental health’s involvement/input into the disciplinary
process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

It is important to note that Defendant made a reasonable effort to provide most of the information requested for this visit. Log books and other reports were ready for review on one the first day and throughout the visit. The balance of information listed above (in bold) in the Baseline and second reports is expected to be provided once it has been developed. Unfortunately, the Warden was not available throughout the visit due to serious illness. Because of this, the Monitor was unable to interview all command staff as a group or the Warden individually. Effective and productive onsite

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monitoring requires the active presence of all command staff as needed to clarify information,

observations, and findings. The Monitor looks forward to this process during the June 2014 and

subsequent visits.

Territory officials and participants were exceptionally cooperative, involved, and supportive throughout this aspect of the monitoring process. The Territory’s repeated desire to fully comply with the Agreement was evidenced by its active cooperation and involvement in the onsite visit. Similarly, United States Department of Justice representatives participating in the onsite assessment were equally cooperative and involved, which helped to maximize visit efficiency and productively. The presence of both Parties during the onsite visit assisted assessment focus and allowed for collaborative and timely resolution of important matters of mutual interest. Therefore, the Monitor and monitoring team respectfully requests that these representatives from both Parties continue participate at all future assessment visits.

The monitoring team used four primary reference points from which to assess compliance and progress with Agreement. These included: 1) the agreed 2012 Findings of Fact document, 2) documents, information, and data provided prior to, during, and following the onsite assessment, 3) the onsite visit, which included meetings, discussions, interviews, campus tours and inspections, and 4) the Baseline and Second Assessment Reports.

During this assessment, the monitoring team toured the campus, inmate housing units and cells, dayrooms and program spaces, food service/kitchen areas, intake/booking area, control rooms and officer posts, portions of the outer perimeter and fencing, and medical and mental health areas. We talked with BOC representatives and staff, and spoke with inmates.

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IV. SAFETY AND SUPERVISION

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in .a jail setting, Defendants will implement appropriate measures to minimize these risks, including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.

A. Supervision

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:

a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No measurable changes were apparent regarding stratification of inmate housing for institutional classification, housing, policy or procedure. Recommendations provided in the Baseline and Second Reports remain appropriate.

Examination of housing unit and supervisor logs, incident log and reports, and evidence log indicated that staff and inmates remain daily exposed to real and potential harm of physical violence.

Housing unit and supervisor logs report continue to reveal serious issues related to staffing and supervisory level deficiencies, verbal and physical violence against staff and inmates, inmate medical problems and unavailable medical staff to respond, no radios and inoperable telephones, other “equipment problems”, and various other problems related to effective care and custody issues.

Examination, comparison, and categorical analysis of 12 housing areas logs provided at and since the Baseline visit. (9A,9B,9C,9D,G,H,I,J,K,L, R&D, and X), appear to show increases in certain events directly and indirectly related to safety and security. This assessment, however, must clarify that additional log books were provided during this visit and could, therefore, skew interpretations about increases in reported events because a similar volume of events could have been assessed from log books not previously provided.

Regarding likely increases in these events, for example, staff recorded approximately 50 times during September thru November 2013 that there were no officers on a housing unit when they arrived to work, officers departed before being properly relieved, being the only officer working a unit, there was no supervisor on duty, “serious staffing shortages,” or other staffing problems. Reporting of these staffing problems more than doubled to 109 from December 2013 thru

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February 2014. An examination of supervisor logs (December 2013 thru February 2014) found

approximately 200 instances where supervisors reported officers calling in sick, leaving work

before being relieved, refusing to work a post or assignment, officers being “AWOL”, or late

to work.

As stated above, housing unit log books were examined for event activity that seemed relevant to compliance with the Agreement. Recorded entries were categorized as shown below and counted. The chart below estimates the number of times staffing problems and other critical issues were reported in housing unit logs. Caution must be used in interpreting these data due to reporting inconsistencies and because additional log books were reviewed during the March 2014 visit. However, the information was recorded in the logs nonetheless.

Month / Year
No Unit Officer / Staffing Problem No Supervisor No Radio / Problem No Flashlight / Problem No Phones / Problem No Equipment NOS No Drinking Water / Problem No Food / Problem Escape / Attempt Contraband Medical Related / Event Suicidal / Self Harm Related Behavior Problem NOS No Medical / Mental Health Staff Available Assault on INM / Officer Threat to Inmate / Officer Locks Inoperable/Can't Secure Unit Hygiene Plumbing Problems Electrical Problems Leaking / Flooding Fire / Fire Related Modified / Full Lockdown Inmate unauthorized action Administrative/Problem

Sep-13 21 4 22 0 7 4 2 0 0 4 12 0 7 1 0 1 10 10 3 5 8 0 9 1 6 Oct-13 14 1 13 0 0 9 4 2 0 7 19 4 7 2 2 0 10 6 5 1 2 1 8 0 6 Nov-13 10 0 5 0 0 5 3 2 1 4 8 4 5 1 2 1 13 15 5 6 11 0 3 1 10 Dec-13 40 6 18 0 11 13 3 5 0 1 12 3 6 4 5 6 47 33 11 4 32 4 7 1 12 Jan-14 47 10 17 0 3 18 4 6 0 5 34 1 13 4 8 7 82 58 7 4 44 10 28 2 11 Feb-14 61 2 9 1 2 15 8 8 0 4 46 2 7 8 5 2 70 41 16 15 9 4 11 4 7 Mar-14 (3/1-17) 18 0 3 0 0 2 1 0 0 2 14 0 6 1 1 1 11 5 7 4 3 0 7 4 7
Total 211 23 87 1 23 66 25 23 1 27 145 14 51 21 23 18 243 168 54 39 109 19 73 13 59 Sep-Dec
2013 45 5 40 0 7 18 9 4 1 15 39 8 19 4 4 2 33 31 13 12 21 1 20 2 22
Dec 2013 -
Feb 2014 148 18 44 1 16 46 15 19 0 10 92 6 26 16 18 15 199 132 34 23 85 18 46 7 30 Change 103 13 4 1 9 28 6 15 -1 -5 53 -2 7 12 14 13 166 101 21 11 64 17 26 5 8
It is safe to say that some of these issues are related to deficient inmate stratification and custody management deficiencies, but even the most effective system is rendered ineffective without consistent and adequate staffing levels.
RECOMMENDATIONS:
1. Revise/develop housing classification policies based on a current validated intake and review classification instrument. Submit document drafts as indicated in the Agreement before implementation.
2. Timely complete and submit a policy development plan that includes, at a minimum, the following elements:

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A. Policy title with related procedure titles

B. Primary policy references

C. Person(s) responsible for document development

D. Expected dates to be forwarded to the Monitor and USDOJ for review and approval,

date(s) of staff training, implementation date

3. Review current population to verify accurate risk/need classification levels and housing,

reclassify and appropriately house as indicated by review process findings.

4. Refer to IV.F. Regarding specific classification and housing policy recommendations.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: An assessment of staffing needs has not been completed but the Territory has requested assistance from the National Institute of Corrections (NIC) for technical assistance in completing that assessment. The Monitor has been informed by NIC that the request is under review and should be approved soon.

Territory officials provided the Monitor several revised Post Orders for review but these orders cannot yet confirm “at least one officer per unit” until the staffing analysis is completed, approved, funded, and implemented. All housing unit posts toured had these post orders and staff seemed versed in information contained in them. However, these post orders do not effectively address the issue of minimum staffing levels as the housing unit logs continue to report units going unstaffed or understaffed.

Recommendations provided in the Baseline Report and second report remain appropriate.

RECOMMENDATIONS:

1. Subsequent to policy and procedure development and revisions, conduct a complete review of existing Specific and General Post Order to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible; E. regularly reviewed, revised, updated; F. consistently enforced; G. known to staff through pre-service, in-service, and ongoing training.
2. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues to be known and resolved in a timely manner.
3. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.

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c. Communication to and from corrections officers assigned to housing units (i.e.

functional radios); and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Territory officials are to be commended for deploying approximately 45 new portable radios throughout the facility. During the tour, the Monitor observed every housing unit officer and supervisor with a portable radio, new or existing. However, the Monitor cannot objectively determine Substantial Compliance until adequate policies and procedures; relevant training curriculum; and, a full inventory of needed and assigned radios are assessed. It is unknown exactly how many radios are required to ensure full compliance and the Monitor requests a complete inventory of radios, radio deployment locations, and how many additional radios are needed.

RECOMMENDATIONS:

1. Revise and/or develop, implement, and evaluate policies and procedures governing radio communication equipment, usage, repair and maintenance.
2. Ensure that all posts are equipped with functionally reliable communications equipment; it is recommended that reliable radios are issued to ALL officers and staff working with and/or around inmates.
3. Repair, replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
4. The Monitor will review radio equipment inventories and functionality during the next onsite assessment.
5. Provide portable radio communications policies and procedures. 6. Provided portable radio communication training curriculum.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and
(ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously described regarding housing and supervisor unit logs, there has been minimal improvement since the Baseline or Second Reports. Cell conditions continue to indicate that adequate and frequent rounds of cell block are not being conducted by officers or supervisors according to housing unit logs reporting a high frequency of staffing shortages and evidence logs reporting the continued presence of contraband.

Although remarkable effort has been made to improve overall housing unit cleanliness, many of the cells were found to be cluttered with excessive personal items, some of which are combustible, and inmates were still allowed to keep dangerous and/or items that can be used to harm officers and other inmates. For example, some of the cells still contain electric fans

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with exposed wiring and electrical mechanisms. Some of the cells still had sheets and/or

towels draped across and over cell doors and/or hanging from the previously described

clotheslines that fully or partially blocked viewing inside the cell. Some of the occupied cells

were very dark making it impossible to perform inmate security / safety checks. R&D logs

reported officers complaining about an inmate being housed in that area and their repeated

inability to view in to the cell due to an obstruction over the window, yet no officer removed

the obstruction.

Other log entries reported that certain inmates were placed on suicide watch or were acting such that officers were concerned about the inmates’ welfare, but no further entries reported whether adequate security and safety rounds were made on those inmates. These records indicate that rounds were not conducted or the round was not recorded.

All cells must be kept reasonably lighted at all times and all visual obstructions into the cells must be removed. Staffing levels must provide for consistent and predictable supervision of inmates and housing areas.

As previously stated, revised post orders regarding this subject were found in the housing units and provided to the Monitor. Unfortunately, however, inadequate staffing levels cause a lack of consistent adherence to these directives by officers and supervisors, rendering the documents virtually ineffective.

All post orders must be supported by well-developed and written policy and procedures, which have not yet been provided to the Monitor for review and approval.

Recommendations provided in the Baseline and Second Reports remain appropriate.

RECOMMENDATIONS:

1. Refer to recommendations regarding Post Orders. 2. Revise and/or develop policies and procedures to ensure consistent and reliable
monitoring of housing units and cell blocks as stated above. 3. Ensure housing units and cell blocks are consistently staffed at levels required to ensure
staff and inmate safety and security, and according to inmate risks and needs. 4. Ensure that special needs inmates (suicide, mentally ill, medical infirm, vulnerable, etc.)
are monitored more frequently and by qualified health care staff. 5. Ensure that supervisors routinely inspect general and special housing units to ensure
compliance staffing requirements, policy and procedures, and to interview inmates to presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. 6. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.

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B. Contraband
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: These policies, as stated in previous reports, remain outdated, under-developed, and incomplete. There was no appreciable improvement determined during this assessment. However, there continues to be an appreciable increase in contraband recovery as indicated in incident reports and contraband logs. GGACF and the GIST Team are commended for this additional attention to controlling contraband but existence of dangerous items continues. Part of the problem is that the GIST program is inadequately staffed to maintain regular and consistent contraband searches; inadequate housing unit staffing levels severely impairs any productive contraband control by those officers. Consequently, housing units and the facility remain very dangerous environments for staff and inmates due to the ongoing high levels of dangerous contraband. This issue will be discussed in more detail in 1b below. Although exiting policies and statutory regulations provide definitions that constitute contraband, the definitions should be reviewed to ensure that staff apply the definitions accurately.

New or revised contraband control policies or procedures have not been provided to the Monitor for review and approval.

RECOMMENDATIONS:

1. Review, revise, and develop contraband policies to include all forms of contraband, consequences for its introduction and possession, and actions staff are to take in its collection and disposition.

b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously stated, GGACF officials are commended for their efforts to control contraband as evidenced in contraband and evidence logs. However, the facility remains very permeable to all sorts of contraband, some of which is very dangerous to inmates and staff.

An examination of evidence logs shows an overall decline in number of contraband items seized between two reporting periods – seven months before and after approval of the Agreement in July 2013. 343 items were collected between November 2012 and June 2013, 287 during July 2013 thru February 2014. However, this decline cannot be reliably interpreted as a decrease in the existence of contraband, but only as a decrease in what was found. What can be reliably

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interpreted from these findings is that specific items posing considerable risk to staff, inmates,

and facility security remain ever present throughout the facility as estimated in the chart below

for the two reporting periods. What is most alarming is the exceedingly high volume of weapons

being found. The fact that these dangerous items were found and removed is commendable.

Contraband
Cell Phone Knife Shank
Machette Cutting Device
Alcohol Marijuana / Leafy
Subs Drugs Total Items Cell Phones Weapons Intoxicatns / Drugs Weapons Intoxicants Cell Phones

Nov 2012 June 2013
74 12 25 1 4 3
52
3 343 74 42
58
12% 17% 22%

July 2013 Feb 2014
52 9 114 3 4 2
24
1 287 52 130
27
45% 9% 18%

The chart below compares all contraband reported on evidence logs for the two reporting periods:

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Contraband Seized

Nov 2012 - June 2013

Cell Phone

74

July 2013 - Feb 2014
52

Phone Charger

15

7

DVD / CD / TV

13

6

Other Electonic Device

36

6

Sewing Machine

1

0

Curency

11

13

Knife

12

9

Shank

25

114

Machette

1

3

Other Weapon

0

0

Cutting Device

4

4

Tattoo Device

2

0

Handcuff key

0

0

Tools

4

2

Alcohol

3

2

Marijuana / Leafy Subs

52

24

Tobacco / Papers

0

1

Cig Lighter / Burning Device

16

11

Toxic Chemical

4

1

Drugs

3

1

Medication

13

9

Scales

0

3

Food Items

2

0

Contraband

4

0

Clolthing

4

0

Jewelry

12

2

Personal Hygiene Product/Device

3

2

Wire / Rope

5

9

ID/BADGE/PATCH

1

0

Papers / Books/ Writing Materials

4

0

Keys

3

0

Eating Utencils / Pots / Pans

10

3

Bottles

1

0

Diaphram

4

1

ETC

1

2

Total Items

343

287

Cell Phones

74

52

Weapons

42

130

Intoxicatns / Drugs

58

27

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GGACF officials are encouraged to continue with improvements to policies and procedures. Previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate contraband control policies that contain, at a minimum, the following elements: A. The purposes for contraband control; B. Safe methods and tactics for identification, seizure, recovery, and disposition; C. All locations where contraband can be hidden and disguised; D. Methods and points of delivery and access; E. Unannounced and irregularly time searches of cells, inmates, and inmate program; recreation and work areas; F. Keep all cabinets and doors locked at all times to prevent access to contraband; G. Use of metal detection equipment; H. Use of other mechanical devices for detection and recovery; I. Respect of inmates’ rights to authorized personal property; J. Clearly articulate differences in inmate property allowed according to gender, religion, health conditions, conviction status, etc.

2. Review, revise, develop, implement, train, and evaluate training policies, procedures, methods, and demonstration of staff proficiency in the prevention, detection, recognition, recovery, and disposition of contraband.

3. Ensure that all posts and high-risk contraband access points are properly secured at all times, adequately staffed, equipped with reliable video surveillance devices, and consistently enforce contraband rules and laws involving inmate, staff, contractors, volunteers, the public, etc.

4. Develop a uniformed incident tracking/reporting system using standardized contraband titles and locations; implement a continuous quality improvement program to ensure the accuracy and completeness of incident reports.

5. The Monitor requests electronic submission of the current incident and evidence logs each month for review and analysis purposes, and to provide technical assistance as indicated.

c. Detection of contraband within Golden Grove, through processes including: (i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinic, and
other areas of Golden Grove to which prisoners may have access; (ii) pat-down, metal detector, and other appropriate searches of prisoners coming from
areas where they may have had access to contraband, such as at intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic; (iii) regular and random searches of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g., clinic, kitchen, dayrooms, storage areas, showers);

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to 1B above. Additionally, it is important to note that the Gang Intelligence and Search Team (GIST) has made some progress in seizing contraband but their search activity does not occur with sufficient regularity to effectively control the high levels of contraband. It is very important that the GIST operate from well-crafted policies and procedures, and increase frequency and regularity of cell searches.

Additionally, the Monitor did not observe any inmate searches during this visit while touring the yard, housing units, or other areas observed. Inmate searches must become a routine practice to help control inmate clandestine motivations and contraband.

RECOMMENDATIONS: Refer to above, expand application of recommendations to provision c (i-iii) above.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change since previous assessment. The evidence confiscation log evidences reasonable efforts to comply with this provision. Previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, and implement, evaluate policies and procedures involving confiscation and preservation of contraband as evidence for administrative and legal enforcement purposes.
2. Ensure staff access to appropriate equipment and supplies needed to safely collect and preserve contraband while maintaining evidentiary integrity.
3. Ensure adequacy of chain-of-custody methods and procedures. 4. Review, revise, develop, implement, train, and evaluate training policies, procedures,
methods, and demonstration of staff proficiency in the proper collection/confiscation and disposition of contraband.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Security staff posted at the main entrance conducted a reasonable search of the Monitoring team and other visitors during this visit. The Monitoring team was appropriately escorted throughout the campus, but did not witness escorts of visitors.

RECOMMENDATIONS: Similar to above specific to admissions policies and procedures, internal and external escorts for visitors to the facility.

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C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As reported in previous reports, inmates continue to wear and possess personal clothing items. This was observed on the yard and in the housing areas. There has been no change since the Baseline or second assessment. Recommendations previously provided remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, implement, train, and evaluate policies and procedures requiring all inmates to wear standard-issue correctional uniforms.
2. Consider acquiring correctional apparel that provides obvious recognition of the inmates’ classification/status.
3. Ensure there is a consistently sufficient supply of uniforms to regular laundry exchanges and changes in an inmate’s classification and/or status.
4. Consider developing a correctional industry for making uniforms onsite. 5. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband
and weapons. 6. Mark all uniforms with highly visible letters/numbers.

b. Identification that prisoners, staff, and visitors are required to carry and/or display;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As reported in the previous report, none of the inmates were observed wearing correctional identification that was to be implemented. On March 21, 2014, the Warden issued a memorandum to staff that provides instructions regarding inmates wearing identification cards. Although it the Monitor has been provided a memorandum issued by the Warden that the cards are now in use, compliance will be assessed further during the next visit.

As previously reported, visitor identification cards and clips were not consistently issued to the monitoring team during this visit due to supply shortages. Neither the Monitor nor USDOJ were issued visitor badges during this visit.

RECOMMENDATIONS:

1. Ensure staff compliance with this provision. 2. Ensure appropriate policies and procedures are in place and made available to staff.

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3. Ensure adequate supplies for making identification cards.

4. Regularly audit identification card inventory and maintain proper controls to prevent

inappropriate acquisition of cards. Conduct regular “identification card counts” using

methods similar to key control inventories.

5. Consistently enforce identification card policies and procedures.

c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: All internal housing unit gates and officer stations were found to be locked upon entry during this visit. However, none of the exterior security slider-doors were locked but standing open or unlocked upon entry into the units; we were advised that the electronic locking mechanisms are inoperable. Despite the security gates being locked upon entry, they were not locked when the monitoring team toured the housing units. These observations clearly support a lax security culture that demonstrates the need for additional training, monitoring, and supervision by GGACF leadership. GGACF staff must consistently practice good security habits by keeping security doors and gates closed and locked. Officers report that inadequate staffing levels require them to not lock security gates upon entry into the housing units for safety reasons. Housing unit logs report that fire escape doors and locks are inoperable. There was improvement found in yard-gate security but some of the locking mechanisms remain inoperable and prevent the gates from being locked.

Despite some progress to fixing locks, there are still delays and many non-functioning locks. Logbook entries continue to report key door/lock issues not being timely addressed. For example, the logbook for Detention R&D has almost daily entries from January 13 to March 4 from different C/O’s complaining about the sally port door. The door must be operated manually, keys don’t work, a metal pipe must be placed behind the outer sally port door to provide security to the area, etc. It appears that the lock work report does not mention this door.

Another example is X Pod, which is the housing unit for sentenced and un-sentenced female inmates that is monitored by one officer, but has gone for hours with no officers assigned according to unit log books. This building is divided into two housing units with a door separating the two populations. This door is not always locked, according to the unit officer, but must be to ensure secure separation between these populations.

Previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluation policies and procedures related to facility security pertaining to locking and unlocking access points, units and cell doors, and other locations requiring consistent access controls.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement.

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5. Ensure staff are adequately trained in the proper use of mechanical and/or electronic locking

systems according to their post assignments.

6. Consistently sanction inmates for attempting or manipulating any security locking system or

device.

7. Secure access to keys and electronic locking control panels.

8. Keep security doors locked!

9. Consider replacing or upgrading existing unit control panels to provide for remote electronic

locking and unlocking of unit and cell doors.

10. Increase video surveillance of internal and external access points to ensure rapid detection

of attempts to disable or damage locking devices/systems.

11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices

and mechanisms.

12. Supervisor should inspect all locking systems during each shift and report for investigation

and/or repair any signs of lock disrepair, malfunctioning, or manipulations.

13. Consistently enforce security locking policies and procedures with staff and inmates.

d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The Monitor met with the facility maintenance director and examined existing and revised locking mechanism repair logs. This interview and document examination reveal positive effort for ongoing lock repair and maintenance. Several housing cell locks have been repaired or replaced, it appears that cell pad locks have been replaced with standard security locks, and efforts are being made to repair or replace inoperable electronic locks located at housing unit entrance and yard gates. However, an “all-locks” maintenance plan has not been provided as previously requested. Additionally, it is the Monitor’s opinion, based on interviews with the maintenance director and facility conditions, that the maintenance program is inadequately staffed to provide the level of attention to facility up-keep needed to comply with this Agreement.

Previously provided recommendations remain appropriate. Additionally, additional maintenance staff should be hired.

RECOMMENDATIONS:

1. As requested in the previous two reports, develop an “all-locks” maintenance plan for review with the Monitor. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken off line. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the local is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc), and lock number, lock type, condition, etc.
2. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.

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e. Pre-employment background checks and required self-reporting of arrests and

convictions for all facility staff, with centralized tracking and periodic supervisory review of

this information for early staff intervention,

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documents provided to the Monitor and discussions with the HR/Training director during this assessment confirm that pre-employment background checks are conducted for all GGACF applications. A review of documents shows a requirement to self-report histories of arrests and convictions. However, personnel records for all GGACF staff were not provided for inspection and verification. Additionally, there remains no centralized tracking and periodic supervisory review process for early staff intervention purpose. These records are reportedly maintained off-campus and available for review by supervisors.

Previously provided recommendations remain appropriate.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate policies and procedures for the applicant and staff records process as indicated by the training assistant.
2. Ensure access to applicant and staff records are adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
3. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.
4. Make records available to the Monitor for inspection and verification of compliance.

D. Security Staffing

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor, for all levels of security staff at Golden Grove;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Territory officials formally requested technical assistance from the National Institute of Corrections (NIC) to assist in completing a comprehensive staffing analysis. It is expected that this assistance will occur sometime in April or early May of this year. It is important to remind the Territory that this technical assistance will not fulfill this requirement but will only assist in the successful completion of the staffing analysis following that assistance. Completion of this analysis and rapid hiring of all additional security staff should be considered of utmost importance due to the ongoing and pervasive health, safety and security deficiencies. Territory officials must reconsider its hiring process to expedite the hiring of all staff allocated to this facility.

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Examination and analysis of housing unit logs demonstrated a pervasive practice of allowing housing units to go without staff for long time periods and operate with only one officer to cover two housing units during a shift. These logs also reported several instances where no supervisors were on-duty or available. Logs document approximately 275 instances of staffing shortages including: 1) no officer on a housing unit, 2) only one officer to cover two housing unit, 3) no supervisor on-duty or available, 4) officers late to work or leaving work without authorization, and 5) officers arriving to work to find no officer in a unit with inmates either out of their cells or locked-in. There were many other examples reported in the log books. This is a deleterious practice that MUST be stopped.

During this visit the Monitor met with the HR/Director and BOC Director regarding the Territory’s hiring process. It was learned that it typically takes one year before a correctional officer applicant is hired and working in the facility. Six-months of this time is spent in the VI Police Academy mostly learning subjects not related to correctional practices or operations. Requiring correctional recruits to attend a full police academy is an unusual practice in the Monitor’s experience as a law enforcement and corrections academy director, and significantly contributes to the current staffing problems. This time period can and should be significantly shortened due to facility safety and security needs combined with ongoing staff attrition.

RECOMMENDATIONS:

1. Complete a comprehensive staffing study using the Staffing Analysis process of the National Institute of Corrections.
2. Appropriate funding to hire sufficient numbers of staff to establish and maintain adequate levels of facility safety and security in accordance with staffing analysis results.
3. Make all reasonable efforts to shorten the time required to hire staff to no more than 90 days, not including basic correctional officer training.

b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the previous report. The required security staffing plan would be based on the pending staffing analysis.

Previously provided recommendations remain appropriate.

RECOMMENDATIONS:

1. Update existing security staffing plans for review with the Monitor during the December site visit.
2. Identify current and anticipated security staffing deficiencies. 3. Complete the required staffing analysis and based this plan on that analysis.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to the above findings.

RECOMMENDATIONS: Review, revise, develop, train, implement, evaluate policies and procedures related to facility staffing with particular focus on staffing levels, deployment, recruitment, selection, training, promotion, development, attrition, maintenance of staffing levels, etc.

2. Defendants will implement the staffing plan developed pursuant to D.1.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous findings related to staffing analysis and planning.

RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated in the previous reports, documents provided to the Monitor by GGACF include a general PREA policy. This policy is not dated, signed, or numbered. It is unknown if staff are aware of the policy or have completed training on PREA or this policy. The policy does not explain PREA and does not include all PREA definitions. The current policy also does not include all PREA requirements according to PREA standards. Additionally, inmate handbooks do not include PREA topics, their rights within PREA and methods for reporting violations, nor are PREA information documents provided to inmates upon admission.

Previously provided recommendations remain appropriate.

RECOMMENDATIONS:

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements. 3. Appoint a PREA Compliance Coordinator as soon as possible. 4. Complete the PREA Self-Audit. 5. Review, revise, develop, train, evaluate policies and procedures that include, at a minimum,
the following PREA topics:

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Policy Organization Definitions Inmate Reporting Staff and Agency Reporting Protection from Retaliation
Hiring and Staffing Viewing and Searches

Staff, Volunteer, and Contractor Training Inmate Education
Inmate Intake and Classification Agency and Staff Response to Inmate Reports Investigations Staff and Inmate Discipline Medical and Mental Health Care Monitoring

F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: There has been no change since the previous reports. No revised policy and procedure drafts have been provided to the Monitor for review as of yet. Compliance with this Provision requires a high level of technical expertise and qualification; it is likely that GGACF officials will require outside technical assistance to comply with this Provision and are encouraged to contact the USDOJ / NIC for this assistance. Recommendations previously provided remain appropriate.
From the Second Compliance Report:
Current classification policies and procedures are found in Section 3 of GGACF Policy and Procedure for Inmate Records, Booking and Inmate Processing, and Inmate Classification (pp.47-55, dated July 1, 1993). According to Territory Officials, the classification process was developed with the assistance of Dr. Jim Austin, classification expert, and the National Institute of Corrections. However, it is unknown whether facility-specific classification protocol was put into place. No additional or new classification policies or procedures consistent with the elements of F.1.a above were provided to the Monitor. Additionally, current policy Table of Contents shows classification procedures on pp. 47-55; Section 3 is paged 49-50 and appears to be missing several pages.
The current admission and review classification instruments are outdated and cannot, therefore, reliably reflect actual classification levels and housing decisions. The current classification is inadequate because: 1) classification decision making is not based on a current and empirically-validated classification tool, and 2) the high levels of institutional violence and

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contraband reporting in incident logs strongly are indicative of the absence of a valid and

reliable classification system.

RECOMMENDATIONS:

1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that
provide more accurate and complete guidance for a valid and reliable classification system for non-convicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance.

b. Housing and separation of prisoners in accordance with their classification;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As found in the previous reports, detainees and convicted offenders are generally held in separate buildings except for sentenced and un-sentenced female inmates who are separated in the same building. Inmates are generally housed according to their security level based on behavioral history and whether their background includes violent criminal acts. Inmates are also housed according to administrative, disciplinary, special needs, and/or work assignments. This is a very basic and unreliable practice for managing inmates and is not based on a reliable classification system. Such a practice is known to facilitate violence against inmates and staff, the introduction of contraband, and can create substantial barriers to inmate health and wellbeing. For example, some inmates with serious mental illness (SMI) are being housed in segregation / lockdown unit for lack of an effective and valid classification system. This practice can exacerbate inmate behavior management problems, their mental illness, and is specifically prohibited by the Order per Provision V.1.p:

“A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;”

Recommendations provided in the Baseline Report remain appropriate. This issue will remain problematic and contribute to continued introduction of contraband and violence until a valid and reliable classification system is developed, implemented, and evaluated. Refer to previous recommendations.

RECOMMENDATIONS:

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks, and needs.

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3. Comply with the Order’s prohibition against housing seriously mentally ill inmates in an

isolation cell or housing unit.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As reported previously in this report, positive improvements were observed in locking the housing unit security gates. However, this system remains flawed because officers continue to leave these gates unlocked when inside the housing area. Current staffing levels and gate locking practices impair GGACFs ability to comply with this Provision. Additionally, a lack of security cameras and monitoring capabilities provides no ability to monitor inmates effectively to detect and potentially prevent them from obtaining unauthorized access to each other. Furthermore, and until all locking systems are repaired and maintained consistently, inmates will be able to disable their cell locks for access to each other.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: As stated in previous reports, there is current practice and general policy for reclassifying inmates following incidents involving violence and disciplinary events. However, this process, as previously stated, should be empirically validated.

Additionally, an examination of Grievance and Discipline Logs continues to show they are incomplete and inconsistent. The Grievance Log is missing several important entries indicating that some important grievances go unanswered. The Discipline Log and disciplinary documents provided evidence that many disciplinary cases are dismissed because timely due process was not provided to the inmate. The accuracy and completeness of these records are very important for making consistent and reliable re-classification decisions. Otherwise, as is indicated in the disciplinary reports, inmates under disciplinary action are given “time served” and release from restrictions without being afforded their right to due process. This will be discussed further in this report.

RECOMMENDATIONS:

1. Refer to previous classification findings and recommendations. 2. Refer to recommends related to grievance and disciplinary policies and procedures.

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e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults,

prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct; and..(f).

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Implementation of a new Incident Reporting Log was described in the Baseline Report and remains in effect. However, and as previously reported, a review of this log shows it is often incomplete and often illegible. This log cannot provide an accurate account for incidents because it contains multiple entries for the same incidents using the same or different incident numbers. This makes using this log for compliance with this provision virtually impossible and its uses should be revised.

The GIST (Gang Intelligence and Search Team) program is inadequately staffed to provide the level of evaluation and intervention needed to meet the apparent high volume of incident activity reported in the incident report, supervisor, and housing unit logs. Staff should be added to this program and a comprehensive evaluation and intervention program developed.

RECOMMENDATIONS:

1. Develop policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.

f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As reported previously, there continues to be no formal mechanism or process for regularly reviewing status and conditions of inmates housed in segregation. Additionally, the Monitor was provided no evidence that GGACF tracks and monitors inmate lengths of stay in segregation or why inmates are segregated. When viewed in combination with the flawed disciplinary process and the incomplete grievance tracking process, it is clear that segregated inmates are not provided adequate levels of due process, monitoring, and review. This practice is very serious and in direct violation of the Agreement.

Additionally, virtually all other housing unit logs are placed on “modified” or “full” lockdown frequently due to staffing shortages. This practice, though apparently necessary for security purposes, effectively creates facility-wide segregation conditions that must be corrected.

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RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or as a treatment for inmates who are mentally ill.

G. Incidents and Referrals

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

a. Reporting by staff of serious incidents, including (i) fights; serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: These policies have not been submitted as required.

It appears that not all incidents are being reported, and when they are reported, many reports are inaccurate, indicating that they are not reviewed closely. There are logbook entries regarding multiple assaults/attacks that have no corresponding incident reports. Only two Use of Force Reports were provided, despite the fact that many more incident reports or log book entries indicated that force was used to break up an altercation or subdue an aggressive or problematic prisoner. This indicates that staff were never trained on when to use different forms, what to include in those forms, and how those forms should be reviewed by upper level management. The result is that these forms are essentially meaningless – incidents are written up, but nothing is done with the reports. In addition, it will be impossible for the Warden or other leadership to evaluate whether the level of force used was excessive if use of force reports are simply not created.

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RECOMMENDATIONS:

1. Complete and submit policies as indicated. 2. Integrate the Incident Tracking system into this policy. 3. Develop protocols for current tracking system to improve data validity and reliability; this
document is replete with duplication and misleading entries. 4. Develop a unified incident coding system for valid and reliable information and data
collection, reporting, and analysis. 5. Establish regular monthly quality assurance meeting process involving all major department
team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity. 6. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol.

b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: As previously reported, senior staff now participate in GIST meetings to review incident activity, but additional work is needed for compliance. However, there are no policies or procedures governing or directing this process and the group does not meet regularly. Furthermore, and as previously discussed, the incident reporting system requires revision before it is a valid and reliable document for incident evaluation purposes.

RECOMMENDATIONS:

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous section on contraband control as it also pertains to confiscation and preservation of evidence

RECOMMENDATIONS:

1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previous findings regarding incident reporting and tracking.

RECOMMENDATIONS:

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1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Such a policy has not been provided.

RECOMMENDATIONS:

1. Include this element in the required policy and procedure. 2. Establish reasonable time frames as indicated. 3. Develop and implement corrective action protocols for staff noncompliance with adopted
policies and procedures.

H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force, Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There has been no change since the Baseline or second visits. The policies and procedures provided to the Monitor are outdated and missing several standard elements. Additionally, the documents do not articulate decision-making protocols for staff when using force involving mentally ill inmates. A review of incident reports provides questionable examples of use of force practices:

Date and Type of Documentation 12/16/13 (Incident Report)

Incident Number (if any) GGACF-120339-13-IR

Description of Incident

Problem with Report and/or Result

Officer reported that Inmate assaulted him/hit him in the face; C/Os went to investigate and inmate became hostile; inmate had a knife with him. C/Os had to restrain inmate

Multiple incident reports were written, some of which stated that officers restrained the inmate and forced him into a cell. However, no Use of Force report was every completed and the officers’ use of force was never evaluated.

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to get him back in his cell

12/18/13

GGACF-12-

Detainee attacked

Assistance was called, but the incident

(Incident Report) 0388-13-IR

Detainee with a

report does not indicate how the

1/14/14 (HDC Dismissal Form)

broomstick in 9C

incident concluded. 12 officers responded. A second incident report notes that a behavioral checklist for Detainee was completed and forwarded to medical, but it is unclear if there was

any follow up.

12/25/13 (Incident Report)
1/11/14 (Incident Report)
1/17/14 (Incident Reports) 1/17/14 (Use of Force Reports)
2/13/14 (Incident Report) 2/13/14 (Use of Force Report)

GGACF-120344-13-IR
GGACF-010358-14-IR (this number was a little hard to read) GGACF-010355-14-IR
GGACF-020378-14-IR

Inmate hit C/O in the back of the head on K Unit. Backup was called and inmate refused to go back in his cell. Officers used a baton to strike inmate until he stopped resisting and could be placed back in his cell. C/O “lightly pushed” Detainee “away from entering a fight” in 9D.
C/O was escorting inmate back to cell from medical building; inmate wouldn’t go back in his cell, and punched C/O; C/O “responded with a one two combination to the facial area” and applied an “arm bear technique” When distributing meds at Det. C/O noticed detainees tampering with the golf cart. When C/O approached the

Detainee did not receive any discipline for this incident because the disciplinary process resulted in a due process violation. Hearing Committee paperwork indicates that no disciplinary hearing was held due to a staff shortage and “security concerns” Use of force was clearly used, but no Use of Force report was completed.
Also, under “description of incident” at the top of the incident form, C/O wrote “Disorderly conduct, murder, attempted murder, assault” – clearly the “murder” and “attempted murder” categories are inappropriate. Yet, the reviewer who signed the back of the form approved the report on 12/25/13. No Use of Force report accompanies this Incident Report
Also Incident Report found regarding the underlying fight Use of Force report completed, but incomplete/not well done. The report says that a video recorded interview with the inmate was conducted – is that true? Where is the video?
The person who completed the Use of Force report also notes that the inmate had injuries “but appeared to be ok”
A Use of Force report was completed following this incident, which was signed off on by Acting Chief. The reports are incomplete, however – the detainee was sent to the hospital to receive medical care for injuries

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detainees, Detainee tried to punch him.

sustained during C/O use of force. This doesn’t appear to be a full review

C/O “preceed [sic] to of the use of force, and it is not

defend [him]self” and indicated whether C/O conduct was

a “strugel ensued”

appropriate or how he was instructed

[sic].

following the incident.

1/29/14 (Incident GGACF-01-

Report)

368-14-IR

2/18/14 (HDC Findings Letter)

Detainee assaulted Detainee. C/O on unit tried to break up the fight and restrain Detainee with the help of another C/O.

Additionally, at the bottom of the Use of Force report, there is a “note” that a detainee attempted to run away during the incident because the door to the classification office was unlocked. The reviewer notes that this was a “situation waiting to happen” and that the door to classification “should be locked or equip with a buzzer.” Force was clearly used to break up this fight, but no Use of Force Report was ever submitted.
The Detainee was punished with 260 days of lockdown.

RECOMMENDATIONS:

1. Review, revise, develop, train, evaluate use of force policies as indicated and include, at a minimum the following policy elements: A. Mission and purpose statement B. Legal authority for use of force C. Definitions: of force, conditions, applications, non-physical and physical force, authorized weapons, deadly force, necessary and unnecessary force, etc.; D. Pre-service staff proficiency training, qualifications, certification, and regular in-service training; E. Use of deadly force; F. Use of any weapon authorized for use; G. Reporting requirements; H. Force event quality control and assurance program and methods; I. Self-defense; J. Impermissible force; K. Staff noncompliance corrective measures; L. Medical/mental health involvement in use of force events; M. Force against special populations, e.g., mentally ill, frail, medically ill, aged; N. Planned and unplanned force; O. Special force operations and equipment; P. Officer safety and protection; Q. Emergency first aid; R. Administrative reviews; S. Use of restraints; T. Centralized incident, training, and qualification record keeping; U. Armory operations and instructor training and certification;

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V. Photographing, videotaping, recording of planned force events;

W. Other.

b. Circumstances under which the permissible forms of physical force may be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to findings in H.a. above, and findings and recommendations for Training Provisions.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See recommendations regarding Training Provisions and apply to use for force requirements.

e. Training and certification required before being permitted to carry and use an authorized weapon;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documents were provided that show the names of several officers who participated in weapons qualifications. However, these documents do not clarify whether all officers currently authorized to carry weapons are trained in accordance with the Agreement. The term

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“weapon” should include any device issued to staff in the use of force against an inmate. This

includes, but is not limited to: firearms, batons, impact weapons, chemical weapons, etc.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Refer to Training Provision recommendations and apply to this requirement.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The chart above evidences inconsistent reporting practices in the use of force that will need to be corrected before this compliance score can be returned to Partial Compliance.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since previous reports. Policies and procedures regarding supervision and videotaping of planned for events were not provided to the Monitor.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since previous reports. Security towers remain inconsistently operational due to staffing and problems rendering them an unreliable security control post.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since previous reports. As noted in the incident report charts provided in this section, it appears that one inmate received medical attention following involvement in a use of force event with officers. However, the report does not refer to whether photographic documentation was completed and submitted for an administrative review of the event.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: As stated in the previous report, the Warden stated that, although there are few incidents of force being used against inmates, that all incidents and reports are reviewed for accuracy and justification in a timely manner by supervisors and management officials. However, a review of reports indicated that some remain incomplete and/or do not effectively articulate what is being reported.

A review of incident reports involving use of force events, as described and listed previously, does not clarify timeliness of the review process but does indicate process flaws evidenced by the problems discussed.

No revised policy or procedure has been provided to the Monitor for review as indicated in the

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: To its credit, the Territory has filled the vacant Chief Investigator position. Records provided for review indicate ongoing problems with the administrative review process that make clear assessment of this provision unreliable. Additionally, problems discussed regarding the inmate grievance process and tracking system further evidence systematic deficiencies in this review process. There does not appear to be any clear criteria guiding the review or referral process.

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RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

l. Administrative investigation of uses of force;

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits. No policy or procedure revision was provided to the Monitor for review. Additionally, a review of the Inmate Grievance and Disciplinary Logs indicates that these documents are often incomplete and do not follow acceptable timeframes for resolution. Additionally, there is no specific mechanism for reviewing grievance or disciplinary events for use of force involvement. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. No policy or procedure revisions were provided to the Monitor for review. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

o. Re-training and sanctions against staff for improper uses of force.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Training records were not provided to the Monitor at this or the Baseline visit and the Training Director was not available for either assessments. No policies or procedures were provided that articulate such a process.

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RECOMMENDATIONS:

1. Refer to previous list of Use of Force policy and procedure topics related to this provision for inclusion in those documents.

I. Use of Physical Restraints on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No records, policies, or procedure were provided to prove compliance with this provision. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

b. Circumstances under which various types of restraint can be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same findings and recommendation as above. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Duration of the use of permitted forms of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline visit. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

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d. Required observation of prisoners placed in restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See below.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Develop, train, implement, and evaluate well-researched, well-written, clear, and complete policies and procedures to managing the use of restraints process.
2. Involve a multidisciplinary process in decision making to use, monitor, and terminate restraint use.
3. Train all staff in this process and the proper use of restraints and less restrictive alternatives.
4. Develop training lesson plans for this process that ensure staff competency in both knowledge and application of the restrain policies and procedures. Always train using the actual restraint devices authorized.
5. Develop and implement a reporting and tracking system for restraint use. Leadership should review all restraint use on a monthly basis to ensure policy compliance and take remedial/corrective actions, whether to policy, procedure, or staff noncompliance, in a timely manner. All remedial/corrective actions should be documented and maintained.

f. Required termination of the use of restraints.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Same as above.

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2. Ensure the policy includes restrictions on restraint use duration and termination

requirements.

J. Prisoner Complaints
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from the Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate.

As stated in the previous report:

Additionally, a review of the Inmate/Detainee Grievance Log Sheet indicates that this process is not consistently maintained. Much of the information required by the Log is missing and incomplete. Several dates are missing, which makes it impossible to determine whether responses to inmates were timely. The “Chief’s Response” column frequently states “no answer” or is empty. This is problematic as several of the inmates’ complaints involved medical issues, officer misconduct, rights violation allegations, request for hygiene products, attorney access, food, assaults by officers, missing eye-wear and personal property, and dietary meals, for example.

There are no clearly written policies and procedures for ensuring confidential access for reporting complaints or that includes assistance to inmates with cognitive and/or communication (verbal/written/auditory) impairments. Although the incident log notes “confidential” in certain cases, this practice is informal and discretionarily determined according to specific circumstances. Discussions with the Warden about this issue revealed that both confidentiality and communication impairment issues are dealt with on a case-by-case basis, but no formal policies and procedures exists. Those discussions also suggest that management is aware of these needs, takes appropriate steps to meet those needs, but does so in the absence of written guidelines.

It is also important that policies and procedures direct under what conditions housing unit officers are authorized to resolve complaints. This issue must be studied carefully with specific written controls when promulgating policies and procedures. It is important for the protection of staff and inmates that inmates have timely access to a complaint/grievance process that is unfettered by unauthorized resolution by correctional staff. Such controls and guidelines will also facilitate inmate access to their rights, care and alert facility officials (administration, security, medical, mental health) to ongoing risks to inmates and staff.

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There is no formal consistent inmate complaint/grievance tracking system currently in place.

Although complaint forms are available to inmates, there is no system established to ensure that

complaints are resolved, followed-up, and/or monitored. Current practices also differ among

unit officers, according to inmate and staff interviews. Some officers allow free access to

complaint forms, others state they attempt to resolve matters informally before issuing a form,

still others require all completed complaint forms to be submitted by the inmate to the officers

for further processing. Inconsistencies in the complaint process exposes staff and inmates to

erroneous allegations of misconduct, increases risks of inmate abuse by staff, places inmate

health care and rehabilitation at risk, and thwarts development of a valid and reliable complaint

reporting and tracking system. However, even the best inmate complaint system is rendered

ineffective if inmates do not have the means to ensure complaints are reliably collected and

reviewed. Many of the boxes used to collect complaints and sick requests at the housing units

were found unlocked and/or broken. Some of these boxes were filled with trash, which clearly

evidences ineffective management oversight by housing unit officers, supervisors, and

management.

RECOMMENDATIONS:

1. Review, revise, develop, train, and implement inmate complaint policies and procedures.
2. Develop and implement a valid a reliable complaint reporting and tracking system. 3. Conduct monthly administrative reviews of the inmate complaint reporting and tracking
process to measure and verify program compliance, take timely and appropriate remedial and correction action.

b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate. Additionally, the development and implementation of a consistent process for timely investigating inmate complaints is thwarted by inmate grievance process discussed above.

RECOMMENDATIONS:

1. Same as above. 2. Include policy and provisions for timely investigations of complaints, prioritization of
complaints related to risks of harm and safety, and medical and/or medical care.

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: No change from Baseline or second visits; there is no formal policy or procedure

on this subject matter. Recommendations provided in the Baseline and second reports remain

appropriate.

RECOMMENDATIONS:

1. Complete required policies and procedures. 2. Include specific policy and procedural provisions requiring corrective action for staff
noncompliance, and that ensures timely, consistent, and appropriate disciplinary action against staff who violate the policy. 3. Also consider Inmate Grievance Log issues described above in developing these policies and procedures. 4. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate. Same issues described above regarding the Grievance Log.

RECOMMENDATIONS:

1. Develop and implement a formal centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate.

Additionally, the Inmate Grievance Log clearly suggests the absence of a systematic and reliable process for reviewing prisoner complaints, trends, or individual and systemic issue.

RECOMMENDATIONS:

1. See previous recommendations related to reporting and tracking complaints. 2. Conduct monthly administrative reviews of inmate complaint/grievance tracking reports
and data to identify patterns of individual staff, inmate, and/or systemic problems and issues.

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K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from or second visits. Recommendations provided in the Baseline Report remain appropriate. No policy or procedure revisions have been submitted to the Monitor for review.

RECOMMENDATIONS:

1. Submit administrative investigation policies and procedures per this provision as indicated.
2. Ensure the policies and procedures clearly describe investigative timelines, officials responsible who are authorized to conduct interviews, methods and locations of interviews, and other relevant topics that maintain the integrity and legality of the investigative review process and determinations.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline or second visits. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling,
preserving, and maintaining administrative investigation evidence, information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: Little change from Baseline or second visits. Additionally as previously discussed, even if an investigation determines that an inmate deserves some form of punishment for a disciplinary infraction, that punishment is often not determined or enforced because due process proceedings often do not occur. A review of prisoner disciplinary files from the last three months shows that some prisoners had disciplinary action taken against him or her; disciplinary charges were dismissed because there were not enough staff to conduct the due process hearings. Recommendations provided in the Baseline Report remain appropriate.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change from Baseline visit. Recommendations provided in the Baseline Report remain appropriate. Training documents related to this provision were not provided nor are there policies and procedures promulgated on this subject. Although the Monitor did not review qualification documents of the new Chief Investigator, he seems qualified for the position based on the Monitor’s interview.

RECOMMENDATIONS:

1. There is no formal pre- or in-service training program to train staff who are involved in initial and/or administrative investigation.
2. Provide adequate training of staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
3. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management.
4. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities.
5. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Documents and reports provided during this assessment, combined with previously such documents, cause this provision to return to Noncompliance; they more clearly evidence the absence of an effective and consistent inmate disciplinary system or process.

A review incident reports and related disciplinary hearing committee documents, including forms indicating dismissal of charges due to lack of due process and forms relaying the results of the hearing committee, show that there is no meaningful, consistent system in place. It appears that hearings occur randomly, and the punishments assigned are equally random. We have yet to see any policy governing when a prisoner receives a hearing, the process for that hearing, and what appropriate punishments should be. See the chart below for examples of the wide disparity in punishments for different rule infractions.

Moreover, the disciplinary sergeant wrote a “monthly report” for January 2014 of all the disciplinary hearing committee (HDC) activities for this month. The report notes several flaws in the disciplinary process at GGACF: 1) it is difficult to hold HDC meetings without adequate staff; 2) officers and supervisors need to attend a “report writing class” and 3) security staff don’t know when to use disciplinary reports and incident report forms, evidencing the lack of any formal policy or guidance for this process. Moreover, the Monitor would like to know whether similar reports been created for previous months. If not, why not? If so, why have they not been produced to the Monitor?

The chart below provides examples of these problems with the inmate disciplinary system:

12/18/13 (Incident Report)

GGACF-120388-13-IR

1/14/14 (HDC Dismissal Form)

12/25/13 (Incident Report)

GGACF-120345-13-IR

1/2/14 (Incident Report)

Detainee attacked Detainee with a broomstick in 9C

Assistance was called, but the incident report does not indicate how the incident concluded. 12 officers responded. A second incident report notes that a behavioral checklist for Detainee was completed and forwarded to medical, but it is unclear if there was any follow up.

GIST team received a call to search inmate, who may have a knife; GIST conducted the search and a knife was recovered
On 9D unit, Detainee beating up with a piece of broomstick;

Detainee did not receive any discipline for this incident because the disciplinary process resulted in a due process violation. Hearing Committee paperwork indicates that no disciplinary hearing was held due to a staff shortage and “security concerns” The incident report indicates that the inmate was placed in lockdown “pending his hearing,” but no Disciplinary Committee Hearing paperwork was submitted along with this incident report. It is unclear if the inmate ever received a hearing, or if he is still on lockdown for this incident without a hearing. Detainee received 90 days lockdown for this incident, but other Detainee received 150 days. It is unclear from the

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1/23/14 (HDC Findings Letter) 2/4/14 (Incident Report)
2/12/14 (HDC unable to continue disciplinary hearing notice) 1/20/14 (Incident Report)
2/18/14 (HDC Findings Letter) 1/24/14 (Disciplinary reports)
2/18/14 (HDC Findings Letter)
02/09/14 (Disciplinary reports)
2/18/14 (HDC Findings Letter)

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Detainee then attacked paperwork why there is a 60 day Detainee with another discrepancy between the two

piece of broomstick. punishments.

GGACF-020371-14-IR

In 9C, Detainee began fighting with another. A third detainee joined in.

All three detainees were written up in incident reports and each received notice on 2/12/14 that the incident reports were not investigated and the charges were deemed a due process violation. Why this fight was never investigated?

GGACF-010359-14-IR

Detainee disobeyed order to stand by cell door during headcount

The HRC findings letter indicates that the Detainee received 100 days in lockdown for this violation. Nothing in the findings letter or HDC disposition form indicates why such a severe punishment was given for this offense.

GGACF-013064-14-IR (but no formal incident report attached; just disciplinary report)
GGACF-020323-14-IR (but no formal incident report attached; just disciplinary report)

Detainee was out of his cell after lockdown; apparently he was able to get out of his cell after the officer locked the door.
Detainee was told to go back to his cell during lockdown, but instead he went to talk to another detainee. The detainee then threw his water bottle, and was then secured in his cell.

The detainee was charged with tampering with a locking device and being in an unauthorized area (i.e., out of his cell and in the common area). He was also convicted of “attempted or planned escape.” He was disciplined with 290 days of lockdown. First, there is nothing in the disciplinary report indicating that he actually tampered with lock – the report reads more like the lock just didn’t work. Second, the report does not indicate that he attempted to escape the housing unit – just that he was out of his cell. Finally, there just seems to be a complete lack of justification for placing this detainee in lockdown for 240 days. Why is the detainee being punished so harshly for a faulty lock? See above. The same detainee was charged with another instance of being in an unauthorized area, disobeying an order, and attempting to commit any category II offense. This time, he was given another 100 days of lockdown as punishment, to run consecutive to the above punishment.
Together, this inmate was placed in lockdown for almost a year simply for disobeying an order. This seems extreme

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and there is no justification in the paperwork submitted.

RECOMMENDATIONS:
1. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.
2. Integrate the information in the above into the administrative policies and procedures previously discussed.
3. Record and maintain onsite records of staff misconduct investigative reports and determinations.
4. Protect the integrity and confidentiality of these staff records; control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
5. Provide training to supervision staff in the appropriate use of this information for staff supervision, counseling, discipline, promotion, etc. purposes.
6. As with all training, especially training required for and, that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:

a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: For this visit, the Health Care Administrator and her team had clearly done a significant amount of work with regard to several of the policies that we had highlighted as priorities. Those include receiving screening, initial health assessment, nonemergency health care requests and services, emergency services, continuity of care during incarceration and chronic disease services. We have indicated that the quality improvement program policy can be delayed until the other policies are in place. In addition, we also indicated that until there is a Medical Director committed to the program, the intoxication and withdrawal policy cannot be drafted, since it will include clinical guidelines which must be drafted by the physician Medical Director. Of the policies, the chronic disease policy appears closest to being approved by the Monitoring team. There were a few minor elements that we discussed. With regard to the receiving screening policy, unfortunately a consultant not really familiar with the work we have been doing modified the draft that the Health Care Administrator had prepared and these modifications are unacceptable. We achieved agreement with the Director of Corrections that this consultant will not address either medical or mental health policies. Once again, we reviewed with the Health Care Administrator the elements in the receiving screening policy, which will enable the removal of the officers from the process, even when there is coverage only 16 hours per day, seven days per week onsite. This is because for people who enter the booking process after midnight but before 8:00 a.m., they can be screened for stability by a nurse over the telephone. If any questions suggest instability, then the Medical Director must be called. If, on the other hand, none of the questions suggest instability, the patient must be seen and provided the standard comprehensive intake screening at 8:00 a.m. when the dayshift begins. Also, we provided to the Health Care Administrator acuity scales utilized by two other jails which can be used to guide the nurse doing the comprehensive screen as to the urgency for the scheduling of the initial health assessment, such as on Day 1, Day 2, Day 3 or, where more monitoring is needed, Day 7. These acuity scales need to be figuratively attached to the screening so that based on the data collected and comparing that to the selected acuity scale, the health assessment will be scheduled. We also suggested some changes to the comprehensive screening tool itself, all of which can be accomplished prior to our next visit. Additionally, we had some suggestions regarding the form utilized for the initial health assessments and we will work closely with the Health Care Administrator in her efforts to refine those forms.

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With regard to the policy on nonemergency health care requests (sick call), we also suggested some

minor revisions. With regard to the emergency services policy, it dealt almost exclusively with

disasters and disaster planning, which is important. However, we discussed an urgent/emergent

policy which will have a much greater operational impact, both for how to respond to emergencies

or urgent verbal requests as well as the requirements for follow up. One important clarification is

that nonemergency requests as perceived by the patients should be submitted in writing on a sick

call request form. On the other hand, if the patient perceives an urgent problem, this is to be

addressed to the nearest officer verbally. The policy must indicate that the officer’s obligation is to

contact the medical staff and inform them of the request. When medical staff receive this request

from an officer, they should document it in an urgent care services logbook and then arrange for an

assessment to be performed as soon as possible. Most of these assessments should be performed in

the clinic area; however, there are rooms in the housing units which can be fixed up and equipped

to function as exam rooms and some assessments can be performed in those newly equipped exam

rooms when they are fully equipped. We were informed that there are now locks available for all

of the sick call boxes and therefore requests should be placed directly into these boxes by the

inmates. We were also informed that the morning medication administration nurse does collect the

slips and returns them to the health care unit for triaging by a registered nurse on a daily basis. This

is consistent with our plans for this policy. On the other hand, the additional nursing staff have not

been hired and the one full-time RN is now on vacation, creating problems for both sick call request

triaging and for the performance of face-to-face assessments, which require an RN. The Monitoring

team reviewed some evidence indicating that triaging of sick call slips is not occurring on the

schedule reported.

With regard to continuity of care, we focused on continuity with regard to intake as well as after both scheduled and unscheduled offsite services. This policy and the policies for each of those services must indicate that patients being returned from offsite services must be brought to the medical area so that any documentation can be reviewed by a nurse and, if needed, the patient queried.

Finally, we reviewed the discharge planning policy, which in the way it was written, was applicable only to sentenced detainees. Although clearly it is much more difficult to provide successful reentry planning and implementation for patients who are in a pretrial detainee status because their release is frequently not known to the program before the court makes a determination, an effort must be made for these detainees. However, we discussed strategies that can be employed, which should provide at least some success in connecting patients with services that can assure continuity upon release.

We discussed a host of new policies that can be promulgated prior to our next visit. When some policies are approved and have begun to be implemented, partial compliance status will be achieved.

RECOMMENDATIONS:

1. Remove the consultant from involvement with the medical policies. 2. Incorporate an acuity scale for the determination of urgency by the screening nurse and
schedule the health assessments on the basis of that acuity scale. 3. Continue to improve both the screening tool and the health assessment tool.

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4. With regard to the ability to remove officers from any involvement in the medical screening

process, develop a list of questions geared to determine whether the patient can wait up to

eight hours in order to be screened. If those questions suggest instability, the nurse

performing those screening questions must contact the physician. If the questions reveal no

instability, the patient can wait until screened in the morning at 8:00 a.m.

5. Hire the additional nursing staff so that both the intake screens as well as the non-emergency

health care request policies can be consistently implemented without any disruptions due to

vacations.

6. Complete the policies that address both scheduled and unscheduled offsite services so that

the follow up after the service has been provided is improved.

7. Make the changes on the chronic disease service policy in order for implementation to

begin. It is especially important for the clinicians to utilize both the initial chronic care visit

form and subsequently the follow up visit chronic care form.

8. The following policies are to be drafted:

i. Hospital and specialty care ii. Urgent/emergent services iii. Access to care iv. Responsible health authority v. Medical autonomy vi. Segregated inmates vii. Patient safety viii. Infection control ix. Right to refuse x. Grievance mechanisms xi. Clinical performance enhancement reviews xii. Health training for correctional officers xiii. Medication administration training

MENTAL HEALTH FINDINGS: SECOND REPORT: December 2013: The intake process remains flawed with no change in the process or tools. As noted in September 2013 "even when incoming inmates are identified through the screening tool or the officer's observations as having mental health problems, referrals often do not occur, resulting in misidentification and lack of services for those individuals." Medical screenings are frequently delayed significantly and at least in one case, medications have been administered to an inmate for several months with no clinician’s order or follow-up visit. Regarding the development of mental health policies and procedures specific to the facility, no new policies have been developed since the time of our initial visit. Staffing remains unchanged and is still considered inadequate in quantity and composition to meet the needs of those seriously mentally ill and acutely symptomatic inmates housed at GGACF.

THIRD REPORT March 2014: A new policy was distributed at the time of the site visit on intake screening. Medical has also drafted a detailed screening form which represents a significant improvement over the prior highly abbreviated and inadequate tool. Dr. Sang, the newly hired psychiatrist, plans on developing mental health policies but has focused on seeing every inmate on the caseload and wants to organize the mental health charts first. Several of the detainee intake screens reviewed this visit revealed a lack of vital signs noted to be due to the unavailability of the proper instruments.

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RECOMMENDATIONS:

1. A more effective intake process should be developed so that medical staff has access to new detainees and prisoners within 24 hours. The initial security screening tool is not robust enough to provide good identification of medically and psychiatrically ill people. Security staff conducting these interviews will require additional training by health services (medical and mental health) and a quality assurance tool should be developed to monitor the completeness of their documentation and the accuracy of their triage two medical and mental health staff.
2. Medication bridging is problematic with evidence of medications being prescribed and administered but not ordered by a clinician. A review method needs to be developed to oversee the reliability of this process.
3. All of the medical policies need to be reviewed and modified as applicable to this facility. 4. The facility needs to purchase sufficient stethoscopes and sphygmomanometers to ensure
availability of more than one of the latter on site. There should be sufficient instrumentation, at a minimum, for the treatment building, reception/suicide watch area, and the emergency response bag.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: With the exception of a physician assistant who is onsite Saturday and Sunday, there has been no advanced level clinician presence at the facility. This makes it impossible to perform timely health assessments. We reviewed the records of five patients who had entered the facility in the last two months.

The first patient, a male with a prior history of treatment for mental health issues. He arrived on 1/8/14. He had no vital signs performed until 1/14. He had a TB skin test which was planted and read, but there were no results in the chart; instead, the results were in a notebook maintained by the nurses. In addition, despite his history, there was no mental health referral.

The next patient is a male who arrived on 1/29/14. He was not seen by an LPN until 1/31 and even then, no vital signs were performed. He also had a TB skin test completed but there were no results in the record.

Another patient who arrived on 1/19/14 who is being treated for mental health problems. He was seen by an LPN three days later, on 1/22, at which time he had a TB skin test planted. The skin test was read on 1/25 and he was sent for a chest x-ray over two weeks later, on 2/14. This patient could have had active disease and yet was allowed in population and there was an extraordinary delay in obtaining the chest x-ray. The chest x-ray was performed and it was abnormal, indicating a density in the left chest. This was reviewed and on 3/4, a request for a CT was made and apparently it was done, but there is no result yet available.

The last record is a male who arrived on 2/6/14 with a history of hypertension and asthma and also sciatica. He was seen by an LPN one day later and had a TB skin test which was planted and read

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three days later as negative. We noticed that there were sections of the new screening form which

appeared blank and we were informed that this was because the way the form is drafted, there is no

allowance for negative responses. We discussed this with the Health Care Administrator, who will

make the appropriate changes. Despite this patient’s multiple chronic problems, there has been no

health assessment in over a month, nor has there been any referral for the chronic care program.

RECOMMENDATIONS:

1. Again, hire the Medical Director, who should be onsite at least three days per week and on call 365 days a year.
2. Fix the intake screening form and utilize it so that the urgency of the health assessment is connected to the acuity status determined by the collected data. If the Medical Director is onsite three days a week during Monday through Friday, and the PA is available onsite Saturday and Sunday, you will have five days per week of advanced level provider coverage, which should be sufficient to perform the assessments timely.
3. Insure that the health screen includes vital signs. 4. TB skin test results must be documented in the medical record, as there is a location on the
comprehensive screening form. 5. Fill the vacant nurse positions so that there are a total of four registered nurses and three LPNs. 6. After the policies are finalized, provide training for both the advanced level providers and the
nurses so that they understand that the data collection on intake, including a health assessment, must lead to identification of problems with a plan to address each problem and insure continuity for follow up in the process.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Intake medical screenings are often delayed by nearly a week following booking. All too frequently there is evidence of the failure to complete a 14 day history and physical assessment by medical staff. This is an essential process designed to allow the inmate a second opportunity to report signs and symptoms that they may have not wish to share with the security officer at the time of intake or may have been impaired at that time and not interested in participating in the process. In addition, failure to complete both of these steps in a timely manner delays or fails completely to provide for mental health referrals. These inmates then become lost to follow-up and current preadmission medications abruptly discontinued.

Most significantly, regarding mental health care is the fact that sentenced inmates do not routinely receive comprehensive mental health assessments unless they are referred to mental health. It is generally a standard throughout the United States that prison inmates all receive an initial evaluation by a qualified mental health professional within the same time frames as the completion of the 14 day history and physical by medical.

THIRD REPORT March 2014: As mentioned elsewhere the intake process remains inadequate in identifying potentially mentally ill inmates entering the facility. The mental health coordinator reported finding a file with a positive mental health screening on the nursing desk one month after an inmate was booked. This inmate reported depression and auditory hallucinations during the correctional officer’s screening. The medical health assessment performed five days later by a registered nurse was completely negative for mental health and medical complaints. No comments were made concerning the discrepancy with the reports on the initial screening. The detainee was finally referred by nursing one month later when he reported that he was

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experiencing something emotional for the past 16 months and needed to speak with someone.

There was a six day delay in the mental health counselor’s discovery of this referral. She saw

him immediately and documented that he was depressed, delusional, not goal directed, had poor

insight and judgment. He was referred to the psychiatrist who again noted psychotic symptoms

and began him on medications. This latter case demonstrates a very flawed system in nursing

assessment and referral that in this case resulted in an inmate entering the system in a psychotic

state and remaining seriously mentally ill and untreated for six weeks.

While on site a review of 24 detainee intake records was completed. As mentioned elsewhere none of these files were organized into a chart but rather were paper clipped together. Of these 24, 3 (13%) had positive mental health screenings yet none of those inmates had been referred to mental health for an assessment. Names of these inmates were relayed to the mental health coordinator so that she could follow up on these cases.

Other critical deficiencies noted in this review of detainees arriving at this facility between October 2013 and the present time noted multiple charts in which no vital signs were completed at the time of intake with the notation that there was only one instrument to measure blood pressures in the facility and it could not leave the Medical Department in order for the nurse to take vital signs in the reception area. There are frequent delays between the time of booking and the medical intake most commonly 2 to 3 days after booking but in some cases as much as six days. One detainee with a history of hypertension and slow heart rate had no intake paperwork.

RECOMMENDATIONS:

1. Despite significant improvements in the intake assessment form, there remain significant deficiencies in the nursing staff's capacity to identify inmates for referral to mental health services and the timeliness in delivering those referrals. Medical administration and the nursing director need to address these deficiencies and develop monitoring tools for quality improvement purposes to ensure that this process has been corrected.

c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This particular requirement we have utilized to address non-emergency sick call requests (sick call). We have identified the following problems. Although frequently requests are being deposited in the boxes, some of them are being given to officers to put in the box. This potentially violates the confidentiality goals. In addition, one of the housing units just received its lock, so that the box was unlocked until very recently. In addition, because of the absence of a physician, the nurse was frequently attempting to respond to issues which should have required a referral. Although we appreciate the commitment of the registered nurse, the appropriate services must be provided by appropriately credentialed clinicians. We also continue to learn that it is common for the nurse to perform a face-to-face triage through a solid door as opposed to performing a nursing assessment in an appropriate space. Frequently, the nurse is doing this because of custody availability issues. The custody problems must be resolved. We did identify that in each of the housing units there are rooms designed for the ability to perform exams in them; however,

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frequently they are unclean and used for storage and lack the required equipment. When those

rooms are properly cleaned and equipped, the custody requirements to move patients to the clinic

for every examination will diminish. Many records that we reviewed reflect the fact that a nursing

assessment was not performed and instead, through a face-to-face triage, the nurse was attempting

to respond to medical concerns. This has to be rectified, by both hiring more nurses and creating

the exam rooms in the housing units.

RECOMMENDATIONS:

1. Insure that the Medical Director position is filled and he is onsite at least three days, Monday through Friday.
2. Fix up the examination rooms, providing the necessary equipment, including an exam table, desk and chair, etc., along with the necessary medical equipment and supplies to insure appropriate sanitation.
3. Hire the remaining nursing staff so that the nurse staffing is four full-time RNs and at least three full-time LPNs.
4. Insure that the sick call process goes from request placed in the box by the patient to collection by health care staff to paper triage by the registered nurse and then nursing assessments in an appropriate environment by a registered nurse. The only alternative is if the paper triage makes it clear that the patient needs to be seen immediately by an advanced level provider, then the nurse should so schedule the patient.
5. Insure that the sick call log contains date of receipt, presenting complaint, date of nurse assessment and if a follow up is indicated, date of advanced level provider assessment.

MENTAL HEALTH FINDINGS: Seventeen sick call requests for behavioral checklists were provided by the mental health coordinator and reviewed for timeliness of response. Of these there were critical delays in receipt of the information by mental health. Examples of the circumstances are as follows:

1. A behavioral checklist was issued December 17, 2013 for behavior such as hiding, refusing to leave cell, poor hygiene, fighting with others, alarmed. The record was received by mental health on January 7, 2014.
2. A consultation was issued for an inmate with multiple abdominal complaints and the belief that food has cockroaches in it. This was issued on December 26, 2013 by the physician and was received by mental health on January 17, 2014.
3. A checklist for auditory and visual hallucinations was issued December 15, 2013 and received by mental health on January 7, 2014.
4. Most of the settlement documents were received with inmate a two to five day window however those with significant delays were for urgent problems.
Review of the records also revealed questionable decision-making regarding follow-up services as follows:

1. One man placed a sick call request on January 7, 2014 for the complaint that his depression and anger was worsened by his medication which he discontinued. He was seen January 13, 2014 and was noted to be handcuffed secondary to locked down. He was described as

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severely depressed. There is inadequate documentation of the signs and symptoms of his

condition and no indication that he has been seen since that time.

2. Another inmate was seen on February 2, 2014 and was described as mute and catatonic. A record of a follow-up appointment was not able to be found. If the individual was truly catatonic he should've been on an inpatient psychiatric unit and not maintained at this facility.
Currently there is one full-time mental health coordinator and a part-time psychiatrist who is at the facility a minimum of three days per week. Delays in access to care continue to focus on the insufficient number of officers available to provide escorts to the treatment building. Other obstacles in the provision of adequate mental health care continue to depend on the performance of an adequate staffing needs analysis and also the development of the vision of what a comprehensive mental health program at this facility should look like.

The treatment building’s dedicated officer has recently had his shift changed from Monday through Friday to Sunday through Thursday. However according to the medical staff Friday has been the busiest clinic day. The first and second Friday since this change resulted in no officer being provided or an officer calling in sick.

RECOMMENDATIONS:

1. The elements in the above findings should be used to promulgate a policy and procedure related to access to care and sick call. A system for a confidential retrieval of sick call request by medical staff should be implemented and codified in policy.
2. Mental health staff with the support of the Health Services Division, the warden and the Bureau should design an adequate mental health delivery system for the facility and develop plans to staff and implement the required services.
3. The Monitor’s team should be utilized for consultation and/or technical assistance. 4. The facility needs to define by policy the qualifications required for each clinical process as
well as time frames to complete these processes and provide the clinically necessary followup. 5. Again, a staffing analysis needs to be completed to determine the required minimum number of psychiatric hours and counseling hours needed. 6. Mental health staff should perform, at a minimum, weekly segregation rounds and monthly well-being checks on all sentenced inmates on the mental health caseload. 7. Nursing transcription omissions should be addressed through education, supervision, and monitored by a Quality Assurance process. 8. GGACF needs to closely monitor shift changes and assignments of officers to ensure that access to medical services is not impeded.

d. Continuity, administration, and management of medications that address: (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices; (iii) review for known side effects of medications; and (iv) sufficient supplies of medications upon discharge for prisoners with serious medical
and mental health needs;

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ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Although the policy has not been finalized, there is significant progress to report. There is now a contract pharmacist responsible for overseeing both the storage and onsite management of the medications. She has reorganized the medication area and has insured, with the cooperation of nursing staff that all medications and especially controlled substances are appropriately secured in conformance with local law. Unfortunately, the progress with regard to storage, which includes involvement of the pharmacist in plans for renovating a new area that will provide more space to both store medications as well as to more appropriately package them in blister cards, is not reflective of improvements in the medication administration process. In fact, when we observed an evening medication administration in the detention facility, we observed a nurse literally handing medications to multiple patients during the course of the administration and then walking away without the detainees ever ingesting the medications, let alone participating in a mouth check, which should occur after the ingestion. This was a failing performance by the nurse; however, occasionally officers did ask to check the mouths of patients, who cooperated immediately. The nurses almost never requested to inspect the mouths or for the inmates to have their mouths inspected. Finally, the way the medication administration is set up, the documentation of the administration does not occur until the nurse returns to the medical unit, which could be 30-60 minutes after the start time. It is this delay without the use of any notes or prompts that makes it likely that the documentation in the medication administration records is susceptible to a significant error rate. One of the policies that we have encouraged deals with the training provided to nurses performing the medication administration duties. This, along with the completion of the medication administration and medication management policy, should assist in improving the performance. In addition, none of the inmates were asked to demonstrate an ID of any form. The nurses presumed that they knew all the inmates. This violates what is required of nurses performing the nursing administrative duty in all other facilities. To review, the nurse should first request the patient present an ID. The patient should also bring a container of water to the nurse or the door of his cell. The nurse should check the ID and the medication administration record and then provide the medications. Finally, after the patient ingests the medication and swallows the water, a mouth check should be completed, after which the nurse documents the administration on the medication administration record. In almost every way, the current procedure violates these basic rules.

RECOMMENDATIONS:

1. The medication management policy should be completed and presented to us for the next visit. 2. With regard to medication administration, the steps outlined above should be described in the
procedure. 3. The lead nurse should develop a way for nurses to be able to carry the medication administration
record with them when they perform the duty. 4. The inspection of the mouth should be performed by an officer and this should be written into
the officer’s post orders. It would be useful for a single officer, as does happen now sometimes, to accompany the nurse on these rounds. What is problematic is that when we observed the process, it was the officer who is stationed in the clinic who gets pulled away for up to an hour to accompany the nurse in the process. This potentially shuts down the clinic unless his post is relieved.

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5. Work with administration and custody to develop strategies that facilitate the health care

program making discharge medications available at the time of release, both to sentenced

inmates and pretrial detainees.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: GGACF has made strides to improve medication management. A consulting pharmacist has been hired and construction to create improved pharmacy facilities and security are underway. The pharmacist is also working with the territories Board of Pharmacy to obtain a facility pharmacy license. … Indeed review of every MAR showed excellent medication administration with sparse refusals.

The psychiatrist reported concerns about the reliability of transcription and implementation of both his medication and laboratory orders and this was substantiated in review of some medical records. Psychiatry does not utilize informed consent forms and there is no routine documentation regarding education about medication side effects and inmate consent. Medication review often is not performed within customary timeframes, with some inmates lost to follow up and psychiatric chronic care review or not seen for 6 months.

THIRD REPORT March 2014: During this visit by review of records and observation this auditor noted that nursing staff delivered medication to inmates but did not administer it, in that, the inmate or at times correctional officer received the medication and the nurse walked on to the next inmate where she again handed out doses to other inmates. This method of delivering medications but not administering them most likely explains why observation of the medication administration records during the second site visit revealed perfect records of administration with no refusals and no skip doses.

The current psychiatrist as well as the mental health professional continued to complain about significant difficulties in the accuracy and timeliness of transcription of medication orders, discontinuation orders, and laboratory study requests despite hand delivering the orders to the nursing person responsible. Dr. Sang has begun to insist that nursing staff obtained vital signs girth and weight on all inmates presenting for a psychiatric appointment. Staff also complained that once a laboratory study was ordered the results were not returned to the physician for review prior to being filed in the medical record.

RECOMMENDATIONS:

1. Nursing staff should be instructed as to the proper procedure when administering medications to all inmates.

2. Supervisory observation of performance should be periodic and unannounced to ensure the effectiveness of in-service training on medication administration.

3. Quality measures should be implemented to monitor the timeliness and accuracy of order transcriptions.

4. Laboratory studies and requested medical records should always be reviewed and dated and initialed by the clinician prior to being filed in the medical record. This process ensures that critical information will not be missed by the treating clinician.

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e. Maintenance of adequate medical and mental health records, including records, results,

and orders received from off-site consultations and treatment conducted while the prisoner

or detainee is in Golden Grove custody;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Since there is no staff person responsible for pulling and filing documents in the records, there tends to be some disorder, particularly in records of patients who have more problems or who have been in the facility longer periods of time. There continue to be documents which are unfiled or filed incorrectly. Given the number of staff utilizing these records, including caseworkers, nursing, medical clinicians, mental health, etc., a person should have the filing, the pulling and the maintenance of these records as their primary responsibility.

RECOMMENDATIONS:

1. Provide a position for a medical records technician who is dedicated to the maintenance and timely provision of medical records.
2. The medical records policy, which was generally well written, should include timeframes for filing of documents and for reviewing, initialing and dating by clinicians.
3. Continue to utilize the monitor staff for input in modifying the medical record policy.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Medical records are stored in a separate room. They are alphabetized and do not have a Bureau of Corrections number. Name alerts are utilized when necessary.

We again noted that the mental health counseling notes were still being retained in the Mental Health Coordinator's office.

One significant improvement was the development and implementation of the psychiatric progress note. As a result of the use of this form, the psychiatrist’s documentation was better, organized, detailed, and easy to read and navigate through.

THIRD REPORT March 2014: Significant difficulties continue to exist regarding the availability and organization of the medical record. During this visit charts were requested from a list of all current detainees housed in the facility in order to review the adequacy of the intake process regarding mental health. Of the 107 charts requested only 24 were able to be located and produced for review. Of these 24 detainees, their records were not filed in folders, but rather paper clipped together waiting to be placed into a chart. Two other inmate records were requested repeatedly but were never able to be located for review. The difficulties in organizing and locating medical records places inmates requiring health services at a significant risk since the clinical staff will not always have prior information available at the time of their encounters. Potential risks can include prescribing medications for which the inmate has an allergy, duplications of laboratory and x-ray studies, potential drug toxicities because serum blood level reports may not be available for clinical review, potential trials of medications that have been documented as ineffective in the past, etc.

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RECOMMENDATIONS: Unchanged from the prior reports. Failure to maintain comprehensive

and accurate medical records is a major deficiency that hampers provision of adequate medical

services and should be addressed with great priority.

1. There is a need to draft a more detailed medical record policy. 2. The Monitor’s staff should be utilized as resources to facilitate development of the policy
and procedure. 3. One chart per inmate, combining medical and mental health documentation for an
integrated record. 4. It is recommended that the mental health professional immediately file her notes in the
medical record so they are available for the psychiatrist to review. 5. A policy needs to be developed with documentation guidelines and instructions for
organizing and maintaining the medical record. 6. Quality improvement effort should be undertaken to track compliance with policy once
implemented.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for the policies.

RECOMMENDATIONS: See letter (c) findings and recommendations.

MENTAL HEALTH FINDINGS: The processes of ensuring that mental health receives sick call requests in a timely manner require significant improvement. Multiple examples of delays in delivery of these triaged documents from nursing to mental health were noted at the time of this site visit. Once these records were received by the mental health coordinator, inmates were seen in an extremely prompt manner with rapid referral to the psychiatrist when indicated. This will be commented on further in this report.

RECOMMENDATIONS: Similar to those of the September 2013 report as follows:

1. A confidential process needs to be established that enables:  monitoring of the timeliness of retrieval of sick call requests  appropriate triaging by a registered nurse or mental health professional (in the case of mental health requests)  timeliness of response by the appropriate qualified health professional  appropriateness and effectiveness of the treatment plan generated.

f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;

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ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Although there is tracking of sick call, the program is in the process of developing a scheduled offsite service log and an unscheduled offsite service log as well as an intake processing log. We reviewed with the staff the fields to be created for each of these logs, which should be clearly described in their respective policies.

RECOMMENDATIONS:

1. Develop these policies with reference to the elements that are required to be tracked for each of the above referenced services.
2. Utilize the resources of the monitor to assist in developing these materials.

MENTAL HEALTH FINDINGS: There has been no change in the mental health caseload tracking form.

RECOMMENDATIONS:

1. The current log should be maintained in a sortable format such as a Word table or Excel worksheet for ease of maintenance of an accurate record.

2. Health services may consider developing an intake log that records the inmates name, number, date a sick call request or behavioral referral are received, the date the request was triaged, the date it is received by the service responsible to respond (medical, dental, mental health), the date the issue has been resolved and the initials of the responding staff person. Such a log would assist in the quality assurance efforts when studying timeliness and access to care.

3. It is also recommended that the date of the last mental health and psychiatric visit as well as housing location, and the follow-up date be entered. This will enable quick assessment as to whether someone has accidentally fallen off the schedule and whether they are in a special housing unit.

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This section addresses the medical chronic and acute care program. We observed delays in both initiating chronic care enrollment and in receipt of medications. We also found medication continuity disruption attributable to inconsistent physician presence at the facility. Due to inconsistencies of physician presence this program has regressed. Patients with chronic problems are not adequately or timely monitored and treated. Medications are continued without assessments. With regard to acute care guidelines, policies and procedures do not exist for assessing and treating acute medical events.

RECOMMENDATIONS:

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1. Ensure adequate Medical Director and advanced level provider hours onsite.

2. Ensure appropriate assessments and monitoring.

3. Promulgate chronic and acute assessment and treatment guideline as indicated, train and monitor

staff in the application of those guidelines.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: unchanged since the baseline assessment as follows:

Currently, the mental health professional maintains the case list that identifies those inmates followed both on the detainee and the sentence side of the facility by the psychiatrist. The psychiatrist stated that inmates prescribed medications for a temporary problem will not be included in the caseload. The list contains the inmates name, diagnosis, medication regimen, BOC number, and date of birth. The list is lacking the date for the next psychiatric and counseling visit and should include the names of every inmate currently receiving any psychiatric medications and who is actively engaged in mental health treatment and follow up. In reviewing the medical records it is clear that people are not scheduled for follow-up as medically necessary or in a timely manner.

Patients are scheduled in chronic care mental health clinic in unpredictable and inconsistent fashions. Frequently people appear to be lost to follow-up despite a diagnosis of a serious mental illness.

It should also be noted that a couple of progress notes by the psychiatrist contain notations that an inmate was unable to be seen due to a lack of an escort officer.

THIRD REPORT March 2014: Since the time of our last visit, GGACF has hired a new psychiatrist who has diligently seen every inmate on the caseload except for two at the time of our visit. She and the mental health coordinator have formed a good working relationship and her availability to the facility exceeds that of the prior psychiatrist. I am optimistic that inmates will be seen at appropriate frequencies going forward.

RECOMMENDATIONS: Similar to those of the September 2013 report as follows:

1. Contact the Monitor and his staff for consultation and/or technical assistance. 2. A minor modification to the current case list log as recommended above would improve the
tracking capabilities of the facility. 3. The list should contain both the BOC number and the inmates’ date of birth. 4. Any inmate followed by mental health should be captured on a log, perhaps one for psychiatry
and one for counseling. 5. As mentioned previously, a policy that would dictate required time frames for follow-up of
people in the chronic care mental health clinic may improve the timeliness of return visits and allow for tracking when looking for quality outcomes. 6. All prison inmates on a mental health caseload should have at a minimum a monthly wellbeing check by a mental health professional. Minimum frequency of psychiatric visits should be outlined by policy not to exceed every 90 days. 7. The mental health caseload should be modified to track the date of the follow-up visit for easy identification of overlooked appointments and housing unit to identify those in segregation or special housing.

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f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;

ASSESSMENT: NONCOMPLIANCE

GENERAL FINDING: Review of the logbooks reveal several instances where security staff did not appropriately respond to serious injuries or life-threatening conditions by contacting medical staff (as would be appropriate). Instead, officers attempted to address seizures or prisoners with mentally acute symptoms on their own. MEDICAL FINDINGS: Although an emergency policy was drafted, its focus was exclusively on disaster planning. Although this is an important part of emergency policy, it does not address the operational needs and guidance needed for urgent onsite care issues as well as problems that require the services of an offsite institution. We worked with the HCUA to describe the elements needed in this policy. The problems with accessing a Medical Director have continued and the current person has resigned. We did participate in an interview for a replacement Medical Director. We clearly hope this recruitment is successful.

We reviewed four records of patients for whom emergent services were required. A consistent pattern was identified with regard to an absence of emergency room reports. In addition, some of the patients were never followed up onsite after returning from the emergency room.

The first patient is a male in his 20s who has been in the facility for two and a half years. On 6/28/13, he presented with shortness of breath. There were no vital signs done, he has never been referred to an asthma chronic care program. He was sent to the emergency room and after he returned, there was no follow up onsite. There is also no emergency room report.

The second case is male in his 30s with no chronic problems. He was sent out to the emergency room because he demonstrated uncontrolled vomiting. He was seen in the emergency room and then returned, where he was seen by the nurse who wrote a note requesting approval to provide Gatorade. There is also no emergency room report or physician follow up.

The third case is male. He has type 2 diabetes and was sent out on 2/24/14 since he stopped eating and taking insulin. This is a very difficult patient who has been intermittently cooperative with his treatment plan. This patient is still in the hospital after more than two weeks.

The fourth case is male in his 20s with a seizure disorder who was sent to the emergency room on 2/15/14 and returned. There is no emergency room note, no note at the time he returned and no monitoring of his ingestion of the anticonvulsant.

We did discuss the requirements that an emergency room report always be retrieved and the Health Care Administrator assign someone to do this. It is also necessary that when patients return from offsite health care services, they are brought back through a nurse who can talk with the patient and receive the paperwork and where indicated perform vital signs. Also, when that paper work is available, the person assigned to obtaining it can schedule a follow up visit with a primary care clinician. These elements should be found in the urgent/emergent policy and included in that policy

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should be that during the clinician follow up visit, a discussion with the patient of the findings and

plan is documented. Ultimately, your quality improvement program should be monitoring this entire

process.

RECOMMENDATIONS:

1. Complete the urgent/emergent policy with the above referenced elements. 2. The person assigned to obtain emergency room reports should be providing reports with regard
to the success or difficulties in obtaining them. 3. The emergency care policy should include requirements for training and certification in basic
life support and first aid as well as the documentation of critiques of quarterly emergency drills. 4. Nurses should be trained that when patients return from unscheduled offsite services, they should document a note that describes the patient’s condition and a set of vital signs and insure that the appropriate paperwork is available. 5. The QI program can begin monitoring these elements of the service.

MENTAL HEALTH FINDINGS: Similar to those of the September 2013 report as follows:

The island hospital has closed their psychiatric unit. When patients have acute situations that cannot be managed within the facility they can be sent to the emergency room. That department can maintain the individual for up to 48 hours while attempting to medicate them for stabilization. Once the patient is compliant with medications they are returned to GGACC. If needed they are placed in isolation until they are able to take their medications, eat, and follow commands. If necessary, the facility will have to locate an off-island psychiatric hospital.

The facility is currently not staffed adequately and designed physically to accept and monitor acutely ill persons with a mental illness once the emergency room releases them after 48 hours if they remain acutely ill.

THIRD REPORT March 2014: Structural modifications are currently underway to create a medical observation area in the treatment building. The mental health staff is optimistic that the space may also be used to accommodate inmates in need of intensive psychiatric monitoring or suicidal ideation. Inmates continue to remain in the housing units on a variety of safety watches or in a completely empty cell in the intake area both without adequate mental health supervision. These issues will be discussed in greater detail under section I.i.

One detainee, diagnosis schizophrenia and diabetes was booked into the facility on December 8, 2013 with a positive intake screening for a serious illness, use of medications, a history of diabetes, mental health treatment and depression. The officer noted that the detainee would talk to himself and appeared to be "delusional". He was seen the next day by medical who did speak with the mental health coordinator and she referred the inmate to see the psychiatrist. However, he was released on December 10, 2013. The inmate was booked again December 23, 2013 and refused to sign or answer any items on the officer’s intake screening. The nurse documented on that date that he planned to contact the psychiatrist for orders. The psychiatrist, on December 24, ordered Haldol decanoate 150 mg intramuscularly and Haldol 10 mg by mouth daily with a notation that it was okay if the inmate refused medication until he was seen by the psychiatrist. Medications were ordered for the inmate’s delusional behavior. By December 25 the inmate was

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transported emergently by the psychiatrist to the hospital for stabilization as he was “in imminent

danger of getting seriously hurt at this facility". This case does demonstrate the use of a local

hospital to manage acutely mentally ill inmates beyond the capability of the facility. However, it

also documents the lack of immediate face-to-face evaluations of inmates reported to be acutely

mentally ill, use of medications prior to a face-to-face evaluation, and raises the question, "Could

this third booking have been avoided had his mental illness been adequately addressed by the jail

and the community at the time of his initial arrest?"

RECOMMENDATIONS:

1. Consider opportunities to improve coordination between GGACF staff and community case managers when dealing with these complex cases.

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We reviewed eight cases of patients referred for specialty care. The biggest problems identified were the follow up upon return, which includes the availability of the offsite services report. Occasionally there were delays, but frequently these were due to lack of custody.

The first patient is female with hypertension and gynecologic problems. On 1/14/14, she was referred to the gyne clinic and this was scheduled for 2/13. The visit was cancelled due to lack of custody staff availability and could not be rescheduled until the month of March.

The second case is female with hypertension. On 1/6/14, there was an order for a gyne clinic and this was to be the same day as the previous patient, 2/13. This patient was also cancelled due to lack of custody and she will be seen in March.

The third case, a male who suffered a possible fracture of a finger, which was x-rayed on 1/27/14. The x-ray report was not reviewed until almost a month later, 2/22/14, and there has been no follow up visit with the patient.

The fourth case female with migraines and asthma. On 10/3/13, there was an order for a gyne clinic visit. On 10/13, the patient was found to have an abnormal Pap smear. There was a repeat Pap smear done in February of 2014 and the results were normal, but there has been no follow up with the patient to explain what was found and what needs to be done in the future.

RECOMMENDATIONS:

1. The Health Care Administrator has appointed a scheduled and unscheduled offsite service coordinator who will be responsible for scheduling the initial visits, retrieving the documents and scheduling any follow up visits with the primary care clinicians. This is very encouraging. This should be written into both the scheduled offsite services policy and the unscheduled offsite services policy.
2. For both services, when patients return they should be returned through a nurse who can inform the coordinator whether the reports are available and also who can see the patients and write a note as to the condition of the patients.

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3. This scheduled offsite service program should be monitored for both timeliness of obtaining of

service, timeliness of obtaining reports and timeliness of follow up encounters with the primary

care clinician.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: This has been discussed under number v.

RECOMMENDATIONS: See number v.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Without a Medical Director in place it is impossible to develop a guideline for the management of intoxication and detoxification, in addition to the appropriate policies and procedures that flow from the guidelines. The revised intake-screening tool does address the issues of substance use and potential withdrawal or intoxication issues. We look forward to working with a Medical Director on developing approaches to both alcohol, opiates and benzodiazepines that include both monitoring performed by nursing staff as well as treatment.

RECOMMENDATIONS:

1. Obtain an involved Medical Director who we can work with to develop the guidelines, policies and procedures for this issue.
2. When this happens, contact the monitor staff for technical assistance.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

Mr. Massey, the Substance Abuse counselor reported that GGACF has no detoxification program and that people are detoxifying while housed in a cell in the booking area.

h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

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ASSESSMENT: NONCOMPLIANCE

In view of the fact that there is only one full-time registered nurse, it is understandable that they have not yet developed an organized infection control program. In the vast majority of facilities, a registered nurse, although sometimes a licensed practical nurse, is assigned this responsibility. The intake screen includes a TB skin test, which currently appears to be done, although there is a problem documenting the results in the medical record. It tends to be exclusively documented in a notebook which contains all of the test results. There is a space on the newly developed screening form which should be utilized in addition to the notebook. Review of the logbooks show instances where positive TB test results were noted by security staff , yet no particular actions were recorded that indicated that the prisoner was quarantined or otherwise segregated.

RECOMMENDATION:

1. Work through the monitor and his staff for consultation and/or technical assistance with regard to the key elements in an appropriate infection control program which includes not only screening for tuberculosis but also tracking of skin infections as well as instruction to inmates and officers regarding how to clean up after body fluid spills.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

i. Adequate suicide prevention, including:

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: GGACF Mental Health did not report placing anyone on suicide watch this last quarter. However, the security logs demonstrated an inmate placed on observation without his possessions for attempting to cut himself and being suicidal. Mental health was not notified and this was not called a suicide watch.

THIRD REPORT March 2014: Security log books continue to demonstrate placement of inmates on safety watches for behavioral health problems including suicidal and self-injurious behavior without notification and oversight by medical and mental health professionals. The mental health service was only aware of one inmate who placed on a mental health watch (by the mental health coordinator) although officer log books indicate other inmates were restricted since our last tour. It should also be pointed out that those instances can only be identified by examining every page in every unit’s log book.

Despite Defendants’ claim that they implemented a new suicide policy in February 2014, this instance demonstrates lack of compliance with the new policy’s requirements pertaining to security as follows:

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Section G.2. “The suicide watch and\or immobilizing restraint log shall be completed on

all offenders placed on suicide watch by the correctional officer."

It is important to note, however, that proper implementation of new policies must follow the requirements of Settlement Agreement IX.3.

Even when appropriate behavioral referrals are issued there are significant delays in the actual notification of the mental health staff. For example, on February 21, 2014 there appears to be a reference in the security log that an inmate was placed on watch and the behavioral checklist was generated that same day. However, this critical document was not received by the mental health professional until March 3, 2014 which represents an unacceptable delay in notification. Inspection of the actual referral form does not indicate the date received by medical, only mental health, and therefore; the conclusion cannot be drawn regarding where the delay occurred. However, most of the delays seen are due to the lack of reliable transfer of referrals and sick call requests by nursing staff to the mental health coordinator. This conclusion was supported by a focused review, while on site, of intake screenings on detainees. Additional observations of other documents now dated when issued by the officer and received by the nurse, demonstrated an obvious delay in the receipt of the referral by mental health. The mental health professional did make appropriate and timely arrangements once she received the referrals.

RECOMMENDATIONS:

1. GGACF needs to develop a communication system that is timely and reliable for notification regarding inmates placed on suicide watch, behavioral referral requests, and intake referrals.
2. Medical Services needs to develop a reliable system to ensure that the mental health clinicians receive referrals in a timely manner. Sufficient training needs to be provided to all staff when new policies are developed and implemented.

(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: THIRD REPORT March 2014: While on site in March 2014 the monitoring team received a copy of a draft policy and procedure on suicide assessment and intervention and observation protocol revised January 2014 and effective February 2014. This policy calls for (B.2.) an offender being placed on continuous observation until appropriate medical, mental health or supervisory assistance is obtained.

Security log books entries beginning December 13, 2013 continue to document haphazard security checks even when the mental health service provided the warden with a memo instructing 15 minute checks for suicide watch on a particular inmate. Documentation of any watches occurred hours apart. Even when an officer clearly documented in the logbook that the mental health professional had called and stated and the inmate must be checked on every 15 minutes the next documented officer check occurred 45 minutes later. When notations are made they usually simply state a check was made and provide no descriptive material regarding the inmate’s condition or behavior.

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RECOMMENDATIONS: An assessment of noncompliance remains in place because, although a draft policy now exists, it clearly has not been adequately implemented. Until a qualified mental health professional assesses the inmate they should be placed on suicide precaution under direct observation and then the necessary level of observation recommended by the mental health professional should be implemented per the new policy and procedure.

1. Quality assurance measures need to be implemented to ensure that all components of the new policy are effectively carried out.
2. Evidence of adequate training of staff should be provided to the monitoring team when new policies are implemented.
3. In the future, all policy drafts should be distributed electronically to the monitoring team and the parties for review prior to acceptance and implementation. The current suicide prevention policy includes provisions that are not possible given the current structural constraints of the facility and the lack of 24 hour daily staffing patterns for health services. Observation status requirements of correctional officers are too infrequent compared to the customary requirements which impose a 30 minute rounds as opposed to the "not less than every hour" requirement in this policy. The policy also requires that the mental health counselor will observe the offender every shift which is not feasible given the staffing pattern of GGACF. The nature of this policy is such that the facility will perpetually be out of compliance with its own policy. This needs to be amended.
4. Please distribute any current mental health policies to the Monitor and USDOJ attorneys in an electronics format.
(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: A standardized and validated risk assessment form has not yet been developed by the mental health service. Currently inmates referred for assessment received a face-to-face interview with a mental health professional. The advantage of a standardized form is that it allows for all components of suicide risk to be identified and for the professional to indicate the level of risk based on their professional opinion, be it low, moderate, or high.

RECOMMENDATIONS:

1. An after hour protocol should be considered as well to allow for notification of mental health staff by the next morning. This is a requirement of the new policy in section H.1. But no 24-hour emergency mental health plan was presented to the monitors at the time of the March site visit.
2. It is suggested that the service develop a standardized suicide assessment progress note that would include a suicide risk assessment and a suicide watch treatment plan.

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(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: As indicated in the Monitor’s previously discussed review, there is a lack of cut-down tools throughout the facility. Additionally, and as reported by the Monitor, some staff are not aware of the location of existing tools, tools are commonly reported as missing on the Officer’s Log, and emergency drill training in the use of these tools is not regularly conducted.

THIRD REPORT March 2014: The Monitor found cut down tools in most housing units toured during this assessment; however, the A Dorm officer stated there was no cut-down tool for that unit and was not able to produce one. Many officers interviewed stated that they were not trained in the use of the tool or have participated in any emergency drills using the tools. Officers interviewed report that they have a basic understanding about how to use these tools but are not routinely assessed in demonstrating proficiency with the tools.

Recommendations provided in the previous report remain appropriate.

RECOMMENDATIONS:

1. Cut down tools should be available in all housing areas, and areas where inmates could have an opportunity to harm themselves i.e. kitchen, medical building, etc.
2. All staff required to use this tool should be well trained and emergency drills demonstrating proficient use of the tool should be conducted on a regular basis.
3. Supervisors should regularly inventory and audit tool location and make immediate provisions to replace missing or non-functioning tools when found.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

SECOND REPORT December 2013: During both site visits, September and December 2013, the training officer was unavailable and no one had access to her files. No proof of in-service training or disaster drills have been made available to the monitoring team.

THIRD REPORT March 2014: No training records verifying the existence of a qualified suicide prevention training program or whether staff have completed a qualified suicide prevention training program. A qualified suicide prevention training program should include, at a minimum, the following guidelines for revising suicide prevention protocols according to the National Center on Institutions and Alternatives.1

1 http://www.ncianet.org/services/suicide-prevention-in-custody/publications/guide-to-developing-and-revisingsuicide-prevention-protocols-within-jails-and-prisons/

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Staff Training

The essential component to any suicide prevention program is properly trained staff, who form the backbone of any correctional facility. Very few suicides are actually prevented by mental health, medical or other professional staff because suicides are usually attempted in housing units, and often during late evening hours or on weekends when they are generally outside the purview of program staff. These incidents, therefore, must be thwarted by correctional staff who have been trained in suicide prevention and have developed an intuitive sense about suicidal inmates. Correctional staff are often the only personnel available 24 hours a day; thus, they form the front line of defense in preventing suicides.

All correctional, medical, and mental health personnel, as well as any staff who have regular contact with inmates, should receive eight (8) hours of initial suicide prevention training, followed by two (2) hours of refresher training each year. The initial training should include administrator/staff attitudes about suicide and how negative attitudes impede suicide prevention efforts, guiding principles to suicide prevention, inmate suicide research, why the environments of correctional facilities are conducive to suicidal behavior, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, identifying suicidal inmates despite the denial of risk, components of the facility’s suicide prevention policy, and liability issues associated with inmate suicide. The two-hour refresher training should include a review of administrator/staff attitudes about suicide and how negative attitudes impede suicide prevention efforts, predisposing risk factors, warning signs and symptoms, identifying suicidal inmates despite the denial of risk, and review of any changes to the facility’s suicide prevention plan. The annual training should also include general discussion of any recent suicides and/or suicide attempts in the facility. In addition, all staff who have routine contact with inmates should receive standard first aid and cardiopulmonary resuscitation (CPR) training. All staff should also be trained in the use of various emergency equipment located in each housing unit. In an effort to ensure an efficient emergency response to suicide attempts, “mock drills” should be incorporated into both initial and refresher training for all staff.

Identification/Referral/Evaluation

Intake screening and on-going assessment of all inmates is critical to a correctional facility’s suicide prevention efforts. It should not be viewed as a single event, but as an on-going process because inmates can become suicidal at any point during their confinement, including the initial admission into the facility; after adjudication when the inmate is returned to the facility from court; following receipt of bad news or after suffering any type of humiliation or rejection; confinement in isolation or segregation; and following prolonged a stay in the facility. In addition, although there is no single set of risk factors that mental health and medical communities agree can be used to predict suicide, there is little disagreement about the value of screening and assessment in preventing suicide. Research consistently reports that approximately two-thirds of all suicide victims communicate their intent some time before death, and that any individual with a history of one or more suicide attempts is at a much greater risk for suicide than those who have never made an attempt.

Intake screening for suicide risk may be contained within the medical screening form or as a separate form. The screening process should include inquiry regarding: past suicidal ideation and/or

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attempts; current ideation, threat, plan; prior mental health treatment/hospitalization; recent

significant loss (job, relationship, death of family member/close friend, etc.); history of suicidal

behavior by family member/close friend; suicide risk during prior confinement; and

arresting/transporting officer(s) belief that the inmate is currently at risk. Specifically, inquiry

should determine the following:

 Was the inmate a medical, mental health or suicide risk during any prior contact and/or confinement within this facility?
 Does the arresting and/or transporting officer have any information (e.g., from observed behavior, documentation from sending agency or facility, conversation with family member) that indicates inmate is a medical, mental health or suicide risk now?
 Have you ever attempted suicide?
 Have you ever considered suicide?
 Are you now or have you ever been treated for mental health or emotional problems?
 Have you recently experienced a significant loss (relationship, death of family member/close friend, job, etc.)?
 Has a family member/close friend ever attempted or committed suicide?
 Do you feel there is nothing to look forward to in the immediate future (expressing helplessness and/or hopelessness)?
 Are you thinking of hurting and/or killing yourself?
Although an inmate’s verbal responses during the intake screening process are critically important to assessing the risk of suicide, staff should not exclusively rely on an inmate’s denial that they are suicidal and/or have a history of mental illness and suicidal behavior, particularly when their behavior and/or actions or even previous confinement in the facility suggest otherwise. The process should also include referral procedures to mental health and/or medical personnel for a more thorough and complete assessment.

The intake screening process should be viewed as similar to taking your temperature, it can identify a current fever, but not a future cold. Therefore, following the intake screening process, should any staff hear an inmate verbalize a desire or intent to commit suicide, observe an inmate engaging in any self-harm, or otherwise believe an inmate is at risk for suicide, a procedure should be in place that requires staff to take immediate action to ensure that the individual is constantly observed until appropriate medical, mental health, and/or supervisory assistance is obtained. Finally, given the strong association between inmate suicide and isolation/special management (e.g., disciplinary and/or administrative segregation) housing unit placement, any inmate assigned to such a special housing unit should receive a written assessment for suicide risk by medical or mental health staff upon admission to the placement.

The screening and assessment process is only one of several tools that increases the opportunity to identify suicide risk in inmates. This process, coupled with staff training, will only be successful if an effective method of communication is in place at the facility.

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Communication

Certain behavioral signs exhibited by the inmate may be indicative of suicidal behavior and, if detected and communicated to others, can reduce the likelihood of suicide. In addition, most suicides can be prevented by correctional staff who establish trust and rapport with inmates, gather pertinent information, and take action. There are essentially three levels of communication in preventing inmate suicides: between the arresting/transporting officer and correctional staff; between and among facility staff (including correctional, medical and mental health personnel); and between facility staff and the suicidal inmate.

In many ways, suicide prevention begins at the point of arrest. At Level 1, what an arrestee says and how they behave during arrest, transport to the facility, and at intake are crucial in detecting suicidal behavior. The scene of arrest is often the most volatile and emotional time for the individual. Arresting officers should pay close attention to the arrestee during this time; suicidal behavior may be manifested by the anxiety or hopelessness of the situation, and previous behavior can be confirmed by onlookers such as family members and friends. Any pertinent information regarding the arrestee’s well-being must be communicated by the arresting or transporting officer to correctional staff. It is also critically important for correctional staff to maintain open lines of communication with family members who often have pertinent information regarding the mental health status of inmates.

At Level 2, effective management of suicidal inmates is based on communication among correctional personnel and other professional staff in the facility. Because inmates can become suicidal at any point during confinement, correctional staff must maintain awareness, share information and make appropriate referrals to mental health and medical staff. At a minimum, the facility’s shift supervisor should ensure that appropriate correctional staff are properly informed of the status of each inmate placed on suicide precautions. The shift supervisor should also be responsible for briefing the incoming shift supervisor regarding the status of all inmates on suicide precautions. Multidisciplinary team meetings (to include correctional, medical and mental health personnel) should occur on a regular basis to discuss the status of inmates on suicide precautions. Finally, the authorization for suicide precautions, any changes in suicide precautions, and observation of inmates placed on precautions should be documented on designated forms and distributed to appropriate staff.

At Level 3, facility staff must use various communication skills with the suicidal inmate, including active listening, staying with the inmate if they suspect immediate danger, and maintaining contact through conversation, eye contact, and body language. Correctional staff should trust their own judgment and observation of risk behavior, and avoid being misled by others (including mental health staff) into ignoring signs of suicidal behavior. Poor communication between and among correctional, medical, and mental health personnel, as well as outside entities (e.g., arresting or referral agencies, family members) is a common factor found in the reviews of many custodial suicides. Communication problems are often caused by lack of respect, personality conflicts and boundary issues. Simply stated, facilities that maintain a multidisciplinary approach avoid preventable suicides.

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Housing

In determining the most appropriate housing location for a suicidal inmates, correctional facility officials (with concurrence from medical and/or mental health staff) often tend to physically isolate (or segregate) and sometimes restrain the individual. These responses might be more convenient for all staff, but they are detrimental to the inmate since the use of isolation escalates the sense of alienation and further removes the individual from proper staff supervision. To every extent possible, suicidal inmates should be housed in the general population, mental health unit, or medical infirmary, located close to staff. Further, removal of an inmate’s clothing (excluding belts and shoelaces) and the use of physical restraints (e.g., restraint chairs or boards, leather straps, handcuffs, and straitjackets) should be avoided whenever possible, and used only as a last resort when the inmate is physically engaging in self-destructive behavior. Housing assignments should be based on the ability to maximize staff interaction with the inmate, not on decisions that heighten depersonalizing aspects of confinement.

All cells designated to house suicidal inmates should be as suicide-resistant as is reasonably possible, free of all obvious protrusions, and provide full visibility. These cells should contain tamper-proof light fixtures, smoke detectors and ceiling/wall air vents that are protrusion-free. In addition, the cells should not contain any live electrical switches or outlets, bunks with open bottoms, any type of clothing hook, towel racks on desks and sinks, radiator vents, or any other object that provides an easy anchoring device for hanging. Each cell door should contain a heavy gauge Lexan (or equivalent grade) clear panel that is large enough to allow staff a full and unobstructed view of the cell interior. Finally, each housing unit in the facility should contain various emergency equipment, including a first aid kit, pocket mask or face shield, Ambu-bag, and rescue tool (to quickly cut through fibrous material). Correctional staff should ensure that such equipment is in working order on a daily basis.

Levels of Observation/Management

In regard to suicide attempts in correctional facilities, the promptness of the response is often driven by the level of supervision afforded the inmate. Medical evidence suggests that brain damage from strangulation caused by a suicide attempt can occur within 4 minutes, and death often within 5 to 6 minutes. Two levels of supervision are generally recommended for suicidal inmates: close observation and constant observation.

Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation (e.g., expressing a wish to die without a specific threat or plan) and/or has a recent prior history of self-destructive behavior. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. Staff should observe such an inmate in a protrusion-free cell at staggered intervals not to exceed every 10 minutes (e.g., 5, 10, 7 minutes).

Constant Observation is reserved for the inmate who is actively suicidal, either threatening or engaging in suicidal behavior. Staff should observe such an inmate on a continuous, uninterrupted basis. In some jurisdictions, an intermediate level of supervision is utilized with observation at staggered intervals that do not exceed every 5 minutes.

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Other aids (e.g., closed-circuit television, cell mates) can be used as a supplement to, but never as a substitute for, these observation levels.

In addition, mental health staff should assess and interact with (not just observe) the suicidal inmate on a daily basis. The daily assessment should focus on the current behavior, as well as changes in thoughts and behavior during the past 24 hours (e.g., “What are your current feelings and thoughts?” “Have your feelings and thoughts changed over the past 24 hours?” “What are some of the things you have done or can do to change these thought and feelings?,” etc.)

An individualized treatment plan (to include follow-up services) should be developed for each inmate on suicide precautions. The plan should be developed by qualified mental health staff in conjunction with not only the inmate, but medical and correctional personnel. The treatment plan should describe signs, symptoms, and the circumstances under which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the inmate and staff will take if suicidal ideation reoccurs.

Finally, due to the strong correlation between suicide and prior suicidal behavior, in order to safeguard the continuity of care for suicidal inmates, all inmates discharged from suicide precautions should remain on mental health caseloads and receive regularly scheduled follow-up assessments by mental health personnel until their release from custody. Although there is not any nationally-acceptable schedule for follow-up, a suggested assessment schedule following discharge from suicide precautions might be: 24 hours, 72 hours, 1 week, and periodically until release from custody.
Intervention

Following a suicide attempt, the degree and promptness of the staff’s intervention often foretells whether the victim will survive. National correctional standards and practices generally acknowledge that a facility’s policy regarding intervention should be threefold. First, all staff who come into contact with the inmate should be trained in standard first aid procedures and CPR. Second, any staff member who discovers an inmate engaging in self-harm should immediately survey the scene to assess the severity of the emergency, alert other staff to call for medical personnel if necessary, and begin standard first aid and/or CPR as necessary. If facility policy prohibits an officer from entering a cell without backup support, the first responding officer should, at a minimum, make the proper notification for backup support and medical personnel, secure the area outside the cell, and retrieve the housing unit’s emergency response bag (that should include a first aid kit, pocket mask or face shield, Ambu-bag, and rescue tool). Third, correctional staff should never presume that the victim is dead, but rather should initiate and continue appropriate life-saving measures until relieved by arriving medical personnel. In addition, medical personnel should ensure that all equipment utilized in responding to an emergency within the facility is in working order on a daily basis.

Finally, although not all suicide attempts require emergency medical intervention, all suicide attempts should result in immediate intervention and assessment by mental health staff.

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Reporting

In the event of a suicide attempt or suicide, all appropriate officials should be notified through the chain of command. Following the incident, the victim’s family should be immediately notified, as well as appropriate outside authorities. All staff who came into contact with the victim before the incident should be required to submit a statement including their full knowledge of the inmate and incident.

Follow-Up/Mortality-Morbidity Review

An inmate suicide is extremely stressful for both staff and other inmates. Staff may also feel ostracized by fellow personnel and administration officials. Following a suicide, misplaced guilt is sometimes displayed by a correctional officer who wonders: “What if I had made my cell check earlier?” Inmates are often traumatized by critical events occurring within a facility. Such trauma may lead to suicide contagion. When crises occur in which staff and inmates are affected by the traumatic event, they should be offered immediate assistance. One form of assistance is Critical Incident Stress Debriefing (CISD). A CISD team, comprised of professionals trained in crisis intervention and traumatic stress awareness (e.g., police officers, paramedics, fire fighters, clergy, and mental health personnel), provides affected staff and inmates an opportunity to process their feelings about the incident, develop an understanding of critical stress symptoms, and seek ways of dealing with those symptoms. For maximum effectiveness, the CISD process or other appropriate support services should occur within 24 to 72 hours of the critical incident.

Every completed suicide, as well as serious suicide attempt (i.e., requiring medical treatment and/or hospitalization), should be examined through a mortality-morbidity review process. If resources permit, clinical review through a psychological autopsy is also recommended. Ideally, the mortality-morbidity review should be coordinated by an outside agency to ensure impartiality. The review, separate and apart from other formal investigations that may be required to determine the cause of death, should include a critical inquiry of: 1) the circumstances surrounding the incident; 2) facility procedures relevant to the incident; 3) all relevant training received by involved staff; 4) pertinent medical and mental health services/reports involving the victim; 5) possible precipitating factors leading to the suicide or serious suicide attempt; and 6) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures.

RECOMMENDATIONS:

1) Develop and implement scenario-based suicide prevention, response, and recovery training program that requires application of policy and procedure, and that topic competence is proven by both written test and demonstration by staff. Adequate initial and annual trainings should be documented and maintained.

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: During both site visits,

September and December 2013, the training officer was unavailable and no one had access to her

files. No proof of in-service training has been made available to the monitoring team.

THIRD REPORT March 2014: Refer to Provision (v) above.

RECOMMENDATIONS:

1. Immediately develop and implement comprehensive pre and in-service suicide prevention training that is 1) evidence based, 2) policy and procedure driven, 3) includes valid and reliable knowledge and application competency evaluation methods. Such training would naturally include detection, recognition, assessment, and intervention topics and materials.
2. Implement policies, procedures, and protocols that govern and control staff response regarding inmate behavioral and/or verbal indications of suicide risk. Governing documents must require initial and ongoing involvement of medical and mental health staff in the response to suicide prevention actions.
3. Suicide prevention is considered a life safety issue that requires, at minimum, quarterly suicide prevention drills involving correctional, medical, and mental health staff to ensure 1) training and response efficacy, 2) effectiveness of policy and procedure, and 3) compliance with the Agreement.

(vii) availability of suicide resistant cells;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: There are no suicide resistant (safety) cells at GGACF. This was further verified in consultation with the Monitor.

THIRD REPORT March 2014: Security escorted an inmate to see mental health on December 6, 2013 and the correctional officer stated that he placed the inmate on a suicide watch after the inmate stated to the officer, "I don't want to live anymore." There is no way of knowing what property the inmate continued to have in his possession. The counselor evaluated the inmate and spoke with the psychiatrist and he was released back to his cell. Mental health did place a phone call to the correctional officer to follow-up regarding the inmate the next day but should have performed a face to face review. The inmate was seen four days later by the psychiatrist to whom he stated he was not suicidal. Three days later a behavioral checklist was appropriately initiated when he expressed feelings of wanting to kill himself and was crying. He was seen that same day by the mental health coordinator who placed him on a 24 hour suicide watch and ordered documentation every 15 minutes concerning his condition. As noted previously the 15 minute watches were not documented in any reliable format. The inmate was reevaluated two days later by the psychiatrist who discontinued the suicide watch.

Pertinent to this section, the inmate was moved to a cell in the intake area of the facility. This room had been observed during our baseline visit and was noted to be a completely empty concrete cell with a drain in the floor. Mental health staff related to the reviewer that inmates on suicide watch do not receive mattresses, suicide resistant blankets or garments. Rather, this inmate was on suicide watch with only his undershorts.

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RECOMMENDATIONS:

1. Appropriate bedding, clothing, food and utensils, property, and pallet should be specified by the mental health clinician were supervising officer placing an inmate on suicide watch.
2. Retrofit cells designated suicide precautions to be suicide proof. 3. Renovation of an intake cell may be the only immediate alternative. If this environment is
utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates. 4. Appropriate bedding, clothing, food and utensils, property, and pallet should be specified by the mental health clinician were supervising officer placing an inmate on suicide watch. 5. The following guidelines should be considered when establishing suicide-resistant housing environments:2

The safe housing of suicidal inmates is an important component to a correctional facility’s comprehensive suicide prevention policy. Although impossible to create a “suicide-proof” cell environment within any correctional facility, given the fact that almost all inmate suicides occur by hanging, it is certainly reasonable to ensure that all cells utilized to house potentially suicidal inmates are free of all obvious protrusions. And while it is more common for ligatures to be affixed to air vents and window bars (or grates), all cell fixtures should be scrutinized, since bed frames/holes, shelves with clothing hooks, sprinkler heads, door hinge/knobs, towel racks, water faucet lips, and light fixtures have been used as anchoring devices in hanging attempts. As such, to ensure that inmates placed on suicide precautions are housed in “suicide-resistant” cells, facility officials are strongly encouraged to address the following architectural and environmental issues:

1. Cell doors should have large-vision panels of Lexan (or low-abrasion polycarbonate) to allow for unobstructed view of the entire cell interior at all times. These windows should never be covered (even for reasons of privacy, discipline, etc.) If door sliders are not used, door interiors should not have handles/knobs; rather they should have recessed door pulls. Any door containing a food pass should be closed and locked. Interior door hinges should bevel down so as not to permit being used as an anchoring device. Door frames should be rounded and smooth on the top edges. The frame should be grouted into the wall with as little edge exposed as possible.

In older, antiquated facilities with cell fronts, walls and/or cell doors made of steel bars, Lexan paneling (or low-abrasion polycarbonate) or security screening (that has holes that are ideally 1/8 inches wide and no more than 3/16 inches wide or 16-mesh per square inch) should be installed from the interior of the cell. Solid cell fronts must be modified to include large-vision Lexan panels or security screens with small mesh;

2. Vents, ducts, grilles, and light fixtures should be protrusion-free and covered with screening that has holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16mesh per square inch;

2 http://www.ncianet.org/services/suicide-prevention-in-custody/publications/checklist-for-the-suicide-resistantdesign-of-correctional-facilities/

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3. Wall-mounted corded telephones should not be placed inside cells. Telephone cords of

varying length have been utilized in hanging attempts;

4. Cells should not contain any clothing hooks. The traditional, pull-down or collapsible hook can be easily jammed and/or its side supports utilized as an anchor;

5. A stainless steel combo toilet-sink (with concealed plumbing and outside control valve) should be used. The fixture should not contain an anti-squirt slit, toothbrush holder, toilet paper rod, and/or towel bar;

6. Beds should ideally be either heavy molded plastic or solid concrete slab with rounded edges, totally enclosed underneath. If metal bunks are utilized, they should be bolted flush to the wall with the frame constructed to prevent its use as an anchoring device. Bunk holes should be covered; ladders should be removed. (Traditional metal beds with holes in the bottom, not built flush to the wall and open underneath, have often been used to attach suicide nooses. Lying flat on the floor, the inmate attaches the noose from above, runs it under his neck, turns over on his stomach and asphyxiates himself within minutes.);

7. Electricity should be turned off from wall outlets outside of the cell;

8. Light fixtures should be recessed into the ceiling and tamper-proof. Some fixtures can be securely anchored into ceiling or wall corners when remodeling prohibits recessed lighting. All fixtures should be caulked or grouted with tamper-resistant security grade caulking or grout. Ample light for reading (at least 20 foot-candles at desk level) should be provided. Low-wattage night light bulbs should be used (except in special, high-risk housing units where sufficient lighting 24 hours per day should be provided to allow closed-circuit television (CCTV) cameras to identify movements and forms). An alternative is to install an infrared filter over the ceiling light to produce total darkness, allowing inmates to sleep at night. Various cameras are then able to have total observation as if it were daylight. This filter should be used only at night because sensitivity can otherwise develop and produce aftereffects;

9. CCTV monitoring does not prevent a suicide, it only identifies a suicide attempt in progress. If utilized, CCTV monitoring should only supplement the physical observation by staff. The camera should obviously be enclosed in a box that is tamper-proof and does not contain anchoring points. It should be placed in a high corner location of the cell and all edges around the housing should be caulked or grouted. Cells containing CCTV monitoring should be painted in pastel colors to allow for better visibility. To reduce camera glare and provide a contrast in monitoring, the headers above cell doors should be painted black or some other dark color. CCTV cameras should provide a clear and unobstructed view of the entire cell interior, including all four corners of the room. Camera lens should have the capacity for both night and low light level vision;

10. Cells should have a smoke detector mounted flush in the ceiling, with an audible alarm at the control desk. Some cells have a security screening mesh to protect the smoke detector from vandalism. The protective coverings should be high enough to be outside the reach of an inmate and far enough away from the toilet so that the fixture could not be used as a

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ladder to access the smoke detector and screen. Ceiling height for new construction should

be 10 feet to make such a reasonable accommodation. Existing facilities with lower ceilings

should carefully select the protective device to make sure it cannot be tampered with, or

have mesh openings large enough to thread a noose through. Water sprinkler heads should

not be exposed. Some have protective cones; others are flush with the ceiling and drop down

when set off; some are the breakaway type;

11. Cells should have an audio monitoring intercom for listening to calls of distress (only as a supplement to physical observation by staff). While the inmate is on suicide precautions, intercoms should be turned up high (as hanging victims can often be heard to be gurgling, gasping for air, their body hitting the wall/floor, etc.);

12. Cells utilized for suicide precautions should be located as close as possible to a control desk to allow for additional audio and visual monitoring;

13. If modesty walls or shields are utilized, they should have triangular, rounded or sloping tops to prevent anchoring. The walls should allow visibility of both the head and feet;

14. Some inmates hang themselves under desks, benches, tables or stools/pull-out seats. Potential suicide-resistant remedies are: (a) Extending the bed slab for use as a seat; (b) Cylinder-shaped concrete seat anchored to floor, with rounded edges; (c) Triangular corner desk top anchored to the two walls; and (d) Rectangular desk top, with triangular end plates, anchored to the wall. Towel racks should also be removed from any desk area;

15. All shelf tops and exposed hinges should have solid, triangular end-plates which preclude a ligature being applied;

16. Cells should have security windows with an outside view. The ability to identify time of day via sunlight helps re-establish perception and natural thinking, while minimizing disorientation. If cell windows contain security bars that are not completely flush with window panel (thus allowing a gap between the glass and bar for use as an anchoring device), they should be covered with Lexan (or low-abrasion polycarbonate) paneling to prevent access to the bars, or the gap, should be closed with caulking, glazing tape, etc. If window screening or grating is used, covering should have holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16-mesh per square inch;

17. The mattress should be fire retardant and not produce toxic smoke. The seam should be tearresistant so that it cannot be used as a ligature;
18. Given the fact that the risk of self-harm utilizing a laundry bag string outweighs its usefulness for holding dirty clothes off the floor, laundry bag strings should be removed from the cell;

19. Mirrors should be of brushed, polished metal, attached with tamper-proof screws;

20. Padding of cell walls is prohibited in many states. Check with your fire marshal. If permitted, padded walls must be of fire-retardant materials that are not combustible and do not produce toxic gasses; and,

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21. Ceiling and wall joints should be sealed with neoprene rubber gasket or sealed with

tamper-resistant security grade caulking or grout for preventing the attachment of an

anchoring device through the joints.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: The facility needs to develop, train to, and implement a policy for suicide prevention. In addition, there does not appear to be any system by which security implements and maintains an adequate watch.

THIRD REPORT March 2014: This provision has been included in the current draft policy but no situations where constant observation has been ordered occurred and could therefore, not be reviewed to monitor compliance with the policy.

RECOMMENDATIONS:

1. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15 minute watches.
2. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
3. Renovation of an intake cell may be the only immediate alternative. If this environment is utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.
4. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15 minute watches.

(ix) procedures to assure implementation of directives from a mental health professional regarding: (1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: There have been no improvements regarding suicide prevention. Security does initiate Behavioral Referrals but these are not always responded to by Health Services/Mental Health Services as promptly as is necessary. It is unclear if the delay is due to delayed arrival of the referral to the clinic, a shortage of security staff to escort the inmate, a shortage of mental health staff, or all of the above plus other obstacles the facility may be aware of.

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The provision of adequate suicide prevention and programming remains a grave concern as

evidenced by the case reviewed during this visit which fails to meet all nine of the above

requirements. Fortunately, no harm befell this individual.

Security places people on lockdown status for self-injurious behavior without notifying mental health services. As a result there is absolutely no mental health review of the inmate. The decision to remove the person from watch is made by security not a psychiatrist or a mental health professional in consultation with a psychiatrist. Grossly inadequate levels of observation are documented in the security logs during the time this person was on lockdown. Therefore, when medical informs the auditing team that there have been no instances of suicide watch in the facility their data and reports are unintentionally inaccurate.

THIRD REPORT March 2014: despite the draft suicide prevention policy, the requirements of this provision 1-3 have not been implemented in practice.

RECOMMENDATIONS: 1. The facility needs a policy that reflects the current capabilities and provides the greatest
amount of supervision required to safely monitor someone on suicide watch. 2. It is recommended that the facility develop a form listing each level of observation that would
also specify what property the inmate is allowed to have in their possession as well as indicating which staff member has ordered the watch and property restrictions. Consultation with the monitoring team may be a useful assistance. 3. The facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates if they continue to be housed in the reception area. 4. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch. 5. Renovation of an intake cell may be the only immediate alternative. 6. If this environment is utilized then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.

j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

MEDICAL FINDINGS: We have discussed in detail with the Territory that a Medical Director on call 365 days a year and onsite at least three days a week, Monday through Friday along with the two weekend days coverage by a PA is sufficient primary care coverage. We also have indicated that a total of four RN positions is also necessary, both for intake and sick call as well as eventually to cover the observation or infirmary area. The use of at least three licensed practical nurses to complete medication administration as well as assisting the advanced level clinicians is also required. Finally, it is our recommendation that a health information technician be provided to manage the medical records. With these elements in place, there will be extremely rapid progress.

RECOMMENDATIONS:

1. Provide a staffing document to the monitor along with the duties assigned to each staff member. 2. Complete the hiring of those positions already budgeted, which should certainly address most
if not all of the nursing needs.

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3. Bring on to the program a Medical Director who will provide three days onsite Monday through

Friday as well as 365 day a year on call coverage.

4. Bring on board a health information technician position.

5. Address the medical records component.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: No staffing analysis was presented to the monitor. Mental health staffing levels remain unchanged from the time of our last visit. Delays in follow-up care are frequently related to the lack of escort officers; however, if security staff was increased it is unlikely that the current mental health staff hours would be sufficient to meet the needs of the facility, particularly if sufficient services were provided to the seriously mentally ill inmates.

THIRD REPORT March 2014: As of the current time there has been no staffing analysis or development of what programs and services the facility will strive to implement.

1. RECOMMEDATIONS: Refer to the Monitor’s assessment, findings and recommendations pertaining to staffing analysis recommendations. Provide the staffing document to the Monitor along with the duties assigned to each staff member.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE

GENERAL FINDINGS: Review of unit logbooks reveals serious deficiencies in security staff’s ability to identify, refer, and supervise prisoners with serious medical and mental health needs.

MEDICAL FINDINGS: We were informed and the records demonstrated that lack of availability of officers compromises the availability of both onsite and offsite services.

RECOMMENDATIONS:

1. There should be a permanent medical transport post of at least one and possibly two officers.
2. In addition, there should be an officer assigned to assist nurses who are performing medication administration and at least one officer onsite in the medical clinic area.
3. All of these posts should be mandatory. 4. There should also be a medical van assigned to primarily provide medical transports offsite. 5. Leadership should complete and implement a comprehensive staffing analysis without
delay. 6. All correctional officers and supervisors must be adequately trained as required in this
provision before being assigned oversight of inmate housing units or duties involving contact with inmates.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Clearly, the consistent availability of offsite officers as well as a transport van has interfered with the ability to provide

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follow up ordered lab and x-ray services. In addition, we are aware of access onsite that was either

delayed or unavailable due to officer staffing.

THIRD REPORT March 2014: Based on observations and staff reporting there remains inadequate correctional officer staffing to ensure that all scheduled appointments occur and that there is the capacity for inmates with urgent issues to also be escorted to the clinic. In addition there can be no growth in the capacity to deliver clinical services until sufficient security staffing is available to support those measures.

RECOMMENDATIONS:

1. Develop staffing policies and procedures that reflect facility and population needs. 2. Develop staffing documents that allow for accurate and timely tracking of staffing levels, shift
and duty assignments, work locations, and shortages. 3. Prepare for performing a comprehensive staffing analysis to determine require staffing levels
using NIC Net Annual Work Hour methodology. 4. Ensure staff members are properly trained in all aspects of their respective duty assignments
working with special needs and mentally ill inmates. 5. Provide Monitor with accurate, complete, and up-to-date staffing schedules as described
above.

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Until the policies and procedures have been finalized and implemented, there cannot be an effective, organized quality improvement program. This also requires an actively involved Medical Director to lead the professional performance review aspects of the program. Once the policies are finalized, the procedures will dictate what specific duties both nursing and clinician staff must perform. These elements can then be monitored by the quality improvement program. The creation of logs for intake processing, sick call, scheduled offsite services and unscheduled offsite services, will facilitate this review and monitoring.

RECOMMENDATIONS:

1. Obtain the Medical Director to work with the Health Care Unit Administrator and Chief Nurse to implement the policies and procedures such that performance can be monitored and improved.
2. Work with the monitor and his staff, who can provide technical assistance.

MENTAL HEALTH FINDINGS: March 2014: Health services did not provide the monitoring team with proof of an implemented quality improvement program. Once a medical director can be hired that person and the psychiatrist and dentist, in conjunction with the health services administrator in charge nurse, may begin to develop an agenda and the underpinnings of the quality management program.

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Until the policies and procedures have been implemented, it is difficult for an organized quality

improvement program to effectively monitor for either process performance or professional

performance. Until an actively involved Medical Director is in place, the professional performance

aspects will not be addressed, certainly with regard to the clinicians. There is a chief nurse, but

until there is clarity with regard to the expectations of the nursing staff performance, there cannot

be accountability expected.

RECOMMENDATIONS:

1. Complete development, training, and implementation of required medical, mental health, and suicide prevention policies
2. Include in each policy core measures, metrics, and methods for continuous quality improvement of these governing documents.
3. As the policies and procedures are finalized, staff are trained and the policies implemented, begin the monitoring of process performance with regard to intake, health assessments, TB screening, sick call, unscheduled onsite and offsite services, scheduled onsite and offsite services as well as chronic disease management and medication management.
4. Work with the monitor and his staff, who can provide technical assistance.

m. Adequate dental care;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We did have the opportunity to interview both the dentist and the dental assistant. We were told that the dentist is available on Wednesdays from 2:30 to 5:30; however, because of custody issues, including lockdown and the absence of out-counting, his time with patients is limited to between 3:30 and possibly 5:00. It is important that for the entire three hour period custody staff arranges for patients to be available. This can be accomplished by out-counting or if necessary changing meal times. We were aware that the medical assistant does some oral screening in the clinic and does sterilization of instruments. We were not able to review the records regarding sterilization and the biologic controls. We look forward to reviewing the remaining issues in the program for our next visit.

RECOMMENDATION:

1. The dental program should track the number of extractions and restorations performed each month and we will be able to review that data upon return.
2. Develop adequate dental care policies, procedures, and protocols.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report.

RECOMMENDATIONS: defer to Dr. Shansky’s report.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

ASSESSMENT: NONCOMPLIANCE

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MEDICAL FINDINGS: There was one death in October of 2013 and we did have the opportunity to review the record. There has been no site review or discussion of this case. During the record review of a male in his 60s with HIV disease and hepatitis C. In August 2012, the records showed that he had a CD4 count of 261 and his viral load was undetectable. This puts him in reasonable shape and certainly not suggestive of being near death. We learned that he was followed by the Department of Health HIV program; however, notes from the Department of Health clinic are not available. Also there were no recent laboratory notes in the record. On 8/17/13, he began complaining of musculoskeletal and digestive problems and he had stopped eating. On 8/22, he was found with red spots on his body and he was not breathing normally and he was sent to the hospital, where he stayed until his death two months later on 10/28/13. We do know that before he was sent out, the Department of Health clinic recommended that he be put on an antibiotic as prophylaxis, which is normally done when a patient’s CD4 count drops below 200. This suggests that he may have been developing resistance to the medicines he was taking. If that was the case, the regimen might have been changed to medications to which his body was not resistant. In any event, it is clear that when any patients are followed in a Department of Health clinic either for HIV or hepatitis C or for OB/GYN, the records of their encounters in the offsite clinic must be made available so that appropriate follow up can be conducted onsite.

RECOMMENDATIONS:

1. Obtain the Medical Director position in place. 2. Arrange for clinic encounters to be made available at the prison for patients seen for
infectious diseases or gynecologic problems or any other problems. 3. Consider utilizing the services of an offsite clinician to perform a death review on all deaths
of patients incarcerated in the Department of Corrections.

MENTAL HEALTH FINDINGS: There have been no deaths or significant morbidity reported for the mental health caseload since the time of our last visit.

RECOMMENDATIONS: defer to Dr. Shansky's report

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We are still awaiting the drafting of the segregation round policy. It would make sense for both nursing and mental health to share this responsibility.

RECOMMENDATION:

1. Draft the policy and procedure for segregation rounds for our review.

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Similar to the baseline assessment as follows:

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We saw no policy on this. We would strongly encourage drafting the policy based on

NCCHC standards utilizing the compliance indicators and discussion sections. Both the

prisoners and mental health staff reported that no mental health isolation/segregation

rounds are conducted at the facility.

THIRD REPORT March 2014: There continue to be no mental health rounds in segregation (Inmates on both the sentenced and detainee units directly reported that there are not medical rounds occurring either). The nursing function on this unit appears to be strictly limited to passing medications.

A striking example of why rounds are an essential process is demonstrated by the report that only a few days before our site visit the psychiatrist was requested to see an inmate who has been maintained in isolation for 10 years. This reviewer also had the opportunity to interview this man while on site. He clearly suffers from a serious and chronic psychotic illness with paranoid delusions. The monitor also reviewed his administrative record which demonstrated a history of repeated assaults on officers. His mental condition has never been treated while incarcerated at this facility. He has persisted in isolation with no awareness by the mental health staff of his presence in segregation and there has been, up until the very present time, no assessment as to whether this is an appropriate placement. In addition, there have been no attempts by security to develop accommodations that would enable trials in a less restrictive environment after years in isolation.

RECOMMENDATIONS: Similar to the baseline assessment as follows: It is recommended that:

1. A policy be developed that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA.
2. Medical and mental health segregation rounds be implemented following national guidelines.
3. Staff training regarding what are critical questions in areas to review during medical and mental health rounds on the segregation unit.
4. The facility will need to provide adequate security staffing and access in order for the medical staff to conduct the appropriate rounds and treatment services.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Mental health staff provide no structured out of cell therapeutic programming for seriously mentally ill inmates in administrative segregation or the special needs housing unit adjacent to segregation. In general, it is recommended that the former, should they require a residential level of care, receive at least 10 hours per week of unstructured out of cell time and 10 hours of structured out of cell encounters per week (individual or group therapy) driven by their individual treatment needs. Those requiring only outpatient care should have more than five hours per week of unstructured

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out of cell time and increased private contact with a counselor and a psychiatrist while housed in

isolation.

Findings also remain the same as the baseline assessment as follows:

No policy and procedure exists addressing a review process for mental health and medical clearance of inmates with serious mental illness being placed in isolation. There are no policies regulating the amount of out-of-cell time provided to special needs prisoners in segregation. Mental health staff does not perform segregation rounds.

THIRD REPORT March 2014: Staff reported that inmates on the mental health caseload are not screened prior to placement in segregation. In addition, the mental health staff is not notified of this placement until they see the patient at the time of his\her next appointment. There is no enhanced mental health programming offered to mentally ill inmates housed in segregation units.

The Monitor, an experienced licensed mental health clinician, observed inmates presenting symptoms of serious mental illness in segregation units having conditions that amount to an isolation environment. Many of these inmates were locked in their cells for most of the day. Many of the cells were very dark with virtual no social interaction other than inmates yelling. These conditions, as reported by the Monitor, and this expert agrees, can seriously exacerbate mental health symptoms and adversely impair mental health recovery.

RECOMMENDATIONS:

1. This Provision mandates a strict prohibition on placing in isolation environment ANY inmate having or suspected of having a serious mental illness. Policies and procedures must articulate this mandate and be monitored by supervisors and mental health staff for compliance.

2. It is recommended that a detailed policy be developed to address this issue that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA.

3. The facility should develop an outline for therapeutic residential level of treatment on these units, identify the staffing needs and coordinate with security to effectively initiated enhanced treatment designed to stabilize and improve inmate function with the goal of possibly moving some of these men into general population and an outpatient level of care.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As reported in the Second Report, there remains no formalized process by which a qualified mental health provider performs a pre-segregation assessment to determine whether the person is at risk of self-injury if placed in isolation and is at risk of an intensification of their mental illness if placed in isolation. Mental health also has no formalized

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process to determine if there are mitigating factors that would lessen or eliminate the disciplinary

sanction.

Similar to the baseline assessment as follows:

There is no policy or procedure requiring participation of mental health staff in the disciplinary process and as a result there currently is no input.

Regarding placement in segregated environments, it is unclear whether a medical and mental health clearance is done for such a housing assignment. We were also told in a meeting with the Health Services Administrator and Medical Director that medical sees everyone when there has been a use of force, and if severe enough, after hours the inmate will go to the emergency department. The medical department has to rely on the security emergency department log to determine if anyone has been taken to the hospital.

RECOMMENDATIONS: Similar to the baseline assessment as follows:

1. A policy and procedure should be established to allow for an assessment by mental health of incidents potentially resulting in disciplinary sanctions in those inmates on the mental health caseload.
2. Input into the disciplinary process should be written and periodically monitored through a quality improvement process to determine if the disciplinary officer is collaborating with mental health staff in adjusting their sanctions when there are mitigating circumstances secondary to the person's illness.
3. Currently, there is no retrospective of use of force as part of the medical quality improvement process but such a process should be put in place.
4. Hire additional qualified mental health professional to ensure consistent and reliable involvement in this process.

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;
ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: The potential examination rooms in the housing units have still not been reestablished as appropriate examination rooms. This would require cleaning, the provision of both a table and chairs, as well as an exam table and appropriate medical equipment. Supplies to insure sanitation should also be made available. We also looked at the space that is to be remodeled but no one has yet seen the official architectural plans even though some construction is occurring.

RECOMMENDATIONS:
1. Reestablish clinically appropriate examination rooms in each of the housing units. 2. During our next visit, provide us with the architectural drawings for the new health care unit
renovation.

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MENTAL HEALTH FINDINGS: There has been no change as reported in the previous

assessment. The physical plant regarding the delivery of mental health services has not altered

since our last visit. We did observe some confidential log material displayed in a manner that

would have been readily visible to inmates being treated within that office space. The staff

member was informed that this was a poor practice and immediately removed the materials.

Currently the Mental Health Coordinator is conducting 1 group therapy in an office that would not comfortably hold more than 4 inmates. The physical limitations, in addition to the shortage of escort officers and mental health staff, severely limit any additional programming opportunities at this time. No adequate programming space exists in or near the special needs unit or segregation for the programming of the seriously mentally ill inmates in these housing units. There is a small satellite medical clinic space that could be used for individual mental health encounters on the segregation pod.

Both the Mental Health Coordinator and the psychiatrist see patients in the medical clinic in sound private settings. There are no private interviewing spaces on the segregation units or in the female housing units, which may create barriers to access since the entire compound would need to be shut down to enable movement of these persons.

RECOMMENDATIONS:

1. The facility needs to explore what barriers may exist to providing frequent and adequate services to inmates in special housing in sound private settings.
2. Send the Monitor the plans as soon as a draft has been developed.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: December 2013: During this visit we again found examples of inmates with delayed or absent psychiatric follow-up.

THIRD REPORT March 2014: New mental health medical record forms have been developed including a treatment plan form. Copies of these were provided during this visit. I did review these forms with the psychiatrist and recommended revision since these forms are better suited for an inpatient hospitalization than a detention/prison facility. It is too soon to be able to monitor the implementation of these components. The new facility psychiatrist employed as of a week and a half ago) is enthusiastic, knowledgeable and energetic. She is establishing relationships with the inmates currently on the caseload and will be a valuable asset to the health team.

RECOMMENDATIONS:

1. Continue to monitor the plans to implement the new forms, modifications to the tracking case list including housing area, past visit and date of return to clinic.
2. Consider developing quality improvement process to monitor outcomes from data collected via the treatment forms.

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(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Similar to the baseline assessment as follows:

Currently there are no programs in mental health for prisoners with serious mental illnesses. The only services currently provided are occasional contacts with the Mental Health Coordinator and often infrequent visits with the psychiatrist with lapses between visits of up to a year.

As mentioned earlier the Mental Health Coordinator has begun one general population group with four or five inmates. There is no mental health programming for segregated or special needs inmates.

While on site I also had the opportunity to meet with Mr. Massey who educated me regarding the substance abuse programming available at the facility. In the past there had been a residential treatment program but this no longer exists. Currently they have a 90 day outpatient program. He provides programming on a voluntary basis. He has an elders program for inmates over the age of 57 who can act as mentors. There are currently eight men in this category that he supervises and meets with them weekly. Each coordinator receives 160 hours of training from him. Approximately 2 years ago the substance abuse program was dismantled and Mr. Massey was laid off from his full-time position. He was hired back part time. Mr. Massey reported that GGACF has no detoxification program and that people are detoxifying while housed in a cell in the booking area. Recruiting inmates to participate in substance abuse programming has been difficult. He reported the units all have crack cocaine, marijuana, cocaine, and alcohol illicitly available to inmates most of whom are unwilling to consider being substance free. In 2013 he has received a total of 10 referrals of dual diagnosed inmates from the mental health service.

THIRD REPORT March 2014: The mental health coordinator continues to offer one structured group activity per week with between five and six attendees. During the month of February 50% of those groups were canceled due to the lack of an escort officer. Ten inmates and detainees are also receiving individual counseling therapy as needed.

The current psychiatric case lists include 16 inmates and 18 detainees. Dr. Sang is committed to ensuring that inmates are seen within the necessary and appropriate clinical time frames. There are no structured program services offered to segregated inmates other than psychiatric visits which may be monthly or quarterly and 1:1 counseling encounters. Currently there were five identified inmates in the prison segregation unit who have a serious mental illness (as prohibited by V.p as discussed above). Only one of those inmates is currently being seen in the mental health coordinator’s weekly group. The others received no programming. Mentally ill inmates in segregation do not receive any additional out of cell time or, as a rule, increased mental health contact compared to the segregation and general populations.

No needs analysis has been performed yet.

RECOMMENDATIONS: Unchanged from the Baseline Assessment as follows:

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1. GGACF Mental Health Department should conduct a needs analysis and make

recommendations to the Health Services Administrator, Medical Director, and Bureau of

Corrections regarding required staff and other resources necessary to provide adequate

services in both general population and segregated areas.

2. Comparable programming should be provided for female inmates and detainees as well.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Unchanged since the Baseline Assessment based on chart review.

GGACC lacks sufficient psychiatry hours (although we were not provided with the staffing schedule, it appears that GGACC has fewer than eight hours per week of psychiatric time) to perform comprehensive initial psychiatric assessments and chronic care follow-ups at clinically necessary frequencies.

There was a surprising underrepresentation of the treatment of mood disorders on the caseload and women.

A continued finding of dependence on long acting injectable neuroleptics rather than oral agents seems a variance from customary practice. This may be a clinical choice designed to increase medication compliance.

There is no policy that addresses the use of emergency and involuntary medication.

THIRD REPORT March 2014: Thus far there is little change from our previous visits. Dr. Sang has begun to make modifications in the medication treatment regimens but it is too soon to monitor the end results. One of the new forms may provide some indication that inmates are informed of medication risks and benefits.

RECOMMENDATIONS:

1. A reasonable informed consent form should be developed and patient education documented. 2. A policy addressing the use of emergency and involuntary medication should be developed. 3. Improved methods of practice and a staffing and programs analysis needs to be completed. 4. GGACCF may wish to consider adding telepsychiatry to increase the availability of
psychiatric resources by contracting with psychiatrists on the mainland who obtain licenses in the USVI. Of course, the latter would require capital investment in equipment and the development of a policy and procedures that would structure this type of service. 5. A reasonable informed consent form should be developed and patient education documented. 6. A policy addressing the use of emergency and involuntary medication should be developed.

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

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ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS SECOND REPORT December 2013: As mentioned previously, the training officer has not been available during our two site visits and no one else has access to her training records. Therefore there is no ability for the monitoring team to make any determinations regarding a level of compliance with this requirement. In addition case #9, indicates that security staff including supervisory level staff have little awareness and or training in the suicide prevention policy. This is demonstrated by security placing an inmate who was self-injurious on lockdown, failing to notify medical services and mental health services of that status, and failing to implement and document the watch requirements of the policy. In addition, security staff terminated the watch without any review by mental health.

THIRD REPORT March 2014: Based on chart review, it is evident that adequate training is not yet in place when new policies are implemented.

RECOMMENDATIONS:

1. GGACF should ensure the training officer or her records are available at the time of the next site visit for review by the monitoring team.
2. Develop, implement, and evaluate comprehensive training curricula to comply with Provision.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: SECOND REPORT December 2013: Unchanged from the Baseline Assessment as follows:
Currently, seriously mentally ill inmates are housed in segregation and by policy may be placed there until their conditions are stabilized. However, the decreased capacity for observation, lack of availability of potable water in their cells, hot conditions with poor ventilation, absence of mental health rounds, absence of any structured therapeutic programming places these individuals at risk for serious life threatening physical illness and behavioral decompensation.

THIRD REPORT March 2014: February 25 2014 GGACF relocated some inmates identified as mentally ill (previously housed in the unit next to long-term segregation) or vulnerable to an older housing unit, A unit. This transition is a positive step in attempting to create a physically more pleasant environment with greater potential for enhanced treatment services; however, the process by which this transition occurred indicates a lack of communication and coordination between the Bureau, security leadership, and health services. It is our understanding that Security requested a copy of the mental health caseload several weeks in advance of the move but no other information was communicated to the mental health team. Neither the psychiatrist nor the mental health coordinator was aware of a plan to re-locate inmates until they arrived at work the following Monday after the transition had been completed. Logbook entries reveal that the unit was unstaffed overnight after the inmates arrived. In addition, little has yet been done to alleviate

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placement of mentally impaired inmates in segregation who may be in that placement because of

their untreated or partially treated serious mental illness.

Inspection of A unit revealed a capacity of 22 inmates with a current census of 10. On entering the unit there is a small officer’s station separated from the housing area by a solid door that has only a small window which does not enable visualization of the housing area by the officer. Plus, this opening currently is ¾’s sealed over by cardboard to keep the officer’s station air-conditioned and is therefore useless as a security measure. Hazardous conditions exist in the housing areas. Many cells have shoelaces or wire knotted to the metal mash or door which the inmates and officer use as door handles. One positive compared to their prior housing circumstance, is the availability of air circulation and sunlight on this unit.

One man was sleeping on a totally shredded mattress which can no longer can be sanitized properly. Clotheslines were observed hanging in several cells. The dayroom area has a long strip of fabric from the padlock through a window in an external door. An easily reached electrical conduit is affixed to the wall that could secure a ligature. Cigarette butts were observed on the floor of the day room. Indeed, one man repeatedly sets fires in his cell despite this being a smoke free facility. There are stout metal grates above every cell which are open mesh where a ligature could be secured. When the inmates are in their cells or in the recreation area there is absolutely no visibility from the officer’s station making this a dangerous environment for inmates and especially mentally ill inmates who may become aggressive or suicidal. Inmates in this unit are currently receiving no structured therapeutic activities.

We also walked to and inspected RSAT unit which currently houses detainees who cannot mingle with the other inmates in detention. This classification of inmate has been housed here for the last 3 to 4 years thereby eliminating the residential substance-abuse treatment program which was initially housed here. The officer who observes the inmates on A Unit also monitors inmates in this housing unit. Thus, when the officer is on one unit the inmates on the other unit have absolutely no security supervision. When we arrived at RSAT Unit there was no officer on the unit. An office is being renovated there. The door was unsecured and there were bundles of plastic coated electrical wires on the floor and readily available to the inmates. Inmates interviewed on this unit stated they were locked down in the evening after 6 or 7 PM. They were only able to recall security doing rounds on the unit 1 to 2 times a week between lockdown and 7 AM. An inmate on this unit easily became highly agitated and verbally threatening towards the mental health coordinator when speaking with the U.S. Department of Justice attorneys. Given his level of agitation, it seems particularly unsafe for him to be housed on a unit with this little supervision. It was also brought to our attention that the facility has been on a modified lockdown since December as a security measure due to both increased inmate violence and officer sick call. 2 to 3 weeks prior to our visit we were told that an inmate was stabbed in the face. Only a few skilled inmates are allowed out to staff the kitchen or perform essential grounds activities.

The clearest example of the failure to comply with this element of the settlement agreement is the example detailed above of a mentally ill inmate who has been housed in isolation for 10 years unbeknownst to the mental health treatment team. Comprehensive assessment has begun, by the psychiatrist, with the hopes of determining whether this man can be stepped off of segregation into less restrictive housing.

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Both segregation units were inspected and both had the odor of marijuana smoke. Both units

were filthy, small expanded metal grates block openings in the door too small to make

observation of the inmate adequate. These grates often were blocked from the inside with

cardboard and other makeshift materials. The grates were covered with accumulated dust.

Inmates controlled the lighting from inside their cells also hampering security observation. Most

cells were further obscured by sheets hanging from the ceilings creating multiple layers of visual

privacy from the officers. Considering that most suicides occur in segregation units, the presence

of so much contraband and layers of concealment in these housing units is concerning. It is also

unclear how inmates can continue to smoke openly in units manned by officers 24 hours per day.

RECOMMENDATIONS:

1. GGACF should develop a plan to introduce adequate programming for this population. 2. Increased out-of-cell-time and life skills activities should be considered. 3. It is also recommended that all inmates with a serious mental illness should be seen in a
confidential setting at a minimum of at least monthly by a psychiatrist and also monthly by a mental health counselor. 4. Weekly mental health rounds are also required for this population to identify mentally ill inmates housed in segregation who have not been referred for mental health services by sick call request or by officer referral. 5. GGACF is a facility that demonstrates fragmented communication and lack of inclusion at the table of critical professional staff when designing and attempting to implement new housing areas and programming. This seems to be a pervasive difficulty at all levels. Even when looking at the organizational chart for health services division, it is clear that the health services administrator does not have centralized authority for the management of the health services department. Rather, all functions and employees are placed beneath the medical director. This structure is problematic in several regards. a. Effectively, there has been no medical director at this facility. Staff reported that Dr.
Williams Hendricks is rarely, if ever, on site. b. Having the medical director be responsible for all personnel activities and administrative
decisions for the service is a highly cost ineffective structure. The medical director should be responsible for the quality improvement program, policy and procedure development, and management and supervision of the clinical staff. c. The health services administrator should be responsible, at a minimum, for all personnel decisions not based on clinical performance and interface with the facility administration regularly. This would include the authority to dismiss personnel based on repetitive absenteeism, inability to follow facility policies, inappropriate behavior with inmates were staff, etc. In addition, they should oversee compliance with policy and procedure, supervise medical records, oversee pharmaceutical, equipment, and supplies availability and ordering. A directors (Medical, Nursing, Pharmacy, Dental, Mental Health) should administratively report to the HSA. 6. These units need to be sanitized, wire grates should be replaced or removed since many are torn and have ragged metal edges. Sheets and other impediments to inmate observation should be removed.

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VI. FIRE AND LIFE SAFETY

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:

a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate. Although the Fire Marshall is involved in fire safety program planning and inspections, the fire safety program lacks the following minimum elements:

 Policies and procedures  An adequate fire suppression system for occupied buildings  An adequate, policy-driven and competency-based training policies, procedures or
curriculum  Quarterly fire drills for all staff  Multiple and easily accessible fire escape doors and pathways  Fire response breathing apparatus for officers

The lack of an adequate fire safety program is particularly troubling considering reported fire incidents. Housing unit logs examined for this reporting period found approximately 18 entries related to arson or fire related events, some duplicate entries. This is an extremely dangerous condition considering the fact that inmates continue to cause fires in their cells and housing units, are allowed to possess cigarette lighters and electrical devices with damaged electrical wires, and maintain high quantities of combustible items.

RECOMMENDATIONS:

1. Develop, train, implement, and evaluate a comprehensive life-fire safety program that includes all policy, procedure, resources, equipment, training, monitoring, and system/programming testing components.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install SCBAs or an appropriate alternatives at all locations where staff would need to
search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities.

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6. Officials must continue to critically review staffing levels to ensure adequate inmate

supervision and flammable contraband control in the housing units, fire detection,

response, suppression, evacuation, and incident security.

7. Additional part-time fire safety officers should be selected from the officer corps,

trained, and participate in the administration of a comprehensive fire safety program. It

is unrealistic to expect one expert to develop and oversee such a complex program.

8. Supervisors should conduct routine, schedule and unscheduled physical inspections of

occupied structures taking particular note of fire risks and hazards, document and report

those findings to administration for timely and appropriate corrective action.

9. The fire inspection program must be clearly detailed in fire safety policies and

procedures, and become a fundamental element of pre-and in-service training.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, cell and housing unit sprinklers are non-functional and regularly used by inmates to support personal clotheslines.

An adequate supply of hand-held fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures.

RECOMMENDATIONS:

1. Refer to recommendations above (a). 2. Consider purchasing fire safety program software from NFPA and/or the American
Correctional Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above. Train
and drill staff as discussed on system use.

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3. Develop emergency key and locking mechanism inspection and reporting system as

discussed above.

4. Implement competency-based staff training as discussed above.

5. Exercise fire safety program using onsite, scenario-based drills; include community

responders in exercise planning and exercise events.

6. Send the training officer and part-time fire safety officers to the National Fire Institute,

National Emergency Training Center, Emmetsburg, MD for additional training.

d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell;
and; (ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline visit, previous recommendations remain appropriate. During this inspection, as previously described some of the Housing Unit locks were found non-functional.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems.

e. Testing of all staff regarding fire and life safety procedures;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision.

f. Reporting and notification of fires, including audible fire alarms;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visit, previous recommendations remain appropriate. The fire reporting and notification system remains operable.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision.

g. Evacuation of prisoners threatened with harm resulting from a fire;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate. There remains no functional fire suppression system in the Housing Units other than fire extinguishers. This system must be made fully operational, regularly tested and maintained.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders. 3. Ensure that the fire suppression system is fully operational, regularly tested, and
maintained.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 5. Qualified medical staff should participate in the development of fire program training topic that involved burns and smoke inhalation concerns. Qualified mental health staff

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should participate in the development of training related to critical incident recovery

and emotional injury and recovery.

j. Control of highly flammable materials.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Inmates continue to be allowed to possess large quantities of combustible products in their cells. Although some of these items might be acceptable in a facility having adequate fire detection, response, and suppression systems and programming, GGACF conditions should not allow inmates to maintain large quantities of these items in their cells.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. Develop a formal writing “Combustion Control and Prevention Plan” component to the comprehensive fire safety program that includes regular and documented inspections and removal of combustible materials (solids, liquids, gases) from all areas and structures. Maintain a current inventory and tracking report of materials and locations, corrective actions and mitigation efforts.

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VII. ENVIRONMENTAL HEALTH AND SAFETY

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

GENERAL COMMENT: Policies and procedures required under this Provision have not been provided to the Monitor or USDOJ for review and approval. However, it is important to note positive efforts made by the Territory to improve certain environmental conditions that were observed during this assessment.

In general, the housing units and most of the cells appeared cleaner; inmates and staff reported a “major effort” to steam clean housing areas. Notwithstanding other environmental improvement required in the kitchen area (broken tiles, deep cleaning of floors; equipment; vent hoods, etc.), the kitchen looked much cleaner and the tool/utensil cage was locked. Most of the housing units previously reported in need of repair were repaired, some with fresh paint. Efforts were made to provide hot water in the housing units but the water felt just above room temperature to the touch but may simply require thermostat changes. A review of the maintenance logs evidence timely inspection of generators, Greece-traps, and some lock repairs. These findings show positive effort to develop a strategic approach to improving environmental conditions and should be expanded to all facility areas and promulgated into well written policies and procedures.

1. There is no hot water in the housing units, which creates serious health and sanitation risks for staff and inmates. Take necessary steps to ensure units are provided with sanitary hot water.
2. Many sinks in the cells were inoperable. 3. Some of the toilets did not flush properly. 4. Inmates are allowed to wash their clothes and linens in the toilets and/or sinks, then hang
them to dry on clothes lines anchored to inoperable fire sprinklers in their cells. 5. Standing water was found in housing units and cells. Inmates and staff state that housing
units will flood during heavy rains. 6. A few shower heads remain broken, some shower stalls remain covered with mold, as
were ceilings and cell-block walls. 7. Mold remains on housing unit ceilings, maintenance closets, pipe chases, recreation areas,
some areas in the kitchen. 8. Housing unit temperatures will rise in the hotter season which, combined with high
humidity can promote and spread infectious diseases, exacerbate certain chronic medical and mental illness, promote inmate frustration and violence, and dissuade correctional staff from leaving air-conditioned control rooms to conduct housing unit inspections, rounds, and security checks. High temperatures also pose very serious health risks to inmates on certain psychotropic medications current being administered to inmates. 9. Food trays being filled in the kitchen with food were still drying after being washed. Overall sanitation in the kitchen has improved some but remains in need of regular deep cleaning.

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10. Housing unit water is essentially undrinkable and inmates are unable to access water when

locked in their cells without the assistance of the housing unit officer. I was told by inmates

that there are times when officers will not respond to requests for water or are away from

control rooms for extended periods. This is evidenced by officer logs where officers have

recorded leaving their units completely unattended to take breaks and/or where no relief

officer was available. Unit logs also report a practice of “last call for water”. This practice

evidences that inmates do not have consistent access to potable drinking water.

11. Many of the inmate mattresses appeared old, tattered, and filthy but the Territory has

purchased new mattress for distribution. Inmates and staff stated that mattresses are not

routinely cleaned or disinfected during and between uses. Linens are allowed to be washed

in toilets and hung to dry as previously described.

12. There is no written formal sanitation inspection and/or infection control program.

13. The facility appears inadequately staffed to provide adequate monitoring, oversight, and

response to routine or emergency sanitation conditions or maintenance issues.

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The Monitor met with the GGACF maintenance director and reviewed revised sanitation and maintenance records. Although formal housing keeping and sanitation plans remain under development, this interview and records review indicated positive progress since the previous inspection. Formal plans should be completed and issued in the form of policies and post orders. The monitoring team was also pleasantly pleased to observe significant improvements in facility cleanliness. GGACF leadership report the implementation of a planned and coordinated facility hygiene program that included high-pressure washing of housing units, painting, kitchen deep cleaning, and making inmates more accountable for personal and cell hygiene. Additionally, it appeared that most of the broken shower plumbing was repaired and housing unit should seem much cleaner. These observations and reports show determined and positive effort by GGACF officials to comply with this provision and should be consistently monitored and maintained.

Most of the housing areas and cells were cleaner; fewer occupied cells were cluttered with empty food cartons, excessive personal items, and there was a noticeable decrease in the number of cell clotheslines as previously report. GGACF staff are commended for this progress and the effort involved to improve these conditions. This effort should be consistently maintained and include other housing and cells areas found unacceptable.

A tour of the juvenile housing area found vegetation growing through cell windows, dirty sinks, and rubbish about the floors. The one juvenile inmate being housing in this unit complained of “constant mosquitos” coming through the torn window screens and biting him “day and night.”

The RSAT unit was in similar condition as the juvenile unit. The day room appear reasonably organized but tables were filled with unattended trash bags, Ajax cleaning power, used latex gloves. A small bathroom near the officer’s stated was dirty and in need of a deep cleaning. Cells, overall, appeared reasonably organized and free of clutter but many of the sinks and

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toilets were dirty. Inmates in this unit also complained of mosquito problems due to torn

window screens. Shower areas were also dirty with some mold.

A Unit is now being used to housing inmates with serious mental illness but does is not an appropriate environment for this population. There is only one officer assigned to it and the RSAT who is unable to provide adequate supervision and monitoring of inmates in either units. A unit sanitation was poor overall. There was mold on ceilings, showers areas, some of the cell walls near the floor, missing exhaust fans, exposed electrical wires, and broken tile. The floor in the janitor’s closet was dirty with muddy water. One occupied cell had words written on the wall with what the Monitor and the unit officer believe was human feces. Another cell emitted a strong order of something burnt. Some of the cells did not have clean mattresses, one had no mattress. Overall, this unit requires deep cleaning and repair as indicated.

RECOMMENDATIONS: Correct the following, and continue the new facility hygiene program:

1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.
8. Repair all housing/cell windows to prevent penetration by insects.

b. Adequate ventilation throughout the facility;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Timely complete an air quality assessment performed by a qualified provider. Implement necessary improvements that reduce housing area temperatures and increase air flow.
2. Ensure inmates have constant access to drinkable water.

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3. Medical and mental health staff should monitor all inmates for heat and airflow-related

health risks. All inmates in segregation or who are locked in their cells should be

monitored by medical and mental health staff for signs of health conditions.

4. Train all staff in detecting and responding to health conditions related to heat and air

circulation contributors.

5. Install environmental health condition monitoring devices, e.g., temperature, humidity,

and air quality readers. Require regular monitoring and recording of readings and take

timely action to mitigate environmental conditions that create health risks caused by

those conditions.

6. Ensure that adequate amounts of drinkable water is always available to inmates.

7. Medical and mental health professionals should closely monitor inmates being

administered medications that are adversely affected by high body temperatures and

take appropriate steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The Monitor was pleased to see that all but one of the external perimeter security lights were functioning. However, many of the occupied cells remain very dark.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and
internal illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness.

d. Adequate pest control for housing units, medical units, and food storage areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: There has been no change since previous inspections. Additionally, inmates housed in RSAT and Intake units reported “constant” mosquito problems. An inspection of these cell areas found broken and missing cell window screens that should be replaced.
RECOMMENDATIONS:
1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.

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2. Ensure that inmates involved in pest control activities are properly trained, equipped,

and clothed for requirements of those activities.

3. Replace all missing and broken unit and cell window screens to prevent access by

insects.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Inspection of housing units, cells, kitchen, and medical areas show consistent presence to personal hygiene and cleaning supplies.

RECOMMENDATIONS: Continue to implement these recommendations:

1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Continue to provide adequate supply of these personal care items in control pods or
housing units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in
their cells and living areas.

This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for bio-hazard safety and exposure control; B. Written and enforced procedures and protocols for bio-hazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all bio-waste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility.

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H. Develop a bio-hazardous control program that involves regular inspections of all

potential contamination areas.

2. GGACF officials should consult an environmental specialist to assess these conditions

and assist them in developing appropriate mitigation plans and policies.

3. This provision can advance to Substantial Compliance once related policies and

procedures have been approved and implemented according to the Agreement.

g. Mattress care and replacement;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Refer to previously discussed sanitation recommendations. 2. Consider replacing all mattresses with those that are more bacteria-resistant. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and
contraband, cleaned and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance
requirements.

h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change since the Baseline or second visit, previous recommendations remain appropriate.

RECOMMENDATIONS:

1. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
2. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.
3. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: An inspection of inmate cells and inmate interviews revealed no substantive

improvement. Inmates continue to wash personal and issued clothing in sinks and toilets, and

dry these items in their cells using make-shift clotheslines anchored to fire sprinkler heads,

walls, window frames, bunks, etc. Additionally, several occupied cells revealed soiled bed

linens, no linens, tattered and dirty mattress, and mattresses with no covers. This compliance

score is move back to Noncompliance unit specific corrective action is accomplished:

1. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks.
2. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells.
3. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of bedding.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.
2. Develop specific policies and procedures for handling, containing, and washing contaminated clothing, linens, and mattresses.
3. Consider replacing all wood laundry carts made of non-absorbing materials that can be sanitized and completely cleaned. Discontinue the practice of moving laundry on carts that have not been cleaned and sanitized.
4. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing should be exchanged with clean items twice per week at minimum, sheets and towels once per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health.
5. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets.
6. Staff and inmates involved in the laundry work progress should be properly training and supervised.
7. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Inspection of kitchen areas found many of those areas much cleaner. Decomposing food particles observed during previous visits were removed, sink and floor cleanliness was improved, and food preparation tables appeared cleaner. Food storage areas appeared better organized and clean. However, food transport carts appeared dirty. Cold storage temperatures were within acceptable ranges. Water problems previously reported at the main kitchen door from the work side and reported electrical wire concerns were repaired.

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No food temperature logs were provided to the Monitor to assess food temperatures between the kitchen and distribution. Inmates interviewed report hot meats as cold by the time they receive them, unit logs report instances of missing meals. Kitchen staff remained in their office, which is located in the kitchen area, and not involved in supervising inmates. However, there was one officer actively observing the inmate workers.

The meal menu appears to provide for adequate nutritional requirements for this population. However, inmates interviewed indicated that they sometimes don’t receive medically-required special diets. The following needed improvements found during the previous inspection were similarly observed during this visit.

1. Entering the women’s bathroom, there is full container of hand sanitizer on the sink. The sink is operational but there is no hot water. The bathroom floor is filthy and requires a deep cleaning.

2. The male bathroom is in similar condition as the female bathroom and requires a deep cleaning. There is a dirty wall urinal, the light over the toilet area was not working, and there is cold water but no hot water. The frame separating the toilet areas is rotting at the base. There was toilet paper but no hand sanitizer found.

3. The kitchen has two large internal cooler/freezers; one of them is operational and one appears to be broken. The broken cooler has no external temperature gauge and appears to be used for non-food storage.

4. The working cooler has an external temperature gauge showing an appropriate temperature of about 47 degrees, and contains various properly stored food products.

5. There is a large iron cook stove here and needs to be replaced. The nearby deep fryer contains used oil. There is also a pan sitting on a cart next to it with some old oil. The second deep fryer appears to be clean and covered by a stainless steel pan.

6. To the opposite side of that group of kitchen equipment is a 12 burner cast iron stove and ovens that are currently being used. This was the oven that was reported in the Baseline Report as positioned too high for safety reasons.

7. There is also a prep area for food distribution. This is the cafeteria are where inmates come here to collect their food. This is a decent size room for distributing food from the kitchen through large food ports. There are additional food service areas nearby, as well as a fairly large stainless steel dish sink. The inmates are busy cleaning this area. There is a single fire extinguisher mounted on the wall as you enter the kitchen area with brief instructions on use that appears recently inspected.

8. In general and although cleaner, the kitchen area remains in the poor condition as it was found at the Baseline visit with broken tiles, mold, and equipment that needs to be replaced.

9. Outside of the kitchen building is another freezer with a temperature reading of 21-22 degrees, which is adequate for frozen products. It is locked and we will not enter it.

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RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with nationally recommended allowance for basic nutrition; F. Prohibitions of using food as a disciplinary measure; G. Involvement of independent outside sources to verify food service facilities and equipment meet government safety codes; H. Prescribes regular cleaning schedules including routine deep cleaning; I. Provide written utensil control methods similar to those used by the tool shop; J. Accident prevention program; K. Personal and environmental sanitation requirements; L. Food temperature monitoring and records keeping; M. Adequate health protections for all staff and inmates including health screens and prohibitions against working in the kitchen when ill; N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that all bathrooms and wash basin are consistently supplied with antibacterial soap and hot water; O. All areas and equipment related to food preparation, distribution, and storage require frequent inspection to ensure they are sanitary, operational, and safe; P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit; between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the final rinse. The person conducting inspections should be a qualified food service inspector; Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit, refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees Fahrenheit or below, unless national or state codes specify otherwise; R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit and cold foods at approximately 41 degrees Fahrenheit; S. Supervisory food service staff should monitor food service operations to ensure that that cooking, cooling, and food temperatures and delivery meet established requirements;
3. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care.
4. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented.

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5. Policies and procedures developed should include controls for the use of caustic, toxic,

and hazardous materials used in the kitchen. Material Safety Data Sheets should be

posted conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since the Baseline or second visits, previous recommendations remain appropriate. Additionally, housing unit logs report instances when water was unavailable, and many of the occupied cells inoperable sinks.

RECOMMENDATIONS:

1. Refer to recommendations regarding sanitation and this provision. 2. Develop and implement a corrective action plan for that ensures inmates have consistent
and reliable access to safe drinking water. 3. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There has been no change since the Baseline or Second assessment reports.

The Monitor was provided several official documents during this and the December and March visits that listed current training topics, invoices for training, partial and staff attendance, a few training materials, and multiple copies of four correctional basic training topic lesson plans. Additionally, Territory officials provided copies of certain training course materials used for recruit officer training. No curricula documents were provided for review, nor any documents that allow for objective and meaningful assessment of compliance.

During this visit, the HR/Training Director was present to discuss this provision and other provisions. She indicated that the training records system remains incomplete and that assessment of topic or staff training files would not evidence compliance with this provision. She was unable to confirm when complete and accurate training program or staff training records would be available but stated that she understood that was a priority and was working hard to complete the work.

However, the Monitor has not been provided any revised policies or procedures to review; it would be impossible, impractical, and non-efficient utilization of resources to re-build the entire training curricula, if required, until all required policies and procedures are approved per the Agreement for implementation. This is not to suggest that certain critical training curriculum should not be immediately reviewed and revised to respond to certain urgent conditions. Territory officials are encouraged to determine those critical topics – focusing on security and health/life safety, and immediately begin reviewing those training plans.

Training curriculum is a total package of learning activities designed to achieve the objectives of the training program. In a competency-based system, the objective, or desired end, is that trainees will acquire the specific knowledge and skills (competencies) they need to do their jobs. There are three primary components to be examined when evaluating any training curriculum. They are:

1. the content or information to be transmitted 2. the organization of the curriculum which includes 3. structure, format, and sequencing 4. the training methods used

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Training Content

Compliance requires that content include specific information, facts, attitudes, and skills to be transmitted by the training program. In a competency-based system, which is defined as “Training” in the Agreement, these are formalized in the competency statements containing measurable training outcomes. The following principles relate to training content:

1. The scope and depth of the content of any curriculum are determined by the competencies the curriculum is designed to teach.
2. Content should transmit a theoretical framework and conceptual rationale for the training. 3. Content should reflect best standards of practice. 4. Content should communicate a values orientation. 5. In an in-service training program, the content must be applicable to direct practice. 6. The content of a curriculum must be congruent and complementary both within and between
sections. 7. Content must clearly distinguish knowledge competencies and knowledge application
competencies.

Structure and Format

This refers to the construction of individual sections, and the organizations of the parts of the curriculum into an integrated whole. It includes the design of each section to achieve objectives, the sequencing of sections and activities, establishing time frames, and designing linkages between sections.

The sequence of activities within each section and within the curriculum as a whole should be concordant with the natural learning process and measureable learning outcomes.

Knowledge and skills that are conceptually related, or that are performed together on the job, should be taught together.

Providing a broad overview of the content early in the sequence provides a conceptual framework within which trainees can organize the parts. This facilitates retention and understanding.

Principles of sequencing are: from simple to complex, from the universal to the exception, and from fundamental to more refined applications:

1. Repeating key concepts in different contexts facilitates understanding. 2. Relating sections within a curriculum helps develop logical linkages between previous and
current training content, and identify different situations in which similar knowledge and skills are applied, which helps to reinforce retention and promote generalization.

Planning adequate time to cover the content to the desired level of depth is essential. Compression of content into an unrealistic time segment limits the effectiveness of the training. It can't be done faster than it can be done.

Training Methods

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Training methods are the strategies used to transmit the content and to promote learning and retention. In an in-service training curriculum, the training methods must be appropriate for use with adult learners in an applied setting. The method that is best suited to achieve the objective of the section should be selected:

1. Use presentation to quickly transmit factual information. 2. Use discussion to promote greater exploration of the information and to develop
understanding. 3. Ask questions of trainees or use exercises that feed information back to the trainer to
determine how well trainees understand the content. 4. Use experiential exercises to develop self-awareness. 5. When trainees have prior knowledge or preconceived ideas about the content, use an
activity that challenges mindsets and motivates trainees to rethink their own beliefs. 6. Use exercises and simulations to promote application of the content to job tasks, and to
develop trainee skills. 7. Use activities that identify solutions to potential barriers in the workplace and action
planning to promote TOL from the workshop back to the job setting. 8. Present the same concepts using a variety of learning strategies to help ensure that trainees
with different learning styles can assimilate the knowledge. Hearing, seeing, modeling, and then practicing the training content also reinforces learning for individual trainees. 9. As determined appropriate, training should be conducted in housing units or other locations where the information is applicable.

Ultimately, this provision asks for a/the training “curriculum,” which has not been provided as required and possibly does not exist based on the training documents provided. The documents provided, as stated above, would not qualify as curriculum by and definition. The training materials provided appear to be outdated reading materials involving a blend of some basic and special topics. The materials provided are considered “canned” resources purchased off the internet from Lockup USA, a company that specializes in producing correctional training videos that includes study reading materials. A review of that website (http://www.lockupusa.com/). The Monitored accessed and reviewed several training videos for corrections and noncorrections staff. Although the website allowed only partial viewing of training videos, their content appeared to provide meaningful training information for basic and in-service training purposes. However, the videos nor supplemental reading materials qualify as curriculum but are considered training supplements that would support a written curriculum if it exists. The Monitor has provided Territory officials curriculum document samples for review and consideration.

Training Materials

Training materials must support the overall curriculum and expected learning outcomes. This can be achieve:

1. Ensure that training materials include all updated policies, procedures, regulations, forms and documents.
2. Ensure that training materials are current and related to subject outcomes.

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3. Ensure that the materials appropriate for adult learners and support trainee learning styles

and abilities.

4. Ensure that training materials support Agreement requirements and Provisions.

RECOMMENDATIONS:

1. Written training policies and procedures should be developed and implemented to govern pre-service, in-service, and ongoing training or corrections and civilian staff. The following are a few recommended elements for training program policies and procedures:

A. Training program mission statement, goals, objectives, and operating procedures; B. Written, understandable, and measurable; C. A training program written code of professional standards and ethics; D. Employees participate in formulation of policies, procedures, and practices; E. The training program is adequately staffed with qualified training and support staff; F. There is a written organizational plan that depicts training program structure, lines of
communication and authority; G. Training records management and control; H. Descriptions and roles of agency, public, and private training agencies and/or
organizations involved in training development and implementation; I. Authorization and description of off-site training facilities; J. Regularly scheduled meetings between training leadership and agency leaders for
program coordination and management purposes; K. A system for monitoring training program methods, content, and outcomes; L. Training program funding and space; M. Training program role in staff recruitment, selection, training, re-training, promotion,
dismissal; N. Prohibitions against and consequences resulting from staff and student misconduct
related to training functions and activities; O. Adequate equipment and supplies are available to develop, prepare, administer, and
evaluate training program and services; P. Appropriate accommodations are available for disabled and/or impaired students; Q. Training curricula and plans are developed, evaluated, and updated based on a valid
assessment of staff performance that identifies current job-related training needs; R. Ongoing formal evaluation of pre-service, in-service, and specialized training program
conducted and/or sanctioned by the agency; S. Adequate reference materials are available to program staff and learners; T. All courses provided include attendance records, lesson plans, instructor name, course
evaluations, methods for demonstrating topic proficiency and test results; records of certificates or completion verification; U. Methods that protect the integrity of testing and assessment processes; V. Courses are based on competency-based curriculum supported by appropriate materials and course resources; W. All instructors are qualified to teach course topics; instructors teaching uses of force, first aid, weapons use, etc. are currently certified to instruct such courses; X. Use of force training includes non-physical, physical, and appropriate use of authorized weapons, force levels, justification, etc.;

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Y. Training topics, content, proficiency, and hours/weeks of training is established for pre-

service, in-service, and specialized training;

Z. Firearms training covers use, safety, and care of firearms and the legal and ethical

constraints on their use. Training includes knowledge and performance, and is

assignment specific (e.g. use of weapon in various settings, conditions, areas);

AA. Chemical agent training covers the use and handling of chemical agents, as well as the

treatment of persons exposed to a chemical agent;

BB.

Emergency responders are available to timely respond to training incidents

involving injury.

CC.

Access the American Jail Association, American Corrections Association, and

National Institute of Corrections training libraries for more resources for designing,

developing, implementing, and evaluating policy driving training curriculum for adult

learners.

2. Training plans should be developed for all revised and new policies and procedures required under this Agreement. These plans should include methods for determining content proficiency as defined in this agreement. The use of pre and post tests and visual demonstration of applied topics should be used in measuring topic competency.

b. Pre-service training for all new employees;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above.

RECOMMENDATIONS:

1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.

c. Periodic in-service training and retraining for all employees following their completion of pre-service training;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above. Training-related documents provided by Territory officials do not provide sufficient information and clarity to assess compliance.

RECOMMENDATIONS:

1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above.

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RECOMMENDATIONS:

1. Provide the Monitor all training program policies and procedures. 2. In the absence of training program policies and procedures, develop such policies and
procedures. 3. Provide the Monitor with documentation on how compliance with this provision is being
met. 4. Develop a basic spread sheet that allows the Monitor to clearly determine the following:
 Total authorized staff per category (correctional, supervisory, civilian, contract, etc.)  YTD actual staffing levels per category, preferably by month  Number and percentage of current staff in each category who have completed
required pre and in-service training, per month

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IX. IMPLEMENTATION

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.

FINDINGS: Territory officials have completed and submitted to the Monitor and USDOJ on April 15, 2014 a more detailed plan and schedule for policy development, training, and implementation. This newly issued plan is currently under review by the Monitor and USDOJ.

2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.

FINDINGS: As stated above, a revised plan has been submitted to the Monitor and USDOJ for review and comment.

3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

FINDINGS: As discussed throughout this assessment report, the Territory provided no evidence that any policies or procedures are in revision. Policies or procedures that comply with the conditions of this Agreement been not provided to the Monitor or USDOJ.

Territory officials recently submitted to the Monitor three documents intended to comply with this requirement. The documents were labeled as “memorandum” to staff regarding important security requirements. Although these documents seem to be valuable for directing staff performance, none of the documents qualify as a policy or procedure, in this Monitor’s opinion.

The Monitor submitted a written objection to the Territory within the required time period and the Territory quickly responded and is currently reviewing that objection. The following objection was submitted to the Territory on April 3, 2014:

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"I am providing the following “written objection” to these documents qualifying as policies or

procedures per section IX 3 of the Agreement as both documents are written in similar form. As

you know, section IX 3 of the Agreement states

“Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

Basis of Objection:

Agreement Intent and Requirements:

The Agreement was based, in part, on the stipulated Findings of Fact document that assessed several deficiencies in GGACF policies and procedures including content and format. I, therefore, interpret the requirement for “policies and procedures” in the Agreement to be documents that address and resolved related FOF findings, and would meet correctional industry standards. I do not believe these documents accomplish the intent or requirements of the Agreement for the following reasons:

1) The documents are issued as “Memoranda.” Memorandums are directives that are not policy or procedure documents according to correctional industry standards. Memorandums are simply that – “memos” that advise, clarify, direct, inform, etc.” Policies and procedures are specific documents having a specific format, are coded (codified), and use standard titles and verbiage. Please see the attached document regarding this industry standard from the National Institute of Corrections for the development of policies and procedures I previously emailed to Territory officials on August 12, 2013.
2) Per the Agreement, there must be training involved in the implementation of policies and procedures. Even if these documents did qualify as policies or procedures, there are no training statements described, which is a standard policy element. Have staff and supervisors been trained on the implementation of these documents? If so, what “…means to instruct (staff) in the skills addressed to a level at which the trainee has demonstrated proficiency to implement those skills as, and when called for, in the training (Section III Definitions)” were used? If staff were trained, I have not received for my “…review and approval” (VIII 1) any curricula regarding that training per Provision VIII 1 (a-d).
3) Implementation of these documents as policy or procedures also appears in conflict with the definition in Section III: “To ‘Implement’ a policy means: the policy has been drafted and disseminated to all staff responsible for following or applying the policy; all relevant staff have been trained on the policy; compliance with the policy is monitored and tracked through audit tools; the policy is consistently applied, as demonstrated by audit tools approved by the Monitor; and there are corrective action measures to address lapses in application of the policy.” I have not received or approved any audit tools for this policy/procedure, nor have I received from the Territory any information regarding compliance or corrective action for non-compliance.

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The memoranda you provided does show meaningful and necessary effort by the Warden to

move compliance in a positive direction; the documents should be followed by official policies

and procedures meeting industry standards that are implemented according to the terms of the

Agreement.

Thank you. Ken”

4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.
FINDINGS: The Monitor received the first semi-annual impact evaluation on January 15, 2014 as agreed. This evaluation, being the first, shows some but little progress toward complying with this requirement and is expected to improve as more progress is made. The Monitor believes that this evaluation is welded to the implementation schedule; evaluation contents should be supportive and reflective of the implementation schedule, which has not yet been adopted.
The Monitor has provided the Territory verbal and written technical assistance as required above; Territory officials and the Monitor continue to maintain a positive and collaborative relation on this matter.
5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.
FINDINGS: The Territory has not submitted to the Monitor any requests, proposals or recommendations to modify policies, procedures or the plan. The Monitor looks forward to reviewing proposed changes and provided requested technical assistance if requested. It is believed, however, that the creation of a better development implementation plan will greatly facilitate the Territories compliance with this requirement.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
FINDINGS: The first four-month report was timely filed on January 15, 2014 as mutually agreed by the Monitor and the Parties.
Report format is adequate and easy to read. It appears to include all substantive provisions and progress statements were applicable, but does not include progress statements for the requirements

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in Section IX Implementation but should. This requirement uses the term “provision” versus

Substantive Provision. Therefore, the Monitor interprets IX.6 to require the four-month progress

report to include actions taken to report progress for all requirements provided in the Agreement.

Despite the fact that the deadline has passed, the Monitor has not received the second four-month report and did not find it filed in PACER ECF.

7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.

FINDINGS: Territory counsel notified the Monitor and DOJ officials of two such incidents via email during the monitoring period:

1) Inmate stabbing (01/10/2014), incident reports emailed on 01/16/2014, health and investigative reports were not provided to the Monitor.
2) Suspected assault of and inmate report (01/12/2014), incident reports, logs, and medical records were provided to the Monitor on January 28, 2014. This notification states that this event occurred on 01/08/2014 and that delay in notification was because it was not timely reported to the Warden or the Director, but was under investigation.

An examination of housing unit, supervisor, and incident report logs for this reporting period indicate several events that may have needed to be reported under this requirement. For example, housing unit logs for this reporting period report an estimated 59 medical-related events, 6 suicidal or self-harm events, and 7 inmate assaults.

Inconsistent reporting methods, lack of continuity between these logs, and lack of clarity in GGACF reporting practices make it very difficult to verify which events should have been reported.

8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorneyclient or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.

FINDINGS: Territory officials appear to be making reasonable, albeit slow, progress in meeting this requirement.

9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.

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FINDINGS: Territory officials provided reasonable access to the facility and staff during the baseline visit. Several log books and other documents were ready for review by the Monitor and USDOJ on the first day of visit and during its duration.

10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.

FINDINGS: Territory responses to specific questions regarding compliance with the Agreement have complied with this requirement according to the Monitor’s best estimate.

 
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United States Virgin Islands GOLDEN GROVE ADULT CORRECTIONAL FACILITY
St. Croix, VI
FOURTH COMPLIANCE MONITORING REPORT
2013 Federal Court Settlement Agreement In re: United States of America v. The Territory of the Virgin Islands (86/265)
Kenneth A. Ray, M.Ed., Monitor September 01, 2014

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Kenneth A. Ray, M.Ed. Monitor

TABLE OF CONTENTS

Topic

Page

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

1

Purpose……………………………………………………………………………..

2

Executive Summary & Overview………………………………………………… 2

Section IV. Safety and Supervision Compliance ………………………………

8

Section V. Medical and Mental Health Care Compliance …………………….

60

Section VI. Fire and Life Safety ………………………………………………… 104

Section VII. Environmental Health and Safety ………………………………… 111

Section VIII. Training ……………………………………………………………. 121

Section IX. Implementation ……………………………………………………… 127

APPENDIX A

Compliance Assessment Methodology ……………………………………………. 130

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PURPOSE

The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) as a tool to assist Defendants in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.

EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

The fourth onsite compliance monitoring assessment was conducted during two separate visits due to conflicts with monitoring team schedules. Dr. Shansky conducted his compliance assessment of medical provisions June 3-6, 2014; This Monitor and Dr. Stellman (mental health / suicide prevention provisions) were onsite June 17-20, 2014. Prior to this site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite assessment.

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance, In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy and procedure formulation, and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing the final report.

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Monitor will advance each provision as certain levels of compliance progress are clearly

demonstrated by the Territory. Generally speaking, the Monitor will advance provisions from

noncompliance to partial compliance when compliance efforts demonstrate the following:

1. Policies, procedures, protocols, and/or plans required of a provision are properly approved;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented.

Provisions are eligible to advance from partial to substantial compliance when efficacious assessment and evaluation of implemented policies, procedures, protocols, plans, etc. quantitatively and/or qualitatively evidence 1) that implementation efforts are producing outcomes intended in the Agreement, and 2) implementation outcome performance is reliable (assessments and evaluations evidence consistency in producing outcomes intended in the Agreement). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately evidenced, this Monitor will and has reversed a compliance rating when the evidence supports doing so.

This assessment found 107 (89%) of the 120 substantive provisions (not including provisions in Section IX. Implementation) in noncompliance; one provision was reversed from partial to noncompliance due to new problems, as described in this report. The compliance ratings in this Fourth Compliance Assessment Report demonstrate virtually no substantive progress since the September 2013 Baseline assessment.

GGACF FOURTH COMPLIANCE ASSESSMENT SCORE CARD

Agreement Compliance Provision Topic Total

Non

Partial Substantial

Areas

Provisions Compliance Compliance Compliance

IV. Safety & Supervision

59

52

7

0

V. Medical & Mental Health Care

36

36

0

0

VI. Fire & Life Safety

10

10

0

0

VII. Environmental Health & Safety

11

5

6

0

VIII. Training

4

4

0

0

Total Substantive Provisions

120

107

13

0

100%

89%

11%

0%

Primary Assessor:

Kenneth A. Ray, Monitor: IV. Safety & Supervision

59

VI. Fire & Life Safety

10

VII. Environmental Health & Safety

11

VIII. Training

4

Dr. Ron Shansky / Dr. Roberta Stellman: V. Medical & Mental Health Care

36

Total: 120

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Implementation (Section IX) provisions were not measured using these rating classifications but

a narrative description of compliance is provided; the required evaluation standards may be

applied in evaluating these provisions in future reports once the Monitor has more clarity about

doing so from the Parties.

FOURTH ASSESSMENT FINDINGS OVERVIEW:

This assessment found virtually no progress from any of the three previous reports. Notwithstanding the commendable efforts by the Territory to maintain the measure of improved housing unit sanitation and complete the required security staffing analysis, GGACF operations and conditions remain much the same as described in the Findings of Fact Report (filed on 02/08/13) and all monitoring reports. Simply stated, GGACF conditions continue to promote real and potential serious harm risks to the physical and psych-emotional safety and security of the community, staff, and inmates as stated in the previous report,

“…based on staff and inmate interviews; reviews of various official logs and records, and direct observations, GGACF remains a very dangerous, violent, unhealthy, under-supervised, under-maintained, and deleteriously understaffed correctional environment. Inmates and staff are unnecessarily exposed to real and potential psycho-social and physical violence, inmates cannot receive adequate levels of medical or mental health services and care, and the lack of an adequate fire suppression system places everyone working and incarcerated at GGACF at constant substantial risk. Substandard and inconsistent security practices i.e. consistently closing and locking security doors and gates are exacerbated by inoperable locking mechanisms. Housing units continue to flood during heavy rains and mold remains profuse throughout most inmate housing areas. The training program, based on documents provided, requires significant overhaul with focus on promulgation and evaluation of standardized curricula that emphasizes contemporary pre and in-service correctional subjects and practices as its priority. GGACF remains very penetrable for dangerous contraband (knives, shanks, cutting devices, impact tools, etc.) as well as cell phones and drugs, and a variety of the kinds of contraband according to evidence logs and incident reports. The inmate grievance process is not consistently managed nor adequately documented according to grievance records review, and the inmate disciplinary process appears to deliver inconsistent consequences and fails to consistently administer due process hearings due to staffing shortages. Inmates continue to be allowed to keep in their cells used prescription needles and unused syringes, which is an extremely hazardous practice, especially considering the regularity that housing units are left with no or inadequate staffing levels. Inmates with mental illness, some with serious mental illness, are housing in segregation or locked in their cells (segregated) for long periods of time and without ongoing assessment and monitoring by mental health professionals. Housing unit logs also report that inmates remain able to “pop” their cell door locks and gain unauthorized access to housing unit areas. Suicidal inmates continue to be placed on suicide watch by correctional officers without the knowledge or involvement by mental health staff, and housing unit logs report that officers either have difficulty summoning medical staff when needed for inmate medical issues or decide to respond to medical issues on their own without

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consulting medical staff. Events involving use of force against inmates is not

reported consistently, and there have been delays in reporting to management

potentially serious medical issues involving inmates assaulted by other inmates.”

Overshadowing Fourth assessment findings are ongoing serious assaults of officers and inmates. Between the third and fourth on-site assessment tours, there were at least two serious prisoneron-prisoner assaults, both requiring emergency medical treatment. There was also the May 11, 2014 escape of a dangerous inmate who reportedly sexually assaulted one of his previous victims while at large. There was also an attempted escape, where five inmates were apprehended by the Virgin Islands Police Department just prior to breaching the outside perimeter fence. During the fourth on-site assessment, there was an inmate-on-staff assault in one of the lock-down units. Following the fourth on-site assessment, there was another prisoner-on-prisoner assault, resulting in stab wounds; no incident reports or follow up information was provided for this event. These events further demonstrate the Territory’s inability to timely and effectively protect staff, inmates, and the community from violence, a fundamental purpose of the Agreement (II.1, 2. Introduction):

1. The purpose of this Agreement is to remedy the ongoing constitutional violations identified subsequent to the July 28, 2011 filing of Defendants' Motion to Terminate pursuant to the Prison Litigation Reform Act, 18 U.S.C. § 3626(b) [Dkt. 565]. Through the provisions of this Agreement, the parties seek to ensure that the conditions at the Golden Grove Adult Correctional and Detention Facility ("Golden Grove") respect the rights of prisoners confined there. By ensuring that the conditions in Golden Grove are constitutional, Defendants also will provide for the safety of staff and promote public safety in the community.

2. Defendants consent to the entry of findings that the conditions at Golden Grove necessitate the remedial measures contained in this Agreement. The parties recognize that the conditions at Golden Grove and the treatment of prisoners confined therein have an impact on whether prisoners will be successfully re-integrated on release, whether released prisoners will re-offend, and public confidence in the criminal justice system.

GGACF continues to allow inmate-occupied housing units to operate without staff and/or inadequate staff. Shift supervision staffing levels are so low most of the time that line staff receive virtually no supervision or monitoring for entire shifts. In one reported instance, a supervisor concerned about shift staffing shortages telephoned an off-duty corrections administrator, only to be told “you’re on your own.” The supervisor provided no assistance. This Monitor finds that administrator’s lack of support, if true as reported, incredible and deliberately indifferent to the safety and security needs of staff, inmates, and the community.

Inmates are still able to defeat locking systems, get out of their cells and housing units, gain access to other inmates for social or dangerous motives, and even escape to commit violence against the community as reported in the May 11, 2014 escape investigation.

Officers continue to be violently attacked and inmates severely assaulted requiring emergency medical care. GGACF continues to lock-down inmates with mental illness without providing adequate rounds by medical and mental health staff or consistent, reliable access to psychiatric care. Housing unit temperatures are quite high – so high that they jeopardize the health of inmates

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being prescribed certain psychotropic medications. Access to timely, consistent, and qualify

health care remains seriously inadequate. There is a severe shortage of qualified nurses, and

vacant positions have not been filled; medication administration is not consistent due to security

staffing problems; the medical records system is devoid of adequate oversight and management;

and the hiring of the new medical director is reportedly jeopardized by professional licensing

prohibitions against supervising the GGACF medical program.

The facility remains penetrable to contraband. Evidence confiscation logs reveal that inmates continue to have access to weapons, drugs, and cell phones. Despite the Territory’s intentional efforts to eliminate the presence of contraband (via the GIST program), the inmate population remains a constant violent threat due to having seemingly unstoppable access to weapons.

The inmate discipline program continues to yield inconsistent discipline or no discipline at all. This is because GGACF consistently fails to give inmates timely disciplinary hearings to contest the disciplinary charges filed against them. GGACF is unable to conduct timely hearings because there is not enough staff to assemble hearing panels on a regular and consistent basis. Subsequently, the GGACF disciplinary system cannot provide meaningful levels of consistent inmate discipline – a fundamental outcome of an effective program.

The two inmate-caused fires that reportedly occurred in a housing unit demonstrate ongoing real and potential life-safety risks to staff and inmates. The automatic fire alarm and suppression system remains inoperable. The fire detection and suppression system consists only of fire extinguishers located in the officer pods within housing units. Effective use of these extinguishers during a fire emergency requires adequate staffing of housing units. GGACF is commended for maintaining operable handheld fire extinguishers in housing units. Fire extinguishers are not, however, an adequate detection and response system, especially given the extreme staffing shortages at GGACF. Moreover, inmates continue to be allowed to use sprinkler heads in their cells to anchor clotheslines. As noted in each prior report, this practice must stop immediately, as it creates a safety and fire hazard for inmates. GGACF also attempted to conduct two emergency evacuation exercises. One of these exercises was cancelled mid-way through, however, because a fight broke out. This means that, to the best of the Monitor’s knowledge, GGACF has only conducted one full emergency evacuation exercise of one housing unit in the last year.

The Territory is commended for maintaining improved sanitation, as found during the third assessment. Housing units and inmate cells did seemed cleaner than they were prior to the previous visit. However, some cells were still filthy, and inmates continue to block cell door windows with various items, preventing good security visibility for inmate counts and reliable welfare inspections. Although the Territory continues to report that they do not condone this practice, the Monitor has noticed such obstructions during each tour, without significant change.

Inmates still do not have consistent and reliable access to drinkable water. Several cell sinks are inoperable, requiring inmates to rely on water containers in the day rooms for hydration. However, inmates have virtually no access to water after lockdown, and no access to water when housing units are not staffed. High temperatures and humidity in the housing units and cells necessitate that inmate have unencumbered access to drinkable water 24/7. This problem has been mentioned in each of the previous reports, but the sinks remain broken, with no plan provided for when they will be fixed.

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Notwithstanding the findings in this assessment, the Territory continues to voice commitment to complying with the Agreement. However, it is this Monitor’s opinion that the Territory has not provided GGACF nearly adequate resources to comply with this Agreement, and various compliance efforts have resulted in delays and missteps. It is clear that, as currently funded and staffed, GGACF does not have the leadership and resources necessary to come into substantial compliance with this Agreement. GGACF will remain a dangerous and unhealthy correctional institution until such time as resources are allocated and leadership are committed to actually creating lasting changes.

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IV. SAFETY AND SUPERVISION

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.

A. Supervision

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:

a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No measurable changes were apparent regarding stratification of inmate housing for institutional classification, housing, policy or procedure since previous onsite assessments. Recommendations provided in the previous reports remain appropriate.

On June 5, 2014, Territory representatives submitted to this Monitor and USDOJ documents intended to satisfy this Provision. The documents included 1) definition for general population inmates and, 2) a custody level chart showing custody levels for most housing areas. However, these documents did not adequately and completely show stratification and housing assignment for all populations, as it did not include Detention populations. No policies or procedures were submitted for population stratification and/or housing.

A review of the Incident Report and Contraband Logs, incident reports, and classification documents evidence that appropriate stratification for classification housing is inadequate and inconsistent. As detailed in other sections of this report, the lack of appropriate screening instruments, housing stratification schemes, and policies and procedures regarding classification continues to place inmates at risk of harm.

RECOMMENDATIONS: 4th Assessment:

1. Stratify population showing Prison and Detention classifications. 2. Include all housing buildings and units in the plan. Specifically, breakdown the data
showing locations of all locations, total capacity of each, numbers of cells and beds, classification for each building and unit..

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3. Show all bed-capacities for each custody level per housing building and unit.

4. Define custody levels more clearly and completely for all inmate classifications in each

custody level.

5. Include intake unit - inmates are held and housed in that location.

6. Specific female unit uses – convicted (where), detention (where).

Previous Recommendations Remain Appropriate:

1. Revise/develop housing classification policies based on a current validated intake and review classification instrument. Submit document drafts as indicated in the Agreement before implementation.
2. Timely complete and submit a policy development plan that includes, at a minimum, the following elements: A. Policy title with related procedure titles B. Primary policy references C. Person(s) responsible for document development D. Expected dates to be forwarded to the Monitor and USDOJ for review and approval, date(s) of staff training, implementation date
3. Review current population to verify accurate risk/need classification levels and housing, reclassify and appropriately house as indicated by review process findings.
4. Refer to IV.F. regarding specific classification and housing policy recommendations.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: GGACF staff are dangerously overworked. Inmate-occupied housing units continue to go unstaffed and/or understaffed for extended time periods. In some instances, entire buildings are not assigned officers for entire shifts. Housing-unit officers continue to leave the facility without authorization. Recent staff and inmate assaults, and the May 11, 2014 escape of a dangerous inmate, who reportedly committed a sexual assault of his previous victim following this escape, demonstrate ongoing real and present dangers resulting from noncompliance with this Provision.

The required Staffing Analysis was recently completed by the National Institute of Corrections (NIC) and submitted to the Territory, who shared it with this Monitor and USDOJ. The findings illustrate this Monitor’s concerns regarding inadequate staffing levels. The analysis proposes necessary increases in staffing as well as strategies for improved deployment of existing staff. The assessment also found that correctional officers are working dangerously high amounts of overtime and those amounts increased two-fold since 2012.

According to payroll records examined by the NIC consultant, almost 50% of GGACF correctional officers worked an average of 60 hours per week or more in 2012. This number increased to nearly 80% in 2013, with 25 employees averaging more than 80 hours (double time) per week in 2013. A graph illustrating this serious problem was pulled from the NIC Staffing Analysis and is shown below. The Purple (or non-jagged) area represents 2012 hrs.

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Settlement Agreement

The blue jagged area represents 2013 employee annual average work hours. Dotted horizontal

lines represent full-time hours (red/lower), time and one-half hours (yellow/middle), and double

time hours (green/upper).

Additionally, payroll documents provided to this Monitor following the May 11, 2014 escape revealed that some officers had worked upwards of 24 consecutive hours the week of the escape, with other officers working in excess of 16 consecutive hours. Such high amounts of overtime create serious staff and inmate safety and security risks in the form of staff chronic fatigue; inattention to the presence of security risks; incomplete inmate and unit searches; and overall burnout/inattention to one’s post. Inadequate staffing levels combined with overworked staff is likely a major contributor to the ongoing personal harm occurring at GGACF, and must be corrected without delay.
Supervisor logs examined by this Monitor during previous monitoring visits, and in the completion of the staffing analysis by the NIC Consultant, continue to evidence seemingly perpetual noncompliance with this provision. It is important, however, to first describe inconsistencies found in the supervisor’s log, and to urge caution in generalizing conclusions with the data abstracted from these logs due to evident inconsistencies.
The supervisor’s log is used to document staffing levels and various activities by shift supervisors for each of the three shifts (shifts A, B, C) on a daily basis. This log should be relied upon by GGACF supervisors and management for effective and reliable management of the facility. Therefore, information and data in the log should be consistent, legible, and complete. This is not the case. The Supervisor log is unreliable for making valid and reliable management decisions, because the log is replete with incomplete information and inconsistency. The level

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Settlement Agreement

of detail and information contained in the log seems to vary depending on which supervisor

was on duty that day. An examination of the supervisor’s log from May 20 thru June 5, 2014

(17 days) vividly demonstrates this problem. The supervisor log for the 17-day period were

examined by the NIC consultant in an effort to clarify staffing levels as part of the staffing

analysis.

For example, GGACF operates three work shifts each day; these three shifts make up a 24-hour coverage schedule. There are, therefore, 51 work shifts during a 17-day work period (3 shifts x 17 days = 51). If there was a policy in place governing the use of the Supervisor’s Log, it should say that each shift supervisor should record staffing levels for all post assignments during their shift each day. There is not currently a policy stating this, however, so this practice is not followed consistently. There were only four days during this 17-day period with complete staff assignment data for all three shifts recorded in the Log Book. On all other days, some shifts were recorded, while others were not:

Supervisor Log Dates

Shifts Per Day

5/20/2013

3

5/21/2013

3

5/22/2013

3

5/23/2013

3

5/24/2013

3

5/25/2013

3

5/26/2013

3

5/27/2013

3

5/28/2013

3

5/29/2013

3

5/30/2013

3

5/31/2013

3

6/1/2013

3

6/2/2013

3

6/3/2013

3

6/4/2013

3

6/5/2013

3

Days / Validate

17

Total Shifts / Logged

51

Percent Shifts Logged

Percent Days Logged

Shift A Staffing Logged
0 1 1 0 0 0 1 1 1 1 0 1 0 1 1 1 1 17 11 65%

Shift B Staffing Logged
0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 0 0 17 8 47%

Shift C Staffing Logged
1 1 1 1 0 1 1 1 0 0 1 0 1 1 1 1 1 17 13 76%

Total Logged Per Day
1 2 2 1 0 1 3 3 2 1 2 2 2 3 3 2 2 17 32 63%

Percent Logged
33% 67% 67% 33% 0% 33% 100% 100% 67% 33% 67% 67% 67% 100% 100% 67% 67% 17 AVG 63% 24%

Notwithstanding these inconsistencies, this Monitor made best-efforts to analyze data that were logged by supervisors to gain a reasonable measure of clarity for assessing compliance.

Approximately 30 of 51 shifts for this 17-day period reported what appeared to be complete staffing assignment/level information, including the presence of shift supervisors. Shift supervisors include (1) T/C (Tour Commander) and (3) Asst. T/Cs. According to the log entries, there was a T/C on duty 28 of the approximate 30 shifts examined; 11 shifts where only one Asst. T/C was on duty; 5 shifts where two Asst. T/Cs were on duty; and only 4 shifts where all three Asst. T/Cs were on duty. Log entries showed no supervisors (no T/C or Asst. T/Cs) on

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Settlement Agreement

duty May 20 or 22 (12a-8a), and only one (1) supervisor on duty May 26 (12a-8a); May 27

(12a-8a & 8a-4p); May 28 (4p-12a); May 30 (8a-4p); May 31 (12a-8a & 8a-4p); June 1 (8a-4p

&4p-12a); June 2 (all three shifts); June 3 (8am-4p & 4p-12a); June 4 (12a-8a & 4p-12a); and,

June 5 (12a-8a). The chart below illustrates these findings:

5/20 5/21 5/21 5/22 5/22 5/23 5/25 5/26 5/26 5/27 5/27 5/27 5/28 5/28 5/29 5/30 5/30 5/31 5/31 6/1 6/1 6/2 6/2 6/2 6/3 6/3 6/3 6/4 6/4 6/5

Date

Shift (Reg / OT

Staffing Logged) (Shifts: A=12a-8a /

C

A

CA

C

C

C

A

CA

B

C

B

CA

B

CA

B

B

CA

B

CA

B

CA

CA

B=8a-4p / C=4p-12a

T/C (Tour Command) Asst. T/C Asst. T/C Asst. T/C
Reported on Shift Total 24/7 Shift Supervisor Posts

101110111111111111111111111111
101110101001101100000000100000 101020000001000000000000000000 101020000000000000000000000000
404260212113212211111111211111
444444444444444444444444444444

Percent on Shift

100% 0%
100% 50% 150% 0% 50% 25% 50% 25% 25% 75% 50% 25% 50% 50% 25% 25% 25% 25% 25% 25% 25% 25% 50% 25% 25% 25% 25% 25%

The Supervisor’s Log (to the extent logged information is reliable) clearly evidences GGACF’s inability to provide adequate, reliable, and consistent shift supervision. It is this Monitor’s professional opinion (based on 34 years of experience in this industry) that GGACF requires a minimum of four (4) shift supervisors on duty during the hours of 8a to 9p (lockdown) and not less than three (3) supervisors on duty from 9pm – 8am.
The Supervisor Log also revealed that in the same 17-day period (May 20 – June 5) there were severe staffing shortages for housing units. There are 14 occupied housing units holding convicted and pretrial inmates, including units holding high risk and mentally ill prisoners. An examination of the 51 shifts during this date range found that only three of the 14 housing units (G,, I, 9C) were staffed 24/7 during this date range.. On May 31, there were five (5) housing units that went unstaffed during the entire 12a-8a shift (Intake, J, K, L, and 9A). RSAT and Intake units reportedly operated without staff for multiple shifts during several consecutive days. It is estimated that 55 shifts for the 14 housing units operated without staff, from May 20 to June 6. The chart below presents these estimates per housing unit:

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Settlement Agreement

Days

Occupied Housing Units

/Shifts % Shifts Post Not Not Staffed

Staffed

A Dorm/RSAT 7 23%

RSAT

15 50%

Intake

18 60%

X or X-Ray

1

3%

G

0

0%

H

1

3%

I

0

0%

J

1

3%

K

2

7%

L

3 10%

9A

3 10%

9B

3 10%

9C

0

0%

9D

1

3%

TOTAL 55

The chart below shows shift staffing estimates (staffed= 1/green, not staffed=0/red).

Date

5/20

Shift (Reg / OT

Staffing

Logged) (Shifts: A=12a-

C

8a / B=8a-4p /

C=4p-12a

A Dorm/RSAT 1

RSAT

1

Intake

1

X or X-Ray 1

G

1

H

1

I

1

J

1

K

1

L

1

9A

2

9B

1

9C

1

9D

1

TOTAL 15

Total 24/7 Security Posts:

14

Post Staffed Per Day:

14

Percent Post Staffed / Shift

5/21 5/21 5/22 5/22 5/23 5/25 5/26 5/26 5/27 5/27 5/27 5/28 5/28 5/29 5/30 5/30 5/31 5/31 6/1 6/1 6/2 6/2 6/2 6/3 6/3 6/3 6/4 6/4 6/5
A C A C C C A C A B C B C A B C A B BCABCABCACA
0 1 0 1 1 1 1 1 1 0 1 1 0 1 1 1 1 0 11110110111 0 1 1 1 1 1 1 1 1 0 1 1 0 0 0 0 1 1 00001000010 0 2 0 1 0 1 1 1 0 1 1 0 0 1 0 0 0 0 00001100001 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11111011111 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 11111111111 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 11111011111 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11111111111 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 11111111111 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 11111111111 0 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 0 1 12011111121 1 2 1 3 1 2 1 2 1 1 2 2 2 1 1 0 0 1 10122221111 1 1 1 2 1 1 1 1 0 0 1 1 1 1 1 1 1 0 11111111111 1 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 2 1 11111111111 1 1 1 2 2 1 1 2 1 1 1 1 1 1 1 1 1 0 11111111111 10 16 11 20 14 15 14 18 12 11 16 14 12 13 12 11 10 10 12 12 11 13 14 12 13 11 12 14 13 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14
10 14 11 14 13 14 14 14 12 11 14 13 11 13 12 11 9 10 12 11 11 12 13 11 12 11 12 11 11

100% 71% 100% 79% 100% 93% 100% 100% 100% 86% 79% 100% 93% 79% 93% 86% 79% 64% 71% 86% 79% 79% 86% 93% 79% 86% 79% 86% 79% 79%

The lack of inmate supervision by correctional officers and staff supervision from T/Cs clearly demonstrates that the Territory will not be able to comply with this or other related provisions until both correctional officer and supervisor staffing levels are adequately increased and supervisors are consistently supervising all shifts daily.

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It is important to note, however, that the new Warden has implemented a shift roster system, primarily to control overtime costs that seems to provide some measure of attention to ensuring housing units are properly staffed. However, based on this Monitor’s discussions with the Warden about this document consideration revision is required to ensure the document is completed, accurate, and understandable for evidencing compliance with staffing level requirements. Nonetheless, the Warden is commended to taking action to improve these conditions.

RECOMMENDATIONS:

1. Rapidly implement the NIC Staffing Analysis recommendations. 2. Create a staffing plan, as required under the Agreement, that reflects the NIC Staffing
Analysis and provides concrete steps for hiring sufficient staff 3. Take immediate steps to either reduce the inmate population commensurate with
existing staffing levels or increase staffing levels commensurate with current inmate population volume. Using the staffing analysis, determine net additional staffing levels needed once inmate population is reduced. 4. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff who work overtime have adequate time away from the facility before returning to work to ensure they are adequately rested. 5. Improve consistency, accuracy, and reliability of supervisor logs entries. 6. Contact the VI Guard to provide temporary internal and perimeter security presence until staffing levels are adequate. 7. Use off-duty VIPD officers to cover unstaffed housing units. 8. Hire PRN nurses with trauma care experience until approved FTEs are onsite. 9. Reassign correctional leadership/supervisory/specialty staff across all shifts to ensure post coverage and consistent inmate monitoring and supervision. 10. Use enabling statues that allow for immediate procurement of security hardware and systems services. 11. Fast-track movement of prisoners off-island. 12. Request emergency funding from the Governor and/or legislator for rapid hiring of additional officers pursuant to the Staffing Study; remove ALL administrative and bureaucratic barriers that have and can impair rapid hiring of qualified candidates. 13. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics. 14. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm.

Previous Recommendations Remain Appropriate:

1. Subsequent to policy and procedure development and revisions, conduct a complete review of existing Specific and General Post Orders to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible;

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E. regularly reviewed, revised, updated;

F. consistently enforced;

G. known to staff through pre-service, in-service, and ongoing training.

2. Develop a plan that provides for regular review of all log books by supervisors to ensure

staffing and other unit safety and security issues to be known and resolved in a timely

manner.

3. Ensure that all posts are staffed according to post complexity and dynamics, risks and

needs.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: All but one housing-unit officer possessed a radio during this assessment; the RSAT officer had no radio or telephone. Additionally, the telephone system remains virtually inoperable throughout the facility. Territory officials report that the new fiber optic system should be functional by the end of September and allow for phone-system operability.
The Territory submitted to this Monitor and USDOJ on June 1st a draft Radio Communications policies and procedures. The policy was generally complete but required several revisions. This Monitor and USDOJ provided the Territory with written comments and recommendations within the 45-day requirement. It is the Territory’s intention to finalize this policy during the September TA visit by this Monitor.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. Revise and/or develop, implement, and evaluate policies and procedures governing radio communication equipment, usage, repair and maintenance.
2. Ensure that all posts are equipped with functionally reliable communications equipment; it is recommended that reliable radios are issued to ALL officers and staff working with and/or around inmates.
3. Repair, replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
4. The Monitor will review radio equipment inventories and functionality during the next onsite assessment.
5. Provide portable radio communications policies and procedures. 6. Provide portable radio communication training curriculum.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and
(ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As previously described, housing units and entire buildings continue to go understaffed or not staffed for extended time periods. Certain housing units and buildings are continually staffed by only one officer. This lack of adequate staff directly contributed to the May 11, 2014 escape.

The A (mental health) and RSAT buildings are routinely staffed by only one officer who must leave one building to supervise inmates in the other. This leaves both inmate populations not supervised for extended time periods. During this visit, however, there was an officer assigned to each building, but the A building officer stated she had no suicide cut-down tool and the RSAT officer had no radio and only a personal cell phone for communications.

Shifts continue to operate without a supervisor onsite and/or the assistance of off-site supervision. An extreme example of this problem is evidenced on May 11, 2014, the day before the escape. Investigation and incident reports for this escape document that the on-duty supervisor called the Assistant Warden for assistance due to that shift having a severe staffing shortage. Reports indicated that the Assistant Warden not only refused to provide this supervisor with any assistance to mitigate the staffing shortage, but reportedly told the requesting supervisor, “… you are on your own…” This supervisor, having worked in excess of 20 consecutive hours, ultimately abandoned his or her post, reporting fatigue and concerns about an existing chronic disease being exacerbated by situational stress and no meal breaks during the shift. Incident reports also revealed that no other supervisors or leadership staff were available for assistance. This means that there were no officers or supervisors conducting adequate rounds in housing units during that shift, as required by this provision. The Territory’s failure to meet this requirement resulted in a serious security breach, and the alleged revictimization of a community member.

This event also evidences inadequate and/or non-existent perimeter security rounds because the inmate was able to easily penetrate the perimeter fence through previously damaged and/or nonmaintained gate structures, and the fencing was found to have been cut prior to the escape. Regular and routine inspection and consistent repair of perimeter fencing could have thwarted this escape and prevented the reported assault on a community member.

The Territory’s failure to comply with this provision was also apparent during an incident that occurred two weeks later. On June 7, 2014 as many as five inmates exited building 9 and gained access to the rear perimeter fencing. Fortunately, a VIPD patrol unit was near this location, and upon observing the VIPD patrol, the inmates ran back into the building. Although VIPD was conducting a patrol, GGACF staff were not, as required by this provision. This case likely demonstrates inadequate housing unit and officer monitoring by supervisors, as it is suspected that the on-duty housing unit officer, either by act or omission, allowed these inmates the ability to exit the building.

Examination of GGACF records and personal observations during this assessment also demonstrate continued noncompliance with this Provision. Adequate rounds in accordance with this provision could prevent or reduce the following problems, all of which have been

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identified in earlier reports and remain uncorrected: 1) the continued presence of dangerous

contraband, 2) the continued covering of cell-door windows with various items, 3) the drying

of clothing on lines tied to sprinkler heads and other anchors in their cells, 4) fires being started

in inmates’ cells, 5) inmates’ continued failure to wear official ID cards, or covering the ID

cards with clothing, 6) inmates wearing non-issued inmate apparel, 7) supervisors not

adequately inspecting housing unit logs and taking steps to remedy problems identified therein.

To summarize, supervision of inmates and staff is inconsistent and inadequate, while \security inspections of housing units and the campus by both correctional officers and supervisory staff seem non-existent or very negligent at best.

It is, however, notable that the new Warden took the initiative to arrange for additional VIPD perimeter patrols, which contributed to thwarting an otherwise potentially successful escape attempt.

Recommendations provided in previous reports remain appropriate.

RECOMMENDATIONS:

1. Refer to recommendations regarding Post Orders. 2. Revise and/or develop policies and procedures to ensure consistent and reliable
monitoring of housing units and cell blocks as stated above. For example, develop policies and procedures for inmate supervision that require regular but randomized checks of all cells in each housing unit, and regular rounds of all other areas of the facility, including the perimeter fences. 3. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff and inmate safety and security, and according to inmate risks and needs. 4. Create a schedule for regular rounds by medical and mental health care staff for each shift to ensure that special needs inmates (suicidal, mentally ill, medical infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff. 5. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. 6. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.

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B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The Territory submitted to the Monitor and USDOJ draft contraband policies and procedures on May 27 and June 10, 2014. These draft policies include definitions of what constitutes contraband at GGACF and a process for collecting and disposing of confiscated contraband. This document was thoroughly reviewed by the Monitor and USDOJ; neither reviewer approved the document and both provided detailed comments and recommendations for revising the policy. This Monitor, subsequent to a review of this policy document and a cursory review of several other non-related policy documents provided by the Territory, rejected all submitted policies wholesale. The policy documents submitted by the Territory contained numerous writing errors, inconsistent formatting, omitted important content, and various other basic policy and procedure document elements. This Monitor believes that draft documents should only be submitted for review that contain all basic elements and are well written. Otherwise, the Monitor cannot efficiently manage the approved monitoring budget efficiently if time is spent correcting basic document deficiencies. This Monitor provided the Territory written and verbal recommendations to the Territory regarding this issue.

Notwithstanding technical problems with policy and procedure drafts, observations during this assessment evidence that staff remain unclear about the definition of contraband. As previously stated, for example, inmates continue to block cell door windows with various objects that remain in the inmates’ possession, which illustrates the importance for definition clarity with regard to consistent security management. Although this Monitor did find a significant decrease in blocked cell door windows, the Territory must take steps to completely eliminate any tolerance of this inmate behavior and ensure that all cell door windows remain unobstructed at all times. This provision is at partial compliance because of the draft document; to move to full compliance, the Territory will need to finalize the policies regarding contraband, get Monitor and USDOJ approval, and fully implement the policies. The effect of those policies will then be evaluated while on-site to assure that the policy has remedied the problems described above.

RECOMMENDATIONS:

1. Issue a post order or memo that clearly defines what constitutes contraband and require supervisors to daily ensure compliance by staff.
2. Prepare for the September onsite TA with the Monitor, during which time the contraband policies will be revised.

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b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: NONCOMPLIANCE No substantive improvement from previous assessment.

FINDINGS: Notwithstanding the draft contraband policies referred to above, a revised, comprehensive contraband policy draft has not yet been submitted to this Monitor or the USDOJ for review and comment and the facility remains porous to contraband to include very dangerous items.

However, the monitoring team and their belongings were searched each day of this assessment upon entry into the facility, but not when we departed. This Monitor also witnessed on several occasions other staff and civilians being searched before entering the administration area. There was some inconsistency on the procedures used to search visitors entering the facility. For example, certain correctional officers assigned to the entrance post required visitors to lift up their pant legs and show their ankles. Other officers did not follow this practice. The thoroughness of the bag searches was also inconsistent amongst officers. This suggests that there is no policy or directive governing how inspections/searches of visitors should be conducted. No vehicle inspections were observed.

This Monitor did not assess other contraband control practices involving mail or package inspections during this assessment and will address this Provision during the 5th onsite
assessment.

Although GGACF records indicate significant reduction in the presence of dangerous contraband within the facility since the previous two assessments, it is unknown whether this decrease results from fewer searches, or less contraband, or extra effort by the Territory to control contraband. Increases in items confiscate does suggest better attention to this problem by the Territory. This Monitor was provided documents from the Territory demonstrating additional efforts to control contraband via large-scare shakedowns. The Evidence Collection Log (since the 3rd assessment) also records continued noncompliance with this Provision and ongoing real and present safety and security dangers to which staff and inmates are exposed daily. An examination of this record shows 56 entries involving collection of the following dangerous items:

 15 Weapons (knives, shanks, razors, blunt objects)  12 Cell phones  16 Drugs (marijuana)  Other tools

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GGACF Dangerous Contraband Collection

Contraband

Nov 2012 June 2013

July 2013 Feb 2014

Cell Phones

74

52

Weapons

42

130

Intoxicants/ Drugs

58

27

Total

174

209

March May 2014
12 15
16
43

RECOMMENDATIONS:
1. Continue positive efforts in searching people before entering the facility. 2. Develop a policy and procedure and/or directive governing how these searches should be
conducted (see below). 3. A “stop and check” protocol for inspecting staff packages after initial entry into the facility
must be developed and implemented. 4. Provide handheld metal detectors for contraband inspections at facility entry points and as
needed for on-campus inspection. 5. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods
and process during the 5th assessment.
Previous Recommendations Remain Appropriate:
1. Review, revise, develop, train, implement, evaluate contraband control policies that contain, at a minimum, the following elements: A. The purposes for contraband control; B. Safe methods and tactics for identification, seizure, recovery, and disposition; C. All locations where contraband can be hidden and disguised; D. Methods and points of delivery and access; E. Unannounced and irregularly time searches of cells, inmates, and inmate program; recreation and work areas; F. Keeping all cabinets and doors locked at all times to prevent access to contraband; G. Use of metal detection equipment; H. Use of other mechanical devices for detection and recovery; I. Respect of inmates’ rights to authorized personal property; J. Clearly articulated differences in inmate property allowed according to gender, religion, health conditions, conviction status, etc.
2. Review, revise, develop, implement, train, and evaluate training policies, procedures, methods, and demonstration of staff proficiency in the prevention, detection, recognition, recovery, and disposition of contraband.
3. Ensure that all posts and high-risk contraband access points are properly secured at all times, adequately staffed, equipped with reliable video surveillance devices, and consistently enforce contraband rules and laws involving inmate, staff, contractors, volunteers, the public, etc.

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4. Develop a uniformed incident tracking/reporting system using standardized contraband titles and locations; implement a continuous quality improvement program to ensure the accuracy and completeness of incident reports.

5. The Monitor renews the previous request for electronic submission of evidence logs each month for review and analysis purposes, and to provide technical assistance as indicated.

c. Detection of contraband within Golden Grove, through processes including: (i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinic, and
other areas of Golden Grove to which prisoners may have access; (ii) pat-down, metal detector, and other appropriate searches of prisoners coming from
areas where they may have had access to contraband, such as at intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic; (iii) regular and random searches of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g., clinic, kitchen, dayrooms, storage areas, showers);

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to 1B above. Previous findings

Once again, this Monitor intentionally looked for but did not observe any inmate searches while touring the yard, housing units, or other areas observed. The failure to conduct inmate searches was discussed in each of the previous reports. Inmate searches must become a routine practice to help control contraband and dampen inmate motivation for smuggling.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

Refer to above, expand application of recommendations to provision c (i-iii) above.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Refer to above findings.

RECOMMENDATIONS:

Review and implement relevant recommendations for Contraband contract above, specifically B1a.

Previous Recommendations Remain Appropriate:

1. Review, revise, develop, train, and implement, evaluate policies and procedures involving confiscation and preservation of contraband as evidence for administrative and legal enforcement purposes.

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2. Ensure staff access to appropriate equipment and supplies needed to safely collect and

preserve contraband while maintaining evidentiary integrity.

3. Ensure adequacy of chain-of-custody methods and procedures.

4. Review, revise, develop, implement, train, and evaluate training policies, procedures,

methods, and demonstration of staff proficiency in the proper collection/confiscation and

disposition of contraband.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Security staff posted at the main entrance conducted a reasonable, but inconsistent search of the Monitoring team and other visitors during this visit (see above, B.1.b) The Monitoring team was appropriately escorted throughout the campus, but did not witness escorts of visitors. However, USDOJ representatives reported moving about the campus unescorted. At one point, a USDOJ representative walked from the administrative building to the medical unit, through an open gate that should have remained locked. There were no supervisors or other staff patrolling the grounds at that time and no escort was made available upon request.

RECOMMENDATIONS:

1. Similar to above specific to admissions policies and procedures, internal and external escorts for facility visitors.
2. Ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
3. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.

C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As reported in all previous reports, inmates continue to wear and possess personal clothing items. This was observed on the yard and in the housing areas. There has been virtually no change. Additionally, during this visit the Monitor observed GGACF staff who were onpost, but not wearing the required GGACF uniforms. When one officer was asked why he was not wearing his uniform shirt, but instead was wearing a t-shirt, the officer replied that it was too hot on the unit to wear his GGACF-issued uniform.

Failure to comply with this Provision allowed the inmate who escaped on May 11, 2014 to go undetected in the community, until GGACF staff were notified of the escape. Because the

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escapee wore personal clothing before and during the escape, he was able to blend in to the

community for many hours prior to his apprehension.

RECOMMENDATIONS:

1. Require inmates to wear issued institutional clothing ONLY. 2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform
policies and inmates who refuse to comply with those policies. 3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and
appropriate corrective action with staff who refuse to do so.

Previous Recommendations Remain Appropriate:

1. Review, revise, develop, implement, train, and evaluate policies and procedures requiring all inmates to wear standard-issue correctional uniforms.
2. Consider acquiring correctional apparel that provides obvious recognition of the inmates’ classification/status.
3. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges and changes in an inmate’s classification and/or status.
4. Consider developing a correctional industry for making uniforms onsite. 5. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband
and weapons. 6. Mark all uniforms with highly visible letters/numbers.

b. Identification that prisoners, staff, and visitors are required to carry and/or display;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As reported in the previous report, none of the inmates were observed to visibly wear correctional identification that was to be implemented. On March 21, 2014, the Warden issued a memorandum to staff providing written instructions regarding inmates wearing identification cards. However, staff did not enforce or otherwise follow the Warden’s instructions. This lack of attention by staff to this requirement also reflects a lack of staff supervision and monitoring by supervisors. Importantly, a new inmate identification system is only effective if inmates are required to wear the identification badges and the system is properly enforced. Otherwise, any resources dedicated to developing and implementing this system are wasted.

The monitoring team and USDOJ were issued visitor identification each day of the visit.

RECOMMENDATIONS:

Recommendations from previous reports remain appropriate.

1. Ensure staff compliance with this provision. 2. Ensure appropriate policies and procedures are in place and made available to staff.

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3. Ensure adequate supplies for making identification cards.

4. Regularly audit identification card inventory and maintain proper controls to prevent

inappropriate acquisition of cards. Conduct regular “identification card counts” using

methods similar to key control inventories.

5. Consistently enforce identification card policies and procedures.

c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The Territory submitted a draft document (“Supervision of Inmates and Detainees” Policy) intended to satisfy this provision on June 6, 2014. However, the document submitted was not fully responsive to this provision and was rejected for failing to include basic elements and formatting. On July 21, 2014, the Territory submitted lesson plan documents pertaining to locking and unlocking doors and gates. This Monitor provided the Territory written recommendations and feedback regarding this lesson plan. On August 22, 2014, the Territory submitted to this Monitor and USDOJ documents demonstrating that this training was conducted July 21 thru August 1, 2014. These documents included:

 Lesson Plan  Post Test  Attendance Rosters  Training Completion Statistical Report

The training completion statistical report is very difficult to interpret for understanding what percent of required staff complete this training but suggests that approximately 65% (30+ staff were not trained) of required staff complete the training. This needs to be clarified and a minimum of 95% of required staff must successfully complete this training before it meets the requirements of this work plan item.

The training plan is acceptable overall but did not include instruction on relevant policies and procedures as those document have not been completed and approved for implementation. It is important that training curricula is based not only on principles of security but must include current policy and procedure to ensure staff compliance can be measured adequately in accordance with policies and procedures. The lesson plan was well written and included basic principles of door locking and unlocking principles. The course was taught by the Warden, a highly qualify correctional professional, and included a ten question post-test. Unfortunately, a post-test cannot measure learning without a pre-test to assess baseline topic knowledge among students. All future training must include a pre-test to ensure learning has been attained.

During this assessment, this monitor found all internal housing unit gates and officer stations to be locked upon entry. However, none of the exterior security slider-doors were locked. These doors – often referred to as the “sally port” doors – were left standing open or unlocked upon entry into the units; we were once again advised that the electronic locking mechanisms are inoperable. Although the various security gates throughout the facility were locked when the Monitoring team first approached, the gates were not locked behind the team when the

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monitoring team toured the housing units. Moreover, on several occasions during the onsite

inspection, the monitoring team/USDOJ representatives were able to simply open the outer

perimeter gate upon arrival at GGACF, revealing that the gate did not always lock. These

observations clearly support a security culture that lacks enforcement and consistency; it also

demonstrates the need for additional training, monitoring, and supervision by GGACF

leadership. GGACF staff must consistently practice good security habits by keeping security

doors and gates closed and locked. Officers still report that inadequate staffing levels require

them to not lock security gates upon entry into the housing units for safety reasons. Housing

unit logs report that fire escape doors and locks are inoperable. There was improvement found

in yard-gate security, but some of the locking mechanisms remain inoperable and prevent the

gates from being locked. Most notably, the last gate from the yard to the administrative

building (which provides access to the outside of the facility) was broken. The supervisor

bubble that looks out at this gate is frequently unstaffed, meaning that inmates can enter or exit

the administrative building area as they please.

Despite some progress to fixing locks, there are still delays and many non-functioning locks. Logbook entries continue to report key door/lock issues not being timely addressed. For example, the Detention R&D entrance door was observed by this Monitor nonfunctional requiring use of a metal pipe to secure it closed. The door must be operated manually, keys don’t work, a metal pipe must be placed behind the outer sally port door to provide security to the area, etc. It appears that the lock work report does not mention this door.

Another example is X Pod, which is the housing unit for sentenced and un-sentenced female inmates. This unit is monitored by one officer, but has gone for hours with no officers assigned according to unit log books. This building is divided into two housing units with a door separating the two populations. This door is not always locked, according to the unit officer. This means that sentenced and unsentenced inmates have access to one another, which should not occur. The lock on this door must be fixed, if broken, to ensure secure separation between these populations. If not broken, policy and procedure must direct officers on this post to keep this door locked at all times.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Review, revise, develop, train, implement, evaluation policies and procedures related to facility security pertaining to locking and unlocking access points, units and cell doors, and other locations requiring consistent access controls.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement. 5. Ensure staff are adequately trained in the proper use of mechanical and/or electronic locking
systems according to their post assignments. 6. Consistently sanction inmates for attempting to manipulate or manipulating any security
locking system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked! 9. Replace or upgrading existing unit control panels to provide for remote electronic locking
and unlocking of unit and cell doors.

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10. Improve video surveillance of internal by placing cameras in all housing units and inmate

locations, and add additional cameras to monitor external access points to ensure rapid

detection of attempts to disable or damage locking devices/systems.

11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices

and mechanisms.

12. Supervisor should inspect all locking systems during each shift and report for investigation

and/or repair any signs of lock disrepair, malfunctioning, or manipulations.

13. Consistently enforce security locking policies and procedures with staff and inmates.

d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As stated in the 3rd Report, “[This] Monitor met with the facility maintenance director and examined existing and revised locking mechanism repair logs. This interview and document examination revealed positive effort for ongoing lock repair and maintenance. Several housing cell locks have been repaired or replaced; it appears that cell pad locks have been replaced with standard security locks, and efforts are being made to repair or replace inoperable electronic locks located at housing unit entrances and yard gates. However, an “alllocks” maintenance plan has not been provided as previously requested. Additionally, it is the Monitor’s opinion, based on interviews with the maintenance director and facility conditions, that the maintenance program is inadequately staffed to provide the level of attention to facility upkeep needed to comply with this Agreement.”
During the 4th assessment, this monitor reviewed the Maintenance Log to find that the inspection program remains inadequately staffed to comply with this Provision. There are simply too many locking mechanisms for current maintenance staffing levels to timely inspect and maintain. Electronic entrance doors of many housing units and R&D remain inoperable and open. The lack of routine inspection of cell door locks by unit officers allows inmates to jam locks with contraband, rendering those locks subject to tampering; inmates reportedly can open their cell doors whether or not housing units are staffed by officers. Inmates can and have escaped and gained access and assaulted other inmates under these conditions.

Notable, this Monitor has requested an “all-locks” plan in each of the previous three reports, yet the Territory has not developed this plan. Without this plan, it is impossible for GGACF maintenance staff to know which locks need repair, when those repairs are scheduled to occur, and whether repairs were successful.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

1. Employ and maintain adequate maintenance staffing levels. 2. As requested in the previous two reports, develop an “all-locks” maintenance plan for
review with the Monitor. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically

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located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number,

lock type, condition, etc.

3. Establish a deadline for developing and implementing the lock plan to include policies,

procedures, training, and continuous quality assurance.

e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The HR/Training director did not participate in this assessment. The HR/Training director was available and present for only one previous on-site assessment, despite knowing the dates for these week-long visits at least two months in advance. This lack of participating in monitoring visits frustrates visit completeness. No additional documentation, including policy and procedure drafts, was provided to move this Provision to Partial Compliance. Third Assessment Findings are as follows:

“Documents provided to the Monitor and discussions with the HR/Training director during this assessment confirm that pre-employment background checks are conducted for all GGACF applications. A review of documents shows a requirement to self-report histories of arrests and convictions. However, personnel records for all GGACF staff were not provided for inspection and verification. Additionally, there remains no centralized tracking and periodic supervisory review process for early staff intervention purpose. These records are reportedly maintained off-campus and available for review by supervisors.”

RECOMMENDATIONS:

1. This Monitor requests inspection personnel records including employment applications; criminal history checks, and background investigations for all housing unit staff working Units 9A/B during the reported escape attempt occurring June 7, 2014.

Previous Recommendations Remain Appropriate:

1. Review, revise, develop, train, implement, evaluate policies and procedures for the applicant and staff records process as indicated by the training assistant.
2. Ensure access to applicant and staff records is adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
3. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.
4. Make records available to the Monitor for inspection and verification of compliance.

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D. Security Staffing

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The National Institute of Corrections completed and submitted the requested staffing analysis on July 21, 2014, following this site assessment. A cursory review of this report indicates that shift factors for all levels of security were determined based on industry standard methodologies.

This Monitor accepted and approved the study and believes that it provides clear and accurate guidance to Territory officials for developing and implementing required policies and procedures.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

1. Appropriate funding to hire sufficient numbers of staff to establish and maintain adequate levels of facility safety and security in accordance with staffing analysis results.
2. Shorten the time required to hire staff to no more than 90 days, not including basic correctional officer training.

b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since the previous report. Now that the Territory has a full staffing analysis, it must develop a security staffing plan to implement the recommendations in that analysis.

The Territory continues to struggle to hire additional correctional staff. As reported in the previous report, “… [t]he Monitor met with the HR/Director and BOC Director regarding the Territory’s hiring process. It was learned that it typically takes one year before a correctional officer applicant is hired and working in the facility. Six-months of this time is spent in the VI Police Academy mostly learning subjects not related to correctional practices or operations. Requiring correctional recruits to attend a full police academy is an unusual practice in the Monitor’s experience as a law enforcement and corrections academy director, and significantly contributes to the current staffing problems. This time period can and should be significantly shortened due to facility safety and security needs combined with ongoing staff attrition.”

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As of the time of this assessment, the Territory continues to require correctional cadets to complete the full police academy before working at GGACF. As discussed in the third assessment, this Monitor believes this practice unnecessarily prevents the Territory from meeting urgent GGACF staffing needs. This practice should stop immediately.

Additionally, as discussed at the April 28, 2014 status conference, 14 new correctional cadets began this academy in January of 2014. Only eight remained in the academy as of the June assessment; and only six reportedly remain in training as of the submission of this report. This means that during the six month academy, GGACF went from 14 potential new correctional officers down to 4 – an attrition rate of over 71%.

As noted throughout this report, examination of certain unit logs, incident reports, and the NIC staffing analysis continue to demonstrate the following:

 Inmate housing units are either not staffed or operate with only one staff for extended periods of time.
 There are periods of time where there are no supervisors on duty and/or available to provide supervision for staff.
 Staff are working excessive overtime hours as previously discussed.

In general, there appears to be no substantive improvement in staffing levels since previous assessments, and no significant effort to increase staffing levels quickly. GGACF continues to remain a dangerous environment for inmates, the staff, and community. The May 11, 2014 escape, the June 7, 2014 attempted escape, and the four serious assaults occurring over the last few months demonstrate the real and present dangers associated with housing units not being adequately staffed and monitored.

RECOMMENDATIONS: Previously provided recommendations remain appropriate

1. Update existing security staffing plans for review with the Monitor during the December site visit.
2. Identify current and anticipated security staffing deficiencies. 3. Complete the required staffing analysis and base this plan on that analysis. 4. Contact the VI Guard to provide temporary internal and perimeter security presence until
staffing levels are adequate. 5. Use off-duty VIPD officers to cover unstaffed housing units. 6. Hire PRN nurses with trauma care experience until approved FTEs are onsite. 7. Reassign correctional leadership/supervisory/specialty staff across all shifts to ensure post
coverage and consistent inmate monitoring and supervision. 8. Use enabling statues that allow for immediate procurement of security hardware and systems
services. 9. Fast-track movement of prisoners off-island. 10. Request emergency funding from the Governor and/or legislator for rapid hiring of additional
officers pursuant to the Staffing Study; remove ALL administrative and bureaucratic barriers that have and can impair rapid hiring of qualified candidates. 11. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics.

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12. Seek Court relief to remove any barriers to rapid remediation of facility safety and security

deficiencies that expose people to harm.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to the above findings. No change since previous visit.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

Review, revise, develop, train, implement, evaluate policies and procedures related to facility staffing with particular focus on staffing levels, deployment, recruitment, selection, training, promotion, development, attrition, maintenance of staffing levels, etc.

1. Defendants will implement the staffing plan developed pursuant to D.1.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to previous findings related to staffing analysis and planning.

RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: According to the Territory’s May 16, 2014 Status Update Report to the court, “The Bureau has begun educating staff and inmates on the policy with training materials from NIC [The National Institute of Corrections]. The PREA policy has been drafted and will be submitted to all parties”. The Territory submitted a draft PREA policy to this Monitor and USDOJ on June 11, 2014. This policy generally meets PREA requirements but requires additional review and revision before it can be approved and fully implemented. Also, staff and inmate training plans or documents verifying completion of training have not been submitted to this Monitor or USDOJ as of yet. Presumably, since training documents must be tied to GGACF policy, these documents will be submitted once the PREA policy is approved.

The Territory has not reported completion of the pre-audit required by PREA but national inspections have begun. It is vital that BOC take steps to complete the required pre-audit as

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soon as possible. PREA policy and procedure content compliance requirements are listed

below:

Standards

§ 115.5 General definitions

§ 115.6 Definitions related to sexual abuse

Prevention Planning

§ 115.11 Zero tolerance of sexual abuse and sexual harassment; PREA coordinator

§ 115.12 Contracting with other entities for the confinement of inmates

§ 115.13 Supervision and monitoring

§ 115.14 Youthful inmates

§ 115.15 Limits to cross-gender viewing and searches

§ 115.16 Inmates with disabilities and inmates who are limited English proficient

§ 115.17 Hiring and promotion decisions

§ 115.18 Upgrades to facilities and technologies

Responsive Planning

§ 115.21 Evidence protocol and forensic medical examinations

§ 115.22 Policies to ensure referrals of allegations for investigations

Training and Education

§ 115.31 Employee training

§ 115.32 Volunteer and contractor training

§ 115.33 Inmate education

§ 115.34 Specialized training: Investigations

§ 115.35 Specialized training: Medical and mental health care

Screening for Risk of Sexual Victimization and Abusiveness

§ 115.41 Screening for risk of victimization and abusiveness

§ 115.42 Use of screening information

§ 115.43 Protective custody

Reporting

§ 115.51 Inmate reporting

§ 115.52 Exhaustion of administrative remedies

§ 115.53 Inmate access to outside confidential support services

§ 115.54 Third-party reporting

Official Response Following an Inmate Report

§ 115.61 Staff and agency reporting duties

§ 115.62 Agency protection duties

§ 115.63 Reporting to other confinement facilities

§ 115.64 Staff first responder duties

§ 115.65 Coordinated response

§ 115.66 Preservation of ability to protect inmates from contact with abusers

§ 115.67 Agency protection against retaliation

§ 115.68 Post-allegation protective custody

Investigations

§ 115.71 Criminal and administrative agency investigations

§ 115.72 Evidentiary standard for administrative investigations

§ 115.73 Reporting to inmates

Discipline

§ 115.76 Disciplinary sanctions for staff

§ 115.77 Corrective action for contractors and volunteers

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§ 115.78 Disciplinary sanctions for inmates

Medical and Mental Care

§ 115.81 Medical and mental health screenings; history of sexual abuse

§ 115.82 Access to emergency medical and mental health services

§ 115.83 Ongoing medical and mental health care for sexual abuse victims and

abusers

Data Collection and Review

§ 115.86 Sexual abuse incident reviews

§ 115.87 Data collection

§ 115.88 Data review for corrective action

§ 115.89 Data storage, publication, and destruction

Audits

§ 115.93 Audits of standards

Auditing and Corrective Action

§ 115.401 Frequency and scope of audits

§ 115.402 Auditor qualifications

§ 115.403 Audit contents and findings

§ 115.404 Audit corrective action plan

§ 115.405 Audit appeals

During this assessment this Monitor encountered an inmate reported being fondled by another inmate while he was experiencing a seizure and semi-conscious. This inmate stated that while he was semi-conscious another inmate groped his groin area, according to other inmates. This inmate stated that when he regained full consciousness other inmates told him about the event and that he does not have clear memory of the event. This inmate presented a written complaint he was preparing to submit to GGACF officials about the event. The inmate was encouraged to follow through with filing the complaint and allowed VI counsel participating in the on-site assessment tour to have a copy of the complaint. This matter will be reviewed for PREA compliance during the next visit in September 2014.

1. Investigate and resolve the PREA complaint described above. 2. Compare the investigative process and outcomes to the PREA requirements and draft
policy to determine compliance with PREA requirement and needed policy revisions, if any. 3. Provide this inmate written communication advising him that his complaint is being investigated and results of the investigation. 4. Finalize the draft PREA policy for review and comment by this Monitor and USDOJ.

RECOMMENDATIONS: Previously provided recommendations remain appropriate.

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements.
3. Appoint a PREA Compliance Coordinator as soon as possible.

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4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s

PREA auditor certification training. All costs are covered by USDOJ.

5. Complete the PREA Self-Audit.

6. Review, revise, develop, train, evaluate policies and procedures that include, at a

minimum, the following PREA topics:

Policy Organization Definitions Inmate Reporting Staff and Agency Reporting Protection from Retaliation
Hiring and Staffing Viewing and Searches

Staff, Volunteer, and Contractor Training Inmate Education
Inmate Intake and Classification Agency and Staff Response to Inmate Reports Investigations Staff and Inmate Discipline Medical and Mental Health Care Monitoring

F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facilityspecific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: There has been no change since the previous reports. Policies and procedures need to be revised according to the outcomes of a classification instrument validation study that should be performed very soon. Although the current classification system does include many of the decision components required in this Provision, classification staff interviewed were generally confused about how to accurately use the classification tools and procedures. Moreover, much of the current classification system seems to be based on the inmate’s offense of conviction or charged offense, and does not account for other risk factors in accordance with best practices. Compliance with this Provision requires a high level of technical expertise and qualification; it is likely that GGACF officials will require outside technical assistance to comply with this Provision and are encouraged to contact the USDOJ / NIC for this assistance.
Notwithstanding the above assessment and findings, Territory officials submitted to this Monitor and USDOJ on June 6, 2014, a draft classification policy. This document contains many of the necessary policy elements but is not based on an updated and valid classification instrument and related classification process. The policy was therefore rejected. The Territory is commended for its efforts in developing this draft policy, but it must seriously engage in a

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process designed to develop and implement a validated classification system. The policy needs

to be revised according to the classification study, once it has been completed.

RECOMMENDATIONS: Recommendations previously provided remain appropriate.
1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that
provide more accurate and complete guidance for a valid and reliable classification system for non-convicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance. 5. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.
b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As found in the previous reports, detainees and convicted offenders are generally held in separate buildings, except for sentenced and un-sentenced female inmates who are in separate wings of the same building. Inmates are generally housed according to their security level based on their offense of conviction or their charged offense and whether their background includes violent criminal acts. Inmates are also housed according to administrative, disciplinary, special needs, and/or work assignments. This is a very basic but dangerously unreliable practice for managing inmates and is not based on a reliable classification system. Such a practice is known to facilitate violence against inmates and staff, the introduction of contraband, and can create substantial barriers to inmate health and wellbeing. For example, some inmates with serious mental illness (SMI) are being housed in segregation/lockdown unit for unknown reasons and without justification. Many of these inmates are placed on lockdown units because of their mental health problems; GGACF’s lack of an effective and valid classification system prevents GGACF staff from identifying other more appropriate and less punitive housing placements. Indiscriminately housing prisoners on 23 hour-a-day lock down units can exacerbate inmate behavior management problems, their mental illness, and is specifically prohibited by the Order per Provision V.1.p:
“A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;”
Recommendations provided in previous reports remain appropriate. Failure to appropriately classify and separate inmates will remain problematic and contribute to ongoing introduction of contraband, violence, and harm to mentally ill inmates. It will also result in the continued housing of inmates with serious mental illness in isolation/lock-down units, in violation of the Agreement. Refer to previous recommendations.

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RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Order’s prohibition against housing seriously mentally ill inmates in an isolation cell or housing unit. Direct mental health staff to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced-side lock down units to determine mental health needs and if a different, less punitive housing placement is available.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As reported previously in this report, there was some positive improvement observed in the locking of housing unit security gates. However, this system remains flawed because it is inconsistently applied: officers continue to leave these gates unlocked when inside the housing area. Current staffing levels and gate locking practices impair GGACFs ability to comply with this Provision. The May 12th escape and June 7th escape attempt clearly demonstrate this ongoing problem.

Additionally, a lack of housing unit security cameras and monitoring capabilities provides no ability to monitor inmates effectively to detect and potentially prevent them from obtaining unauthorized access to each other. Furthermore, until all locking systems are repaired and maintained consistently, as described above, inmates will be able to disable cell locks and access each other with both social and dangerous intentions.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: This provision reverts to noncompliance due to there being no action taken to improve grievance and incident report tracking, as described in the previous report. Additionally, a review of classification records and interviews with classification staff clearly

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demonstrate serious flaws in the re-classification process. For example, a review of one initial

and re-classification record showed that the inmate was correctly classified as maximum

security upon initial entry into the facility. Later, the inmate was re-classified as minimum risk,

but placed in a medium security housing unit. The inmate then escaped from that housing unit.

This inmate’s classification should not have been reduced to minimum risk simply based on his known history of serious criminal violence; he should have remained as a maximum security detainee and housed accordingly. However, classification decision-making and housing is moot if housing units are not adequately staffed to control inmates.

Interviews with GGACF classification staff revealed no consensus on how to use the current initial and re-classification system.

As stated in previous reports, there is current practice and general policy for reclassifying inmates following incidents involving violence and disciplinary events. However, this process, as previously stated, should be empirically validated.

Additionally, an examination of Grievance and Discipline Logs continues to show they are incomplete and inconsistent. The Grievance Log is missing several important entries indicating that some important grievances go unanswered. The Discipline Log and disciplinary documents provided evidence that many disciplinary cases are dismissed because timely due process was not provided to the inmate. The table below reflects inmate disciplinary cases dismissed during the months of March, April, and May 2014:

March: 6 April: 7 May: 25

Hearing and Disciplinary Committee Monthly Report(s) for April and May both state, “The numbers of Due Process Violation submittals have decreased tremendously”, but reported due process violations increased in April and May.

The accuracy and completeness of these records are very important for making consistent and reliable re-classification decisions. Otherwise, as is indicated in the disciplinary reports, inmates under disciplinary action are given “time served” and released from restrictions without being afforded their right to due process. This will be discussed further in this report.

RECOMMENDATIONS:

1. Refer to previous classification findings and recommendations. 2. Refer to recommendations related to grievance and disciplinary policies and procedures. 3. Ensure accuracy of monthly disciplinary committee reports. 4. The Territory must correct problems reported in the monthly disciplinary. 5. Train classification staff to accurately and consistently complete initial and re-classifications
accordingly.

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e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults,

prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct; and..(f).

ASSESSMENT: PARTIAL COMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As stated in the 3rd report:

Implementation of a new Incident Reporting Log was described in the Baseline Report and remains in effect. However, and as previously reported, a review of this log shows it is often incomplete and often illegible. This log cannot provide an accurate account for incidents because it contains multiple entries for the same incidents using the same or different incident numbers. This makes using this log for compliance with this provision virtually impossible and its uses should be revised.

The GIST (Gang Intelligence and Search Team) program is inadequately staffed to provide the level of evaluation and intervention needed to meet the apparent high volume of incident activity reported in the incident report, supervisor, and housing unit logs. Staff should be added to this program and a comprehensive evaluation and intervention program developed.

Additionally, errors and missing incident reports, as reported in the monthly disciplinary report, impede accurate collection, analysis, and tracking of data to comply with this provision.

RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Develop policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.

f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As reported previously, there remains no formal mechanism or process for regularly reviewing status and conditions of inmates housed in segregation. Additionally, the Monitor was provided no evidence that GGACF tracks and monitors inmate lengths of stay in

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segregation or why inmates are segregated. When viewed in combination with the flawed

disciplinary process, outdated classification system, and the incomplete grievance tracking

process, it is clear that segregated inmates are not provided adequate levels of due process,

monitoring, and review. This practice is very serious and remains in direct violation of the

Agreement. It is also clear that mental health staff are not involved in the decision to place a

prisoner in a segregation unit, nor do they conduct evaluations or otherwise monitor the mental

health of prisoners on these units. This is discussed further below.

Additionally, the frequent practice of “modified” or “full” lockdown due to staffing shortages remains very troubling. This practice, though apparently necessary for security purposes, effectively creates facility-wide segregation/lockdown conditions for days at a time. This must be corrected.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or as a treatment for inmates who are mentally ill.

G. Incidents and Referrals

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

a. Reporting by staff of serious incidents, including (i) fights; serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: These policies have not been submitted as required.

The GGACF incident reporting system remains woefully inaccurate and flawed. For example, a review of incident reports and logs show that more over 50 incidents had no corresponding incident report; 21 incidents with corresponding incident reports were not recorded in the log; and, where multiple incident reports were written regarding the same incident, the narrative accounts given are inconsistent and no attempt was made to correct or otherwise investigate the inconsistencies.

Incomplete, inaccurate, and inconsistent reporting of incidents makes it impossible to effectively manage GGACF resources and facility safety.

RECOMMENDATIONS:

1. Complete and submit policies as indicated. 2. Integrate the Incident Tracking system into this policy. 3. Develop protocols for current tracking system to improve data validity and reliability; this
document is replete with duplication and misleading entries. 4. Develop a unified incident coding system for valid and reliable information and data
collection, reporting, and analysis. 5. Establish regular monthly quality assurance meeting process involving all major department
team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity. 6. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol. 7. Require supervisors to carefully review all incident reports for completeness, accuracy, and consistency.

b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: PARTIAL COMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As previously reported, senior staff now participate in GIST meetings to review incident activity, but additional work is needed for compliance. Moreover, there are no policies or procedures governing or directing this process, and the group does not meet regularly. Furthermore, and as previously discussed, the incident reporting system requires revision before it is a valid and reliable document for incident evaluation purposes.

It is also worth noting that GGACF does not have a Chief Investigator. Warden Redwood was serving in this role prior to being named interim Warden. USDOJ and the Monitor inquired whether and when the Chief Investigator position would be filled, but the Territory has not provided an answer. Without a Chief Investigator, the Warden becomes responsible for investigating all incidents. This places too much on the Warden’s plate and also potentially sets up a conflict of interest. The Warden is both conducting the investigation and signing off on it, meaning there is no additional layer of review to correct errors or suggest areas for follow up.

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RECOMMENDATIONS:

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to previous section on contraband control as it also pertains to confiscation and preservation of evidence

RECOMMENDATIONS:

1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to previous findings regarding incident reporting and tracking.

RECOMMENDATIONS:

1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Such a policy has not been provided.

RECOMMENDATIONS:

1. Include this element in the required policy and procedure. 2. Establish reasonable timeframes as indicated. 3. Develop and implement corrective action protocols for staff noncompliance with adopted
policies and procedures.

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H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The Territory provided to this Monitor and USDOJ a use of force policy draft for review and comment on June 6, 2014. Although these documents reflect good effort by the Territory to comply with this provision, these documents require considerable revision before being implemented. USDOJ provided detailed comments on how to revise this policy to ensure it meets the requirements of the Agreement. The Monitor will work with the Territory to revise this policy during the September technical assistance visit.

RECOMMENDATIONS:

1. Review, revise, develop, train, evaluate use of force policies as indicated and include, at a minimum, the following policy elements: A. Mission and purpose statement; B. Legal authority for use of force; C. Definitions: use of force, conditions, applications, non-physical and physical force; authorized weapons, deadly force, necessary and unnecessary force, etc.; D. Pre-service staff proficiency training, qualifications, certification, and regular in-service training; E. Use of deadly force; F. Use of any weapon authorized for use; G. Reporting requirements; H. Force event quality control and assurance program and methods; I. Self-defense; J. Impermissible force; K. Staff noncompliance corrective measures; L. Medical/mental health involvement in use of force events; M. Force against special populations, e.g., mentally ill, frail, medically ill, aged; N. Planned and unplanned force; O. Special force operations and equipment; P. Officer safety and protection; Q. Emergency first aid; R. Administrative reviews; S. Use of restraints; T. Centralized incident, training, and qualification record keeping; U. Armory operations and instructor training and certification;

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V. Photographing, videotaping, recording of planned force events; W. Other.

b. Circumstances under which the permissible forms of physical force may be used;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since previous reports. See above.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: See above findings.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to findings in H.a. above, and findings and recommendations for Training Provisions. There has been no change since previous reports.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See recommendations regarding Training Provisions and apply to use for force requirements.

e. Training and certification required before being permitted to carry and use an authorized weapon;

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous

assessment.

FINDINGS: No change since previous reports. Per the 3rd report, “Documents were provided that show the names of several officers who participated in weapons qualifications. However, these documents do not clarify whether all officers currently authorized to carry weapons are trained in accordance with the Agreement. The term “weapon” should include any device issued to staff in the use of force against an inmate. This includes, but is not limited to: firearms, batons, impact weapons, chemical weapons, etc.”

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Refer to Training Provision recommendations and apply to this requirement.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since previous reports.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft use of force policy included a provision that requires videotaping by the shift supervisor of all “planned” use of force events. However, the draft should define the term “planned event”. Additionally, the policy should specify who is responsible for video equipment upkeep and reliability, and how videotapes are handled and managed for incident review and investigative purposes.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since previous reports. Security towers remain inconsistently operational due to inadequate staffing and physical plant problems, rendering them an unreliable security control post. Policies and procedures pertaining to this provision were not submitted to this Monitor and USDOJ for review and comment.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft use of force policy contained specific (but not comprehensive) provisions for medical evaluation and treatment of inmates following a use of force event, but does not include a requirement for photographic documentation of injuries.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Revise the draft use of force policy to include all content requirements in this provision.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: NON COMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: A review of incident reports demonstrates several examples of noncompliance with this provision to include the following:

On March 11, 2014, an incident occurred involving confiscation of a cell phone during a random cell search. This confiscation included use of force (GGACF-03-0397-14-IR / GGACF-030394-14-IR). However, officer reports conflicted regarding when force was used. One report states that force was used immediately upon entering the cell to confiscate the contraband; another report stated that force was used after the inmate failed to follow verbal orders from an officer. The incident review does not resolve these conflicting reports to determine whether force was appropriately used.

On April 11, 2014, an incident occurred involving an altercation among several inmates (GGACF-04-0082-14-IR). The incident report indicated that correctional officers used force to

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quell the altercation. This use of force was reported in the incident report, but no use of force

report was completed nor was there documentation indicating whether this use of force was

reviewed and/or investigated.

Although several other reports reveal problems with reporting accuracies, these events demonstrate the need for consistent utilization of a use of force tracking log and supervisory monitoring of incident reports to ensure compliance with use of force reporting requirements.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft use of force policy provided to this Monitor and USDOJ for review and comment includes some, but not all, of the elements required in this provision. The policy should 1) specify circumstances and guidelines for referring use of force events for criminal investigation, 2) include language for resolving report inconsistencies, and 3) describe how prison complaints are resolved. This Monitor will work with the Territory to add these elements to the policy during the September technical assistance meeting.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

l. Administrative investigation of uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The Territory has produced no documents or other information demonstrating compliance with this provision. This Monitor review a draft use of force policy for technical assistance purposes while conducting the SEA assessment. This draft policy was basically well written by lacked specific and complete provisions for administrative investigations of use of force events. This Monitor will be onsite September 8-12 to assist Territory officials to complete this policy.

The Territory provide this Monitor and USDOJ supervisor review documentation for a small number force events. The review document entitled, “Incident Commander’s Review/Critique [of] Use of Force Incidents”, is intended to provide supervisory staff a structured review process “…as

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a means to ensure that the Use of Force Policy and its related procedures/training were adhered to,”

according to the printed form.

The form directs supervisors completing it to include explanations for any areas “checked no” unless otherwise specified.

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft use of force policy does not include language requiring a central tracking system, as required by this provision. This system must be developed and implemented. Deficiencies previously reported in the inmate complaint/ grievance and disciplinary system must be corrected prior to implementing this system, so that the system is comprehensive and accurate.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Correct deficiencies in the inmate complaint/grievance and disciplinary system

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft use of force policy includes a provision for supervisor review of use of force incidents to determine whether and what corrective action is required. This section of the draft policy should be revised to include:

1. Review the reports/investigation for sufficiency and completeness of the documentation surrounding the event;
2. Training needs as related not only to decision making by staff involved in the incident, but also training needs related to compliance with policy and skill applied when using force.

Moreover, supervisors should be reviewing incident reports to determine whether a corresponding use of force report was required, and if required, adequately completed. There are too many incident reports which describe uses of force, but no use of force report is ever provided for review. These two systems must work in tandem with one another to ensure supervisors are reviewing the actions of officers and taking appropriate steps to correct inappropriate behavior.

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RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Revise the draft policy to specifically state the review elements listed in this provision.

o. Re-training and sanctions against staff for improper uses of force.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Training records were again not provided to the Monitor for review during this visit, and the training director was not available during this assessment to discuss this topic. The draft use of force policy should specify conditions in which staff re-training and sanctions for policy violations will occur.

RECOMMENDATIONS:

1. Revise draft use of force policy to include retraining and staff sanctioning content described above.
2. Produce staff training records for review by this Monitor during the next onsite visit.

I. Use of Physical Restraints on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Draft policies and procedures on the use of physical restraints were submitted to this Monitor and USDOJ by the Territory on June 6, 2014. USDOJ provided detailed comments on this policy. The draft policy was unclear with regard to permissible and unauthorized types of use of restraints. The draft should be revised to clearly state and described permissible and unauthorized types of use of restraints. Additionally, it is acceptable and beneficial for training purposes to include use of restraints policies and procedures within a comprehensive use of force policy document.

RECOMMENDATIONS:

1. Revise the draft policy to clearly state and describe permissible and unauthorized types of use of restraints.
2. Consider including use of restraints policies and procedures in a comprehensive use of force policy.

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b. Circumstances under which various types of restraint can be used;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As stated above, the draft policy does not clearly articulate circumstances under which the various types of restraints can be used. For example, the draft policy prohibits staff from using physical restraints until verbal orders have repeatedly failed. There are, however, exigent circumstances when restraint is required immediately to protect staff and/or inmates from imminent risk of serious physical harm. Such circumstances should be clearly stated and staff properly trained in the use of restraints under those circumstances.

The draft policy also fails to clearly articulate circumstances where certain types of restraints might be inappropriate, such the use of chemical restraints on inmates with known medical conditions. The lack of a clear policy in this regard has led to the inappropriate use of force and harm to prisoners. For example, on March 13, 2014, an officer used chemical restraint on an inmate known to have a seizure disorder (GGACF-03-0401-14-IR). In this incident, the inmate apparently became upset with officers for using force against another inmate and this inmate became verbally resistant toward officers. This inmate reportedly “lunged” at an officer and the officer deployed pepper spray at this inmate; the inmate immediately had a seizure. Additionally, other inmates and officers were affected by the pepper spray and had to be decontaminated.

Use of restraint policies and related training should clearly specify circumstances and conditions under which such force can and cannot be safely deployed.

RECOMMENDATIONS:

1. Revise draft policies and procedures to clearly articulate all circumstances under which various types of restraints are authorized for use.
2. Staff must be trained in the use of restraint options with regard to inmate medical conditions, environmental conditions, and controlled use of restraint deployment.

c. Duration of the use of permitted forms of restraints;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Duration of the use of permitted forms of restraints is included in the draft policy discussed above, but revision is required to ensure clarity. The policy draft should also clearly describe the basis for the length of time different restraints are used. For example, one part of the policy states that restraints should not exceed four (4) hours without a face-to-face evaluation by a physician. The policy should specify that the 4-hour limit pertains to “mechanical” restraints. Another part of the policy authorizes continued restraint use not to exceed 30 consecutive days unless approved by the Director. This section of the policy must specifically state what type of restraints can be used for 30 days and for what purposes, especially given the other limitation just described. Although it may be reasonable to require

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additional security restraints during the movement of an inmate for security purposes, keeping

an inmate physically restrained for 30 days is never acceptable and places the inmate at severe

risk of medical and psych-emotional harm.

Overall, the policy must be revised to reflect that total duration of mechanical restraint should not exceed 12 hours without clear justification, approval by the Director, and only after all least restrictive alternatives are considered and verified as ineffective by a multi-disciplinary team consisting of appropriate corrections and health services personnel. Additionally, the 30-day duration period should specifically articulate conditions under which this duration period is used, intended purpose(s), and types of restraints authorized.

The policy should also include clear guidance for limiting the frequency and duration in the use of chemical restrains (e.g., pepper spray).

RECOMMENDATIONS:

1. Revise policy draft as discussed above. 2. Ensure all staff authorized to use restraints are properly trained, supervised, and
monitored in the use of such force.

d. Required observation of prisoners placed in restraints;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft policy previously discussed includes required observation of prisoners placed in restraints. However, the policy requires significant revision before it will be approved.

For example, one part of the policy requires that prisoners placed in mechanical restraints are monitored every 15 minutes by health and security staff while restrained. However, another section seems to contradict this requirement, stating that prisoners are monitored by health care staff every 30 minutes for signs of health problems and injury. This assessment must be documented by medical staff during their 15-minute monitoring. Inconsistencies such as this must be corrected in the draft document before it will be approved.

RECOMMENDATIONS:

1. Revise policy draft as discussed above. 2. Ensure appropriate and consistent documentation and supervisor oversight of
observation requirements.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: The draft policy discussed does not include any provisions for using restraints on

mentally ill prisoners or inmates suspected of suffering from mental illness. This must be

addressed when the policy is revised during the technical assistance visit in September.

RECOMMENDATIONS:

1. Revise the draft policy to specifically address restraint use on mentally ill prisoners and prisoners suspected of mental illness.
2. The policy should include collaborative decision making requirements in the use of restraints involving security, medical, and mental health supervisory staff.
3. Require periodic, routine, structured and documented mental health status assessments by qualified medical / mental health staff for the duration the inmate is under restraint.
4. Include immediate and safe restraint alternatives when a qualified medical / mental health staff person determines such alternatives are required to prevent psycho-emotional harm of the prisoner.

f. Required termination of the use of restraints.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: The draft policy previously discussed above includes a general requirement for terminating the use of restraints when the restrained inmate becomes cooperative/compliant. The policy should be revised to include requirements for terminating restraint use when not doing so subjects the inmate to serious physical and/or psycho-emotional injury and/or harm. Additional, the policy must contain elements mandating involvement of medical and mental health staff with regard to restraint termination decision-making.

RECOMMENDATIONS:

1. Revise policy draft to include requirements to terminate use of restraints when it is determined that not doing so will subjects the inmate to serious physical and/or psychoemotional injury and/or harm.
2. Involve the collaborative decision making process previously discussed in making this determination and to determine less potentially harmful/injurious restraint alternatives.

J. Prisoner Complaints

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: The Territory submitted to this Monitor and USDOJ a draft complaint and appeal process policy on June 9, 2014. The draft requires considerable revision to comply with this provision. This Monitor will provide the Territory specific recommendations once the draft policy is re-submitted to include all basic policy elements. In addition to (or perhaps because of) the deficiencies in the draft policy, the existing inmate complaint/grievance remains woefully deficient.

An examination of inmate complaints/grievances found numerous very troubling deficiencies. There were approximately 122 complaints/grievances written by inmates that were recorded in the GGACF Grievance Log for January – June 16, 2014. The complaints received fall into the following categories:

INM GRIEVANCES COUNT

MEDICAL

11

MENTAL HEALTH

1

MEDICATION

5

ATTY ACCESS

7

WRDN ACCESS

16

FOOD / DIET

15

GT / RELEASE

0

RELIGION

1

PRS PROPERTY

7

WORK PMT

2

STAFF CONDUCT

3

HOUSING

5

GENERAL PRIVILEGES

7

PERSONAL HYGIENE PROC

0

SANITATION

15

RACIAL

0

DENIED HEARING

4

CHARGES

2

DISPUTES

12

INM PROBS

9

DEST GOV PROPERTY

0

APPROX TTL:

122

The log fails to: consistently record complaint types and descriptions; include the date the complaint was received; assign a complaint identification number; note the housing location from which the complaint was submitted; and note the date the complaint was sent to the chief for response. Although most complaints include the date the complaint was submitted to the chief, very few included the date when the complaining inmate received a response or a description of the response. It is exceptionally troubling that only one of the inmate health care complaints for this time period was provided a response by responsible GGACF officials, based

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on log entries. Some of the most serious inmate complaints logged in the Grievance Log

included issues involving medical and/or mental health concerns:

GRV# 101069 281287
271131
271131

Date Received 01/10/14 01/10/14
01/10/14
02/20/14

COMPLAINT DESCRIBED ON GGACF LOG (as written on log)
Inmate is ready to come out of lock down. Said he is mentally competant. Taking meds daily Inmate requesting adequate medical treatment for bladder condition, catterat on both eyes, swelling of feet, stress & constipation Need immediate medical attention. Need to see an expert doctor specializing in traumatic brian injuries on the outside. No Dentist in Medical to do extractions. Inmate request to be allowed to see outside doctor to have it done.

Date Sent to Chief 01/10/14 01/10/14
02/28/14
02/20/14

Date of Response Not Logged Not Logged
Not Logged
Not Logged

Response (as Date Returned

written)

to Inmate

Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

281181 262051

04/11/14 04/29/14

Inmate request medical treatment for ear problem Inmate said he got hurt in the yard by metal sticking out of the ground. He and Inmate []is best of friends. No conflict betweeen them.

04/11/14 04/29/14

212076 271131 271131 942081
201184 271131

05/15/14 05/15/14 06/06/14 06/13/14
06/13/14

Inmate had back & leg pain. Request to be taken to the hospital . Inmate need tooth extraction. Request adequate dental care. No Medical Provider Inmate has pain in leg, not getting enough food, no access to phone to call his athorney and no commisory. Inmate ha seisure in his cell & hit his

05/15/14 05/15/14 06/06/14 06/13/14
06/13/14

06/16/14 No progress on Medical Condition since 06/16/14 last Grievance

Not Logged Not Logged Not Logged

Not Logged

Response 5.15.14: Chief [] stated that investigation is on going about the situatuion that took place
on 1.10.14. Inmate would have a chance
to voice his concern in
court.

Not Logged

Not Logged Not Logged Not Logged

Not Logged Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

Not Logged Not Logged

The grievance system is especially important given that there is inadequate medical and mental health care staff to conduct regular rounds on each housing unit. The grievance system may be one of the only ways for prisoners to get access to such staff. However, when the grievance system is not functioning properly and grievances are not tracked, logged, and timely responded to, prisoners will not get the help they need. This is evidenced in the log entries listed above. The GGACF prisoner complaint / grievance system does not provide a reliable mechanism for inmates to obtain legitimate relief and/or resolution for serious and important issues and concerns. The complaint system’s records management is very problematic because of log

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omissions, noted inconsistencies, and its unresponsiveness to inmate complaints. Furthermore,

if the grievance log is an accurate reflection of the system’s management, it would be virtually

useless for proving exhaustion of administrative remedies required under PLRA.

RECOMMENDATIONS:

1. Revise draft complaint / appeals policy to comply with this provision. 2. Conduct monthly administrative reviews of the inmate complaint reporting and tracking
process to measure and verify program compliance, take timely and appropriate remedial and correction action. 3. Ensure tracking log is consistently completed and accurate. 4. Develop from a valid and reliable tracking a quality management statistical report for monitoring inmate and facility needs and problems.

b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No substantive improvement since previous assessment. See above description of current complaint system deficiencies.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Same as above. 2. Include policy and provisions for timely investigations of complaints, prioritization of
complaints related to risks of harm and safety, and medical and/or medical care.

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: See above description of current complaint system deficiencies.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Complete required policies and procedures. 2. Include specific policy and procedural provisions requiring corrective action for staff
noncompliance, and that ensures timely, consistent, and appropriate disciplinary action against staff who violate the policy. 3. Also consider Inmate Grievance Log issues described above in developing these policies and procedures. 4. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

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d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: See above description of current complaint system deficiencies. The current complaint tracking system is mismanaged, incomplete, inconsistent, and inaccurate.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: See above description of current complaint system deficiencies. The grievance log problems reported above were also described in previous compliance reports; yet, GGACF has done nothing to review or improve the grievance process. This demonstrates the absence of an effective management review process.

Deficiencies in the Inmate Grievance Log continue to demonstrate the absence of a systematic and reliable process for reviewing prisoner complaints, trends, or individual and systemic issue.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. See previous recommendations related to reporting and tracking complaints. 2. Conduct monthly administrative reviews of inmate complaint/grievance tracking reports
and data to identify patterns of individual staff, inmate, and/or systemic problems and issues.

K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

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1. Timely, documented interviews of all staff and prisoners involved in incidents;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No policy or procedure revisions have been submitted to the Monitor for review and there have been no substantive changes since the previous assessment. Additionally, the Chief Investigator position is vacant due to the appointment of the previous Chief Investigator to GGACF Warden.

RECOMMENDATIONS:

1. Submit administrative investigation policies and procedures per this provision as indicated.
2. Ensure the policies and procedures clearly describe investigative timelines, officials responsible who are authorized to conduct interviews, methods and locations of interviews, and other relevant topics that maintain the integrity and legality of the investigative review process and determinations.
3. Fill the vacant investigator position.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No policy or procedure revisions have been submitted to the Monitor for review. Notably, despite the numerous high-level security incidents that occurred at GGACF in the last few months, only one investigative report was submitted to this Monitor for review. This report concerned the May 11, 2014 escape.

RECOMMENDATIONS:

1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling,
preserving, and maintaining administrative investigation evidence, information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No substantive change since previous visit.

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Additionally, and as previously discussed, even if an investigation determines that an inmate

deserves some form of punishment for a disciplinary infraction, that punishment is often not

determined or enforced because due process proceedings often do not occur. A review of

prisoner disciplinary files from the last three months shows that some prisoners had disciplinary

action taken against them, but the disciplinary charges were dismissed because there were not

enough staff to conduct the due process hearings. Recommendations provided in the previous

report remain appropriate. There were no administrative investigations initiated to look into

staff misconduct, to the best of this Monitor’s knowledge. These investigations must also be

conducted, reviewed, and tracked.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No substantive change since the previous assessment. The Monitor has not received any information outlining when and how investigators will be trained. It is also unclear how many investigators are on staff and assigned to conduct investigations at GGACF. The only investigative report received during the last few months was completed by the Warden, not an investigator. RECOMMENDATIONS: Fill the currently vacant Chief Investigator position. Previous recommendations also remain appropriate:

1. Create a formal pre- or in-service training program to train staff who are involved in initial and/or administrative investigation.
2. Provide adequate training of investigative staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
3. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management.
4. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities.
5. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review upon his/her appointment.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous

assessment.

FINDINGS: No substantive change since previous assessment with regard to policy and procedure submissions. Regarding staff discipline, however, GGACF officials reported (but did not provide any documentation of) several instances of disciplining staff where their involvement in misconduct was determined. This Monitor requests full review of these instances during the upcoming site visit.

Regarding inmate discipline, and as previously discussed, the current system remains ineffective for delivering fair, reliable, consistent, and meaningful inmate discipline for multiple reasons, as demonstrated by a review of numerous documents and an interview with the discipline coordinator.

As previously stated, the monthly disciplinary hearing reports continue to report a high number of inmate disciplinary cases being dismissed as a result of due process violations. The coordinator continues to write in the March, April, and May monthly reports the following problems with regard to ensuring a timely, consistent, and reliable inmate disciplinary process:

“I am still having difficulty in forming a solid [inmate disciplinary] panel to conduct hearings. My dilemma is that all the officers that I have suggested/recommended to assist me to conduct these hearings are assigned to provide shift coverage/special assignments/re-assignments. This has resulted in my utilizing staff on an overtime basis.”

“HDC are still receiving incident reports that are being submitted with supervisors signing off without proof reading the incident reports. As per last discussion with then Warden [], a report writing class is very much needed to assist and improve noticeable deficiencies among officers and supervisors alike”.

“Security staff are still not utilizing the newly implemented incident report forms (Disciplinary Report & Incident Reports). Staff needs clarification and proper orientation on what is warranted for each report document for smooth transition. Those who are using the correct form are not inputting the codes that are being violated in the provided section or even a description of the incident. Responding or assisting officers are not submitting supplemental reports. A few reports are being tagged with a report number from central control.”

[Regarding due process violations] “…I am still getting unaccounted reports after the fact and are not being properly documented, which is resulting in inaccurate numbers for reports/compilation”.

These problems demonstrate an ongoing serious lack of quality control and staff and supervisor accountability that should be corrected without delay. The inmate discipline system is not only ineffective due to lack of adequate staffing, but lacks sufficient oversight and organization to deliver meaningful and consistent outcomes.

The following examples are demonstrative of the problems with inmate discipline at GGACF:

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 4/11/14: three inmates (AW, RB, JI) were charged with fighting and given 90 days in lock down. However, on 4/6/14 another inmate (CB) was also charged with fighting,

plus additional charges for multiple other violations. Unlike AW, RB, and JI, CB was

given only 60 days in lockdown with a good time loss of 12 days. It appears that a lesser

penalty was issued for multiple violations.

 4/6/14, 3/26/14, and 3/26/14: inmates RM, MR, and AS were each charged with disorderly conduct. RM received 15 days lockdown, MR received 44 days lockdown, and AS was given a verbal reprimand. Again, these penalties seem inconsistent considering these inmates were charged with the same violation.

 3/27/14 and 4/15/14: inmates JI and AS were both charged with possession of an unauthorized sharpened instrument; AS was also charged with possession of contraband. Inmate JI (only charged with one violation) was given 120 days lockdown while inmate AS (charged with two violations) was given 50 days with a six day loss of good time. Again, these penalties seem inconsistent, and also suggest that staff are not clear about how to charge inmates with violations. If possession of an unauthorized sharpened weapon can be charged as two violations (possession of unauthorized weapon and possession of contraband), staff should be instructed to always charge an inmate with both of the violations or only one of the violations. Inconsistent charging practices cannot yield consistent meaningful outcomes and comport with due process.

The monthly disciplinary committee report also demonstrates ongoing reliability problems with the incident reporting system. The Incident Report Log for 3/5/14 to 6/6/14 is inconsistent with the Monthly Disciplinary Reports for March – May, 2014. Here just a couple of examples:

 The March incident log shows only one offender-on-offender assault occurring on 3/20/14, involving inmate JD. The disciplinary report also shows only one such assault, but reports that it occurred 3/1/14 and involved inmates KM and CF. (Note: the April disciplinary report does not show the 3/20/14 assault so it was not carried over to April for disposition).

 The April incident log shows three offender-on-offender assaults, occurring on 4/15, 4/16, and 4/28. These assaults involved inmates JD, LD, and PD respectively. The disciplinary report for April shows five such assaults (4/3, 4/10, 4/11, 4/23, 4/28, 4/29) involving inmates CP&RM, ED&EV, AW&RB&JI, ER&PD, AJ&FH, and FS&MJ respectively. The incident log reports two such assaults that were not reported on the disciplinary report. The discipline report shows four such assaults not reported on the incident log.

The problems noted above with the administrative investigations system also demonstrate noncompliance with all provisions of the Agreement that rely on a valid and reliable incident reporting system.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.

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2. Integrate the information in the above into the administrative policies and procedures

previously discussed.

3. Record and maintain onsite records of staff misconduct investigative reports and

determinations.

4. Protect the integrity and confidentiality of these staff records, control access to records,

provide a process for authorizing legitimate access and review of these records for

general reporting purposes, monitoring, and supervision of staff.

5. Provide training to supervision staff in the appropriate use of this information for staff

supervision, counseling, discipline, promotion, etc. purposes.

6. As with all training, especially training required for and that supports the monitoring of

the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:

a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;

ASSESSMENT: NONCOMPLIANCE – - No substantive improvement from previous assessment.

MEDICAL FINDINGS: First, we reviewed with the Health Care Administrator and the new Medical Director the policy regarding intake screening as well as health assessment and tuberculosis screening. Based upon prior discussions, we worked on finalizing the intake screen form to be utilized by nursing staff as well as the health assessment form to be used by PAs or physicians. The new policy is designed to insure that, based on the intake screen, patients with positive screens would be seen for their health assessment by an advanced level clinician within one to three days. The intake screen policy includes an acuity scale which would describe to the nurses, based on the positive findings, the urgency with which the health assessment must be completed. More urgent problems must be assessed the same day or within 24 hours. The least urgent must be assessed within three days of entry. The only patients who would have their assessment in a longer timeframe would be based on a decision reviewed by a clinician that the patient needed to be monitored daily and the data for one week must be reviewed in order to determine the nature of the problem. As an example, a patient who had a history of hypertension and a normal blood pressure on intake, but who had been off medications for a month, would have his blood pressure repeated daily and then be assessed by the physician on day 7 to determine whether or not the patient needed to be enrolled in the hypertension program. Such a process is being utilized in other facilities and forces the intake process to utilize clinical data in making determinations with regard to assessments and their urgency. In fact, after revising the forms somewhat, both the intake screen and the health assessment form, we had each of the two registered nurses perform an intake screening, one on Dr. Burton and the other on Dr. Shansky. We then jointly had a discussion about how to interpret positive answers to questions in relationship to the utilization of the acuity scale. This exercise should be performed by the former Medical Director, , with the nurses on at least a weekly basis while the forms are being implemented. This way, questions can be resolved and the performance by the nurses will achieve the threshold level sought by the Medical Director. It is important to note that none of the new forms have been submitted to the Monitor or USDOJ per the Agreement and must be approved before full implementation.

We also reviewed several records of patients who had entered the facility over the last few months, focusing on the intake process. Not surprisingly, we found major deficiencies. This was due to

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shortages of nurses as well as shortages of advanced level clinicians. The problems we found

included the absence of officer health questions which should be used to deflect unstable patients

to a hospital for clearance, the absence of a nurse screen, the absence of a health assessment and

also the incorrect performance of the health screen and lack of data in the record of TB skin test

results. Finally, we found instances where the health screen was performed three days after the

patient had arrived at the facility. Some examples follow.

Patient #1 A male in his twenties arrived at the facility on 4/11/14. In his record there was lack of an officer questionnaire, there was lack of a nurse screen and there was no health assessment. There was only a note by the doctor, which did include a physical exam but was deficient in that there was absolutely no subjective or historical data obtained from the patient.

Patient #2 A young man arrived at the facility on 4/10/14. His intake screen, performed by a nurse, had multiple blank spaces suggesting that the questions had not been asked. There was a record of a TB skin test having been planted but not read. There were vital signs performed. The patient was given an acuity number 3, but no health assessment was ever performed.

Patient #3 A 34-year-old inmate arrived on 4/19/14. In this record, there was an officer form but it was incompletely filled out. There was a nurse screen; however, it was performed three days after the patient arrived. This patient had an elevated blood pressure of 144/98. Much of the nurse screen was left blank. The acuity scale assigned was number 1, which should have necessitated a health assessment done on the same day or within 24 hours, and yet there was no history and physical. There was a note indicating a follow-up visit for the patient who had received a gunshot wound to the right thigh prior to entering the jail; however, this gunshot wound was not mentioned on the nurse screen.

Patient #4 A 43-year-old entered the facility in April 2014. There was a nurse screen done; however, there were many blank fields and no vitals were performed.

It is clear that the program needs to finalize its forms and the policy, and provide training to the nursing staff. However, that staff needs to be bolstered. There are at least two more vacant registered nurse positions and those need to be filled as soon as possible.

RECOMMENDATIONS:

1. Hire the additional two registered nurses. 2. Finalize with the Medical Director the intake policy and the forms, and once feedback is
received from the monitor, begin training and implementation of the policy and the forms. 3. The Head Nurse should continue to review and provide feedback to the nurses with the
assistance of the Medical Director, who should also review the timeliness and quality of the performance of the PA and physicians. 4. With regard to the after-hours ability to remove officers from any involvement in the medical screening process as opposed to the pre-book questions, develop a list of questions by the Medical Director geared to determine whether the patient can wait up to eight hours

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in order to be screened. If those questions suggest instability, the nurse performing those

screening questions over the telephone must contact the physician. If the questions reveal

no instability, the patient can wait until screening can be performed in the morning at 8:00

a.m.

5. Hire the additional nursing staff so that both the intake screens and the nonemergency health

care request policies can be consistently implemented without any disruptions due to

vacations.

6. Complete the policies that address both scheduled and unscheduled offsite services so that

follow up after the service has been provided is improved.

7. Make the changes on the chronic disease service policy in order for implementation to

begin. It is especially important for the clinicians to utilize both the initial chronic care visit

form and subsequently the follow-up chronic care form.

8. The following policies can begin to be drafted or modified:

a. Hospital and specialty care b. Urgent/emergent services c. Access to care d. Responsible health authority e. Medical autonomy f. Segregated inmates g. Patient safety h. Infection control i. Right to refuse j. Grievance mechanisms k. Clinical performance enhancement reviews l. Health training for correctional officers m. Medication administration training

MENTAL HEALTH FINDINGS: - No substantive improvement from previous assessment.

During this fourth site visit all provisions of the settlement agreement were reviewed with the on-site health management team which included:

1. Vernita Charles, Health Services Administrator 2. Dr. Sang, psychiatrist 3. David Nowak, head nurse 4. Theresa Drigo, case management planner 5. Kendrick Robertson, Assistant Attorney General for the USVI

Mental health policies have never been sent through the required process under the Settlement Agreement. The Health Services Administrator will initiate that process and policies will be reviewed prior to or during the next site visit in September 2014. The staff are aware that Dr. Shansky and I are both willing to assist in any policy development under the technical assistance provision of the settlement agreement prior to their being advanced under the formal process in the agreement. Additions to the intake form were made at the time of the site visit and given to Ms. Charles.

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RECOMMENDATIONS: 4th Assessment:

Continue to develop mental health policies to be vetted through the process defined in the settlement agreement

Previous Recommendations Remain Appropriate:

1. A more effective intake process should be developed so that medical staff has access to new detainees and prisoners within 24 hours. The initial security screening tool is not robust enough to provide good identification of medically and psychiatrically ill people. Security staff conducting these interviews will require additional training by health services (medical and mental health) and a quality assurance tool should be developed to monitor the completeness of their documentation and the accuracy of their triage to medical and mental health staff.
2. Medication bridging is problematic with evidence of medications being prescribed and administered but not ordered by a clinician. A review method needs to be developed to oversee the reliability of this process.
3. All of the medical policies need to be reviewed and modified as applicable to this facility. 4. The facility needs to purchase sufficient stethoscopes and sphygmomanometers to ensure
availability of more than one of the latter on site. There should be sufficient instrumentation, at a minimum, for the treatment building, reception/suicide watch area, and the emergency response bag.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: See medical findings under (a). The deficiencies listed under (a) reflect both inadequate staffing as well as insufficient training of the health care staff as well as insufficient review and feedback to them. With the addition of the Medical Director and one registered nurse, the program is closer to but not yet in a place where staffing is considered adequate. The leadership team, while it strives to obtain additional resources, must work with the staff so that to the maximum extent possible, the performance of the existing staff meets the standards sought by the leadership team. We talked with the Medical Director about his role and especially his presence and involvement onsite. It is absolutely critical that both the health care staff as well as the custody staff view him as the practitioner who manages the patients at the correctional facility. Unfortunately, however, Dr. Burton’s contract was terminated following this onsite assessment due to miss-steps by Territory officials with regard the selection process.

RECOMMENDATIONS: 1. See the recommendations under letter (a). 2. Provide training for the nurses using the intake screening form so that all fields are filled out,
even when the response describes a negative answer.

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3. Insure that the health screen includes vital signs.

4. The Medical Director should provide guidance to the nurses with regard to the level of

abnormality that requires an immediate physician contact.

5. Insure that TB skin test results are documented in the record in the appropriate space and not only

in a logbook.

6. Both the head nurse and the Medical Director should, on an ongoing basis, provide a review of

the quality of the intake process as well as the completeness, with feedback to the nurses as well

as the physician assistant.

MENTAL HEALTH FINDINGS: No substantive improvement from previous assessment. Currently the health service does not keep an intake log, sick call log, behavioral checklist referral log, or a chronic care log. Health service does have an emergency room log that tracks follow-up of the patient by a nurse or doctor within 24 hours.

RECOMMENDATIONS: 4th Assessment:

Appropriate logs need to be developed to track critical processes to ensure inmates have adequate access and follow-up for medical and mental health services.

Previous Recommendation(s) Remain Appropriate:

1. Despite significant improvements in the intake assessment form, there remain significant deficiencies in the nursing staff's capacity to identify inmates for referral to mental health services and the timeliness in delivering those referrals. Medical administration and the nursing director need to address these deficiencies and develop monitoring tools for quality improvement purposes to ensure that this process has been corrected.

c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: Given the shortage of nursing staff as well as the absence of a Medical Director, there were periods of time when the only RN available was required to perform other activities and was not able to perform sick call. In addition, there was no predictable onsite physician presence. Therefore, this area remains in noncompliance. The problem of access remains a critical one in that there frequently are insufficient officers to provide escort to patients. In addition, rooms in the housing units that could be and should be utilized for sick call assessments have neither been cleaned nor supplied with appropriate equipment and supplies. Therefore, all sick call has to be performed in the clinic area, requiring officer escorts. The sick call program cannot be effectively implemented until there are both adequate nursing and physician staff, adequate escort security staff to bring patients to and from appointments (where necessary), and the ability to perform the process in the housing units when appropriate. We identified records where patients had submitted requests and were either not seen by a nurse at all or were seen several days after the

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sick call request was received. There is a sick call log in place and this is a step forward. However,

in order for the program to achieve partial compliance, both the medical staff and custody staff

support must be adequate and all related policies must be completed and approved. This

requirement has proven thus far impossible to achieve.

RECOMMENDATIONS: 1. Obtain a schedule from the Medical Director such that he provides sufficient time onsite to acquit his responsibilities so that nurses can schedule both follow ups from sick call, chronic disease visits, and follow ups from scheduled and unscheduled offsite services as required. 2. Fix up the examination rooms in the housing units, providing the necessary equipment, including exam table, desk and chairs, along with the necessary medical equipment and supplies to insure appropriate sanitation. 3. Hire the remaining nursing staff so that the nurse staffing is four full-time RNs and at least three full-time LPNs. 4. Insure that your log tracks the sick call process from request placed in the box by the patient to collection by health care staff and receipt, which is time-stamped by the registered nurse and then triaged by the registered nurse. Symptom-describing requests should be assessed by a registered nurse within one day. 5. Have the head nurse utilize the sick call log to insure the timeliness and clinical appropriateness of the nursing assessments.

MENTAL HEALTH FINDINGS: The Psychiatry Service is maintaining a clinical log which still lacks the requirements necessary to determine timeliness of follow-up services. However, the psychiatrist has drafted a new spreadsheet that will address the monitoring aspects of this provision.

Access to permanently assigned escort officer(s) remains a major impediment in the operation of an efficient and timely clinic process for medical, dental, and mental health. The clinic officer is still leaving his post frequently to carry out other functions and repeatedly has difficulty obtaining escort officer assistance.

RECOMMENDATIONS: 4th Assessment:

1. Recommend creating two permanent security posts for the medical clinic, a clinic officer and an escort officer, to ensure that access to medical services is not impeded and safety of staff and inmates is preserved.
2. Mental health staff with the support of the Health Services Division, the Warden and the Bureau should design an adequate mental health delivery system for the facility and develop plans to staff and implement the required services.
3. The Monitor’s team should be utilized for consultation and/or technical assistance. 4. The facility needs to define by policy the qualifications required for each clinical process as
well as time frames to complete these processes and provide the clinically necessary followup. 5. Once an approved programming plan is established, an additional internal staffing analysis needs to be completed to determine the required minimum number of psychiatric hours and counseling hours needed to implement the plan.

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6. Mental health staff should perform, at a minimum, weekly segregation rounds and monthly

well-being checks on all sentenced inmates on the mental health caseload.

Previous Recommendations Remain Appropriate:

1. The elements in the above findings should be used to promulgate a policy and procedure related to access to care and sick call. A system for a confidential retrieval of sick call request by medical staff should be implemented and codified in policy.
2. Mental health staff, with the support of the Health Services Division, the warden and the Bureau should design an adequate mental health delivery system for the facility and develop plans to staff and implement the required services.
3. The Monitor’s team should be utilized for consultation and/or technical assistance. 4. The facility needs to define by policy the qualifications required for each clinical process as
well as time frames to complete these processes and provide the clinically necessary followup. 5. Again, a staffing analysis needs to be completed to determine the required minimum number of psychiatric hours and counseling hours needed. 6. Mental health staff should perform, at a minimum, weekly segregation rounds and monthly well-being checks on all sentenced inmates on the mental health caseload. 7. Nursing transcription omissions should be addressed through education, supervision, and monitored by a Quality Assurance process. 8. GGACF needs to closely monitor shift changes and assignments of officers to ensure that access to medical services is not impeded.

d. Continuity, administration, and management of medications that address (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We did not have the opportunity to review the most recent version of the medication policy. We have seen a report prepared by the contract pharmacist which raises some serious questions. She performed a record review in which she found inconsistencies between orders that were present in the medical record or should have been present versus orders on the medical administration records (MARs). There were instances where there was a MAR but no order in the chart, there was an order in the chart that was inconsistent with what was on the MAR, and there were orders in the chart for which there was no MAR. She recommended a review of all records be accomplished and the inconsistencies be resolved and eliminated. This is necessary in order to protect the patients as well as the nurses and the community. We did find out that on at least one occasion, there were no nurses onsite and the medication pass was skipped. There have also been instances where there has been no officer to escort the nurse to do medication pass, thus completely compromising the ability of the nurse to perform this task. Finally, on some days, especially on weekends, we are aware that the nurse completed the evening pass by 4:30 in the afternoon, much too early and clinically inconsistent with what was required. We did not have an opportunity to

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review the medication pass itself on this visit; however, it is important that the head nurse review

with each nurse the appropriate requirements for a professionally correct medication administration.

RECOMMENDATIONS:

1. Fill the nursing positions. 2. Ensure adequate custody staffing to maintain consistent access to inmates for medication
administration, whether cell-side or at the medical building. 3. Draft the medication management policy for review by the medical expert at the time of the
next visit. 4. The lead nurse should work with the Medical Director in order to develop a procedure that
allows the nurses to carry the medications with them to the cell houses and also to bring the medication administration records so that, at a minimum, they are recorded no later than when the nurses are ready to leave each housing unit. 5. The officers’ post orders should require that they perform a mouth check after each administration. 6. Develop a procedure that enables timely provision of discharge medications to both sentenced and pretrial detainees at the time of release. 7. Perform a review of all of the records to look for inconsistencies between orders written on an order sheet and individual medication administration records. Any inconsistencies found must be corrected.

MENTAL HEALTH FINDINGS: Chart reviews demonstrated continued clinically significant problems in the timeliness and adequacy of psychiatric and medical follow-up as follows:

 A black male in his sixties presents with chronic schizophrenia. He has had active and persistent psychotic symptoms for the last several months. Yet despite the acuity of his symptomatology and repeated lockdowns because of it, he has been seen only on three occasions since January 2014 for mental health follow-up.
 A male in his thirties has been diagnosed with chronic paranoid schizophrenia. He has been incarcerated on several occasions with a recent readmission on March 25, 2014, at which time he was seen and immediately referred to the emergency room where Dr. Sang saw him. He eventually returned to GGACF but he has not been seen since that initial visit in March. His chart lacks an intake screening form and a 14-day history and physical as well.
 A male in his twenties has been incarcerated at least since March 2014. There is no intake screen or history and physical in his record. In fact, his medical record consists of three sheets of paper, one March 12, 2014, describing a lip injury for which he was sent to the emergency room; a follow-up for suture removal on March 20, 2014; and an evaluation by the psychiatrist June 6, 2014, where he was diagnosed with an adjustment disorder and placed on Haldol 2 mg and Ambien 10 mg at bedtime.
 A male inmate in his thirties (chart was reviewed upon referral from Ms. Myrthil) had an xray ordered in April 2014, following complaints of low back pain. The x-ray was never done; the referral was retained by the offsite scheduler and no appointment was scheduled because there was no medical director on staff to approve the request. The medical director began work two weeks prior to the June on-site assessment, but during that assessment it was discovered that the medical director never received the referral for review. The inmate was not been seen again after the referral was ordered in April.

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 A male in his fifties has a diagnosis of cardiovascular disease (chart was reviewed upon referral from Ms. Myrthil). He has not had chronic care follow up for the 5 months between 10/1/13 and 3/12/14.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

1. Nursing staff should be instructed as to the proper procedure when administering medications to all inmates.
2. Supervisory observation of performance should be periodic and unannounced to ensure the effectiveness of in-service training on medication administration.
3. Quality measures should be implemented to monitor the timeliness and accuracy of order transcriptions.

4. Laboratory studies and requested medical records should always be reviewed and dated and initialed by the clinician prior to being filed in the medical record. This process ensures that critical information will not be missed by the treating clinician.

e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: The medical records we reviewed with the Medical Director were nothing short of appalling. There was no chronologic consistency, there was no filing within given sections consistently and it was extremely difficult, if not impossible, to track what was happening for each patient. There must be a medical records clerical position added to the staffing as soon as possible. Such a position does not have substantial budget implications. It is not clear why this has not been accomplished. It was extremely difficult to attempt to track the occurrence of encounters, lab reports and offsite services, given the state of the medical records.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. Hire a medical records technician as soon as possible, presumably before our next visit. 2. The medical records policy should include timeframes for filing of documents and for
reviewing, initialing and dating by clinicians. 3. Continue to utilize the monitor’s staff for input in modifying the medical record policy.

MENTAL HEALTH FINDINGS: Ms. Jennifer Charles, the mental health clinic coordinator, has not been at work since two weeks after our March visit. She has used up her sick leave and has not contacted the BOC with a formal notification of resignation. Staff report that she shredded all of the documents in her office the last day she was on site. It is unknown what materials were destroyed.

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Since Ms. J. Charles was not in the habit of filing her clinical records in the medical chart, it is likely

some of those encounters were among the papers shredded.

No medical records person has been hired and the clinic is still waiting for temporary help. The medical records remain disorganized. Cover sheets have been added to some charts to improve the format of the medical records.

The reviewer observed that the Medication Administration Records for the entire year 2014 were unfiled and reportedly stored in piles in the nursing station. This problem was discussed with the team and it is my understanding that during a lunch break that same day the administrator addressed this problem with the staff. She reports they all filed some forms during this break.

RECOMMENDATIONS: Unchanged from the prior reports. Failure to maintain comprehensive and accurate medical records is a major deficiency that hampers provision of adequate medical services and should be addressed with great priority.
4th Assessment:

1. It is essential that the clinic develop a culture of functioning as a whole and during periods when there is little inmate movement they all contribute to team building tasks.

Previous Recommendations Remain Appropriate:

1. There is a need to draft a more detailed medical record policy. 2. The Monitor’s staff should be utilized as resources to facilitate development of the policy
and procedure. 3. One chart per inmate, combining medical and mental health documentation for an
integrated record. 4. It is recommended that the mental health professional immediately file her notes in the
medical record so they are available for the psychiatrist to review. 5. A policy needs to be developed with documentation guidelines and instructions for
organizing and maintaining the medical record. 6. Quality improvement effort should be undertaken to track compliance with policy once
implemented.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for the policies.

RECOMMENDATIONS: See letter (c) findings and recommendations.

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MENTAL HEALTH FINDINGS: As stated above there is no mental health sick call log. Requests that come in are given to the psychiatrist by nursing staff but none are stamped with the time and date of receipt. Dr. Sang reported that if the inmate placed her name on the sick call request she will receive it quickly. The new medical case management planner also reported checking daily for sick call requests and referrals to mental health for which delays were noted in the Third Report and were a significant deficiency.

Women on X Dorm reported that the nurse stops by the outer lock gates to the unit and pass medication through the gate. If an inmate is unaware or unable to walk to the gate to be seen, no medical rounds are actually done in the unit.

RECOMMENDATIONS: 4th Assessment:

No change from the last report.

The Health Services Administrator stated that she would generate a mental health sick call log that will track:
1. the date the request is initiated 2. the date the request is received by medical 3. the date the request was triaged by a qualified health professional 4. the date the request is received by mental health 5. the date the request is resolved 6. Proper medical rounds should be completed in all housing units.

Previous Recommendations Remain Appropriate:

1. A confidential process needs to be established that enables:  monitoring of the timeliness of retrieval of sick call requests  appropriate triaging by a registered nurse or mental health professional (in the case of mental health requests)  timeliness of response by the appropriate qualified health professional  appropriateness and effectiveness of the treatment plan generated.

f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There has been some progress regarding the development of logs for intake processing, sick call, scheduled offsite services and unscheduled offsite services. Most of these logs have the recommended fields. However, what is lacking is the ability to insure that the data reflects the full complement of services scheduled and provided. We found unscheduled visit logs which had no dates for a week and a half. It strains our credulity to believe that there were no unscheduled sendouts during this time period. Similarly, the infrastructure has not been set up to insure that the

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logbooks capture all of the relevant data. We would encourage the Health Care Administrator to sit

down with the Head Nurse, the Medical Director and the offsite services coordinator and figure out

how they can set up a procedure that insures that each of these individual logs contains the entire

compliment of services provided.

RECOMMENDATIONS: 1. The Health Care Administrator, the Head Nurse, the Medical Director and the offsite services coordinator should meet and analyze what procedure should be put into place to insure that the intake processing log, the sick call log, the scheduled offsite services log and the unscheduled offsite services log all contain the full complement of required services provided. The same should be done for the chronic care log. 2. The monitor’s staff are available as resources to assist in developing these procedures.

MENTAL HEALTH FINDINGS: There has been no change in the mental health caseload tracking form. Dr. Sang has developed a new spreadsheet that, when implemented, should address most all of the requirements of this provision.

RECOMMENDATIONS: 4th Assessment:

The new log should be maintained in a sortable format such as a Word table or Excel worksheet for ease of maintenance of an accurate record. Electronic logs can also be shared with the Health Services Administrator and Medical Director for quality management purposes.

Previous Recommendations Remain Appropriate:

1. The current log should be maintained in a sortable format such as a Word table or Excel worksheet for ease of maintenance of an accurate record.
2. Health services may consider developing an intake log that records the inmate’s name, number, date a sick call request or behavioral referral is received, the date the request was triaged, the date it is received by the service responsible to respond (medical, dental, mental health), the date the issue has been resolved and the initials of the responding staff person. Such a log would assist in the quality assurance efforts when studying timeliness and access to care.
3. It is also recommended that the date of the last mental health and psychiatric visit as well as housing location, and the follow-up date be entered. This will enable quick assessment as to whether someone has accidentally fallen off the schedule and whether they are in a special housing unit.
f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: This section addresses the medical chronic and acute care program. We

reviewed records of patients with chronic illnesses and were frustrated by the difficulty in attempting

to assess the care provided. The following are a few examples.

Patient #1 Male inmate in his thirties has a chart with a blank problem list but a history of diabetes type 2, including a toe amputation. There were no chronic care forms filled out in his chart except for an initial baseline visit that was used inappropriately as a follow-up visit. It was extremely difficult to track how his care had been given.

Patient #2 Inmate in his thirties arrived in 2013, and was assessed as having diabetes type 2 and bipolar disorder. There were no chronic care forms utilized and under assessment, rather than describing the degree of disease control, the assessment area literally said, “diabetes type 2 or diabetes stable.” There was no hemoglobin A1c in the chart since October 2013. Given the absence of both physicians and nurses, it is not surprising that there would be these deficiencies. With the departure of the Medical Director, we are very concerned that the performance in this area will remain problematic, placing these inmates a serious health risk.

RECOMMENDATIONS: 1. The Head Nurse should work with the nursing staff, supervised by the Medical Director, to develop a list based on medications of patients being seen for each of the common chronic diseases. This list should then be turned over to another nurse who will be responsible for maintaining it, that is, adding new names of people who enter and eliminating the names of people who have been released. The patients should be seen based on disease control, with those in better control being scheduled for less frequent visits. 2. The Medical Director should contact the medical monitor to discuss the chronic care program.

MENTAL HEALTH FINDINGS: Currently, the mental health professional maintains the case list that identifies those inmates followed both on the detainee and the sentence side of the facility by the psychiatrist. The psychiatrist stated that inmates prescribed medications for a temporary problem will not be included in the caseload. The list contains the inmates name, diagnosis, medication regimen, BOC number, and date of birth. The list is lacking the date for the next psychiatric and counseling visit and should include the names of every inmate currently receiving any psychiatric medications and who is actively engaged in mental health treatment and follow up. In reviewing the medical records it is clear that people are not scheduled for follow-up as medically necessary or in a timely manner.

Patients are scheduled in the chronic care mental health clinic in unpredictable and inconsistent fashions. Frequently, people appear to be lost to follow-up despite a diagnosis of a serious mental illness.

There are no published mental health treatment guidelines provided to clinicians for appropriate and timely chronic and acute mental health patient follow-up.

RECOMMENDATIONS:

Develop and make available to clinical staff practice guidelines under this provision.

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Previous Recommendations Remain Appropriate:

1. Contact the Monitor and his staff for consultation and/or technical assistance. 2. A minor modification to the current case list log as recommended above would improve the
tracking capabilities of the facility. 3. The list should contain both the BOC number and the inmates’ date of birth. 4. Any inmate followed by mental health should be captured on a log, perhaps one for psychiatry
and one for counseling. 5. As mentioned previously, a policy that would dictate required time frames for follow-up of
people in the chronic care mental health clinic may improve the timeliness of return visits and allow for tracking when looking for quality outcomes. 6. All prison inmates on a mental health caseload should have at a minimum a monthly wellbeing check by a mental health professional. Minimum frequency of psychiatric visits should be outlined by policy not to exceed every 90 days. 7. The mental health caseload should be modified to track the date of the follow-up visit for easy identification of overlooked appointments and housing unit to identify those in segregation or special housing.

f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: Given the shortage of staffing, there are lengthy periods of time when there are no medical staff onsite. This creates real gaps in understanding what happens to patients. We are told that when a patient presents with a serious condition, custody becomes aware and then sends the patient out. Once another Medical Director is appointed, there should be an arrangement with the Warden such that officers are trained that no patients will be sent out as medical emergencies unless the Medical Director has been contacted. We believe that from 8:00 a.m. to 8:00 p.m. Monday through Friday and possibly 8:00 a.m. to 6:00 p.m. on Saturday and Sunday, there are medical staff onsite. When they are onsite, they are contacted and they frequently make their own decision as to when to send the patient out. Even when medical staff are onsite, they should now be contacting the Medical Director and should arrange for the Medical Director to interview the patient by phone if he so indicates a need. We continue to find records in which patients were sent out emergently with no prior notes and patients were returned with no follow-up notes. All patients upon return who arrive when health care staff are there should be seen by a health staff member and then be scheduled for a follow up with a physician or a PA as soon as possible.

RECOMMENDATIONS: 1. Complete the urgent/emergent policy, insuring that the Medical Director is involved and there is timely follow up onsite.

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2. The offsite service coordinator should be responsible for insuring the emergency room reports

are available timely and that follow-up visits with the clinician are scheduled timely.

3. The emergency care policy should include requirements for training and certification in basic

life support and first aid as well as the documentation of critiques of quarterly emergency

drills.

4. Nurses should be trained that when patients return from unscheduled offsite services, they

should document a note that describes the patient’s condition along with a set of vital signs

and insure that the appropriate paperwork is available.

MENTAL HEALTH FINDINGS: No change since previous report. The training on the management of mental health crises was to have been completed June 1, 2014, but had not been initiated at the time of the site visit. Importantly, the BOC made no attempt to involve any mental health staff in the development of this training. During the on site visit, we discussed the importance of involving Dr. Sang in the training curriculum development. This is discussed further below.

RECOMMENDATIONS: 4th Assessment:

Develop and submit required training curriculum to the Monitor for review and approval, commence training.

Previous Recommendation(s) Remain Appropriate:

1. Consider opportunities to improve coordination between GGACF staff and community case managers when dealing with these complex cases.

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We discussed the role of the offsite service coordinator to both schedule offsite service visits as well as in obtaining the offsite service reports. The person assigned appears very conscientious and anxious to accomplish her responsibilities. Hopefully, when another Medical Director is appointed, the follow-up visits can be scheduled by the offsite service coordinator based on when the Medical Director is scheduled to be present. Our record review detailed an absence of offsite service reports as well as follow-up care.

Patient #1 A male in his late twenties arrived in 2010 with a seizure disorder. He was sent to the ER for a seizure on 2/15/14. The record was impossible to track chronologically. There was no note in the chart on 2/15/14 and no note on return, as well as no ER report and no CT scan report. This record was fairly typical.

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RECOMMENDATIONS: The offsite service coordinator should track the date of the order, the

date of the appointment, the date offsite service reports are received and the date of the follow-up

visit with the Medical Director.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This has been discussed under number v.

RECOMMENDATIONS: See number v.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We discussed with the Medical Director the need to develop guidelines for the approach to intoxication and detoxification. He indicates he is prepared to do this. We offered to send him a model policy from which he can use to develop his own Golden Grove policy and guideline.

RECOMMENDATIONS:

1. The Medical Director should draft an intoxication and detoxification policy and clinical guideline.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: There has been only one full-time registered nurse; a second registered

nurse started the day of our arrival. Therefore, it is not surprising that the infection control program

has not yet been developed. The focus of an infection control program in a correctional setting

should be based on tuberculosis screening as well as response to suspect cases, the monitoring and

management of acute skin infections and the identification, monitoring and reporting of sexually

transmitted diseases. The intake process, which includes a TB skin test, should include

documentation of the results in the record and this should be done timely. Each day the person who

records the results should pull the records and document them directly in the chart.

RECOMMENDATION: 1. Discuss with the monitoring staff the requirements of an infection control nurse.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

i. Adequate suicide prevention, including:

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS - On day one of the site visit the A-Unit security log from the last quarter was reviewed. What was noted were repeated and prolonged periods of cell restriction by the security officer of several seriously mentally ill inmates due to their behavioral dysfunctions. Evident from the review were three cases from A-Unit where medical and mental health staff were not notified of repeated lockdowns (cell restrictions). The psychiatrist has made rounds in the A dorm only twice since March 2014, despite reporting at the April status conference that such rounds would be conducted weekly. Inmates also reported that Ms. Drigo has been on the unit very briefly once or twice to begin case management services. Mental health rounds in the segregation units (both detention side and sentenced side) occurred only once since our site visit in March. Mental health staff identified the lack of an escort officer accompanying them to segregation as a deterrent to this generally accepted weekly standard.

Serious mental health crises inmates can be referred to the emergency room at the local hospital whenever the psychiatrist is not in the facility. Dr. Sang will see those inmates at the hospital whenever needed. However, St. Croix still lacks inpatient psychiatric beds and therefore inmates must be returned to the facility per emergency department guidelines.

Nursing staff does make rounds in the units and will refer inmates that concern them to Dr. Sang, who will see the inmate immediately onsite in the treatment building or in the hospital emergency department.

Inadequate recognition of mental health crises and appropriate referral to the medical/mental health service are partly due to the lack of promised training for security staff in the recognition, deescalation and referral of the serious mentally ill inmate. Evidence of this is seen in the frequent use

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of cell restriction by security for several acute mental health inmates for days and weeks on end

without involvement by professional medical and mental health staff.

For example, a male inmate in his sixties has been diagnosed as having chronic schizophrenia and was observed directly by this auditor during the first and third site visits. The officer’s log on March 29, 2014 noted that he was "still fasting". There is no acknowledgment of his fasting state in the medical record and no monitoring of his health status. The inmate was placed on cell restriction with limited access to fresh water (we have observed faucet water from three different faucets that does not appear potable, was discolored and had particulate matter in it). The officer’s log has no comments of nursing making checks on this particular inmate. The log notes that he is on cell restriction, which may or may not have been continuous, until he was moved to the segregation unit on April 28, 2014. The officer’s log is silent on whether he was ever removed from cell restriction during this period of time. Notations in the medical record for this inmate are inadequate as well. He was seen on January 27, 2014 by a psychiatrist, at which time he was actively delusional. Haldol was held and the plan was to observe him for decompensation. However, he was not seen again until March 28, 2014, an undue period of time considering medications were altered in January. The behavioral checklist was not initiated until March 30, 2014, which stated that he was in his room without clothing, asking the nurse for sex after chasing her down the hall and refusing to leave his cell in hiding. He was seen April 2, 2014, and his Haldol was restarted. When he was reviewed again on April 16, 2014, he was still sexually inappropriate around female officer, which he denied. His medications were continued and the plan was for him to return in one month. There are no follow-up psychiatric notes since April 16, 2014, although on April 21, 2014 the psychiatrist received a report that he was still sexually "expressive" and his Haldol was increased. On April 21, 2014, a behavioral checklist was sent stating he was refusing medications, argumentative, hiding, unable to sleep, depressed, and planning to inflict bodily harm. No other notes are in his file. During this site visit he allegedly struck a segregation officer on the back of her head when escorted outside his cell.

This problems at GGACF demonstrated by this case include:  delayed psychiatric follow-up and management of an actively psychotic inmate;  inadequate responsiveness to behavioral checklist issues, partly due to the lack of availability of
mental health programming;  serious lack of communication between medical and security when a mentally ill inmate has been
secluded;  use of isolation with no programming offered to redirect his behavior, and continued use of
segregation rather than hospitalization;  no report to medical that the inmate was fasting and therefore no medical monitoring of an inmate
at increased risk of heat management issues secondary to his psychiatric medications and therefore at greater risk of serious to life threatening consequences of dehydration.

Significantly, during the discussions with the leadership staff it became evident that the Bureau of Corrections has not communicated with the on-site leadership regarding training of corrections staff on how to identify and respond to inmates with medical or mental health needs, as required by the Settlement Agreement and the Work Plan implementing it. Rather, the bureau scheduled a training coordinator from St. Thomas to arrive at Golden Grove the following day to do some level of suicide prevention training. However, the training promised was to also include crisis management instruction. Neither Dr. Sang nor the Health Services Administrator had been approached regarding developing the curriculum and implementing this training on site. Dr. Sang planned to do the training

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once there were enough officers to provide relief and also has volunteered to develop pre-and post-

tests.

GGACF does not have the structural or clinical capacity to monitor and treat acutely mentally ill

persons.

RECOMMENDATIONS: 4th Assessment:

1. Substantial problems in the involvement of professional staff to specialty mental health housing in segregation units continues.
2. The facility needs to either develop internal capacity to manage acutely mentally ill cases or develop a reliable inpatient hospital referral source(s).
3. GGACF needs to develop a comprehensive vision of what an adequate mental health service should provide. Efforts should then be made to systematically develop the appropriate facilities, policies and procedures, programming curricula, professional staffing, and integration and support of security staff assigned to those areas.
4. The practice of cell restriction of inmates for behavioral health issues without notification of medical staff ASAP needs to terminate. Any inmate restricted to a single cell for the circumstances should be covered under a seclusion and restraint policy which clearly outlines time frames and who has the authority to issue and continue the states of confinement. In addition, any inmate in seclusion must be seen by professional qualified health providers, including the psychiatrist/QMHP on a daily basis accompanied by progress note documentation.

Previous Recommendations Remain Appropriate:

1. GGACF needs to develop a communication system that is timely and reliable for notification regarding inmates placed on suicide watch, behavioral referral requests, and intake referrals.
2. Medical Services needs to develop a reliable system to ensure that the mental health clinicians receive referrals in a timely manner.
3. Sufficient training needs to be provided to all staff when new policies are developed and implemented.

(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: A formal suicide prevention policy has not yet been vetted by the process outlined in the settlement agreement and approved by the Monitor.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

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1. Quality assurance measures need to be implemented to ensure that all components of the new

policy are effectively carried out.

2. Evidence of adequate training of staff should be provided to the monitoring team when new policies are implemented.

3. In the future, all policy drafts should be distributed electronically to the monitoring team and the parties for review prior to acceptance and implementation. The current suicide prevention policy includes provisions that are not possible given the current structural constraints of the facility and the lack of 24 hour daily staffing patterns for health services. Observation status requirements of correctional officers are too infrequent compared to the customary requirements, which impose 30-minute rounds as opposed to the "not less than every hour" requirement in this policy. The policy also requires that the mental health counselor will observe the offender every shift, which is not feasible given the staffing pattern of GGACF. The nature of this policy is such that the facility will perpetually be out of compliance with its own policy. This needs to be amended.

4. Please distribute any current mental health policies to the Monitor and USDOJ attorneys in an electronic format.

(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: There has been no instance reported of an inmate being placed on suicide watch during the last reporting period, so no assessment could be made to determine if there has been improvement since the last site visit. A standardized risk assessment form has not yet been developed by the mental health service

RECOMMENDATIONS:

Previous Recommendation(s) Remain Appropriate:

1. An after-hour protocol should be considered as well to allow for notification of mental health staff by the next morning. This is a requirement of the new policy in section H.1. But no 24-hour emergency mental health plan was presented to the monitors at the time of the March site visit.

2. It is suggested that the service develop a standardized suicide assessment progress note that would include a suicide risk assessment and a suicide watch treatment plan.

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(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: There was no cut-down tool again found in the mental health housing unit nor RSAT, according to the Monitor who inspected these units. It seems obvious that recommendations pertaining to quality control that ensures the presence of cut-down tools as required is not being followed.

RECOMMENDATIONS:

Previous Recommendation(s) Remain Appropriate:

1. Cut down tools should be available in all housing areas, and areas where inmates could have an opportunity to harm themselves, i.e. kitchen, medical building, etc.
2. All staff required to use this tool should be well-trained and emergency drills demonstrating proficient use of the tool should be conducted on a regular basis.
3. Supervisors should regularly inventory and audit tool location and make immediate provisions to replace missing or non-functioning tools when found.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: As stated earlier, the required training was to have been completed June 1, 2014, but has not yet occurred and the curriculum has never been sent to the Monitor for review and approval.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. Develop and implement scenario-based suicide prevention, response, and recovery training program that requires application of policy and procedure, and that topic competence is proven by both written test and demonstration by staff.
2. Refer the completed materials to the Monitor for review and approval 3. Adequate initial and annual trainings should be documented and maintained.

Additionally, the Monitor’s staff training discussion from the previous report should be used in developing policy and training materials.

Staff Training

The essential component to any suicide prevention program is properly trained staff, who form the backbone of any correctional facility. Very few suicides are actually prevented by mental health,

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medical or other professional staff because suicides are usually attempted in housing units, and

often during late evening hours or on weekends when they are generally outside the purview of

program staff. These incidents, therefore, must be thwarted by correctional staff who have been

trained in suicide prevention and have developed an intuitive sense about suicidal inmates.

Correctional staff are often the only personnel available 24 hours a day; thus, they form the front

line of defense in preventing suicides.

All correctional, medical, and mental health personnel, as well as any staff who have regular contact with inmates, should receive eight (8) hours of initial suicide prevention training, followed by two (2) hours of refresher training each year. The initial training should include administrator/staff attitudes about suicide and how negative attitudes impede suicide prevention efforts, guiding principles to suicide prevention, inmate suicide research, why the environments of correctional facilities are conducive to suicidal behavior, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, identifying suicidal inmates despite the denial of risk, components of the facility’s suicide prevention policy, and liability issues associated with inmate suicide. The two-hour refresher training should include a review of administrator/staff attitudes about suicide and how negative attitudes impede suicide prevention efforts, predisposing risk factors, warning signs and symptoms, identifying suicidal inmates despite the denial of risk, and review of any changes to the facility’s suicide prevention plan. The annual training should also include general discussion of any recent suicides and/or suicide attempts in the facility. In addition, all staff who have routine contact with inmates should receive standard first aid and cardiopulmonary resuscitation (CPR) training. All staff should also be trained in the use of various emergency equipment located in each housing unit. In an effort to ensure an efficient emergency response to suicide attempts, “mock drills” should be incorporated into both initial and refresher training for all staff.

Identification/Referral/Evaluation

Intake screening and ongoing assessment of all inmates is critical to a correctional facility’s suicide prevention efforts. It should not be viewed as a single event, but as an ongoing process because inmates can become suicidal at any point during their confinement, including the initial admission into the facility; after adjudication when the inmate is returned to the facility from court; following receipt of bad news or after suffering any type of humiliation or rejection; confinement in isolation or segregation; and following prolonged a stay in the facility. In addition, although there is no single set of risk factors that mental health and medical communities agree can be used to predict suicide, there is little disagreement about the value of screening and assessment in preventing suicide. Research consistently reports that approximately two-thirds of all suicide victims communicate their intent some time before death, and that any individual with a history of one or more suicide attempts is at a much greater risk for suicide than those who have never made an attempt.

Intake screening for suicide risk may be contained within the medical screening form or as a separate form. The screening process should include inquiry regarding: past suicidal ideation and/or attempts; current ideation, threat, plan; prior mental health treatment/hospitalization; recent significant loss (job, relationship, death of family member/close friend, etc.); history of suicidal behavior by family member/close friend; suicide risk during prior confinement; and arresting/transporting officer(s) belief that the inmate is currently at risk. Specifically, inquiry should determine the following:

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 Was the inmate a medical, mental health or suicide risk during any prior contact and/or confinement within this facility?
 Does the arresting and/or transporting officer have any information (e.g., from observed behavior, documentation from sending agency or facility, conversation with family member) that indicates inmate is a medical, mental health or suicide risk now?
 Have you ever attempted suicide?
 Have you ever considered suicide?
 Are you now or have you ever been treated for mental health or emotional problems?
 Have you recently experienced a significant loss (relationship, death of family member/close friend, job, etc.)?
 Has a family member/close friend ever attempted or committed suicide?
 Do you feel there is nothing to look forward to in the immediate future (expressing helplessness and/or hopelessness)?
 Are you thinking of hurting and/or killing yourself?
Although an inmate’s verbal responses during the intake screening process are critically important to assessing the risk of suicide, staff should not exclusively rely on an inmate’s denial that they are suicidal and/or have a history of mental illness and suicidal behavior, particularly when their behavior and/or actions or even previous confinement in the facility suggest otherwise. The process should also include referral procedures to mental health and/or medical personnel for a more thorough and complete assessment.

The intake screening process should be viewed as similar to taking your temperature, it can identify a current fever, but not a future cold. Therefore, following the intake screening process, should any staff hear an inmate verbalize a desire or intent to commit suicide, observe an inmate engaging in any self-harm, or otherwise believe an inmate is at risk for suicide, a procedure should be in place that requires staff to take immediate action to ensure that the individual is constantly observed until appropriate medical, mental health, and/or supervisory assistance is obtained.

Finally, given the strong association between inmate suicide and isolation/special management (e.g., disciplinary and/or administrative segregation) housing unit placement, any inmate assigned to such a special housing unit should receive a written assessment for suicide risk by medical or mental health staff upon admission to the placement.

The screening and assessment process is only one of several tools that increases the opportunity to identify suicide risk in inmates. This process, coupled with staff training, will only be successful if an effective method of communication is in place at the facility.

Communication

Certain behavioral signs exhibited by the inmate may be indicative of suicidal behavior and, if detected and communicated to others, can reduce the likelihood of suicide. In addition, most

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suicides can be prevented by correctional staff who establish trust and rapport with inmates, gather

pertinent information, and take action. There are essentially three levels of communication in

preventing inmate suicides: between the arresting/transporting officer and correctional staff;

between and among facility staff (including correctional, medical and mental health personnel);

and between facility staff and the suicidal inmate.

In many ways, suicide prevention begins at the point of arrest. At Level 1, what an arrestee says and how they behave during arrest, transport to the facility, and at intake are crucial in detecting suicidal behavior. The scene of arrest is often the most volatile and emotional time for the individual. Arresting officers should pay close attention to the arrestee during this time; suicidal behavior may be manifested by the anxiety or hopelessness of the situation, and previous behavior can be confirmed by onlookers such as family members and friends. Any pertinent information regarding the arrestee’s well-being must be communicated by the arresting or transporting officer to correctional staff. It is also critically important for correctional staff to maintain open lines of communication with family members who often have pertinent information regarding the mental health status of inmates.

At Level 2, effective management of suicidal inmates is based on communication among correctional personnel and other professional staff in the facility. Because inmates can become suicidal at any point during confinement, correctional staff must maintain awareness, share information and make appropriate referrals to mental health and medical staff. At a minimum, the facility’s shift supervisor should ensure that appropriate correctional staff are properly informed of the status of each inmate placed on suicide precautions. The shift supervisor should also be responsible for briefing the incoming shift supervisor regarding the status of all inmates on suicide precautions. Multidisciplinary team meetings (to include correctional, medical and mental health personnel) should occur on a regular basis to discuss the status of inmates on suicide precautions. Finally, the authorization for suicide precautions, any changes in suicide precautions, and observation of inmates placed on precautions should be documented on designated forms and distributed to appropriate staff.

At Level 3, facility staff must use various communication skills with the suicidal inmate, including active listening, staying with the inmate if they suspect immediate danger, and maintaining contact through conversation, eye contact, and body language. Correctional staff should trust their own judgment and observation of risk behavior, and avoid being misled by others (including mental health staff) into ignoring signs of suicidal behavior.

Poor communication between and among correctional, medical, and mental health personnel, as well as outside entities (e.g., arresting or referral agencies, family members) is a common factor found in the reviews of many custodial suicides. Communication problems are often caused by lack of respect, personality conflicts and boundary issues. Simply stated, facilities that maintain a multidisciplinary approach avoid preventable suicides.

Housing

In determining the most appropriate housing location for a suicidal inmates, correctional facility officials (with concurrence from medical and/or mental health staff) often tend to physically isolate (or segregate) and sometimes restrain the individual. These responses might be more convenient for all staff, but they are detrimental to the inmate since the use of isolation escalates the sense of

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alienation and further removes the individual from proper staff supervision. To every extent

possible, suicidal inmates should be housed in the general population, mental health unit, or medical

infirmary, located close to staff. Further, removal of an inmate’s clothing (excluding belts and

shoelaces) and the use of physical restraints (e.g., restraint chairs or boards, leather straps,

handcuffs, and straitjackets) should be avoided whenever possible, and used only as a last resort

when the inmate is physically engaging in self-destructive behavior. Housing assignments should

be based on the ability to maximize staff interaction with the inmate, not on decisions that heighten

depersonalizing aspects of confinement.

All cells designated to house suicidal inmates should be as suicide-resistant as is reasonably possible, free of all obvious protrusions, and provide full visibility. These cells should contain tamper-proof light fixtures, smoke detectors and ceiling/wall air vents that are protrusion-free. In addition, the cells should not contain any live electrical switches or outlets, bunks with open bottoms, any type of clothing hook, towel racks on desks and sinks, radiator vents, or any other object that provides an easy anchoring device for hanging. Each cell door should contain a heavy gauge Lexan (or equivalent grade) clear panel that is large enough to allow staff a full and unobstructed view of the cell interior. Finally, each housing unit in the facility should contain various emergency equipment, including a first aid kit, pocket mask or face shield, Ambu-bag, and rescue tool (to quickly cut through fibrous material). Correctional staff should ensure that such equipment is in working order on a daily basis.

Levels of Observation/Management

In regard to suicide attempts in correctional facilities, the promptness of the response is often driven by the level of supervision afforded the inmate. Medical evidence suggests that brain damage from strangulation caused by a suicide attempt can occur within 4 minutes, and death often within 5 to 6 minutes. Two levels of supervision are generally recommended for suicidal inmates: close observation and constant observation.

Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation (e.g., expressing a wish to die without a specific threat or plan) and/or has a recent prior history of self-destructive behavior. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. Staff should observe such an inmate in a protrusion-free cell at staggered intervals not to exceed every 10 minutes (e.g., 5, 10, 7 minutes).

Constant Observation is reserved for the inmate who is actively suicidal, either threatening or engaging in suicidal behavior. Staff should observe such an inmate on a continuous, uninterrupted basis. In some jurisdictions, an intermediate level of supervision is utilized with observation at staggered intervals that do not exceed every 5 minutes.

Other aids (e.g., closed-circuit television, cell mates) can be used as a supplement to, but never as a substitute for, these observation levels.

In addition, mental health staff should assess and interact with (not just observe) the suicidal inmate on a daily basis. The daily assessment should focus on the current behavior, as well as changes in thoughts and behavior during the past 24 hours (e.g., “What are your current feelings and thoughts?”

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“Have your feelings and thoughts changed over the past 24 hours?” “What are some of the things

you have done or can do to change these thought and feelings?,” etc.)

An individualized treatment plan (to include follow-up services) should be developed for each inmate on suicide precautions. The plan should be developed by qualified mental health staff in conjunction with not only the inmate, but medical and correctional personnel. The treatment plan should describe signs, symptoms, and the circumstances under which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the inmate and staff will take if suicidal ideation reoccurs.

Finally, due to the strong correlation between suicide and prior suicidal behavior, in order to safeguard the continuity of care for suicidal inmates, all inmates discharged from suicide precautions should remain on mental health caseloads and receive regularly scheduled follow-up assessments by mental health personnel until their release from custody. Although there is not any nationally-acceptable schedule for follow-up, a suggested assessment schedule following discharge from suicide precautions might be: 24 hours, 72 hours, 1 week, and periodically until release from custody.

Intervention

Following a suicide attempt, the degree and promptness of the staff’s intervention often foretells whether the victim will survive. National correctional standards and practices generally acknowledge that a facility’s policy regarding intervention should be threefold. First, all staff who come into contact with the inmate should be trained in standard first aid procedures and CPR. Second, any staff member who discovers an inmate engaging in self-harm should immediately survey the scene to assess the severity of the emergency, alert other staff to call for medical personnel if necessary, and begin standard first aid and/or CPR as necessary. If facility policy prohibits an officer from entering a cell without backup support, the first responding officer should, at a minimum, make the proper notification for backup support and medical personnel, secure the area outside the cell, and retrieve the housing unit’s emergency response bag (that should include a first aid kit, pocket mask or face shield, Ambu-bag, and rescue tool). Third, correctional staff should never presume that the victim is dead, but rather should initiate and continue appropriate life-saving measures until relieved by arriving medical personnel. In addition, medical personnel should ensure that all equipment utilized in responding to an emergency within the facility is in working order on a daily basis.

Finally, although not all suicide attempts require emergency medical intervention, all suicide attempts should result in immediate intervention and assessment by mental health staff.

Reporting

In the event of a suicide attempt or suicide, all appropriate officials should be notified through the chain of command. Following the incident, the victim’s family should be immediately notified, as well as appropriate outside authorities. All staff who came into contact with the victim before the incident should be required to submit a statement including their full knowledge of the inmate and incident.

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Follow-Up/Mortality-Morbidity Review

An inmate suicide is extremely stressful for both staff and other inmates. Staff may also feel ostracized by fellow personnel and administration officials. Following a suicide, misplaced guilt is sometimes displayed by a correctional officer who wonders: “What if I had made my cell check earlier?” Inmates are often traumatized by critical events occurring within a facility. Such trauma may lead to suicide contagion. When crises occur in which staff and inmates are affected by the traumatic event, they should be offered immediate assistance. One form of assistance is Critical Incident Stress Debriefing (CISD). A CISD team, comprised of professionals trained in crisis intervention and traumatic stress awareness (e.g., police officers, paramedics, fire fighters, clergy, and mental health personnel), provides affected staff and inmates an opportunity to process their feelings about the incident, develop an understanding of critical stress symptoms, and seek ways of dealing with those symptoms. For maximum effectiveness, the CISD process or other appropriate support services should occur within 24 to 72 hours of the critical incident.

Every completed suicide, as well as serious suicide attempt (i.e., requiring medical treatment and/or hospitalization), should be examined through a mortality-morbidity review process. If resources permit, clinical review through a psychological autopsy is also recommended. Ideally, the mortality-morbidity review should be coordinated by an outside agency to ensure impartiality. The review, separate and apart from other formal investigations that may be required to determine the cause of death, should include a critical inquiry of: 1) the circumstances surrounding the incident; 2) facility procedures relevant to the incident; 3) all relevant training received by involved staff; 4) pertinent medical and mental health services/reports involving the victim; 5) possible precipitating factors leading to the suicide or serious suicide attempt; and 6) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures.

RECOMMENDATIONS:

1) Develop and implement scenario-based suicide prevention, response, and recovery training program that requires application of policy and procedure, and that topic competence is proven by both written test and demonstration by staff. Adequate initial and annual trainings should be documented and maintained.

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: See f.iv.

RECOMMENDATIONS: 4th Assessment:

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Annual disaster drills should include scenarios with response to a mental health emergency/suicide

and be documented in a file maintained by the training supervisor.

Previous Recommendations Remain Appropriate:

1. Immediately develop and implement comprehensive pre and in-service suicide prevention training that is 1) evidence based, 2) policy and procedure driven, 3) includes valid and reliable knowledge and application competency evaluation methods. Such training would naturally include detection, recognition, assessment, and intervention topics and materials.
2. Implement policies, procedures, and protocols that govern and control staff response regarding inmate behavioral and/or verbal indications of suicide risk. Governing documents must require initial and ongoing involvement of medical and mental health staff in the response to suicide prevention actions.
3. Suicide prevention is considered a life safety issue that requires, at minimum, quarterly suicide prevention drills involving correctional, medical, and mental health staff to ensure 1) training and response efficacy, 2) effectiveness of policy and procedure, and 3) compliance with the Agreement.

(vii) availability of suicide resistant cells;
ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.
MENTAL HEALTH FINDINGS: No change from previous reports. GGACF has no suicideresistant cells.
RECOMMENDATIONS:
4th Assessment:
The appropriate forms documenting the clinicians orders for security implementation should be developed and then vetted through the process in the settlement agreement
Previous Recommendations Remain Appropriate:
1. Appropriate bedding, clothing, food and utensils, property, and pallet should be specified by the mental health clinician when supervising officer placing an inmate on suicide watch.
2. Retrofit cells designated suicide precautions to be suicide proof. 3. Renovation of an intake cell may be the only immediate alternative. If this environment is
utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates. 4. The following guidelines should be considered when establishing suicide-resistant housing environments:1

1 http://www.ncianet.org/services/suicide-prevention-in-custody/publications/checklist-for-the-suicide-resistantdesign-of-correctional-facilities/

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The safe housing of suicidal inmates is an important component to a correctional facility’s

comprehensive suicide prevention policy. Although impossible to create a “suicide-proof” cell

environment within any correctional facility, given the fact that almost all inmate suicides occur by

hanging, it is certainly reasonable to ensure that all cells utilized to house potentially suicidal

inmates are free of all obvious protrusions. And while it is more common for ligatures to be affixed

to air vents and window bars (or grates), all cell fixtures should be scrutinized, since bed

frames/holes, shelves with clothing hooks, sprinkler heads, door hinge/knobs, towel racks, water

faucet lips, and light fixtures have been used as anchoring devices in hanging attempts. As such, to

ensure that inmates placed on suicide precautions are housed in “suicide-resistant” cells, facility

officials are strongly encouraged to address the following architectural and environmental issues:

1. Cell doors should have large-vision panels of Lexan (or low-abrasion polycarbonate) to allow for unobstructed view of the entire cell interior at all times. These windows should never be covered (even for reasons of privacy, discipline, etc.) If door sliders are not used, door interiors should not have handles/knobs; rather they should have recessed door pulls. Any door containing a food pass should be closed and locked. Interior door hinges should bevel down so as not to permit being used as an anchoring device. Door frames should be rounded and smooth on the top edges. The frame should be grouted into the wall with as little edge exposed as possible.

In older, antiquated facilities with cell fronts, walls and/or cell doors made of steel bars, Lexan paneling (or low-abrasion polycarbonate) or security screening (that has holes that are ideally 1/8 inches wide and no more than 3/16 inches wide or 16-mesh per square inch) should be installed from the interior of the cell.

Solid cell fronts must be modified to include large-vision Lexan panels or security screens with small mesh;

2. Vents, ducts, grilles, and light fixtures should be protrusion-free and covered with screening that has holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16mesh per square inch;

3. Wall-mounted corded telephones should not be placed inside cells. Telephone cords of varying length have been utilized in hanging attempts;

4. Cells should not contain any clothing hooks. The traditional, pull-down or collapsible hook can be easily jammed and/or its side supports utilized as an anchor;

5. A stainless steel combo toilet-sink (with concealed plumbing and outside control valve) should be used. The fixture should not contain an anti-squirt slit, toothbrush holder, toilet paper rod, and/or towel bar;

6. Beds should ideally be either heavy molded plastic or solid concrete slab with rounded edges, totally enclosed underneath. If metal bunks are utilized, they should be bolted flush to the wall with the frame constructed to prevent its use as an anchoring device. Bunk holes should be covered; ladders should be removed. (Traditional metal beds with holes in the bottom, not built flush to the wall and open underneath, have often been used to attach

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suicide nooses. Lying flat on the floor, the inmate attaches the noose from above, runs it

under his neck, turns over on his stomach and asphyxiates himself within minutes.);

7. Electricity should be turned off from wall outlets outside of the cell;

8. Light fixtures should be recessed into the ceiling and tamper-proof. Some fixtures can be securely anchored into ceiling or wall corners when remodeling prohibits recessed lighting. All fixtures should be caulked or grouted with tamper-resistant security grade caulking or grout. Ample light for reading (at least 20 foot-candles at desk level) should be provided. Low-wattage night light bulbs should be used (except in special, high-risk housing units where sufficient lighting 24 hours per day should be provided to allow closed-circuit television (CCTV) cameras to identify movements and forms). An alternative is to install an infrared filter over the ceiling light to produce total darkness, allowing inmates to sleep at night. Various cameras are then able to have total observation as if it were daylight. This filter should be used only at night because sensitivity can otherwise develop and produce aftereffects;

9. CCTV monitoring does not prevent a suicide, it only identifies a suicide attempt in progress. If utilized, CCTV monitoring should only supplement the physical observation by staff. The camera should obviously be enclosed in a box that is tamper-proof and does not contain anchoring points. It should be placed in a high corner location of the cell and all edges around the housing should be caulked or grouted. Cells containing CCTV monitoring should be painted in pastel colors to allow for better visibility. To reduce camera glare and provide a contrast in monitoring, the headers above cell doors should be painted black or some other dark color. CCTV cameras should provide a clear and unobstructed view of the entire cell interior, including all four corners of the room. Camera lens should have the capacity for both night and low light level vision;

10. Cells should have a smoke detector mounted flush in the ceiling, with an audible alarm at the control desk. Some cells have a security screening mesh to protect the smoke detector from vandalism. The protective coverings should be high enough to be outside the reach of an inmate and far enough away from the toilet so that the fixture could not be used as a ladder to access the smoke detector and screen. Ceiling height for new construction should be 10 feet to make such a reasonable accommodation. Existing facilities with lower ceilings should carefully select the protective device to make sure it cannot be tampered with, or have mesh openings large enough to thread a noose through. Water sprinkler heads should not be exposed. Some have protective cones; others are flush with the ceiling and drop down when set off; some are the breakaway type;

11. Cells should have an audio monitoring intercom for listening to calls of distress (only as a supplement to physical observation by staff). While the inmate is on suicide precautions, intercoms should be turned up high (as hanging victims can often be heard to be gurgling, gasping for air, their body hitting the wall/floor, etc.);

12. Cells utilized for suicide precautions should be located as close as possible to a control desk to allow for additional audio and visual monitoring;

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13. If modesty walls or shields are utilized, they should have triangular, rounded or sloping tops

to prevent anchoring. The walls should allow visibility of both the head and feet;

14. Some inmates hang themselves under desks, benches, tables or stools/pull-out seats. Potential suicide-resistant remedies are: (a) Extending the bed slab for use as a seat; (b) Cylinder-shaped concrete seat anchored to floor, with rounded edges; (c) Triangular corner desk top anchored to the two walls; and (d) Rectangular desk top, with triangular end plates, anchored to the wall. Towel racks should also be removed from any desk area;

15. All shelf tops and exposed hinges should have solid, triangular end-plates which preclude a ligature being applied;

16. Cells should have security windows with an outside view. The ability to identify time of day via sunlight helps re-establish perception and natural thinking, while minimizing disorientation. If cell windows contain security bars that are not completely flush with window panel (thus allowing a gap between the glass and bar for use as an anchoring device), they should be covered with Lexan (or low-abrasion polycarbonate) paneling to prevent access to the bars, or the gap, should be closed with caulking, glazing tape, etc. If window screening or grating is used, covering should have holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16-mesh per square inch;

17. The mattress should be fire retardant and not produce toxic smoke. The seam should be tearresistant so that it cannot be used as a ligature;

18. Given the fact that the risk of self-harm utilizing a laundry bag string outweighs its usefulness for holding dirty clothes off the floor, laundry bag strings should be removed from the cell;

19. Mirrors should be of brushed, polished metal, attached with tamper-proof screws;

20. Padding of cell walls is prohibited in many states. Check with your fire marshal. If permitted, padded walls must be of fire-retardant materials that are not combustible and do not produce toxic gasses; and,

21. Ceiling and wall joints should be sealed with neoprene rubber gasket or sealed with tamper-resistant security grade caulking or grout for preventing the attachment of an anchoring device through the joints.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: No Change from prior reports. No suicide prevention policy has been formally submitted to the Bureau of Corrections and The Monitor per the Settlement Agreement. There does not appear to be a protocol in place for providing this supervision.

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RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15-minute watches.
2. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
3. Renovation of an intake cell may be the only immediate alternative. If this environment is utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.
4. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15-minute watches.

(ix) procedures to assure implementation of directives from a mental health professional regarding:
(1)the confinement and care of suicidal prisoners; (2)the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: No change from previous reports.
RECOMMENDATIONS:
Previous Recommendations Remain Appropriate:
1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
2. It is recommended that the facility develop a form listing each level of observation that would also specify what property the inmate is allowed to have in their possession as well as indicating which staff member has ordered the watch and property restrictions. Consultation with the monitoring team may be a useful assistance.
3. The facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates if they continue to be housed in the reception area.
4. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
5. Renovation of an intake cell may be the only immediate alternative. 6. If this environment is utilized then the facility needs to carefully monitor how readily medical
and mental health staff can maintain daily contact with the inmates.
j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: The Medical Director started the day we arrived as did one other registered nurse but the Medical Director was terminated shortly thereafter. That leaves no Medical Director to provide and supervise primary care, and at least two registered nurses and one LPN that still need to be hired. We understand the registered nurses have been budgeted but we are not aware that an additional LPN has been budgeted. Given the requirement to pass meds seven days a week, a task which the LPNs perform, it makes no sense to not build in relief so that when one of the LPNs cannot provide services there is a relief person. There was at least one medication pass when the entire pass was cancelled due to the absence of both medical staff and escort staff. At least two RNs and one LPN should be hired as soon as possible. In addition, a medical records technician should be hired also as soon as possible. The state of the medical records is unacceptable. This must be corrected immediately.

RECOMMENDATIONS: 1. Hire another qualified Medical Director without delay. 2. Hire two RNs and one LPN before our return. 3. Hire a medical records technician before our return.

MENTAL HEALTH FINDINGS: A bachelor-prepared Medical Case Management Planner has been hired by the Health Services Department. To date, the Qualified Mental Health Professional has not returned to duty and it is unclear whether she has any plans to return to work. The only Qualified Mental Health Professional remains the psychiatrist. Dr. Sang usually arrives on site at 11 a.m. because she has no access to inmates prior to that time due to the duty officer accompanying the nurse for medication passes. She is currently averaging about four hours per day on site but is available to see any inmate in the hospital emergency room seven days a week.

The required staffing analysis had not been completed at the time of this assessment.

RECOMMEDATIONS:

Previous Recommendations Remain Appropriate:

Refer to the Monitor’s assessment, findings and recommendations pertaining to staffing analysis recommendations. Provide the staffing document to the Monitor along with the duties assigned to each staff member.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have been constantly reminded that some of the services that do not occur are a result of lack of officer escort. In addition, if an officer is assigned to medication

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administration, which occurs around 8:00 a.m. and again at 6:00 p.m., then during the day that

officer could accompany a nurse or a doctor who would see patients in the hopefully soon-to-be

refurbished exam rooms on each housing unit. This would be an efficient use of BOC resources,

since it would mitigate the need in many instances to provide escorts to the clinic because patients

would be seen in the housing areas.

RECOMMENDATIONS: 1. Provide a post assignment as a medical escort for both medication administration and sick call in the housing units to be available on two shifts, day shift and evening shift. 2. There should also be a current medical transfer post of at least one and possibly two officers.

MENTAL HEALTH FINDINGS: Based on observations and staff reporting there remains inadequate correctional officer staffing to ensure that all scheduled appointments occur and that there is the capacity for inmates with urgent issues to also be escorted to the clinic. In addition there can be no growth in the capacity to deliver clinical services until sufficient security staffing is available to support those measures. It was reported that medical personnel such as the consultant pharmacist has outstanding invoices pending payment with the BOC. The BOC must timely pay providers in order to retain their services.

RECOMMENDATIONS: 4th Assessment:

1. A review of accounts payable practices should be performed to ensure retention of critical medical personnel.
2. BOC, in conjunction with the health services staff, should develop a vision and mission for mental health services at GGACF. This should be reviewed by the monitoring team's expert and if deemed adequate, a plan should be developed to achieve established goals and implemented within acceptable time frames.

Previous Recommendations Remain Appropriate:

1. Develop staffing policies and procedures that reflect facility and population needs. 2. Develop staffing documents that allow for accurate and timely tracking of staffing levels, shift
and duty assignments, work locations, and shortages. 3. Ensure staff members are properly trained in all aspects of their respective duty assignments
working with special needs and mentally ill inmates. 4. Provide Monitor with accurate, complete, and up-to-date staffing schedules as described
above.

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: This requirement is for the quality improvement program.Until a

Medical Director is appointed and all staff positions are filed, creation of a meaningful and

productive quality improvement policy and committee is impossible. Nonetheless, we discussed

important elements of the quality improvement program which should be performed and reflected

in the minutes of monthly meetings and reiterate that conversation with the medical program is

fully staffed.

1. The quality improvement program should review the timeliness and appropriateness of both intake screening and health assessments as well as the completeness of the intake screening, including TB screening.
2. The quality improvement program should monitor emergency care, including the consistency of calls to the Medical Director as well as timeliness and appropriateness of follow up onsite.
3. The quality improvement program should monitor the non-emergent request program for both timeliness and appropriateness of response.
4. The quality improvement program should monitor the chronic disease program from initial entry and follow up with regard to appropriateness and consistency with chronic care guidelines.
5. The quality improvement program should monitor the timeliness and appropriateness and continuity of care of patients who received scheduled offsite services.
6. The quality improvement program should monitor the discharge planning process with respect to release medications for both detainees as well as sentenced prisoners.
7. The quality improvement program should monitor care for pregnant females for consistency with American College of OB/GYN guidelines.
8. The quality improvement program should monitor the medication program for (a) consistency between orders and medication administration records and (b) the timeliness of receipt of medications after initial order.
9. The quality improvement program should monitor the maintenance of medical records after a medical records technician has been hired and able to have had an impact on the quality of the records.

RECOMMENDATIONS: 1. Follow the above list of nine elements to begin the quality improvement program.

MENTAL HEALTH FINDINGS: No change since previous visit.

RECOMMENDATIONS: 4th Assessment:

The Mental Health Department, under the supervision of the Medical Director needs to develop a schedule of quality improvement activities and systems to measure the clinical processes and their outcomes. Currently there is a monthly report, which was not provided for our review, to the Health Services Administrator.

Previous Recommendations Remain Appropriate:

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1. Complete development, training, and implementation of required medical, mental health,

and suicide prevention policies.

2. Include in each policy core measures, metrics, and methods for continuous quality

improvement of these governing documents.

3. As the policies and procedures are finalized, staff are trained and the policies implemented,

begin the monitoring of process performance with regard to intake, health assessments, TB

screening, sick call, unscheduled onsite and offsite services, scheduled onsite and offsite

services as well as chronic disease management and medication management.

4. Work with the monitor and his staff, who can provide technical assistance.

m. Adequate dental care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We again had the opportunity to speak with the dentist and were told that his dental assistant/hygienist is sometimes not able to attend since she lives in St. Thomas. We also continue to hear that his biggest access obstacle is due to officer availability. This is an area that continues to need attention. Without the access problems, this area could achieve substantial compliance.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. The dental program should report to the QI program the numbers of scheduled patients and the numbers who arrive and the reason for non-arrival for each of the patients who did not arrive.
2. The above information should be reported to the QI program monthly. 3. The dental program should track the number of extractions and restorations performed each
month and we will be able to review that data upon return. 4. Develop adequate dental care policies, procedures, and protocols.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report.

RECOMMENDATIONS: defer to Dr. Shansky’s report.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There have been no deaths or sentinel events since our last visit.

RECOMMENDATIONS:

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Previous Recommendation Remains Appropriate:

1. Consider utilizing the services of an offsite clinician to perform a death review on all deaths of patients incarcerated in the Department of Corrections.

MENTAL HEALTH FINDINGS: No change since previous visit. No deaths or serious suicide attempts were reported during this assessment.

RECOMMENDATIONS: defer to Dr. Shansky's report

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We are still awaiting the drafting of the segregation round policy. It would make sense for both nursing and mental health to share this responsibility.

RECOMMENDATION:

Previous Recommendation Remains Appropriate:

1. Draft the policy and procedure for segregation rounds for our review.

MENTAL HEALTH FINDINGS: Despite reassurances at the March 28, 2014 federal court status conference that these rounds were occurring, while on site we learned that a mental health counselor has been to segregation to round only once, shortly after the third site visit. Segregation and isolation rounds are not occurring as required by the Agreement.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate: 1. A policy be developed that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA. 2. Medical and mental health segregation rounds be implemented following national guidelines. 3. Staff training regarding what are critical questions in areas to review during medical and mental health rounds on the segregation unit. 4. The facility will need to provide adequate security staffing and access in order for the medical staff to conduct the appropriate rounds and treatment services.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MENTAL HEALTH FINDINGS: GGACF continues to place inmates with serious mental illness in lock-down/isolated cell settings. There remains no regular review of inmates in segregation to 1) minimize time in segregation or 2) assess mental health status to ensure segregated inmates do not suffer adverse psychiatric conditions while segregated.

One inmate referenced earlier has been placed in segregation and, per the disciplinary hearing officer, no incident report or disciplinary report was filed associated with this placement. Not only is this a poor mental health practice because it does not meet any standard of care, it also violates, in this writer's opinion, his right to due process. It was also reported that persons isolated in administrative segregation on L-Unit go through no periodic review process, no matter how many years they may remain on that unit. Officers can place someone in their cell for 1-2 days but there is no policy allowing this practice.
As stated in the 3rd Report, “Staff reported that inmates on the mental health caseload are not screened prior to placement in segregation. In addition, the mental health staff is not notified of this placement until they see the patient at the time of his\her next appointment. There is no enhanced mental health programming offered to mentally ill inmates housed in segregation units.”
As stated in the 3rd Report, the monitor once again observed mentally ill inmates locked in an isolated cell environment.

“The Monitor, an experienced licensed mental health clinician, observed inmates presenting symptoms of serious mental illness in segregation units having conditions that amount to an isolation environment. Many of these inmates were locked in their cells for most of the day. Many of the cells were very dark with virtually no social interaction other than inmates yelling. These conditions, as reported by the Monitor, and this expert agrees, can seriously exacerbate mental health symptoms and adversely impair mental health recovery.”

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. No inmate should be placed in segregation without a concomitant incident report or disciplinary report being generated, which would initiate a due process review.
2. This Provision mandates a strict prohibition on placing in isolation environment ANY inmate having or suspected of having a serious mental illness. Policies and procedures must articulate this mandate and be monitored by supervisors and mental health staff for compliance.
3. It is recommended that a detailed policy be developed to address this issue that incorporates the requirements of national accrediting bodies such as the NCCHC or the ACA.
4. The facility should develop an outline for therapeutic residential level of treatment on these units, identify the staffing needs and coordinate with security to effectively initiate enhanced treatment designed to stabilize and improve inmate function with the goal of possibly moving some of these men into general population and an outpatient level of care.

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q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: No change since previous visit. There is no process for review and consultation in place at this time. Mental health providers are not consulted prior to or following the imposition of disciplinary sanctions.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

1. A policy and procedure should be established to allow for an assessment by mental health staff of incidents potentially resulting in disciplinary sanctions in those inmates on the mental health caseload.
2. Input into the disciplinary process should be written and periodically monitored through a quality improvement process to determine if the disciplinary officer is collaborating with mental health staff in adjusting their sanctions when there are mitigating circumstances secondary to the person's illness.
3. Currently, there is no retrospective of use of force as part of the medical quality improvement process but such a process should be put in place.
4. Hire additional qualified mental health professional to ensure consistent and reliable involvement in this process.

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: No change since previous visit; findings and recommendation remain the same.

The potential examination rooms in the housing units have still not been reestablished as appropriate examination rooms. This would require cleaning, the provision of both a table and chairs, as well as an exam table and appropriate medical equipment. Supplies to ensure sanitation should also be made available. Privacy screens may also be needed to ensure confidentiality during exams. We also looked at the space that is to be remodeled but no one has yet seen the official architectural plans, even though some construction is occurring.

RECOMMENDATIONS:

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1. Reestablish clinically appropriate examination rooms in each of the housing units. 2. During our next visit, provide us with the architectural drawings for the new health care unit
renovation.

MENTAL HEALTH FINDINGS: There is a private office within the medical treatment building for use by the psychiatrist. Currently the qualified mental health professional’s position is unfilled, but it is anticipated that this staff person will have access to the smaller office next to the psychiatrist's office. An area in the treatment building, which is not sound private, has been created where small groups can be conducted. The lack of full privacy raises some concerns regarding confidentiality during group sessions. . RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. The facility needs to explore what barriers may exist to providing frequent and adequate services to inmates in special housing in sound private settings.
2. Send the Monitor the plans as soon as a draft has been developed.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: The psychiatrist reported that she is only using the treatment plan form when asked for it by the courts because she does not have the time to complete this form for each inmate. She continues to do reports for the courts and was also acting as the interim medical director until Dr. Burton began on site two weeks before our June visit. In addition to her clinical assignments, she has been barraged by reviewing inmate materials from the Selma prison in California that houses the Virgin Islands inmates, as well as Department of Health competency reviews. The multiple demands on Dr. Sang’s time prevent her from developing adequate treatment plans for all inmates as required by this Agreement.

RECOMMENDATIONS: 4th Assessment:

BOC should review all the tasks Dr. Sang is completing and give clear instruction to outside agencies regarding what should not be referred to the site psychiatrist but be handled through an outside agency.

Previous Recommendations Remain Appropriate:

1. Continue to monitor the plans to implement the new forms, modifications to the tracking case list including housing area, past visit and date of return to clinic.

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2. Consider developing quality improvement process to monitor outcomes from data collected

via the treatment forms.

(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: At the time of the second site visit a small housing area for the seriously mentally ill inmates was created (A-Unit). These inmates were interviewed in a group setting during the June visit. Several of the inmates were so psychologically impaired that, although they were physically present, they were unable to participate in the group process. Currently, there is extremely limited presence by a mental health professional on the unit. The new case management planner has visited only once or twice to begin working on case management issues. The officer’s log indicates that Dr. Sang was on the unit only once, on May 30, 2014. There is absolutely no programming nor are there recreational activities on the unit. Supervision is by the correctional officer. Several inmates reported they spend most of their time sleeping. One positive change which has occurred since the time of our last visit, as reported to us by GGACF staff, is that this officer is now solely assigned to this unit.

Warden Redwood joined us for the meeting with the unit and expressed his interest in obtaining a television set for the unit and working with the mental health staff to improve conditions for these inmates. The only seating available in the dayroom area was two picnic tables with attached benches and one square spider table with four seats.

The inmates were enthusiastic about the possibility of therapeutic programming on the unit. No mental health programming is currently available to the seriously mentally ill inmates, segregated mentally ill inmates, or the general population other than chronic care visits with the psychiatrist.

RECOMMENDATIONS: 4th Assessment

1. It is that the facility develop a description for A-Unit that would include admitting criteria and the components needed to create a therapeutic milieu. Since this is essentially a health services unit, control of movement in and out of this unit should be by authorization from the psychiatrist in cooperation with classification. This should be formalized into a policy and procedure that also outlines, at a minimum, the required number of activities per week driven by the inmates individualized treatment plans, frequency of psychiatry and mental health counseling individual visits, and the development of a multidisciplinary treatment team and time frames for review of treatment plans.
2. In order for mental health staff to conduct a variety of groups and activities throughout the facility, the facility should consider different types of correctional furniture that would lend themselves to the group setting. The psychiatrist on site can provide helpful input into the types of chairs and other equipment needed.

Previous Recommendations Remain Appropriate:

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1. GGACF Mental Health Department should conduct a needs analysis and make

recommendations to the Health Services Administrator, Medical Director, and Bureau of

Corrections regarding required staff and other resources necessary to provide adequate

services in both general population and segregated areas.

2. Comparable programming should be provided for female inmates and detainees as well.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: Dr. Sang has been reviewing patients on a regular basis and monitoring for the presence of side effects. A signed informed consent process is currently not in place. This is required under the Agreement but has not been submitted for approval. This Monitor is hopeful that the psychiatrist and I will have time to review medication practices in greater detail at the time of the next site visit.

A pharmacist consultant is onsite about one or two times a week for a few hours and is currently working on policies, licensure and formulary development. Reportedly, she will not be coming back until the new pharmacy construction is completed. It is unclear when this will be done.

However, no policies or procedures have been developed and approved for these practices, which causes this provision to remain in noncompliance.

RECOMMENDATIONS: 4th Assessment:

Ensure that duration of medication is included in all prescriptions and monitored appropriately.

Previous Recommendations Remain Appropriate:

1. A reasonable informed consent form should be developed and patient education documented. 2. A policy addressing the use of emergency and involuntary medication should be developed. 3. Improved methods of practice and a staffing and programs analysis needs to be completed. 4. GGACCF may wish to consider adding telepsychiatry to increase the availability of
psychiatric resources by contracting with psychiatrists on the mainland who obtain licenses in the USVI. Of course, the latter would require capital investment in equipment and the development of a policy and procedures that would structure this type of service. 5. A reasonable informed consent form should be developed and patient education documented. 6. A policy addressing the use of emergency and involuntary medication should be developed.

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous

assessment.

MENTAL HEALTH FINDINGS: No change since previous visit. A training curriculum has not been submitted to and approved by the Monitor. Training has not been completed.

RECOMMENDATIONS: 4th Assessment:

1. A detailed curriculum should be submitted for review to the monitoring team and approval by the Monitor.
2. Once obtained, training should be implemented with pre-and post-testing or other performance measures that have been approved by the Monitor.

Previous Recommendations Remain Appropriate:

1. GGACF should ensure the training officer or her records are available at the time of the next site visit for review by the monitoring team.
2. Develop, implement, and evaluate comprehensive training curricula to comply with Provision.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.
ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.
MENTAL HEALTH FINDINGS: Inmates with serious and active mental illness continue to be placed in segregation, and in at least one case, without due process. On A-Unit (mental health housing), 9 inmates were interviewed and 5 reported being in lockdown on L-Unit at some point during their incarceration.
Also, the Monitor, a licensed and Board Certified mental health clinician, reported that he observed inmates presenting symptoms of mental health problems locked down in their cells. The Monitor reported several inmates presenting cognitive impairments manifesting in slowed speech, confusion, limited verbal responsiveness. The Monitor also reported some inmates presenting symptoms of a Major Depressive Disorder: flat affect, slowed speech and gate, anhedonia, poor hygiene, low energy, pessimism. It is obvious that these conditions of confinement and lack of adequate levels of qualified mental health staff create and exacerbate mental health problems for inmates.
RECOMMENDATIONS:
Previous Recommendations Remain Appropriate:
1. GGACF should develop a plan to introduce adequate programming for this population.

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2. Increased out-of-cell time and life skills activities should be considered.

3. It is also recommended that all inmates with a serious mental illness should be seen in a

confidential setting at a minimum of at least monthly by a psychiatrist and also monthly by a

mental health counselor.

4. Weekly mental health rounds are also required for this population to identify mentally ill

inmates housed in segregation who have not been referred for mental health services by sick

call request or by officer referral.

5. GGACF is a facility that demonstrates fragmented communication and lack of inclusion at

the table of critical professional staff when designing and attempting to implement new

housing areas and programming. This seems to be a pervasive difficulty at all levels. Even

when looking at the organizational chart for health services division, it is clear that the health

services administrator does not have centralized authority for the management of the health

services department. Rather, all functions and employees are placed beneath the medical

director. This structure is problematic in several regards.

a. Once again there is no Medical Director and the position must be filled without delay. b. Having the medical director be responsible for all personnel activities and administrative
decisions for the service is a highly cost ineffective structure. The medical director should be responsible for the quality improvement program, policy and procedure development, and management and supervision of the clinical staff. c. The health services administrator should be responsible, at a minimum, for all personnel decisions not based on clinical performance and interface with the facility administration regularly. This would include the authority to dismiss personnel based on repetitive absenteeism, inability to follow facility policies, inappropriate behavior with inmates and staff, etc. In addition, they should oversee compliance with policy and procedure, supervise medical records, oversee pharmaceutical, equipment, and supplies availability and ordering. All directors (Medical, Nursing, Pharmacy, Dental, Mental Health) should administratively report to the HSA. 6. These units need to be sanitized, wire grates should be replaced or removed since many are torn and have ragged metal edges. Sheets and other impediments to inmate observation should be removed.

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VI. FIRE AND LIFE SAFETY

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:

a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS:. The Territory submitted on June 10, 2014 a draft policy intended to satisfy this provision, but this Monitor rejected it on June 13th due to inconsistencies, failure to include basic elements, and other problems, similar to the deficiencies with other draft policies noted throughout this report. No adequate fire and life safety policy currently governs GGACF. As a result, inmates and staff remain at risk of serious injury or death. Inmates continue to set fires inside their living units and the automatic fire suppression system remains inoperable.

Supervisor, housing unit, and incident logs, and monthly disciplinary reports indicate there were at least 17 fire and/or arson events inside housing units between January 1 and June 16, 2014. Although there appears to be some reporting inconsistencies between the documents examined, reconciliation of these records indicates the following:

Reported Fire Incidents

Incident Logs

Jan-14 0

Feb-14 1

Mar-14 2

Apr-14 0

May-14 0

Jun-14 1

Totals:

4

Housing Unit Logs 10 4 0
14

Monthly Disciplinary
Reports
2 0 0
2

On May 30, 2014, the Territory submitted to this Monitor documents demonstrating some efforts towards compliance with this provision. These included:

1. Fire drill calendar for October 2013 thru December 2014 2. Two fire drill exercise reports for March 13 and 28, 2014

The fire drill calendar shows fire and emergency drills occurring as follows:

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1. December 18, 2013 – Simulated Fire Drill, Unit Charlie 9 Delta

2. March 12, 2014 – Simulated Fire Drill, Unit Alpha 9 Bravo

3. March 28, 2014 – Evacuation Fire Drill, location illegible

4. May 5, 2014 – Evacuation Fire Drill, Units India / Juliette

5. May 29, 2014 – Evacuation Fire Drill, Units Gulf / Hotel

6. June 2, 2014 – Table Top Fire Drill Exercise for BOC Senior Staff 7. June 23, 2014 – Full Scale Total Evacuation Fire Drill (scheduled)

8. July 11, 2014 – Simulated Fire Explosion, GGACF Kitchen (scheduled)

9. July 28, 2014 – Evacuation Fire Drill Kitchen and Laundry (scheduled)

10. September 24, 2014 – Evacuation Fire Drill at GGACF Housing Unit / Administration

(scheduled)

11. October 8, 2014 – Chemical Fire Drill at GGACF w/ Haz-Mat Response (scheduled)

12. November 6, 2014 – Table Top Exercise w/ Medical Response (scheduled)

13. December 17, 2014 – Fire Drill Exercise at GGACF, Full Response (schedule)

However, the Monitor has not received any notification that the above drills were completed, with the exception of two reports – one for March 13, 2014 and one for March 28, 2014. The fire drill reports show some positive efforts. The reports included a description of the event scenario and specific notification protocols. The chronology of events provided shows a systematic approach was used to evaluate the exercise by qualified evaluators. Although some competencies were not tested (see section VI.1.c below), this is a positive first step. Unfortunately, however, the March 13 exercise ended prematurely due to fight between an officer and inmate. The March 28 exercise report indicates the fire drill was completed successfully.

The outcome of the March 13 exercise is another example of how inadequate staffing levels can thwart GGACF’s best efforts to comply with life and fire safety provision of the Agreement. Inmate disturbances during emergency exercises are not unusual and should be taken into account during exercise planning and execution. Emergency exercise scenarios for correctional facilities should incorporate responses to inmate disturbances, provide adequate staffing levels to respond, and complete the exercise as planned. The March 13 exercise provides clear evidence that GGACF, due to inadequate staffing levels, is unprepared to effectively protect staff and inmates from such emergencies. This condition must be corrected without delay.

Findings in the previous report remain appropriate:

Although the Fire Marshall is involved in fire safety program planning and inspections, the fire safety program lacks the following minimum elements:

 Policies and procedures  An adequate fire suppression system for occupied buildings  An adequate, policy-driven and competency-based training policies, procedures or
curriculum  Quarterly fire drills for all staff  Multiple and easily accessible fire escape doors and pathways  Fire response breathing apparatus for officers

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RECOMMENDATIONS: Previous recommendations remain appropriate. Additionally, the Monitor requests the reports for all drills and exercises conducted.

1. Develop, train, implement, and evaluate a comprehensive life-fire safety program that includes all policy, procedure, resources, equipment, training, monitoring, and system/programming testing components.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install SCBAs or an appropriate alternatives at all locations where staff would need to
search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate
supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security. 7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program. 8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action. 9. The fire inspection program must be clearly detailed in fire safety policies and procedures, and become a fundamental element of pre-and in-service training.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No changes. As stated in the previous report:

Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, cell and housing unit sprinklers are non-functional and regularly used by inmates to support personal clotheslines.

An adequate supply of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures.

RECOMMENDATIONS:

1. Refer to recommendations above (a). 2. Consider purchasing fire safety program software from NFPA and/or the American
Correctional Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

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c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: None of the fire drills reported incorporated competency in the use of fire and life safety equipment or use of emergency keys by touch as required by this provision. This should be corrected, and demonstration of such competency should be included for all future drills.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above.
Train and drill staff as discussed on system use. 3. Develop emergency key and locking mechanism inspection and reporting system as
discussed above. 4. Implement competency-based staff training as discussed above. 5. Exercise fire safety program using onsite, scenario-based drills; include community
responders in exercise planning and exercise events. 6. Send the training officer and part-time fire safety officers to the National Fire Institute,
National Emergency Training Center, Emmetsburg, MD for additional training.

d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell;
and; (ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since previous reports. During this inspection, as previously described, some of the Housing Unit locks were found non-functional. However, the maintenance coordinator was not available during this assessment to discuss maintenance plans and progress. Additionally, the remote cell-lock technology remains inoperable and does not provide for remote locking and unlocking of the cells. This is partly why all cell locks must be reliably functional and maintained. Log books continued to note that certain emergency exit doors are inoperable.

RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems. 3. Repair all remote cell locking notification technology.

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e. Testing of all staff regarding fire and life safety procedures;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: No substantive change since previous assessment. No records were provided to verify that all staff have been trained and tested on safety procedures. The two fire drill exercise reports do not document what emergency procedures were exercised, and do not document that all staff were tested during these events or that their competency regarding GGACF policies was evaluated
RECOMMENDATIONS:
1. Develop / revise written emergency plans, policies, and procedures as required. 2. Test all staff on knowledge and application of emergency procedures. 3. Maintain records proving that staff have been trained and tested on emergency
procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
f. Reporting and notification of fires, including audible fire alarms;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: The fire reporting and notification system remains operable. There is no audible fire alarm system at GGACF. Currently, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency. Staff must then rely on operable portable radios, but there are still instances when a single housing unit officer does not have radio. Moreover, housing unit telephone systems remain unreliable.
RECOMMENDATIONS:
1. Refer to previous recommendations for this provision. 2. All officers must be provided operably reliable radios and communications equipment
at all times while on duty.
g. Evacuation of prisoners threatened with harm resulting from a fire;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: The March 2014 emergency exercise reports demonstrate positive efforts to comply with this provision. However, those are the only two reports submitted, and for one of the two exercises, the exercise was cancelled part way through. It is therefore inadequate to

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rely on those two reports for evidence of compliance with this provision. It is important that

all housing units, staff, and inmates participate in emergency evacuation exercises as required.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since previous visits. There remains no functional fire suppression system in the housing units other than fire extinguishers. This system must be made fully operational, regularly tested and maintained.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders. 3. Ensure that the fire suppression system is fully operational, regularly tested, and
maintained.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Neither of the March 2014 emergency exercises reported involvement by medical staff. Medical staff should be involved in future exercises so that they are aware of their obligations.

RECOMMENDATIONS: 1. Refer to previous recommendations for this provision. 2. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 5. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff

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should participate in the development of training related to critical incident recovery

and emotional injury and recovery.

j. Control of highly flammable materials.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: There were at least two inmate-caused housing unit fires reportedly occurring on March 24, 2014. In both of these events the inmates reportedly started fires outside of their cell doors. An inspection of these cell areas by this Monitor found large fire-scotched stains just outside these cells, indicating that these were very hot fires. Inmate used combustible items from their cells to ignite both fires. The risk of serious harm or death remains extremely high; the fact the inmates are left locked in their cells for long time periods with no officer in the housing unit further exacerbates this risk and begs for: expeditious increase in staffing levels; removal of combustible items from inmate cells; and repair of the automatic fire notification and suppression system.

As stated in the previous report:

Inmates continue to be allowed to possess quantities of combustible products in their cells. Although some of these items might be acceptable in a facility having adequate fire detection, response, and suppression systems and programming, GGACF conditions should not allow inmates to maintain large quantities of these items in their cells.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop a formal writing “Combustion Control and Prevention Plan” component to the
comprehensive fire safety program that includes regular and documented inspections and removal of combustible materials (solids, liquids, gases) from all areas and structures. Maintain a current inventory and tracking report of materials and locations, corrective actions and mitigation efforts.

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VII. ENVIRONMENTAL HEALTH AND SAFETY

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

GENERAL COMMENT: No substantive improvement from previous assessment.

On May 30, 2014, the Territory submitted to this Monitor for review a Safety and Sanitation Assessment that was completed on May 25, 2014. This report states that this assessment was conducted of all housing units at GGACF but does not include units A, RSAT, and Intake. This assessment focused on mold infestation in the housing units but included other findings pertaining to structural integrity, cleanliness, and general repair. This assessment reported the following problems:

1. 9-Alpha — Multipurpose area showing severe signs of structural deterioration due to leaks in roof.
2. 9-Bravo — Unit showing signs of mold. 3. 9-Alpha/9Bravo — Showers need heavy cleaning. 4. 9-Charlie — Mold in sally port and shower doors are falling apart; need immediate repairs. 5. 9-Delta — Unit has signs of mold. Detainee in Cell#25 complained that his cell has mold;
however, upon Inspection no mold was found. 6. Gulf/Hotel — Areas of roof with mold and also signs of algae where water was
accumulating. 7. India/Juliette — No visual signs of mold were observed, however, showers need heavy
cleaning. 8. Kilo/Lima — Heavy stain spots in ceilings of housing units that come from water leaking
in roof. 9. In all showers in units that were not tiled there are heavy signs of mold as part of the
remediation process. These showers should be tiled immediately. 10. GIST Office — Mold in ceiling tile at entrance to office. 11. Classification Unit — No visual signs of mold, however, mold spores might be
present in the air and this situation can easily be remediated with an air purifier.
This assessment is consistent with observations of this Monitor during this onsite assessment. No remedial action plan was submitted to deal with these environmental issues.

Additionally, findings from the previous assessment indicate no significant change. As stated in the previous report:

Policies and procedures required under this Provision have not been provided to the Monitor or USDOJ for review and approval. However, it is important to note positive efforts continue to be made by the Territory to improve certain environmental conditions that were observed during this assessment.

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In general, the housing units and most of the cells appeared cleaner; inmates and staff reported a “major effort” to steam clean housing areas. Notwithstanding other environmental improvement required in the kitchen area (broken tiles, deep cleaning of floors; equipment; vent hoods, etc.), the kitchen looked much cleaner and the tool/utensil cage was locked. Most of the housing units previously reported in need of repair were repaired, some with fresh paint. Efforts were made to provide hot water in the housing units but the water felt just above room temperature to the touch and may simply require thermostat changes. A review of the maintenance logs evidence timely inspection of generators, Grease-traps, and some lock repairs. These findings show positive effort to develop a strategic approach to improving environmental conditions and should be expanded to all facility areas and promulgated into well written policies and procedures.

1. There is no hot water in the housing units, which creates serious health and sanitation risks for staff and inmates. Take necessary steps to ensure units are provided with sanitary hot water.
2. Many sinks in the cells were inoperable. 3. Some of the toilets did not flush properly. 4. Inmates are allowed to wash their clothes and linens in the toilets and/or sinks, then hang
them to dry on clotheslines anchored to inoperable fire sprinklers in their cells. 5. Standing water was found in housing units and cells. Inmates and staff state that housing
units will flood during heavy rains. 6. A few shower heads remain broken, some shower stalls remain covered with mold, as were
ceilings and cell-block walls. 7. Mold remains on housing unit ceilings, maintenance closets, pipe chases, recreation
areas, some areas in the kitchen. 8. Housing unit temperatures will rise in the hotter season which, combined with high
humidity, can promote and spread infectious diseases, exacerbate certain chronic medical and mental illness, promote inmate frustration and violence, and dissuade correctional staff from leaving air-conditioned control rooms to conduct housing unit inspections, rounds, and security checks. High temperatures also pose very serious health risks to inmates on certain psychotropic medications current being administered to inmates. 9. Food trays being filled in the kitchen with food were still drying after being washed. Overall sanitation in the kitchen has improved some but remains in need of regular deep cleaning. 10. Housing unit water is essentially undrinkable and inmates are unable to access water when locked in their cells without the assistance of the housing unit officer. I was told by inmates that there are times when officers will not respond to requests for water or are away from control rooms for extended periods. This is evidenced by officer logs where officers have recorded leaving their units completely unattended to take breaks and/or where no relief officer was available. Unit logs also report a practice of “last call for water”. This practice evidences that inmates do not have consistent access to potable drinking water. 11. Many of the inmate mattresses appeared old, tattered, and filthy but the Territory has purchased new mattress for distribution. Inmates and staff stated that mattresses are not routinely cleaned or disinfected during and between uses. Linens are allowed to be washed in toilets and hung to dry as previously described. 12. There is no written formal sanitation inspection and/or infection control program.

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13. The facility appears inadequately staffed to provide adequate monitoring, oversight, and

response to routine or emergency sanitation conditions or maintenance issues.

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;

ASSESSMENT: PARTIAL COMPLIANCE – No substantive change since previous assessment.

FINDINGS: The maintenance coordinator was not available during this assessment. Formal housekeeping and sanitation plans remain under development as stated in the previous assessment report. Formal plans should be completed and issued in the form of policies and post orders.

To its credit, however, the Territory appears to have maintained the measure of improved cleanliness as described in the previous report:

Most of the housing areas and cells were cleaner; fewer occupied cells were cluttered with empty food cartons, excessive personal items, and there was a noticeable decrease in the number of cell clotheslines as previously reported, but some inmates continue to use broken fire sprinklers to anchor the lines hanging across their cells. This effort should be consistently maintained and include other housing and cells areas found unacceptable.

The juvenile housing area still has vegetation growing through cell windows, and dirty sinks but rubbish on the floors was reduced greatly. The RSAT unit was in similar condition as the juvenile unit. Both units appeared to have mold growing on ceilings and shower areas. The Aunit was in a similar state of cleanliness with areas of mold and disrepair.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.

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8. Repair all housing/cell windows to prevent penetration by insects.

b. Adequate ventilation throughout the facility;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing, can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many of which can cause harmful reactions when body temperatures are elevated).

The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lock down. Access to drinkable water is generally available during the “out of cell” periods but inmates must rely on the presence and actions by officers following lock down. Inmates have no access to drinkable water when there are no officers on the units to provide it and water from cell-sinks is considered not safe for drinking.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Timely complete an air quality assessment performed by a qualified provider. 2. Implement necessary improvements that reduce housing area and cell temperatures
and increase air flow. 3. Ensure inmates have constant access to drinkable water. 4. Medical and mental health staff should monitor all inmates for heat and airflow-
related health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions. 5. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors. 6. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions. 7. Ensure that adequate amounts of drinkable water is always available to inmates. 8. Medical and mental health professionals should closely monitor inmates being administered medications that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The Monitor was pleased to see that all but one of the external perimeter security lights were functioning. However, many of the occupied cells remain very dark, as stated in the previous report. Dark cells create very dangerous conditions for staff and inmates because high

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visibility into the inmate cells is fundamental for effective safety and security. Additionally,

some inmates continue to block their cell door windows and hang blinds in their cells. These

conditions must be permanently corrected without delay.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and
internal illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness. 6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that impedes good visibility from the cell door window.

d. Adequate pest control for housing units, medical units, and food storage areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: There has been no change since previous inspections and this provision remains in Partial Compliance has no decline in performance was found. Additionally, inmates housed in RSAT and Intake units again reported “constant” mosquito problems. An inspection of these cell areas again found broken and missing cell window screens that should be replaced.

RECOMMENDATIONS: Previous recommendations remain appropriate

1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: PARTIAL COMPLIANCE – No substantive improvement from previous assessment.

FINDINGS: Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies.

RECOMMENDATIONS: Continue to implement these recommendations:

1. Ensure that all inmates have access to hygiene products upon admission to the facility.

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2. Continue to provide adequate supply of these personal care items in control pods or

housing units to ensure timely exchange of use-for-new products.

3. Prohibit inmates from bartering these supplies and from hoarding empty containers in

their cells and living areas.

This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change from previous assessment. Related policies and procedures have not be submitted for review by this Monitor.

RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for biohazard safety and exposure control; B. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all biowaste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a biohazardous control program that involves regular inspections of all potential contamination areas.
2. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
3. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

g. Mattress care and replacement;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Several inmates were issued new mattresses but other inmates still use tattered and unsanitary mattresses. This provision can move into Partial Compliance once all inmates are issued new and/or intact and clean mattresses.

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RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Refer to previously discussed sanitation recommendations. 2. Consider replacing all mattresses with those that are more bacteria-resistant. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and
contraband, cleaned and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance
requirements.

h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change since previous assessment. Implementation of approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance.

RECOMMENDATIONS:

1. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
2. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.
3. This provision can advance to Substantial Compliance once related policies and procedures are approved and implemented according to the Agreement.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets, and dry these items in their cells using clotheslines anchored to fire sprinkler heads, walls, window frames, bunks, etc. This Monitor also observed soiled bed linens, no linens, tattered and dirty mattress, and mattresses with no covers in several occupied cells.

RECOMMENDATIONS:

1. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks.
2. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells.

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3. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning

of bedding.

4. Review, revise, develop, train, implement, and evaluate a comprehensive laundry

management plan that governs total laundry operations.

5. Develop specific policies and procedures for handling, containing, and washing

contaminated clothing, linens, and mattresses.

6. Consider replacing all wood laundry carts made of non-absorbing materials that can be

sanitized and completely cleaned. Discontinue the practice of moving laundry on carts

that has not been cleaned and sanitized.

7. The initial issue of inmate supplies should include, at minimum: one (1) corrections

issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket.

Clothing should be exchanged with clean items twice per week at minimum, sheets and

towels once per week at minimum. Blankets should be exchanged monthly at minimum.

Any clothing, linens or bedding should be changed immediately if they appear damaged

and/or unsanitary, or appear to present a risk to health.

8. Ensure that inmate handbooks provide clear rules and information about the laundry

program, how to access clothing, linens, and bedding. Cease the practice of allowing

inmates to wash clothing in housing unit or cell sinks and toilets.

9. Staff and inmates involved in the laundry work program should be properly trained and

supervised.

10. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: An assessment of the kitchen was not performed during visit due to time constraints. The above compliance score is based on the aggregate of previous reports and the fact that no progress was reported in the Territory’s May 15, 2014 Status Report.

RECOMMENDATIONS: Previous recommendations remain appropriate. This provision can advance to Partial Compliance when policies and procedures addressing recommendations are approved and implemented per this Agreement.

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records;

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E. That menus are reviewed at least annually by a qualified dietitian to ensure meals

comply with nationally recommended allowance for basic nutrition;

F. Prohibitions of using food as a disciplinary measure;

G. Involvement of independent outside sources to verify food service facilities and

equipment meet government safety codes;

H. Prescribes regular cleaning schedules including routine deep cleaning;

I. Provide written utensil control methods similar to those used by the tool shop;

J. Accident prevention program;

K. Personal and environmental sanitation requirements;

L. Food temperature monitoring and records keeping;

M. Adequate health protections for all staff and inmates including health screens and

prohibitions against working in the kitchen when ill;

N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that

all bathrooms and wash basins are consistently supplied with antibacterial soap and

hot water;

O. All areas and equipment related to food preparation, distribution, and storage require

frequent inspection to ensure they are sanitary, operational, and safe;

P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit;

between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the

final rinse. The person conducting inspections should be a qualified food service

inspector;

Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit,

refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees

Fahrenheit or below, unless national or state codes specify otherwise;

R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit

and cold foods at approximately 41 degrees Fahrenheit;

S. Supervisory food service staff should monitor food service operations to ensure that

that cooking, cooling, and food temperatures and delivery meet established

requirements;

3. GGACF officials should review food service requirements promulgated by the National

Correctional Association and National Commission on Correctional Health Care.

4. Develop a food service training program that includes inmate and staff training records

and ensure that all training is well-documented.

5. Policies and procedures developed should include controls for the use of caustic, toxic,

and hazardous materials used in the kitchen. Material Safety Data Sheets should be

posted conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No improvement was observed in the housing units during this assessment. Several cell sinks remain inoperable, inmates do not have consistent access to drinkable water following lock-down; they have no access to water at all when locked down and there are no officers working in housing units.

RECOMMENDATIONS: Previous recommendations remain appropriate.

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1. Refer to recommendations regarding sanitation and this provision. 2. Develop and implement a corrective action plan that ensures inmates have consistent
and reliable access to safe drinking water. 3. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Required policies and procedures have not yet been submitted to this Monitor for review. Additionally, the BOC training director was (once again) not available during this assessment to review this provision and discuss progress. No records have been provided to this Monitor evidencing compliance with this provision.

The following discussion from the previous report regarding training curriculum remains appropriate to remind Territory officials of content and processes involved in developing efficacious training curricula:

Training curriculum is a total package of learning activities designed to achieve the objectives of the training program. In a competency-based system, the objective, or desired end, is that trainees will acquire the specific knowledge and skills (competencies) they need to do their jobs. There are three primary components to be examined when evaluating any training curriculum. They are:

1. the content or information to be transmitted 2. the organization of the curriculum which includes
 structure, format, and sequencing  the training methods used

Training Content

Compliance requires that content include specific information, facts, attitudes, and skills to be transmitted by the training program. In a competency-based system, which is defined as “Training” in the Agreement, these are formalized in the competency statements containing measurable training outcomes. The following principles relate to training content:

1. The scope and depth of the content of any curriculum are determined by the competencies the curriculum is designed to teach.
2. Content should transmit a theoretical framework and conceptual rationale for the training. 3. Content should reflect best standards of practice.

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4. Content should communicate a values orientation.

5. In an in-service training program, the content must be applicable to direct practice.

6. The content of a curriculum must be congruent and complementary both within and between

sections.

7. Content must clearly distinguish knowledge competencies and knowledge application

competencies.

Structure and Format

This refers to the construction of individual sections, and the organizations of the parts of the curriculum into an integrated whole. It includes the design of each section to achieve objectives, the sequencing of sections and activities, establishing time frames, and designing linkages between sections.

The sequence of activities within each section and within the curriculum as a whole should be concordant with the natural learning process and measureable learning outcomes.

Knowledge and skills that are conceptually related, or that are performed together on the job, should be taught together.

Providing a broad overview of the content early in the sequence provides a conceptual framework within which trainees can organize the parts. This facilitates retention and understanding.

Principles of sequencing are: from simple to complex, from the universal to the exception, and from fundamental to more refined applications:

1. Repeating key concepts in different contexts facilitates understanding. 2. Relating sections within a curriculum helps develop logical linkages between previous and
current training content, and identify different situations in which similar knowledge and skills are applied, which helps to reinforce retention and promote generalization.

Planning adequate time to cover the content to the desired level of depth is essential. Compression of content into an unrealistic time segment limits the effectiveness of the training. It can't be done faster than it can be done.

Training Methods

Training methods are the strategies used to transmit the content and to promote learning and retention. In an in-service training curriculum, the training methods must be appropriate for use with adult learners in an applied setting. The method that is best suited to achieve the objective of the section should be selected accordingly:

1. Use presentation to quickly transmit factual information. 2. Use discussion to promote greater exploration of the information and to develop
understanding. 3. Ask questions of trainees or use exercises that feed information back to the trainer to
determine how well trainees understand the content. 4. Use experiential exercises to develop self-awareness.

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5. When trainees have prior knowledge or preconceived ideas about the content, use an

activity that challenges mindsets and motivates trainees to rethink their own beliefs.

6. Use exercises and simulations to promote application of the content to job tasks, and to

develop trainee skills.

7. Use activities that identify solutions to potential barriers in the workplace and action

planning to promote TOL from the workshop back to the job setting.

8. Present the same concepts using a variety of learning strategies to help ensure that

trainees with different learning styles can assimilate the knowledge. Hearing, seeing,

modeling, and then practicing the training content also reinforces learning for individual

trainees.

9. As determined appropriate, training should be conducted in housing units or other

locations where the information is applicable.

Ultimately, this provision asks for a/the training “curriculum,” which has not been provided as required and possibly does not exist, based on the training documents provided. The documents provided, as stated above, would not qualify as curriculum by definition. The training materials provided appear to be outdated reading materials involving a blend of some basic and special topics. The materials provided are considered “canned” resources purchased off the internet from Lockup USA, a company that specializes in producing correctional training videos that includes study reading materials. A review of that website (http://www.lockupusa.com/). This During the previous assessment, this Monitored accessed and reviewed several training videos for corrections and non-corrections staff. Although the website allowed only partial viewing of training videos, their content appeared to provide meaningful training information for basic and in-service training purposes. However, neither the videos nor supplemental reading materials qualify as curriculum but are considered training supplements that would support a written curriculum if it exists. The Monitor has provided Territory officials curriculum document samples for review and consideration.

Training Materials

Training materials must support the overall curriculum and expected learning outcomes. This can be achieved:

1. Ensure that training materials include all updated policies, procedures, regulations, forms and documents.
2. Ensure that training materials are current and related to subject outcomes. 3. Ensure that the materials are appropriate for adult learners and support trainee learning
styles and abilities. 4. Ensure that training materials support Agreement requirements and Provisions.

RECOMMENDATIONS: Previous recommendation remain appropriate, also:

The Territory should reach out to the University of the Virgin Islands’ Graduate School of Education (Curriculum and Instruction) for assistance in developing adequate training curricula. This Monitor has done this with other universities and found such assistance invaluable and very inexpensive.

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1. Written training policies and procedures should be developed and implemented to govern

pre-service, in-service, and ongoing training or corrections and civilian staff. The following

are a few recommended elements for training program policies and procedures:

A. Training program mission statement, goals, objectives, and operating procedures; B. Written, understandable, and measurable; C. A training program written code of professional standards and ethics; D. Employees participate in formulation of policies, procedures, and practices; E. The training program is adequately staffed with qualified training and support staff; F. There is a written organizational plan that depicts training program structure, lines of
communication and authority; G. Training records management and control; H. Descriptions and roles of the agency, public, and private training agencies and/or
organizations involved in training development and implementation; I. Authorization and description of off-site training facilities; J. Regularly scheduled meetings between training leadership and agency leaders for
program coordination and management purposes; K. A system for monitoring training program methods, content, and outcomes; L. Training program funding and space; M. Training program role in staff recruitment, selection, training, re-training, promotion,
dismissal; N. Prohibitions against and consequences resulting from staff and student misconduct
related to training functions and activities; O. Adequate equipment and supplies are available to develop, prepare, administer, and
evaluate training program and services; P. Appropriate accommodations are available for disabled and/or impaired students; Q. Training curricula and plans are developed, evaluated, and updated based on a valid
assessment of staff performance that identifies current job-related training needs; R. Ongoing formal evaluation of pre-service, in-service, and specialized training program
conducted and/or sanctioned by the agency; S. Adequate reference materials are available to program staff and learners; T. All courses provided include attendance records, lesson plans, instructor name, course
evaluations, methods for demonstrating topic proficiency and test results; records of certificates or completion verification; U. Methods that protect the integrity of testing and assessment processes; V. Courses are based on competency-based curriculum supported by appropriate materials and course resources; W. All instructors are qualified to teach course topics; instructors teaching uses of force, first aid, weapons use, etc. are currently certified to instruct such courses; X. Use of force training includes non-physical, physical, and appropriate use of authorized weapons, force levels, justification, etc.; Y. Training topics, content, proficiency, and hours/weeks of training is established for preservice, in-service, and specialized training; Z. Firearms training covers use, safety, and care of firearms and the legal and ethical constraints on their use. Training includes knowledge and performance, and is assignment specific (e.g. use of weapon in various settings, conditions, areas); AA. Chemical agent training covers the use and handling of chemical agents, as well as the treatment of persons exposed to a chemical agent;

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BB. Emergency responders are available to timely respond to training incidents involving

injury.

CC. Access the American Jail Association, American Corrections Association, and

National Institute of Corrections training libraries for more resources for designing,

developing, implementing, and evaluating policy driving training curriculum for adult

learners.

2. Training plans should be developed for all revised and new policies and procedures required under this Agreement. These plans should include methods for determining content proficiency as defined in this agreement. The use of pre and post tests and visual demonstration of applied topics should be used in measuring topic competency.

b. Pre-service training for all new employees;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

FINDINGS: Similar findings as discussed above.

RECOMMENDATIONS:

1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.

c. Periodic in-service training and retraining for all employees following their completion of pre-service training;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

FINDINGS: Similar findings as discussed above. Training-related documents provided by Territory officials do not provide sufficient information and clarity to assess compliance.

RECOMMENDATIONS:

1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

FINDINGS: Similar findings as discussed above.

RECOMMENDATIONS:

1. Provide the Monitor all training program policies and procedures. 2. In the absence of training program policies and procedures, develop such policies and
procedures.

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3. Provide the Monitor with documentation on how compliance with this provision is being

met.

4. Develop a basic spread sheet that allows the Monitor to clearly determine the following:

 Total authorized staff per category (correctional, supervisory, civilian, contract, etc.)

 YTD actual staffing levels per category, preferably by month

 Number and percentage of current staff in each category who have completed

required pre and in-service training, per month

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IX. IMPLEMENTATION

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.

FINDINGS: The Territory has failed to meet many deadlines in the Court-approved schedule. On July 11, 2014 the Territory requested from this Monitor a 90-day extension to all deadlines that were not yet missed (i.e., deadlines that were after July 11, 2104). The Monitor approved this request but later modified that decision in part, requiring new timelines for any items pertaining to provision of adequate staffing. The Monitor required that those items be completed in 45 days. The United States is seeking Court resolution regarding the Territory’s failure to meet deadlines prior to July 11, 2014, for which no modification request was submitted.

2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.

FINDINGS: As stated above.

3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

FINDINGS: The Territory submitted to this Monitor and the USDOJ several policy and procedure draft documents during this reporting period. However, following a review of certain documents, the Monitor rejected all submitted drafts without further review. In the Monitor’s opinion, the documents reviewed were so devoid of basic document requirements and littered with formatting, spelling, and grammatical errors that reviewing and commenting on each document submitted was an inefficient and inappropriate use of the monitoring budget. This Monitor advised Territory officials to submit only documents that contained those basic elements and provided technical assistance for doing so.

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4. Defendants will conduct a semiannual impact evaluation to determine whether the

policies, procedures, protocols, and training plan are achieving the objectives of this

Agreement and to plan and implement any necessary corrective action. The Monitor

will assist Defendants in identifying and analyzing appropriate data for this

evaluation. The evaluation and all recommendations for changes to policies,

procedures, or training will be provided to the United States and the Monitor.

FINDINGS: The Territory submitted to this Monitor is semiannual impact evaluation report on April 15, 2014. The plan includes a summary of Major Initiatives as well as a descriptive narratives for each provision reporting progress efforts. These descriptions, however, do not describe evaluative impact outcomes as stated in this requirement. This is somewhat expected due to lack of progress in meeting substantive requirements of the Agreement. This Monitor will continue to assist the Territory to develop qualitative and quantitative measures for evaluating progress and compliance as requested.

5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.

FINDINGS: As stated previously.

6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.

FINDINGS: The Monitor received from the Territory a status report dated May 15, 2014. The limited volume of information contained in this report supports this Monitor’s conclusion that little progress has been achieved. The Monitor expects that these reports will be much more detailed going forward. Repeated, general responses to each provision will not be accepted. The Territory is expected to adequately assess its own progress towards compliance and what actions it is currently taking or it is expecting to take in the future with regard to each provision.

7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.

FINDINGS: Although the Territory notified the Monitor shortly after numerous serious incidents occurred, those notifications were devoid of detail and promised prompt follow up. However, the Monitor often read the details of these incidents in local Virgin Islands newspapers long before any details were communicated directly from the Territory. The Monitor requests that, when such incidents occur, the Monitor be kept up to date as new information is learned. The Monitor to this Agreement should not read about these incidents second hand.

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8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorneyclient or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.

FINDINGS: The Territory has provided numerous documents and information throughout the first year of monitoring. However, during most of the onsite visit previously requested records with either not timely made available and/or were incomplete, illegible, or not provided at all. Improvement in the timely production of complete and legible documents is essential to efficient and meaningful monitoring.

9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.

FINDINGS: Generally speaking, the Territory’s adherence to this requirement remains troublesome. There have been ongoing delays in responsiveness to information requests by this Monitor and USDOJ, the HR/Training director is consistently not available to meet and discuss important non-compliance issues during onsite assessments, forms and policies are reportedly promulgated an implemented without review and comment by this Monitor and USDOJ, staff have reported feeling intimidated by Territory administrators for sharing information with USDOJ and the monitoring Team and report being ordered by the Director not to share information. This is a very troubling and seriously impairs both monitoring and compliance progress efforts. This must be remediated.

10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.

FINDINGS: This Monitor is aware that several written requests progress of the Territory by USDOJ for documents, information, deadlines, clarification of progress have exceeded the 30day response deadline imposed by this requirement. This Monitor has been unsuccessful in resolving this matter.

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APPENDIX A ASSESSMENT METHODOLOGY

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.

Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Pre visit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.

Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.

1. Description of how the Monitor will assess compliance with each of the Compliance Measures.

In general, compliance assessment will include the following activities:

A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning. I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.

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J. Examination of any and all available records, data, and/or information relevant to

compliance and compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Incident reports and logs

 Evidence / contraband reports and logs

 Use of force incidents and logs

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (noncompliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
 Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.

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 Compliance Management: Implies activities designed and intended to ensure targeted

compliance outcomes.

 Domain: A core aspect of the organization’s performance, such as access to care, costs of

care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or

consumer satisfaction).

 Performance Indicator: A defined, objectively measurable variable that can be used to assess

an organization’s performance within a given domain. For example, within the domain of

consumer satisfaction, a performance indicator might be: “the percentage of consumers who

state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)  Online media information  Online public records  Electronic and standard mailing of information  Email communication and phone consultations

3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for the Baseline and subsequent visits and monitoring includes the following. Many of these documents were not provided at the Baseline and second

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visit as requested but more were provided during the second and third visits. Territory officials

stated that they intend to continue to generate and provide the requested documents. It is important

to reiterate the need for the documents listed below. Considering the size of this list, and

GGACF’s limited staff and technical resources, the Monitor intends to assist the Territory in

narrowing this list to the most salient items. Documents in bold below have either not been

provided or have not been updated but are necessary for effective monitoring.

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months.

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23. Records and/or lists of physical improvements, repairs, and renovation completed to

correct security problems and deficiencies over the past 36 months.

24. Past 36 months of agency budgets.

25. List and contact information for any and all community vendors who provide services

of any kind to GGACF and contracts or professional services agreement authorizing

those services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of
their records. 31. To the extent not provided above, the policies and procedures governing medical and
mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers,
including on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to
include health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment.

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46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location.

47. To the extent not provided above, external and internal reviews or studies of medical or mental

health services including needs assessments and any American Correctional Association and

National Commission on Correctional Healthcare reports.

48. List of all inmates placed in restraints, and all inmates receiving mental health

treatments, under suicide watch, or taking psychotropic drugs.

49. Current mental health case list including inmate name, number, diagnosis, date of intake, last

psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed

only by counseling staff with last appointment date and follow-up appointment.

50. Documentation reflecting any training that facility staff have received on suicide

prevention, including certificates and training materials.

51. All documents related to the any suicide occurring within the past year.

52. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms
utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and
investigative reports of all inmate suicide victims within the past three years. 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications
for the past year. 66. A description of medical and mental health’s involvement/input into the disciplinary
process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

It is important to note that the Territory made a reasonable effort to provide most of the information requested for this visit. However, log books and other reports were not ready for review on one the first day as they were during the previous visit. The balance of information listed above (in bold) is expected to be provided once it has been developed.

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Territory officials and participants were exceptionally cooperative, involved, and supportive

throughout this aspect of the monitoring process. The Territory’s repeated desire to fully comply

with the Agreement was evidenced by its active cooperation and involvement in the onsite visit.

Similarly, United States Department of Justice representatives participating in the onsite assessment

were equally cooperative and involved, which helped to maximize visit efficiency and productively.

The presence of both Parties during the onsite visit assisted assessment focus and allowed for

collaborative and timely resolution of important matters of mutual interest. Therefore, the Monitor

and monitoring team respectfully requests that these representatives from both Parties continue

participate at all future assessment visits.

The monitoring team used four primary reference points from which to assess compliance and progress with Agreement. These included: 1) the agreed 2012 Findings of Fact document, 2) documents, information, and data provided prior to, during, and following the onsite assessment, 3) the onsite visit, which included meetings, discussions, interviews, campus tours and inspections, and 4) the previous reports.

During this assessment, the monitoring team toured the campus, inmate housing units and cells, dayrooms and program spaces, intake/booking area, control rooms and officer posts, portions of the outer perimeter and fencing, and medical and mental health areas. We talked with BOC representatives and staff, and spoke with inmates.

 
 United States Virgin Islands
GOLDEN GROVE ADULT CORRECTIONAL FACILITY
St. Croix, VI
FIFTH COMPLIANCE MONITORING REPORT
2013 Federal Court Settlement Agreement In re: United States of America v. The Territory of the Virgin Islands (86/265)
Kenneth A. Ray, M.Ed., Monitor November 28, 2014

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Kenneth A. Ray, M.Ed. Monitor

TABLE OF CONTENTS

Topic

Page

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

1

Purpose……………………………………………………………………………..

2

Executive Summary & Overview………………………………………………… 2/5

Section IV. Safety and Supervision Compliance ………………………………

11

Section V. Medical and Mental Health Care Compliance …………………….

54

Section VI. Fire and Life Safety …………………………………………………

93

Section VII. Environmental Health and Safety ………………………………… 98

Section VIII. Training ……………………………………………………………. 106

Section IX / X. Implementation / Monitoring…………………………………… 108/111

APPENDIX A

Compliance Assessment Methodology ……………………………………………. 112

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PURPOSE

The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) as a tool to assist Defendants in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.

EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

The fifth onsite compliance monitoring assessment was conducted September 22-25, 2014, and included an onsite Court status conference on Thursday, September 25th. Prior to this site visit,
the Monitor coordinated communication between the Parties and monitoring team in preparation
for the onsite assessment.

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing the final report.

The Monitor will advance each provision as certain levels of compliance progress are clearly demonstrated by the Territory. Generally speaking, the Monitor will advance provisions from noncompliance to partial compliance when compliance efforts demonstrate the following:

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1. Policies, procedures, protocols, and/or plans required of a provision are properly approved;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented.

Provisions are eligible to advance from partial to substantial compliance when efficacious assessment and evaluation of implemented policies, procedures, protocols, plans, etc. quantitatively and/or qualitatively evidence: 1) that implementation efforts are producing outcomes intended in the Agreement and 2) that implementation outcome performance is reliable (assessments and evaluations evidence consistency in producing outcomes intended in the Agreement). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately evidenced, this Monitor will and has reversed a compliance rating when the evidence supports doing so.

There was no change in compliance ratings for this assessment. As stated in the Fourth Compliance Assessment Report, 107 (89%) of the 120 substantive provisions (not including provisions in Section IX. Implementation) remain in noncompliance; one provision was reversed from partial to noncompliance due to new problems, as described in this report. The compliance ratings in this Fifth Compliance Assessment Report demonstrate virtually no substantive progress since the September 2013 Baseline assessment.

GGACF FIFTH COMPLIANCE ASSESSMENT SCORE CARD
Areas of Compliance Per Agreement
IV. Safety and Security V. Medical, Mental Health Suicide Prevention VI. Fire and Life Safety VII. Environmental Health and Safety VIII. Training Total Substantive Provisions Percent Compliance Primary Assessor: Mr. Kenneth Ray, Monitor
Mr. Manny Romero
Dr. Ronald Shansky Dr. Roberta Stellan

Total

Non

Provisions Compliance

59

52

36

36

10

10

11

5

4

4

120

107

100%

89%

Partial Compliance
7 0 0 6 0 13 11%

IV. Safety and Security VIII. Training VI. Fire and Life Safety VII. Environmental Health and Safety V. Medical V. Mental Health/Sucide Prevention

Substantial Compliance
0 0 0 0 0 0 0%
59 4 10 11 36 36

This Monitor intends to assign additional Provisions to Mr. Romero in an effort to further improve the quality and efficiency of the monitoring process, and to leverage Mr. Romero’s expertise to add additional value to technical assistance and consultation provided to Territory officials pe r this Agreement.

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Implementation (Section IX) provisions were not measured using these rating classifications but a narrative description of compliance is provided; the required evaluation standards may be applied in evaluating these provisions in future reports once the Monitor has more clarity about doing so from the Parties.

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FIFTH ASSESSMENT FINDINGS OVERVIEW:

In early September, prior to the Fifth onsite visit, this Monitor and another monitoring team member, Mr. Manuel Romero, worked onsite with Territory officials to develop two, top priority policy and procedure drafts, Classification and Use of Force. Together, we worked for five days on these documents. BOC Director Wilson and other BOC and GGACF staff participated in all five days and provided information necessary to complete the policy drafts. Additionally, BOC staff worked tirelessly to quickly modify and print various versions of draft documents and forms in order to keep the process moving and on track. BOC participation and support of this process is very appreciated, and contributed to the production of two well-developed policy drafts.

To its credit, the Territory did provide to this Monitor and USDOJ numerous policy drafts prior to the onsite technical assistance visit described above. However, these documents were replete with various content, format, and other writing errors making the review and approval process by the monitoring team and USDOJ unnecessarily cumbersome and time-consuming. This Monitor provided Territory officials specific recommendations for improving draft documents and advised the Territory to only submit for review draft documents with content that appropriately focused on Provision requirements, and only documents mostly free of format and writing errors. Subsequently, the Territory virtually stopped submitting document drafts for review and failed to meet Schedule deadlines approved by this Monitor following the Territory’s written request to do so. Ultimately, the Territory requested this Monitor to assist in writing all required policies and procedures, and upon agreement to do so, the Court ordered the Monitor to complete and submit all required policy and procedure drafts to the Territory no later than 12/31/14.

Concomitant to the Court ordering this Monitor to develop and submit policy and procedures drafts by 12/31/14, this Monitor, also per Court order, submitted a revised Schedule with new compliance deadlines to account for the 12/31/14 policy submission deadline. This Monitor complied with the Court order as directed in collaboration with USDOJ and the Territory. It is also important to note that both of these Court-directed tasks for the Monitor were agreed to by the parties in order for USDOJ to withdraw its contempt motion.

The revised schedule uses an abbreviated scheduling matrix setting deadlines that prioritize Settlement Agreement Provisions:

PRIORITY A: Most critical to safety, security, and health care. PRIORITY B: Very important to safety, security, and health care. PRIORITY C: Important to safety, security, and health care.

PRIORITY A 1. Staffing
a. Staffing Analysis with realistic shift factors (IV.D.1a) b. Security staffing plan with implementation timetables (IV.D.1b) 2. Supervision of Prisoners a. Appropriate stratification of housing units (IV.A.1a) b. Post orders (IV.A.1.b) c. Rounds and supervision in general population housing units (IV.A.1.d)

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d. Rounds and supervision in special population housing units (to include A Dorm, RSAT,

Lima, 9A, R/D) (IV.A.1.d)

e. Rounds and supervision in all other areas of the facility (IV.A.1.d (ii))

3. Requirements for Locking and Unlocking Doors and Maintenance/Inspection of Locks

(IV.C.1.c and IV.C.1.d)

4. Contraband

a. Definitions (IV.B.1.a)

b. Prevention (IV.B.1.b)

c. Detection (IV.B.1.c)

i. Supervision (IV.B.1.c (i))

ii. Inmate searches upon return to housing unit (IV.B.1.c. (ii))

iii. Regular and randomized searches of housing units and other common areas of facility

(IV.B.1.c. (iii))

d. Response (IV.B.1.d)

5. Use of Force and Use of Restraints (IV.H and IV.I)

6. Incident Reporting

a. Procedures for reporting (IV.G.1.a)

b. Procedures for supervisory review of incident reports (IV.G.1.b)

c. Preservation of evidence (IV.G.1.c)

d. Central tracking of incidents (IV.G.1.d)

e. Reporting/reviews/corrective action (IV.G.2)

7. Discipline of Staff and Inmates

a. Discipline of staff (IV.K.1.5)

b. Discipline of inmates (IV.k.1.5)

8. Medical and Mental Health (V)

9. Fire drills and emergency evacuation exercises (VI.1.c and VI.1.g)

10. Adequate Supply of Drinking Water (VII.1.k) (including how and when water should be

distributed in housing units)

11. Training (general) (VIII)

12. Auditing of Policies (this is necessary because the definition of “implementation” includes the

need to track policy use through audit tools)

PRIORITY B 1. Staffing
a. Staffing Analysis and Staffing Plan – Annual Review and Revision (IV.D.1.c) b. Staffing Analysis/plan implementation (IV.D.1.d) c. Pre-Employment Background Checks and Periodic Review (IV.C.1.e) 2. Radio Communications and Radio Control (IV.A.1.c) 3. Visitation and Escorts for Visitors (IV.B.1.e) 5. Inmate Identification (IV.C.1.b) 6. PREA (IV.E.1) 7. Classification (IV.F.1 and IV.A.1.a) 8. Prisoner complaints/Grievances a. Procedures for filing grievances (IV.J.1.a) b. Investigation of grievances and response (IV.J.1.b and IV.J.1.c) c. Tracking and management of records (IV.J.1.d) d. Review of grievance data to identify trends (IV.J.1.e) 9. Fire and life safety (VI – all provisions)

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a. Creation of fire safety plan (VI.1.a)

b. Provision of adequate fire detection and suppression equipment (VI.1.f and VI.1.h)

c. Inspection of fire and life safety equipment (VI.1.b)

d. Security inspections of housing units and locking mechanisms (VI.1.d)

e. Training and evaluation of staff regarding fire and life safety procedures (VI.1.e)

f. Control of flammable materials (VI.1.j)

g. Medical treatment for persons injured as a result of fire (VI.1.i)

10. Environmental Health and Safety

a. Sanitation

i. General sanitation policies and procedures (VII.1.a)

ii. Cleaning, handling, storing, and disposing of bio-hazardous materials (VII.1.f)

iii. Chemical control (VII.1.h)

iv. Use of cleaning materials (VII.1.e)

v. Mattress care (VII.1.g)

b. Ventilation (VII.1.b)

c. Lighting (VII.1.c)

d. Pest control (VII.1.d)

e. Laundry (VII.1.i)

PRIORITY C 1. Uniforms
a. Inmate Uniforms (IV.C.1.a) b. Staff Uniforms (IV.C.1.a) 2. Administrative Investigations a. Investigative procedures (IV.K.1.1) b. Writing of investigative reports (IV.K.1.2) c. Tracking and review of investigations (IV.K.1.3) d. Training of investigators (both pre-service and in-service) (IV.K.1.4) 3. Food Services (VII.1.j)

The schedule also differentiates completion deadlines following final approval of policies and procedures by the Territory. Training begins no later than the dates shown below and according to established priority levels for each Provision:

PRIORITY A: Not to exceed 60 days after final approval by the Territory PRIORITY B: Not to exceed 90 days after final approval by the Territory PRIORITY C: Not to exceed 120 days after final approval by the Territory

Additionally, training for all Provisions shall be completed no later than 60 days after the commencement of training, and the evaluation of Provision implementation shall begin no later than 150 days after training has been completed:

PRIORITY

Monitor Submits Drafts to Territory

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Territory Submits Revised Drafts to Monitor/DOJ (30 Days)

Monitor/DOJ Returns
Comments to Territory (45 Days)

Final Approval
by Territory (14 Days)

Training Begins (60,90,120 Days)

Training Completed (60 Days)

Evaluation of Implementation
Begins (150 Days)

A 12/31/2014 1/30/2015

3/16/2015 3/30/2015 5/29/2015 7/28/2015

12/25/2015

B 12/31/2014 1/30/2015

3/16/2015 3/30/2015 6/28/2015 8/27/2015

1/24/2016

C 12/31/2014 1/30/2015

3/16/2015 3/30/2015 7/28/2015 9/26/2015

2/23/2016

Despite this assessment finding no measurable progress to support advancing any of the compliance ratings, participation by Territory and GGACF remained active throughout the assessment process. And, although two U.S. Marshals provided onsite security to expedite our movement during campus tours, the Warden and/or the Security Chief maintained a consistent presence while touring.
During the Fourth Assessment exit meeting, this Monitor gained consensus from the parties to modify the onsite assessment process to include more time to discuss the Territory’s specific progress toward compliance. This Monitor believes that this modification was extremel y helpful for two specific reasons: 1) All GGACF compliance teams were able to discuss their compliance efforts, clarify barriers to progress, and identify potential options for removing those barriers, and; 2) we reviewed each substantive Provision and clarified GGACF staff understanding about how each Provision was assessed and rated, and what specific improvements were necessary to meet compliance requirements. The GGACF staff were exceptionally cooperative and informative during all of these meetings, and it is hoped that this change in the assessment process improves clarification of compliance expectations, responsiveness to the Monitor’s request for information, and garners better communication between the Territory, USDOJ, and the Monitor.
The fundamental goal of this onsite assessment was to determine what, if any measurable progress was accomplished following the Fourth assessment. Although progress was reported and described by GGACF officials, no measurable improvement following the Fourth assessment was found by the monitoring team.
For example, the Warden stated that all items used by inmates to block cell door windows had been removed; however, this Monitor again found cell door windows blocked with paper, cardboard, or towels. This Monitor was also told that Supervisory staff had been directed in writing by the Warden to commence conducting rounds of all housing units to ensure staff were compliance with policies and procedures, and to ensure that staff had all equipment needed to operate their shift. However, this Monitor found inoperable flashlights, a housing unit with no suicide cut-down tool, and mixtures of obsolete and new post order and policy and procedure documents at most housing unit officer stations.
Regarding staffing, the Warden presented for review a revised shift schedule intended to improve post coverage and on-duty security staffing levels. This effort would seem promising but would has not adequately reduced penetration of dangerous contraband or the high levels of inmate-oninmate or inmate-on-staff violence as demonstrated by the Incident Log and reported incidents prior to and following this assessment (as described in Provision assessment findings).

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Additionally, inmates continue to set fires inside housing units due, in part, to inadequate staffing

levels and GGACF’s inability to eliminate methods use by inmates to ignite fires. This is

extremely troubling due to the fact that the GGACF automatic fire detection and suppression

system remains inoperable. GGACF officials discussed plans to repair and reactivate the

automatic fire protection system within the next six months. No fire drills have been conducted

since June of 2014.

The incident and use of force reporting process remains inconsistent and incomplete making it virtually impossible for GGACF officials to effectively assess and correct operational conditions and needs, or for this Monitor to consistently and accurately assess problems and progress. The Incident Log continues to omit reported incidents while use-of-force incidents appear to go either unreported and/or do not undergo administrative review as required under this agreement, or those documents are not being provided to this Monitor as requested.

Inmates continue to wear “street clothing”, and cloak their identification cards under their shirts while outside their housing units.

Regarding sanitation, GGACF officials discussed plans to completely renovate the kitchen and replace some of the cooking equipment, however, no timelines for this work were available at the time of this assessment. Housing unit mold remains prolific, inmates continue to complain about not having ready access to drinkable water, and housing unit ventilation remains poor. The Territory is to be commended for maintaining improved sanitation, as found during the third and fourth assessments. Housing units and inmate cells did seem even cleaner than found during the previous visit. However, a few cells were still filthy.

Structural security remains very problematic. Several security doors are inoperable due to nonfunctioning electric motors and/or inoperable door locking devices. On one occasion, an inmate remained locked in his cell for several hours because his cell-door lock malfunctioned and would not release the door. Such occurrences can be deadly considering instances of inmatecaused fires occurring in housing units.

The inmate disciplinary system remains inconsistent and flawed based review of reports provided by GGACF officials. However, the monthly Disciplinary Committee Report has not provided for review to fully assess documented progress, if any. The inmate complaint system also remains incomplete, inconsistently managed, and seeming erroneous in several ways. First, this process is not properly managed, which causes the grievance tracking log to be replete with errors and inconsistencies. Second, and equally troublesome, is the tracking log continues to consistently omit much of the information needed to determine what, if any, action was taken to resolve prisoner complaints.

The Territory has made some effort to provide staffing training in the areas of security locking, mental health, and suicide prevention. A review of the lock training found the curriculum was adequate but failed to include a pretest to assess learning. Additionally, not all required staff completed the training and the Territory has yet to verify if or when all staff would complete this training. The mental health and suicide prevention training was provided by two qualified instructors. However, the training materials provided was not based on policy and some of the information provided in the training appear outdated or incorrect; this training lacked many of the essential elements needed for use with correctional populations. Again, this training was

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provided before the curriculum was approved by this Monitor or USDOJ, which is inconsistent

with the terms of the Agreement.

Finally, inmate health care services remain troubling (as described in this report). It was also very troubling to again learn that from the Medical Director he has still not been paid for his services, there remains no contract with for pharmacy services, and no additional qualified mental health staff have been employed. This must be permanently corrected.

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IV. SAFETY AND SUPERVISION

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:
a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Monitor assisted Territory officials in developing a very basic stratification matrix for GGACF. This matrix will not be shown in this report due to security and inmate confidentiality reasons. Territory officials submitted a revised stratification matrix to the Monitor following the transfer of 78 inmates off-island and closing four (4) housing units. Completion of the stratification matrix should include total beds and cell-types in each of the housing units, i.e. single/double bunk, etc.
Incident Report and Contraband Logs, incident reports, and classification documents again evidence that stratification for classification housing remains inadequate and inconsistent. As detailed in other sections of this report, the lack of appropriate screening instruments, housing stratification schemes, and policies and procedures regarding classification continues to place inmates at risk of harm. Monitor is providing technical assistance to defendants in developing policies and procedures which are expected to be completed by December 31, 2014.
RECOMMENDATIONS: Previous Recommendations Remain Appropriate
1. Complete Stratification Matrix as discussed above to include 1) total capacity (beds) for each population stratified.
2. Include all housing buildings and units in the plan. Specifically, breakdown the data showing locations of all locations, total capacity of each, numbers of cells and beds, classification for each building and unit..
3. Show all bed-capacities for each custody level per housing building and unit. 4. Define custody levels more clearly and completely for all inmate classifications in each
custody level.

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5. Include intake unit - inmates are held and housed in that location.

6. Specific female unit uses – convicted (where), detention (where).

7. Review current population to verify accurate risk/need classification levels and housing,

reclassify and appropriately house as indicated by review process findings.

8. Refer to IV.F. regarding specific classification and housing policy recommendations.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The GGACF Warden issued a written directive shortly prior to this assessment requiring all supervisory staff to visit and inspect housing units routinely on a daily basis. The Warden developed and implemented a daily inspection compliance form for supervisors to complete for accountability purposes. However, assessment of this new process was not possible during this visit due to its recent implementation. This process will be assessed for consistency, completeness, and compliance during the 6th onsite visit. Nonetheless, GGACF remains dangerously understaffed, with an inadequate number of both correctional officers and supervisors.

The foundation of efficacious correctional safety and security, with regard to staffing and supervision, involves planned integration of the following elements:

1. Sufficient numbers of correctional officers and supervisors; 2. Correctional officers and supervisors are adequately trained and retrained to carry their
duties assignments proficiently; 3. Correctional officers and supervisors continuously and consistently adhere to and apply
sound correctional policies and procedures; 4. Officers and supervisors are held accountable for their performance and adherence to
policies, procedures, and practices continuously and consistently; 5. Officers and supervisors who comply with agency performance requirements are
rewarded; re-training and/or corrective action consistently occurs for performance deficiencies.

GGACF remains unable to meet any of these five elements, primarily due to staffing shortages. Corrections officer and supervisor staffing levels remain insufficient, pre-service and in-service training remains inadequate, continuous and consistent performance compliance monitoring is impossible due to insufficient staffing levels and inadequate training. Singularly or combined, GGACF’s inability to meet these foundational elements creates and maintains a very unsafe and unhealthy work environment for all staff, inmates, visitors, and the community at large. The following comparative analysis clearly demonstrates GGACF staffing-level deficiencies:

An analysis of housing unit officer and supervisor staffing levels was performed similar to the analysis completed for the previous (4th) report. As before, officer and supervisor staffing data
were collected from the Supervisor Log and analyzed to determine and compare the following
staffing conditions:

1. Number of shifts that all 14 occupied housing units WERE NOT staffed by officers;

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2. Percent of all 14 occupied housing units that WERE staffed by officers during the shift;

3. Number of shifts that each occupied housing unit WAS NOT staffed by officers;

4. Percent of shifts that each occupied housing unit WAS staffing by officers;

5. Number of supervisory staff per shift;

6. Percent of supervisor staff on-duty per shift.

An equivalent number of security and supervisory work-shifts were examined and compared for the following two periods:

4th Assessment: 30 Shifts – May 20 thru June 5, 2014 5th Assessment: 29 Shifts – August 22 thru September 22, 2014

Number of shifts that all 14 occupied housing units WERE NOT staffed by officers:

During August 22 thru September 22, occupied housing units were not staffed on 46 shifts compared to 55 shifts during May 20 thru June 5, 2014. This is a very slight, but insignificant improvement considering the fact that inmates in an entire housing unit are not supervised and monitored when the housing unit is not staffed during a shift. Unstaffed housing units expose inmates to constant potential and real risk of harm from other inmates, prevents inmates from getting immediate necessary medical attention, increases opportunities for inmates to share and collect dangerous contraband, increases escape opportunities, and prevents timely detection and suppression of fires – just to name a few of the constant potential and real risks to safety and security.

The two charts below provide a visual comparison of these shifts and the housing units that were occupied by inmates, but unstaffed, during the two periods compared (red indicates housing units not staff for each shift shown):

CONTINUE TO NEXT PAGE

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August 22 thru September 22, 2014 (5th Assessment)

May 20 thru June 5, 2014 (4th Assessment)

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The chart below shows the number of occupied housing units that were not staffed during each shift for the periods examined.

Percent of all 14 occupied housing units that WERE staffed by officers during the shift;
As shown in the graph below, at least one housing unit went unstaffed for almost all shifts in both of the time periods examined. In fact, the data indicate all housing units were staffed for only two shifts during the 8/22 period. For the last reporting period, in the time period examined all housing units were staffed only 7 times. It is reasonable to conclude that inmates went unsupervised and monitored for a majority of shifts for both periods examined and more often during the 8/22 period.

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Number shifts that each occupied housing unit WAS NOT staffed by officers:
Staffing levels were examined and compared for each of the 14 housing units. This analysis further demonstrates the number of times (shifts) inmates went without officer supervision and monitoring for the periods examined. The graph below shows these comparisons.

Percent of shifts that each occupied housing unit WAS staffed by officers:
The Supervisor Log reported that only three of the 14 housing units (H, 9C, 9D) were consistently staffed on all shifts examined for the 8/22 period. This is a significant increase in housing units that were not staff compared to the previous (5/20) period where

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Number of supervisory staff per shift:
Shifts examined and compared continue to demonstrate lack of adequate officer supervision as required under this Provision. Inadequate supervision during any period of correctional operations enables serious risk of harm to people and can promote unprofessional and potentially unconstitutional staff behavior. But for the vast majority of staff, who strive to perform as professionals, inadequate supervision and supervisory support is frustrating and increases officer stress levels when they are making every effort to professionally monitor and manage prisons. Adequate levels of shift supervision helps to consistently and routinely ensure officers 1) comply with agency rules and regulations, 2) perform proficiently, and 3) are provided timely feedback to correct and/or praise performance.
There are four (4) supervisor positions (posts) for each shift, according to GGACF officials; these staffing levels appear to be adequate if shifts are consistently staffed at these levels.
1- Tour Commander (TC) 3- Assistant Tour Commanders (ATC)
According to Supervisor Log entries for the periods examined (8/22-9/22; 5/20-6/5), none of the 29 shifts examined during the 8/22 period were fully staffed by supervisors. In fact, according to these logs, and as shown in the table below, only seven shifts were staffed with three (3) supervisors; 18 with only two (2) supervisors; and, two (2) shifts operated with only one (1) supervisor. In sum, none of the shifts were fully staffed with four (4) supervisors, and most operated with only two supervisors.
The 8/22-9/22 period demonstrates virtually no improvement in supervisor staffing compared to the 5/20-6/5 period. As shown in the chart below, two (2) of the shifts for the 5/20-6/5 period (red) were not staffed with any supervisors (red/4). By comparison however, this shift period was staffed more frequently with three (3) supervisors per shift than was the 8/22-9/22 (blue) period. The 8/22-9/22 period was more often staffed with only two (2) supervisors, and these shifts were always staffed with at least one supervisor.
All shifts must be fully staff consistently without deviation to help ensure maximum safety and security of the facility as well as staff and inmate oversight. Additionally, it will be impossible for the Territory to comply with this Agreement at these supervisor staffing levels. There were only three (3) shifts (5/20, 21, 22) out of all 59 shifts examined that operated with a full complement of supervisors.

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Percent of supervisory staffing per shift:
Finally, we examined percent of shifts having full complement of supervisors. As stated above, there were only three (3) of combined 59 shifts examined that operated at 100% or better. The chart below demonstrates none of the 8/22-9/22 shifts were fully staffed.

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The following charts visually demonstrate supervisory staffing deficiencies for all shifts during

the two periods compared.

8/22-9/22 Shift Period (29 Shifts):

. 5/20-6/5 Shifts Period (30 Shifts):

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It is very important to point out that these data and analyses are based on Supervisor Log information. These logs are typically incomplete and inconsistent. It is possible that some of the shift housing units and/or supervisory staffing levels were higher than reported, but it is impossible to know for sure considering the variation used by supervisors to document shift staffing activity. It is, therefore, vital that GGACF officials standardize these documentation procedures.

Finally, it is equally important to commend Territory officials for very recent action to increase staffing levels in occupied housing units. Five officers started at GGACF this summer after completing the Academy. The Territory reported that it is trying to recruit another class. As of the last day of the visit, 6 candidates had been vetted.

The Territory recently transferred 78 inmates to mainland facilities. This action emptied four (4) housing units and reassigned those officers to remaining housing units. This is a step in the right direction for improving safety and security of the facility. The efficacy of these efforts will be evaluated during the 6th onsite assessment in December 2014.

Although those efforts are to be commended, they are not sufficient to correct the severe staffing shortage at Golden Grove. It is unclear when the next training academy will start. The Territory has not provided any additional information on its plans to start new recruits at GGACF before sending them to the full peace officer academy. Even if six new recruits start before the end of 2014, that is still insufficient to ensure adequate coverage. The Territory needs to meaningfully commit its resources to building up staffing levels. Until that occurs, the Territory will remain noncompliant with many of these provisions. The Territory has provided no additional information regarding plans to add additional correctional staff since the onsite status conference with the Court.

National Institute of Corrections Staffing Analysis

The staffing analysis required by this Agreement was completed by the National Institute of Corrections on July 14, 2014 and provided to Territory officials. This comprehensive analysis assessed several factors with regard to providing and maintaining sufficient security-staffing levels. Based on that analysis, the Report issued the following “Urgent Recommendations”:

1. Occupancy should be reduced as much as possible in order to reduce staffing needs at the facility. This will reduce the gap between staffing needs and the actual number of staff deployed. This will probably require boarding offenders in another jurisdiction. Closing the three large sentenced buildings would reduce security staffing needs by 27%. While this is not enough to eliminate the staffing gap, it is a good start.

2. Occupancy of GGACF should not be increased until relieved security staff deployment has increased consistently for a period of at least two months. The number of prisoners who are brought back should correlate to the increase in the number of deployed security staff.

3. Technical assistance should be requested to review current detainee classification, separation, and programming practices. Detainees should be allowed to participate in

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programs and to work inside the perimeter of the facility, consistent with classification

findings.

4. Overtime must be reduced from current levels by approximately half. No more than 25% of the employees working on any shift should be working overtime hours. New policies must be developed to set limits on the total number of hours an employee may work consecutively, the total overtime hours allowed per employee within a pay period, and the time away from the facility before returning to work after an overtime shift.

5. Employees should be paid at the rates established in the compensation plan. Annual increases should be routinely awarded, consistent with employment contracts. Failing to pay employees at the rates that were promised when they were hired undermines morale, force employees to work overtime, and increases staff turnover.

The Territory has reduced its inmate (convicted) population by transferring 78 inmates off-island and subsequently closed five housing units. Territory officials reported that the officers assigned to the closed housing units were redeployed to increase staffing levels at housing units that remain open. Although this is a good start to improving facility security, on-duty supervisor and officer staffing levels from dangerously inadequate. Overtime remains extraordinarily high, most shifts operated with insufficient supervisor staff, and inmate-occupied housing units continue to operate with insufficient security staff or without any security staff for entire shifts.

The Territory has provided no additional information regarding is plan to fully implement the NIC staffing plan as required under this Agreement and need to improve staffing levels remains extremely urgent.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Rapidly implement the NIC Staffing Analysis recommendations. 2. Create a staffing plan, as required under the Agreement, that reflects the NIC Staffing
Analysis and provides concrete steps for hiring sufficient staff 3. Continue immediate steps to either reduce the inmate population commensurate with
existing staffing levels or increase staffing levels commensurate with current inmate population volume. Using the staffing analysis, determine net additional staffing levels needed once inmate population is reduced. 4. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff who work overtime have adequate time away from the facility before returning to work to ensure they are adequately rested. 5. Improve consistency, accuracy, and reliability of supervisor logs entries. 6. Contact the VI Guard to provide temporary internal and perimeter security presence until staffing levels are adequate. 7. Use off-duty VIPD officers to cover unstaffed housing units. 8. Hire PRN nurses with trauma care experience until approved FTEs are onsite. 9. Reassign correctional leadership/supervisory/specialty staff across all shifts to ensure post coverage and consistent inmate monitoring and supervision. 10. Use enabling statues that allow for immediate procurement of security hardware and systems services.

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11. Request emergency funding from the Governor and/or legislator for rapid hiring of additional

officers pursuant to the Staffing Study; remove ALL administrative and bureaucratic barriers that

have and can impair rapid hiring of qualified candidates.

12. Create a fast-track basic officer training program that ensures recruits are adequately trained on

salient correctional topics.

13. Seek Court relief to remove any barriers to rapid remediation of facility safety and security

deficiencies that expose people to harm.

14. Subsequent to policy and procedure development and revisions, conduct a complete

review of existing Specific and General Post Orders to ensure they are:

A. post specific;

B. accurately represent post staffing needs and post resources needed to operate the

post safely and consistently;

C. are numbered, cross-referenced with policies/procedures, and formatted in a manner

that makes them easy to interpret and apply;

D. maintained at each post, kept current, and easily accessible;

E. regularly reviewed, revised, updated;

F. consistently enforced;

G. known to staff through pre-service, in-service, and ongoing training.

15. Develop a plan that provides for regular review of all log books by supervisors to ensure

staffing and other unit safety and security issues to be known and resolved in a timely

manner.

16. Ensure that all posts are staffed according to post complexity and dynamics, risks and

needs.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Functioning radios were observed in all housing units, and only one officer was observed not wearing their radio because it was charging in the officer booth. Each officer should wear their radio at all times while on-duty, especially when assigned to a housing unit. Additional radios or batteries should be assigned to each housing unit to enable this recommended practice. It was very impressive to find the new phone system installed and operational throughout the housing units. Although some of the officers remain uncertain about how to fully operate the new phones, all seemed very pleased to have a reliable phone system. Post orders should be created and training should occur to ensure all officers are aware of how to use the phones.

RECOMMENDATIONS:

1. Timely repair, replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
2. The Monitor will continue to review radio equipment inventories and functionality during each onsite assessment.
3. Ensure adequate supply of radio batteries enable officers to carry radios on their person at all times. Issue directives requiring officers to carry radios on their person at all times while at the facility and anytime they are supervising/monitoring inmates.

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d. Supervision by corrections officers assigned to cellblocks, including any special

management housing units (e.g., administrative or disciplinary segregation) and cells to

which prisoners on suicide watch are assigned, including:

(i) conducting of adequate rounds by corrections officers and security supervisors in all

cellblocks; and

(ii) conducting of adequate rounds by corrections officers and security supervisors in areas

of the prison other than cellblocks.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: GGACF remains noncompliant with elements of this Provision due to inadequate correction officer and supervisor staffing levels. One of the reasons why these provisions remain in noncompliance is the Territory’s seemingly torpid response to chronic understaffing discussed throughout this report and throughout previous reports. Until such time that all occupied housing units and shift supervisor posts are consistently and appropriately staffed 24/7, the facility, inmates, staff, and the public remain at risk of real and present harm.

Examination of GGACF records and personal observations during this assessment also demonstrate continued noncompliance with this Provision. Adequate rounds in accordance with this provision could prevent or reduce the following problems, all of which have been identified in earlier reports and remain uncorrected:

1) Continued presence of dangerous contraband 2) Continued covering of cell-door windows with various items, 3) Drying of clothing on lines tied to sprinkler heads and other anchors in their cells, 4) Fires being started by inmates in their housing units 5) Continued failure by inmates to wear official ID cards, or covering the ID cards with clothing, 6) Inmates wearing non-issued inmate apparel, 7) Supervisors not adequately inspecting housing unit logs and taking steps to remedy problems identified therein.

Supervision of inmates and staff remains inconsistent and inadequate; security inspections of housing units and the campus by correctional officers and supervisory staff lack routine and consistency. Noncompliance with Provision ensures ongoing risk of harm to staff and inmates as demonstrated, for example, by ongoing contraband control problems, inmate’s continuing to block cell-door windows preventing safe visual inspection of cells, and inmates manipulated cell-door locking devices.

Additionally, there is no schedule for conducting regular rounds by medical and mental health care staff during each shift to ensure that special needs inmates (suicidal, mentally ill, medical infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff. This population MUST be regularly monitored to ensure their health needs are consistently assessed and monitored, to detected signs and symptoms of psychological and medical decompensation, to ensure basic needs are being met, to monitor medication compliance; efficacy; and need, and to making timely decisions to ensure all health and safety requirements are compliant. This is not happening and the Territory has demonstrated no substantive actions or plans to correct this basic constitutional requirement for this population.

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RECOMMENDATIONS: Some Previous Recommendations Remain Appropriate

1. Refer to recommendations regarding Post Orders. 2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure
staff and inmate safety and security, and according to inmate risks and needs. 3. Create a schedule for regular rounds by medical and mental health care staff for each
shift to ensure that special needs inmates (suicidal, mentally ill, medical infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff. 4. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. The supervisory rounds forms should be filled out at the end of each round and collected in a central location, and submitted to the Monitor and USDOJ on a monthly basis. 5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.

B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Territory officials and monitoring team members recently developed very good Contraband policies and procedures that include all elements of the Contraband Provisions. Those documents are now in final review and approval process. Upon approval, these policies and procedures will be set for staff training, implementation and evaluation according to the newly adopted Schedule. However, inadequate correctional officer and supervisor staffing levels will continue to disable the Territories best efforts to comply with Contraband Provisions until those staffing deficiencies are permanently corrected. Until such time, contraband prevention and control will remain at very limited levels as demonstrated by Incident Log entries, incident reports, and continued assaults on officers and inmates.

RECOMMENDATIONS:

1. Issue a post order or memo that clearly defines what constitutes contraband and require supervisors to daily ensure compliance by staff.
2. Finalize and implement approved Contraband policies and procedures. 3. Provide Monitor accurate, complete, and current Evidence Collection Logs on a monthly
basis.

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b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to above Assessment and Findings.

RECOMMENDATIONS:

1. Continue positive efforts in searching people before entering the facility. 2. A “stop and check” protocol for inspecting staff packages after initial entry into the facility
must be developed and implemented. 3. Provide handheld metal detectors for contraband inspections at facility entry points and as
needed for on-campus inspection. 4. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods
and process during the 5th assessment.

c. Detection of contraband within Golden Grove, through processes including: (i) supervison of prisoners in common areas, the kitchen, shops, laundry, clinical, and other areas of Golden Grove to which prisoners may have access; (ii) pat-down search, metal detector, and other appropriate searches of prisons coming from areas where they may have had access to contraband, such as intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic; (iii) regular and random search of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e,g. clinic, kitchen, dayrooms, storage areas, showers);

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to 1B above.

An examination of the Incident Log, June 20 thru September 14, 2014 found numerous incidents involving contraband of various types, including sharp objects used by inmates to assault and seriously harm other inmates, create fires in housing units, cause self-inflicted harm, etc.

Approximately 51 incidents were reported on the Incident Log from June 20 thru September 14. Log entries included 13 assaults, 1 cell phone confiscation, 12 “possession of contraband” incidents (type of contraband not identified), 3 fires, 2 drug confiscations, 6 fights, 2 inmateon-inmate stabbings, and 1 inmate who caused “self-harm”. Most of the events logged involved some kind of contraband.

Inadequate corrections officer and supervisory staffing levels impair compliance with all Contraband Provisions. In addition, GGACF officials reported that contraband control practices were further limited by temporarily changing GIST schedules, which will not be discussed further for security reasons. To compensate, the Warden has issued directives that housing unit

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officers and supervisors increase rounds and inspections in housing units and cells. Again,

however, inadequate staffing levels will significantly impair staff compliance with this

directive. The efficacy of these directives will be assessed during the 6th monitoring visit in

December 2014.

As stated in previous reports, this Monitor intentionally looked for but did not observe any inmate searches while touring the yard, housing units, or other areas observed. The failure to conduct inmate searches was discussed in each of the previous reports. Inmate searches must become a routine practice to help control contraband and dampen inmate motivation for smuggling.

RECOMMENDATIONS:

1. Refer to above, expand application of recommendations to provision c (i-iii) above. 2. See recommendations regarding staffing levels.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Refer to above findings.

Examination of Supervisor and Incident logs, incident report, and discussions with GGACF managers and line staff confirm ongoing efforts to confiscate and preserve and destroy evidence. An examination of the Evidence Collection Log further evidences these positive practices.

RECOMMENDATIONS:

Review and implement relevant recommendations for Contraband contract above, specifically B1a.

1. Continue to ensure staff access to appropriate equipment and supplies needed to safely collect and preserve contraband while maintaining evidentiary integrity.
2. Continue to ensure adequacy of chain-of-custody methods and procedures. 3. Develop a Uniformed Incident Reporting system (discussed further in this report) that
provides cross-referencing and continuity between all reports and logs involving detection and confiscation of contraband. 4. Develop and implement a continuous quality improvement (CQI) protocol to evaluate adherence to Contraband policies and procedures and reporting.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Security staff posted at the main entrance conducted a reasonable and consistent search of the monitoring team during this visit. The Monitoring team was appropriately escorted throughout the campus, but did not witness escorts of visitors. USDOJ representatives invited

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two US Marshalls to assist with security escorts due to GGACF staffing problems during

previous visits that caused long delays for the inspection process.

RECOMMENDATIONS:

1. Ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.

C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: This Monitor observed most prisoners wearing appropriate prison attire. However, many inmates continue to wear “street clothes”, which creates a real and present risk to facility safety and security. As mentioned in the previous report, this practice aided in the May 11, 2014 escape. This practice, as previously recommended, must stop. All inmates must wear only standard prison attire at all times.

RECOMMENDATIONS:
1. Require inmates to wear issued institutional clothing ONLY. 2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform
policies and inmates who refuse to comply with those policies. 3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and
appropriate corrective action with staff who refuse to do so. 4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’
classification/status. 5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges
and changes in an inmate’s classification and/or status. 6. Consider developing a correctional industry for making uniforms onsite. 7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband
and weapons. 8. Mark all uniforms with highly visible letters/numbers. 9. Revise inmate ID card policies to ensure inmates visibly wear their ID as discussed above,
monitor.
b. Identification that prisoners, staff, and visitors are required to carry and/or display;

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ASSESSMENT: NONCOMPLIANCE
FINDINGS: See above Findings.
The monitoring team and USDOJ were issued visitor identification each day of the visit.
The recently implemented inmate identification card system requires improvement. The Warden stated that the policy, as stated on the card itself, is somewhat confusing in that only requires prisoners to carry their ID on their person at all times outside of their housing units. However, the Warden stated that the policy was intended to require prisoners to visibly display their IDs in at all times outside housing units. During the tour, the Warden engaged several prisoners outside housing units to check for IDs. All prisoners checked possessed their ID but none wore their ID visibly. These prisoner interactions made clear that prisoners are confused about the policy but are complying with their understanding of this requirement. The policy must be revised to clearly require ID to be visibly worn at all times while outside housing units, and to require inmate workers to visibly wear their ID at all times when working in housing units other than their own.
RECOMMENDATIONS:
1. Ensure staff compliance with this provision. 2. Ensure adequate supplies for making identification cards. 3. Regularly audit identification card inventory and maintain proper controls to prevent
inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories. 4. Consistently enforce identification card policies and procedures.
c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Territory officials have not provided documents demonstrating full compliance with this training following the previous report as reiterated below. The training report previously provided showed a 65 percent training complete rate. The Monitor patiently awaits requested training records demonstrating a 95 percent minimum successful completion rate.
4th Report Findings;
The Territory submitted a draft document (“Supervision of Inmates and Detainees” Policy) intended to satisfy this provision on June 6, 2014. However, the document submitted was not fully responsive to this provision and was rejected for failing to include basic elements and formatting. On July 21, 2014, the Territory submitted lesson plan documents pertaining to locking and unlocking doors and gates. This Monitor provided the Territory written recommendations and feedback regarding this lesson plan. On August 22, 2014, the Territory

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submitted to this Monitor and USDOJ documents demonstrating that this training was

conducted July 21 thru August 1, 2014. These documents included:

 Lesson Plan  Post Test  Attendance Rosters  Training Completion Statistical Report

The training completion statistical report is very difficult to interpret for understanding what percent of required staff complete this training but suggests that approximately 65% (30+ staff were not trained) of required staff complete the training. This needs to be clarified and a minimum of 95% of required staff must successfully complete this training before it meets the requirements of this work plan item.

The training plan is acceptable overall but did not include instruction on relevant policies and procedures as those document have not been completed and approved for implementation. It is important that training curricula is based not only on principles of security but must include current policy and procedure to ensure staff compliance can be measured adequately in accordance with policies and procedures. The lesson plan was well written and included basic principles of door locking and unlocking principles. The course was taught by the Warden, a highly qualify correctional professional, and included a ten question post-test. Unfortunately, a post-test cannot measure learning without a pre-test to assess baseline topic knowledge among students. All future training must include a pre-test to ensure learning has been attained.

During this assessment, this monitor found all internal housing unit gates and officer stations to be locked upon entry. However, none of the exterior security slider-doors were locked. These doors – often referred to as the “sally port” doors – were left standing open or unlocked upon entry into the units; we were once again advised that the electronic locking mechanisms are inoperable. Although the various security gates throughout the facility were locked when the Monitoring team first approached, the gates were not locked behind the team when the monitoring team toured the housing units. Moreover, on several occasions during the onsite inspection, the monitoring team/USDOJ representatives were able to simply open the outer perimeter gate upon arrival at GGACF, revealing that the gate did not always lock. These observations clearly support a security culture that lacks enforcement and consistency; it also demonstrates the need for additional training, monitoring, and supervision by GGACF leadership. GGACF staff must consistently practice good security habits by keeping security doors and gates closed and locked. Officers still report that inadequate staffing levels require them to not lock security gates upon entry into the housing units for safety reasons. Housing unit logs report that fire escape doors and locks are inoperable. There was improvement found in yard-gate security, but some of the locking mechanisms remain inoperable and prevent the gates from being locked. Most notably, the last gate from the yard to the administrative building (which provides access to the outside of the facility) was broken. The supervisor bubble that looks out at this gate is frequently unstaffed, meaning that inmates can enter or exit the administrative building area as they please.

Despite some progress to fixing locks, there are still delays and many non-functioning locks. Logbook entries continue to report key door/lock issues not being timely addressed. For example, the Detention R&D entrance door was observed by this Monitor nonfunctional requiring use of a

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metal pipe to secure it closed. The door must be operated manually, keys don’t work, a metal pipe

must be placed behind the outer sally port door to provide security to the area, etc. It appears that

the lock work report does not mention this door.

Another example is X Pod, which is the housing unit for sentenced and un-sentenced female inmates. This unit is monitored by one officer, but has gone for hours with no officers assigned according to unit log books. This building is divided into two housing units with a door separating the two populations. This door is not always locked, according to the unit officer. This means that sentenced and un-sentenced inmates have access to one another, which should not occur. The lock on this door must be fixed, if broken, to ensure secure separation between these populations. If not broken, policy and procedure must direct officers on this post to keep this door locked at all times.

RECOMMENDATIONS:

1. Provide Monitor requested training records showing a 95 percent minimum successful completion rate.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement. 5. Continue to ensure staff are adequately trained in the proper use of mechanical and/or
electronic locking systems according to their post assignments. 6. Consistently sanction inmates for attempting to manipulate or manipulating any security
locking system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked! 9. Replace or upgrading existing unit control panels to provide for remote electronic locking
and unlocking of unit and cell doors. 10. Improve video surveillance of internal by placing cameras in all housing units and inmate
locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations. 13. Consistently enforce security locking policies and procedures with staff and inmates.

d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Preventive and ongoing lock maintenance remains problematic due to inadequate maintenance staffing levels as previously discussed. Examination of locking system maintenance records show continued inspection, replacement, and repair of electronic and mechanical locks and locking mechanisms. However, inadequate maintenance staffing levels

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prevent timely inspections, repairs, and replacement of these security devices considering that

the small maintenance team serves the entire facility.

RECOMMENDATIONS:

1. Employ and maintain adequate maintenance staffing levels. 2. As requested in the previous two reports, develop an “all-locks” maintenance plan for
review with the Monitor. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number, lock type, condition, etc. 3. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.

e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,

ASSESSMENT: NONCOMPLIANCE

FINDINGS: BOC officials concurred that the current background process is problematic. They advised that correctional trainees are on occasion dismissed from the Academy due to background investigation results. As a result, the trainee’s employment is terminated and the recruitment process to fill the position restarts. The hiring process is, therefore, inefficient and very problematic. All conditions of employment should be fully completed before an applicant is employed and trained. Territory officials should assess history of terminations, identify determining factors, and realign completion of pre-employment practices to avoid postemployment terminations.

RECOMMENDATIONS:

1. Territory officials should assess history of terminations, identify determining factors, and realign completion of pre-employment practices to avoid post-employment terminations.
2. This Monitor again requests inspection personnel records including employment applications; criminal history checks, and background investigations for all housing unit staff working Units 9A/B during the reported escape attempt occurring June 7, 2014. Please have these documents at GGACF for the upcoming site visit.
3. Ensure access to applicant and staff records is adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
4. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.
5. Make records available to the Monitor for inspection and verification of compliance.

D. Security Staffing

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1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The NIC Staffing Analysis has been completed and remains under review by Territory officials. This staffing analysis included realistic shift factor calculations for all security staff and GGACF. This Monitor has provided Territory officials draft basic staffing plans but the Territory has not provided any follow-up communication with the Monitor with regard to these draft plans. This Monitor remains available and committed to assist the Territory in finalizing and implementing approvable staffing plans.

RECOMMENDATIONS:

Complete and approvable Staffing Plan that accounts for the recent closing of four housing units. Secure funding to comply with Plan staffing requirements. Revise staffing hire process to improve its efficiency and timely hiring of officers.

b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to previously discussed housing unit and supervisor staffing deficiencies. The Territory has not completed a security staffing plan, using the NIC security staffing analysis, as required by the Settlement Agreement. This is a critical next step for the Territory to complete. The staffing plan should be completed as soon as possible, taking into account the Territory’s experiences recruiting and hiring staff on-island and the need to potentially advertise for positions off-island as well. On site, the Territory said they would try to complete this by December, but the Monitor received no notification of progress prior to writing this report.

RECOMMENDATIONS: See above.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to the above findings. No change since previous visit.

RECOMMENDATIONS: See above.

1. Defendants will implement the staffing plan developed pursuant to D.1.

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ASSESSMENT: See above

FINDINGS: Refer to previous findings related to staffing analysis and planning.

RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: During the previous assessment this Monitor spoke with an inmate who reported being fondled by another inmate while he was experiencing a seizure and semi-conscious. This inmate stated that while he was semi-conscious another inmate groped his groin area, according to other inmates. This inmate stated that when he regained full consciousness other inmates told him about the event and that he does not have clear memory of the event. This inmate presented a written complaint he was preparing to submit to GGACF officials about the event. The inmate was encouraged to follow through with filing the complaint and allowed VI counsel participating in the on-site assessment tour to have a copy of the complaint. This matter will be reviewed for PREA compliance during the next visit in September 2014.

1. Investigate and resolve the PREA complaint described above. 2. Compare the investigative process and outcomes to the PREA requirements and draft
policy to determine compliance with PREA requirement and needed policy revisions, if any. 3. Provide this inmate written communication advising him that his complaint is being investigated and results of the investigation.

RECOMMENDATIONS:

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements.
3. Appoint a PREA Compliance Coordinator as soon as possible. 4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s
PREA auditor certification training. All costs are covered by USDOJ. 5. Complete the PREA Self-Audit. 6. Review, revise, develop, train, evaluate policies and procedures that include, at a
minimum, the following PREA topics:

F. Classification and Housing of Prisoners

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1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facilityspecific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:

a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE

FINDINGS: There has been no change since the previous reports. Although this Monitor assisted the Territory in the development of a Classification policy, the classification instruments require validation to ensure that the instruments and classification process is objective. However, according to Territory officials, a national expert in classification validation is expected to be onsite for this purpose by the end of 2014.

Additionally, the Territory has not responded to the Monitor’s request to provide classification forms to be used in the application of the new policy in order to complete the policy.

RECOMMENDATIONS: Recommendations previously provided remain appropriate.

1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that
provide more accurate and complete guidance for a valid and reliable classification system for non-convicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance. 5. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.

b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As found in the previous reports, detainees and convicted offenders are generally held in separate buildings, except for sentenced and un-sentenced female inmates who are in separate wings of the same building. Inmates are generally housed according to their security level based on their offense of conviction or their charged offense and whether their background includes violent criminal acts. Inmates are also housed according to administrative, disciplinary, special needs, and/or work assignments. This is a very basic but dangerously unreliable practice for managing inmates and is not based on a reliable classification system. Such a practice is

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known to facilitate violence against inmates and staff, the introduction of contraband, and can

create substantial barriers to inmate health and wellbeing. For example, some inmates with

serious mental illness (SMI) are being housed in segregation/lockdown unit for unknown

reasons and without justification. Many of these inmates are placed on lockdown units because

of their mental health problems; GGACF’s lack of an effective and valid classification system

prevents GGACF staff from identifying other more appropriate and less punitive housing

placements. Indiscriminately housing prisoners on 23 hour-a-day lock down units can

exacerbate inmate behavior management problems, their mental illness, and is specifically

prohibited by the Order per Provision V.1.p:

“A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;”

Recommendations provided in previous reports remain appropriate. Failure to appropriately classify and separate inmates will remain problematic and contribute to ongoing introduction of contraband, violence, and harm to mentally ill inmates. It will also result in the continued housing of inmates with serious mental illness in isolation/lock-down units, in violation of the Agreement. Refer to previous recommendations.

RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Order’s prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Direct mental health staff to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced-side lock down units to determine mental health needs and if a different, less punitive housing placement is available.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As reported previously in this report, there was some positive improvement observed in the locking of housing unit security gates. However, this system remains flawed because it is inconsistently applied: officers continue to leave these gates unlocked when inside the housing area. Current staffing levels and gate locking practices impair GGACFs ability to comply with this Provision. The May 12th escape and June 7th escape attempt clearly demonstrate this ongoing problem.

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Additionally, the lack of housing unit security cameras or other monitoring equipment frustrates

GGACF staff’s ability to monitor inmates effectively to detect and potentially prevent them

from obtaining unauthorized access to each other. Furthermore, until all locking systems are

repaired and maintained consistently, as described above, inmates will be able to disable cell

locks and access each other with both social and dangerous intentions.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: This provision reverts to noncompliance due to there being no action taken to improve grievance and incident report tracking, as described in the previous report. Additionally, a review of classification records and interviews with classification staff clearly demonstrate serious flaws in the re-classification process. For example, a review of one initial and re-classification record showed that the inmate was correctly classified as maximum security upon initial entry into the facility. Later, the inmate was re-classified as minimum risk, but placed in a medium security housing unit. The inmate then escaped from that housing unit.

This inmate’s classification should not have been reduced to minimum risk simply based on his known history of serious criminal violence; he should have remained as a maximum security detainee and housed accordingly. However, classification decision-making and housing is moot if housing units are not adequately staffed to control inmates.

Interviews with GGACF classification staff revealed no consensus on how to use the current initial and re-classification system.

As stated in previous reports, there is current practice and general policy for reclassifying inmates following incidents involving violence and disciplinary events. However, this process, as previously stated, should be empirically validated.

Additionally, an examination of Grievance and Discipline Logs continues to show they are incomplete and inconsistent. The Grievance Log is missing several important entries indicating that some important grievances go unanswered. The Discipline Log and disciplinary documents provided evidence that many disciplinary cases are dismissed because timely due process was not provided to the inmate.

Hearing and Disciplinary Committee Monthly Report(s) for April and May both state, “The numbers of Due Process Violation submittals have decreased tremendously”, but reported due process violations increased in April and May. These reports were not provided for June thru August so it is assumed there has been no change in this practice.

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The accuracy and completeness of these records are very important for making consistent and reliable re-classification decisions. Otherwise, as is indicated in the disciplinary reports, inmates under disciplinary action are given “time served” and released from restrictions without being afforded their right to due process. This will be discussed further in this report.

RECOMMENDATIONS:

1. Refer to previous classification findings and recommendations. 2. Refer to recommendations related to grievance and disciplinary policies and procedures. 3. Ensure accuracy of monthly disciplinary committee reports. 4. The Territory must correct problems reported in the monthly disciplinary. 5. Train classification staff to accurately and consistently complete initial and re-classifications
accordingly.

e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct; and..(f).
ASSESSMENT: PARTIAL COMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As stated in the 3rd report:

Implementation of a new Incident Reporting Log was described in the Baseline Report and remains in effect. However, as previously reported, a review of this log shows it is often incomplete and illegible. This log cannot provide an accurate account for incidents because it contains multiple entries for the same incidents using the same or different incident numbers. This makes using this log for compliance with this provision virtually impossible and its uses should be revised.

The GIST (Gang Intelligence and Search Team) program is inadequately staffed to provide the level of evaluation and intervention needed to meet the apparently high volume of incident activity reported in the incident reports, supervisor, and housing unit logs. Staff should be added to this program and a comprehensive evaluation and intervention program developed.

Additionally, errors and missing incident reports, as reported in the monthly disciplinary report, impede accurate collection, analysis, and tracking of data to comply with this provision.

RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Develop policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.

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4. Establish an incident tracking database to produce and regularly review valid and

reliable incident information and data.

5. Revise use of the incident reporting system as discussed above

6. Assign additional staff to GIST as described above.

f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As reported previously, there remains no formal mechanism or process for regularly reviewing status and conditions of inmates housed in segregation. Additionally, the Monitor was provided no evidence that GGACF tracks and monitors inmate lengths of stay in segregation or why inmates are segregated. When viewed in combination with the flawed disciplinary process, outdated classification system, and the incomplete grievance tracking process, it is clear that segregated inmates are not provided adequate levels of due process, monitoring, and review. This practice is very serious and remains in direct violation of the Agreement. It is also clear that mental health staff are not involved in the decision to place a prisoner in a segregation unit, nor do they conduct evaluations or otherwise monitor the mental health of prisoners on these units. This is discussed further below.

Additionally, the frequent practice of “modified” or “full” lockdown due to staffing shortages remains very troubling. This practice, though apparently necessary for security purposes, effectively creates facility-wide segregation/lockdown conditions for days at a time. This can only be corrected by ensuring that all shifts consistently maintain sufficient staffing levels.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment. A routine schedule for conduction these rounds must be regularized and continuously monitored for compliance.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or as a treatment for inmates who are mentally ill.

G. Incidents and Referrals

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

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a. Reporting by staff of serious incidents, including

(i) fights; serious rule violations;

(iii) serious injuries to prisoners;

(iv) suicide attempts;

(v) cell extractions;

(vi) medical emergencies;

(vii) contraband;

(viii) serious vandalism;

(ix) fires; and

(x) deaths of prisoners;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: These policies have not been submitted as required.

The GGACF incident reporting system remains woefully inaccurate and flawed. For example, a review of incident reports and logs show that more over 50 incidents had no corresponding incident report; 21 incidents with corresponding incident reports were not recorded in the log; and, where multiple incident reports were written regarding the same incident, the narrative accounts given are inconsistent and no attempt was made to correct or otherwise investigate the inconsistencies.

Incomplete, inaccurate, and inconsistent reporting of incidents makes it impossible to effectively manage GGACF resources and facility safety.

Moreover, because incident reporting is so inconsistent, the Territory makes no effort to identify patterns and trends and take corrective action. This renders the incident reporting system meaningless. Incidents should not be reported simply for reporting sake; they should be reported and acted upon, and internal changes should be made in accordance with the results of proper investigations. This is not happening. There is no quality control or evidence of review for accuracy.

RECOMMENDATIONS:

1. Complete and submit policies as indicated. 2. Integrate the Incident Tracking system into this policy. 3. Develop protocols for current tracking system to improve data validity and reliability; this
document is replete with duplication and misleading entries. 4. Develop a unified incident coding system for valid and reliable information and data
collection, reporting, and analysis. 5. Establish regular monthly quality assurance meeting process involving all major department
team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity. 6. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol. 7. Require supervisors to carefully review all incident reports for completeness, accuracy, and consistency.

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b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: PARTIAL COMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As previously reported, senior staff now participate in GIST meetings to review incident activity, but additional work is needed for compliance. Moreover, there are no policies or procedures governing or directing this process, and the group does not meet regularly. Furthermore, and as previously discussed, the incident reporting system requires revision before it is a valid and reliable document for incident evaluation purposes.

It is also worth noting that GGACF does not have a Chief Investigator. Warden Redwood was serving in this role prior to being named interim Warden. Mr. Redwood is no longer working for the BOC. USDOJ and the Monitor inquired whether and when the Chief Investigator position would be filled, but the Territory has not provided an answer. Without a Chief Investigator, the Warden becomes responsible for investigating all incidents. This places too much on the Warden’s plate and also potentially sets up a conflict of interest. The Warden is both conducting the investigation and signing off on it, meaning there is no additional layer of review to correct errors or suggest areas for follow up. It is also unclear what, if any, experience or training the acting warden has in investigations.

RECOMMENDATIONS:

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to previous section on contraband control as it also pertains to confiscation and preservation of evidence

RECOMMENDATIONS:

1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Refer to previous findings regarding incident reporting and tracking.

RECOMMENDATIONS:

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1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Such a policy has not been provided.

RECOMMENDATIONS:

1. Include this element in the required policy and procedure. 2. Establish reasonable timeframes as indicated. 3. Develop and implement corrective action protocols for staff noncompliance with adopted
policies and procedures.

H. Use of Force by Staff on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Territory officials and members of the monitoring together completed Use of Force policies and procedures. USDOJ provided written comments and recommendations to those documents and the documents are pending final approval and implementation

A review of incident reports provided by BOC staff document there were at least ten (10) incidents between 6/20 and 9/17 involve officer use of force against inmates. However, the Monitor was provided documentation of supervisory review for only two (2) of the ten (10) incidents. It is unknown whether 1) all use of force incidents were reported, 2) all use of force reports were provided to the Monitor, 3) all force incidents received the required supervisory review, and/or 4) whether the Monitor was provided with documentation for all completed supervisor reviews. The Monitor has experienced considerable frustration with Territory officials not consistently providing all use of force documentation requested well in advance of each onsite visit. In most instances, not all requested documents are being provided during the onsite visit, and/or are very disorganized and incomplete, and/or are provided, if at all, well after the visit.

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This Monitor submits to the Territory a request for documents in advance of each visit. The

Monitor and monitoring team require the requested documents to help focus their onsite work

and to efficiently maximize the completeness of the onsite visit, timely completion of the

Monitor’s reports, and to contain monitoring costs, as required, to the authorized budget.

However, during none of the onsite visits were all requested documents provided.

Additionally, the Monitor has not yet submitted to the Territory the list of documents and information required for “routine” monitoring as set forth in the Agreement. This partly due to the Territory’s consist non-responsiveness to providing all requested pre-visit documents, and its non-responsive or very late responses to post-visit requests. Documentation required for routine monitoring will be expected regularly on a monthly. The Monitor will have no other option but to seek Court intervention if documents requested for routine monitoring are not consistently provided as requested.

The ten use of force incident reports provided document that force was used by officers to 1) stop inmate physical violence against staff or other inmates, and 2) effect inmate compliance with officer instructions intended to maintain facility security. The types of force used by officers include:

Impact Weapon (expandable baton) Force: x4 Hands-on / Restraint Control Physical Force: x6 Electronic Stun Shied: x1

Although incident reports appear to justify all force and force levels used, the Monitor is unable to assessment compliance with this Provision without reviewing adequately completed supervisory review documentation, which was, again, not provided.

This provision will remain in noncompliance until approved policies and procedures are adequately implemented to include consistent submission to the Monitor of all required documentation for compliance evaluation purposes.

RECOMMENDATIONS:

1. Implemented draft use of force policies and procedures upon approval and according to the new Schedule.
2. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
3. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review document are 1) complete, 2) accurate, and 3) comprehensive.

b. Circumstances under which the permissible forms of physical force may be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change since previous reports. See above.

RECOMMENDATIONS:

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1. Include this requirement in policy, procedures, and training as discussed in

recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Refer to findings in H.a. above, and findings and recommendations for Training Provisions. There has been no change since previous reports.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See recommendations regarding Training Provisions and apply to use for force requirements.

e. Training and certification required before being permitted to carry and use an authorized weapon;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No change since previous reports. Per the 4rd report, “Documents were provided that show the names of several officers who participated in weapons qualifications. However, these documents do not clarify whether all officers currently authorized to carry weapons are trained in accordance with the Agreement. The term “weapon” should include any device issued to staff in the use of force against an inmate. This includes, but is not limited to: firearms, batons, impact weapons, chemical weapons, etc.” It is unclear whether the officers involved in recent uses of force, as described above, were ever trained in the use of those types of force (batons, electronic shields, etc).

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

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2. Refer to Training Provision recommendations and apply to this requirement.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Dates shown on incident reports involving use of force seemed to show timely submission of reports. However, some of the reports are missing page numbers, clear description of the event, and other elements. Supervisors must review all reports to ensure compliance with this Provision before approving any report.

RECOMMENDATIONS:

1. Implement supervisory quality improvement review for all reports to ensure accuracy and completeness before approval.
2. As requested in the previous report, the Territory must develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: This Provision is included in the draft policies. However, this practice can and should be initiated pending finalization and implementation of this policy.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously reported, no change since previous reports. Security towers remain inconsistently operational due to inadequate staffing and physical plant problems, rendering them an unreliable security control post. Policies and procedures pertaining to this provision were not yet submitted to this Monitor and USDOJ for review and comment.

RECOMMENDATIONS:

1. Provide the Monitor documentation of Compliance for this Provision.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: The draft use of force policy contained provisions for medical evaluation and treatment of inmates following a use of force event, but does not include a requirement for photographic documentation of injuries but will.

RECOMMENDATIONS:

1. Provide Monitor documentation of Compliance with this Provision.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: NON COMPLIANCE

FINDINGS: As stated above, this Monitor is unable to evaluate compliance with this Provision without being provided all supervisory review documentation for all incidents involving use of force.

RECOMMENDATIONS:

1. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above

l. Administrative investigation of uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: This Provision is included in the draft policy. However, the current grievance log remains very problematic. This log continues to be incomplete. It frequently omits necessary information, including information about dispositions. There remains no structured, organized, and accurate system in place to comply with this Provision. Training on the new policy and supervisory oversight will be vital to ensuring this provision is met.

RECOMMENDATIONS:

1. Develop and implement Central Tracking system to include all required elements.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The draft use of force policy includes a provision for supervisor review of use of force incidents to determine whether and what corrective action is required. This is not occurring consistently yet. Hopefully the new policy will improve compliance with this provision. In the meantime, while the Territory finalizes the policy, immediate directives could be issued (as noted in the Recommendations section) and the Warden should review for compliance with the directives.

Refer to previous Findings regarding supervisor review of use of force incidents.

RECOMMENDATIONS:

1. Immediately issue directives to supervisors to complete reviews for all incidents involving use of force. Monitor compliance, correct deficiencies, document compliance with this provision.

o. Re-training and sanctions against staff for improper uses of force.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Training records were again not provided to the Monitor for review during this visit.

It is impossible for GGACF to fully comply with this Provision until supervisors comply with use of force review requirements.

RECOMMENDATIONS:

1. Produce staff training records for review by this Monitor during the next onsite visit.

I. Use of Physical Restraints on Prisoners

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1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The Territory and the Monitor jointly developed a draft policy on Use of Force that also including information on proper and improper use of restraints. USDOJ provided detailed comments on the policy but it is unclear when the Territory intends to finalize the policy. Until this policy is finalized and all staff are trained on it, the Territory will remain noncompliant with this provision and all other provisions related to use of restraints.

RECOMMENDATIONS:

1. Implement this policy once approved according to the new schedule.

b. Circumstances under which various types of restraint can be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Same as above.

c. Duration of the use of permitted forms of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

d. Required observation of prisoners placed in restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

f. Required termination of the use of restraints.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS:
J. Prisoner Complaints
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:
a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The inmate grievance process remains ineffective and problematic with no improvement since the previous assessment.
As previously stated:
1. The log fails to: consistently record complaint types and descriptions; include the date the complaint was received; assign a complaint identification number; note the housing location from which the complaint was submitted; and note the date the complaint was sent to the chief for response.
2. Although most complaints include the date the complaint was submitted to the chief, very few included the date when the complaining inmate received a response or a description of the response.
3. It is exceptionally troubling that only one of the inmate health care complaints for this time period was provided a response by responsible GGACF officials, based on log entries. Some of the most serious inmate complaints logged in the Grievance Log included issues involving medical and/or mental health concerns for which disposition information is not recorded.
4. The grievance system is especially important given that there is inadequate medical and mental health care staff to conduct regular rounds on each housing unit.

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5. The grievance system may be one of the only ways for prisoners to get access to such staff.

However, when the grievance system is not functioning properly and grievances are not

tracked, logged, and timely responded to, prisoners will not get the help they need.

6. The GGACF prisoner complaint / grievance system does not provide a reliable mechanism

for inmates to obtain legitimate relief and/or resolution for serious and important issues and

concerns. The complaint system’s records management is very problematic because of log

omissions, noted inconsistencies, and its unresponsiveness to inmate complaints.

Furthermore, if the grievance log is an accurate reflection of the system’s management, it

would be virtually useless for proving exhaustion of administrative remedies required under

PLRA.

Additionally troubling is the chronic lack of administrative oversight of the grievance process and log. According to the Warden, these responsibilities were assigned to the Assistant Warden, who was in that position up until Warden Redwood resigned in early October. It is unclear who is now monitoring this system. And, despite this Monitor reporting the same deficiencies in each compliance report, the grievance system has not substantively improved. This situation must be permanently corrected. Inmates must have access to a reliable and responsive complaint process.

RECOMMENDATIONS:

1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking process to measure and verify program compliance, take timely and appropriate remedial and correction action.
2. Ensure tracking log is consistently completed and accurate. 3. Assign oversight of the inmate complaint process and logs to a staff person who will
provide the process consistent, dedicated, and comprehensive attention. 4. Develop from a valid and reliable tracking a quality management statistical report for
monitoring inmate and facility needs and problems.

b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement since previous assessment. See above description of current complaint system deficiencies.

RECOMMENDATIONS: Same as above.

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above description of current complaint system deficiencies.

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RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: See above description of current complaint system deficiencies. The current complaint tracking system remains mismanaged, incomplete, inconsistent, and inaccurate.

RECOMMENDATIONS: Same as above, and:

1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. Deficiencies in the Inmate Grievance Log continue to demonstrate the absence of a systematic and reliable process for reviewing prisoner complaints, tracking trends, and addressing individual and systemic issues.

RECOMMENDATIONS: Same as above.

1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. Use data from those reviews identify patterns of individual staff and inmate problems, as well as systemic problems in need of correction.

K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: The elements of this Provision will be included in Monitor’s policies and procedures.

The vacant Investigator position remains unfilled; former Warden Redwood stated that he continued to conduct administrative investigations or assigned them to the Security Chief with the Warden overseeing the Chief’s work. The administrative investigation process remains very problematic because with Mr. Redwood’s resignation, there is now absolutely no qualified staff person dedicated to conduct investigations and inadequate supervision levels severely limit oversight of staff conduct. Lack of adequate supervisory review of use of force reports prohibits further demonstrates the Territory’s noncompliance with this Provision. It is very likely that administrative investigations have not been initiated at all, or timely initiated, on various policy and procedure violations. Mismanagement of the inmate complaint process, as previously discussed, further evidences insufficient attention and a laissez faire approach to staff accountability. Revised administrative investigation policies and procedures will be ineffective until the staff accountability measures consistently implemented, beginning with supervisory/management staff.

RECOMMENDATIONS:

1. Fill the vacant investigator position. 2. Supervisory / management must be consistently held appropriately accountable for
adherence to agency rules, regulations, policies, and procedures.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling,
preserving, and maintaining administrative investigation evidence, information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive change since previous visit.

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Additionally, and as previously discussed, even if an investigation determines that an inmate

deserves some form of punishment for a disciplinary infraction, that punishment is often not

determined or enforced because due process proceedings often do not occur.

Recommendations provided in the previous report remain appropriate. There were no

administrative investigations initiated to look into staff misconduct, to the best of this Monitor’s

knowledge. These investigations must also be conducted, reviewed, and tracked.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Fill the currently vacant Chief Investigator position.

1. Create a formal pre- or in-service training program to train staff who are involved in initial and/or administrative investigation.
2. Provide adequate training of investigative staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
3. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management.
4. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities.
5. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review upon his/her appointment.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously reported, regarding staff discipline, GGACF officials reported (but did not provide any documentation of) several instances of disciplining staff where their involvement in misconduct was determined. This Monitor requests full review of these instances during the upcoming site visit.

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Regarding inmate discipline, no substantive improvements were found since previous reports.

As previously stated:

1. The current system remains ineffective for delivering fair, reliable, consistent, and meaningful inmate discipline for multiple reasons, as demonstrated by a review of numerous documents and an interview with the discipline coordinator.

2. The monthly disciplinary hearing reports continue to report a high number of inmate disciplinary cases being dismissed as a result of due process violations. The coordinator continues to document the following problems with the disciplinary and discipline committee process:

 In ability to form a consistent disciplinary committee to conduct hearings;  Late reports from supervisors;  Incident reports containing inconsistencies, inconsistencies, writing errors;  Inconsistent use of the new report form and staff failure to include all information
requested on the incident report form;  Facts not being properly documented;  Duplication of incident report numbers;  Inconsistent / inaccurate completion of the Incident Log.

This assessment demonstrates chronic lack of quality control and staff and supervisor accountability that should be corrected without delay. The inmate discipline system is not only ineffective due to lack of adequate staffing, but lacks sufficient oversight and organization to deliver meaningful and consistent outcomes.

The problems noted above with the administrative investigations system also demonstrate noncompliance with all provisions of the Agreement that rely on a valid and reliable incident reporting system.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.
2. Integrate the information in the above into the administrative policies and procedures previously discussed.
3. Record and maintain onsite records of staff misconduct investigative reports and determinations.
4. Protect the integrity and confidentiality of these staff records, control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
5. Provide training to supervision staff in the appropriate use of this information for staff supervision, counseling, discipline, promotion, etc. purposes.
6. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
OVERALL NOTE: Due to the absence of approved policies the reader will notice that no provision can yet be moved to partial compliance. The monitoring team has now been instructed to provide technical assistance in reviewing and modifying all of the proposed policies generated by the GGACF staff. Both the health services administrator and the psychiatrist have worked diligently to prepare the initial mental health policy drafts which we will now collaboratively modify for final submission to BOC and DOJ by the end of this year.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: NONCOMPLIANCE – No substantive improvement from previous assessment.
MEDICAL FINDINGS: With regard to medical screening, we have been provided a policy that demonstrates a substantial number of provisions which had previously not been included. In addition, the Health Care Administrator along with the Medical Director have developed an acuity prioritization scale that will enable the nursing staff who perform the medical screens to determine the scheduling of the intake comprehensive health appraisal based on the acuity and complexity of the problems identified. There is real, significant progress being made in the policy area. In fact, it was clear that the Health Service Administrator had accomplished a great deal in the area of policy drafting since the June visit. I was presented with and reviewed more than 30 policies. A majority of them are directly related to the Settlement Agreement. I had suggestions for additions or revisions for about 25. But it is important to note that the vast majority of those 25 needed relatively few significant changes. There were a few policies and procedures that needed to be completely revised and we provided the Medical Director and the HSA with copies of policies that have been approved on these specific topics in other jurisdictions. We expect to continue to work with the HSA and Medical Director and are hopeful that we will be able to approve the policies before the time of our next visit in December. USDOJ would then be able to review the policies for approval, in accordance with the Settlement Agreement. We reviewed the policies which have been drafted in a manner that is consistent with the National Commission on Correctional Health Care standards but also related the policies to the relevant paragraphs or sections of the Settlement Agreement. We also identified specific language in the Agreement that needed to be addressed in certain of the policies. Therefore, we are extremely optimistic that the final steps will be accomplished.

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We were informed that beginning on August 8, 2014, only nurses are performing the intake screen.

At the time of this visit there were three registered nurses, which includes the head nurse, and two

LPNs. There is a plan to recruit two part-time registered nurses to cover the weekends and add one

additional LPN. We were also provided with a log of the intakes processed through over the prior

six weeks. However, the log began on August 21, but this log includes inmates who arrived several

days before, thus many of the screens were not conducted within the required timeframe of “as soon

as possible but no later than 24 hours.” There were also a few names on the log of people who were

released before the screen could be conducted. The first case is an example of some of these

problems.

Patient #1 This is a 22-year-old who entered in mid-August. and the custody screen yielded a history of asthma. The nurse screen was performed a week after the prisoner entered the facility. The nurse also learned that the prior attack was two years ago. This patient had no peak flow conducted, which is an assessment of his asthma status, and he also did not have the comprehensive initial health appraisal because in fact there has been no physician onsite due to problems yet to be worked out with the Medical Director. Although his skin test was performed and read as negative, his laboratory tests were not performed.

Patient #2 This is a 32-year-old detainee who arrived in late August. Two days later, the screen was attempted but the patient refused. He has had no recent labs and does not need a PPD. His refusal was because he had been incarcerated recently. The policy on screening needs to include a description of the frequency with which to repeat the intake screen and how that should be conducted (whether an interval history will suffice for returnees out less than 90 days) if someone has had a screen within the last three months. In general, when people refuse for any reason there must be an effort documented to offer the screen daily.

Patient #3 This is a 31-year-old who arrived in early August and was screened the next day. He had a history of taking mental health meds and had suffered from PTSD and depression and anxiety. He also had a wound on his left thumb. He was seen as an acuity scale 1 on 8/13, but the comprehensive intake appraisal form was not utilized. He indicated to the doctor that he had been on medication for hypertension but this was not written in the plan and no laboratory tests were ordered. His PPD was negative.

The following problems exist with the medical process:

1. Screens must be conducted as soon as possible after entry. My understanding is that there is nursing coverage 8:00 a.m. to 8:00 p.m. daily and therefore the longest duration without a screen should be 12 hours. We have also discussed with the Medical Director designing a form that will allow a nurse who is on call to address questions over the telephone to the patient who is newly arrived. If these questions suggest instability, the nurse will call the doctor and have the patient sent to the hospital. If, on the other hand, the questions suggest stability, then the patient can wait the 12 hours until the nurse comes in the morning and conducts the screen.
2. The second part of the problem is there was some information on some of the forms which should have been collected but was not and this is obviously a training problem, although the nurse screens are a vast improvement over what was present on our earlier monitoring visits.

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3. The acuity scale did not always assess the patient correctly and this is a matter of training and

feedback.

4. The policy on refusals needs to be addressed.

5. Without a regularly scheduled advanced level clinician, (either physician, PA or nurse

practitioner) available regularly, there cannot be compliance with the health appraisal policy.

RECOMMENDATIONS:

1. Continue to refine the screening policy, including how to handle refusals as well as rapid returnees.
2. Develop the telephone triage to be used between 8:00 p.m. and 8:00 a.m. 3. Add the additional weekend nursing coverage. 4. Stabilize the advanced level clinician schedule so that the nursing staff can predictably insure
that patients are seen timely in compliance with the policy. 5. The refusal policy must include daily rescheduling and offering of intake physical exams.

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: GGACF has implemented an intake screening form which is completed by nursing staff. However, the current form does not correlate with the prompts on the correctional officer’s intake screening so that when the officer indicates a positive history for depression and treatment, these indicators are not necessarily addressed on the medical intake screen. During the site visit the discussion was conducted with the psychiatrist and health services administrator to create a separate mental health intake screening form with greater detail while remaining simple in its completion to better aid in the identification and referral of inmates to a mental health professional.

A review of 24 randomly pulled intake records of current detainees revealed continued problems in the identification of inmates with potential mental illnesses. Six inmates -- or 25% -- either had a positive history of mental health treatment or a mental health condition on the officer’s intake but were not referred for a mental health evaluation. Two detainees were referred and promptly seen by the psychiatrist.

RECOMMENDATIONS:

1. Detainees or inmates entering the system with a positive mental health screen, particularly with a history of prior mental health treatment and complaints of depression or oddities in behavior and thought should be referred by the registered nurse performing the intake screen to the psychiatrist or a qualified mental health professional (once one is hired) for a comprehensive mental health evaluation to determine the need for further treatment or the lack of risk and assignment to “as requested” services.

2. This monitor will draft a new intake screening form for the facility with review and input by the psychiatrist. The new intake screen for mental health will be developed and hopefully implemented within the next several months and should include a triaged acuity level.

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b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical

and mental health professionals within three days of admission.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have submitted a new intake screening form which includes an acuity scale that determines the urgency of the intake health appraisal. Unfortunately, there has been no stability to the scheduling of the intake health appraisal and we identified records where the appraisal was either were not done within the required timeframe or was performed very late. Also, we reviewed one record in which, because the form was not utilized, all of the necessary data was not collected and the policy with regard to chronic disease was not followed. Again, due to contractual problems and the obtaining of the correct license, Dr. Burton has not been available since the middle of August, including all through September. He was present for our monitoring visit and participated fully. We hope that his license for the upcoming year is available as he expects by the end of September and also that the pharmacist contract is approved, because he was clear that he would not work in the absence of a licensed pharmacist. It is also clear that the clinician staff needs to be reminded by the nursing staff that when they perform a comprehensive intake they must use the appropriate form and complete all the required information, including developing an initial problem list and a diagnostic and therapeutic plan for each problem. As commented earlier, this is impossible without a stable schedule so that the nurses can refer based on their intake screen and the acuity scale.

RECOMMENDATIONS:

1. The comprehensive health appraisal form should be modified so that it creates space for an initial problem list and space to make the appropriate referrals, including the chronic care program, mental health, dental and any other appropriate referrals.
2. The policy should also be modified such that for acuity level 1 and level 2, they should all be reviewed at the end of a week by the Medical Director, who can insure that there is appropriate follow up based on both laboratory and TB skin test results. Since the 1s and 2s are likely to be seen for their appraisal before the data is available, the Medical Director can insure that the approach is comprehensive. This should be added to the policy. Also, the QI program performed by the HSA should review the compliance with the timeliness of the health appraisal in relationship to the acuity designation. This should be monitored with data monthly.

MENTAL HEALTH FINDINGS: Those inmates referred to the psychiatrist are seen by her in a very prompt manner. However, the current form that is in place is not guiding documentation to reflect her comprehensive assessment of the inmate and her initial treatment plan. Therefore it is suggested that a different form be utilized to better guide the process.

RECOMMENDATIONS: While on site, I electronically provided sample forms to the psychiatrist that she can modify or completely redevelop to better suit her documentation needs. I anticipate the new form will be in use before the next site visit.

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c. Prisoners' timely access to and provision of adequate medical and mental health care for

serious chronic and acute conditions, including prenatal care for pregnant prisoners;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We were provided a log for the sick call encounters. However, the log does validate that most patients were not seen timely, especially in August, and many were not seen at all. In addition, some notes lacked any subjective or objective data. In addition, some patients referred to a doctor two weeks before our visit had still not been seen.

From our record review as well as discussion with staff, it appears that some of the patients may not have been seen due to an absence of escort or an absence of medical staff. Therefore, the log must be modified to contain a field that explains the reason the patient was not seen. When the reason the patient was not seen is due to an absence of either availability of medical staff or an absence of custody, the patient must be rescheduled. The absence of custody when onsite services are scheduled can be mitigated by the presence of exam rooms in the housing units which currently are functional only in the lockdown units. Therefore, it is important to create exam room availability on each of the housing units that has such an exam room. This capability includes a clean and sanitary environment which is properly equipped with an exam table and supplies, including those necessary to maintain professionally appropriate sanitation. If there is no capability for running water, hand sanitizer must be provided. If there is plumbing in place it must be made operational. Appropriate equipment includes equipment to perform vital signs. The exam table must include appropriate paper to be utilized for each patient on the exam table. Examples of opportunities for improvement in the nursing performance follow.

Patient #1 This is a 43-year-old who requested service in late August and he was seen the day following admission. However, the nurse note has no subjective or objective data; in fact, the entire note consists of requesting Benadryl.

Patient #2 This is a 47-year-old who complained of knee pain in mid September. He has not had either a nurse or physician assessment.

Patient #3 This is an 83-year-old who in mid September requested service regarding a cough and chest congestion. He was seen four days later (not within the required timeframe) and the note is appropriate, accept for the subjective, which only says “as above.” It does not indicate the duration of his problem, whether he had coughed up blood, what is the description of what he coughed up and whether he has any other associated symptoms.

Patient #4 This is a 65-year-old who requested service in late August because of pain in her ribs and waist and she had blackouts. She had been seen by a physician 10 days earlier and only complained of the rib pain at that visit. The nurse did not address the waist pain and the blackouts and thus two of the three problems were not addressed.

RECOMMENDATIONS:

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1. Stabilize the nursing and advanced level clinician schedules so that patients can be seen timely for a nursing assessment as well as in follow up if needed by an advanced level clinician.
2. The nursing performance and the quality and completeness of their notes should be reviewed with them on a regular basis so expectations are clear.
3. There should be a logbook for referrals to the physician so that it can be tracked and even if patients are not seen timely, they are all seen or there is an explanation and a description of the reason that they are not seen.
4. It must be reviewed with the nurses that when a patient has multiple complaints, every complaint must be addressed during the nursing assessment.
5. The log should be modified to include an explanation of why the visit did not take place. The potential reasons are patient refusal, absence of medical staff or absence of custody staff.

I have used this letter (c) to address acute care, including sick call. Subsequently I will address chronic diseases.

MENTAL HEALTH FINDINGS: This will be covered under the mental health sections of this agreement.

d. Continuity, administration, and management of medications that address (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: I was not sent the medication policy but I was told that I will be sent this policy. It is not one of the more than 30 policies that I reviewed. Therefore, on the policy I cannot report on any progress. I am aware that there is a serious issue in obtaining licensed pharmacy services and the Bureau must resolve this as urgently as possible since it jeopardizes the availability of the Medical Director. There are legitimate concerns about not only the appropriateness but the legality of some of the practices. We were not able to perform a review of medication administration, but in our discussions it was apparent that the current practices remain problematic. The delays in access to nursing assessments and intake screens suggests that, in fact makes it inevitable, that there are delays in patients receiving medication timely. The staffing issues are paramount to resolve.

RECOMMENDATIONS:

1. Insure that there are sufficient nursing hours and physician hours to provide the services timely. 2. Resolve the contract and licensing issues with the pharmacist so that she can continue the work
that she has begun. 3. Send me the latest version of the medication policy so that I may review and comment. 4. The lead nurse should work with the Medical Director in order to develop a procedure that allows
the nurses to not only carry the medications with them to the cell houses but also bring the

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medication administration records so that at a minimum they are recorded no later than when the

nurses are ready to leave each housing unit.

5. The officers’ post order should require that they perform a mouth check after each medication

administration and we believe there should be an officer who is assigned to the nurse and they

perform this as a team at each medication administration.

6. There is a draft policy regarding discharge medications. We have discussed this and we have

suggested some revisions. Those should be implemented and a strategy to insure that inmates

receive especially chronic medical and mental health medications needs to be implemented.

MENTAL HEALTH FINDINGS: Staff reported that mouth checks are not reliably done at the time of medication administration.

RECOMMENDATIONS: defer to Medical recommendations

e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: During our review of records we found that the documents were frequently not filed chronologically or not filed within the correct section. This is a result of all medical staff sharing the responsibility to file and it is clear that several people are not performing this responsibility conscientiously. The records are now filed by Bureau of Corrections terminal digits and there are stickers with identifying information on each document in the chart. I do believe the rate of retrieval of actual records has improved but the filing within the medical records has yet to improve, thus inhibiting the provision of services. We were also told that a permanent medical records clerk is being sought.

RECOMMENDATIONS:

1. Hire a medical records technician as soon as possible, hopefully before our next visit. 2. The medical records policy should include timeframes for filing of documents and for reviewing,
initialing and dating by clinicians. 3. There should be guidelines for thinning the records and in particular, what documents from the
inactive record need to be moved to the active records. Those documents that should be in the active record include intake information and documents in progress notes, consultations, laboratory and x-ray from at least the most recent year.

MENTAL HEALTH FINDINGS: Currently the facility has retained a temporary medical records clerk for 90 days. Recruitment for a permanent medical records clerk was reported as successful with a full-time clerk starting the week following this audit. The efficacy of the new records clerk’s work will be assessed on-site in December. The health services administrator is proposing that the new medical records clerk also do a weekly audit as part of the quality improvement process in the medical records department.

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Despite attempts by the health services administrator to better organize the chart via the use of

section tabs, the medical records remain very disorganized, out of chronological sequence, and

lacking critical documents such as prior medication administration records. The latter were identified

at the time of the last site visit as being stored in the nursing station and to date remain un-filed. One

record, randomly selected from a stack of records, is for an inmate receiving chronic psychotropic

medications. The last filed medication administration record in that chart is from February 2013.

The health services administrator has implemented significant improvements in the medical record process by: 1. Generating computer printed labels with the patient identifiers stored in each record for easy use
by staff. As a result there are far fewer documents currently generated that lack patient identification on the form. 2. Staff are now filing charts based on the BOC# and not the inmates name for better accuracy in the event there are inmates with the same or similar names. 3. The medical records clerk is also now assigned as the only person who will file and remove records from the file room. 4. Doctors’ orders are entered on an order sheet along with other task orders.

RECOMMENDATIONS:

1. At the time of the next site visit the review will be done of recent records to determine if the organization and quality of records filed has improved with the presence of a permanent records clerk.
2. A review of the site medical records audits will be conducted at the time of the visit.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for the policies.

RECOMMENDATIONS: See letter (c) findings and recommendations.

MENTAL HEALTH FINDINGS: The clinic has implemented a written behavioral health checklist/sick call requests log that identifies:

1. the patient's name, 2. date initiated by patient, 3. date received by medical, 4. date received by mental health, 5. date resolved.

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Since July 2014 there have been a total of 120 behavioral health checklists and sick call requests.

During the initial tracking there were several examples of significant delays between the time

received by medical and the time received by mental health. However, since September 9, 2014,

there were no delays in the delivery of these documents to mental health. The psychiatrist has

done an excellent job in seeing people promptly upon receipt of the sick call request or referral

from security.

RECOMMENDATIONS:

1. The development of the current log is a significant improvement for the facility. It is recommended that these logs be maintained in electronic form to ease the manipulation of the data for quality improvement study purposes.
2. The mental health log should indicate whether the document received is a sick call request or a behavioral checklist generated by a correctional officer for tracking purposes.

f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This is already dealt with under letter (c), including recommendations for this provision.

RECOMMENDATIONS: This is already dealt with under letter (c), including recommendations for this provision.

MENTAL HEALTH FINDINGS: The psychiatrist has created and implemented an Excel worksheet that provides information on all indicators previously recommended by this monitor to aid her in ensuring inmates are seen for timely follow-up. Once a mental health professional is hired, this tracking form will also enable her to track whether they are being seen in counseling too. While on site the psychiatrist and I electronically modified the current form to make it easier to sort the data and also added some fields useful in monitoring the caseload.

RECOMMENDATIONS: Continue using the tracking form.

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This section addresses the medical chronic care program. Our record review demonstrated both an absence of care being provided as well as a delay in care being provided, along with an absence of collection of required data by the clinician per the policy and this was frequently due to utilization of the wrong form (initial vs. follow-up) by the clinician. The chronic care clinician has not been conscientiously adhering to his agreed upon schedule. Examples follow.

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Patient #1

This is a 56-year-old female whose record includes no problem list. The patient arrived in October of

2013. The screen identified both diabetes type 2 and hypertension. The form was not completely filled

out correctly and there have been no follow-up visits until recently. This patient, based on degree of

control, should have been seen within a month. The initial form was not completely filled out. The

patient was on insulin as well as medications for the diabetes type 2 and hypertension. The form

lacked the page for documenting objective data as well as assessment. The patient was seen recently

on 9/15/14. The clinician did not use the appropriate follow-up visit form. The lab report in the record

showed the diabetes hemoglobin A1c was 10.2, which is consistent with poor control and requires a

follow-up visit in one month or less.

Patient #2 This is a 74-year-old with hypertension and type 2 diabetes who entered in June of 2014. His initial chronic care visit was documented on 7/18, which is more than a month after intake. According to the acuity scale, this patient should have been seen within three days for his initial comprehensive assessment, which could also have included a chronic care visit. He was on medication for his diabetes and hypertension. He received no medications until one week after the delayed initial chronic care visit. The incorrect chronic care form was used, thus a follow-up visit form was used rather than an initial visit form, and therefore the subjective data collected was insufficient. The patient was assessed as being in fair control for both the diabetes and the hypertension, but a 90-day rather than a 60-day follow-up was scheduled. The initial labs were not ordered and even though the initial assessment was done on the day of the screening, labs were not ordered at that time either.

Patient #3 This is a 59-year-old who arrived in August 2013 with diabetes and asthma. He was seen in chronic care on 11/29/13, but then had no follow up until August 2014. At that visit, his diabetes was assessed as being in fair control even though there had been no recent lab data for one year, including his hemoglobin A1c. Thus the assessment of fair control was made based on data that was a year old. At the 2014 visit, none of the appropriate laboratory tests were ordered.

The log used to track chronic care must include a field which explains why the patient was not seen on the scheduled date. When the reason is patient refusal, there must be a signed refusal in the chart. The other reasons may be absence of custody resources or absence of clinicians. In either case, the patient must be rescheduled. If the reason is patient was released that should also be documented.

RECOMMENDATIONS:

1. The clinicians must be retrained on the chronic care guidelines and the appropriate use of the initial and follow up forms. This should be done by the Medical Director.
2. Add a field that explains why the patient was not seen. If the reason is patient refusal, there must be a signed refusal in the medical record. If the reason is absence of custody support or absence of clinician, the patient must be rescheduled. If the reason is patient was released that should also be documented.

MENTAL HEALTH FINDINGS: The mental health program remains without written clinical practice guidelines for chronic and acute psychiatric/mental health assessment, care, and follow-up. Clinical policies and procedures should be grounded in written evidence-based clinical practice guideline for the inmate population and include assessment, treatment, and care for all conditions of

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mental illness. Following websites are provided to assist GGACF health care staff develop and

implement clinical mental health practice guidelines for this population:

1. American Psychiatric Association Clinical Practice Guidelines at: http://www.psychiatry .org/practice/clinical-practice-guidelines
2. United States Veterans Administration Clinical Practice Guidelines at: http://www. healthquality.va.gov/
3. International Society for Traumatic Stress Clinical Practice Guidelines at: http://www.istss. org/InternationalPracticeGuidelines.htm
4. United States Department of Health and Human Services, AHRQ Clinical Practice Guidelines Clearinghouse at: http://www.guideline.gov/content.aspx?id=33135

RECOMMENDATIONS: Develop and implemented evidence-based, written mental health clinical practice guidelines for assessment, treatment, and follow-up up.

f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There is a draft emergency services policy which lacks provisions addressing urgent problems. We had a discussion and provided a policy from another facility which had been approved through the DOJ process as a basis for helping understand what should be included. We did review some records and this describes some of these cases. The biggest problems are related to the periods when there are no nurses available onsite. This should be mitigated by expansion of the availability of hours to initially 12 hours and ultimately 16 hours of onsite nursing service. Those problems relate to inappropriate assessment before the patient is sent offsite, but there are also problems about follow up by a clinician upon return.

Patient #1 This is a 24-year-old who was sent out on 8/3/14 for self-inflicted injuries. He was seen at 11:00 at night and sent out. There were no health staff involved since there is no coverage by health staff after 8:00 p.m. He returned within a few hours, which again means there were no health staff involved. He has had no follow-up on return and as far as we could see no referral for onsite services. Finally, on 8/15 he saw a nurse and appeared paranoid and not eating for two weeks. There was no weight taken and there were no orthostatic blood pressures, and as far as we can tell there was still no site referral.

Patient #2 This is a 42-year-old seen on 8/11/14 by a physician and sent out to the emergency room for chest pain. He returned the following day with a diagnosis of costochondritis and was appropriately followed up by the physician. None of the patients, either on return or subsequently, had the appropriate emergency room report in their record to be utilized by the follow up physician for both patient education and for scheduling appropriate follow up.

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Patient #3 This is a 24-year-old sent out for a facial contusion on 8/14/14 from a basketball injury. He was sent to the emergency room but had no follow up until three weeks later. There is no ER report.

Patient #4 JL 251259 This is a 29-year-old sent out on 8/25/14 for chest pain. He also had no follow-up visit until a sick call request on 9/3, and at that point was referred to the physician. There was also no emergency room report.

We do not have documented training of staff by a Medical Director regarding recognizing serious injuries and life-threatening problems. There is also no training by the Medical Director in first aid procedures for serious injuries and life-threatening conditions, and other than in the basic officer training, there is no training to recognize and timely respond to emergency medical crisis.

RECOMMENDATIONS:

1. The offsite service coordinator must insure that the emergency room report is made available to the facility timely (this may require a high level discussion between the hospital and the HSA and Medical Director).
2. The Medical Director should provide the training to officers and this should be documented in their training file.
3. The unscheduled services log should contain a field for whether the patient was seen in follow up and if not, the explanation as to why not and if the explanation is absence of clinician or custody, the patient must be rescheduled.

MENTAL HEALTH FINDINGS: Mental health training was provided by the mental health professional from St. Thomas after our last site visit. The psychiatrist provided additional training for security and health staffs and plans on developing the curriculum for future training for correctional officers and health staff at GGACF.

Security staff continues to generate excellently detailed and useful behavioral checklist referrals to mental health.

RECOMMENDATIONS:

1. Future training curricula will need to be presented to the monitoring team for review and approval.
2. Continue tracking timeliness in response to behavioral checklists. 3. A continued reminder by supervisory staff regarding the location and use of cut down tools is
needed and can be enhanced by incorporating these tools into disaster drill scenarios.

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: The Health Services Administrator has appointed an offsite service

coordinator who is responsible for both scheduling and retrieving the offsite service documents, be

they consultations or procedures or emergency services reports. She has been logging all of these

things. Although we had difficulty finding some of the reports in the record, she was able to find

them and the log had documented that they were available. This is a problem related to filing which

must be addressed. Her log does include a field for follow-up visits and some of these cases

documented both reports and follow-up visits, but we could not find either the report in the chart

or the follow-up visit note. Chart notes continue to be incomplete. Examples follow.

Patient #1 This is a 60-year-old who arrived in Early May. In early August, a note requests a urology appointment. This appointment was scheduled for 8/12. We could not find the report in the chart. The offsite service coordinator was ultimately able to find it. The log indicated the follow-up appointment had occurred, but there was no note in the chart documenting a follow-up visit.

Patient #2 This patient was scheduled for an appointment with gastroenterology services in mid-August. Unfortunately, the note from the gastroenterologist only indicates, “change meds and follow up by physician.” There is no explanation of what was found and why the changes.

Patient #3 This is a 23-year-old who has no problem list in his chart and there was an order for an ultrasound to be requested in mid-July. The ultrasound was performed on 8/1 and the report was not reviewed until 8/18, almost three weeks later. There is a note, however, on the report itself which indicates this report was discussed with the patient.

Patient #4 This is a 72-year-old seen by the chronic care physician mid July, who ordered a Doppler and a special stress test to be done off-island. He did have an echo done in the chronic care physician’s office but he has not yet brought in the report. He also had a Doppler study which showed narrowing of an artery in each leg and the follow-up was scheduled to be done on the Friday of our visit.

RECOMMENDATIONS:

1. Retrieved reports must be brought to the appropriate physician or Medical Director for review and signature and follow up must be carried out, including a follow-up visit with the patient.
2. The offsite service coordinator should be in touch with the chronic care physician’s office in order to retrieve reports of procedures done at his office.
3. The chronic care log should be created and it should include a field for whether the patient was seen as scheduled and if not seen, the reason for the patient not being seen must be identified. If that reason is absence of custody or of clinician the patient must be rescheduled.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

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f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or

treatment; See above

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This has been discussed under number v.

RECOMMENDATIONS: See number v.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We discussed this with the Medical Director and provided him a policy that has been approved in a DOJ process from another facility. He is to work with the HSA and draft both the policy and individual substance guidelines for both alcohol and substance intoxication and withdrawal.

RECOMMENDATIONS:

1. The Medical Director in working with the HSA should draft both a policy on intoxication and detoxification from substances including alcohol, opiates and benzodiazepines.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There has been only one full-time registered nurse; a second registered nurse started the day of our arrival. Therefore, it is not surprising that the infection control program has not yet been developed. The focus of an infection control program in a correctional setting should be based on tuberculosis screening as well as response to suspect cases, the monitoring and management of acute skin infections and the identification, monitoring and reporting of sexually transmitted diseases. The intake process, which includes a TB skin test, should include documentation of the results in the record and this should be done timely. Each day the person who records the results should pull the records and document them directly in the chart.

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RECOMMENDATION:

1. Discuss with the monitoring staff the requirements of an infection control nurse.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

i. Adequate suicide prevention, including:

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: Due to time constraints during this site visit the monitor was unable to review officers’ logs in an effort to identify anyone placed on observation by security but unknown to the mental health service. There are, however, many examples of behavioral checklists completed and submitted in timely fashion to mental health when an officer identifies unusual or concerning behaviors.

A chart reviewed upon referral by Ms. Brett, USDOJ, was of an inmate seen for intake in late July, 2014 who was noted to be uncooperative. His medical intake three days later was negative for mental health issues and no referrals were generated. Mid-August, 2014 there is a notification that he was refusing meals and medications because he had found a roach in his oatmeal and believed that the jail was trying to poison him. At that time a licensed practical nurse asked the officer to fill out a behavioral checklist rather than generate one herself. Four days prior to that encounter the inmate had been seen for self-inflicted lacerations of his arms at the hospital emergency department. The inmate was released from jail on August 22, 2014. This case highlights several issues:

1. the reluctance by medical staff to initiate an emergency referral to psychiatry 2. improper management due to a lack of follow-up regarding his emergency department visit and 3. the report to the nurse that he was avoiding food which should have generated a medical referral
for, at a minimum, weights, vital signs, and counseling

These issues need to be corrected.

RECOMMENDATIONS:

1. The service is encouraged to create an electronic suicide watch log that would contain information useful in future quality improvement projects. Recommended data fields would include at a minimum: a. the inmates name b. BOC# c. date of referral, if one is made d. date and time placed on suicide watch

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e. an indication of what level of suicide watch the inmate was initially placed on

f. date and time a suicide watch level is changed

g. date and time the inmate is removed from suicide watch

h. date of completion of the post-24-hour risk assessment

i. date of completion of the post one week risk assessment

j. date of completion of any other post-suicide watch risk assessment

2. Any evidence of food avoidance should prompt a medical evaluation and possible initiation

of a hunger strike protocol, if warranted.

3. A hunger strike policy should be developed.

4. Information concerning any recent self-inflicted laceration should generate an urgent referral

by any staff person observing or receiving the report of this type of behavior to mental health.

(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: No records were identified for review that would enable monitoring of this provision during this visit.

RECOMMENDATIONS: Complete and implement suicide policies and protocols upon approval.

(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: At the current time a suicide risk assessment instrument is not developed and in use.

RECOMMENDATIONS:

1. An Internet search for a suicide risk assessment tool will provide links to multiple websites. Staff can review the assessment tools located on the Internet and determine if any would be pertinent to the facility as is or with modifications. The SAMSHA website has links to several free instruments including the Columbia suicide risk assessment tool which has Internet training available. It is important, however, that suicide detection assessment tools used are validated for jail settings and the specific population being assessed.

2. Screening Tools Assessing Risk of Suicide and Self-Harm in Adult Offenders: A Systematic Review at: http://ijo.sagepub.com/content/early 2010/03/11/ 0306624X09359757. abstract

This systematic review assessed the validity of screening instruments to identify the risk of suicide and self-harm behavior in offenders. A search of 11 electronic databases and grey literature resulted in the inclusion of five studies. The five studies revealed four screening instruments, including the

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Suicide Checklist, the Suicide Probability Scale, Suicide Concerns for Offenders in Prison

Environment (SCOPE), and the Suicide Potential Scale. Two instruments, SCOPE and Suicide

Potential Scale, shared promising levels of sensitivity and specificity. The reporting of information

was generally varied across items on the Standards for the Reporting of Diagnostic accuracy

(STARD). Research is needed to assess the predictive validity of tools for offender populations in the

identification of those at risk, particularly those in probation and community settings.

3. Develop for approval valid suicide screening and assessment tools for initial and follow-up screening purposes.

(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: For the fifth consecutive assessment, the A-Dorm officer reported having no cut-down tool. Additionally, the officer working in detention housing unit was not able to locate a cut-down tool; the tool was later found and presented by another officer. It seems obvious that recommendations pertaining to quality control that ensures the presence of cutdown tools as required is not being followed. The presence of this tool is vital to ensure that if suicide is attempted by an inmate, staff have the tools at their disposal to potentially save the inmate’s life.

RECOMMENDATIONS:

1. Cut-down tools must be readily available in all housing units and all officers must be able to rapidly locate and obtain those tools when needed. The tools should be stored in exactly the same location in each housing unit. This will help to ensure consistent and reliable access by staff
2. Cut down tools should be available in all housing areas, and areas where inmates could have an opportunity to harm themselves, i.e. kitchen, medical building, etc.
3. All staff required to use this tool should be well-trained and emergency drills demonstrating proficient use of the tool should be conducted on a regular basis.
4. Supervisors should regularly inventory and audit tool location and make immediate provisions to replace missing or non-functioning tools when found.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: The Territory conducted Suicide Prevention and Mental Health training in September involving many staff. Instructor qualifications, curriculum, lesson plans, course hand-outs, and pre/post tests were provided to this Monitor for review. Course instructors appeared well qualified and the training materials were well organized and professionally developed but are considered very basic and somewhat inaccurate. For example, the “Facts about Suicide” Power Point slide used in this training reports that “Jail suicide is 9 times higher than in the general pop[ulation].” This comparative prevalence information is inconsistent with national research. According to the U.S. Bureau of Justice Statistics, the 2012

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per 100,000 inmate suicide rate for jails and prisons was 40 and 16 respectively. By comparison,

the American Association of Sociology reported the national suicide at 12.9 – a rate difference

of 3.1 higher for jail inmates and 1.24 higher for prison inmates. It is very important that the

suicide prevention training program present accurate and current facts.

Although this training does not meet the requirements of this Provision for several reasons explained below, the training nonetheless seems important and valuable.

This training failed to meet the requirements of this Provision for the following reasons:

1. Lesson plans did not include scenario-based instructional methods; 2. Lesson plans did not include any related policies, procedures, or forms related to suicide
detection, intervention, housing, management, aftercare; 3. Lesson plans did not include use of cut-down tools; 4. Demonstration of proficiency was not determined or it was not reported to this Monitor; 5. All required staff did not complete the training; 6. Training information was not corrections-specific; 7. Training did not include current research or “best-practices” in correctional suicide detection,
intervention, management, aftercare.

RECOMMENDATIONS: In addition to the previous recommendations reiterate below, all suicide prevention training must:

1. Comply with the elements of this Provision as stated above; 2. Be corrections-specific; 3. Base lesson plans on current research with regard to:

a. Inmate populations and characteristics relevant to suicide risks b. Prevalence of suicides and suicidal behavior in correctional settings c. Conditions and circumstances relevant to risk of suicide d. Locations in facilities e. Effects of solitary confinement f. Methods of suicide in correctional settings g. Instruments and items used to attempt/commit suicide h. Safe housing

Staff Training

The essential component to any suicide prevention program is properly trained staff, who form the backbone of any correctional facility. Very few suicides are actually prevented by mental health, medical or other professional staff because suicides are usually attempted in housing units, and often during late evening hours or on weekends when they are generally outside the purview of program staff. These incidents, therefore, must be thwarted by correctional staff who have been trained in suicide prevention and have developed an intuitive sense about suicidal inmates. Correctional staff are often the only personnel available 24 hours a day; thus, they form the front line of defense in preventing suicides.

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All correctional, medical, and mental health personnel, as well as any staff who have regular contact

with inmates, should receive eight (8) hours of initial suicide prevention training, followed by two

(2) hours of refresher training each year. The initial training should include administrator/staff

attitudes about suicide and how negative attitudes impede suicide prevention efforts, guiding

principles to suicide prevention, inmate suicide research, why the environments of correctional

facilities are conducive to suicidal behavior, potential predisposing factors to suicide, high-risk

suicide periods, warning signs and symptoms, identifying suicidal inmates despite the denial of

risk, components of the facility’s suicide prevention policy, and liability issues associated with

inmate suicide. The two-hour refresher training should include a review of administrator/staff

attitudes about suicide and how negative attitudes impede suicide prevention efforts, predisposing

risk factors, warning signs and symptoms, identifying suicidal inmates despite the denial of risk,

and review of any changes to the facility’s suicide prevention plan. The annual training should also

include general discussion of any recent suicides and/or suicide attempts in the facility. In addition,

all staff who have routine contact with inmates should receive standard first aid and

cardiopulmonary resuscitation (CPR) training. All staff should also be trained in the use of various

emergency equipment located in each housing unit. In an effort to ensure an efficient emergency

response to suicide attempts, “mock drills” should be incorporated into both initial and refresher

training for all staff.

Identification/Referral/Evaluation

Intake screening and ongoing assessment of all inmates is critical to a correctional facility’s suicide prevention efforts. It should not be viewed as a single event, but as an ongoing process because inmates can become suicidal at any point during their confinement, including the initial admission into the facility; after adjudication when the inmate is returned to the facility from court; following receipt of bad news or after suffering any type of humiliation or rejection; confinement in isolation or segregation; and following prolonged a stay in the facility. In addition, although there is no single set of risk factors that mental health and medical communities agree can be used to predict suicide, there is little disagreement about the value of screening and assessment in preventing suicide. Research consistently reports that approximately two-thirds of all suicide victims communicate their intent some time before death, and that any individual with a history of one or more suicide attempts is at a much greater risk for suicide than those who have never made an attempt.

Intake screening for suicide risk may be contained within the medical screening form or as a separate form. The screening process should include inquiry regarding: past suicidal ideation and/or attempts; current ideation, threat, plan; prior mental health treatment/hospitalization; recent significant loss (job, relationship, death of family member/close friend, etc.); history of suicidal behavior by family member/close friend; suicide risk during prior confinement; and arresting/transporting officer(s) belief that the inmate is currently at risk. Specifically, inquiry should determine the following:

 Was the inmate a medical, mental health or suicide risk during any prior contact and/or confinement within this facility?
 Does the arresting and/or transporting officer have any information (e.g., from observed behavior, documentation from sending agency or facility, conversation with family member) that indicates inmate is a medical, mental health or suicide risk now?
 Have you ever attempted suicide?

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 Have you ever considered suicide?

 Are you now or have you ever been treated for mental health or emotional problems?

 Have you recently experienced a significant loss (relationship, death of family

member/close friend, job, etc.)?

 Has a family member/close friend ever attempted or committed suicide?

 Do you feel there is nothing to look forward to in the immediate future (expressing

helplessness and/or hopelessness)?

 Are you thinking of hurting and/or killing yourself?

Although an inmate’s verbal responses during the intake screening process are critically important to assessing the risk of suicide, staff should not exclusively rely on an inmate’s denial that they are suicidal and/or have a history of mental illness and suicidal behavior, particularly when their behavior and/or actions or even previous confinement in the facility suggest otherwise. The process should also include referral procedures to mental health and/or medical personnel for a more thorough and complete assessment.

The intake screening process should be viewed as similar to taking your temperature, it can identify a current fever, but not a future cold. Therefore, following the intake screening process, should any staff hear an inmate verbalize a desire or intent to commit suicide, observe an inmate engaging in any self-harm, or otherwise believe an inmate is at risk for suicide, a procedure should be in place that requires staff to take immediate action to ensure that the individual is constantly observed until appropriate medical, mental health, and/or supervisory assistance is obtained.

Finally, given the strong association between inmate suicide and isolation/special management (e.g., disciplinary and/or administrative segregation) housing unit placement, any inmate assigned to such a special housing unit should receive a written assessment for suicide risk by medical or mental health staff upon admission to the placement.

The screening and assessment process is only one of several tools that increases the opportunity to identify suicide risk in inmates. This process, coupled with staff training, will only be successful if an effective method of communication is in place at the facility.

Communication

Certain behavioral signs exhibited by the inmate may be indicative of suicidal behavior and, if detected and communicated to others, can reduce the likelihood of suicide. In addition, most suicides can be prevented by correctional staff who establish trust and rapport with inmates, gather pertinent information, and take action. There are essentially three levels of communication in preventing inmate suicides: between the arresting/transporting officer and correctional staff; between and among facility staff (including correctional, medical and mental health personnel); and between facility staff and the suicidal inmate.

In many ways, suicide prevention begins at the point of arrest. At Level 1, what an arrestee says and how they behave during arrest, transport to the facility, and at intake are crucial in detecting suicidal behavior. The scene of arrest is often the most volatile and emotional time for the individual. Arresting officers should pay close attention to the arrestee during this time; suicidal behavior may be manifested by the anxiety or hopelessness of the situation, and previous behavior can be confirmed by onlookers such as family members and friends. Any pertinent information

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regarding the arrestee’s well-being must be communicated by the arresting or transporting officer

to correctional staff. It is also critically important for correctional staff to maintain open lines of

communication with family members who often have pertinent information regarding the mental

health status of inmates.

At Level 2, effective management of suicidal inmates is based on communication among correctional personnel and other professional staff in the facility. Because inmates can become suicidal at any point during confinement, correctional staff must maintain awareness, share information and make appropriate referrals to mental health and medical staff. At a minimum, the facility’s shift supervisor should ensure that appropriate correctional staff are properly informed of the status of each inmate placed on suicide precautions. The shift supervisor should also be responsible for briefing the incoming shift supervisor regarding the status of all inmates on suicide precautions. Multidisciplinary team meetings (to include correctional, medical and mental health personnel) should occur on a regular basis to discuss the status of inmates on suicide precautions. Finally, the authorization for suicide precautions, any changes in suicide precautions, and observation of inmates placed on precautions should be documented on designated forms and distributed to appropriate staff.

At Level 3, facility staff must use various communication skills with the suicidal inmate, including active listening, staying with the inmate if they suspect immediate danger, and maintaining contact through conversation, eye contact, and body language. Correctional staff should trust their own judgment and observation of risk behavior, and avoid being misled by others (including mental health staff) into ignoring signs of suicidal behavior.

Poor communication between and among correctional, medical, and mental health personnel, as well as outside entities (e.g., arresting or referral agencies, family members) is a common factor found in the reviews of many custodial suicides. Communication problems are often caused by lack of respect, personality conflicts and boundary issues. Simply stated, facilities that maintain a multidisciplinary approach avoid preventable suicides.

Housing

In determining the most appropriate housing location for a suicidal inmates, correctional facility officials (with concurrence from medical and/or mental health staff) often tend to physically isolate (or segregate) and sometimes restrain the individual. These responses might be more convenient for all staff, but they are detrimental to the inmate since the use of isolation escalates the sense of alienation and further removes the individual from proper staff supervision. To every extent possible, suicidal inmates should be housed in the general population, mental health unit, or medical infirmary, located close to staff. Further, removal of an inmate’s clothing (excluding belts and shoelaces) and the use of physical restraints (e.g., restraint chairs or boards, leather straps, handcuffs, and straitjackets) should be avoided whenever possible, and used only as a last resort when the inmate is physically engaging in self-destructive behavior. Housing assignments should be based on the ability to maximize staff interaction with the inmate, not on decisions that heighten depersonalizing aspects of confinement.

All cells designated to house suicidal inmates should be as suicide-resistant as is reasonably possible, free of all obvious protrusions, and provide full visibility. These cells should contain tamper-proof light fixtures, smoke detectors and ceiling/wall air vents that are protrusion-free. In

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addition, the cells should not contain any live electrical switches or outlets, bunks with open

bottoms, any type of clothing hook, towel racks on desks and sinks, radiator vents, or any other

object that provides an easy anchoring device for hanging. Each cell door should contain a heavy

gauge Lexan (or equivalent grade) clear panel that is large enough to allow staff a full and

unobstructed view of the cell interior. Finally, each housing unit in the facility should contain

various emergency equipment, including a first aid kit, pocket mask or face shield, Ambu-bag, and

rescue tool (to quickly cut through fibrous material). Correctional staff should ensure that such

equipment is in working order on a daily basis.

Levels of Observation/Management

In regard to suicide attempts in correctional facilities, the promptness of the response is often driven by the level of supervision afforded the inmate. Medical evidence suggests that brain damage from strangulation caused by a suicide attempt can occur within 4 minutes, and death often within 5 to 6 minutes. Two levels of supervision are generally recommended for suicidal inmates: close observation and constant observation.

Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation (e.g., expressing a wish to die without a specific threat or plan) and/or has a recent prior history of self-destructive behavior. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. Staff should observe such an inmate in a protrusion-free cell at staggered intervals not to exceed every 10 minutes (e.g., 5, 10, 7 minutes).

Constant Observation is reserved for the inmate who is actively suicidal, either threatening or engaging in suicidal behavior. Staff should observe such an inmate on a continuous, uninterrupted basis. In some jurisdictions, an intermediate level of supervision is utilized with observation at staggered intervals that do not exceed every 5 minutes.

Other aids (e.g., closed-circuit television, cell mates) can be used as a supplement to, but never as a substitute for, these observation levels.

In addition, mental health staff should assess and interact with (not just observe) the suicidal inmate on a daily basis. The daily assessment should focus on the current behavior, as well as changes in thoughts and behavior during the past 24 hours (e.g., “What are your current feelings and thoughts?” “Have your feelings and thoughts changed over the past 24 hours?” “What are some of the things you have done or can do to change these thought and feelings?” etc.)

An individualized treatment plan (to include follow-up services) should be developed for each inmate on suicide precautions. The plan should be developed by qualified mental health staff in conjunction with not only the inmate, but medical and correctional personnel. The treatment plan should describe signs, symptoms, and the circumstances under which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the inmate and staff will take if suicidal ideation reoccurs.

Finally, due to the strong correlation between suicide and prior suicidal behavior, in order to safeguard the continuity of care for suicidal inmates, all inmates discharged from suicide

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precautions should remain on mental health caseloads and receive regularly scheduled follow-up

assessments by mental health personnel until their release from custody. Although there is not any

nationally-acceptable schedule for follow-up, a suggested assessment schedule following discharge

from suicide precautions might be: 24 hours, 72 hours, 1 week, and periodically until release from

custody.

Intervention

Following a suicide attempt, the degree and promptness of the staff’s intervention often foretells whether the victim will survive. National correctional standards and practices generally acknowledge that a facility’s policy regarding intervention should be threefold. First, all staff who come into contact with the inmate should be trained in standard first aid procedures and CPR. Second, any staff member who discovers an inmate engaging in self-harm should immediately survey the scene to assess the severity of the emergency, alert other staff to call for medical personnel if necessary, and begin standard first aid and/or CPR as necessary. If facility policy prohibits an officer from entering a cell without backup support, the first responding officer should, at a minimum, make the proper notification for backup support and medical personnel, secure the area outside the cell, and retrieve the housing unit’s emergency response bag (that should include a first aid kit, pocket mask or face shield, Ambu-bag, and rescue tool). Third, correctional staff should never presume that the victim is dead, but rather should initiate and continue appropriate life-saving measures until relieved by arriving medical personnel. In addition, medical personnel should ensure that all equipment utilized in responding to an emergency within the facility is in working order on a daily basis.

Finally, although not all suicide attempts require emergency medical intervention, all suicide attempts should result in immediate intervention and assessment by mental health staff.

Reporting

In the event of a suicide attempt or suicide, all appropriate officials should be notified through the chain of command. Following the incident, the victim’s family should be immediately notified, as well as appropriate outside authorities. All staff who came into contact with the victim before the incident should be required to submit a statement including their full knowledge of the inmate and incident.

Follow-Up/Mortality-Morbidity Review

An inmate suicide is extremely stressful for both staff and other inmates. Staff may also feel ostracized by fellow personnel and administration officials. Following a suicide, misplaced guilt is sometimes displayed by a correctional officer who wonders: “What if I had made my cell check earlier?” Inmates are often traumatized by critical events occurring within a facility. Such trauma may lead to suicide contagion. When crises occur in which staff and inmates are affected by the traumatic event, they should be offered immediate assistance. One form of assistance is Critical Incident Stress Debriefing (CISD). A CISD team, comprised of professionals trained in crisis intervention and traumatic stress awareness (e.g., police officers, paramedics, fire fighters, clergy, and mental health personnel), provides affected staff and inmates an opportunity to process their feelings about the incident, develop an understanding of critical stress symptoms, and seek ways of

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dealing with those symptoms. For maximum effectiveness, the CISD process or other appropriate

support services should occur within 24 to 72 hours of the critical incident.

Every completed suicide, as well as serious suicide attempt (i.e., requiring medical treatment and/or hospitalization), should be examined through a mortality-morbidity review process. If resources permit, clinical review through a psychological autopsy is also recommended. Ideally, the mortality-morbidity review should be coordinated by an outside agency to ensure impartiality. The review, separate and apart from other formal investigations that may be required to determine the cause of death, should include a critical inquiry of: 1) the circumstances surrounding the incident; 2) facility procedures relevant to the incident; 3) all relevant training received by involved staff; 4) pertinent medical and mental health services/reports involving the victim; 5) possible precipitating factors leading to the suicide or serious suicide attempt; and 6) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures.

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: See f.iv.

RECOMMENDATIONS: Annual disaster drills should include scenarios with response to a mental health emergency/suicide and be documented in a file maintained by the training supervisor.

Previous Recommendations Remain Appropriate:

1. Immediately develop and implement comprehensive pre and in-service suicide prevention training that is 1) evidence based, 2) policy and procedure driven, 3) includes valid and reliable knowledge and application competency evaluation methods. Such training would naturally include detection, recognition, assessment, and intervention topics and materials.
2. Implement policies, procedures, and protocols that govern and control staff response regarding inmate behavioral and/or verbal indications of suicide risk. Governing documents must require initial and ongoing involvement of medical and mental health staff in the response to suicide prevention actions.
3. Suicide prevention is considered a life safety issue that requires, at minimum, quarterly suicide prevention drills involving correctional, medical, and mental health staff to ensure 1) training and response efficacy, 2) effectiveness of policy and procedure, and 3) compliance with the Agreement.

(vii) availability of suicide resistant cells;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: GGACF remains without a suicide resistant cell. Construction is well underway to create a new dental suite, medical observation cell, and two mental health observation/suicide prevention rooms. This new area will have the nursing station

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directly outside the window of the identified suicide prevention room. In addition, there will be

a security officer’s desk steps away.

Suicide resistant gowns and blankets have been purchased and are on site. Soft four-point restraints are also on site but as yet there is no restraint bed available. Staff will need to ensure that there are no ligature points in the suicide prevention rooms. Retrofitting of those rooms should occur prior to the placement of any inmates in those cells.

RECOMMENDATIONS: Continue with the current modifications to the medical treatment building.

The appropriate forms documenting the clinicians orders for security implementation should be developed and then vetted through the process in the settlement agreement

Previous Recommendations Remain Appropriate:

1. Appropriate bedding, clothing, food and utensils, property, and pallet should be specified by the mental health clinician when supervising officer placing an inmate on suicide watch.
2. Retrofit cells designated suicide precautions to be suicide proof. 3. Renovation of an intake cell may be the only immediate alternative. If this environment is
utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates. 4. The following guidelines should be considered when establishing suicide-resistant housing environments:1

The safe housing of suicidal inmates is an important component to a correctional facility’s comprehensive suicide prevention policy. Although impossible to create a “suicide-proof” cell environment within any correctional facility, given the fact that almost all inmate suicides occur by hanging, it is certainly reasonable to ensure that all cells utilized to house potentially suicidal inmates are free of all obvious protrusions. And while it is more common for ligatures to be affixed to air vents and window bars (or grates), all cell fixtures should be scrutinized, since bed frames/holes, shelves with clothing hooks, sprinkler heads, door hinge/knobs, towel racks, water faucet lips, and light fixtures have been used as anchoring devices in hanging attempts. As such, to ensure that inmates placed on suicide precautions are housed in “suicide-resistant” cells, facility officials are strongly encouraged to address the following architectural and environmental issues:

1. Cell doors should have large-vision panels of Lexan (or low-abrasion polycarbonate) to allow for unobstructed view of the entire cell interior at all times. These windows should never be covered (even for reasons of privacy, discipline, etc.) If door sliders are not used, door interiors should not have handles/knobs; rather they should have recessed door pulls. Any door containing a food pass should be closed and locked. Interior door hinges should bevel down so as not to permit being used as an anchoring device. Door frames should be rounded and smooth on the top edges. The frame should be grouted into the wall with as little edge exposed as possible.

1 http://www.ncianet.org/services/suicide-prevention-in-custody/publications/checklist-for-the-suicide-resistantdesign-of-correctional-facilities/

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In older, antiquated facilities with cell fronts, walls and/or cell doors made of steel bars, Lexan

paneling (or low-abrasion polycarbonate) or security screening (that has holes that are ideally

1/8 inches wide and no more than 3/16 inches wide or 16-mesh per square inch) should be

installed from the interior of the cell.

Solid cell fronts must be modified to include large-vision Lexan panels or security screens with small mesh;

2. Vents, ducts, grilles, and light fixtures should be protrusion-free and covered with screening that has holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16-mesh per square inch;

3. Wall-mounted corded telephones should not be placed inside cells. Telephone cords of varying length have been utilized in hanging attempts;

4. Cells should not contain any clothing hooks. The traditional, pull-down or collapsible hook can be easily jammed and/or its side supports utilized as an anchor;

5. A stainless steel combo toilet-sink (with concealed plumbing and outside control valve) should be used. The fixture should not contain an anti-squirt slit, toothbrush holder, toilet paper rod, and/or towel bar;

6. Beds should ideally be either heavy molded plastic or solid concrete slab with rounded edges, totally enclosed underneath. If metal bunks are utilized, they should be bolted flush to the wall with the frame constructed to prevent its use as an anchoring device. Bunk holes should be covered; ladders should be removed. (Traditional metal beds with holes in the bottom, not built flush to the wall and open underneath, have often been used to attach suicide nooses. Lying flat on the floor, the inmate attaches the noose from above, runs it under his neck, turns over on his stomach and asphyxiates himself within minutes.);

7. Electricity should be turned off from wall outlets outside of the cell;

8. Light fixtures should be recessed into the ceiling and tamper-proof. Some fixtures can be securely anchored into ceiling or wall corners when remodeling prohibits recessed lighting. All fixtures should be caulked or grouted with tamper-resistant security grade caulking or grout. Ample light for reading (at least 20 foot-candles at desk level) should be provided. Low-wattage night light bulbs should be used (except in special, high-risk housing units where sufficient lighting 24 hours per day should be provided to allow closed-circuit television (CCTV) cameras to identify movements and forms). An alternative is to install an infrared filter over the ceiling light to produce total darkness, allowing inmates to sleep at night. Various cameras are then able to have total observation as if it were daylight. This filter should be used only at night because sensitivity can otherwise develop and produce aftereffects;

9. CCTV monitoring does not prevent a suicide, it only identifies a suicide attempt in progress. If utilized, CCTV monitoring should only supplement the physical observation by staff. The camera should obviously be enclosed in a box that is tamper-proof and does not contain anchoring points. It should be placed in a high corner location of the cell and all edges around

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the housing should be caulked or grouted. Cells containing CCTV monitoring should be painted

in pastel colors to allow for better visibility. To reduce camera glare and provide a contrast in

monitoring, the headers above cell doors should be painted black or some other dark color.

CCTV cameras should provide a clear and unobstructed view of the entire cell interior,

including all four corners of the room. Camera lens should have the capacity for both night and

low light level vision;

10. Cells should have a smoke detector mounted flush in the ceiling, with an audible alarm at the control desk. Some cells have a security screening mesh to protect the smoke detector from vandalism. The protective coverings should be high enough to be outside the reach of an inmate and far enough away from the toilet so that the fixture could not be used as a ladder to access the smoke detector and screen. Ceiling height for new construction should be 10 feet to make such a reasonable accommodation. Existing facilities with lower ceilings should carefully select the protective device to make sure it cannot be tampered with, or have mesh openings large enough to thread a noose through. Water sprinkler heads should not be exposed. Some have protective cones; others are flush with the ceiling and drop down when set off; some are the breakaway type;

11. Cells should have an audio monitoring intercom for listening to calls of distress (only as a supplement to physical observation by staff). While the inmate is on suicide precautions, intercoms should be turned up high (as hanging victims can often be heard to be gurgling, gasping for air, their body hitting the wall/floor, etc.);

12. Cells utilized for suicide precautions should be located as close as possible to a control desk to allow for additional audio and visual monitoring;

13. If modesty walls or shields are utilized, they should have triangular, rounded or sloping tops to prevent anchoring. The walls should allow visibility of both the head and feet;

14. Some inmates hang themselves under desks, benches, tables or stools/pull-out seats. Potential suicide-resistant remedies are: (a) Extending the bed slab for use as a seat; (b) Cylinder-shaped concrete seat anchored to floor, with rounded edges; (c) Triangular corner desk top anchored to the two walls; and (d) Rectangular desk top, with triangular end plates, anchored to the wall. Towel racks should also be removed from any desk area;

15. All shelf tops and exposed hinges should have solid, triangular end-plates which preclude a ligature being applied;

16. Cells should have security windows with an outside view. The ability to identify time of day via sunlight helps re-establish perception and natural thinking, while minimizing disorientation. If cell windows contain security bars that are not completely flush with window panel (thus allowing a gap between the glass and bar for use as an anchoring device), they should be covered with Lexan (or low-abrasion polycarbonate) paneling to prevent access to the bars, or the gap, should be closed with caulking, glazing tape, etc. If window screening or grating is used, covering should have holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16-mesh per square inch;

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17. The mattress should be fire retardant and not produce toxic smoke. The seam should be tear-

resistant so that it cannot be used as a ligature;

18. Given the fact that the risk of self-harm utilizing a laundry bag string outweighs its usefulness for holding dirty clothes off the floor, laundry bag strings should be removed from the cell;

19. Mirrors should be of brushed, polished metal, attached with tamper-proof screws;

20. Padding of cell walls is prohibited in many states. Check with your fire marshal. If permitted, padded walls must be of fire-retardant materials that are not combustible and do not produce toxic gasses; and,

21. Ceiling and wall joints should be sealed with neoprene rubber gasket or sealed with tamperresistant security grade caulking or grout for preventing the attachment of an anchoring device through the joints.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: At the current time there are no inmate records for review of constant supervision pertaining to suicide prevention. However, there is one man who assaulted a female officer in the segregation unit. He has a long-standing chronic serious mental illness. The medical staff and security removed him from segregation and have modified an office in the clinic into a medical observation room. This man is currently living in this room under the constant supervision of an officer until such time as a better accommodation is available. This has resulted in one fewer mental health interviewing rooms available in the clinic. It is also an inappropriate long term housing solution as the office has not been adequately retrofitted. It is my understanding that the BOC is attempting to locate a facility on the mainland capable of managing a seriously mentally ill inmate with physical and classification limitations.

RECOMMENDATIONS: GGACF should develop a suicide prevention observation log form that allows for officers’ entries of their staggered 15 minute checks.

Previous Recommendations Remain Appropriate:

1. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15-minute watches.
2. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
3. Renovation of an intake cell may be the only immediate alternative. If this environment is utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.

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4. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in

the medical record or by security. This log could indicate property allowed and whether the

inmate is on constant or staggered 15-minute watches.

(ix) procedures to assure implementation of directives from a mental health professional regarding:
(1)the confinement and care of suicidal prisoners; (2)the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: There are currently no clinical cases to review for compliance to this provision.
RECOMMENDATIONS: The suicide prevention policy directing this process is currently under review.
Previous Recommendations Remain Appropriate:
1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
2. It is recommended that the facility develop a form listing each level of observation that would also specify what property the inmate is allowed to have in their possession as well as indicating which staff member has ordered the watch and property restrictions. Consultation with the monitoring team may be a useful assistance.
3. The facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates if they continue to be housed in the reception area.
4. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
5. Renovation of an intake cell may be the only immediate alternative. 6. If this environment is utilized then the facility needs to carefully monitor how readily medical
and mental health staff can maintain daily contact with the inmates.
j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MEDICAL FINDINGS: We have identified the need for more regular clinician hours. We have been informed that the Medical Director will be available three days per week and a fill-in physician will be available three days per week on the weeks that the Medical Director is not available. The second contract must be obtained and the Medical Director position must be solidified by also resolving the licensed pharmacist issues. The Territory also must resolve payment issues in order

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to retain qualified staff – we understand that the Medical Director has not been paid consistently

for his services, and non-payment may result in the Medical Director’s resignation.

Also, there are to be four registered nurses, one of which positions will be split between two halftime nurses, each working the weekends. There will also be a third LPN who will complement the two existing LPNs. There must also be hired a permanent medical records technician. These are by our determination the medical staffing needs at present.

RECOMMENDATIONS:

1. Fill the two RN positions who are each identified as half time, thus completing the fourth fulltime RN position.
2. Solidify both the Medical Director hours and the fill-in clinician hours so that there are regularly scheduled visits for a clinician including sick call follow up, offsite service follow up and where necessary, chronic care visits and initial health appraisal visits along with urgent care visits.
3. Fill the vacant licensed pharmacist position or contract. 4. Fill the LPN position. 5. Fill the permanent medical records clerical position.

MENTAL HEALTH FINDINGS: Current staffing allows for a part-time psychiatrist and one full-time qualified mental health professional. The latter position is currently unfilled. No formal staffing analysis has been provided for review. However, at the current time since the facility lacks a mental health programming vision, it would be difficult for them to develop a staffing plan to meet the unknown needs.

RECOMMENDATIONS:

1. As previously discussed, leadership will begin to develop an initial plan for presentation at the next site visit of what their desired mental health program will look like. Based on that outline and my prior recommendations the preliminary staffing needs analysis can then be performed and reviewed by the monitoring team.
2. It is my opinion that the current psychiatric (psychiatrist) staffing for this site is quite sufficient. However the supporting staff position is insufficient to meet the needs of the inmate population and will be elaborated in the following sections.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: Without a doubt, staffing must increase to meet the needs of the inmate population. In the meantime, the Territory can take some steps to alleviate the burdens on current staff. For example, the exam rooms in the housing units must be cleaned, sanitized and appropriately equipped, thus potentially reducing some needs for medical transport onsite to the clinic. On the other hand, an officer does need to accompany the medication nurse both mornings and evenings, seven days per week. In addition, there should be a second officer working with the

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current officer in the clinic area which will soon also include an infirmary area and two officers

will manage that population.

RECOMMENDATIONS:

1. Fill a correctional officer position to work with the medication nurses mornings and evenings to accompany the nurse and work as a team with that nurse.
2. Provide a second correctional officer for the clinic/infirmary area. 3. There should be a medical van and offsite service medical transporters. 4. The exam rooms in the housing unit should be cleaned and sanitized and appropriately equipped
in order to reduce the onsite escort needs.

MENTAL HEALTH FINDINGS: Correctional officer staffing levels remain inadequate to ensure compliance with this Provision. Required training curricula does not sufficiently address all subject matter required.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate:

1. Develop staffing policies and procedures that reflect facility and population needs. 2. Develop staffing documents that allow for accurate and timely tracking of staffing levels, shift
and duty assignments, work locations, and shortages. 3. Ensure staff members are properly trained in all aspects of their respective duty assignments
working with special needs and mentally ill inmates. 4. Provide Monitor with accurate, complete, and up-to-date staffing schedules as described
above.

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There is a QI policy. We are emphasizing that by utilizing the logs and improving them as recommended, the HSA could begin monitoring the following services:

1. Intake processing for completeness and timeliness 2. Sick call for timeliness 3. Urgent care for completeness and timeliness, including offsite emergency room reports 4. Scheduled offsite services for completeness and timeliness, including offsite service report 5. Chronic care visits for timeliness 6. Dental services for timeliness 7. Sick call for timeliness

RECOMMENDATIONS: Follow the above list of nine elements to begin the quality improvement program.

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MENTAL HEALTH FINDINGS: No such protocol has been received by this monitor for

assessment.

RECOMMENDATIONS: Please provide copies of the required protocol for review.

m. Adequate dental care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There is an oral care policy which is close to final form but we have recommended some revisions. We have also learned that there continues to be a problem with access to the dentist due to escort problems as well as availability of the dentist in terms of his arrival per schedule at the facility. Until the policy has been finalized this area will remain in noncompliance. The dentist needs to insure his availability and custody staff needs to insure that they are bringing the patients to him. On the day of our visit when he was there all of the patients were seen, but from the records this was clearly an exception and not the rule. There must be a dental log including the reasons why patients are not seen; when the reason is absence of dentist or absence of custody, these patients must be rescheduled.

RECOMMENDATIONS:

1. The HSA should track both the availability of the dentist as well as the availability of custody escorts as part of the QI program.
2. The dental program should report to the QI program the numbers of scheduled patients and the numbers who arrive and the reason for non-arrival for each of the patients who did not arrive.
3. The above information should be reported to the QI program monthly. 4. The dental program should track the number of extractions and restorations performed each
month and we will be able to review that data upon return. 5. Develop adequate dental care policies, procedures, and protocols.

MENTAL HEALTH FINDINGS: defer to Medical Findings.

RECOMMENDATIONS: defer to Medical Findings.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We provided the Territory with a policy from another institution in another jurisdiction which has been approved through the DOJ review. There have been no deaths since our last visit and we are waiting completion of the mortality review policy.

RECOMMENDATIONS:

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1. Utilizing the policy we provided, redraft the mortality review policy.

2. This is a restatement of a prior recommendation: arrange for reports from offsite clinic

encounters to be made available at the prison for patients seen for offsite infectious disease or

gyne problems or any other problems be obtained by the offsite service coordinator.

3. Consider utilizing the services of an offsite service clinician to perform a death review on all

deaths of patients incarcerated in Department of Corrections.

MENTAL HEALTH FINDINGS: No change since previous visit. There have been no deaths or suicide attempts reported for the mental health caseload since the time of our last visit. However, there has been a case that should be reviewed of an inmate with a serious mental illness who decompensated over several months’ time, ended up in segregation without any disciplinary reports and then struck an officer.

RECOMMENDATIONS: Recommend a morbidity review for the case of the inmate housed in the MTB by the facility prior to our next audit. Please submit the reports and supporting documents (incident reports, etc.) generated by that review to the monitor’s team for review.

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We do have a draft segregation round policy. We have discussed issues regarding both the medical and mental health rounds and this draft is to be revised for our approval.

RECOMMENDATION: Previous Recommendation Remains Appropriate:

1. Draft the policy and procedure for segregation rounds for our review.

MENTAL HEALTH FINDINGS: Mental health rounds in segregation units are not occurring. In addition the women in X unit continued to report that medication pass still occurs at the outside gate to the housing unit and nurses rarely enter the unit (exceptions reported are mostly due to inclement weather). Inmates frequently have medical and mental health issues that are not reported to staff via a sick call request. Oftentimes this is a direct result of a mental illness that may cause the individual to be withdrawn or paranoid. It is essential that medical and mental health staff have direct visualization of these individuals in order to identify potential infectious diseases, undiagnosed medical illnesses, and signs of the onset of or reactivation of the mental illness. An example of this is a seriously mentally ill inmate in segregation seen by this auditor who had a highly infected right eye. When asked about this he informed this reviewer that he was placing menthol in his eye because it itched. This information was relayed to the medical director so proper health education could be provided to the inmate and so medical staff could conduct a physical examination of the inmate’s eye for signs of injury.

RECOMMENDATIONS: In-service training to medical and mental health staff should be provided regarding the purposes of these rounds in identifying inmates with active medical and mental health issues, especially when housed in segregated units.

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p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: At the current time this provision is unmet. Inmates with serious mental illnesses remain in segregation. One inmate in particular is in a corner cell with no inmate in the cell next to his. Therefore, this man with a serious mental illness is at a level of confinement that approximates isolation.

The psychiatrist reported that she receives no notification when an inmate on the mental health caseload is placed in segregation.

RECOMMENDATIONS:

1. Inmates in segregated units with a serious mental illness should be entitled to a minimum of 10 hours per week of unstructured out of cell time. Security will need to develop a plan and a means of tracking the number of hours each of these inmates is allowed to be out of cell.
2. GGACF needs to develop a plan for identifying seriously mentally ill inmates in segregation units. Treatment needs should be determined by the mental health staff and a plan for implementing the required programming in the segregation unit. Those inmates who are observed to have difficulties tolerating the segregation environment due to their mental illness should be removed and placed in appropriate housing with treatment programming available to address their mental health condition.
3. Medical should be notified of any inmate placed in segregation and when staff is on site, a pre-segregation review should be completed.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: At the current time there is no process in place by which the mental health provider reviews or consults with the disciplinary hearing officer regarding potential disciplinary sanctions for those inmates with a mental illness. The psychiatrist has never been contacted by the hearing officer for her input. This is a potentially dangerous practice that will result in the placement of seriously mentally ill individuals in isolation, or subject them to improper discipline, in contravention of the Settlement Agreement and best practices.

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RECOMMENDATIONS:

1. GGACF should develop a process incorporated in the disciplinary policy that describes the protocol for communication between the hearing officer and a qualified mental health professional whenever an inmate on the mental health caseload is facing disciplinary sanctions.
2. A notification form should be developed that would request written input by the behavioral health staff to the hearing officer. It is recommended that a copy of that completed form be retained by the health services administrator or mental health director. This quality improvement data can be reviewed to determine if disciplinary sanctions are mitigated as a result of the input by the health staff.
3. Mental health input into the disciplinary process, and a clear plan for pre-segregation mental health and medical assessments should be implemented. Because the service does not offer 24 hour nursing and mental health staffing, segregation assessments should be performed during the next business day following placement. The purpose of these assessments is to look for risk factors that would necessitate restricting placement in segregation because of a clinical determination that the medical or mental health condition is likely not to improve in that housing location when compared to other placements, such as a specialized mental health unit.

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This area was also discussed in letter (c); however, additionally construction has gone forward on the infirmary space, including two dental operatories, a pharmacy area and areas for both mental health suicide observation and acute and chronic medical housing. These areas are close to being finished. They then have to be appropriately equipped and this remains an ongoing need. Also in (c) we discussed the need to refurbish, clean and sanitize the exam rooms in the housing units other than lockdown and appropriately equip them. The Territory is to be commended for progress in the work in the infirmary area.

RECOMMENDATIONS:

1. Complete the infirmary renovations. 2. Appropriately equip the infirmary area, including two dental operatories. 3. Insure that there is at least one more officer available in the clinic/infirmary area. 4. Complete per our recommendations the infirmary policy.

MENTAL HEALTH FINDINGS: In the past there had been two private offices in the medical treatment building designated as mental health offices. Currently one is occupied full-time by an inmate patient and the other is being used for medical records. As a result, the psychiatrist is using the former director of nursing's office to see patients. Should a qualified mental health professional be located and hired, there is currently no office designated for that person to provide treatment services.

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RECOMMENDATIONS: It would be helpful if there was a general current and future plan presented to the monitors regarding clinical space for both medical and mental health staff once a full complement of staff are on board.

Previous Recommendations Remain Appropriate:

1. The facility needs to explore what barriers may exist to providing frequent and adequate services to inmates in special housing in sound private settings.
2. Send the Monitor the plans as soon as a draft has been developed.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: As mentioned in prior sections, visits to psychiatry are timely. However, current staffing is inadequate to provide the types of services necessary for the mental health care and treatment to be considered adequate by national standards. GGACF is currently only providing psychiatrist services. Due to staffing shortages there are no ongoing programs for individual counseling. In the absence of a mental health professional other than the psychiatrist, comprehensive treatment planning is not occurring; nor is treatment other than visits to the psychiatrist who does include her treatment plan in that section of her progress note.

RECOMMENDATIONS: Continue all efforts to hire qualified mental health professionals to comply with this Agreement and provide adequate levels of mental health staff to ensure provision of qualified, consistent assessment and treatment.

Previous Recommendations Remain Appropriate:

1. Continue to monitor the plans to implement the new forms, modifications to the tracking case list including housing area, past visit and date of return to clinic.
2. Consider developing quality improvement process to monitor outcomes from data collected via the treatment forms.

(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: The psychiatrist currently is in the clinic Monday through Thursday 11 AM to 5 PM. She reports being able to see anyone security can bring to her. She has noticed fewer days without a patrol officer (now maybe one day per week) which has greatly improved her access to the inmates on her clinical caseload. The psychiatrist remains enthusiastic and committed to supporting the service in any way she can. When off-site she is available to the facility 24 hours a day and frequently will see urgent cases in the emergency department on the days that she is in the hospital. In addition to her duties seeing inmates at the facility she also completes forensic evaluations requested by the courts.

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The prior qualified mental health professional finally submitted her letter of resignation two weeks prior to the September site visit. That position has been posted and advertised and hopefully will be filled by the time of our next site visit. As a result of this critical staff shortage, services such as programming in A dorm (the housing area containing those with the most serious mental illnesses), outpatient counseling and initial psychological assessments, and rounds in segregation units by a mental health professional are not occurring.

Medical recently hired additional registered nurses and one nurse was going to be assigned to the psychiatrist. However, prior to leaving St. Croix, we learned that this nurse chose another job on the island and would, therefore, not be available to assist the psychiatrist.

RECOMMENDATIONS:

1. Successfully hire the authorized qualified mental health professional. 2. It is recommended the BOC consider creating at least one more qualified mental health
professional position in order to, at a minimum: a. share coverage for the intake and assessment process, b. provide programming to seriously mentally ill inmates in both segregation units as well
as A dorm and general population, c. provide weekly segregation mental health rounds, d. generate treatment and discharge plans, e. complete suicide watch follow-up.

Then, additional staff positions, if needed, may be able to be filled with less specially trained personnel to provide structured activities such as recreational activities, life skills groups, patient education groups, etc. in programming units.

3. At the time of the next site visit, I am hopeful that the health services administrator, psychiatrist, and warden will have begun to brainstorm their own mission and vision of what an adequate mental health system and individualized treatment plan driven programming should entail at their facility. At a minimum, inmates in specialized mental health housing units (A Dorm) and those with a serious mental illness in segregation should be provided at least 10 hours per week of structured therapeutic activities as well as 10 hours of unstructured out of cell time (the latter pertains to segregated inmates). Inmates in the general population, particularly those with a serious mental illness, should have access to some group programming and individual counseling as needed.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: The psychiatrist has created a tracking form to monitor the date of the last psychiatric evaluation. In this field she actually tracks all appointments in the year 2014 for each individual. Most inmates were seen at least once every two months with a few being seen every three months. The psychotropic consent form being used and is quite

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adequate. Medication side effects are being assessed at the time of outpatient visits. On chart

review it was noticed that there is no quantitative tool in place for monitoring movement

disorders such as the AIMS. To her credit, the psychiatrist does obtain vital signs including

weight and girth to monitor for the development of metabolic syndrome.

RECOMMENDATIONS: Inmates on neuroleptic medication should receive an AIMS test at the time of initiation of neuroleptic medication and at least every six months.

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: See f. (iv)

RECOMMENDATIONS: See f. (iv)

RECOMMENDATIONS:

1. A detailed curriculum should be submitted for review to the monitoring team and approval by the Monitor.
2. Once obtained, training should be implemented with pre-and post-testing or other performance measures that have been approved by the Monitor.
3. GGACF should ensure the training officer or her records are available at the time of the next site visit for review by the monitoring team.
4. Develop, implement, and evaluate comprehensive training curricula to comply with Provision.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: Inmates with serious and persistent mental illnesses remain housed in segregation units, sometimes without disciplinary reports. As of yet, there are no housing units at the facility that would allow for the safe integration of these inmates into a psychiatric treatment unit. Currently the seriously mentally ill inmates in general population are primarily congregated in A Dorm. Although this housing unit is preferable to some of the other prison units primarily because it is airy and sunny; it remains an undesirable location. However, problems with this unit include, but are not limited to:

1. a narrow central corridor flanked by inmate cell, 2. a day room that is unobservable from the officer’s station 3. no access to outside recreation.

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4. the inmates’ cells are also unobservable from the officer’s station which is divided from the

housing unit by a closed-door.

5. If the officer is in the dayroom, then there is no observation of the front door, nor the inmate’s

remaining in their cells.

RECOMMENDATIONS:

1. If programming is instituted in the current unit, an officer will need to be present to monitor the desk and inmates not attending the group. A second officer will need to be in the dayroom while the group activity is being conducted.
2. Inmates in this housing unit should have access to outside recreation. 3. Inmates taking certain psychotropic should also be cautioned as to an increased risk for
photosensitivity and complications of disrupted heat regulation placing them at greater risk for heatstroke. Inmates from a mental health unit should have access to fresh water during times of outdoor recreation and shade. 4. Particularly for seriously mentally ill inmates on the prison's side where lengths of stay are longer, GGACF should determine what these inmates recreation and programming needs are in order to determine the configuration of appropriate housing. 5. It is likely that the facility will need to request capital improvement funds in order to meet the needs of this subclass.

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VI. FIRE AND LIFE SAFETY

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: The Territory provided this Monitor draft Fire Safety policies and procedures during the July onsite technical assistance visit. However, during this visit the Fire Safety consultant advised this Monitor that he had revised these policies and would thereafter provide them. The monitor has not yet received revised policy drafts despite making a written request.
The finalization of this policy is vital. Inadequate housing unit staffing levels and contraband control practices continue to enable inmate-caused fires in housing units. According to the Incident Log there were at least four (4) inmate-caused “fires and/or arsons” between 6/14 and 8/24; all of these reported incidents occurred in Detention units. Seven inmates were involved. Incident reports were only provided for two (2) of these events despite this Monitor’s request for all such reports prior to this onsite visit.
Reports were provided for two (2) fire-related incidents occurring 7/16 and 8/24; both incident reports titled the incidents as “arsons”.
The 7/16 arson occurred in unit 9A and involved an inmate starting a fire in his cell. The fire was extinguished and the inmate was moved to the Intake unit. The report fails to clearly articulate fire causes or ignition sources.
The 8/24 arson occurred in unit 9D and involved an inmate throwing a burning object at cell door #29 that “started a fire”. An officer used a bottle of water to extinguish the fire. The inmate involved was locked in his cell. Again, the report fails to clearly articulate fire causes or ignition sources.
There were no other documents provided to this Monitor indicating further investigation of these events or whether a post fire-incident review was conducted by GGAF administration or the Fire Safety Consultant. As described above, incident reporting and investigations at GGACF are woefully inadequate. The Monitor is aware of no corrective action taken, disciplinary hearings conducted, contraband confiscated, or changes made as a result of these incidents.

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These two incidents, alone, clearly demonstrate how dangerous incarceration and employment

as a corrections officer at GGACF can be. The automatic fire detection and suppression system

remains inoperable, inadequate staffing levels and contraband control leaves housing units

deleteriously under controlled and monitored, inmates apparently have undetected and

interrupted access to items to ignite fires, and inmates obviously have no inhibition about

starting fires.

RECOMMENDATIONS: Previous recommendations remain appropriate. Additionally, the Monitor requests the reports for all drills and exercises conducted.

1. Finalize and implement fire safety policies once approved and according to the Monitor’s schedule by 12/31/14.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all
locations where staff would need to search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate
supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security. 7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program. 8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action. 9. The fire inspection program must be clearly detailed in fire safety policies and procedures, and become a fundamental element of pre-and in-service training.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, cell and housing unit sprinklers are non-functional and regularly used by inmates to support personal clotheslines. The primary fire detection and suppression system was designed to automatically detect and extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates.

An adequate supply of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures. However, these devices are not always used to extinguish fires in housing units as demonstrated in a reported arson that occurred in August 24, 2014. During this event, the housing unit officer used a water bottle to extinguish a fire in a housing unit that was

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caused by an inmate. The report does not articulate the accelerant used to create this fire but

chose not to use the approved fire extinguisher to put out this fire. Although the officer showed

quick action to prevent potential harm to other staff and inmates, it is very dangers to use water

to extinguish a fire under certain circumstances and only approved fire extinguishers should be

use. Furthermore, this report was not accompanied by any documentation discussing any

follow-up actions, a review by the fire inspector, or counseling/retraining of the officer for

failing to following policy.

On-site, GGACF staff indicated that sprinkler heads may be replaced in the “newer” buildings at some point in the next year, but the exact plans for this were not made available. Moreover, GGACF plans to continue to house individuals in the “older” buildings, and has no plans to update or install fire suppression equipment in those buildings. GGACF will never come into compliance with these provisions if that remains the case.

RECOMMENDATIONS:

1. Refer to recommendations above (a). 2. Consider purchasing fire safety program software from NFPA and/or the American
Correctional Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. It is unclear when, if ever, full fire drills are conducted. This continues to put inmates at risk of injury or death, should a fire break out that cannot be suppressed by the hand-held fire extinguishers present in the officer control pods of housing units.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above.
Train and drill staff as discussed on system use. 3. Develop emergency key and locking mechanism inspection and reporting system as
discussed above. 4. Implement competency-based staff training as discussed above. 5. Exercise fire safety program using onsite, scenario-based drills; include community
responders in exercise planning and exercise events. 6. Send the training officer and part-time fire safety officers to the National Fire Institute,
National Emergency Training Center, Emmetsburg, MD for additional training.

d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell;
and;

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(ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance.

RECOMMENDATIONS: Same as above.

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems. 3. Repair all remote cell locking notification technology.

e. Testing of all staff regarding fire and life safety procedures;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated in the previous report, no records were provided to verify that all staff have been trained and tested on safety procedures.

RECOMMENDATIONS:

1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
2. Provide this Monitor documentation evidencing compliance with this Provision.

f. Reporting and notification of fires, including audible fire alarms;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The fire reporting and notification system remains operable. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a hand-held air horn to alert inmates evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. Currently, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.

RECOMMENDATIONS: Same as above.

g. Evacuation of prisoners threatened with harm resulting from a fire;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

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RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves
community emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.
2. Repair the automatic fire detection, notification, and suppression system. 3. Replace cell sprinklers with tamper proof mechanisms.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: 1. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 2. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 3. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 4. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.

j. Control of highly flammable materials.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. Additionally, there appeared to be some reduction in combustible clutter in inmate cells. Continue and monitor this practice.

RECOMMENDATIONS: Same as above.

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VII. ENVIRONMENTAL HEALTH AND SAFETY

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Documentation was provided that demonstrates ongoing efforts of GGACF officials, maintenance supervisors, and the Fire Safety Consultant to assess, improve, and monitor facility sanitation and hygiene. Draft policies were provided to this Monitor for review prior to the Court ordering the monitoring team to write draft operational policies.

Again, however, housekeeping and sanitation plans will not be meet compliance with this Provision without adequate staffing levels as previously stated.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.
8. Repair all housing/cell windows to prevent penetration by insects.

b. Adequate ventilation throughout the facility;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated).

RECOMMENDATIONS:

1. Timely complete an air quality assessment performed by a qualified provider. 2. Implement necessary improvements that reduce housing area and cell temperatures
and increase air flow. 3. Medical and mental health staff should monitor all inmates for heat and airflow-
related health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions. 4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors. 5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions. 6. Medical and mental health professionals should closely monitor inmates being administered medications that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Attention to lighting repair and replacement remains positive. However, not all housing unit emergency lights are functional and must be repaired or replaced.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and
internal illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness. 6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that impedes good visibility from the cell door window. 7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are reliably operational.

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d. Adequate pest control for housing units, medical units, and food storage areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Very little change since previous inspections. This provision remains in Partial Compliance but no decline in performance was found. Inmates housed in RSAT and Intake units again reported “constant” mosquito problems. An inspection of these cell areas again found broken and missing cell window screens that should be replaced.

RECOMMENDATIONS: Previous recommendations remain appropriate

1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: PARTIAL COMPLIANCE – No substantive improvement from previous assessment.

FINDINGS: Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies.

RECOMMENDATIONS:

1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Continue to provide adequate supply of these personal care items in control pods or
housing units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in
their cells and living areas.

This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change from previous assessment.

There is no formal sanitation plan or protocols covering compliance with this Provision nor a form training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling biohazardous materials, provided and instructed on the

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proper use of bio-protective clothing and supplies, and supervisors must closely monitor bi-

hazard clean-ups. Remaining in Partial Compliance with this Provision can jeopardize the

health of staff and inmates.

RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for biohazard safety and exposure control; B. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all biowaste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a biohazardous control program that involves regular inspections of all potential contamination areas.
2. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
3. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

g. Mattress care and replacement;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Although a large supply of new mattresses were acquired, some inmates remain with filthy, tattered mattresses. Although none of these inmates complained about this conditions, clean and usable mattresses must be issued to every inmate.

RECOMMENDATIONS:

1. Refer to previously discussed sanitation recommendations. 2. Issue clean and usable mattresses to all inmates. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and
contraband, cleaned and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance
requirements.

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h. Control of chemicals in the facility, and supervision of prisoners who have access to these

chemicals;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change since previous assessment. Implementation of approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff who supervise inmates allowed to handle these chemicals must be properly trained in that role and those responsibilities. This has yet to occur.

RECOMMENDATIONS:

1. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
2. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.
3. This provision can advance to Substantial Compliance once related policies and procedures are approved and implemented according to the Agreement.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously reported, housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets, and dry these items in their cells using clotheslines anchored to fire sprinkler heads, walls, window frames, bunks, etc. This Monitor again observed soiled bed linens, no linens, tattered and dirty mattress, and mattresses with no covers in several occupied cells.

RECOMMENDATIONS:

1. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks.
2. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells.
3. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of bedding.
4. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.
5. Develop specific policies and procedures for handling, containing, and washing contaminated clothing, linens, and mattresses.

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6. Consider replacing all wood laundry carts made of non-absorbing materials that can be

sanitized and completely cleaned. Discontinue the practice of moving laundry on carts

that has not been cleaned and sanitized.

7. The initial issue of inmate supplies should include, at minimum: one (1) corrections

issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket.

Clothing should be exchanged with clean items twice per week at minimum, sheets and

towels once per week at minimum. Blankets should be exchanged monthly at minimum.

Any clothing, linens or bedding should be changed immediately if they appear damaged

and/or unsanitary, or appear to present a risk to health.

8. Ensure that inmate handbooks provide clear rules and information about the laundry

program, how to access clothing, linens, and bedding. Cease the practice of allowing

inmates to wash clothing in housing unit or cell sinks and toilets.

9. Staff and inmates involved in the laundry work program should be properly trained and

supervised.

10. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Territory officials report the initiation of a major project to repair and clean-up the kitchen area. The project is pending RFP approval.

Inspection of the kitchen found that utensils properly secured but the Territory still has not implemented a utensil check-in/out system to monitor tool inventory. Fire extinguishers were fully charged with current inspection certificates. Cooler temperatures were appropriate at about 38 degrees Fahrenheit. Inmate workers were engaged in cleaning activities under the supervision of an officer. No clutter was observed and the overall environment appeared organized.

Overall, there was little change from the previous assessment. This Provision could easily advance to Partial Compliance once policies are approved and implemented, and upon completion of the planned repair project.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records;

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E. That menus are reviewed at least annually by a qualified dietitian to ensure meals

comply with nationally recommended allowance for basic nutrition;

F. Prohibitions of using food as a disciplinary measure;

G. Involvement of independent outside sources to verify food service facilities and

equipment meet government safety codes;

H. Prescribes regular cleaning schedules including routine deep cleaning;

I. Provide written utensil control methods similar to those used by the tool shop;

J. Accident prevention program;

K. Personal and environmental sanitation requirements;

L. Food temperature monitoring and records keeping;

M. Adequate health protections for all staff and inmates including health screens and

prohibitions against working in the kitchen when ill;

N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that

all bathrooms and wash basins are consistently supplied with antibacterial soap and

hot water;

O. All areas and equipment related to food preparation, distribution, and storage require

frequent inspection to ensure they are sanitary, operational, and safe;

P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit;

between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the

final rinse. The person conducting inspections should be a qualified food service

inspector;

Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit,

refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees

Fahrenheit or below, unless national or state codes specify otherwise;

R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit

and cold foods at approximately 41 degrees Fahrenheit;

S. Supervisory food service staff should monitor food service operations to ensure that

that cooking, cooling, and food temperatures and delivery meet established

requirements;

3. GGACF officials should review food service requirements promulgated by the National

Correctional Association and National Commission on Correctional Health Care.

4. Develop a food service training program that includes inmate and staff training records

and ensure that all training is well-documented.

5. Policies and procedures developed should include controls for the use of caustic, toxic,

and hazardous materials used in the kitchen. Material Safety Data Sheets should be

posted conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No improvement was again observed in the housing units during this assessment.

The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lock down. Access to drinkable water is generally available during the “out of cell” periods but inmates must rely on the presence and actions by officers following lock down. Inmates have no access to drinkable

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water when there are no officers on the units to provide it and water from cell-sinks is

considered not safe for drinking.

This problem was particularly acute in X dorm, per interviews with X Dorm prisoners and our observations. There is no sink or fountain available for providing drinking water, and the women reported that in lieu of drinking water, correctional staff deliver large buckets of ice from which the women chip chunks into individual cups and allow to melt overnight to provide water the next day. This practice is unsafe and falls far below constitutional standards.

RECOMMENDATIONS:

1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable access to safe drinking water.
2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The Monitor will develop and submit Training Policies consistent with this Provision as ordered by the Court, and has provided Territory officials several documents pertaining training curricula development. Training curricula was provided for the Mental Health/Suicide Prevention, and Locking training as previously discussed.

RECOMMENDATIONS:

1. Implement training policies and curricula once approved.

b. Pre-service training for all new employees;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above.

RECOMMENDATIONS:

1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.

c. Periodic in-service training and retraining for all employees following their completion of pre-service training;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above. Training-related documents provided by Territory officials do not provide sufficient information and clarity to assess compliance.

RECOMMENDATIONS:

1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

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d. Documentation and accountability measures to ensure that staff complete all required

training as a condition of commencing/continuing employment.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar findings as discussed above.

RECOMMENDATIONS:

1. Provide the Monitor all training program curricula and completion of training reports. 2. Provide the Monitor with documentation on how compliance with this provision is being
met. 3. Develop a basic spread sheet that allows the Monitor to clearly determine the following:
 Total authorized staff per category (correctional, supervisory, civilian, contract, etc.)  YTD actual staffing levels per category, preferably by month  Number and percentage of current staff in each category who have completed
required pre and in-service training, per month

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IX. IMPLEMENTATION

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.

FINDINGS: As a result of the Territory’s failure to meet deadlines in the revised Schedule, the Court ordered the Monitor to create and issue a revised Schedule. That schedule was completed by the Monitor as ordered and in collaboration with the parties, and is shown and described in this Report’s Summary section.

2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.

FINDINGS: As stated above.

3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

FINDINGS: By agreement of the parties, the Court ordered the Monitor to complete and submit to the parties all required policies and procedures no later than December 31, 2014. Several policies and procedures have since been submitted to the parties for review and approval.

4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.

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FINDINGS: Impact evaluations submitted continue to lack sufficient detail and metrics to

quantitatively or qualitatively evaluate compliance achievement. This Monitor will continue to

assist Territory officials to improve this required document.

5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.

FINDINGS: The Monitor is charged by the Court to complete required policies and procedures as previously stated. Territory officials have neither submitted any compliance plans or requested modifications to any plans. In fact, the Territory has not submitted any plans whatsoever except for previous Schedules, which the Court ultimately directed this Monitor to complete.

6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.

FINDINGS: Status reports submitted lack sufficient information and detail to assess compliance achievement. A review of various other documents suggest that much more compliance activity is underway but not being included in status reports. The Territory is encouraged to involve an interdisciplinary group to complete this report to ensure all areas of progress are included in the status report.

7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.

FINDINGS: The Monitor continues to experience long delays in receiving documentation regarding serious incidents.

8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.

FINDINGS: The Monitor provided a list of requested documents well before each onsite inspection. Once again, documents were not made available to the Monitor or USDOJ prior to arriving on site. This practice MUST change. All documents should be provided 10 days in advance of the visit for proper review prior to coming on-site. This will streamline monitoring efforts on site and save everyone considerable time. Moreover, during this visit, not all requested documents were provided on site, and multiple copies of some requested documents given.

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Additionally, the Territory did not respond to the Monitor’s request for additional documents

following this assessment. It is impossible for the monitoring team to effective perform without

needed cooperation from the Territory in the production of requested documents.

9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.

FINDINGS: The monitoring team experience no serious delays during this site visit. However, not all documents requested before and following this visit were provided. Monitoring effectiveness, completeness, and accuracy critically relies on timely and complete submission of requested documents.

10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.

FINDINGS: As previously stated.

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X. Monitoring

D.1 Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.

Upon appointment to this case, this Monitor issued to the Territory and USDOJ written documents described how this Monitor would assess compliance with each Compliance Measure, how information would be gathered, what information would be requested prior to each onsite assessment, much of which would be used for routine reporting and ongoing monitoring. As stated previously, the Monitor and USDOJ continue experience difficulties consistently obtaining all requested records in a timely manner, albeit there has been some improvement on the part of the Territory, some requested records have not been provided at all.

Timely response to requests for records is critical to help ensure 1) timely and efficient monitoring of this Agreement, 2) the Court is provided timely, complete, and accurate information from the Monitor, and 3) consistent control and responsible management of monitoring resources, including the approved budget.

The Monitor, therefore, requests that all requests for records are provided timely and completely going forward. Additionally, this Monitor request the following records on a monthly basis for the purposes stated above:

1. Hand-written Incident Log 2. Hand-written Evidence (contraband) Collection Log 3. Excel Grievance Log 4. All Use of Force Review Reports 5. Monthly Disciplinary Committee Report / Discipline Log 6. Monthly Staffing Compliance Report (to be developed based on previously provided
documents and communication) 7. Monthly Life and Fire Safety Inspection/Activity Report 8. Updates on capital improvements 9. Copies of all incident reports 10. YTD Prisoner Census Report (by housing unit) 11. Segregation (Special Housing) Census and Review Logs 12. Training Complete Logs 13. Any new forms created for administration or operational purposes 14. Other documents as determined need for routine monitoring

It is realized that providing these documents on a monthly basis will require the Territor y to somewhat retool its resource management priorities and practices to some extent. This Monitor, therefore, extends assistance to the Territory to identify methods and processes for complying with this request and requirement.

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APPENDIX A ASSESSMENT METHODOLOGY

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.

Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.

Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.

1. Description of how the Monitor will assess compliance with each of the Compliance Measures.

In general, compliance assessment will include the following activities:

A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning. I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.

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J. Examination of any and all available records, data, and/or information relevant to

compliance and compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Incident reports and logs

 Evidence / contraband reports and logs

 Use of force incidents and logs

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (noncompliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
 Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.

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 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.

 Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or

consumer satisfaction).

 Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of

consumer satisfaction, a performance indicator might be: “the percentage of consumers who

state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)  Online media information  Online public records  Electronic and standard mailing of information  Email communication and phone consultations

3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for the Baseline and subsequent visits and monitoring includes the following. Many of these documents were not provided at the Baseline and second visit as requested but more were provided during the second and third visits. Territory officials

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stated that they intend to continue to generate and provide the requested documents. It is important

to reiterate the need for the documents listed below. Considering the size of this list, and

GGACF’s limited staff and technical resources, the Monitor intends to assist the Territory in

narrowing this list to the most salient items. Documents in bold below have either not been

provided or have not been updated but are necessary for effective monitoring.

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months.

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23. Records and/or lists of physical improvements, repairs, and renovation completed to

correct security problems and deficiencies over the past 36 months.

24. Past 36 months of agency budgets.

25. List and contact information for any and all community vendors who provide services

of any kind to GGACF and contracts or professional services agreement authorizing

those services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of
their records. 31. To the extent not provided above, the policies and procedures governing medical and
mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers,
including on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to
include health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment.

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46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location.

47. To the extent not provided above, external and internal reviews or studies of medical or mental

health services including needs assessments and any American Correctional Association and

National Commission on Correctional Healthcare reports.

48. List of all inmates placed in restraints, and all inmates receiving mental health

treatments, under suicide watch, or taking psychotropic drugs.

49. Current mental health case list including inmate name, number, diagnosis, date of intake, last

psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed

only by counseling staff with last appointment date and follow-up appointment.

50. Documentation reflecting any training that facility staff have received on suicide

prevention, including certificates and training materials.

51. All documents related to the any suicide occurring within the past year.

52. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms
utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and
investigative reports of all inmate suicide victims within the past three years. 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications
for the past year. 66. A description of medical and mental health’s involvement/input into the disciplinary
process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

It is important to note that the Territory made a reasonable effort to provide most of the information requested for this visit. However, log books and other reports were not ready for review on one the first day as they were during the previous visit. The balance of information listed above (in bold) is expected to be provided once it has been developed.

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Territory officials and participants were exceptionally cooperative, involved, and supportive

throughout this aspect of the monitoring process. The Territory’s repeated desire to fully comply

with the Agreement was evidenced by its active cooperation and involvement in the onsite visit.

Similarly, United States Department of Justice representatives participating in the onsite assessment

were equally cooperative and involved, which helped to maximize visit efficiency and productively.

The presence of both Parties during the onsite visit assisted assessment focus and allowed for

collaborative and timely resolution of important matters of mutual interest. Therefore, the Monitor

and monitoring team respectfully requests that these representatives from both Parties continue

participate at all future assessment visits.

The monitoring team used four primary reference points from which to assess compliance and progress with Agreement. These included: 1) the agreed 2012 Findings of Fact document, 2) documents, information, and data provided prior to, during, and following the onsite assessment, 3) the onsite visit, which included meetings, discussions, interviews, campus tours and inspections, and 4) the previous reports.

During this assessment, the monitoring team toured the campus, inmate housing units and cells, dayrooms and program spaces, intake/booking area, control rooms and officer posts, portions of the outer perimeter and fencing, and medical and mental health areas. We talked with BOC representatives and staff, and spoke with inmates.

 
 United States Virgin Islands
GOLDEN GROVE ADULT CORRECTIONAL FACILITY
St. Croix, VI
SIXTH COMPLIANCE MONITORING REPORT
2013 Federal Court Settlement Agreement In re: United States of America v. The Territory of the Virgin Islands (86/265)
Submitted February 17, 2015 Kenneth A. Ray, M.Ed., Monitor
November 28, 2014

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Kenneth A. Ray, MEd, Monitor TABLE OF CONTENTS

Topic

Page

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

1

Purpose……………………………………………………………………………..

2

Executive Summary & Findings Overview………………………………..……

4

Section IV. Safety and Supervision Compliance ………………………………

6

Section V. Medical and Mental Health Care Compliance …………………….

40

Section VI. Fire and Life Safety ………………………………………………… 77

Section VII. Environmental Health and Safety ………………………………… 85

Section VIII. Training ……………………………………………………………. 94

Section IX / X. Implementation / Monitoring…………………………………… 96

APPENDIX A

Compliance Assessment Methodology ……………………………………………. 100

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PURPOSE

The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) as a tool to assist U.S. Virgin Island officials in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.

EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

The Sixth onsite compliance monitoring assessment was conducted December 8-11, 2014, and included an onsite Court status conference on Wednesday, December 10th. Prior to this site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite assessment.

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing this final report.

The Monitor will advance each provision as certain levels of compliance progress are clearly demonstrated by the Territory. Generally speaking, the Monitor will advance provisions from noncompliance to partial compliance when compliance efforts demonstrate the following:

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1. Policies, procedures, protocols, and/or plans required of a provision are properly approved in accordance with this Agreement;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented. Implementation includes evaluation that implemented policies, procedures, and training are performing within the expectation of this Agreement.

Provisions are eligible to advance from partial to substantial compliance when efficacious assessment and evaluation of implemented policies, procedures, protocols, plans, etc. quantitatively and/or qualitatively evidence: 1) that implementation efforts are producing outcomes intended in the Agreement and 2) that implementation outcome performance is reliable (assessments and evaluations evidence consistency in producing outcomes intended in the Agreement). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately demonstrated using appropriate compliance evaluation methods and measures, this Monitor will and has reversed a compliance rating when the evidence supports doing so.

This assessment found reasonable cause for the Monitor to reverse Provision G.1.b (Incident Reporting, senior management reviews) from its Partial Compliance rating to Non Compliance. This assessment found no effort on the part of GGACF management staff to maintain the previously established incident review process. No documents were provided to demonstrate compliance with this provision, and the few management staff available to discuss this provision were unable to reasonably articulate substantive efforts to comply with this Provision. This Monitor’s reasoning for this action is discussed further in Provision G.1.d D Findings. Consequently, overall assessment ratings are slightly lower from the previous assessment.108 (90%) of the 120 Provisions are now rated in Noncompliance; 12 (10%), Partial Compliance; and, none are rated in Substantial Compliance. The score card below shows current compliance ratings.

GGACF SIXTH COMPLIANCE ASSESSMENT SCORE CARD
Areas of Compliance Per Agreement
IV. Safety and Security V. Medical, Mental Health Suicide Prevention VI. Fire and Life Safety VII. Environmental Health and Safety VIII. Training Total Substantive Provisions Percent Compliance

Total Provisions
59 36 10 11 4 120 100%

Non Compliance
53 36 10 5 4 108 90%

Partial Compliance
6 0 0 6 0 12 10%

Substantial Compliance
0 0 0 0 0 0 0%

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SIXTH ASSESSMENT FINDINGS OVERVIEW:

Compared to most of the previous onsite assessments, this assessment was extraordinarily disappointing, frustrating, and punctuated with unnecessary delays and disruptions. Pre-requested documents were not ready for inspection upon arrival, numerous other documents requested during the visit were not provided until weeks following the completion of this assessment requiring the USDOJ to submit several requests for documents previously requested. Additionally, most of the staff required to participate in the process were either absent, not available, or refused to take the initiative to engage the assessment process. Despite the efforts of the Director and small few key management staff, this site visit was practically devoid of complete and timely access to documents, information, and staff needed to ensure a comprehensive assessment. This, combined with observations by the monitoring team, again found virtually no progress overall.

The above stated, the Territory is to be commended for achieving substantial improvement in housing unit staffing levels following its transfer of inmates to the mainland; these transfers allowed VIBOC officials to redeploy staff from housing that were closed as a result of transferring these prisoners. Examination of supervisor shift logs, which are moderately reliable sources for measuring progress, record a significant decrease in housing units operating without staff. A provisional analysis of data abstracted from these records indicates an 84 percent decrease in the number of shifts when inmate-occupied housing units were operated without correctional staff. These records also indicate a measureable increase in housing unit staffing levels. There was no measurable improvement found in shift supervisor staffing levels.

GGACF corrections and supervisor staffing levels, nonetheless, remain insufficient to prevent and control ongoing high levels of violence against staff and inmates, contraband, to provide adequate and consistent access to medical and mental health care, maintain adequate life and health safety conditions, or provide adequate staff supervision and organizational management. Territory officials must redouble their efforts and complete and implement the required staffing plan. All staff must be properly trained to consistently perform their duties competently. GGACF management and supervisory personnel must adopt a shared vision for professional and contemporary corrections and work as an integrated, interdependent, and collaborative team. Accountability must become an unequivocal value that is consistently enforced and practiced by all GGACF leaders. Noncompliance with agency policies, procedures, and standards of professional conduct should never be tolerated; leaders must model the utmost professional competence so as to promote consistent professionalism among subordinates.

Abuse and/or neglect of inmates should never be tolerated or minimized by any corrections professional. Concomitantly, GGACF leaders must redouble their efforts to protect the safety and security of all inmates and staff. Serious assaults on inmates and staff, staff being required to suppress a fiery and dangerous housing unit riot without proper attire and breathing devices, due process hearings not being provided to discipline inmates, mentally ill inmates languishing for months or years in segregation, a broken inmate complaint system, and other serious operational deficiencies continue to stall progress toward compliance. More importantly, noncompliance with the Agreement continues to perpetuate protracted litigation, violations of inmate civil rights, human suffering, and preventable harm to staff, inmates and the community.

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The following assessment describes, as best as possible considering the problems faced during

this assessment process, progress toward compliance with this Agreement.

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IV. SAFETY AND SUPERVISION

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:

a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Monitor assisted Territory officials in developing a very basic stratification matrix for GGACF prior to this monitoring visit of December 8-11, 2014. This matrix will not be shown in this report due to security and inmate confidentiality reasons. Territory officials submitted a revised stratification matrix to the Monitor following the transfer of 78 inmates offisland and closing four (4) housing units. Completion of the stratification matrix should include total beds and cell-types in each of the housing units, i.e. single/double bunk, etc.
During the December 8-11, 2014 monitoring visit, we were able to tour and inspect all of the housing units at GGACF. We found that risky housing and supervision practices of inmates at GGAC are still evident. For example, in Housing Unit K (Housing Unit for sentenced inmates), we were informed by the assigned officer that this Unit houses inmates ranging from classification levels of minimum to maximum custody, as well as some special management prisoners, including those with mental illness. The extreme mixing of prisoners in a single housing unit exposes them to an unreasonable risk of harm as well as to the safety of the assigned staff. Equally troubling was that the sole officer assigned to Housing Unit L reported being employed at GGAC for two (2) months and was not aware as to the classification level of the inmates being supervised. The supervisor advised us that the assigned inmates to this Housing Unit were maximum custody. These types of classification discrepancies and inmate supervision deficiencies create an unreasonable risk of harm to prisoners as well as to the safety of the assigned staff.
Incident Report and Contraband Logs and classification documents continue to evidence that application of the GGACF stratification (See Classification Section) for classification housing remains inadequate and inconsistent. As detailed in other sections of this report, the lack of

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appropriate screening instruments, application of housing stratification schemes, deficient

inmate supervision practices and policies and procedures regarding classification continues to

place inmates at risk of harm. The Monitor provided technical assistance to defendants in

developing policies and procedures which were all finally completed and provided in draft form

to the parties by the December 31, 2014 deadline.

RECOMMENDATIONS:

1. Apply the approved Housing Stratification matrix as designed 2. Review current population to verify accurate risk/need classification levels and housing,
reclassify and appropriately house as indicated by review process findings. 3. Refer to IV.F. regarding specific classification and housing policy recommendations.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Post orders found on the housing units remain outdated as previously reported. There was no change with regard to previous findings or recommendations to update those documents.

No staff plan was provided that demonstrates application of the staffing analysis required under this Agreement, which was previously completed by the National Institute of Corrections.

Supervisor logs continued to report several staffing shortages and periods of time when occupied housing units are not staffed by correctional officers. These logs also continued to report very high levels of staff overtime to cover housing units and security schedules. This remains a serious concern for staff and inmates safety and security. However, these logs do demonstrate improvement in staffing of the occupied housing units. It appears that fewer units were not staffed during this reporting period.

GGACF officials report that first-line supervisors continue to visit housing units on a daily basis as directed in a memo by the previous Warden.

Supervisor logs were examined to update supervisory and housing unit staffing levels reported in the Monitor’s 4th and 5th Reports. As stated in those reports, the following data analyses and findings must be considered moderately reliable due to inconsistent recording of shift staffing levels by supervisors. Data presented are only reliable to the extent the data were complete and measurable.

This Provision will remain in non-compliance until all occupied housing units and supervisory posts are continuously staffed 24/7, the staffing-analysis-based staff plan is approved, and staffing-level documents are determined by this Monitor as consistently valid and reliable sources from which to evaluate compliance.

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Staffing-level data from 10/13/2014 to 12/1/2014 were abstracted from shift supervisor logs to

examine. Twenty shifts were sampled (October, N=10; November, N=10; December, N=1) and

compared to similar data used in the previous two monitoring reports:

1. Total shifts assessed 2. Number of housing units assessed (note: Units RSAT, Intake, I and J were closed in
October, 2014 when approximately 78 inmates were move to a main-land facility to improve GGACF staffing deployments). 3. Total number of shifts housing units were not staffed 4. Est. hours housing units were not staffed 5. Est. days housing units were not staffed

Based on this comparative analysis, housing unit staffing levels have improved substantially because the total number of shifts were reduced when prisoners were transferred off-island and housing units were closed:

The number of shifts operating non-staffed housing units decreased 84 percent (84%) from 56, 4th Report; 46, 5th Report; to 9, this report.

Estimated hours that housing units operated without staffed also dropped 84 percent from 448, 368, to 72 respectively. The concomitant decrease in the number of days that housing units operated without staff is estimated at 18.67, 15.33, to 3 days respectively. Table 1 below shows these estimates.

Table 1
Monitoring Visit
Sgt. Log Book Date Range Reported
Shifts Assessed Housing Units Assessed Total Shifts Housing Units Not Staffed (N) Multiplier (Shifts Reported x # Housing Units) Est. Hours Housing Units Not Staffed (Nx8) Est. Days Housing Units Not Staffed (Hrs./24)

4th Assessment
5/206/05/2014
30 14 56

5th Assessment
8/229/22/2014
29 14 46

420

406

448

368

18.67

15.33

6th Assessment
10/1312/1/2014
21 10 9

Improvement -84%

90

-79%

72

-84%

3.00

-84%

Table 2 below shows staffing level improvements for all housing units assessed; the number of shifts that each housing unit operated without staff are shown for the reporting periods compared. This comparison indicates that only three housing units (K, L, 9B) were not staffed for nine shifts combined, whereas all but 9C were not staffed for the previous two reporting periods totaling 56 and 49 unstaffed shifts respectively. Simply stated, the number of times that housing units were not staffed dropped from 56 and 46 to 9.

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Table 2 below must be cautiously interpreted due to the problems previously noted in the supervisor’s log books. Although these data strongly indicate a significant improvement in staffing levels, there is no empirical basis to assume that supervisor or housing unit staffing levels are yet adequate. Staffing levels cannot be adequately measured until this Monitor is provided 1) an approved staffing plan, 2) daily shift logs provide consistently accurate and complete staffing information, and 3) GGACF is able to significantly reduce use of staff overtime as a means for supplanting fulltime staffing levels.

Table 2.
Housing Units Reported / Shifts Not Staffed A DORM (Male Detainee Protective Housing) RSAT (Juvenile Housing) A/D & Intake (Male Detainee Protective Housing) X or X-Ray (Female Detainee & Inmates) G (Male Inmate Med/Max/Long Term) H (Male Inmate Min/Med) I (Male Inmate Protective Housing) J (Not on Classification Matrix) K (Male Inmate Protective Housing) L (Male Inmate Admin/Discipline Seg) 9A (Male Detainee Admin/Discipline Seg) 9B (Male Detainee Med/Max) 9C (Male Detainee Min/Med/Special Needs/ MH/Med 9D (Male Detainee Min/Med/Special Needs/ MH/Med
Shifts Housing Units Not Staffed:

5/20-6/05/2014 7 15 18 1 0 1 0 1 2 3 3 3 0
2
56

8/22-9/22/2014 2.5 11.5 19 2 2 0 1.5 2.5 1 1 1 2 0
0
46

10/13-12/1/2014 0
CLOSED CLOSED
0 0 0 CLOSED CLOSED 4 4 0 1 0
0
9

Shift staffing levels were analyzed to assess changes/improvements in housing unit staffing levels for three reporting periods. This analysis estimates a 32.48 percent improvement in shift staffing levels per housing unit from .93 staff per housing unit to 1.23. Table 3 illustrates these estimates.

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Table 3.
Shift Average Staffing Level / Housing Units
A DORM (Male Detainee Protective Housing) RSAT (Juvenile Housing) A/D & Intake (Male Detainee Protective Housing) X or X-Ray (Female Detainee & Inmates) G (Male Inmate Med/Max/Long Term) H (Male Inmate Min/Med) I (Male Inmate Protective Housing) J (Not on Classification Matrix) K (Male Inmate Protective Housing) L (Male Inmate Admin/Discipline Seg) 9A (Male Detainee Admin/Discipline Seg) 9B (Male Detainee Med/Max) 9C (Male Detainee Min/Med/Special Needs/ MH/Med 9D (Male Detainee Min/Med/Special Needs/ MH/Med
Averages Shift Staffing Levels:

5/206/05/2014
0.77 0.50 0.43
0.97 1.03 1.00 1.00 0.97 0.93 1.00 1.33 0.93 1.10
1.07
0.93

8/229/22/2014
0.95 0.57 0.28
0.93 0.93 1.03 0.98 0.91 1.00 1.45 1.62 1.00 1.31
1.31
1.02

10/1312/1/2014
1.00 CLOSED CLOSED
1.00 1.24 1.19 CLOSED CLOSED 1.00 1.14 1.76 1.05 1.33
1.62
1.23

Improvement
30.43% CLOSED CLOSED
3.45% 19.82% 19.05% CLOSED CLOSED 7.14% 14.29% 32.14% 12.24% 21.21%
51.79%
32.48%

Shift supervision levels showed no significant improvement overall, except that all shifts were staffed with at least one supervisor for the 5th and 6th reporting periods. Supervision staffing
levels remain very inadequate with an average of 1.9 supervisors per shift. Table 4 below
compares shifts not staffed by the full complement of supervisors.

Table 4
Shifts Not Staffed w/Full Complement of Supervisors
Est. Shift Supervisors Post Not Staffed
Multiplier (Shifts Reported x 4 Supervisor Posts) Est. Hours Supervisor Posts Not Staffed (Nx8) Est. Days Supervisor Posts Not Staffed (Hrs./24)

5/20-6/05/2014 78 120 624
26.00

8/229/22/2014
56 116
448
18.67

10/1312/1/2014
44
84

Improvement
-34 -36

352

-272

14.67

-11.33

Table 5 below shows the number of shifts staffed by the number of supervisors. These indicated that no shift is likely to be staffed with a full complement (4) of supervisors and about 70 percent of shifts are staffed with no more than two supervisors.

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Supervisor Shift Staffing Levels
Shifts w/ No Supervisor Shifts w/ 1 Supervisor Shifts w/2 Supervisors Shifts w/3 Supervisors Shifts w/ 4 or More Supervisors
Shifts Assessed: Per Shift Supervisor Staffing Levels

5/206/05/2014
2 17 7 1 3 30 1.6

8/229/22/2014
0 5 17 7 0 29 1.9

10/1312/1/2014
0 4 15 2 0 21 1.9

Territory and GGACF officials are to be commended for achieving these improvements in housing unit staffing levels but is again reminded that excessive staff overtime leads to staff burnout, unsafe and poor performance. For example, some security staff reported to USDOJ and Mr. Romero (Monitor’s expert) instances of them working as many as three (3) overtime shifts per week. Additionally, the supervisor log books showed excessive amounts of overtime for most shifts assessed. Using excessive overtime to supplant hiring and maintaining adequate staffing levels is operationally and economically counterproductive. Overworked staff make more and more serious mistakes and cannot consistently maintain the requisite level securityawareness to ensure facility safety. Additionally, the Territory should take the necessary steps to improve shift supervision levels. Do so will provide and maintain consistent supervisor presence that officers can rely upon for reliable and timely assistance. Development and effective implementation of the required staffing plan, based on the staffing analysis, is likely to yield rapid improvements in inmate and staff safety and security while improving overall care and custody of prisoners.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Rapidly implement the NIC Staffing Analysis recommendations. 2. Create a staffing plan, as required under the Agreement, that reflects the NIC Staffing
Analysis and provides concrete steps for hiring sufficient staff 3. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff
who work overtime have adequate time away from the facility before returning to work to ensure they are adequately rested. 4. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics. 5. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm. 6. Subsequent to policy and procedure development and revisions, conduct a complete review of existing Specific and General Post Orders to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post
safely and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that
makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible; E. regularly reviewed, revised, updated; F. consistently enforced;

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G. known to staff through pre-service, in-service, and ongoing training.

7. Develop a plan that provides for regular review of all log books by supervisors to ensure

staffing and other unit safety and security issues to be known and resolved in a timely

manner.

8. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Operable hand-held radios were found in all occupied housing units and for all officers assigned to those security posts. However, some officers were not wearing their radios at all times, which was reported in previous reports. Officers must keep their radios with them at all times while working within the security perimeter to ensure timely communications in cases of emergencies. It was also reported that a few radios were in need of repair, and some staff reported not knowing how to completely operate their radios.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Timely repair, replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
2. The Monitor will continue to review radio equipment inventories and functionality during each onsite assessment.
3. Ensure adequate supply of radio batteries enable officers to carry radios on their person at all times. Issue directives requiring officers to carry radios on their person at all times while at the facility and anytime they are supervising/monitoring inmates.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and
(ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Despite improvements in staffing levels previously discussed, staffing levels remain inadequate. And, despite reported daily visits to the housing units by supervisors, continued high levels contraband and violence against inmates and staff clearly demonstrate inadequacies in compliance.

RECOMMENDATIONS: Some Previous Recommendations Remain Appropriate

1. Refer to recommendations regarding Post Orders.

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2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff

and inmate safety and security, and according to inmate risks and needs.

3. Create a schedule for regular rounds by medical and mental health care staff for each shift

to ensure that special needs inmates (suicidal, mentally ill, medical infirm, vulnerable, etc.)

are monitored more frequently and by qualified health care staff.

4. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely

inspect general and special housing units to ensure compliance staffing requirements, policy

and procedures, and to interview inmates presenting problem conditions. Supervisors

should also ensure that all safety and security equipment is present and functional during

these inspections and immediately replace any nonfunctional equipment. The supervisory

rounds forms should be filled out at the end of each round and collected in a central location,

and submitted to the Monitor and USDOJ on a monthly basis.

5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell

inspections, keep all housing unit doors locked, repair broken control panels to improve unit

security.

B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: The revised policy includes a clear definition of what items constitute contraband but requires final approval by this Monitor and USDOJ. This Provision can move to Substantial compliance once the policy is effectively implemented. Effective implementation is demonstrated with 1) all staff have been adequately trained according to requirements of this Agreement, and 2) a quality management process clearly shows that the policy produces it’s intended outcomes.

RECOMMENDATIONS:

1. Implement the new policy according to the terms of this Agreement once approved.

b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The introduction and presence of contraband appears to remain pervasive and unfettered by GGACF efforts to comply with this provision. An examination of the Evidence Log entries (10/3-12/3) demonstrates the continued presence and high volume of dangerous and other contraband as follows:

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Money – 3

Cell Phones (some with chargers): 32

Drugs (an paraphernalia): 9

Weapons (knives, sharp objects, shanks): 21

Jewelry: 1

DVD’s: 1

SD Card: 1

Continued introduction and high volume of contraband is indicative of inadequate searches by staff of inmates and structures, which is symptomatic of inadequate staffing levels, staff supervision, and training. The high volume of dangerous contraband continues to place inmates and staff constant extreme risk of harm. Additionally, tours of housing units revealed evidence of fire ignition sources such as “burning wicks” and housing unit floors scorched by fire. It is obvious that prisoners continue to possess contraband for starting fires, which is further discussed in the Fire and Life Safety Section of this report. GGACF officials must increase their efforts to eliminate the introduction and presence of contraband without delay.

RECOMMENDATIONS:

1. Continue positive efforts in searching people before entering the facility. 2. A “stop and check” protocol for inspecting staff packages after initial entry into the facility
must be developed and implemented. 3. Provide handheld metal detectors for contraband inspections at facility entry points and as
needed for on-campus inspection. 4. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods
and process during the 5th assessment. 5. Train supervisors to provide on-the-job-training OJT and staff mentoring in the areas of
adequate searches, contraband prevention and control, and basic inmate supervision and security.

c. Detection of contraband within Golden Grove, through processes including: (i) supervison of prisoners in common areas, the kitchen, shops, laundry, clinical, and other areas of Golden Grove to which prisoners may have access; (ii) pat-down search, metal detector, and other appropriate searches of prisons coming from areas where they may have had access to contraband, such as intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic; (iii) regular and random search of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g. clinic, kitchen, dayrooms, storage areas, showers);

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings and discussion.

USDOJ and the Monitor’s expert, Mr. Romero, were advised by staff that security searches of kitchen workers had become very lax. Staff stated that prisoners are no longer searched when entering and leaving the kitchen due to security staffing shortages. Additionally, the kitchen log book show that at least one utensil, a ladle, was missing from the inventory. Even more

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troubling is that fact that there were no supervisors appeared to be present in the maintenance

shop areas during this inspection. These areas, like the kitchen, contain numerous small tools

and objects that can be easily smuggled into housing units are used to harm others.

RECOMMENDATIONS:

1. Refer to above, expand application of recommendations to provision c (i-iii) above. 2. See recommendations regarding staffing levels. 3. Ensure inmates are systematically and consistently searched each time they entered and exit
maintenance shop areas, kitchen areas, and any area and/or building containing items that can be used as contraband. 4. Always search prisoners each time they enter and exit housing units. 5. Always search all containers entering and exiting the facility, buildings, and housing units.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change was found since previous reports. Previous recommendations should be implemented.

RECOMMENDATIONS:

Review and implement relevant recommendations for Contraband contract above, specifically B1a.

1. Continue to ensure staff access to appropriate equipment and supplies needed to safely collect and preserve contraband while maintaining evidentiary integrity.
2. Continue to ensure adequacy of chain-of-custody methods and procedures. 3. Develop a Uniformed Incident Reporting system (discussed further in this report) that
provides cross-referencing and continuity between all reports and logs involving detection and confiscation of contraband. 4. Develop and implement a continuous quality improvement (CQI) protocol to evaluate adherence to Contraband policies and procedures and reporting.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: To be assessed at the 7th site visit.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.

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C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement from previous assessment. Inmates continued to wear and possess personal clothing, including polo shirts, while in the housing units and in the outdoor areas of the facility. Previous recommendations do not appear to have been implemented.

RECOMMENDATIONS:

1. Require inmates to wear issued institutional clothing ONLY. 2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform
policies and inmates who refuse to comply with those policies. 3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and
appropriate corrective action with staff who refuse to do so. 4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’
classification/status. 5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges
and changes in an inmate’s classification and/or status. 6. Consider developing a correctional industry for making uniforms onsite. 7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband
and weapons. 8. Mark all uniforms with highly visible letters/numbers.

b. Identification that prisoners, staff, and visitors are required to carry and/or display;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Identification badges were not provided to the monitoring team for each day of the visit due to there being a shortage of badges. Additionally, prisoners were observed traveling in and out of housing units, in the yard, in maintenance and kitchen areas. This problem has not been address by GGACF officials as agreed at the previous visit.

RECOMMENDATIONS:

1. Ensure staff compliance with this provision. 2. Ensure adequate supplies for making identification cards. 3. Regularly audit identification card inventory and maintain proper controls to prevent
inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories.

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4. Consistently enforce identification card policies and procedures.

c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Policy drafts include requirements for locking and unlocking exterior and interior gates and doors. However, no documents were provided that demonstrate that all staff have been trained in protocols for properly locking and unlocking exterior and interior security access points. No documents were provided demonstrating that previous recommendations were implemented but officers continue to document in housing unit log books inoperable sally port doors. Additionally, we again observed prisoners using objects to prop open cell doors.

The Maintenance Supervisors again stated that several sally port doors at housing units have remained unrepaired for several years and that he has been unable to make needed repairs to do lack of adequately skilled maintenance staffing levels and funding.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Provide Monitor requested training records showing a 95 percent minimum successful completion rate.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement. 5. Continue to ensure staff are adequately trained in the proper use of mechanical and/or
electronic locking systems according to their post assignments. 6. Consistently sanction inmates for attempting to manipulate or manipulating any security
locking system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked! 9. Replace or upgrading existing unit control panels to provide for remote electronic locking
and unlocking of unit and cell doors. 10. Improve video surveillance of internal areas by placing cameras in all housing units and
inmate locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations. 13. Consistently enforce security locking policies and procedures with staff and inmates.

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d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above

RECOMMENDATIONS: Previous Recommendations Remain Appropriate.

1. Employ and maintain adequate maintenance staffing levels. 2. As requested in the previous two reports, develop an “all-locks” maintenance plan for
review with the Monitor. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number, lock type, condition, etc. 3. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.

e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There was no change found from previous assessments. No documents were provided to demonstrate implementation of the recommendations below, and the requested documents were not provided. This Monitor was unable to assess progress.

RECOMMENDATIONS:

1. Territory officials should assess history of terminations, identify determining factors, and realign completion of pre-employment practices to avoid post-employment terminations.
2. This Monitor again requests inspection personnel records including employment applications; criminal history checks, and background investigations for all housing unit staff working Units 9A/B during the reported escape attempt occurring June 7, 2014. These documents were requested for all previous visits but not provided. Please have these documents at GGACF for the upcoming site visit.
3. Ensure access to applicant and staff records is adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
4. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.
5. Make records available to the Monitor for inspection and verification of compliance.

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D. Security Staffing

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: As stated in the previous report, the Staffing Analysis was completed as required by this Provision. However, the Territory has yet to submit a staffing plan that incorporates the results of the analysis as required by the Monitor’s Schedule and recent Court Order. This Monitor has provided Territory officials documents to assist them in developing such a staffing plan with no response.

A document provided to this Monitor by BOC officials during this visit show 117 correctional positions are authorized in the 2015 BOC budget. The document also shows that 88 (75%) of those positions were filled as of 11/30/14, with an additional 12 officers beginning the training academy in December. BOC officials are commended for their ongoing efforts to recruit additionally officers but must submit a staffing plan that incorporates the results of the staffing analysis.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Complete and approvable Staffing Plan that accounts for the recent closing of four housing units and overtime.
2. Secure funding to comply with Plan staffing requirements. 3. Revise staffing hire process to improve its efficiency and timely hiring of officers.

b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: See above.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

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RECOMMENDATIONS: See above.

1. Defendants will implement the staffing plan developed pursuant to D.1.

ASSESSMENT: See above

FINDINGS: Refer to previous findings related to staffing analysis and planning.

RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The Territory has not complete the PREA self-audit. PREA draft polices are currently under review by this Monitor and USDOJ.

RECOMMENDATIONS:

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements. 3. Appoint a PREA Compliance Coordinator as soon as possible. 4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s PREA
auditor certification training. All costs are covered by USDOJ. 5. Complete the PREA Self-Audit. 6. Review, revise, develop, train, evaluate policies and procedures that include, at a minimum,
the following PREA topics:

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F. Classification and Housing of Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:

a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security -needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;

ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in the 5th Report - There has been no change since the previous reports. Although this Monitor assisted the Territory in the development of a Classification policy, the classification instruments require validation to ensure that the instruments and classification process is objective. However, according to Territory officials, a national expert in classification validation is expected to be onsite for this purpose by the end of 2014.

Additionally, the Territory has not responded to the Monitor’s request to provide classification forms to be used in the application of the new policy in order to complete the policy.

RECOMMENDATIONS: Recommendations previously provided remain appropriate.

1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that provide
more accurate and complete guidance for a valid and reliable classification system for nonconvicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance. 5. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.

b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Notwithstanding the lack of validated classification instrument and policies, Territory officials provide adequate documentation demonstrating and adequate classification / housing scheme as previously requested this Monitor. These documents include the following Provision requirements:

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 Total Institutional Monthly Average Daily Population (Pre-sentenced and Sentenced Prisoners)

 Total Outside of Territory Contract Prisoners (BOC prisoners held off-island)

 Monthly Average Daily Population, Admissions and Releases

 Classification / Housing Stratification for all Currently Used Housing Units

 Custody Classification Level Volume Report (number of prisoners in each primary

classification).

 Names of all prisoners by classification, conviction statues, and housing unit.

These documents do not, however, clarify whether the Territory conducts regular classification reviews to ensure prisoners continue to be properly housed and separated from other inmates according to changes in their classification status.

RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Order’s prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Direct mental health staff to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced-side lock down units to determine mental health needs and if a different, less punitive housing placement is available.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Same findings as above.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: No documents were provided demonstrating compliance with this Provision. The

Monthly Disciplinary Committee Report was not provided to fully assess compliance.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Refer to previous classification findings and recommendations. 2. Refer to recommendations related to grievance and disciplinary policies and procedures. 3. Ensure accuracy of monthly disciplinary committee reports. 4. The Territory must correct problems reported in the monthly disciplinary. 5. Train classification staff to accurately and consistently complete initial and re-classifications
accordingly.

e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct;

ASSESSMENT: PARTIAL COMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No documents were provided to demonstrate efforts to comply with this Provision. Additionally, the current incident reporting system remains inadequate for collecting valid and reliable data from which to evaluate any incident activities. The Incident Log does not always record all reported incidents, multiple incident numbers are being assigned to single incidents in some instances and not in other instances. Some incidents are reported on the log inconsistently using incident code numbers and incident types, and some entries are illegible.

GGACF officials will remain unable to accurately and consistently evaluate serious incident activity until a uniformed incident reporting system is successfully implemented.

RECOMMENDATIONS: Previous recommendations remain appropriate:

1. Timely approved and implement policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.

f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: Segregation and Lock-Down Review documents were provided to examine

compliance with this Provision. GGACF officials represented these documents as the complete

segregation-review records for prisoners housing in a segregation status. However, the quality

and completeness of the documents makes assessing compliance with this Provision impossible.

The majority of these records were not properly completed and information required for an

adequate assessment was not recorded. The majority of the documents omitted:

1. Location of segregation and type (disciplinary, administrative) 2. Time of review 3. Specific date of placement 4. Projected date of disciplinary segregation release 5. Prisoner special needs, if any (physical handicap, mental illness) 6. Officer or staff remarks regarding review findings 7. Required follow-up 8. Reasons and circumstances that validate continued placement in segregation 9. Alternatives to segregation that were discussed and considered prior to segregation
placement 10. Final action or instructions by the Review Committee

The following was determined from those records providing enough information to draw cursory, albeit, reasonably reliable conclusions about compliance with this Provision:

There was no documentation to determine whether GGACF followed-up on recommendations made by staff who conducted the review:

1. FJ – Officer notes the prisoner is not receiving daily showers and recommends that the inmate should be returned to GP. No follow-up action recorded.
2. WA – Officer notes the prisoner should be evaluated by MH but no record was provided to verify whether a referral was submitted or an evaluation was completed.
3. PC – Officer notes the mentally ill prisoner in disciplinary segregation is concerned about disciplinary time calculations but fails to document action to investigate and resolve this concern.
4. JW – Officer notes prisoner is to return to GO but then states “Subject was not placed in G.P / To remain in A.S”.
5. JT – Officer documents prisoner needs “+ Dental Cleaning” but fails to document a medical referral.
6. RC – Officer fails to record prisoner’s level of “…wellbeing” (Good, Fair, Poor) 7. FR – Officer notes the prisoner “needs social help” but fails record required follow-up
actions to be taken. The document does not include the second page (reverse side). 8. AP – Officer notes inmate states “being harassed by officers…” but no follow-up action is
documented. 9. JP – Officer notes the prisoner “Refused” [to cooperate with review process] but fails to
document any observations about inmate physical condition. This document omits reverse side of form. 10. TD – Officer notes inmate was “punched in the face [by another inmate,” and “needs to see a dentist” but no follow-up action is recorded.

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11. NB – Officer determines and records the prisoner’s overall level of wellbeing is “poor” but

does not record what the prisoner means by this statement and no required follow-up action

is documented.

12. WJ – Officer notes prisoner requests a “physical checkup” but no follow-up action is

recorded.

13. PS – Officer notes prisoner “needs a new bed, pain in left hand” but no follow-up action is

recorded.

14. Officer notes, “[prisoner] needs to see a psychiatrist…” and records “Remains in SMU –

cc: Dr. Sang.” Follow-up action is not recorded, reverse page is omitted.

15. RE – Officer does not record any health and wellness information.

16. JR – Officer notes, “[prisoner] threatened by staff and inmates… staff and other staff

threatens to put him in a body bag…” No follow-up action recorded. No administrative

investigation provided to this Monitor regarding possible threats to inmate life.

17. DJ – Officer notes prisoner “Requested medical (Dental)” but no follow-up action is

recorded other than, “CC: HSA Charles.”

18. US – Officer notes on several review forms this mentally ill prisoner “Refused”. This is

interpreted to mean the inmate refused to participate with the review process. No health and

welfare information is recorded on forms from January to July 2014.

19. MH – Officer does not document health and wellness information, notes “Refused, needs

to be evaluated or assessed.” No required follow-up action shown, page missing.

The GGACF segregation review process is inadequate and non-functional. It is likely that some inmates are kept in segregation…

1. without being afforded their legal due process rights; 2. for unnecessary and/or extended periods; 3. are not being provided adequate health care services; 4. are not being properly and routinely monitored and assessed for physical and mental health
needs; 5. are not have their reported complaints, needs, concerns resolved; 6. prisoners with serious mental illness are being held in segregation in violation of the
Agreement.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment. A routine schedule for conduction these rounds must be regularized and continuously monitored for compliance.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or as a treatment for inmates who are mentally ill.
5. Improve the quality and completeness of segregation review documentation.

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G. Incidents and Referrals

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

a. Reporting by staff of serious incidents, including (i) fights; serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Draft policies and procedures are currently under review by this Monitor and USDOJ. That said, the current incident reporting system remains disorganized, unreliable, and not well managed based on examination of incident reports and logs since the Baseline Report:

1. Inconsistent incident report numbers 2. Incomplete reports 3. Page numbers and other basic information missing 4. Reports not being recorded on the incident log 5. Using different incident numbers for each inmate involved in the same incident 6. Using different incident numbers for different officers reporting the same incident 7. Illegibility 8. Missing signatures 9. Inconsistent recording of incident type 10. No recording of incident type 11. Incident, Evidence, and Disciplinary logs don’t cross-reference each other

Simply stated, the current incident reporting system must be completely overhauled if it is to provide valid and reliable information from which to evaluate serious events in order to comply with this Provision, or any provision requiring accurate and complete incident reporting to assess compliance levels.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Develop protocols for current tracking system to improve data validity and reliability; this document is replete with duplication and misleading entries.

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2. Develop a unified incident coding system for valid and reliable information and data

collection, reporting, and analysis.

3. Establish regular monthly quality assurance meeting process involving all major department

team leaders to review serious incident reports and recommend evidence-based remedial

measures for eliminating/mitigating incident frequency and severity.

4. Train staff in applying adopted policies and use of forms, implement a continuous quality

assurance protocol.

5. Require supervisors to carefully review all incident reports for completeness, accuracy, and

consistency.

b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: NONCOMPLIANCE (from Partial Compliance) - No substantive improvement from previous assessment.

FINDINGS: This Provision returns to Non Compliance. As stated above, the current incident reporting system is incapable of producing consistently reliable information from which to identify, ascertain, and address incident trends. Additionally, previous recommendations were not implemented and no documents have been provided to this Monitor demonstrating efforts to improve the current incident reporting system or administrative review system.

RECOMMENDATIONS:

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement from previous assessment.

RECOMMENDATIONS:

1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement from previous assessment.

RECOMMENDATIONS:

1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

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2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.
ASSESSMENT: NONCOMPLIANCE -

FINDINGS: No substantive improvement from previous assessment.

RECOMMENDATIONS:

1. Include this element in the required policy and procedure. 2. Establish reasonable timeframes as indicated. 3. Develop and implement corrective action protocols for staff noncompliance with adopted
policies and procedures.

H. Use of Force by Staff on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures were submitted to the Territory for review as ordered by the Court; that document remains under review by the Monitor and USDOJ.

Use of force used by GGACF staff appears questionable and possibly in violation of prisoner rights. A recent housing unit riot involving several inmates was quelled by use of force by several officers. Several inmates involved in this incident reported to monitoring team members that officers used unjustified physical force that resulted in physical injuries. This information was forwarded to the United States Department of Justice for investigation.

RECOMMENDATIONS:

1. Implemented draft use of force policies and procedures upon approval and according to the new Schedule.
2. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
3. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review document are 1) complete, 2) accurate, and 3) comprehensive.
4. All planned uses of force must be monitored and controlled by an onsite supervisor. 5. GGACF must promptly and thoroughly investigate all inmate complaints of excessive force
and take necessary corrective action to project inmates and staff.

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b. Circumstances under which the permissible forms of physical force may be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. No improvement.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings.

RECOMMENDATIONS: Same as above, and

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No use of force training has been provided to staff as described in this Provision. The Territory continues to be nonresponsive to this Monitor’s several requests for all training curricula. This Monitor requested these documents prior to each onsite visit and several times between visits. The Territory’s non-responsiveness to the Monitor’s request prevents the Monitor from adequately assessing compliance with this section specifically, and all Provisions involving training.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See recommendations regarding Training Provisions and apply to use for force requirements. 3. Provide this Monitor and DOJ with all current training curricula.

e. Training and certification required before being permitted to carry and use an authorized weapon;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: Same as above. Not change.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Refer to Training Provision recommendations and apply to this requirement.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Despite several incident reports documenting several incidents involving staff use of force on prisoners, the Territory did not comply with this Monitor’s request for documents; all use of force reports and administrative reviews of force were not provided. This Monitor was unable to assess compliance with this Provision.

RECOMMENDATIONS:

1. Implement supervisory quality improvement review for all reports to ensure accuracy and completeness before approval.
2. As requested in the previous report, the Territory must develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.
3. Comply with Monitor’s request for documents.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: GGACF officials continue to not videotape planned uses of force. For example, the recent riot was not officially videoed by any GGACF supervisor but was videoed privately by an officer using their personal phone. During this visit, received conflicting information from GGACF officials about this recording. The GGACF Security Administrator stated this incident was not videotaped but a supervisor involved in the incident stated that it was. Based on this supervisor’s statement we requested a copy of this videotape; the Territory provided this video to the Monitor and USDOJ January 30, 2015, 50 days after it was requested by this Monitor and USDOJ.

This Monitor’s cursory review this video found much of its content very troubling as listed below:

1. In a November 10, 2014 internal report to the VIBOC Director, the GGACF Acting Warden refers to this incident as a “Semi Riot”. The video clear demonstrates this incident was a full riot involving many prisoners who were destroying property, burning objects, and flooding the housing unit.

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2. While some prisoners threw objects at the officer station windows, other inmates stoked

burning mattresses they placed over the entrance gate intending to prevent staff from

entering the housing unit and seriously harm them if they tried to do so.

3. Fires were burning on the upper tier of the housing unit.

4. The housing unit was filling with smoke. Officers observing the violence in the officer station were not adequately protected from smoke inhalation and had no ability to stop the fires or the violence. Inmates who were locked in their cells could not escape the smoke nor could they safely enter the day room without risk of serious violence from inmates engaged in the riot.

5. Officers entering the housing unit to stop the violence were not adequately equipped with the proper equipment to protect them from physical harm from inmates, the fires or smoke. Many officers were seen leaving the housing unit covering their faces with their shirts and choking from smoke inhalation. None of the officers involved in responding to the fire wore proper breathing equipment or smoke-filtering masks.

6. There was no security containment perimeter established within the housing unit while the entrance gate, officer station entrance, and external slider remained open simultaneously.

7. There appeared to be no command and control of the GGACF response; many officers were seen walking about the smoky housing unit for no apparent reasons, others came in and out of the housing unit with no direction from supervisory staff. Staff response appeared disorganized, chaotic, and not directed. Staff who were obviously overcome by smoke were allowed to reenter the housing unit and there were not oxygen tanks observed to assist staff or inmates who were experiencing respiratory difficulties.

8. The prisoners appeared to have been locked back in their cells rather than evacuated into a secured containment location. These inmates continued to inhale smoke and any toxic fumes produced from the burned mattresses.

9. None of the forced used by GGACF was observed in this video.

Despite the fact that this video cannot be used to demonstrate compliance with this Provision, VIBOC officials should use its content for emergency management planning and response training purposes. This recording clearly demonstrates the degree to which GGACF is not prepared, equipped, staffed, and managed to effectively respond to such emergencies.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

This Monitor respectfully urges the Court to review this video in chambers to better understand the Monitors concerns.

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h. Appropriate oversight and processes for the selection and assignment of staff to armory

operations and to posts permitting the use of deadly force such as the perimeter towers;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change.

RECOMMENDATIONS:

1. Provide the Monitor documentation of Compliance for this Provision.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Not change.

No photographic documentation was provided from inmate injuries sustained when physical force was used by staff to quell the recent riot. Photographs of inmate injuries were published in the local newspaper. Documentation was inadequate to determine if and to what extend injured prisoners were provided medical treatment for injuries sustained from staff use of force.

RECOMMENDATIONS:

1. Provide Monitor documentation of Compliance with this Provision.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: NON COMPLIANCE

FINDINGS: This Monitor was not provided with “ALL previous use of force incidents as requested” (Recommendation 2 below and in the Fifth Assessment Report). As such, this Monitor was unable to adequately asses this Provision and believes that administrative reviews of staff use of force remains inconsistent, incomplete, and/or non-existent. This Monitor was provided several administrative review documents regarding use of force used during the recent housing unit riot.

RECOMMENDATIONS:

1. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

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ASSESSMENT: NONCOMPLIANCE

FINDINGS: This Monitor was not provided requested documentation to adequately assess compliance with this provision.

RECOMMENDATIONS: Same as above

l. Administrative investigation of uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. Documentation requested to assess compliance with this Provision was not provided.

RECOMMENDATIONS:

1. Develop and implement Central Tracking system to include all required elements.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Immediately issue directives to supervisors to complete reviews for all incidents involving use of force. Monitor compliance, correct deficiencies, and document compliance with this provision.

o. Re-training and sanctions against staff for improper uses of force.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Training records were again not provided to the Monitor for review during this visit.

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It is impossible for GGACF to fully comply with this Provision until supervisors comply with use of force review requirements.

RECOMMENDATIONS:

1. Produce staff training records for review by this Monitor during the next onsite visit.

I. Use of Physical Restraints on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. The draft policy remains under review. Documents were not provided to assess compliance with this Provision.

RECOMMENDATIONS:

1. Implement this policy once approved according to the new schedule.

b. Circumstances under which various types of restraint can be used;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above

RECOMMENDATIONS:

1. Same as above.

c. Duration of the use of permitted forms of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

d. Required observation of prisoners placed in restraints;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

f. Required termination of the use of restraints.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above

J. Prisoner Complaints

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Staff who maintain the complaint system did not participate in this assessment and this Monitor was unable to adequately assess compliance with this Provision.

The Inmate Grievance Log was provided for examination but no staff were available to clarify log entries and document deficiencies. The log shows no substantive improvement from the previous report. This Monitor is very concerned that many inmate complaints continue to go unresolved, providing inmates no access to relief from alleged rights violations and safety and security concerns.

RECOMMENDATIONS:

1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking process to measure and verify program compliance, take timely and appropriate remedial and correction action.
2. Ensure tracking log is consistently completed and accurate.

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3. Assign oversight of the inmate complaint process and logs to a staff person who will provide

the process consistent, dedicated, and comprehensive attention.

4. Develop from a valid and reliable tracking a quality management statistical report for

monitoring inmate and facility needs and problems.

5. Ensure staff are available during onsite visits to allow this Monitor to adequately assess this

Provision.

b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above, and:

1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: This review process continues to not exist.

RECOMMENDATIONS: Same as above.

1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. Use data from those reviews identify patterns of individual staff and inmate problems, as well as systemic problems in need of correction.

K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The elements of this Provision were included in this Monitor’s policies and procedure drafts.
Administrative investigation documents involving the recent housing unit riot demonstrate a troubling lack of concern for staff and inmates. The documents provided demonstrate a systematic failure to adequately investigate event by any measure of adequacy. This event involved several obvious operational failures regarding:
 Effective inmate communication  Key control  Housing unit security and prisoner control  Fire response, suppression, and follow-up  Staff and inmate health and welfare  Emergency management, command and control  Constructive/objective post-event assessment and corrective-action planning  Staff training
 The investigator position remains vacant.
RECOMMENDATIONS:
1. Fill the vacant investigator position.

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2. Supervisory / management must be consistently held appropriately accountable for

adherence to agency rules, regulations, policies, and procedures.

3. The recent housing unit riot must be thoroughly investigated and reviewed to prevent similar

future events and to improve organizational planning, response, and management of these

types of major incidents.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling,
preserving, and maintaining administrative investigation evidence, information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive change since previous visit.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The current investigator position remains vacant. No documents have been provided to assess the Territory’s intentions or efforts to fill this position.

RECOMMENDATIONS: Fill the currently vacant Chief Investigator position.

1. Create a formal pre- or in-service training program to train staff who are involved in initial and/or administrative investigation.

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2. Provide adequate training of investigative staff on topics in areas of incident scene

investigation and appropriate administrative investigation methods, processes, techniques,

legal and ethical issues, etc.

3. Provide training for administrative/leadership in the areas of administrative investigation

oversight, coordination, and management.

4. Develop and implement, as an adjunct to these policies and procedures, an “Investigators

Manual” that provides guidance to staff responsible for oversight and investigative

activities.

5. Provide the Monitor qualification documents for the newly appointed Chief Investigator for

review upon his/her appointment.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: This Monitor was not provided requested documents to adequately assess this Provision. Monthly disciplinary hearing records were not made available for review. One GGACF staff person stated that disciplinary due process hearings had not been conducted since July 2014. This Monitor is very troubled and concerned that various forms of disciplinary sanctions are being imposed on prisoners without due process.

The Territory provided no documents, as requested, regarding staff discipline except for a document dated October 10, 2014 that directed an officer to a disciplinary hearing. This document articulated no other information about the reasons for this hearing.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.
2. Integrate the information in the above into the administrative policies and procedures previously discussed.
3. Record and maintain onsite records of staff misconduct investigative reports and determinations.
4. Protect the integrity and confidentiality of these staff records, control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
5. Provide training to supervision staff in the appropriate use of this information for staff supervision, counseling, discipline, promotion, etc. purposes.
6. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:

a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: NONCOMPLIANCE – No substantive improvement from previous assessment.
MEDICAL FINDINGS: We have been working with the Health Service Administrator since our last monitoring visit. A number of policies have been completed and seven requiring some additional modifications are now complete and currently under review by the Monitor and U.S. Department of Justice. Those seven policies include receiving screening, chronic disease, infection control, urgent and emergent care, non-emergent care, grievance mechanisms and emergency response plan.
With regard to the receiving screening, we have redesigned the nurse-utilized receiving screening form so that the design of the form facilitates appropriate completion. During this visit we reviewed approximately 10 records with regard to the receiving screening process. We were encouraged by the fact that almost all of these forms were completed by a registered nurse and most were completed within 24 hours of the patient’s arrival at the facility. However, the professional performance does not show improvement. Some of the problems found were sections that did not appear to be completed because there were no items circled, either as positive or negative within that section. In addition, there were several forms that were completed but the acuity scale was not utilized, so there was no assigned acuity and therefore no sense of urgency with regard to the completion of the health assessment. There was an improvement in the planting and reading of the tuberculosis skin test; however, a few of the forms lacked the documentation with regard to the reading. This area clearly needs work and that begins with the approval of the policy followed by the appropriate training. Some examples follow.
Patient #1 This is a 44-year-old who arrived on 10/20/14. The screen lacked an acuity scale and there also was no physical assessment. However, the TB skin test was planted on 10/21 and was read as 0.0 mm on 10/23.

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Patient #2 J.L. This is a 57-year-old male who had a nurse screen on 11/1. There was no physical exam. There was a recent TB skin test which was 0.0 mm in August 2014. The acuity scale was not utilized and there was no physical exam.

Patient #3 H.O. This is a 48-year-old who arrived on 11/2/14. The screen was performed but there was no signature and no physical assessment. An acuity scale was listed as 3, but there did not seem to be any basis in the screening data that would suggest acuity level 3.

The following problems exist with the medical process: 1. As cited in the last visit, screens are to be conducted as soon as possible after entry. Our
understanding is that there is nursing coverage only between 8:00 a.m. and 8:00 p.m. seven days a week and therefore the longest duration without a screen should be no more than 12 hours. We have also discussed with the Medical Director designing a form that will allow a nurse who is on call to address questions over the telephone with the patient who is newly arrived. This is for patients who arrive between 8:00 p.m. and 8:00 a.m. If these questions contain positive answers that suggest instability, the nurse will call the doctor on call who can then determine if the patient can wait or needs to be sent to the hospital. The physician could also speak with the patient. If all the answers are negative, the patient should be seen first thing in the morning when the next RN arrives on duty and that will be the time that the receiving screening is completed. 2. It was clear from this visit that although training may have been provided, the performance was not consistent with the requirements. Therefore, we redesigned the form in a manner that should facilitate improved performance. 3. The acuity scale did not always assess the patient correctly and this of course is a matter of training and feedback to the individual nurses. 4. Without a regularly scheduled advanced level clinician, physician, PA or nurse practitioner available regularly, there cannot be compliance with the requirements with regard to the timing of the health appraisal.

RECOMMENDATIONS:

1. Continue to refine the screening policy, including utilization of the acuity scale. 2. Develop the questionnaire for the telephone triage to be used between 8:00 p.m. and 8:00
a.m. 3. Continue to recruit for the nursing staff and fill the remaining vacancies. 4. Establish predictable and regular hours for the advanced level clinician services so that the
acuity scale based on the screen data can be achieved for patient care.

MENTAL HEALTH FINDINGS: Medical staff are performing intake health screenings in a timely fashion. Positive mental health findings did initiate referral to the psychiatrist by security and medical intake screeners. As mentioned elsewhere, a freestanding mental health intake screen will be developed and implemented with the assistance of this monitor.

A review of the intake screening log was performed in order to study the health of the referral process by the intake screeners to a mental health professional. Between October 1 and

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December 4, 2014 there were a total of 79 intakes. Of these, 8% (n=6) were referred to the

psychiatrist because of positive responses on their intake screening of mental health issues. All

of these charts were reviewed. Of the six, all were seen within 3 business days of referral by the

psychiatrist (with the longest delay being 5 days since time of identification). It should be noted

that if the facility had a Qualified Mental Health Practitioner (“QMHP”) on staff they would be

the professional who would complete the initial psychological evaluation and then determine

who required referral to the psychiatrist. The current time frames for referral represent excellent

responsivity by the psychiatrist.

Results of the review with concerns are as follows:

Concern: Inmate number 1 was not screened as lacking mental health issues on admission. However, two days later a correctional officer issued a behavioral checklist referring the inmate to the psychiatrist for depression. In this case, the inmate was seen nine days later by the psychiatrist who noted that he did not speak English and referred him to see a physician with whom he could communicate. This second clinician only addressed the inmate’s complaint of elbow pain and not the referral issue of depression. This case is a vivid showing on noncompliance with the Agreement as it demonstrates how care for this inmate was impaired by language barriers.

Significant concern: Inmate number 3 was referred from intake for a diagnosis of bipolar disorder. The medical intake screen noted no suicidal ideation. He was seen by the psychiatrist five days later who noted he was psychotic. Concerns with this record are the follow-up date set for two weeks hence (being too lengthy period of time to reevaluate someone recently hospitalized prior to booking and diagnosed with an acute psychosis); and the fact that the inmate was not placed on any observation status pending reevaluation or referred for any kind of special mental health housing (the latter is not yet available at GGACF).

Between psychiatric appointments he was seen by a general clinician who noted a history of significant self-induced trauma with injury but when he was assessed by the psychiatrist this behavior was not specifically addressed although the assessment indicated no suicide risk. When reevaluated by the psychiatrist two weeks later there was no evidence of psychotic symptomatology and a follow-up appointment was scheduled for one month. However, there was also no specific comments regarding suicidal or homicidal risk despite his positive history of self-injury. (It should be noted that some of this is a product of the formatted progress note which only requires the psychiatrist to make an entry when there are positive signs of suicidal ideation as opposed to a general statement indicating no risk. New mental health forms were drafted by this monitor for review by the psychiatrist prior to implementation to remedy some of the inefficiencies of the current forms formatting.)

Concern: Inmate #5 had a negative officer intake screen but a positive medical screen for suicidality six days later. He was referred to the psychiatrist and seen within two days. Documentation was sparse and only recorded on a progress note as opposed to a complete initial assessment form.

Significant concern: Inmate #6 was noted to have psychotic symptoms at the time of intake. This was again noted by the psychiatrist at the time of her review. She appropriately increased the dose of the inmate's medication but follow-up was 30 days later. Considering there is little to no

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mental health programming, supervision, or specialized housing, a follow-up with one month on

the inmate with psychotic symptoms is too long a time frame in the judgment of this reviewer.

A second review was done of all detainee bookings for the month of November 2014 to see if any inmates with positive mental health issues were not identified for referral to the psychiatrist. 16 records were reviewed and all inmates with any positive mental health issues were identified. The monitor observed that there were no 14 day history and physicals in any record. There were some timeliness issues but the Health Services Administrator reported they were down 2 RNs that month and stated that it was unknown when or if these positions would be filled.

RECOMMENDATIONS:

1. The psychiatrist is attempting to see people quickly upon their referral to her. However because of the absence of a QMHP, the psychiatrist is only doing focused intakes and there are few documented comprehensive initial assessments which with the appropriate staffing would have been performed by the mental health professional. Many of the documentation deficiencies appear to be related to the formatting of the medical record forms as well as the lack of any assistance for the psychiatrist by mental-health professionals. It is critical that GGACF make every effort to offer competitive salaries in order to hire the necessary number of QMHPs to accommodate the mental health needs of the inmates housed within this facility.

2. Renovations to the secure observation area for mental health with the appropriate correctional and nursing staffing to monitor these inmates must expeditiously continue in order to provide the required level of care and safety for inmates entering or developing critical mental illness symptomatology on site at GGACF. This is especially needed considering this island lacks any inpatient psychiatric facility that can receive these inmates and the Bureau of Corrections still has the legal and moral obligation to meet the basic mental health needs of these seriously ill individuals.
3. GGACF must also develop basic mental health programming to support these individuals in achieving and maintaining remission. This will be discussed further in the preceding section on mental health programming.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: Just as we have redesigned the intake screening form, we have also redesigned the practitioner health assessment form. The redesign was an effort to facilitate capturing sufficient data to achieve compliance with the requirements. A bigger challenge for the program, however, is to achieve stable, predictable advanced level clinician coverage such that the requirements of the acuity scale can and will be met. We learned that during our visit Dr. Burton’s contractual obligations finally had been met, which should result in more stable and predictable advanced level clinician scheduling. Dr. Burton was present during part of our monitoring visit and we continue to look forward to working with him on an ongoing basis. Our review of the intake process revealed that a majority of the records we reviewed either did not contain an initial practitioner health assessment at all or contained a practitioner health assessment that was not

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completed within the required timeframe. We cannot emphasize enough the need for several of the

service requirements covered in this agreement to insure timely, predictable advanced level

RECOMMENDATIONS:

1. Stabilize the advanced level clinician schedule so that each week there is advanced level clinician presence on at least three days.
2. Develop a system, possibly utilizing a logbook that enables the Medical Director to review acuity level 1 and 2 intakes to insure that their problems are being appropriately addressed and adequately followed up. This should be part of the quality improvement program.

MENTAL HEALTH FINDINGS: Currently no inmates are receiving comprehensive initial assessments by a mental health professional. The psychiatrist is the only mental health professional on staff and sees everyone referred from intake. Most individuals are receiving a focused interview at the time of their initial visit documented on a mental health progress note rather than a comprehensive assessment, most likely due to the absence of additional QMHP who would ordinarily perform this task prior to referral to the psychiatrist.

RECOMMENDATIONS:

1. This monitor will assist GGACF in developing standardized mental health intake screening, initial behavioral health evaluation, and progress note forms for implementation in the coming months.
2. See recommendations under paragraph V.1. J.

c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have used this section to address medical sick call; therefore it focuses on acute care needs, since chronic care services are covered in another section. We continue to discuss with the staff modifications to the log that include, when patients are not seen, the reason why they are not seen. We reviewed 10 records of patients who requested sick call services. We identified records in which we believe the nurse who did the triaging determined that the patient was going to require advanced level provider assessment and therefore skipped the nurse assessment. The requirement is independent of the credentials; the assessment must take place within 48 hours during the week and 72 hours on the weekend. Therefore, in order to achieve compliance with this aspect of the agreement, nursing staff should not be permitted to skip their assessment, even when they believe that an advanced level clinician assessment is required. Thus, every symptom containing health services request must have a timely nursing assessment conducted by a registered nurse in an appropriately designed and equipped space which allows for confidentiality.

The problems continue to persist with regard to accessing patients in the clinic because of lack of custody escort services. We have already described a solution, which is to utilize the potential exam rooms built into the housing units. These rooms need to be cleaned, sanitized and appropriately

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equipped. Nursing leadership has developed a list of required equipment and supplies for these

exam rooms. We would expect that before our next visit, prison leadership will make these rooms

available for health care assessments.

Here are some examples of patient records.

Patient #1 A.L. This is a 24-year-old who complained of severe neck and back pain on 10/5/14. He was seen four days later by the physician, whose documentation does not address the neck and back pain.

Patient #2 D.R. This is a 39-year-old who complained on 11/19/14 of fever and constipation. We could not find a note in his chart addressing these items.

Patient #3 J.R. This is a 42-year-old whose record lacks a problem list, who complained on 11/14 of pressure in his chest and chest pain. There was no nurse assessment. There is an indication that he was to be seen by the cardiologist on Friday, December 12. The patient is currently being treated by Dr. Galibare for hypertension.

RECOMMENDATIONS:

1. Continue your efforts to fill the nursing vacancies in order to facilitate timely assessments. 2. The head nurse should continue to review and provide feedback with regard to the quality of
the nursing performance during the sick call process. 3. The sick call log book should contain patient identifiers, date of request, date of nursing
assessment, if the assessment did not occur, a field for the reasons why and date for reschedule if the reasons were other than patient refusal and finally, disposition, that is referral to a clinician, yes or no and date that the referral takes place. 4. A patient who submits a request with multiple complaints must have each of these areas assessed by the nurse at the visit.

MENTAL HEALTH FINDINGS: The psychiatrist has been seeing inmates on a regular basis for chronic care follow-up. However, this monitor continues to see notations in the medical record indicating that inmates have not been brought to the clinic for their visits due to the absence of security staff. Although it is reported that this occurs less frequently than last spring, it remains a major barrier to access to care for inmates with chronic health conditions.

RECOMMENDATIONS:

1. It is recommended that the health services and correctional leadership develop a corrective action plan to ensure improved access to medical and mental health care by inmates with following tracking to establish efficacy of the plan.

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d. Continuity, administration, and management of medications that address (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MEDICAL FINDINGS: The issue with the pharmacist has still not been completely resolved as of the current visit, but I am told that there is a commitment to resolve it, so we will wait to see. The pharmacist did stop in for the first time in several months the weekend before our tour, but I am awaiting the report that her appearances will be regular. We did not observe medication administration during this visit. However, we do remain concerned about the medication administration practice and its documentation. Because of the delays, especially in access to advanced level clinicians, and sometimes due to the absence of escort officers, it is our understanding that assessments are delayed and therefore on that basis alone, access to medications are delayed.
RECOMMENDATIONS:
1. Submit the medication administration policy for approval by the Monitor and USDOJ. 2. Fill both the nursing and advanced level clinician hours and regularize them so that there is timely
access to assessments as well as medications. 3. The head nurse should work with the Medical Director in order to develop a procedure that allows
the nurses not only to carry the medications with them, which is occurring, but also to bring the medication administration records so that at a minimum the administration of the medications is recorded no later than when the nurses are about to leave each housing unit.
MENTAL HEALTH FINDINGS: The medication administration records did not indicate a problem with the administration of medication. However, we were informed that at least one inmate was refused medications because he was not wearing his shirt when the medication was being administered at the housing unit. This is unacceptable. Inmates must be provided their medications as directed by the responsible prescriber. However, no quality improvement data was available to dispute previous observations of medications being distributed without observation of ingestion. Additionally, the log book for housing unit 9C notes a complaint that a detainee’s seizure medication was withheld. Additionally, one inmate who was admitted to the facility on a Saturday reported not receiving prescribed seizure medication until the following Wednesday, five days later. This inmate reported having several seizures during this period of time.
RECOMMENDATIONS: defer to Medical recommendations

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e. Maintenance of adequate medical and mental health records, including records, results,

and orders received from off-site consultations and treatment conducted while the prisoner

or detainee is in Golden Grove custody;

ASSESSMENT: NONCOMPLIANCE -

MEDICAL FINDINGS: During this visit I have approved the medical records policy. There is clerical staff available but that staff’s contract is about to expire. The charge is to fill the medical record position on a permanent basis. Although there are some improvements, certainly in access to the records and in the diminution of loose filing, we still found documents within a section not being filed chronologically and some documents were not filed in the appropriate section. In addition, several records lacked problem lists and the problems lists, when present, were not available on the top of the side in which they were filed.

RECOMMENDATIONS:

1. Hire a medical records technician as soon as possible, hopefully before our next visit. 2. The medical records policy should include timeframes for filing of documents and for reviewing,
initialing and dating by clinicians. 3. There should be guidelines for thinning the records and in particular, what documents from the
inactive record need to be moved to the active records. Those documents that should be in the active record include intake information and documents in progress notes, consultations, laboratory and x-ray from at least the most recent year.

MENTAL HEALTH FINDINGS: The facility has yet been able to hire a permanent medical records clerk. In the interim two retired employees are currently being utilized to organize the medical records department. Since the time of our last site visit they have assigned a medical record number to every chart and have begun filing charts numerically. All old records have been removed from boxes and organized in file cabinets for easy access. Records that are currently in use are still in the process of being shifted over to the new system. Most of the records, other than mental health records, have been placed in file cabinets in numerical order. However, most of the mental health records are filed loosely on a records cart.

42 medical records were reviewed during the course of this visit. Significant problems were identified in many of those records as follows:

 The practice of using identification labels which were pre-printed for ease-of-use appears to have stopped.
 Clinical records occasionally had no identifiers including inmate name, date of the transaction, or the name of the clinical staff person delivering the service.
 Many records are completely out of sequence, for example, medical record entries from 2013 are on top of entries from 2014.
 Charts are unthinned.  Loose papers are in the records.  Unfiled medication administration records (MARS) were seen dating back as far as 2012.
MARS should always be within the first half of the next month.  Loose filing was placed in the wrong inmate’s chart.

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RECOMMENDATIONS:

1. GGACF continues to have a vacant full time medical records position that needs to be filled with a qualified person.
2. Once all records are appropriately organized and filed, a quality improvement tool needs to be developed to track compliance with this provision.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for this provision.

RECOMMENDATIONS: See letter (c) findings and recommendations.

MENTAL HEALTH FINDINGS: The Sick Call Log was reviewed from September 16, 2014 through December 5, 2014. During this time 255 inmates submitted a sick call request. Of those only five (2%) had a mental health complaint, representing an unusually low rate of self-referrals. Of these, one was seen within 72 hours of submitting the request. Four were seen in more than three days. All 5 charts were reviewed. Results with concerns are as follows:
1. One record of a 37 year old man contained a security log entry in the unit log that he was moved to cell 1 and placed on a suicide watch by Dr. Sang. There are no other notations in the log indicating a 15 minute or direct observation status. Dr. Sang told me she had placed no one on a suicide watch so this indicates a communications misunderstanding. Also, the inmate’s request concerned his feeling depressed and losing his mind yet it was handled as a routine request and not urgent with a 5 day delay to be seen by nursing.
2. A second inmate’s sick call request could not be found in the medical record which was 3-4 inches thick with quite a bit of unfiled paperwork.
3. Another inmate had been allowed to sign a carte blanche refusal to see the psychiatrist who he had last seen on 10/18/14.

RECOMMENDATIONS:

1. If the officer’s understanding was that an inmate was on a suicide watch, then whatever instruction was given regarding how to document observation of such an inmate is inadequate. GGACF needs to develop performance measure tools to track the effectiveness of training.

2. I discussed with medical staff and the psychiatrist reasons why inmates cannot sign a carte blanche refusal for care but rather can only refuse a specific treatment. Since inmates have no other avenue for treatment due to their confinement the psychiatrist should still continue to schedule the necessary treatment and counsel the inmate on the risks of their refusal. Inmates

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should also be evaluated for their capacity to make treatment decisions if they suffer from a

serious mental illness and are continually refusing care.

f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: For this response, I am interpreting this to refer to the tracking of chronic care patients but other care-tracking is ultimately required for full compliance with this Provision.

There is a chronic care notebook but it is not maintained in such a way that newly identified patients are immediately placed in the logbook and patients released are immediately deleted from the logbook. Many facilities use an Excel spreadsheet and compare it to daily lists of releases. They also have a process which at the time of the initial practitioner assessment is used to identify the chronic disease, and notify the nurse who is managing the Excel spreadsheet so that the newly identified patient can be entered into this tracking log.

RECOMMENDATIONS:

1. Establish an Excel log with one nurse responsible for adding and deleting names as appropriate. This log should contain patient identifiers, the types of chronic problems by disease as well as the most recent degree of control at the specific clinic visit and the date of the sequence of chronic care visits, including the most recent chronic care visit.

MENTAL HEALTH FINDINGS: During the site visit the psychiatrist was on leave. No one else at the clinic was able to provide a current copy of the chronic mental health care list. At the time of our previous visit the psychiatrist and I did review the tracking form and this monitor was able to make recommendations to improve the comprehensiveness of the database. It is my understanding that the psychiatrist continues to use this updated database, however no one else at the clinic had access to that computer file.

RECOMMENDATIONS:

1. Currently the psychiatrist is the only mental health professional working for the facility. In the past the chronic mental health care list was maintained by the mental health coordinator who was a QMHP. In general, the maintenance of current clinical logs should have a central and accessible record available to all medical and mental health staff, especially in the absence of any single individual. Therefore, I would recommend that the Health Services Administrator develop the means for all clinic entries (medical, mental health and dental) to be shared and stored in a common computer file that she or her designee can access.

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: We have reviewed and approved the chronic disease guidelines. However, our record review indicated that patients were not being seen necessarily within the timeframe that the clinician recommended. We were told that this was due to the inconsistency of the presence of the chronic disease physician. He is supposed to be on site two days a month, but many months he is only on site one day. If there were consistent Medical Director or other physician presence, they could see the patients who were supposed to be seen by the chronic disease physician when he did not appear. Our review of patients with chronic diseases demonstrated sometimes inadequate histories, sometimes delays in follow-up visits for the reasons previously mentioned as well as incorrect assessment of degree of control. Examples of patients follow.

Patient #1 S.S. This is a 59-year-old who has been in the facility since 1996. He was diagnosed with both asthma and diabetes type 2. His baseline visit was on 11/29/13 and his most recent visit was 8/15/14. He should have had a chronic disease visit since the August visit but has not. At that time, his blood pressure was143/83, elevated for a diabetic, but he has not been seen since.

Patient #2 R.M. This is a 58-year-old who arrived in July of 2012 and was assessed as having diabetes mellitus type 2 as well as hypertension. His baseline chronic disease visit was on 9/20/13. However, the assessment page in the initial baseline visit form was missing. Unfortunately, this patient has not been seen since September 2013 in the chronic disease program.

Patient #3 J.F. This is a 48-year-old who arrived at the prison in March of 2011. He was seen and diagnosed as having hypertension within one week. He was not seen by the chronic disease physician until September 2013, which is two and a half years later. His blood pressure was quite elevated and the chronic disease physician ordered an increase in his medications. However, he was not seen until a year later for reasons that are unclear.

RECOMMENDATIONS:

1. The Medical Director must retrain the chronic disease physician on the use of the chronic disease forms and what the expectations are with regard to documentation.
2. As referred to under section f (ii), develop an Excel spreadsheet for monitoring the chronic disease program that includes patient identifiers, names of diseases, the date of the baseline visit, the assessment for control for each disease and the date of the subsequent visits.
3. In addition, there should be a field that indicates if a patient’s visit was cancelled, the reason why the visit was cancelled and whether the visit has been rescheduled.

MENTAL HEALTH FINDINGS: See section V.s.1.Dr. Shansky for items v, vi, g. and h.

RECOMMENDATIONS: Develop and implemented evidence-based, written mental health clinical practice guidelines for assessment, treatment, and follow-up as stated in the 5th Report.

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f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have approved both a draft emergency services policy and an urgent/emergent care policy. However, there has not been approval from all the parties as well as training for implementation yet. We reviewed several records of patients sent offsite on an emergency basis. We identified the following types of problems: We found records in which there was no note prior to send out, which may be attributable to the hours when there are no staff onsite. We also found records in which although there was nurse staffing onsite, the patient was never brought to medical for the nurse to insure that the proper documentation was available and to see the patient. We also learned that for patients who return during periods when there is no nursing staff onsite, the officers drop the paperwork in a box which is checked by one of the senior nurses each morning. We also found there were not consistently follow-up visits with the primary care clinician after the unscheduled offsite services. Of the records we reviewed, here are some examples.

Patient #1 J.R. This is a 27-year-old with seizures who complained of abdominal pain on 10/21. She saw the physician and complained of blood in her stool and epigastric discomfort. She also indicated her commode had been filled with blood. The physician’s plan was to send her to the ER; however, when she arrived in the ER, she ultimately refused because of the long waiting time in the ER. She has had no follow up since and was finally released on 11/26.

Patient #2 G.E. This is a 42-year-old patient with asthma sent to the emergency room for shortness of breath on 10/11/13. This patient had a PPD that was planted but not read. Despite the identification of the asthma in May of this year, there has been no chronic disease follow up. When the patient returned there has been no ER report in the record and no chronic disease clinic.

Patient #3 J.L. This is a 29-year-old who on 11/11 was sent to the ER after complaining of pepper spray in his mouth. There is no ER report in the record and there has been no follow up.

We were not informed that the Medical Director has provided training to both medical and nonmedical staff regarding recognizing serious injuries and life-threatening problems. We do know that the basic officer training does include some of that material.

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RECOMMENDATIONS:

1. The offsite services coordinator must insure that emergency room reports are available and reviewed by the Medical Director before patients are scheduled for a visit with the Medical Director.
2. The Medical Director should provide training to officers and this should be documented in their training file.
3. The unscheduled services log should contain a field for whether the patient was seen in follow up and if not, an explanation as to why not. If the explanation is due to absence of clinician or custody the patient must be rescheduled.

MENTAL HEALTH FINDINGS: see section V. i. RECOMMENDATIONS: see section V. i., also, as stated in 5th Report:

1. Future training curricula will need to be presented to the monitoring team for review and approval.
2. Continue tracking timeliness in response to behavioral checklists. 3. A continued reminder by supervisory staff regarding the location and use of cut down tools is
needed and can be enhanced by incorporating these tools into disaster drill scenarios.

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We did continue to find problems with both the availability of the offsite service documents as well as the follow-up visits with the clinicians. There was a little improvement but not sufficient yet to give us confidence that the service is provided well. Patient examples follow.

Patient #1 N.P. This is a 36-year-old with asthma who had an appointment with a surgeon on 9/19/14 for his left zygamotic fracture that was depressed. The surgeon saw him and his note indicates he is planning to do surgery. When the patient returned there was no discussion between the patient and the primary care clinician. However, the patient was seen by the surgeon and did have the surgery. He had a discussion with the Medical Director after the surgery was completed as well as a followup visit with the surgeon post-operatively.

Patient #2 J.E. This is a 57-year-old with hypertension and HIV and there was a referral to ortho for bilateral lower extremity numbness as a result of spinal stenosis. The orthopedist was seen on 10/20; however, there is no nursing note on return even though the return occurred during hours when nurses were on site. The orthopedist recommended an MRI and physical therapy. The MRI was performed and the report reveals multilevel spinal stenosis, especially at L4 and L5. The patient was to see a surgeon on 12/23/14. After the MRI, there was no visit between the Medical Director

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and the patient. Apparently, the visit with the surgeon is to determine whether physical therapy is

in fact needed.

Patient #3 N.W. This is a 19-year-old who was sent to gyne for an initial visit. There is a report from the specialist in the chart and lab tests were ordered, but the lab reports are not in the chart and there has been no follow-up visit with the Medical Director or primary care physician.

RECOMMENDATIONS:

1. The offsite service coordinator must obtain the reports and bring them to the physician or Medical Director for review and signature, after which a follow-up visit with the physician and the patient must occur.
2. The offsite service coordinator should also be in touch with the chronic care physician’s office, since some procedures are performed at his office.
3. The chronic care log should be created and should include a field for whether the patient was seen as scheduled and if not seen, the reason for the patient not being seen. If that reason is absence of custody or of clinician, the patient must be rescheduled.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This has been discussed under f (v).

RECOMMENDATIONS: This has been discussed under f (v).

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have discussed with the Medical Director and provided him draft examples from other facilities. He indicated he has not yet completed the guidelines with regard to alcohol and other substance intoxication and withdrawal.

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RECOMMENDATIONS:

1. The Medical Director in working with the HSA should draft both a policy on intoxication and detoxification from substances including alcohol, opiates and benzodiazepines.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We are in the process of reviewing and approving the infection control program. We discussed with the nursing staff the documentation of the TB skin tests and reviewing the presence of the planting and result by the quality improvement program. We also discussed the need to notify the infection control nurse with regard to patients presumptively treated for MRSA so that this nurse can report on the frequency of MRSA cases.

RECOMMENDATION:

1. The head nurse should assign a nurse to be responsible for the infection control program.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

i. Adequate suicide prevention, including:

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: Inmates entering with identified risk factors for increased risk of suicidal ideation and behavior were identified in the review of the intake screening log. 50% (4 inmates) should have qualified for some level of enhanced observation in a well-functioning system. However, none of these inmates were placed under observation. One inmate had a positive history serious self-injurious behavior and was never placed on suicide prevention observation prior to being seen by the psychiatrist at the facility.

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RECOMMENDATIONS:

1. The Quality Improvement Committee should meet regularly, per policy, and monitor the intake screening process for accuracy of detection of inmates with risk factors and implement systems of care to address those needs, especially for potentially suicidal or aggressive inmates (either due to withdrawal, psychosis or other conditions).

(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Only one instance, a 37 year old male, mentioned previously, was noted to be placed on a suicide watch by the correctional officer. There is no documentation of and enhanced observation offered to this inmate.

RECOMMENDATIONS:

1. An observation log form be developed for correctional officers’ use whenever an individual placed on close observation or 15 minute watch. This will standardize documentation facility wide. 2. Once implemented, these should be reviewed regularly to ensure compliance with the policy.

(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: A suicide risk assessment instrument is not in place.

RECOMMENDATIONS:

1. An Internet search for a suicide risk assessment tool will provide links to multiple websites. Staff can review the assessment tools located on the Internet and determine if any would be pertinent to the facility as is or with modifications. The SAMSHA website has links to several free instruments including the Columbia suicide risk assessment tool which has Internet training available. It is important, however, that suicide detection assessment tools used are validated for jail settings and the specific population being assessed.

2. Screening Tools Assessing Risk of Suicide and Self-Harm in Adult Offenders: A Systematic Review at: http://ijo.sagepub.com/content/early 2010/03/11/ 0306624X09359757. abstract

This systematic review assessed the validity of screening instruments to identify the risk of suicide and self-harm behavior in offenders. A search of 11 electronic databases and grey literature resulted in the inclusion of five studies. The five studies revealed four screening instruments, including the Suicide Checklist, the Suicide Probability Scale, Suicide Concerns

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for Offenders in Prison Environment (SCOPE), and the Suicide Potential Scale. Two

instruments, SCOPE and Suicide Potential Scale, shared promising levels of sensitivity and

specificity. The reporting of information was generally varied across items on the Standards

for the Reporting of Diagnostic accuracy (STARD). Research is needed to assess the

predictive validity of tools for offender populations in the identification of those at risk,

particularly those in probation and community settings.

3. Develop for approval valid suicide screening and assessment tools for initial and follow-up screening purposes.

4. All mental health encounters should record the presence or absence suicidal or homicidal ideation by the mental-health professional performing the service.

(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: Cut down tools were available in the units visited by this reviewer. The Monitor reports that cut down tool was not found in A Dorm as reported in all previous reports.

RECOMMENDATIONS:

1. Cut-down tools must be readily available in all housing units and all officers must be able to rapidly locate and obtain those tools when needed. The tools should be stored in exactly the same location in each housing unit. This will help to ensure consistent and reliable access by staff
2. Cut down tools should be available in all housing areas, and areas where inmates could have an opportunity to harm themselves, i.e. kitchen, medical building, etc.
3. All staff required to use this tool should be well-trained and emergency drills demonstrating proficient use of the tool should be conducted on a regular basis.
4. Supervisors should regularly inventory and audit tool location and make immediate provisions to replace missing or non-functioning tools when found.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: No change since 5th Report. Appropriate training curriculum has not been provided as required. Staff remain inadequately trained.

RECOMMENDATIONS: In addition to the previous recommendations reiterated below, all suicide prevention training must:

1. Comply with the elements of this Provision as stated above; 2. Be corrections-specific; 3. Base lesson plans on current research with regard to:

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a. Inmate populations and characteristics relevant to suicide risks b. Prevalence of suicides and suicidal behavior in correctional settings c. Conditions and circumstances relevant to risk of suicide d. Locations in facilities e. Effects of solitary confinement f. Methods of suicide in correctional settings g. Instruments and items used to attempt/commit suicide h. Safe housing

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: Per the Monitor’s review of training records, and because no approved suicide prevention policy exits, staff have not been trained as required under this provision.

RECOMMENDATIONS:

Previous Recommendations Remain Appropriate:

1. Immediately develop and implement comprehensive pre and in-service suicide prevention training that is 1) evidence based, 2) policy and procedure driven, 3) includes valid and reliable knowledge and application competency evaluation methods. Such training would naturally include detection, recognition, assessment, and intervention topics and materials.
2. Implement policies, procedures, and protocols that govern and control staff response regarding inmate behavioral and/or verbal indications of suicide risk. Governing documents must require initial and ongoing involvement of medical and mental health staff in the response to suicide prevention actions.
3. Suicide prevention is considered a life safety issue that requires, at minimum, quarterly suicide prevention drills involving correctional, medical, and mental health staff to ensure 1) training and response efficacy, 2) effectiveness of policy and procedure, and 3) compliance with the Agreement.

(vii) availability of suicide resistant cells;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: There has been no change regarding the provision of suicide resistant cells for inmates on mental health observation, meaning; there are no suicide resistant cells in use at GGACF. Renovations to the infirmary area have been on hold since the time of our prior site visit. Thus, any inmate placed on observation would most likely remain in their current cell or be transferred to a segregation cell.

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RECOMMENDATIONS: GGACF is encouraged to complete renovations in the infirmary in

order to provide appropriate and safe suicide and close observation cells. As expressed in the last

report, all measures should be taken to provide adequate space within the cell, suicide resistant

sinks and commodes and the absence of any protruding objects within the cell that would

facilitate the placement of a ligature. Please refer to all of the detailed recommendations in the

Monitor's fifth assessment report regarding the configuration and structure of suicide resistant

housing.

The appropriate forms documenting the clinicians orders for security implementation should be developed and then vetted through the process in the settlement agreement

Previous Recommendations Remain Appropriate:

1. Appropriate bedding, clothing, food and utensils, property, and pallet should be specified by the mental health clinician when supervising officer placing an inmate on suicide watch.
2. Retrofit cells designated suicide precautions to be suicide proof. 3. Renovation of an intake cell may be the only immediate alternative. If this environment is
utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates. 4. The following guidelines should be considered when establishing suicide-resistant housing environments:1

The safe housing of suicidal inmates is an important component to a correctional facility’s comprehensive suicide prevention policy. Although impossible to create a “suicide-proof” cell environment within any correctional facility, given the fact that almost all inmate suicides occur by hanging, it is certainly reasonable to ensure that all cells utilized to house potentially suicidal inmates are free of all obvious protrusions. And while it is more common for ligatures to be affixed to air vents and window bars (or grates), all cell fixtures should be scrutinized, since bed frames/holes, shelves with clothing hooks, sprinkler heads, door hinge/knobs, towel racks, water faucet lips, and light fixtures have been used as anchoring devices in hanging attempts. As such, to ensure that inmates placed on suicide precautions are housed in “suicide-resistant” cells, facility officials are strongly encouraged to address the following architectural and environmental issues:

1. Cell doors should have large-vision panels of Lexan (or low-abrasion polycarbonate) to allow for unobstructed view of the entire cell interior at all times. These windows should never be covered (even for reasons of privacy, discipline, etc.) If door sliders are not used, door interiors should not have handles/knobs; rather they should have recessed door pulls. Any door containing a food pass should be closed and locked. Interior door hinges should bevel down so as not to permit being used as an anchoring device. Door frames should be rounded and smooth on the top edges. The frame should be grouted into the wall with as little edge exposed as possible.
In older, antiquated facilities with cell fronts, walls and/or cell doors made of steel bars, Lexan paneling (or low-abrasion polycarbonate) or security screening (that has holes that are ideally
1 http://www.ncianet.org/services/suicide-prevention-in-custody/publications/checklist-for-the-suicide-resistantdesign-of-correctional-facilities/

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1/8 inches wide and no more than 3/16 inches wide or 16-mesh per square inch) should be

installed from the interior of the cell.

Solid cell fronts must be modified to include large-vision Lexan panels or security screens with small mesh;

2. Vents, ducts, grilles, and light fixtures should be protrusion-free and covered with screening that has holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16-mesh per square inch;

3. Wall-mounted corded telephones should not be placed inside cells. Telephone cords of varying length have been utilized in hanging attempts;

4. Cells should not contain any clothing hooks. The traditional, pull-down or collapsible hook can be easily jammed and/or its side supports utilized as an anchor;

5. A stainless steel combo toilet-sink (with concealed plumbing and outside control valve) should be used. The fixture should not contain an anti-squirt slit, toothbrush holder, toilet paper rod, and/or towel bar;

6. Beds should ideally be either heavy molded plastic or solid concrete slab with rounded edges, totally enclosed underneath. If metal bunks are utilized, they should be bolted flush to the wall with the frame constructed to prevent its use as an anchoring device. Bunk holes should be covered; ladders should be removed. (Traditional metal beds with holes in the bottom, not built flush to the wall and open underneath, have often been used to attach suicide nooses. Lying flat on the floor, the inmate attaches the noose from above, runs it under his neck, turns over on his stomach and asphyxiates himself within minutes.);

7. Electricity should be turned off from wall outlets outside of the cell;

8. Light fixtures should be recessed into the ceiling and tamper-proof. Some fixtures can be securely anchored into ceiling or wall corners when remodeling prohibits recessed lighting. All fixtures should be caulked or grouted with tamper-resistant security grade caulking or grout. Ample light for reading (at least 20 foot-candles at desk level) should be provided. Low-wattage night light bulbs should be used (except in special, high-risk housing units where sufficient lighting 24 hours per day should be provided to allow closed-circuit television (CCTV) cameras to identify movements and forms). An alternative is to install an infrared filter over the ceiling light to produce total darkness, allowing inmates to sleep at night. Various cameras are then able to have total observation as if it were daylight. This filter should be used only at night because sensitivity can otherwise develop and produce aftereffects;

9. CCTV monitoring does not prevent a suicide, it only identifies a suicide attempt in progress. If utilized, CCTV monitoring should only supplement the physical observation by staff. The camera should obviously be enclosed in a box that is tamper-proof and does not contain anchoring points. It should be placed in a high corner location of the cell and all edges around the housing should be caulked or grouted. Cells containing CCTV monitoring should be painted in pastel colors to allow for better visibility. To reduce camera glare and provide a contrast in

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monitoring, the headers above cell doors should be painted black or some other dark color.

CCTV cameras should provide a clear and unobstructed view of the entire cell interior,

including all four corners of the room. Camera lens should have the capacity for both night and

low light level vision;

10. Cells should have a smoke detector mounted flush in the ceiling, with an audible alarm at the control desk. Some cells have a security screening mesh to protect the smoke detector from vandalism. The protective coverings should be high enough to be outside the reach of an inmate and far enough away from the toilet so that the fixture could not be used as a ladder to access the smoke detector and screen. Ceiling height for new construction should be 10 feet to make such a reasonable accommodation. Existing facilities with lower ceilings should carefully select the protective device to make sure it cannot be tampered with, or have mesh openings large enough to thread a noose through. Water sprinkler heads should not be exposed. Some have protective cones; others are flush with the ceiling and drop down when set off; some are the breakaway type;

11. Cells should have an audio monitoring intercom for listening to calls of distress (only as a supplement to physical observation by staff). While the inmate is on suicide precautions, intercoms should be turned up high (as hanging victims can often be heard to be gurgling, gasping for air, their body hitting the wall/floor, etc.);

12. Cells utilized for suicide precautions should be located as close as possible to a control desk to allow for additional audio and visual monitoring;

13. If modesty walls or shields are utilized, they should have triangular, rounded or sloping tops to prevent anchoring. The walls should allow visibility of both the head and feet;

14. Some inmates hang themselves under desks, benches, tables or stools/pull-out seats. Potential suicide-resistant remedies are: (a) Extending the bed slab for use as a seat; (b) Cylinder-shaped concrete seat anchored to floor, with rounded edges; (c) Triangular corner desk top anchored to the two walls; and (d) Rectangular desk top, with triangular end plates, anchored to the wall. Towel racks should also be removed from any desk area;

15. All shelf tops and exposed hinges should have solid, triangular end-plates which preclude a ligature being applied;

16. Cells should have security windows with an outside view. The ability to identify time of day via sunlight helps re-establish perception and natural thinking, while minimizing disorientation. If cell windows contain security bars that are not completely flush with window panel (thus allowing a gap between the glass and bar for use as an anchoring device), they should be covered with Lexan (or low-abrasion polycarbonate) paneling to prevent access to the bars, or the gap, should be closed with caulking, glazing tape, etc. If window screening or grating is used, covering should have holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or 16-mesh per square inch;

17. The mattress should be fire retardant and not produce toxic smoke. The seam should be tearresistant so that it cannot be used as a ligature;

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18. Given the fact that the risk of self-harm utilizing a laundry bag string outweighs its usefulness

for holding dirty clothes off the floor, laundry bag strings should be removed from the cell;

19. Mirrors should be of brushed, polished metal, attached with tamper-proof screws;

20. Padding of cell walls is prohibited in many states. Check with your fire marshal. If permitted, padded walls must be of fire-retardant materials that are not combustible and do not produce toxic gasses; and,

21. Ceiling and wall joints should be sealed with neoprene rubber gasket or sealed with tamperresistant security grade caulking or grout for preventing the attachment of an anchoring device through the joints.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: A draft protocol has been submitted to the parties for review and approval. Therefore, this provision remains in noncompliance since there is not an adopted and approved policy in place, training has not begun and no measurements of efficacy of the training exists. And in fact, as mentioned previously, there is observable evidence that little if any observation is provided and documented currently.

RECOMMENDATIONS:

1. Complete the process of policy approval, implementation and monitoring.

Previous Recommendations Remain Appropriate:

1. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15-minute watches.
2. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
3. Renovation of an intake cell may be the only immediate alternative. If this environment is utilized, then the facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates.
4. Suggest a separate inmate log be developed for inmates placed on watch that can be filed in the medical record or by security. This log could indicate property allowed and whether the inmate is on constant or staggered 15-minute watches.

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(ix) procedures to assure implementation of directives from a mental health professional regarding:
(1)the confinement and care of suicidal prisoners; (2)the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: A draft protocol has been submitted to the parties for review and approval. Therefore, this provision remains in noncompliance since there is not an adopted and approved policy in place, training has not begun and no measurements of efficacy of the training exists. Also, according to the psychiatrist's report, there have been no cases of some moist on suicide watch for this monitor to be able to assess this provision.

RECOMMENDATIONS: The suicide prevention policy directing this process is currently under review. Complete the process of policy approval, implementation and monitoring.

Previous Recommendations Remain Appropriate:

1. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
2. It is recommended that the facility develop a form listing each level of observation that would also specify what property the inmate is allowed to have in their possession as well as indicating which staff member has ordered the watch and property restrictions. Consultation with the monitoring team may be a useful assistance.
3. The facility needs to carefully monitor how readily medical and mental health staff can maintain daily contact with the inmates if they continue to be housed in the reception area.
4. The facility needs a policy that reflects the current capabilities and provides the greatest amount of supervision required to safely monitor someone on suicide watch.
5. Renovation of an intake cell may be the only immediate alternative. 6. If this environment is utilized then the facility needs to carefully monitor how readily medical
and mental health staff can maintain daily contact with the inmates.

j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: Since our last visit, two registered nurses departed and one registered nurse was added along with a part-time nurse. There also was one LPN departure. Our understanding is the complete staffing should include four registered nurses and three LPNs. Therefore, there is at least one full-time and a part-time registered nurse vacancy along with two LPN vacancies. In addition, there has not been at least three days a week onsite advanced level clinician coverage. That presence includes the Medical Director. The program needs to insure that

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at least that level of nursing and advanced level clinician staffing are available. Finally, the clerk

position, which has been filled by a temporary staff member, is going to be vacated. We understand

interviews are to be conducted the week following this assessment, and it is important to fill that

position as expeditiously as possible.

RECOMMENDATIONS:

1. Fill the two LPN positions. 2. Fill the 1.5 vacant RN positions. 3. Fill the clerical position. 4. Complete the pharmacy contract situation.

MENTAL HEALTH FINDINGS: Mental health staffing remains inadequate to provide even the most basic services required by a jail and prison. The only mental health professional currently onsite is the psychiatrist. Because of her other obligations, she has only had the time to do focused interviews on new referrals and complete her follow-up chronic care visits. It has been the monitoring team’s recommendations that GGACF require a minimum of two full time QMHPs. Only after providing this level of staffing can it be determined what the need may be for a third professional. The obvious lack of professional staff remains any critical obstacle to the development of any mental health programming within the facility. Currently those inmates identified as seriously mentally ill receive only psychiatric chronic care appointments.

RECOMMENDATIONS:

Hiring of two qualified mental health professionals with the development and implementation of appropriate psychosocial programming essential to the maintenance and treatment of the seriously mentally ill inmates within the facility is an essential requirement for the facility to advance out of noncompliance status.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There has been no change in either the demand for services to be performed in the clinic or the staffing to facilitate access. We have indicated that if the housing unit exam rooms are cleaned, sanitized and appropriately equipped, they can be available to reduce the need for escorts to bring patients for assessments up to the clinic. However, this has still not occurred. In addition, the escort staffing has not improved.

RECOMMENDATIONS:

1. Clean and appropriately equip the exam rooms in the housing units. 2. Provide a second correctional officer for the clinic/infirmary area. 3. Insure that a physician other than the one who works in the clinic accompanies the medication
nurses on their rounds.

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MENTAL HEALTH FINDINGS: There is no progress on this front due to the lack of submission of an adequate and an approved training curriculum to the monitor. Given the absence of any mental health programming plan, it remains impossible for the facility to determine what the adequate number of correctional officers are to properly supervise prisoners serious mental health needs.

We also are aware that mental health services, limited as they are, are still obstructed by the absence of security staff to transport inmates to the clinician as scheduled. One can extrapolate from this statement the fact that adequate staffing by correctional officers to meet the mental health needs of the inmate population are grossly inadequate since the needs of a single mental health provider cannot be met at the current time and; therefore, the needs of at least two additional qualified mental health professionals could not be met either.

Indeed, there exists an egregious clinical example of an elderly inmate with a chronic and persistent serious mental illness who sustained a hip fracture while in segregation (most likely on June 20, 2014) which was unidentified for sufficient time for him to develop a large and obvious decubitus. This advanced tissue breakdown went undiscovered until an inmate helper was called to assist the inmate (July 8, 2014). Most remarkably, he was on daily medications and should have been observed regularly by nursing staff. However, his immobility and probable verbal refusals did not raise suspicion in the nursing staff and were not reported to the psychiatrist by nursing staff or the unit officer. The absence of mental health rounds in segregation also contributed to the delayed identification of this man serious health issues. During his period of confinement there is documentation by the psychiatrist of the scheduled visit that indicates there was no security staff available to transport him to the clinic, and therefore the inmate was not seen. This case also demonstrates irreparable harm to this individual who, as a result of not receiving timely medical intervention, remains permanently non-ambulatory due to contractions of his leg muscles--put simply, he will never walk again. Also very troubling was the fact that this inmate was taken into the yard and showered using a hose, rather than using the shower that was available inside the medical building. These actions demonstrate an unconscionable and deliberate disregard for this inmate’s personal integrity and privacy.

RECOMMENDATIONS: No change from baseline assessment. GACCF will need to develop approved training tools and curricula. These will be presented to the monitoring team for approval and then training and implementation.

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There is a QI policy that we have now reviewed and approved. We are reemphasizing that by utilizing the logs and improving them as recommended, the HSA can begin to facilitate the monitoring of services such as:

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1. Intake processing for completeness and timeliness. 2. Sick call for timeliness as well as for professional performance. 3. Urgent care for completeness and timeliness, including offsite emergency room reports. 4. Scheduled offsite services for completeness and timeliness, including offsite service report. 5. Chronic care visits for timeliness and professional performance. 6. Dental services for timeliness and professional performance. 7. Sick call for timeliness and nursing professional performance.

RECOMMENDATIONS:

1. Implement the QI program with respect to the above service areas.

MENTAL HEALTH FINDINGS: Until policies are approved, trained to, and implemented this provision cannot be met. In addition, since our last visit there have been no meetings of the Medical Administration Committee or the Quality Improvement Committee. Justification for the cessation of these meetings were reported as due to an absence of a medical director.

RECOMMENDATIONS:

Essential monthly or quarterly management meetings should occur regardless of whether a single committee member cannot be present. Although it is useful for the medical director to be present this should not be an essential component blocking communication between medical staff and other department leaders.

m. Adequate dental care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There is an oral care policy which we have approved. We were going to discuss the program with the dentist, but he did not show up on the day he was scheduled. Clearly, there needs to be a strategy to improve the consistency with which the dentist is available. We believe there continues to be a problem with access to dental services because of escort issues.

RECOMMENDATIONS:

1. The HSA should track both the availability of the dentist as well as the availability of custody escorts under the QI program.
2. The dental program should report to the QI program the number of scheduled patients and the numbers who arrive and the reason for non-arrival of patients.
3. The dental program should track the number of extractions as well as the number of restorations performed each month.
4. Develop adequate dental policies, procedures and protocols.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report.

RECOMMENDATIONS: defer to Dr. Shansky’s report.

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n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We provided the territory with a policy from another institution. We have not yet seen the mortality review policy. As far as we understand, there have been no deaths since our last visit and we are awaiting completion of the mortality review policy.

RECOMMENDATIONS:

1. Draft the mortality review policy. 2. Consider utilizing the services of an offsite service clinician to perform an external death review
on all patients who die while incarcerated in Department of Corrections.

MENTAL HEALTH FINDINGS: No deaths were reported this quarter. However, as stated in V.1.k, there has been a case of serious morbidity which has generated no comprehensive combined internal investigation or review by security and health services.

RECOMMENDATIONS

1. The clinical directors, newly hired Director of Nursing and Health Services Administrator should develop mechanisms to identify and review all cases of mortality and serious morbidity as part of the Quality Improvement process. These reviews should also include security leadership.

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We do have a draft segregation round policy but our discussions indicate that there are no consistently held segregation rounds either by medical or mental health staff. . RECOMMENDATION:

1. Draft the policy and procedure and begin insuring that rounds are performed weekly by mental health staff and twice a week by nursing staff.

MENTAL HEALTH FINDINGS: Since the onset of the monitoring teams work at GGACF, mental health rounds in segregation units has occurred on only one occasion. This provision remains in absolute and complete noncompliance.

RECOMMENDATIONS:

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1. GGACF will need to hire adequate mental health staff to meet this requirement.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: As identified at earlier site visits, there is one individual with a chronic and persistent serious mental illness who has been housed in segregation for at least 10 years. His current housing status approximates that of isolation because he has no inmate housed in the cell next to his corner cell. Therefore, he is deprived of even the opportunity of conversing with another individual throughout the course of the day. Inmates in segregation do not have access to radios or televisions either. This monitor also received mixed reports from the inmate population as to the reliability of weekly transportation to the library and their ability to borrow reading materials on a regular basis.

RECOMMENDATIONS:

1. As per the provisions of this Memorandum of Agreement, inmates with serious mental illnesses should not be placed in isolation. However, it is also noted that the facility lacks any specialized programming unit to adequately accommodate the treatment needs of the seriously mentally ill population and is unable to currently provide any relief to the mentally ill inmates in segregation who require heightened programming and structure. The latter however does not relieve the Bureau of that obligation to develop, in a timely manner, the necessary treatment programs and housing requirements for these inmates. The lack of programming and appropriate housing has been an issue identified by this monitor for the past year and half. The Bureau of Corrections needs to develop a corrective action plan with specific recommendations for capital improvements and dates to remedy this deficiency.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: There is observable evidence that without a structured programming area under the supervision of clinical mental health staff, inmates with serious mental illnesses who become symptomatic remain likely subjects of disciplinary charges and sanctions at GGACF.

RECOMMENDATIONS:

1. GGACF needs to develop an effective policy and process to provide mental health review and input into the disciplinary process.

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2. Mitigating factors discovered by the mental health professional must be considered by the

disciplinary committee.

3. Mental health services should track the effectiveness of their input in mitigating sanctions or

terminating sanctions as appropriate.

4. Alternative housing and treatment services are an essential component in diverting seriously

mentally ill inmates committing infractions due to their impaired judgment and mental processing.

Again, it is recommended that GGACF provide appropriate staffing and housing alternatives for

this population. (See V.1.p.)

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This area was discussed in letter (c); additionally, it appears that there have been no changes to the proposed infirmary area since our last visit. This includes no additional equipment and no changes to the housing unit examination spaces.

RECOMMENDATIONS:

1. Complete the infirmary renovations, including the purchase of appropriate equipment and supplies.
2. Appropriately equip the infirmary area, including two dental operatories. 3. Insure that there is at least one more officer available for the clinic/infirmary area.

MENTAL HEALTH FINDINGS: The psychiatrist’s office is currently being used to house a chronically ill inmate who requires 24 hour nursing care. For the last six months, the psychiatrist has been providing services in a small office behind the nursing station. Clinical services are disrupted due to the comings and goings of other staff who also share this office area. Because of the lack of visibility, the office door must remain open to ensure the safety of the psychiatrist. This is an unacceptable office space and fails to meet the requirements of this provision.

RECOMMENDATIONS:

1. Appropriate sound private office space with reasonable visibility by security staff needs to be made available to the psychiatrist and to any mental health professionals that are hired providing services in the medical treatment building. 2. If the infirmary construction resumes then this particular inmate could be housed in a medical observation cell, thereby, allowing the psychiatrist access to her old office space.

Previous Recommendations Remain Appropriate:

1. The facility needs to explore what barriers may exist to providing frequent and adequate services to inmates in special housing in sound private settings.
2. Send the Monitor the plans as soon as a draft has been developed.

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s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS:

1. The psychiatrist was absent during this visit due to a conflict with vacation time offered by her other employer, the local hospital. This reviewer did have the opportunity to speak with her by phone and her willingness to do so during her time off was greatly appreciated. She continues to be the only mental health professional on site. In addition to providing services to the inmates Golden Grove Adult Correctional Facility, she continues to volunteer her time to provide forensic evaluations on GGACF inmates to the court. Each of these forensic evaluations is taking approximately 16 hours to complete. This cuts into the time she has available to see patients for direct services.
2. The psychiatrist’s office in the medical treatment building has been changed in order to accommodate the housing of a seriously ill inmate. For the last several months she has been seeing inmates in what was formerly the head nurses office. This space is not private and is shared by nursing staff. The doctor noted that nurses walk in and out even during her interviews with inmates.
3. Regarding the timeliness and completeness of the medical encounter, it should be noted that the psychiatrist usually sees all referrals within a very timely period, often within 24 hours of referral. Cases sited in this section are examples of some of the exceptions.
4. Too often the mental status examination was incompletely documented. Even negative findings, such as normal mood and affect, should be noted.
5. Inmates on neuroleptic medication do not consistently have documented AIMS examination at the time neuroleptic medication was initiated, semiannually, or at the time they present with signs of an involuntary movement disorder. a. A 37-year-old man was referred after reporting that he was depressed and losing his mind on October 9, 2014. The sick call request was received two days later by medical. On October 16, 2014 there was a very thin response stating that the inmate denied suicidal intent and he was scheduled to be seen by the psychiatrist. He was ultimately seen on October 20, 2014 by the doctor and medication was stopped for torticollis and protrusion of his tongue (likely extra-pyramidal side effects of his medication). No test for extrapyramidal side effects was documented. What should have been triaged as an urgent request took nine days for an assessment to be completed. On his follow-up visit 10 days later no mental status examination was documented in the record.
6. Psychiatric documentation is not always complete with partial details of the examination or history being absent. Every encounter with an inmate by a psychiatrist should have, at a minimum, a brief history of the present illness, a complete mental status examination, a diagnosis and a plan. Deficiencies noted may be due to the lack of efficiencies of the forms being utilized with frequent observations by this reviewer of an absence to record mood, risk assessments, AIMS exams, etc.
7. Delays or failure to provide security for psychiatric visits which could have disastrous consequences.

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a. One inmate was reported to have suicidal ideation at the time of intake on 9/26/14.

He was referred to the psychiatrist who noted on 9/30/14 that the inmate could not be

seen because there was no patrol officer. He was finally seen on 10/30/14 (an

excessive delay considering he was referred because of suicidal ideation, an urgent

issue) and there is no narrative regarding his suicidal risk factors and the nature of his

intake findings. It was noted that the current note only asks for a positive finding of

suicidal ideation but it should always include the absence of any suicidal ideation or

plan too.

8. Complete an inmate Friday refusal form upon intake stating that the inmates refuses any future

treatments with the psychiatrist. Therefore, he was not scared with the doctor for any evaluations

despite previous diagnoses consistent with serious mental illness by a different doctor.

RECOMMENDATIONS:

1. The psychiatrist and mental health professionals must be provided with sound private interviewing space that minimizes distractions and disruptions in order to allow them to establish adequate rapport with the patient when discussing sensitive issues such as mental health symptomatology and history.
2. As previously discussed with Dr. Sang and Mr. Robertson, the facility psychiatrist should not be performing competency to stand trial evaluations since that could compromise her role as the attending psychiatrist for the prisoners. In addition, these activities reduce the power she has available for direct patient services.
3. This monitor will work with Dr. Sang and Ms. Charles to develop new forms that will hopefully correct some of the documentation deficiencies noted during this visit.
4. Inmates should not be allowed to sign a carte blanche refusal for current and future care. A refusal should only stand for the current service being offered. Otherwise, an inmate may be lost to care, especially if their mental illness interfered with their capacity to appreciate the ramifications of refusing treatment during the initial contact. In addition, a clinician cannot refuse to routinely treat an inmate in a correctional facility unless there are other comparably trained individuals who can accept the transfer of care of the prisoner. In addition, for inmates with a serious mental illness, there should always be documentation that their competence to refuse care has been assessed by the proper clinician (generally an MSW or higher).
5. Again attached please find general documentation guidelines, this are not standards but simply recommendations for standardizing the quantity and quality of records:

Mental Health Documentation Guidelines

These guidelines represent minimal requirements for documentation of clinical encounters.

GUIDELINES APPLICABLE TO ALL MEDICAL RECORD ENTRIES: 1. All entries shall be legible 2. Each entry shall list the inmate’s name and MDC number 3. Each entry shall be signed by the clinician and indicate their professional degree 4. All entries shall be dated and timed 5. Current housing location, such as special housing or isolation, should be apparent by reading the chart. 6. Every assessment and clinical visit notation shall follow the SOAP format (unless the documentation is on a required template that is structured differently) and make every effort to

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provide the narrative information necessary for another clinician to understand the writer’s

assessment.

THE INITIAL ASSESSMENTS:

SUBJECTIVE/ OBJECTIVE: 1. The subjective portion of the entry shall contain critical elements required by the DSM (current version) to support the differential diagnosis and global assessment of function. 2. Past history will note pertinent findings such as prior hospitalizations, commitments, periods of outpatient psychiatric treatment and substance abuse treatment, any episodes a self-injury, suicidal ideation are intent and/or significant aggression. In addition, a history of victimization or perpetration of abuse should be noted. Significant medical illnesses and history of traumatic brain injury should be listed. 3. Inquiry into previous work history, military history, prior incarceration, and other significant psychosocial information should be provided. 4. Family history should include any history of psychiatric or substance abuse disorders as well as suicidal behavior in close family members. 5. Substance abuse history including current use and previous symptoms when withdrawing should be entered in the chart. 6. Current medications as well as response to prior treatment regimens should be listed. 7. The mental status examination will contain appropriate corroboration in a narrative form to the symptom checklist. Thus, should the clinician check a box indicating hallucinations, it is appropriate to describe the content and nature of the reported symptom.

ASSESSMENT: 8. All assessments completed by psychiatrists, independently licensed mental health professionals, or nurse practitioners shall contain a full five axis diagnosis based on the American Psychiatric Association's DSM (current version) unless a template form does not require this information.

PLAN: 9. The plan will include medications (or referral for a medication evaluation) if indicated. Referrals for appropriate psychosocial interventions, comments on discharge planning, and a follow-up for general health needs will also be indicated in the plan. In addition, a risk assessment, if indicated, as well as the clinician’s professional opinion as to the degree of risk will be entered. All records will indicate the date (or approximate date (e.g., return in 3 weeks) of the next clinically appropriate follow-up visit. Medical practitioners will indicate laboratory studies, obtain and file the appropriate consent forms, and perform clinically appropriate tests such as the AIMS and the MMSE.

10. Primary Axis I and Axis II diagnoses should be entered on the master problem list by psychiatrists, psychologists and advance practice nurses. Other disciplines may initially list the symptom deficits such as cognitive deficits and thereafter defer to the diagnosis provided by the above specified disciplines.

THE PSYCHIATRIC PROGRESS NOTE:

SUBJECTIVE/OBJECTIVE:

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1. Comments should be entered concerning any reports of side effects or relevant clinical

symptoms presented by the patient.

2. The clinician should comment on any recent PAC admissions, or transfers to segregation and

the impact of those status changes as reported by the inmate.

3. The clinician should indicate the clinical response by the patient to the current treatment plan

and the presence of medication side effects.

4. Significant additions and deletions in diagnostic categories should be substantiated by DSM

(current version) criteria recorded in the subjective portion of the note.

5. The reasons prompting significant changes in medications or the patient’s treatment plan

should be explained by history or findings

ASSESSMENT: 6. Provide an assessment pertinent to the data documented.

PLAN: 7. The appointment designated as the return to clinic time should be clinically appropriate. 8. Laboratory studies should be ordered as clinically appropriate. 9. Any planned interventions are documented

THE INDIVIDUALIZED TREATMENT PLAN:

1. Treatment plans should follow a problem-oriented format. 2. Problems listed should be descriptive and meaningful with measurable goals. 3. The plan should indicate time frames to complete the above goals. 4. Planned interventions are documented 5. A date of the scheduled review of the individual treatment plan will be listed on the chart. 6. All members of the treatment team in attendance shall sign the treatment plan and indicate their professional degree. 7. A notation by the team will also indicate progress made towards previous goals. 8. The patient shall also sign the treatment plan indicating participation and awareness of the established goals.

THE GENERAL POPULATION AND SEGREGATION MENTAL HEALTH PROGRESS NOTE:

SUBJECTIVE/OBJECTIVE: 1. The subjective portion of the note should contain descriptions of any current problems, the inmate's level of activity and function, programs participation, job assignments, family issues, and any other pertinent information. 2. Documentation of any reports of medication issues or side effects 3. A brief mental status examination unless the template does not require that information.

ASSESSMENT: 4. A DSM (current version) diagnostic list as well as an estimate of the current global assessment of function 5. An assessment pertinent to the data documented

PLAN:

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6. A clinically appropriate follow-up appointment

7. A description of the recommended, if any, appropriate psychosocial intervention and an

estimate of the timeframe to complete such treatment. For example, "The inmate will be seen

weekly for four visits focusing on cognitive behavioral therapy for bereavement counseling."

ENVIRONMENT OF CARE:

1. As a general rule, all psychiatric and counseling encounters, including face to face encounters in response to a sick call request and pre-segregation interviews, should be conducted in an area guaranteeing sound privacy. 2. Only segregation rounds may routinely be conducted at the cell front or in a day room area. 3. Variance may be permissible during extended states of lock down, if the inmate is deemed to lack behavioral control, and other crisis situations.

(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: There are no mental health programs currently offered for the inmate population. Since the time of our last site visit, the psychiatrist offered a single group session in addition to the individual visits she provides. The facility has not been able to locate a promising candidate with the proper credentials to hire as a QMHP. In that absence, the psychiatrist has continued to provide psychiatric services consisting of evaluation and the prescription and monitoring of psychiatric medications.

RECOMMENDATIONS:

1. QMHPs must be hired in order for GGACF to begin developing and implementing a mental health treatment program.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: The psychiatrist is doing an excellent job in obtaining vital signs including girth at the time of each visit. However, as mentioned elsewhere the service needs to diligently include a standardized measurement for involuntary movement disorders for the early identification of potentially irreversible extrapyramidal side effects from neuroleptic medication.

It is hoped that at the time of our next visit the medical records will be organized to expedite tracking the ordering of laboratory studies and the location of the results reports in the records. Currently the mental health files have not been collated to reliably support overview in this area.

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RECOMMENDATIONS:

Please refer to the following previously provided suggested minimum guidelines (these are not standards, simply suggestions).

LABORATORY GUIDELINES:

Lithium: 1. Initial (within 3 months of initiating drug) 2. U/A 3. CBC 4. SMAC 5. TSH 6. EKG if over 40 7. Level every one to two weeks after reaching dose of =/> 600 mg day until level stabilizes. 8. Once a plateau is reached levels should be obtained q 4 months.

Tricyclic antidepressants: 1. Initial same as above except a U/A is not required 2. Level every 6 months or sooner if clinically indicated (Dose exceeds daily recommended
dose, etc.)

Atypical Neuroleptics: 1. At least quarterly weights, HgA1C and fasting lipids q six months especially for Clozaril,
and Zyprexa. 2. AIMS (Assessment of Involuntary Movement Symptoms ) initially and q 6 months

Anticonvulsants (Depakote, Tegretol): 1. Hepatitis screen within last three months 2. SMAC 3. CBC with platelet count 4. Monitor levels of Tegretol and Depakene until within a therapeutic range

Chronic use: 1. Level q six months 2. Follow up LFT’s for Depakene

Beta blockers 1. Initial vital signs and follow up pulse and BP whenever dose is changed

Benzodiazepines 2. Baseline vital signs 3. Random UDS q 3-6 months or whenever clinically indicated

Psychostimulants 1. Baseline vital signs 2. Random UDS q 3months

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3. Consider TSH whenever clinically appropriate.

Other reference sources on:

1. practice algorithms include the American Psychiatric Association’s Practice Guidelines at www.psych.org; http://www.urmc.rochester.edu/psychiatry/links/practice-guidelines.aspx
2. AIMS http://www.cqaimh.org/pdf/tool_aims.pdf

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: No documents demonstrating that this training has been adequately provided.

RECOMMENDATIONS: Correctional officers at GGACF should be commended for continuing to comprehensively complete behavioral checklists to initiate referrals for mental health services. However, it is greatly concerning that a seriously injured mentally impaired individual mentioned previously was allowed to languish in segregation with no staff detecting serious impairment that in other circumstances would have resulted in a timely behavioral checklist referral being initiated.

RECOMMENDATIONS:

1. Continue to utilize the Behavioral Checklist process. 2. Conduct a facility quality improvement morbidity review that can be submitted to the
monitoring team for review. 3. A detailed curriculum should be submitted for review to the monitoring team and approval
by the Monitor. 4. Once obtained, training should be implemented with pre-and post-testing or other
performance measures that have been approved by the Monitor. 5. GGACF should ensure the training officer or her records are available at the time of the next
site visit for review by the monitoring team. 6. Develop, implement, and evaluate comprehensive training curricula to comply with
Provision.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: There continues to be no improvement in this area. Inmates with serious mental health issues continue to be maintained in segregation and isolation (in the

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case of one individual) due to the lack of appropriate housing, programming, and coordination

with security and classification. The psychiatrist has continued to encourage the facility to release

one individual from isolation into general population without success.

At the time of our initial site assessment visit, we made recommendations to move the mentally ill inmates out of K unit due to the oppressive environmental issues such as elevated heat, humidity and lack of ventilation. Shortly after that visit, the then-Warden and his staff selected individuals, without input from the psychiatrist, who were deemed to be seriously mentally ill and relocated them to A dorm to meet the recommended accommodations.

On the last day of our site visit in December 2014, this reviewer went to the A dorm in an effort to speak with the seriously mentally ill inmates who have been housed in that area. Upon arriving at the unit it was learned that all of these inmates had been moved back to K unit by Acting Warden Prosper, without notice to or input from the Health Services Administrator, and without notice to or input from the monitoring team or U.S. Department of Justice. In fact, the Health Services Administrator was completely unaware that this housing change had occurred.

RECOMMENDATIONS:

1. Facility leadership continues to fail to include critical medical and mental health staff in decisions regarding housing and programming of the seriously ill inmates. In addition, observations at the time of this visit indicate an ineffective or nonexistent system of communication by the facility leadership to health services leadership. It is strongly recommended that the Warden’s office establish weekly communication meetings between the critical health services leadership (Health Services Administrator, Medical Director, Psychiatric Director, Director of Nursing, etc.) and that the Health Services Administrator coordinate monthly Medical Administration Committee (MAC) meetings occur, documented by minutes and attendance sign in sheets.

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VI. FIRE AND LIFE SAFETY

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment. Draft policies and procedures were completed by the monitoring team in the area of Fire and Life Safety by the December 31, 2014 deadline and were provided to both parties.
FINDINGS: No substantive improvement from previous assessment. The Territory provided this Monitor draft Fire Safety policies and procedures during the July onsite technical assistance visit. However, during that visit the Fire Safety consultant advised the Monitor that he had revised these policies and would thereafter provide them. The monitor reported in his previous report that he had not yet received revised policy drafts despite making a written request. The revised policies and procedures were not provided to the monitoring team during or after the December 2014 monitoring visit. However, the monitoring team completed a draft version of the GGACF Fire Safety policies and procedures and provided them to both parties by the December 31, 2014 deadline. The staff training and implementation of these policies and procedures remains vital.
Inadequate housing unit staffing levels and contraband control practices continue to enable inmate-caused fires in housing units. For example, according to a November 10, 2014 memorandum from Acting Warden Prosper directed to Director Wilson, Prosper reports that a “Semi Riot and Officer Assault” occurred in 9 Alpha Housing Unit. Although this memorandum does not capture the full extent of the incident in terms of the force used by GGACF staff to quell the disturbance, it does indicate that the majority of the inmates were let out of their cells by another inmate and lit several mattresses on fire, thus creating considerable smoke in the Housing Unit. Video of the incident shows several inmates out of their cells and three separate fires in the unit. Even though the video and photos of the fire damage provided by BOC staff reflect substantial fire and smoke damage, the Fire Safety Consultant was not notified to investigate the incident, from a fire and life safety perspective. This is an unacceptable fire and life safety practice.
Beside the November 10, 2014 memorandum, there were no other documents provided to the Monitor indicating that an investigation of this event took place or whether an adequate post fire-incident review was conducted by GGAF administration or the Fire Safety Consultant. As evidenced above, incident reporting and investigations at GGACF remains woefully inadequate.

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This incident alone, clearly continues to demonstrate how dangerous incarceration and

employment as a corrections officer at GGACF can be. The automatic fire detection and

suppression system remains inoperable, inadequate staffing levels and contraband control

leaves housing units deleteriously under controlled and monitored, inmates apparently have

undetected and interrupted access to items to ignite fires, and inmates obviously have no

inhibition about starting fires.

During this monitoring visit we were also informed about a very serious and potential life threatening electrical explosion that occurred in the Kitchen in the month of October 2014. This incident was investigated by the Fire Safety Consultant and he found that the electrical explosion was caused by a short circuit in an oven. The Kitchen was evacuated and fortunately they found no gas leak. However, it could have been a disastrous situation, but averted by an electrician who promptly found the source of the ignition in an oven where the electrical wires were burning. The near disastrous situation, according to the Fire Safety Inspector, was that the Kitchen could have blown up with gas accelerant that is used to operate the food service stoves, ovens and other equipment. This near disaster was further exacerbated by having an untrained officer assigned to the Kitchen who did not know the location of the valve to shut of the gas feed to the Kitchen. Apparently, this officer was filling in for the regularly assigned Kitchen officer. Certainly, this incident, at a minimum, reflects the need to regularly inspect the food service equipment for functionality and electrical dangers, as well as the overall Kitchen electrical system and the need train all staff regarding fire safety emergencies and the location of electrical, water, and gas shut-off valves.

During our inspection of the Kitchen, we also observed exposed electrical wiring throughout various areas of the Kitchen; boxes stacked in the dry storage area nearly up to the ceiling (should be stacked no higher than 30 inches below the ceiling); and the fire alarm panel box had trouble lights blinking. Also, the Kitchen log book notes that that upon arrival to open the kitchen the stove was found to be on. These findings reveals the urgent need to develop and implement a comprehensive fire safety program at GGACF.

The Fire Safety Inspector reported that the facility has provided copies of the Fire Evacuation Plans to the VI Fire Marshal; however, those evacuation plans only address the housing units. Furthermore, there is no documentation available to demonstrate that even those limited evacuation plans were approved by the VI Fire Marshall. A comprehensive fire evacuation plan that includes all areas and buildings within the confines of GGACF and the contents of the overall fire safety program, such as the fire safety policies and procedures, needs to be developed and provided to the VI Fire Marshal for review.

Further detracting from the fire safety program at GGACF, we were informed during this monitoring visit that the Fire Safety Consultant’s contract was in limbo and his contract with the BOC is on a month to month renewal basis. It is of critical importance that a contract or other method of employment remains in place for a qualified individual to oversee the fire safety program at GGACF. The Fire Safety Consultant also provides fire related services to the St. Thomas facility as well.

RECOMMENDATIONS: Previous recommendations remain appropriate. Additionally, the Monitor continues to request the reports for all drills and exercises conducted. It is also that

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when the GGACF Fire Safety Program and the Fire Safety Plan are finalized, that they be

provided to the Fire Marshal and with a copy to the Monitor.

1. Finalize and implement fire safety policies once approved and according to the Monitor’s schedule by 12/31/14.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all
locations where staff would need to search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate
supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security. 7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program. 8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action. 9. The fire inspection program is now detailed in the draft fire safety policies and procedures that the monitor provided to the parties, and they should become a fundamental element of pre-and in-service training.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Almost Identical to previous Monitor’s reports, we found that the Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, cell and housing unit sprinklers are non-functional and regularly used by inmates to support personal clotheslines. The primary fire detection and suppression system was designed to automatically detect and extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates.

An adequate supply of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures.

GGACF staff continue to indicate that sprinkler heads may be replaced in the “newer” buildings at some point in 2015. We were provided with a letter, dated November 24, 2014, directed to the Department of Interior from the BOC Director requesting to allocate funding to aid in the replacement of the fire suppression system and for refurbishing the Kitchen at GGACF. However, the scope of work for the fire suppression system seems to only include the purchase and installation of fire sprinkler heads and related parts in areas of the Facility

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where there is a fire sprinkler system, but does not seem address to the need to install a fire

sprinkler system such as in the old housing units where there is no fire sprinkler system. This

needs to be clarified. The estimated cost for the fire sprinkler heads and related parts is

approximately $89,700.00. Moreover, GGACF plans to continue to house individuals in the

“older” buildings, and has no plans to update or install fire suppression equipment in those

buildings. GGACF will never come into compliance with these provisions if that remains the

case. GGACF staff provided a verbal estimate of the cost to upgrade the fire/smoke alarm and

fire sprinkler system at a cost of approximately $230,000.00; however, all facility upgrade

projects are dependent on funding allocation.

RECOMMENDATIONS:

1. Refer to recommendations above (a). 2. Consider purchasing fire safety program software from NFPA and/or the American
Correctional Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. GGACF staff indicated that fire drills are not conducted on a regular basis and that there were none conducted for the last quarter. As reported in earlier Monitor reports, it is unclear when, if ever, full fire drills are conducted. The failure of GGACF staff to conduct fire drills continues to put inmates at risk of injury or death, should a fire break out that cannot be suppressed by the hand-held fire extinguishers present in the officer control pods of housing units.

During our inspection of the Housing Units, GGACF staff indicated that the emergency set of keys is kept in the office of the Chief of Security. However, this is problematic because when he is not present at the facility, no one has access to his office and the emergency keys. A set of emergency keys need to be made available to all security supervisors in a secure, but accessible location of the facility at all times. At another Housing Unit we were informed by GGACF staff that there is a set of emergency keys located in Master Control. There needs to be a clear and concise understanding by all security staff as to where the facility emergency keys are kept. Some emergency keys for fire exit doors are kept in the housing unit control centers; however, staff took considerable time to locate the proper emergency exit keys in Housing Unit G.

Emergency keys are not appropriately marked and identifiable by touch. A system for marking and identifying all emergency keys that match the proper door locking mechanism needs to be developed and implemented.

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RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above. Train
and drill staff as discussed on system use. 3. Develop emergency key and locking mechanism inspection and reporting system as
discussed above. 4. Implement competency-based staff training as discussed above. 5. Exercise fire safety program using onsite, scenario-based drills; include community
responders in exercise planning and exercise events. 6. Send the training officer and part-time fire safety officers to the National Fire Institute,
National Emergency Training Center, Emmetsburg, MD for additional training.

d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell;
and; (ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Almost identical to our previous monitoring report, documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance.

There is not a written preventative maintenance program or a regular security inspection program in place for checking that cell locks are functional and are not jammed from the inside or outside of the cell nor a system for ensuring that all facility remote locking cell mechanisms are functional. During the monitoring visit we observed evidence of inmates possessing materials such as, small blocks of wood or paper and other materials for jamming the cell locks. We also observed numerous housing unit grills whereby the locking mechanism was inoperable.

There is also no position for a locksmith at the facility; therefore, the Maintenance Supervisor has to assume the duty of working on the locking system as well as supervising the Maintenance Department. We also observed that the R and D entrance doors are still inoperable from previous monitoring visits.

RECOMMENDATIONS: Same as above.

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems. 3. Repair all remote cell locking notification technology.

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e. Testing of all staff regarding fire and life safety procedures;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Although the Fire Safety Inspector reported that he is involved in training staff on fire and life safety procedures, we were unable to ascertain its’ validity because as stated in the previous reports and in our current site visit, no records have been provided to verify that all staff have been trained and tested on safety procedures.

RECOMMENDATIONS:

1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
2. Provide this Monitor documentation evidencing compliance with this Provision.

f. Reporting and notification of fires, including audible fire alarms;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The fire reporting and notification system remains inoperable as reported in previous Monitor reports. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a hand-held air horn to alert inmates’ evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. As identified in previous Monitor reports and consistent with this inspection, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.

During this monitoring visit we observed that GGACF has had the necessary equipment for installing a manual fire alert notification system stored in an office for about two (2) years. It appears that in order to install this system, the facility needs to provide the necessary electrical components. It is mind boggling that management staff have not intervened in ensuring that, at a minimum, the manual fire alert notification system was given priority and installed promptly instead of being stored in an office for two (2) years.

RECOMMENDATIONS:

1. Install and routinely test the stored file alert notification system without delay 2. See previous fire safety recommendations

g. Evacuation of prisoners threatened with harm resulting from a fire;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously stated, the fire evacuation policies have not been approved and no evacuation drills were conducted during the preceding quarter.

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RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves community
emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as previously stated. There is no functional fire suppression system. Additionally, and as stated in the previous report, officers do not follow basic fire safety practices when suppression fires. This was demonstrated when an officer use a water bottle to extinguish an inmate-made fire using an unknown flammable liquid. The officer used water from a water bottle rather than the readily available and functional fire extinguisher. Using water on an unknown flammable liquid could have triggered an explosion in the housing unit and exposed all persons present to very serious harm.

RECOMMENDATIONS:

1. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.
2. Repair the automatic fire detection, notification, and suppression system. 3. Replace cell sprinklers with tamper proof mechanisms. 4. Monitor staff response to fires, ensure they comply with basic fire safety principles, and
implement appropriate staff corrective action as needed.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The requirements for this provision are addressed in the draft Fire and Life Safety Policies and procedures that were provided to the parties in December 2014. Once approved, staff must be trained on them and they need to be fully implemented.

RECOMMENDATIONS: 1. The comprehensive fire safety program development must involve health care leadership to
ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 2. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 3. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 4. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.

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j. Control of highly flammable materials.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There seems to have been slippage from the previous inspection because we found that many inmate cells contain considerable personal property, thus creating a fire and safety risk. The Monitor provided a draft policy and procedure dealing with the Control of Chemicals, Flammables, Toxic and Caustic Materials to the parties which substantially addresses this provision.

RECOMMENDATIONS: Same as above.

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VII. ENVIRONMENTAL HEALTH AND SAFETY

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Documentation was provided during the previous monitoring visit that demonstrated ongoing efforts of GGACF officials, maintenance supervisors, and the Fire Safety Consultant to assess, improve, and monitor facility sanitation and hygiene. Draft policies were provided to this Monitor for review prior to the Court ordering the monitoring team to write draft operational policies. The Monitoring team reviewed and further revised these policies and procedures and provided them to both parties in December 2014.
Again, however, housekeeping and sanitation plans will not be meet compliance with this Provision without adequate staffing levels as previously stated.
During our review of the Maintenance Department we observed that the Maintenance Supervisor maintains preventative maintenance schedules for various components of the GGACF physical plant, including the emergency generator.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.

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7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this

program are trained in proper cleaning methods and use of materials and chemicals. Ensure

mattress storage areas are sanitary at all times.

8. Repair all housing/cell windows to prevent penetration by insects.

b. Adequate ventilation throughout the facility;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated).

The Maintenance Supervisor indicated that the housing unit exhaust system was not properly designed to operate effectively, compounded by the severe problem that most of the exhaust fans are not even operable.

The Monitoring team was provided with a draft proposal regarding a Detailed Energy Audit conducted by Energy Systems Group, dated November 10, 2014. This proposal includes measures to retrofit the lighting system, the air conditioning system, the PV Panels and for conducting plumbing upgrades at the Facility at an estimated cost of approximately $8,425,106.69. Certainly these upgrades are necessary for the continued operation of GGACF. However, we also caution that concomitant with physical plant repairs, the facility needs to ensure that there are adequate preventative maintenance systems in place, the availability of spare parts for conducting repairs and adequate maintenance staffing levels to maintain the systems. Furthermore, the Facility needs to ensure that there are adequate levels of trained correctional officers and supervisors available in order to properly supervise the inmate/detainee population and especially within the housing units, in order to prevent vandalism and costly repairs of these systems.

RECOMMENDATIONS:

1. Timely complete an air quality assessment performed by a qualified provider. 2. Implement necessary improvements that reduce housing area and cell temperatures and
increase air flow. 3. Medical and mental health staff should monitor all inmates for heat and airflow-related
health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions. 4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors. 5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions.

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6. Medical and mental health professionals should closely monitor inmates being administered

medications that are adversely affected by high body temperatures and take appropriate

steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Attention to lighting repair and replacement remains positive. However, security staff are allowing inmates/detainees to cover their cell lights, which is creating a fire hazard.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and
internal illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness. 6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that impedes good visibility from the cell door window. 7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are reliably operational.

d. Adequate pest control for housing units, medical units, and food storage areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Very little change since previous inspections. This provision remains in Partial Compliance but no decline in performance was found. In the Kitchen we found flies as well as insects in the inoperable refrigerator. Inmate accounts and at least one logbook entry indicate the presence of insects in food. We also noted that the overhead door to the storage area of the Kitchen is not properly sealed and rodents and vermin can easily infiltrate the Kitchen. Inmates in the housing units complained of mosquitos. Some inmates have lit “wicks” made, apparently, of toilet paper on their cell windows, hoping that the smoke will deter mosquitoes. We also observed missing or broken screens on many facility windows.

GGACF staff reported that they have a contract for pest control services; however, we were not provided with a copy of such contract.

The Monitoring Team developed a draft Vermin and Pest Control Policy and Procedure that was provided to both parties in December 2014.

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RECOMMENDATIONS: Previous recommendations remain appropriate

1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: PARTIAL COMPLIANCE – No substantive improvement from previous assessment.

FINDINGS: There was no substantive improvements from previous assessments. Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies. However, there were a number of inmate complaints in the Housing Units claiming they do not have sufficient quantities of cleaning materials to properly sanitize the showers. We observed that many inmate showers are in deplorable condition both from a sanitary standpoint, including mold problems and physical plant deterioration.

The Monitor provided the parties with draft policies and procedures for this area of Environmental Health and Safety.

RECOMMENDATIONS:

1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Continue to provide adequate supply of these personal care items in control pods or housing
units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in their
cells and living areas.

This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change from previous assessment.

There is no formal sanitation plan or protocols covering compliance with this Provision nor a form training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling bio-hazardous materials, provided and instructed on the proper use of bio-protective clothing and supplies, and supervisors must closely monitor bihazard clean-ups. Remaining in Partial Compliance with this Provision can jeopardize the health of staff and inmates.

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During the inspection of the medical department we asked the assigned officer where the biohazard spill clean-up kits were maintained; however, the assigned officer could not locate them. After some time, the Health Services Administrator showed us where they are maintained in the medical area. Even though it appears that the medical department is the central storage area for bio-hazard clean-up kits, the Health Services Administrator does not recall the last time anyone asked for such a kit.

RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for biohazard safety and exposure control; B. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all biowaste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a biohazardous control program that involves regular inspections of all potential contamination areas.
2. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
3. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

g. Mattress care and replacement;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: I did not see this area to be problematic during this monitoring visit. There were no inmate complaints regarding their mattresses and the ones I inspected were adequate. However, GGACF staff have not yet substantially addressed the Monitor’s previous recommendations as listed below, including mattress care.

RECOMMENDATIONS:

1. Refer to previously discussed sanitation recommendations. 2. Issue clean and usable mattresses to all inmates. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and contraband,
cleaned and sanitized.

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5. Maintain reliable records that verify mattress inventories, cleaning and maintenance

requirements.

h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change since previous assessment. Implementation of approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff who supervise inmates allowed to handle these chemicals must be properly trained in that role and those responsibilities. This has yet to occur.

The Monitor provided the parties with a draft Control of Chemicals, Flammables, Toxic and Caustic Materials policy and procedure which incorporates this Provision.

RECOMMENDATIONS:

1. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
2. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.
3. This provision can advance to Substantial Compliance once related policies and procedures are approved and implemented according to the Agreement.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously reported, housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports and found during this monitoring visit, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets, and dry these items in their cells using clotheslines anchored to fire sprinkler heads, walls, window frames, bunks, etc. We also observed worn out linens and dirty linen in many inmate cells.

The Monitor provided a draft Inmate/Detainee Clothing, Bedding, and Linen Supplies policy and procedure to both parties in December 2014 that addresses the requirements of this Provision.

RECOMMENDATIONS:

1. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks.

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2. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their

cells.

3. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of

bedding.

4. Review, revise, develop, train, implement, and evaluate a comprehensive laundry

management plan that governs total laundry operations.

5. Develop specific policies and procedures for handling, containing, and washing

contaminated clothing, linens, and mattresses.

6. Consider replacing all wood laundry carts made of non-absorbing materials that can be

sanitized and completely cleaned. Discontinue the practice of moving laundry on carts that

has not been cleaned and sanitized.

7. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue

shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing

should be exchanged with clean items twice per week at minimum, sheets and towels once

per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing,

linens or bedding should be changed immediately if they appear damaged and/or unsanitary,

or appear to present a risk to health.

8. Ensure that inmate handbooks provide clear rules and information about the laundry

program, how to access clothing, linens, and bedding. Cease the practice of allowing

inmates to wash clothing in housing unit or cell sinks and toilets.

9. Staff and inmates involved in the laundry work program should be properly trained and

supervised.

10. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Territory officials report the initiation of a major project to repair and clean-up the kitchen area. A scope of work for the project was submitted to the BOC Director on July 11, 2014. However, it is not clear if funding has been approved for this project.

The physical plant of the Kitchen has substantial deterioration as does the food service equipment. We found the flooring to be substandard with numerous broken tiles resulting in standing water and unable to properly clean and sanitize it. The dishwasher has not being working properly for a lengthy period of time. We observed numerous plumbing leaks throughout the Kitchen. We observed inoperable ovens. There is an inoperable walk-in refrigerator that is unsanitary and had insect infestation, along with a foul smell. There is no hot water in the inmate bathroom to properly clean their hands, nor was there soap readily available. It was not possible to check food temperatures because there was no food thermometer in the Kitchen. We observed the presence of flies and other insects in the Kitchen. The kitchen doors are not rodent proof. We observed an inmate putting food in the trays who had a beard but was not wearing a beard guard. Inmates in the housing units complained of seeing hair and insects in their food trays. We found that there is no master inventory of the utensils and dangerous implements. The Territory still has not implemented a utensil checkin/out system to monitor tool/utensil inventory.

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The Monitor provided the parties with draft Food Service Sanitation and Hygiene policies and procedures that can serve as the foundation for the food service program once they are approved and implemented and staff are trained on them.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with nationally recommended allowance for basic nutrition; F. Prohibitions of using food as a disciplinary measure; G. Involvement of independent outside sources to verify food service facilities and equipment meet government safety codes; H. Prescribes regular cleaning schedules including routine deep cleaning; I. Provide written utensil control methods similar to those used by the tool shop; J. Accident prevention program; K. Personal and environmental sanitation requirements; L. Food temperature monitoring and records keeping; M. Adequate health protections for all staff and inmates including health screens and prohibitions against working in the kitchen when ill; N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that all bathrooms and wash basins are consistently supplied with antibacterial soap and hot water; O. All areas and equipment related to food preparation, distribution, and storage require frequent inspection to ensure they are sanitary, operational, and safe; P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit; between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the final rinse. The person conducting inspections should be a qualified food service inspector; Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit, refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees Fahrenheit or below, unless national or state codes specify otherwise; R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit and cold foods at approximately 41 degrees Fahrenheit; S. Supervisory food service staff should monitor food service operations to ensure that that cooking, cooling, and food temperatures and delivery meet established requirements;

3. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care.
4. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented.

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5. Policies and procedures developed should include controls for the use of caustic, toxic, and

hazardous materials used in the kitchen. Material Safety Data Sheets should be posted

conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No improvement was again observed in the housing units during this assessment.

The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lock down. Access to drinkable water is generally available during the “out of cell” periods but inmates must rely on the presence and actions by officers following lock down. Inmates have no access to drinkable water when there are no officers on the units to provide it and water from cell-sinks is considered not safe for drinking.

This problem was again particularly acute in X dorm, per interviews with X Dorm prisoners, officers and our observations. There is no sink or fountain available for providing drinking water, and the women reported that in lieu of drinking water, correctional staff deliver large buckets of ice from which the women chip chunks into individual cups and allow to melt overnight to provide water the next day. This practice is unsafe and falls far below constitutional standards.

Further exacerbating the problem is the lack of cooling and ventilation in theses housing units. We found these Housing Units to be unbearably hot, both for the inmates and the staff.

RECOMMENDATIONS:

1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable access to safe drinking water.
2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This Monitor has repeatedly requested, over a period of months, all pre-service and in-service training curricula and related documents. The Territory has not provided any such material.
RECOMMENDATIONS:
1. Implement training policies and curricula once approved. 2. Provide this Monitor and DOJ all requested training documents.
b. Pre-service training for all new employees;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS:
1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.
c. Periodic in-service training and retraining for all employees following their completion of pre-service training;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS:
1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

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d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Provide the Monitor all training program curricula and completion of training reports. 2. Provide the Monitor with documentation on how compliance with this provision is being
met. 3. Develop a basic spread sheet that allows the Monitor to clearly determine the following:
 Total authorized staff per category (correctional, supervisory, civilian, contract, etc.)  YTD actual staffing levels per category, preferably by month  Number and percentage of current staff in each category who have completed required
pre and in-service training, per month

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IX. IMPLEMENTATION

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.
FINDINGS: This Monitor completed and issued a revised Schedule as directed by the Court. Policy and procedure drafts were provide to the Territory on 12/31/14 as directed by the Court.
2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.
FINDINGS: Same as above.
3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.
FINDINGS: This Monitor issued policy and procedures drafts as on 12/31/14 as directed by the Court. The Monitor’s Schedule includes deadlines for all document reviews and implementation in accordance with this Agreement.
4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.
FINDINGS: There have been no semiannual impact evaluations submitted by the Territory. The reports submitted do not include evaluation of progress.

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5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.
FINDINGS: The Territory will propose modifications to the Monitor’s draft policies and procedures by 1/30/2015. The Monitor and DOJ shall thereafter provide written objections, if any, as needed. This Monitor will assist the parties resolve and related disputes.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
FINDINGS: The December 5, 2014 Status Report largely provides inadequate information to reliably assess or evaluate progress toward compliance. The information provided does not link progress to compliance.
7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.
FINDINGS: Documents provided were inadequate to assess compliance with this requirement. However, a review of the incident log, medical records, and incident reports indicate that the Territory has failed to notify this Monitor and DOJ of all incidents requirement emergency medical attention for inmate injuries. This issue will be further assessed during the upcoming site assessment.
8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.
FINDINGS: The Territory failed to provide all documents requested prior to this assessment visit. Documents requested to adequately conduct this assessment are similar to those requested for all previous assessments. Significant delays in submission of requested documents and information disabled a complete and thorough site assessment. It is hope that the Territory will furnish the monitoring team and DOJ all requested documents in a timely manner going forward. This Monitor intends to seek Court intervention, if required, to obtain all requested documents authorized under this Agreement.

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9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.
FINDINGS: This assessment experience numerous unnecessary delays and disruptions due to management interference with DOJ obtaining access to the facility. The Acting Warden ordered one DOJ attorney to exit the premises due to their apparel – a business suit. This event caused an unnecessary delay and disruption to the monitoring process. Upon being advised of the reason for this delay, this Monitor asked the Acting Warden to contact BOC Director Wilson to verify her order to remove the DOJ attorney from the premises. The Acting Warden refused to contact the Director and refused to provide this Monitor the Director’s telephone number stating, “I don’t need to call him, I made this decision.” This Monitor respectfully reiterated that request but was denied the information; the Acting Warden stormed out of the meeting room, reportedly grabbed her purse and left the facility, and did not involve herself in much of the assessment process thereafter. This Monitor was eventually provided the Director’s telephone and called the Director. The Director quickly returned to GGACF and advised the Acting Warden and other staff to allow facility access to DOJ attorney. He then departed from the facility. Around noon (same day), the DOJ attorney was again prohibited access to the facility for the same reason. This Monitor again contacted the Director who returned to the facility and resolved the matter.
The event seemed to demonstrate disparate enforcement of facility access policies and vivid insubordination to the Director’s orders by certain GGACF staff. The event caused a troubling and absolutely unnecessary disruption to the assessment process and waste of limited onsite assessment time. Going forward, this Monitor prays that GGACF staff and management officials will afford the monitoring team more respect and consideration for the assessment process and work we are obligated to complete while onsite.
10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.
FINDINGS: This Monitor believes that DOJ continues to experience considerable delays in Territory responses to written questions/requests for information concerning compliance with the requirements of this Agreement. This Monitor defers to DOJ for more specific information concerning compliance with this requirement.
The Monitor requests court intervention to remediate this ongoing problem for the monitoring process.

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X. Monitoring

D.1. Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.
FINDINGS: This Monitor complied with this requirement before conducting the Baseline visit in September 2013. This Monitor continues to provide the parties this information prior to, during, and following each onsite assessment.
D.2. Monitoring Access: With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility and Detention Center, all facility non-privileged records, prisoners' medical and mental health records, staff members, and prisoners, Defendants will direct all employees to cooperate fully with the Monitor, Reasonable advance notice must be provided to the Bureau of Corrections prior to conducting any on-site compliance reviews. Other than as expressly provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. All nonpublic information obtained by the Monitor will be maintained in a confidential manner,
FINDINGS: The Monitor has consistently provided reasonable advanced requests for documents and information that are essential for carrying out his duties required and authorized within this Agreement. As previously discussed in this and previous reports, the Monitor (an USDOJ for that matter) continues to experience significant delays in receiving requested documents and information and not received some requested documents at all.
The Monitor, hereby, respectfully requests intervention from the Court that will permanently remedy this ongoing problem.

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APPENDIX A ASSESSMENT METHODOLOGY

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.
Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.
Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.
1. Description of how the Monitor will assess compliance with each of the Compliance Measures.
In general, compliance assessment will include the following activities:
A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning. I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.

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J. Examination of any and all available records, data, and/or information relevant to

compliance and compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Incident reports and logs

 Evidence / contraband reports and logs

 Use of force incidents and logs

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (noncompliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
 Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.

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 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.

 Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or

consumer satisfaction).

 Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of

consumer satisfaction, a performance indicator might be: “the percentage of consumers who

state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)  Online media information  Online public records  Electronic and standard mailing of information  Email communication and phone consultations

3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for the Baseline and subsequent visits and monitoring includes the following. Many of these documents were not provided at the Baseline and second visit as requested but more were provided during the second and third visits. Territory officials

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stated that they intend to continue to generate and provide the requested documents. It is important

to reiterate the need for the documents listed below. Considering the size of this list, and

GGACF’s limited staff and technical resources, the Monitor intends to assist the Territory in

narrowing this list to the most salient items. Documents in bold below have either not been

provided or have not been updated but are necessary for effective monitoring.

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months.

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23. Records and/or lists of physical improvements, repairs, and renovation completed to

correct security problems and deficiencies over the past 36 months.

24. Past 36 months of agency budgets.

25. List and contact information for any and all community vendors who provide services

of any kind to GGACF and contracts or professional services agreement authorizing

those services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of
their records. 31. To the extent not provided above, the policies and procedures governing medical and
mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers,
including on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to
include health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment.

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46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location.

47. To the extent not provided above, external and internal reviews or studies of medical or mental

health services including needs assessments and any American Correctional Association and

National Commission on Correctional Healthcare reports.

48. List of all inmates placed in restraints, and all inmates receiving mental health

treatments, under suicide watch, or taking psychotropic drugs.

49. Current mental health case list including inmate name, number, diagnosis, date of intake, last

psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed

only by counseling staff with last appointment date and follow-up appointment.

50. Documentation reflecting any training that facility staff have received on suicide

prevention, including certificates and training materials.

51. All documents related to the any suicide occurring within the past year.

52. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms
utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and
investigative reports of all inmate suicide victims within the past three years. 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications
for the past year. 66. A description of medical and mental health’s involvement/input into the disciplinary
process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

 
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United States Virgin Islands
GOLDEN GROVE ADULT CORRECTIONAL FACILITY

St. Croix, VI
SEVENTH COMPLIANCE MONITORING REPORT

2013 Federal Court Settlement Agreement
 In re: United States of America v. The Territory of the Virgin Islands (86/265)

Submitted May 31, 2015
 Kenneth A. Ray, M.Ed., Monitor


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“Progress is the attraction
that moves humanity”
Marcus Garvey

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Kenneth A. Ray, MEd, Monitor

TABLE OF CONTENTS

Topic

Page

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

1

Purpose……………………………………………………………………………..

2

Executive Summary & Findings Overview………………………………..……

2

Section IV. Safety and Supervision Compliance ………………………………

6

Section V. Medical and Mental Health Care Compliance …………………….

42

Section VI. Fire and Life Safety ………………………………………………… 70

Section VII. Environmental Health and Safety ………………………………… 78

Section VIII. Training ……………………………………………………………. 87

Section IX / X. Implementation / Monitoring…………………………………… 89

APPENDIX A

Compliance Assessment Methodology ……………………………………………. 93

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PURPOSE

The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) as a tool to assist U.S. Virgin Island officials in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.

EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW

The seventh onsite compliance monitoring assessment was conducted during weeks of March 2­ 5, 2015 and April 23-25, 2015 due to scheduling conflicts with the monitoring team caused by weather-related delays, and included an onsite Court status conference on Thursday, March 5th. Prior to this site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite assessment.

This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.

Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:

“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”

Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provi ded to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing this final report.

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The Monitor will advance each provision as certain levels of compliance progress are clearly

demonstrated by the Territory. Generally speaking, the Monitor will advance provisions from

noncompliance to partial compliance when compliance efforts demonstrate the following:

1. Policies, procedures, protocols, and/or plans required of a provision are properly approved in accordance with this Agreement;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented. Implementation includes evaluation that implemented policies, procedures, and training are performing within the expectation of this Agreement.

Provisions are eligible to advance from partial to substantial compliance when efficacious assessment and evaluation of implemented policies, procedures, protocols, plans, etc. quantitatively and/or qualitatively evidence: 1) that implementation efforts are producing outcomes intended in the Agreement and 2) that implementation outcome performance is reliable (assessments and evaluations evidence consistency in producing outcomes intended in the Agreement). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately demonstrated using appropriate compliance evaluation methods and measures, this Monitor will and has reversed a compliance rating when the evidence supports doing so.

This assessment found reasonable cause for the Monitor to reverse two Provisions from Partial Compliance to Non Compliance. Provisions IV.B.1a (Contraband) was downgraded due to decreases in security searches, Provision IV.D.a (Security Staffing) was downgraded as a result of occupied housing units continuing to not be staffed and continued inadequate shift supervision staffing levels. Consequently, overall assessment ratings are slightly lower from the previous assessment. 110 (92%) of the 120 Provisions are now rated in Noncompliance; 10 (8%), Partial Compliance; and, none are rated in Substantial Compliance. The score card below shows current compliance ratings.

GGACF SEVENTH COMPLIANCE ASSESSMENT SCORE CARD

Areas of Compliance Per Agreement

Total Provisions

IV. Safety and Security

59

V. Medical, Mental Health, & Suicide Prevention

36

VI. Fire and Life Safety

10

VII. Environmental Health and Safety

11

VIII. Training

4

Total Substantive Provisions

120

Percent Compliance

100%

Non Compliance
55 36 10 5 4 110 92%

Partial Compliance
4 0 0 6 0 10 8%

Substantial Compliance
0 0 0 0 0 0 0%

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SEVENTH ASSESSMENT FINDINGS OVERVIEW:

Compared to all previous onsite assessment, this visit was well organized and attended by Territory, BOC, and GGACF officials and staff. Acting Director Benjamin took charge of our initial meeting and set very professional expectations for his staff to fully cooperate and collaborate with the monitoring team and USDOJ. The GGACF compliance coordinators ensured timely access to the facility and available documents, though several requested documents required post-visit follow up and submission, and staff could not find the requested Supervisor’s Logbook for January 15, 2015, to February 27, 2015. All GGACF staff participated openly and seemed to answer all questions honestly. Access to the facility was much more fluid and timely. Officials from the VI Fire Service also participated and provided valuable information with regard to a forthcoming mutual agreement with BOC to provide facility fire safety compliance support. Counsel from the Governor’s office, BOC, and GGACF attended the March visit in its entirety to provide timely counsel and support to the process. The Territory, BOC, and GGACF officials and staff are commended for the extra effort given to ensure a more effective and efficient assessment process.

An equally important aspect of the monitoring process, however, is the monitoring team’s regular review of BOC and GGACF documents. The Territory must submit certain documents to the Monitor and United States on a monthly basis, and under the Settlement Agreement must also notify the Monitor and United States immediately if certain events occur, such as inmate deaths.

Generally speaking, progress toward overall compliance remains very slow. Although the Territory presented various new plans and intentions for improving the pace and substance of compliance, 92% of Agreement provisions remain in noncompliance. This is primarily due to these factors:

1. The Territory’s failure to finalize and approve all policies and procedures required under the Agreement by the court-ordered March 30th deadline.
2. Inadequate correctional and supervisory staffing levels. 3. Lack of staff training and accountability to ensure compliance with basic security and
correctional practices.

These factors permeate facility-wide operations. Inadequate staffing levels continue to create substantial safety, security, and health risks to inmates and staff. Occupied housing units continue to operate without correction officers for entire shifts at a time. Dangerous and nuisance contraband volume remains very high. Assaults on officers and inmates continue to be a very serious problem. Most staff uses of force against inmates are not properly documented or reviewed and administrative investigations have ceased altogether since the resignation of former GGACF Warden Donald Redwood, who simultaneously served as the facility investigator, on October 18, 2014. Most incident reports are submitted incomplete and provide no consistent method for developing an effective incident tracking and management system. Inmate disciplinary and complaint systems remain broken. Disciplinary due process hearings are infrequent, resulting in numerous Due Process Violations. The inmate grievance log remains incomplete and demonstrates continued problems in timely resolution of inmate complaints; there are often no responses to inmate complaints. Facility hygiene, lighting, and structures remain marginal due primarily to inadequate maintenance staffing levels. Mentally ill inmates languish

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in isolation conditions and problems with inmates accessing medical and mental health services

continue. Many inmates are held in administrative and disciplinary segregation for extraordinary

periods of time—some indefinitely—and without an adequate review process prior to or during

such detention. The inmate classification system remains invalid and mostly unreliable.

Despite continued noncompliance and ongoing problems, some very serious, it appears the Territory has renewed its commitment to compliance. Significant and impressive improvements to the medical building have been accomplished. Additional medical and mental health staff hired, and several new correctional recruits were observed. New equipment security equipment has been purchased and issued to staff and the new security camera system is being tested in preparation for full activation once the camera room is completed and operational. Although significant and extensive work remains to resolve this federal order, these accomplishments deserve positive recognition as each contributes positively to this ultimate goal.

Finally, we note that there does not seem to be a system in place for ensuring that the respective GGACF department heads receive our monitoring reports in a timely manner, if ever; therefore, they are incapable of providing follow-up actions. For example, the current Fire and Life Safety Officer had only received our report a few days prior to our on-site visit. We urge the Territory to distribute this report to all department heads immediately upon filing, and promptly schedule internal meetings to discuss the findings, how to address them, and any questions or concerns they may have.”

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

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Settlement Agreement

IV. SAFETY AND SUPERVISION

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:

a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory remains committed to finalizing, approving, and implementing policies and procedures required under this provision. Substantive progress is anticipated once these policies are promulgated and staff are appropriately trained.
Progress remains noncompliance due to 1) inadequate staffing levels (discussed in proceeding sections), 2) inadequate supervision and oversight of staff and housing-unit safety and security, and 3) mixing violent with non-violent prisoners. Additionally, the facility’s broken prisoner disciplinary and grievance systems concomitantly and deleteriously limit consistent control of dangerous and disruptive prisoner conduct while affording only anemic resolution to prisoner complaints and victimization. However, the Warden changed the shift schedule in an attempt to address the staffing needs indicated in the NIC Staffing Analysis. New Shift hours are 6am to 2pm, 2pm to 10pm, and 10pm to 6am. Future staffing assessments will provide Territory officials in information about the effects of this change with regard to attaining and maintaining adequate and durable staffing levels.
RECOMMENDATIONS: Previous recommendations remain appropriate
1. Apply the approved Housing Stratification matrix as designed 2. Review current population to verify accurate risk/need classification levels and housing,
reclassify and appropriately house as indicated by review process findings. 3. Refer to IV.F. regarding specific classification and housing policy recommendations.
b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

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Settlement Agreement

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Revised Post Orders have not yet been promulgated to comply with this provision of the Agreement. Supervisor logs from 12/16/2014-02/23/2015 were analyzed to assess compliance with this provision and compared with previous compliance assessments.

This analysis assessed 43 work days and involved 62 housing unit work shifts for all 13 prisoner-occupied housing units. Fifty-nine of the 62 shifts (95%) were not fully staffed during this 43-day period. The table below compares assessments.

Monitoring Visit
Sgt. Log Book Date Range Reported
Days Assessed Shifts Assessed Housing Areas Assessed Total Shifts Housing Units Not Fully Staffed Percent All Shifts Not Fully Staffed Total Shifts Housing Units Fully Staffed Percent All Shifts Housing Units Staffed Assessed Shifts x Housing Areas Assessed

4th Assessment
5/206/05/2014

5th Assessment
8/229/22/2014

6th Assessment
10/1312/1/2014

7th Assessment
12/16/142/23/15

16

21

21

43

25

29

21

62

14

14

10

13

21

29

4

59

84%

100%

19%

95%

4

0

17

3

16%

0%

81%

5%

350

406

210

806

The graph below illustrates compared shifts not fully staffed.

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

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Settlement Agreement

7th Assessment Housing Unit Shifts not Fully Staffed

70

60

50

84%

40

30

21

20

10

0

100% 29

59 95%
19% 4

120% 100% 80% 60% 40% 20% 0%

5/20-6/05/2014 8/22-9/22/2014 10/13-12/1/2014 12/16/14-2/23/15

4th Assessment 5th Assessment 6th Assessment 7th Assessment

Total Shifts Housing Units Not Fully Staffed Percent All Shifts Housing Units Not Fully Staffed

This analysis finds a peculiar and relatively significant increase in the percent of shifts not fully staffed compared to previous assessments. Supervisor logs again document serious housing unit staffing shortages on several shifts for the period assessed. Staffing improvements were documented for housing units H, K, L, and 9B. Notably, the treatment building houses medically infirm inmates but was reported as not staffed on three (3) shifts. This is very troubling, especially considering that one inmate housed in the treatment building is physically immobile and has serious mental illness. The table below compares percent of housing units not staffed.

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

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Settlement Agreement

7th Assessment Analysis of Housing Unit Staffing Levels
A DORM

4th Assessment Shifts Not Fully Staffed

Percent

5th Assessment Shifts Not Fully Staffed

5

20.0%

3

Percent 10.3%

6th Assessment Shifts Not
Fully Staffed
0

Percent 0.0%

7th Assessment Shifts Not Fully Staffed
21

Percent 33.9%

RSAT

14

56.0%

19

65.5%

Closed Closed

51

82.3%

Intake

16

64.0%

27

93.1%

Closed Closed

54

87.1%

X or X-Ray

1

4.0%

2

6.9%

0

0.0%

4

6.5%

G

0

0.0%

2

6.9%

0

0.0%

2

3.2%

H

1

4.0%

0

0.0%

0

0.0%

1

1.6%

I

0

0.0%

2

6.9%

Closed Closed Closed Closed

J

1

4.0%

3

10.3% Closed Closed Closed Closed

K

1

4.0%

1

3.4%

4

19.0%

4

6.5%

L

2

8.0%

1

3.4%

4

19.0%

3

4.8%

9A

3

12.0%

2

6.9%

0

0.0%

0

0.0%

9B

3

12.0%

1

3.4%

1

4.8%

0

0.0%

9C

0

0.0%

0

0.0%

0

0.0%

0

0.0%

9D

1

4.0%

0

0.0%

0

0.0%

0

0.0%

TB Treatment Bldg

0

0.0%

0

0.0%

0

0.0%

3

4.8%

# Times Housing Unit Not Fully Staffed

48

63

# Times Housing Fully Staffed

302

343

Percent

86%

84%

9

143

201

663

96%

82%

Estimated total hours housing units were understaffed are calculated to assess duration of real and potential risk to staff and inmates. As shown below, most housing areas operated understaffed for many hours during the period assessed.

Estimated Number of Hours Housing Units not Fully Staffed by Unit Classification
A DORM (Male Detainee Protective Housing) RSAT (Juvenile Housing) Intake (Male Detainee Protective Housing) X or X-Ray (Female Detainee & Inmates) G (Male Inmate Med/Max/Long Term) H (Male Inmate Min/Med) I (Male Inmate Protective Housing) J (Not on Classification Matrix) K (Male Inmate Protective Housing) L (Male Inmate Admin/Discipline Seg) 9A (Male Detainee Admin/Discipline Seg) 9B (Male Detainee Med/Max) 9C (Male Detainee Min/Med/Special Needs/ MH/Med 9D (Male Detainee Min/Med/Special Needs/ MH/Med
TB Treatment Bldg.
Total Hrs. Housing Units Not Staffed

4th Assessment
40 112 128
8 0 8 0 8 8 16 24 24 0
8
0 384.00

5th Assessment
20 100 176 16 16
0 0 20 12 8 8 16 0

6th Assessment
0.00 Closed Closed 0.00 0.00 0.00 Closed Closed 32.00 32.00 0.00 8.00 0.00

7th Assessment
94.64 302.64 390.64 32.00
0.00 0.00 Closed Closed 32.00 24.00 24.00 0.00 0.00

0

0.00

0.00

0 392.00

0.00 72.00

24.00 923.92

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

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Settlement Agreement

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Rapidly implement the NIC Staffing Analysis recommendations. 2. Complete the draft staffing, as required under the Agreement that reflects the NIC Staffing
Analysis and provides concrete steps for hiring sufficient staff. 3. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff
working overtime have adequate time away from the facility before returning to work to ensure they are adequately rested. 4. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics. 5. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm. 6. Subsequent to policy and procedure development and revisions, conduct a complete review of existing specific and general post orders to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post
safely and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that
makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible; E. regularly reviewed, revised, updated; F. consistently enforced; G. known to staff through pre-service, in-service, and ongoing training. 7. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues are detected and resolved in a timely manner. 8. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: This assessment found operable two-way radios in all housing units assessed. However, as discussed in the previous report, officers must carry radios with them at all times; a few radios were observed unattended on counters (not in chargers) in officer stations. Officers should always keep radios attached to their duty belts at all times while on duty. Additionally, officers should never leave radios unattended and accessible to prisoners. An X-dorm portable radio was observed sitting on the officer desk with the office door open while the officer was in the day room talking to prisoners and 7th tour participants. This can be easily corrected with an appropriate written directive and compliance monitoring by shift supervisors. Additionally, one officer stated they did not know what the radio’s “red button” did. This Monitor recommended this officer ask a supervisor for that answer. This provision is otherwise ready to advance to Substantial Compliance once policies and procedures are implemented according to the terms of the Agreement.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Finalize, approve, and implement all related policies and procedures.

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

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Settlement Agreement

2. Timely repair and replace nonfunctioning radio and telephone communications equipment

throughout the facility, and add additional communications equipment where indicated.

3. The Monitor will continue to review radio equipment inventories and functionality during

each onsite assessment.

4. Ensure adequate supply of radio batteries to enable officers to carry radios on their person at

all times. Issue directives requiring officers to carry radios on their person at all times while

at the facility and anytime they are supervising/monitoring inmates.

5. Ensure all persons carrying radios are fully trained to understand and operate all radio

functions proficiently.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and
(ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: GGACF remains inadequately staffed to ensure consistent, timely, and thorough management of housing units, including special housing areas. Inadequate staffing levels prevent housing officers from conducting adequate cell security and contraband checks. Lack of adequate housing unit staffing affords very little, if any, time for officers to perform thorough searches of prisoners entering and exiting housing units, which is evidence of ongoing high volume of dangerous and nuisance contraband reported on the monthly Evidence Logs.

Shift supervisor staffing levels remain inadequate to ensure supervision consistency and a continuum of leadership and staff guidance. For example, a minimum of three (3) shift supervisors are required to provide effective shift supervision. However, examination of 62 shifts recorded in supervisor’s logs from 12/17/2014 through 2/23/2015 found most shifts staffed with only two supervisors. Approximately 70 percent of the 62 shifts examined were staffed with two or fewer supervisors. Thirty shifts were staffed with two supervisors (48.4%), 13 shifts with one supervisor (21%). Approximately 30 percent of shifts were staffed with three or more supervisors as shown below.

Shift Supervision Staffing

N %

4 Supervisor Shifts 2 3.2%

3 Supervisor Shifts 17 27.4%

2 Supervisor Shifts 30 48.4%

1 Supervisor Shifts 13 21.0%

0 Supervisor Shifts 0 0.0%

Totals 62 100.0%

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

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Settlement Agreement

These shift supervision staffing levels clearly demonstrate that GGACF is unable to:

1. Provide consistent and effective continuum of housing unit staff supervision and leadership. 2. Provide supervisory monitoring of staff compliance with policies, procedures, and
Agreement requirements. 3. Ensure housing units are consistently managed in accordance with industry standards. 4. Provide minimum levels of staff on-the-job training, coaching, counseling, and guidance. 5. Provide consistently reliable supervisory response to multiple concurrent facility crises.

Safety and security risks to staff and inmates increase for each shift not adequately staffed by supervisors; in this case increased risk involved 43 of 62 shifts according to supervisor logs examined. Timely implementation of the Staff Plan could positively remedy this problem, especially if required additional supervisor positions are filled as a high priority.

RECOMMENDATIONS: Some Previous Recommendations Remain Appropriate

1. Refer to recommendations regarding Post Orders. 2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff
and inmate safety and security, and according to inmate risks and needs. 3. Create a schedule for regular rounds by medical and mental health care staff for each shift
to ensure that special needs inmates (suicidal, mentally ill, medically infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff. 4. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. The supervisory rounds forms should be filled out at the end of each round and collected in a central location and submitted to the Monitor and USDOJ on a monthly basis. 5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.

B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: NON COMPLIANCE (Downgraded from Partial Compliance)

FINDINGS: Draft policies and procedures have not been completed. This provision is downgraded from Partial Compliance to Non Compliance due to ongoing high volume of dangerous and nuisance contraband combined with decreased GIST facility search activity, according to staff interviewed during this onsite visit. GGACF officials reported that facility

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Settlement Agreement

shakedown searches have not been conducted since shift scheduling was changed February 8,

2015. This is very troubling. High volume of dangerous and nuisance contraband creates very

high safety and security risks for staff and inmates that must be remediated.

RECOMMENDATIONS:

1. Finalize, approve, and implement the new policy according to the terms of this Agreement once approved.

b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Dangerous and nuisance contraband continues to permeate the facility and housing units with little abatement. Examination and comparison of evidence logs demonstrates very serious safety and security risks as shown in the chart shown below. This assessment found several items of contraband very troubling due to extreme risks the items pose to staff and inmates. Specifically, the evidence log examined for this assessment documents seizure of a handcuff key, two “combat knives”, one machete, and a “16 inch metal shank”. The presence of these weapons exaggerate risks and can only be eliminated with adequate staffing, diligent and regular prisoner and facility searches.

GGACF Contraband Seizures
1. Days Reporting 2. Weapons (Knives, Shanks) 3. Cell Phones 4. Drugs, Alcohol,
Paraphernalia 5. Handcuff Key 6. Money

6th Report (10/3-
12/3/2014 60 21 32
9 0 3

7th Report 12/25/2014 -
4/15/2015 111 28 16
11 1 3

Combined Total
171 49 48
20 1 6

As stated in the previous report, continued introduction and high volume of contraband is indicative of inadequate searches by staff of inmates and structures, which is symptomatic of inadequate staffing levels, staff supervision, and training. The high volume of dangerous contraband continues to place inmates and staff in constant and extreme risk of harm. Additionally, tours of housing units revealed evidence of fire ignition sources such as “burning wicks” and housing unit floors scorched by fire. It is obvious that prisoners continue to possess contraband for starting fires, which is further discussed in the Fire and Life Safety Section of this report. For example, during this visit we observed a prisoner returning from an outside medical visit through R&D, holding a large tote bag, but this prisoner was not searched. Additionally, an R&D logbook entry dated 1/21/2015 (p.70) documents a prisoner was found carrying drugs. GGACF officials must increase their efforts to eliminate the introduction and presence of contraband without delay.

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Settlement Agreement

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Continue positive efforts in searching people before entering the facility. 2. A “stop and check” protocol for inspecting staff packages after initial entry into the facility
must be developed and implemented. 3. Provide handheld metal detectors for contraband inspections at facility entry points and as
needed for on-campus inspection. 4. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods
and process during the 8th onsite tour and assessment. 5. Train supervisors to provide on-the-job-training (OJT) and staff mentoring in the areas of
adequate searches, contraband prevention and control, and basic inmate supervision and security.

c. Detection of contraband within Golden Grove, through processes including: (i) supervison of prisoners in common areas, the kitchen, shops, laundry, clinical, and other areas of Golden Grove to which prisoners may have access; (ii) pat-down search, metal detector, and other appropriate searches of prisons coming from areas where they may have had access to contraband, such as intake, returning from visitation or returning from the kitchen, shops, laundry, or clinic; (iii) regular and random search of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g. clinic, kitchen, dayrooms, storage areas, showers);

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings and discussion.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Refer to above, expand application of recommendations to provision c (i-iii) above. 2. See recommendations regarding staffing levels. 3. Ensure inmates are systematically and consistently searched each time they enter and exit
maintenance shop areas, kitchen areas, and any area and/or building containing items that can be used as contraband. 4. Always search prisoners each time they enter and exit housing units. 5. Always search all containers entering and exiting the facility, buildings, and housing units.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No change was found since previous reports. Previous recommendations should be implemented.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

Review and implement relevant recommendations for Contraband above, specifically B1a.

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Settlement Agreement

1. Continue to ensure staff access to appropriate equipment and supplies needed to safely

collect and preserve contraband while maintaining evidentiary integrity.

2. Continue to ensure adequacy of chain-of-custody methods and procedures.

3. Develop a Uniformed Incident Reporting system (discussed further in this report) that

provides cross-referencing and continuity between all reports and logs involving

detection and confiscation of contraband.

4. Develop and implement a continuous quality improvement (CQI) protocol to evaluate

adherence to Contraband policies and procedures and reporting.

e. Admission procedures and escorts for visitors to the facility.

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Additional staffing were assigned to the public entrance during this assessment period. This was accomplished by rotating newly hired corrections recruits to this post to search the persons and belongings of the monitoring team and USDOJ participants. This Monitor also observed similar searches of the public and a few officers at this entrance. This Monitor did not experience any delays in being escorted for facility tours and inspections.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Continue to ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.

C. General Security

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There was no substantive improvement with this provision. Inmates continued to wear and possess personal clothing, including polo shirts, while in the housing units and in the outdoor areas of the facility. Previous recommendations do not appear to have been implemented.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Require inmates to wear issued institutional clothing ONLY. 2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform
policies and inmates who refuse to comply with those policies. 3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and
appropriate corrective action with staff who refuse to do so.

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Settlement Agreement

4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’

classification/status.

5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges

and changes in an inmate’s classification and/or status.

6. Consider developing a correctional industry for making uniforms onsite.

7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband

and weapons.

8. Mark all uniforms with highly visible letters/numbers.

b. Identification that prisoners, staff, and visitors are required to carry and/or display;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Identification badges were provided to the monitoring team for each day of the visit. However, there were prisoners again observed traveling in and out of housing units and the yard without visible identification badges.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Ensure staff compliance with this provision. 2. Ensure adequate supplies for making identification cards. 3. Regularly audit identification card inventory and maintain proper controls to prevent
inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories. 4. Consistently enforce identification card policies and procedures.

c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Some housing unit doors were found closed and some open during this visit. Most housing unit gates were closed and locked but a few were closed and unlocked. Some of the officer station doors were locked, some unlocked. Maintenance reports demonstrate ongoing problems with cell door locks. Additionally, certain cells in the intake area continue to be padlocked and staff seemed to have considerable difficulty and delays in locating keys to these locks. This poses a clear and present danger to prisoners under emergency conditions. These observations demonstrate continued inconsistency in facility security that requires improvement monitoring and remediation by supervisors and GGACF management. The facility remains unsecured anytime basic locking and unlocking practices are not followed and monitored by supervisors.

Additionally, per the previous report, related training documents were not provided as requested. This Monitor renews the previous request for these training documents.

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Settlement Agreement

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Provide Monitor requested training records showing a 95 percent minimum successful completion rate.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement. 5. Continue to ensure staff are adequately trained in the proper use of mechanical and/or
electronic locking systems according to their post assignments. 6. Consistently sanction inmates for attempting to manipulate or manipulating any security
locking system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked! 9. Replace or upgrade existing unit control panels to provide for remote electronic locking and
unlocking of unit and cell doors. 10. Improve video surveillance of internal areas by placing cameras in all housing units and
inmate locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations. 13. Consistently enforce security locking policies and procedures with staff and inmates.

d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. Inspection and maintenance procedures have not been approved nor submitted. The maintenance program remains understaffed to provide timely and consistent repair/replacement of locks and locking systems.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate.

1. Employ and maintain adequate maintenance staffing levels. 2. As requested in the previous two reports, develop an “all-locks” maintenance plan for
review with the Monitor. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number, lock type, condition, etc. 3. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.

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Settlement Agreement

e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,

ASSESSMENT: NONCOMPLIANCE
FINDINGS: There was no change found from previous assessments. No documents were provided to demonstrate implementation of the recommendations below, and the requested documents were not provided. This Monitor was unable to assess progress.

RECOMMENDATIONS: Per the previous report

1. Territory officials should assess history of terminations, identify determining factors, and realign completion of pre-employment practices to avoid post-employment terminations.
2. This Monitor again requests inspection personnel of records including employment applications; criminal history checks, and background investigations for all housing unit staff working Units 9A/B during the reported escape attempt occurring June 7, 2014. These documents were requested for all previous visits but not provided. Please have these documents at GGACF for the upcoming site visit.
3. Ensure access to applicant and staff records is adequately controlled and protected, and that access to these records is based on a legitimate, work related “need to know” basis.
4. Ensure there is an adequate centralized information tracking system in place to support periodic supervisory review of staff records for professional development, counseling, and corrective action decision-making.
5. Make records available to the Monitor for inspection and verification of compliance.

D. Security Staffing

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;

ASSESSMENT: NONCOMPLIANCE (Downgraded from Partial Compliance)

FINDINGS: As previously indicated, security staffing levels remain inadequate.

A draft Staffing Plan, based on the NIC Staffing Analysis, was submitted for review and approval on April 1, 2015. The plan demonstrates incorporation of realistic relief factors for all security levels, housing units and non-housing posts, and security supervision.

The following table from the Plan shows that 179 total security staff is required for adequate security and security supervision. An additional 80 security staff are required to meet plan requirements.

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Security Positions

Staffing Plan 2015 Budget

3/2015

Authorized

Security Management

6

6

TC Command (Lt)

5

4

ATC Command (Sgt)

13

7

Officer

155

117

Total Security Staff

179

134

Actual Staffing as of
3/17/15
4 2 5 88
99

Staff Needed
2 3 8 67 80

It must be noted that this staffing plan does not account for the closing of two housing units following prisoner transfers off-island. The plan will, therefore, require revisions if those housing units are reactivated with additional inmates.

The plan has been reviewed by this Monitor and the United States. The Monitor provided recommendations to the Territory for relatively minor substantive revisions via email April 23, 2015:

Good morning, Shari/Paula –

I have reviewed the proposed seven year staffing plan submitted April 1, 2015 and inserted two charts on pages 6 & 7 that clarify targeted staff hiring and levels for each of the seven years. I have no objections to the proposed seven year plan after considering various unique challenges faced by the Territory involving staff recruitment and retention. However, seven years is considerable longer than has been my experience monitoring cases. For example, in one case where I monitor for defendants I was only able to negotiate with the United States a three year term for hiring 53 officers. That said, I would like to expedite final approval of the plan within two weeks, if possible, and make every effort to resolve objections to the plan by the United States within that timeframe. … Thanks you. Ken

As stated above, the United States objects to a seven-year implementation duration as too long, considering ongoing serious GGACF safety and security problems. This Monitor agrees but also considers the Territory’s reported unique challenges regarding staff recruitment and retention. The United States has requested dispute mediation by this Monitor, which has been tentatively scheduled for May 8, 2015 and later rescheduled to May 13, 2015. The United States requested that the Territory supplement the Staffing Plan by detailing specific efforts the BOC has already undertaken to recruit and retain staff, additional steps BOC has considered but has not yet taken to recruit and retain staff, identify individuals by name and title responsible for recruitment and retention strategies, identification of priority housing unit/facility posts, including indication of whether these posts are currently staffed. By May 28, 2015, the Territory stated that it intends to provide the supplemented Staffing Plan and the parties will schedule a follow-up conference to discuss this same. This Monitor will update the Court on this matter.

RECOMMENDATIONS:

1. Incorporate Monitor’s recommendations into the draft plan. 2. Resolve the United States objections by Monitor dispute resolution or the court, if required.

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3. Quickly implement the approved staffing plan without delay.

b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. Also, the Monitor recommends the Territory consider the following timetables for the seven-year implementation. This schedule would be revised if the seven-year implementation period is changed due to mediation or Court resolution of this matter.

VI BOC/ GGACF Hiring Plan

Security Positions
Security Management TC Command (Lt) ATC Command (Sgt) Officer Total Security Staff

Staffing Plan 3/2015
6 5 13 155
179

Staff Needed
2 3 8 67 80

Year 1
2016
1 1 2 10 14

Year 2
2017
1 1 2 10 14

Year 3
2018
0 1 2 10 13

Year 4
2019
0 0 2 10 12

Year 5
2020
0 0 0 10 10

Year 6
2021
0 0 0 10 10

Year 7
2022
0 0 0 7 7

Total
20162022
2 3 8 67 80

Staff Needed
100% 100% 100% 100% 100%

VI BOC/ GGACF Hiring Plan

Security Positions

Staffing Plan 3/2015

Actual Staffing
as of 3/17/15

Year 1
2016

Year 2
2017

Year 3
2018

Year 4
2019

Year Year

5

6

2020 2021

Year 7
2022

Total
20162022

Security Management

6

4

5

6

6

% Staffing

67% 83% 100%

TC Command (Lt)

5

2

3

4

5

5

% Staffing

40% 60% 80% 100%

ATC Command (Sgt)

13

5

7

9

11

13

13

% Staffing

38% 54% 69% 85% 100%

Officer

155 % Staffing

88 57%

98 108 118 128 138 148 155 155
63% 70% 76% 83% 89% 95% 100%

Total Security Staff

179

% Staffing

99

113 127 140 152 162 172 179 179

55% 63% 71% 78% 85% 91% 96% 100%

RECOMMENDATIONS: Same as above.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Draft policies and procedures have not been finalized or approved but the Territory reports having selected a qualified vendor to assist in completion of these required documents, pursuant to the Court’s April 20, 2015 order.

RECOMMENDATIONS: See above.

1. Defendants will implement the staffing plan developed pursuant to D.1.

ASSESSMENT: See above

FINDINGS: Refer to previous findings related to staffing analysis and planning.

RECOMMENDATIONS: Refer to previous recommendations.

E. Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously reported, the Territory has not completed the required PREA selfaudit. PREA draft polices have not yet been approved and implemented.

Additionally, a prisoner’s October 20, 2014 complaint of sexual abuse remains not investigated due to the Investigator vacancy according to GGACF officials. Failure to properly investigate and resolve such compliances violates PREA and federal law. The Territory is encouraged to ensure it fully complies with PREA regardless of whether this vacancy is filled.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements. 3. Appoint a PREA Compliance Coordinator as soon as possible. 4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s PREA
auditor certification training. All costs are covered by USDOJ. 5. Complete the PREA Self-Audit. 6. Review, revise, develop, train, evaluate policies and procedures that include, at a minimum,
the following PREA topics: 7. Fill the Investigator vacancy immediately.

F. Classification and Housing of Prisoners

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1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:

a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: In July 2014, the BOC Director advised this Monitor that Dr. James Austin was scheduled to validate the existing Classification instruments. During the September and December 2014 visits the Director advised that this work was temporarily delayed but would be rescheduled. BOC and GGACF officials could not provide an update on when this work would be completed as of this assessment. The existing classification instrument, therefore, remains invalid and unreliable; it must be validated without further delay to ensure all classification and prisoner housing, security, and program decisions are sound and reliable.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate.

1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that provide
more accurate and complete guidance for a valid and reliable classification system for nonconvicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance. 5. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.

b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: As previously stated, notwithstanding the lack of validated classification instrument and policies, Territory officials provide adequate documentation demonstrating an adequate classification / housing scheme as previously requested by this Monitor. These documents include the following Provision requirements:

 Total Institutional Monthly Average Daily Population (Pre-sentenced and Sentenced Prisoners)
 Total Outside of Territory Contract Prisoners (BOC prisoners held off-island)

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 Monthly Average Daily Population, Admissions and Releases

 Classification / Housing Stratification for all Currently Used Housing Units

 Custody Classification Level Volume Report (number of prisoners in each primary classification).

 Names of all prisoners by classification, conviction statues, and housing unit.

Again, these documents do not, however, clarify whether the Territory conducts regular classification reviews to ensure prisoners continue to be properly housed and separated from other inmates according to changes in their classification status. BOC officials have indicated that classification reviews are regularly performed based on the draft classifications policy. However, BOC officials also report that due to challenges, prisoners’ classification may not be reviewed in strict adherence to the timelines. BOC officials have agreed to provide this information in the monthly routine monitoring document submissions.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Settlement Agreement prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Direct mental health staff to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentencedside lock down units to determine mental health needs and if a different, less punitive housing placement is available.

c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Same findings as above.

RECOMMENDATIONS:

1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: The prisoner disciplinary system remains broken and ineffective for ensuring

access to due process and supporting prisoner control and order. Interviews with GGACF

officials and examination of monthly Disciplinary Committee Reports demonstrate ongoing

problems with the disciplinary process. These reports document the following problems

continue:

 No set time for conducting disciplinary hearings  Lack of staff to assemble a full hearing committee consistently  Needed hearings are not being conducted  Disciplinary program management staff are not receiving incident reports and other
documentation required for fair, objective, and accurate decisions  Shift supervisors are not reviewing incident reports for accuracy and completeness
before submission for disciplinary review  No resolution by GGACF management staff to the above previously reported problems  Prisoner due process violations continue due to the above problems

Examination of monthly Disciplinary Committee Reports concur with these statements and show insignificant change in due process violations volume. Monthly committee reports indicate there were 100 reports submitted for review for July, August, and September 2014 with 50 due process violations (50%). February, March, and April 2015 reports indicate that 40 reports were submitted and 17 due process violations (43%). The reader is reminded to interpret these findings with caution because GGACF documents are known to be incomplete, inconsistent, and inaccurate. Nonetheless, these findings reliably demonstrate that GGACF prisoners remain without a constitutional disciplinary process.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Refer to previous classification findings and recommendations. 2. Refer to recommendations related to grievance and disciplinary policies and procedures. 3. Ensure accuracy of monthly disciplinary committee reports. 4. The Territory must correct problems reported in the monthly disciplinary committee reports. 5. Train classification staff to accurately and consistently complete initial and re-classifications
accordingly.

e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct;

ASSESSMENT: PARTIAL COMPLIANCE - Previous Recommendations Remain Appropriate

FINDINGS: There remains no formal process for collecting, analyzing, or distributing data and reports as required under this provision. Incident logs and reports continue to document ongoing prisoner-on-prisoner and prisoner-on-officer assaults, gang activities, and other serious incidents. However, the absence of a formal incident reporting system prevents GGACF officials from effectively planning and executing sustainable remedial actions. Thus, staff and inmates remain precariously subject to many risks that are otherwise preventable with the

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implementation of an effective and strategic incident prevention and management reporting

system. GGACF officials will remain unable to accurately and consistently evaluate serious

incident activity until a uniform incident reporting system is successfully implemented.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Timely approve and implement policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.

f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: A sample of completed segregation review forms were examined. These documents continue to demonstrate lack of attention to detail, completeness, and documenting whether reportedly needed medical and mental health services were followed-up and provided. Additionally, this sample clearly indicates excessive disciplinary sanctions and continued violations of the Agreement with regard to housing mentally ill inmates in what amounts to long term isolation.

Document omissions and deficiencies include the following:

1. Location of segregation and type (disciplinary, administrative) 2. Time of review 3. Specific date of placement 4. Projected date of disciplinary segregation release 5. Prisoner special needs, if any (physical handicap, mental illness) 6. Officer or staff remarks regarding review findings 7. Required follow-up for medical or mental health care 8. Reasons and circumstances that validate continued placement in segregation 9. Alternatives to segregation that were discussed and considered prior to segregation
placement 10. Final action or instructions by the Review Committee

The following examples further demonstrate deficiencies in segregation practices and violations of the Agreement:

AS: Held in administrative segregation for five months for having “2 cell phones”.

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JP: Held in administrative segregation for three years for “misunderstanding”. Reports needing 


clean bedding with no follow-up documented.


MW: Held in administrative segregation for one year, three months for “misunderstanding”. 


JW: Held in disciplinary segregation for three months for fighting. Report needing medical and


mental health services with no documented follow-up.


PD: Held in disciplinary segregation for six months for fighting. Reports needed medical and 


mental health care follow-up not documented.


EV: Held in disciplinary segregation for fighting. Reports inmate as “poor wellbeing” but no 


health care referral or follow-up documented.


PS: Held in administrative segregation for two months. Reports inmate states “pain in left hand”


with no medical referral or follow-up documented.


JW: Held in administrative segregation for two years for threatening officers. Reports need for


medical services but follow-up not documented.


These few examples are repeated throughout the majority of the documents examined. The
 GGACF segregation review process is inadequate and non-functional. It is probable that some
 inmates are kept in segregation:


1. without being afforded their legal due process rights; 2. for unnecessary and/or extended periods; 3. without being provided adequate health care services; 4. without being properly and routinely monitored and assessed for physical and mental health
needs; 5. without having their reported complaints, needs, concerns resolved; 6. with serious mental illness in violation of the Agreement.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Review, revise, develop, train, implement, and evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment. A routine schedule for conducting these rounds must be regularized and continuously monitored for compliance.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or serve as a treatment for inmates who are mentally ill, and may never be used for inmates with serious mental illness.
5. Improve the quality and completeness of segregation review documentation.

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G. Incidents and Referrals

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

a. Reporting by staff of serious incidents, including (i) fights; (ii) serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Examination of incident reports provided by GGACF officials continued to demonstrate virtually no change in previously reported deficiencies:

1. Inconsistent incident report numbers 2. Incomplete reports 3. Page numbers and other basic information missing 4. Reports not being recorded on the incident log 5. Using different incident numbers for each inmate involved in the same incident 6. Using different incident numbers for different officers reporting the same incident 7. Illegibility 8. Missing signatures 9. Inconsistent recording of incident type 10. No recording of incident type 11. Incident, Evidence, and Disciplinary logs don’t cross-reference each other

As previously stated, the existing incident reporting system must be completely overhauled if it is to provide valid and reliable information from which to evaluate serious events in order to comply with this Provision or any provision requiring accurate and complete incident reporting to assess compliance levels.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Develop protocols for current tracking system to improve data validity and reliability; this document is replete with duplication and misleading entries.

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2. Develop a unified incident coding system for valid and reliable information and data

collection, reporting, and analysis.

3. Establish regular monthly quality assurance meeting process involving all major department

team leaders to review serious incident reports and recommend evidence-based remedial

measures for eliminating/mitigating incident frequency and severity.

4. Train staff in applying adopted policies and use of forms, implement a continuous quality

assurance protocol.

5. Require supervisors to carefully review all incident reports for completeness, accuracy, and

consistency.

b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);

ASSESSMENT: NONCOMPLIANCE

FINDINGS: A formal and regular administrative process as indicted remains nonexistent. Effective implementation of this process first requires substantial improvements in the current incident reporting systems. Furthermore, valid and meaningful incident data for tracking and management purposes relies completely on the quality of the incident reporting system, quality compliance monitoring, and timely data management.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Refer to recommendations in G.1.a above.

c. Requirements for preservation of evidence; and.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement from previous assessment.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Refer to similar recommendations regarding contraband.

d. Central tracking of the above incidents.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement from previous assessment.
RECOMMENDATIONS: Previous Recommendations Remain Appropriate
1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of
incident reporting and data analysis.

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2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.
ASSESSMENT: NONCOMPLIANCE ­

FINDINGS: As previously stated, deficiencies in the incident reporting system, lack of reporting quality management, and the vacant Investigator position exacerbate making positive progress with this provision despite the absence of approved policies and procedures.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Include this element in the required policy and procedure. 2. Establish reasonable timeframes as indicated. 3. Develop and implement corrective action protocols for staff noncompliance with adopted
policies and procedures.

H. Use of Force by Staff on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Approved policies and procedures have not been submitted. Furthermore, the Territory has not yet provided current training curricula for use of force as requested by this Monitor several times.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Finalize, approve, and implement draft use of force policies and procedures upon approval and once the revised implementation schedule is approved.
2. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
3. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review of document are 1) complete, 2) accurate, and 3) comprehensive.
4. All planned uses of force must be monitored and controlled by an onsite supervisor. 5. GGACF must promptly and thoroughly investigate all inmate complaints of excessive force
and take necessary corrective action to protect inmates and staff.

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b. Circumstances under which the permissible forms of physical force may be used;


ASSESSMENT: NONCOMPLIANCE


FINDINGS: Same as above. No improvement.


RECOMMENDATIONS: Previous Recommendations Remain Appropriate


1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: See above findings. 


RECOMMENDATIONS: Previous Recommendations Remain Appropriate


1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated previously reported and stated above, no use of force training has been provided to staff as described in this Provision. The Territory continues to be nonresponsive to this Monitor’s several requests for all training curricula. This Monitor requested these documents prior to each onsite visit and several times between visits. The Territory’s nonresponsiveness to the Monitor’s request prevents the Monitor from adequately assessing compliance with this section specifically, and all Provisions involving training. Simply stated, the monitoring team cannot do its job without this information.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. See recommendations regarding Training Provisions and apply to use of force requirements. 3. Provide this Monitor and DOJ with all current training curricula.

e. Training and certification required before being permitted to carry and use an authorized weapon;

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous

assessment.

FINDINGS: Same as above. No change.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.
2. Refer to Training Provision recommendations and apply to this requirement.

f. Comprehensive and timely reporting of use of force by those who use or witness it;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: Despite several incident reports documenting incidents involving staff use of force on prisoners, the Territory did not comply with this Monitor’s request for documents; all use of force reports and administrative reviews of force were not provided. Inadequate documentation combined with the Territory’s failure to submit required documents as requested demonstrates noncompliance with this provision.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Implement supervisory quality improvement review for all reports to ensure accuracy and completeness before approval.
2. As requested in the previous report, the Territory must develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.
3. Comply with Monitor’s request for documents.

g. Supervision and videotaping of planned uses of force;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

FINDINGS: No planned uses of force were reported during this assessment period. However, the Territory did not provide proof that GGACF staff had access to video equipment if needed.

RECOMMENDATIONS:

1. Include this requirement in policy, procedures, and training as discussed in recommendations H.a. (1A-W) above.

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h. Appropriate oversight and processes for the selection and assignment of staff to armory

operations and to posts permitting the use of deadly force such as the perimeter towers;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Provide the Monitor documentation of Compliance for this Provision.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No change.

RECOMMENDATIONS:

1. Provide Monitor documentation of Compliance with this Provision.

j. Prompt administrative review of use of force reports for accuracy;

ASSESSMENT: NON COMPLIANCE

FINDINGS: Examination of incident reports involving use of force by correctional officers continues to demonstrate chronic absence of required administrative reviews. For example, this Monitor found 22 reported uses of force where administrative reviews were not performed. Territory officials stated during this visit that this was due to a misunderstanding about this provision and the definition of force. This Monitor directed GGACF staff to the definition of force in the Agreement and these officials agreed to comply with this provision going forward.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Inadequate incident reporting, lack of administrative reviews and the Investigator vacancy prevent compliance with this provision. Territory officials document that no allegation

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of any staff misconduct has been investigated since the departure of the Warden, who also

conducted administrative investigations.

RECOMMENDATIONS: Same as above

l. Administrative investigation of uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. Documentation requested to assess compliance with this Provision was not provided.

RECOMMENDATIONS:

1. Develop and implement Central Tracking system to include all required elements.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.


RECOMMENDATIONS: Previous Recommendations Remain Appropriate


1. Immediately issue directives to supervisors to complete reviews for all incidents involving use of force. Monitor compliance, correct deficiencies, and document compliance with this provision.

o. Re-training and sanctions against staff for improper uses of force.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Training records were again not provided to the Monitor for review during this visit.

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As previously stated, it is impossible for GGACF to fully comply with this Provision until

supervisors comply with use of force review requirements.

RECOMMENDATIONS:

1. Produce staff training records for review by this Monitor during the next onsite visit.

I. Use of Physical Restraints on Prisoners

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;


ASSESSMENT: NONCOMPLIANCE


FINDINGS: Same as above. 


RECOMMENDATIONS: Previous Recommendations Remain Appropriate


1. Implement this policy once approved according to the new schedule.

b. Circumstances under which various types of restraint can be used;


ASSESSMENT: NONCOMPLIANCE


FINDINGS: Same as above


RECOMMENDATIONS:


1. Same as above.

c. Duration of the use of permitted forms of restraints;


ASSESSMENT: NONCOMPLIANCE


FINDINGS: Same as above.


RECOMMENDATIONS: Same as above.


d. Required observation of prisoners placed in restraints;


ASSESSMENT: NONCOMPLIANCE


FINDINGS: Same as above.


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RECOMMENDATIONS: Same as above.

e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above.

RECOMMENDATIONS: Same as above.

f. Required termination of the use of restraints.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Same as above

J. Prisoner Complaints

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The inmate grievance log from 12/16/2014 to 03/26/2015 was examined for completeness and to assess complaint system efficacy. As previously reported, this document continues to be incomplete and demonstrates serious deficiencies. Numerous data cells in the document requiring data/information were left blank. These omissions involved information/data regarding inmate housing unit location, date and time received, staff response to complaint, response date, and date response was returned to the complaining inmate. Eleven (approximately 25% of complaints) recorded “no response”. This is especially troubling considering that no response was given for complaints involving medical care, housing conditions, disciplinary sanctions, staff misconduct, need for personal hygiene products, and food service.

This record continues to demonstrate that GGACF prisoners have no reliable system for resolving complaints. The current system remains inconsistent and not responsive in resolving inmate health and safety concerns and must be improved quickly.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

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1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking

process to measure and verify program compliance, take timely and appropriate remedial

and correction action.

2. Ensure tracking log is consistently completed and accurate.

3. Assign reliable and timely oversight of the inmate complaint process and logs to a staff

person who will provide the process consistent, dedicated, and comprehensive attention.

4. Develop a valid and reliable tracking a quality management statistical report for monitoring

inmate and facility needs and problems.

5. Ensure staff are available during onsite visits to allow this Monitor to adequately assess this

Provision.

b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Only half (21/40) of the complaints examined recorded dates to assess timeliness of responses. However, this is not to suggest that proper investigations were conducted. Inmates waited from one (1) to 63 days for a response to their complaint. Seventy-five percent (75%) of these 21 complaints were returned to inmates ten (10) or more days after staff received the complaint. Such delay in responding to inmate complaints creates frustration among inmates and increases tension in housing units. Frustration and tension exacerbate safety and security risks to staff, inmates, and the facility. Unresolved inmate complaints involving health care concerns expose inmates to serious physical harm and the Territory to significant criminal and civil liability.

RECOMMENDATIONS: Same as above

c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same finding related to administrative and use force investigations and reviews.

RECOMMENDATIONS: Refer to administrative and use of force investigation review recommendations, and:

1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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FINDINGS: Same as above.

RECOMMENDATIONS: Same as above, and:

1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.

e. Periodic management review of prisoner complaints for trends and individual and systemic issues.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Similar to administrative investigations, use of force and incident reviews, this process remains essentially nonexistent.

RECOMMENDATIONS: Same as above.

1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. 
 Use data from those reviews identify patterns of individual staff and inmate problems, as 
 well as systemic problems in need of correction.


K. Administrative Investigations

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This policy remains in unapproved draft form. The Territory informed this Monitor during this onsite that the investigator’s position remains vacant. On April 27, 2015, the Territory informed this Monitor in an email that “there has been allegations of staff misconduct and matters requiring investigation but the Bureau does not have an investigator, hence no administrative investigations.” This Monitor’s responded the same date requesting further clarification but has not yet received a response from the Territory:

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Good evening, Shari – I appreciate your response to both subjects. Please provide further

clarification and related documentation in order for me to more clearly assess this situation

relative to compliance with the Agreement.

Administrative Investigations:

You state that no administrative investigations have been conducted for known allegations of staff misconduct because the BOC does not have an investigator. Please provide the following information:

1. Date the investigator position became vacant 2. When BOC first had knowledge the investigator position would become vacant 3. Action taken by BOC to fill the investigator vacancy, anticipated date vacancy will be
filled 4. What, if any, level of administrative investigations have been initiated and the name of the
person(s) performing this work since the investigator position became vacant 5. Action/plans for ensuring when allegations of staff misconduct would be investigated 6. Dates, nature and description of all non-investigated allegations of staff misconduct since
the investigator position became vacant 7. Dates, nature and descriptions, and dispositions of all investigated allegations of staff
misconduct since the investigator position became vacant 8. Dates, nature and descriptions of all staff discipline take by BOC since the investigator
position became vacant
The Territory responded on May 15th to this Monitor’s above information requested in seriatim as follows:

1. Date the investigator position became vacant.

The position became vacant in May 15, 2014 when, the Chief Inspector (Donald Redwood), who performed administrative investigations, was assigned to be the Acting Warden of GGACF by former BOC Director Julius Wilson. During this period, the administrative investigator position was vacant.

2. When BOC first had knowledge the investigator position would become vacant?

Shortly before the then-Chief Inspector was assigned to Acting Warden of GGACF, BOC had knowledge that the position would be vacant.

3. Action taken by BOC to fill the investigator vacancy, anticipated date vacancy will be filled.

To provide context, the procedure for filling the administrative investigator position is as follows: 1) BOC sends a personnel requisition form to the Office of Management and Budget to get approval that there are available funds in the budget for the vacant position. 2) If the personnel requisition form is approved, BOC notifies the Division of Personnel of the vacant position. 3) The Division of Personnel publishes a vacancy announcement and interested candidates apply with the Division of Personnel. 4) The Division of Personnel then sends a list of eligible candidates to BOC. 5) BOC then contacts those candidates and provides the pre-

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employment package which includes necessary paperwork for the medical and criminal

background check. 6) Those that pass the background check are then interviewed and BOC

untimely selects the successful candidate.

On or about May 5, 2015, Acting Director Benjamin signed the personnel requisition form and the same is with the Office of Management and Budget. At this time, BOC cannot provide an anticipated date when the vacancy will be filled until it receives notification from the Office of Management and Budget.

4. What, if any, level of administrative investigations have been initiated and the name of the person(s) performing this work since the investigator position became vacant?

Yvette Phillip, Administrative Assistant, who is responsible for processing grievances, has compiled preliminary a list of matters requiring investigation based on information disclosed in the grievances. The list includes the associated grievances. See attached. Based on the documents, Chief Herbert indicated that he would investigate at least one matter. The Territory will provide a follow-up response regarding the same.

5. Action/plans for ensuring when allegations of staff misconduct would be investigated

See response to Number 3. In addition, Acting Director Benjamin and Acting Attorney General Terri Griffiths met on April 28, 2015 concerning the need to conduct independent administrative investigations into the misconduct of staff and corrections officers at BOC. As a result of the April 28th meeting, BOC and DOJ intend to execute a Memorandum of Understanding identifying where the administrative investigator will be housed. The administrative investigator’s office will be located in the VI Department of Justice, St. Croix office, in order to create clear lines of separation between the administrative investigator and the BOC personnel who will be the subject of investigation.

6. Dates, nature and description of all non-investigated allegations of staff misconduct since the investigator position became vacant

See response to Number 4 and see attached.

7. Dates, nature and descriptions, and dispositions of all investigated allegations of staff misconduct since the investigator position became vacant.

Since the position is vacant, there have been no formal investigations and thus, no dispositions.

8. Dates, nature and descriptions of all staff discipline take by BOC since the investigator position became vacant.

See attached. (This attachment contains protected information that this Monitor is restricted from including herein per the Settlement Agreement).

As stated in the previous report, the investigator’s position must be filled without further delay. It is the opinion of this Monitor that timely and qualified administrative investigations are crucial to operating a safe and secure correctional facility. The fact that alleged staff misconduct

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and other matters remain not investigated is very troubling. Compounding this problem is that

Use of Force Reviews remain essentially not done.

RECOMMENDATIONS: Same as previous report

1. Fill the vacant investigator position. 2. Supervisory/management staff must be consistently held appropriately accountable for
adherence to agency rules, regulations, policies, and procedures. 3. The November 2014 housing unit riot must be thoroughly investigated and reviewed to
prevent similar future events and to improve organizational planning, response, and management of these types of major incidents.

2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS:

1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling,
preserving, and maintaining administrative investigation evidence, information, data, etc.

3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive change since previous visit.

RECOMMENDATIONS:

1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: The current investigator position remains vacant. No documents have been

provided to assess the Territory’s intentions or efforts to fill this position.

RECOMMENDATIONS: Fill the currently vacant Chief Investigator position immediately.

1. Finalize, approve, and implement relevant policies and procedures. 2. Create a formal pre- and in-service training program to train staff who are involved in initial
and/or administrative investigation. 3. Provide adequate training of investigative staff on topics in areas of incident scene
investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc. 4. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management. 5. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities. 6. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review upon his/her appointment.

5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: It is impossible for the Territory to take staff corrective and/or disciplinary action without a fair and complete administrative investigation. The investigator’s position must be filled.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Finalize, approve, and implement relevant policies and procedures. 2. Review and revise current regulations on staff disciplinary actions and penalties to ensure
completeness and efficacy. 3. Integrate the information in the above into the administrative policies and procedures
previously discussed. 4. Record and maintain onsite records of staff misconduct investigative reports and
determinations. 5. Protect the integrity and confidentiality of these staff records, control access to records,
provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff. 6. Provide training to supervision staff in the appropriate use of this information for purposes of staff supervision, counseling, discipline, promotion, etc. 7. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE


Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:

a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: Although the assessment remains noncompliance, it is clear to the medical reviewer nonetheless that progress is being made. This is evidenced by the fact that all medical policies have been submitted to the monitor as well as the U.S. Department of Justice for their review. The medical monitor has worked very closely with leadership staff at the facility and has provided input to all of the policies related to this agreement. This reviewer has not yet seen the Department of Justice comments regarding the medical policies but we expect to have a conference call within the next week to discuss their recommendations. Revisions may be made after that conference call. In any event, I would expect the policy sequence to be concluded prior to our next visit.
With regard to the receiving screening process, within the last 1-2 months, RN staffing has increased such that there are now RNs onsite Monday through Friday from 8:00 a.m. until midnight. Also, on the weekends there is 8:00am to 8:00 p.m. coverage. We were informed at this visit that there are now plans to add additional nursing hours such that there in fact will be 24 hours seven days a week RN coverage. The program is now using a log for the intake process, although we reviewed with the Director of Nursing the necessity of nursing staff completing every field on every patient in order for the log to be complete. For all of the logs we have indicated blank spaces are in fact an error and should be reviewed as such.
In our review of seven randomly selected records of patients who entered the facility within the prior six weeks, each record contained an intake screen performed by a registered nurse. All of these screens were performed on the old intake screening form as opposed to the one we had recently revised, which I am told will be used in the future. All intake screens were performed timely except for one who was moved by custody out of the intake area on the same day he arrived. That intake screen was not performed until Day 4. It must be a custody policy that no detainees or inmates are moved from intake without having had a nurse intake screen. Among the problems we found with the professional performance included a patient receiving psychotropics without the presence of documented mental illness. We found a case with no TB skin test result in the medical

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record. We also found a patient who entered but no acuity scale was documented. Finally, the most

consistent problem we found was that the health assessment was either not done or when done was

completed belatedly. The Director of Nursing was confident that the nursing performance with

regard to the new screen would be improved and more consistent with the requirements by the time

of our next visit. In fact, we discussed her responsibility to monitor and provide feedback to the

staff on a weekly basis. This should be a key component of their quality improvement program.

What follows are some of the specific cases reviewed.

Patient #1 MJ is a 26-year-old whose screen was performed on 2/26/15. His medications include an antipsychotic medication as well as a medication used to prevent side effects of the psychotropic medicine. The acuity scale appears to have been changed from 1 to 2. Given his antipsychotic medications, he should have been assessed as a level 1. On the day of the screen, telephone orders were received for the antipsychotic medication. The history part of the form left blank the questions regarding nervous conditions or mental illness. This patient was seen by the psychiatrist the next day; however, his health assessment has not yet been done.

Patient #2 JIC is a 20-year-old whose intake screen was completed on 2/21/15 and he had a completely negative screen. However, he had no health assessment.

Patient #3 EM is a 24-year-old who was booked on 2/11/15. He lacked a TB skin test result in the medical record and he was on psychotropic medication for mood swings. He also lacked a health assessment.

Patient #4 PG is a 27-year-old who was booked on 1/2/15. He was a federal transfer who had had a CT scan of the chest which was negative and a prior positive TB skin test. His acuity screen was not filled in and he was not screened until 1/6, four days after he was booked. We investigated this case and found that he had been moved by custody immediately after booking and this resulted in a delay of the nurse intake screen. Nurses are in the habit of calling the booking area and querying whether there are inmates there requiring a screen. When patients are moved prematurely the response from the officer is a negative response. It is not clear how medical was notified that a patient was in a housing area who lacked the booking screen. Custody should have a policy that precludes moving out of the intake area until the screen is completed.

Patient #5 AL is a 20-year-old who was booked on 2/6/15 and was assessed as an acuity level 2 on the basis of his history of hypertension. His blood pressure on intake was somewhat elevated at 154/86. His TB skin test was negative. Six days after booking, his intake assessment was completed and he was enrolled in the chronic care hypertension program. However, he should have had his health assessment by 2/9 and instead it was completed three days later.

RECOMMENDATIONS: 1. Finalize, approve, and implement relevant policies, procedures, and forms. 2. Given the plan to provide 24/7 RN coverage, fill those hours as soon as possible.

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3. The Director of Nursing should begin a weekly review of the intake process, including

timeliness of screen, completeness of documentation including TB skin test results and

acuity assessment.

4. Regarding the quality of integrity of the professional performance, nurses should receive

feedback when the documentation includes internal inconsistencies, such as a patient on

psychotropic medication but no documentation of mental illness.

5. This ongoing feedback and review should be documented so that it can form a part of the

overall quality improvement program.

6. After incorporating the input from the Department of Justice, finalize the intake policies.

7. Custody needs a policy that prevents movement from intake to a housing unit until the

nurse intake screen has been completed.

MENTAL HEALTH FINDINGS: Nursing staff are performing intake mental health screenings in a timely fashion, usually within 24 hours of intake. Positive mental health findings do initiate referral to the mental health staff by security and medical intake screeners. A freestanding mental health intake screen has not been implemented at the time of this visit.

RECOMMENDATIONS: It is still this reviewer's recommendation that a one page intake mental health screen be implemented to improve clarity, comprehensiveness and identification of needs rather than have components of the screen contained within a multipage medical screening. Sample screening tools have been discussed with the staff during past visits and this reviewer remains available to assist in the form development whenever requested by the site staff.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.

MEDICAL FINDINGS: We discussed with the Medical Director the deficiencies with regard to this area. In our discussions we made it clear that compliance with the performance as well as the timeliness rests solely on his shoulders. Noncompliance can only be corrected by his performing or arranging for another clinician to perform these assessments both timely and appropriately. In the seven records we reviewed we found one health assessment that was not performed timely and all the others lacked the health assessment. Clearly this is a serious deficiency. We believe nursing staff should inform the Medical Director whenever an intake health assessment is due and it is the Medical Director’s responsibility to insure that the intake health assessment is completed timely and the professional performance is consistent with expectations.

RECOMMENDATIONS: 1. The nursing staff should begin contacting the Medical Director regarding the need to complete
an intake health assessment and this should be documented in the medical record. 2. The Director of Nursing, as part of her review of the intake process, should track performance of
and lateness of performance of intake health assessments and this should become part of the GGACF QI program.

MENTAL HEALTH FINDINGS: Ms. Ava Murray, LCSW, the mental health coordinator and Qualified Mental Health Professional (QMHP,) provided a log of intake screenings for the month

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of April referred to Mental Health and all 4/6 medical records were available and reviewed.

Screenings by medical were timely and complete. All but one inmate were released within a very

short period of time. The remaining inmate did receive a comprehensive review by mental health

and a referral to the psychiatrist.

Since the hiring of Mr. Nemuel Rosas, mental health professional (MHP), initial mental health assessments have been completed on a partial portion of the caseload. The facility’s plan is to do an initial psychosocial assessment, per this component of the Settlement Agreement, on all intakes. Now that this requirement has been initiated, a request for clarity in the interpretation of the Settlement Agreement was indicated. A discussion which included Ms. Myrthil, USDOJ, and Ms. D’Andrade, Territory counsel, regarding the interpretation of "within three days of admission" as to whether this represents three calendar days or three business days occurred on the first day of the site visit. This reviewer will monitor based on the final decision of how to interpret this language by the parties.

Since the time of the December 2014 site visit there have been major additions to the mental health staff. A mental health coordinator and Qualified Mental Health Professional (QMHP), Ms. Ava Murray, LCSW, licensed in Florida and the United States Virgin Islands was hired and began work on April 7, 2015. Ms. Murray also has a registered nursing degree and received a master’s in social work degree in 2006 specializing in palliative care. She is currently working fulltime. Specific to this provision of the Settlement Agreement, Ms. Murray has created a log to track intakes to the facility to monitor timeliness of assessments.

On February 9, 2015, Mr. Rosas, BSW, began work as a MHP on a fulltime basis. Mr. Rosas has three years of experience working in Puerto Rican prisons as well as inpatient psychiatric experience. He has begun doing the initial comprehensive assessments on all inmates on the mental health caseload but has not yet made it through the entire case list. The Settlement Agreement does require that all inmates in the facility receive a comprehensive initial mental health assessment and it will take some time to complete that task. He has initiated group therapy based on inmate needs for those people on Dr. Sang’s psychiatric case list. Groups occur weekly for ½ to 1 hour with five or six attendees per group. Topics range from anger management, law awareness, independent living, family issues, and relapse prevention. Mr. Rosas is attempting to complete individual encounters with all inmates on the mental health case list (approximately 57 inmates).

Ms. Benita Randolph, RN, was hired on January 12, 2015, and assists the mental health team with tasks such as scheduling appointments and referrals, and reviewing psychiatric order transcriptions for accuracy.

GGACF is also in the process of recruiting a second QMHP to complete its complement of mental health professionals. The current staff members all appear very bright, capable and motivated. Their presence should make a dramatic difference in the quality and availability of mental health services to the population on both sides of the facility. Dr. Sang remains a stable and predictable clinical presence in the treatment building weathering transition in the general medical and dental clinics.

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RECOMMENDATIONS:

1. This monitor remains available to assist GGACF in developing standardized mental health intake screening, initial behavioral health evaluation, and progress note forms for implementation in the coming months.
2. Technical assistance is also always available and encouraged regarding development of treatment programs at the facility.
3. Continue to track inmates entering the facility and monitor time from admission, screening, and initial psychosocial assessment. In addition, referrals to the psychiatrist should be monitored for time to completion.

c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have used this section to address medical sick call. Therefore, it focuses on acute care needs. Another section deals with chronic care needs. The sick call log has been modified in a manner consistent with our recommendations and it is being used. However, we did identify blank spaces in the log which should have been completed. The blank spaces include date or location of assessment and on occasion some of the identifying demographic information. We reviewed 10 records of patients who had requested acute care or sick call services. In general, we found the nursing assessments timely, although we did find one record in which the logbook documents the date of a nursing assessment but in fact the record lacked any nursing note. We found, as we would expect to find, some instances of opportunities for improvement in nursing professional performance, but the most consistent problem we identified was the absence of timely physician assessment related to nursing referral. Our expectation is that these referrals be scheduled by the nurses based on their clinical assessment of the nature of the urgency but that the least urgent be seen within one week. Unfortunately, commonly this standard was not met. On the other hand, the nursing assessments were overwhelmingly timely. We will describe some of the specifics of our findings.

Patient #1 RG This patient requested to be seen on 1/31/15 regarding discomfort urinating. He was seen by the nurse on 2/2 according to the log but we could not find any note in the medical record.

Patient #2 MP This patient requested, on 2/5/15, to be seen by the Medical Director. There is no documentation by the Medical Director of ever seeing him.

Patient #3 EM This patient requested to be seen on 1/28/15 regarding flank pain. He was seen by the RN on the same day and referred to the physician. However, the RN note lacked any questions regarding the relationship between the flank pain and any difficulty urinating, whether there was any blood in the urine or any other abnormalities associated with the flank pain. This information would be helpful to the physician in sorting out what might be the basis for the symptom. This patient was

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seen by the doctor but not until two weeks after the referral. The physician ordered a urinalysis but

this was not collected until more than two weeks later. These delays are not acceptable.

Patient #4 SR This is a 27-year-old who requested on 2/9/15 to be seen for a sharp pain in her head. She was seen by the nurse on the same day and a referral was made to the physician. Unfortunately, she was not seen by the physician until nine days later. Again, the lack of timely response is problematic.

Patient #5 CB This is a 35-year-old who on 1/29/15 complained of stomach pain and a headache. He was seen on the same day by the nurse. Unfortunately, the nurse did not perform a physical assessment. She did refer the patient to the physician but he was not seen by the physician until three weeks later, at which point the stomach problem had been resolved but the physician made no queries regarding the headache.

RECOMMENDATIONS: 1. The Director of Nursing, as part of the quality improvement program, should on a regular basis
review both the timeliness and professional performance of the nurses and provide direct feedback with discussion for the nurses whose performance needs improvement. This review and feedback needs to be documented so that it can be part of the quality improvement program. 2. The sick call logbook must be filled out conscientiously and accurately. Thus, for every documented assessment in the logbook there must be an associated record of that assessment in the medical record. 3. The Medical Director is responsible for insuring that nurse sick call referrals to the physician occur within the required time constraints. 4. Both nurses and physicians should insure that each symptom on a request is addressed with the patient and that the documentation of the assessment includes the fact that some problems may have been resolved.

MENTAL HEALTH FINDINGS: In the 6th monitor’s report this reviewer noted, "The psychiatrist has been seeing inmates on a regular basis for chronic care follow-up. However, this monitor continues to see notations in the medical record indicating that inmates have not been brought to the clinic for their visits due to the absence of security staff. Although it is reported that this occurs less frequently than last spring, it remains a major barrier to access to care for inmates with chronic health conditions."

In my meetings with staff, all reported few if any difficulties regarding transportation of inmates to scheduled therapeutic encounters. Staff have good cooperation with the newly assigned officer in the medical treatment building and improved organization and availability of transport officers.

Currently, the only mental health log of follow-up appointments at the clinic is for the psychiatrist. With the addition of new staff, it is encouraged that the mental health clinics also track inmates\detainees seen for general mental health services, special observation status, and segregation rounds in order to develop data to demonstrate quality, appropriateness and timeliness in the delivery of services. While on site, we did discuss the development of simple but effective tracking tools regarding inmates’ status and well-being for segregation reviews by the mental health staff.

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The psychiatric log was reviewed in its entirety and charts were selected for both focal and general review and will be described under specific sections of the Agreement. No chart reviewed demonstrated patients being lost to follow up or not being seen within a reasonable time frame as was the case during our early visits.

RECOMMENDATIONS: Moving forward, a variety of quality indicators regarding services should be developed and maintained to aid the staff in ongoing quality improvement reviews as well as provide proof of practice for the monitoring team and any other Bureau or independent agency or accrediting reviews.

d. Continuity, administration, and management of medications that address (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We met for some time with the pharmacist and understand that because there is a new administration she must have a new contract with the Bureau of Corrections. She is in the process of contract submission. She is also awaiting compensation for the last three months of 2014. We discussed with her the plans to move forward. She anticipates that the equipment should be onsite within the next three to six months. The process will require a person working in essence full-time as a pharmacy tech; the current LPN who is quite conscientious could meet the requirements and obtain the appropriate credentials. This person would work under the pharmacist’s supervision. The person would be responsible for receiving medications and following the pharmacist’s instruction with regard to storage and maintenance as well as responding to new orders from the clinicians.

My discussion with the pharmacist included selecting pharmacy software that would allow the pharmacy technician to enter orders into the software, but those orders could not be carried out until review and sanction by the pharmacist, who would have a second level of privileges. I also discussed the possibility that the pharmacist should be able to technologically perform this function even from home and if that is the case, then at least five days a week there should be timely availability of prescription medications. This capability would have to be worked out with the information technology people at the Bureau. However, I believe that this would be the most efficient way to accomplish the tasks.

I did observe a medication pass and was chagrined to observe that detainees were surprised to be requested to open their mouths for inspection after they had ingested the medication. The officer accompanying the medication nurse on both the morning and evening passes, seven days a week must insure that inmates present themselves at their door with a cup of water and are clearly identified. They must take and ingest the medication in front of the nurse, swallow the water and then open their mouths for inspection to insure that the medication is ingested. It is critically important that officers understand their responsibility for this part of the process and that this occur

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during all medication passes. The medical monitor has seen this work in jails and prisons all over

the United States and invariably the patients are not the problem when custody enforces the

requirements for participation in the medication process.

We also observed that the medication administration records are now brought with the nurse in a carrying bag. However, the nurse was not immediately documenting in the control room after each housing unit was completed. Nursing boards require that documentation of medication administration occur as soon as possible after the administration takes place.

RECOMMENDATIONS: 1. An officer needs to accompany the nurse on all medication rounds. 2. That officer’s responsibility besides accompanying the nurse is to insure that all inmates present
themselves at the door, carrying a container of water and that after receipt of the medication they immediately ingest it, swallow the water and open their mouths for inspection to insure that no pills are retained as contraband. 3. Nurses should document medication administration within the control room of a housing unit immediately after completing the administration for that housing unit. 4. The Director of Nursing should monitor the performance of the medication administration process as part of the quality improvement program.

MENTAL HEALTH FINDINGS: 100% of all mental health medication administration records (MARS) were inspected for completeness during this visit. The medication administration records did not indicate a problem with the administration of medication. However, no quality improvement data was available to dispute previous observations of medications being distributed without observation of ingestion. It was reported that the nurse administers medication and is also performing mouth checks.

RECOMMENDATIONS: defer to Medical recommendations

e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: With the hiring of the new full-time medical records technician, we did observe some records which were well organized, appropriately sectioned and contained documents in the appropriate chronologic order. For this the records technician is to be commended. However, this was not the case with all records. Some records, especially of inmates who have been housed for longer periods of time, remain somewhat chaotic. We look forward to our return in June and expect that the reorganization of the medical records will have been completed.

RECOMMENDATIONS: Complete the task of reorganizing the documents within the medical records so that they are contained in the appropriate section on the appropriate side and in the correct chronologic order.

MENTAL HEALTH FINDINGS: The maintenance of medical records is another area that has demonstrated remarkable improvement since the time of the December 2014 review. The facility

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has hired a permanent full-time medical records clerk, Ms. Franklin, as of January 12, 2015. Almost

all of the mental health records, which at the time of the last visit had not shown any reorganization,

are almost all reformatted. Charts are now assigned a numerical number for filing and have tabs to

organize the location of materials within the record. It was noted during the records review that many

of the entries within the sections still remain out of chronological order. I did not note any loose

filing within the records, which again is a major improvement. Ms. Franklin continues to work on

improving and thinning the records and I am quite optimistic that the charts will be in excellent

condition within the next several months.

Dr. Sang noted that she has set up a meeting with her staff to go over the development of forms for the different functions within the team in the near future.

RECOMMENDATIONS:

1. Once all records are appropriately organized and filed, a quality improvement tool needs to be developed to track compliance with this provision.
2. It is recommended that the mental health team contact this reviewer by e-mail once the new mental health forms are drafted for technical assistance prior to implementation. This process will hopefully avoid after the fact modification to ensure their completeness.

f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for this provision.

RECOMMENDATIONS: See letter (c) findings and recommendations.

MENTAL HEALTH FINDINGS: Eight mental health sick call requests have been submitted by inmates since the December 2014 site visit. Of these 6 (75%) records were located and reviewed. There were some delays in time to resolution but no adverse outcomes. I did discuss with Ms. Murray and Ms. Charles some issues noted such as original sick call requests being placed in a folder for a provider and not making it into the medical record.

RECOMMENDATIONS: This process needs to be tracked more closely to prevent delays in resolution in the future.

f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: We interpret this as referring to a chronic care list and an ability to track the sequence of visits. There is not yet a process to guarantee an accurate list is available based on new admissions added to the chronic care program as well as recent releases deleted from the chronic care program. The nursing staff will have to work with custody so that they receive a daily list of releases and can compare that list with the chronic care list. The chronic care tracking system should contain the names of patients, the date of referral into the chronic care program, the date of the initial baseline visit and then the dates of follow-up visits. Most systems set this up in an Excel-type format; however, it can be done manually as well. We reviewed five records of patients with chronic diseases, which we obtained from the chronic care list. We found problems with the timeliness of follow up as well as the documentation of the degree of control and the timeliness of the scheduling of the followup visits. We discussed with the Medical Director the desirability of reassigning the chronic care program to a clinician whose focus goes beyond a single subspecialty. The person performing chronic care certainly can be retained for patients whose disease is within his specialty. Of the five records we reviewed, at least three were problematic.

Patient #1 JH This patient is a 71-year-old with hypertension whose initial comprehensive visit occurred in August of 2013. The old forms were utilized, which did not allow for documentation of the assessment of degree of control. His next follow-up visit was one year later in September 2014 and his subsequent follow-up visit was four months later in January 2015. He has had no laboratory test results in his record since 2011. This patient is not being appropriately followed.

Patient #2 RM This is a 56-year-old whose initial baseline visit occurred in March 2014. He is assessed as having hypertension. At that time his blood pressure was slightly elevated at 161/87. This was assessed as fair control and he was given a follow-up visit in 60 days. However, that follow-up visit, which should have been in May 2014, contained no date. He has not been seen since and has no recent laboratory studies.

Patient #3 HR This is a 54-year-old with diabetes and hypertension whose baseline chronic care visit lacks a date. He was most recently seen on January 9, 2015, as a follow-up visit. However, there was no assessment of his diabetes despite the fact that he is on oral hypoglycemic agents.

The program remains disorganized.

RECOMMENDATIONS: The Director of Nursing should assign a chronic disease nurse who will be responsible for (a) maintaining the chronic disease tracking log, including adding new names and deleting released names, (b) working with the doctor to insure that follow up is consistent with the assessment of degree of control, (c) insuring that based on the guidelines, required laboratory studies are drawn and available in the medical record at the time of the scheduled visits, (d) insuring that where medications are ordered, patients continue to be seen without any disruption in the availability of their medications.

MENTAL HEALTH FINDINGS: The mental health clinic continues to maintain a tracking log for all patients followed by Dr. Sang that appears to be up to date during this review.

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RECOMMENDATIONS:

1. No further recommendations at this time

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: See f (ii).

RECOMMENDATIONS: See f (ii).

MENTAL HEALTH FINDINGS: The only current provision for acute mental healthcare is referral to the local emergency department where Dr. Sang can retain the individual for up to 48 hours. She reports she has kept inmates for up to nine days at the hospital in a general medical bed. No inpatient psychiatric beds are available on St. Croix. St. Thomas's mental health unit has been reduced in bed size due to inadequate staffing and they have refused transfers from Golden Grove Adult Correctional Facility. Officers do accompany inmates when they are at the local hospital for security purposes.

One inmate was placed in full security restraints and the medical record did not indicate any well­ being and circulation checks performed by medical staff. Even if restraints are not medically ordered, nursing staff should conduct frequent checks for positioning and circulation.

RECOMMENDATIONS: defer to Dr. Shansky’s report

f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We are encouraged that in several of the housing units we visited, there was an emergency response bag, which appeared to contain appropriate supplies for an emergency medical response. We did not review all housing units. However, in the five or six housing units we visited, the emergency response bag was available under lock and key and it was appropriately supplied. With the increased availability of nursing staff, officers now have access to medical staff for a greater number of hours. There is an emergency response log which is being maintained. However, as with the other logs, there are some blank fields which must be completed. We reviewed four records from that log. Some aspects of the process appear to be working. However, the most consistent deficiency was physician follow up after an emergency send out. This is a responsibility of the Medical Director to insure his availability or some other appropriately credentialed clinician. We will describe several of the cases.

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Patient #1 JE is a 21-year-old who was sent out on 2/1/15 to the ER at 7:42 a.m. for an acute asthma attack. We did not find a nursing note prior to the send out. The emergency room report was present and the patient returned on the same day at 2:30 p.m. The patient was given prednisone, a steroid medication, to reduce inflammation but five days after the medication expired Dr. Burton wrote an order for a second prednisone order. He did not, however, place the patient on an inhaled steroid. The patient was seen by the chronic disease doctor, who indicated the patient had no complaints but that he heard wheezing in both lungs. He also did not order inhaled steroids but only ordered pulmonary function tests. Four days later, the patient was again sent to the emergency room. That last emergency send out would probably have been prevented had the patient been started on an inhaled steroid. The patient has not been followed up since his return.

Patient #2 ES This is a 34-year-old who was sent to the emergency room on 2/22/15 as a result of left-sided chest pain. The emergency room documentation indicates that vital signs were normal and the patient was given an injection for the pain. A chest x-ray was done and the ER diagnosed costochondritis. There is a nursing note on return to the prison, but there has been no follow up by a clinician.

Patient #3 NW This is a 19-year-old sent out on 12/17/14 for a gluteal abscess. This patient had been seen by Dr. Burton and sent to the emergency room for an incision and drainage. These services were provided at the hospital and the patient returned and was seen by a nurse the following day. However, there has been no follow-up visit by a clinician to review the wound and insure that the problem has been resolved.

Patient #4 FC This is an 83-year-old who was sent out on 1/16/15 after complaining of dizziness after he had eaten. The emergency room note only indicates that the dizziness had resolved and there does not appear to have been any other diagnostic studies or treatment. This patient had no follow up until he requested to be seen for leg swelling, which happened about a month later.

RECOMMENDATIONS: 1. There must be, during the hours when nurses are on site, a nursing note prior to each emergency send out. 2. There must be a nursing note when the patient returns and the emergency room documentation must be available and reviewed by the Medical Director. 3. There must be a Medical Director follow-up visit within a few days of the patient’s return in order to insure that the problem has been appropriately followed up and is being resolved. 4. Medical staff should, on a regular basis, document the presence of emergency bags in each housing unit. There should be a sheet available to review in which custody has already documented the presence of these bags that are fully supplied. 5. We would like to see documentation of training being provided to officers by the Medical Director regarding emergency response.

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MENTAL HEALTH FINDINGS: see section V. i.

RECOMMENDATIONS: see section V. i., also, as stated in 5th Report:

f. (v) adequate and timely referral to specialty care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There is a log which is being maintained; however, we did find occasional blank spaces. Over a two-week period of time, four patients had to be rescheduled due to unavailability of officers or the transport van. However, all reschedules were accomplished timely. We were informed that radiology procedures take up to two weeks to accomplish and receive the report. We are still awaiting a computer in the medical unit to allow access to the hospital records including consultation reports, ER reports, radiographic reports, etc. We understand the hospital has agreed to this; however, the local BOC IT person has not been able to meet with IT at the hospital. This must be accomplished as soon as possible.

In the four records we reviewed, the most common problem was follow up by a clinician after the service was received at the hospital. This again is a responsibility of the Medical Director. Specific cases will be provided.

Patient #1 JM is a 58-year-old for whom the chronic care doctor requested an ortho consult after he complained of right hand and knee problems. He was seen by ortho timely on 2/3/15 and diagnosed as having cervicalgia and imaging of the neck and shoulders were ordered. This imaging has still not been accomplished. There has been no follow-up visit with the clinician to discuss the plan with the patient.

Patient #2 CL is a 47-year-old whose problem was left hip tenderness and for which an ortho referral was requested. Ortho indicated that a CT scan for the hip was indicated to determine whether a procedure needed to be done. After the ortho appointment there was no follow-up visit with the clinician. The CT scan was accomplished but there has been no follow-up visit after the CT scan. We discussed this case with Dr. Burton, who indicated because the patient may need surgery off island, he has discussed this with several other specialists but he is waiting to hear from a third and if that specialist concurs (that the service must be obtained off island), he will make the arrangements.

Patient #3 BC is a 58-year-old referred for a renal ultrasound and then on to a nephrologist. These referrals were done on 12/19/14 as a result of the patient having a blood test consistent with early renal failure. The ultrasound was done on 1/8/15 and the results are consistent with mild renal scarring and mild bladder retention. There has been no follow up with the clinician after these procedures. The patient did see a nephrologist on 1/27, but the nephrologist never mentioned early renal failure and ordered a follow-up visit which did take place in February, but again never commented on the elevated blood test and the diagnosis of early renal failure. This case was poorly handled and discussed with Dr. Burton.

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RECOMMENDATIONS: 1. Dr. Burton needs to insure that he is available for follow-up discussion with the patients after consultations or procedures. 2. The electronic link that would allow for accessing the electronic record of the hospital at the prison needs to be implemented. The IT person from the Bureau needs to work with IT at the hospital as soon as possible so that this link is functioning by the time of our next visit.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: This has been discussed under f (v).

RECOMMENDATIONS: This has been discussed under f (v).

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have reviewed the draft policy and procedure from the Medical Director on alcohol and drug treatment. Our only recommendation is that the policy and procedure should make it clear at what point, based on nurse monitoring, the nurse is obligated to contact the Medical Director for direction. This should be specified in the guidelines.

RECOMMENDATIONS: Modify the policy and procedure so that it is clear when the nurses must contact the Medical Director.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous

assessment.

MEDICAL FINDINGS: We now have received and reviewed the infection control policy and procedure and are comfortable with the latest draft. We are purely awaiting comments from the Department of Justice. On the other hand, when I was observing the medication pass, the registered nurse who was performing the medication administration also had a list of patients whose TB skin tests needed to be read. At that time she saw several inmates and read their TB skin tests. However, one of the inmates appeared to potentially have a positive skin test, which the nurse told me after feeling the degree of induration she would list as positive. The problem was she had not used a centimeter ruler in order to measure the size of the induration. Since the measured size of the induration is necessary to determine whether a skin test is positive and the results have to be documented in terms of millimeters of induration, I counseled her on the need to return and measure the size and then document on that basis. The TB skin test process requires that the Director of Nursing review the requirements for appropriate reading as well as documentation.

RECOMMENDATIONS: The Director of Nursing must train all nurses who will potentially either plant or read a TB skin test as to what the procedure requires, including documentation of all positives in terms of the number of millimeters.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report

RECOMMENDATIONS: defer to Dr. Shansky’s report

i. Adequate suicide prevention, including:

(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: There are no validated cases located by this reviewer of suicidal behavior or ideation to review GGACF’s actions for this provision.

In the past, review of the unit logs, especially the segregation units, contained frequent notations by security staff of behavioral problems on their units. These logs were very helpful in being able to identify charts for review to ascertain whether appropriate and timely behavioral health checklist referrals were generated. However, inspection of the segregation unit logs this visit demonstrated a complete absence of any description of any unusual behavior on the part of inmates housed in the L and 9A units with identified or unidentified mental illnesses.

The mental health coordinator is beginning a log to track behavioral health referrals from security as well as sick call requests.

RECOMMENDATIONS: Continue to monitor and review future behavioral health checklist referral tracking logs.

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(ii) a protocol for constant observation of suicidal prisoners until supervision needs are

assessed by a qualified mental health professional;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Ms. Charles and Dr. Sang reported no instances of deaths, including suicides, suicide attempts nor adverse events since the time of this reviewer's visit in December 2015. No medical records examined documented a suicide watch. However, the United States discovered during the April 2015 site visit that at least one inmate had in fact died in January 2015. That death was not reported to the monitoring team as required by the Settlement Agreement. The Territory confirmed the death by letter dated May 11, 2015, in response to the United States’ April 30, 2015 inquiry. The monitoring team has requested additional documentation about the inmate’s death and will evaluate it once it is received. The monitoring team’s logbook review uncovered at least one serious suicide attempt that apparently had not been communicated to medical mental health staff.

RECOMMENDATIONS:

1. An observation log form be developed for correctional officers’ use whenever an individual is placed on close observation or 15 minute watch. This will standardize documentation facility-wide. 2. Once implemented, these should be reviewed by mental health staff regularly to ensure security’s compliance with the policy.

(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: A suicide risk assessment instrument is not in place.

RECOMMENDATIONS:

Per previous monitor reports, a suicide risk assessment form should be developed and

implemented as part of the intake screening process as well as any other follow-up

services.

One reference for correctional use can be located at:

http://www.cdcr.ca.gov/realignment/docs/PRCS-MH-pre-release-planV2-11-20­

2012.pdf

2. All mental health encounters should record the presence or absence of suicidal or homicidal ideation by the mental-health professional performing the service.

(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

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MENTAL HEALTH FINDINGS: During this visit we learned that there was no cut down tool

in the medical treatment building. This situation was corrected prior to the reviewer’s exit. For a

complete assessment of all units within the facility this reviewer defers to the report by the security

monitors.

RECOMMENDATIONS: defer to Mr. Romero’s or Mr. Ray’s report

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Currently the monitor has not yet received nor approved an adequate training curriculum. Therefore, this provision remains noncompliant.

While on site, I did discuss this continuing deficiency with Mr. Benjamin and again requested a copy of the training curriculum be sent to me and Mr. Ray for review and approval. He assigned Ms. Andrade the task of obtaining and distributing that document. As of this report, the document still has not been provided to the monitoring team.

RECOMMENDATIONS: A complete training curriculum on suicide prevention needs to be forwarded to the monitors for review and approval.

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: There has been no change reported in this area. Ms. Charles reports no suicide prevention training has occurred since last fall. They are waiting to bring on a significant number of new hires and will then schedule training. However, it is again noted that there is no curriculum yet approved by the monitoring team.

RECOMMENDATIONS: GGACF will submit their curricula for training officers and facilities staff in suicide prevention for approval by the monitoring team. Once approved, the facility will need to develop a training schedule for all staff. Effectiveness of the training will need to be demonstrated by the use of competency measuring tools and follow-up quality improvement studies.

(vii) availability of suicide resistant cells;

ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

MENTAL HEALTH FINDINGS: By inspection, GGACF continues to operate without any suicide-resistant cells. Inmates requiring close observation are housed in the regular housing units. That placement would require that inmates be placed on constant observation. However,

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even when inmates have been listed as on suicide watch in the past it has been noted that

observation occurred on an intermittent and unpredictable schedule, if at all.

Construction of a small infirmary and suicide prevention housing area within the medical treatment building has come to a halt, reportedly due to finances and relocation of inmate workers to off-site facilities (the latter as a remedy to improve inmate officer-to-inmate staffing ratios). One physically disabled mentally ill inmate is currently being housed in a single cell fitted with a hospital bed and access to the bathroom facilities. We were informed that an officer is assigned around the clock to the treatment building to provide supervision for this inmate. However, as noted above (see Section IV.A.1.b), documents reveal that the treatment building was not staffed on at least three (3) shifts.

RECOMMENDATIONS GGACF is encouraged to complete renovations in the infirmary in order to provide appropriate and safe suicide and close observation cells. As expressed in the last report, all measures should be taken to provide adequate space within the cell, suicide resistant sinks and commodes and the absence of any protruding objects within the cell that would facilitate the placement of a ligature. Please refer to all of the detailed recommendations in the Monitor's fifth assessment report regarding the configuration and structure of suicide resistant housing.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: No change has occurred since the time of the last site visit. A draft protocol had been submitted to the parties for review and approval. Therefore, this provision remains in noncompliance since there is not an adopted and approved policy in place, training has not begun and no measurement of efficacy of the training exists. And in fact, as mentioned previously, there is observable evidence that little if any observation is provided and documented currently.

The supervisor’s log dated Thursday, March 19th, 2015, indicated one person had been brought in by VIPD on suicide watch per the person’s attorney. The medical department had no records on this individual and it is unclear whether they were ever booked into the facility.

RECOMMENDATIONS: Complete the process of policy approval, implementation and monitoring.

(ix) procedures to assure implementation of directives from a mental health professional regarding:
(1)the confinement and care of suicidal prisoners; (2)the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MENTAL HEALTH FINDINGS: It was reported there have been no cases of suicide watch for this monitor to review and no final policy. However, the logbooks indicate that there may have been at least one serious suicide attempt and a suicide watch, neither of which were brought to the mental health staff’s attention.

RECOMMENDATIONS: Complete the process of policy approval, implementation and monitoring.

j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: Since the last visit, a full-time medical records staff has been added and in addition there have been additional hours provided of registered nurse staffing. The current staffing as of the time of our visit is one full-time Director of Nursing and three full-time registered nurses plus an additional two hours of registered nursing. We have been informed that in order to cover the gaps that preclude 24/7 RN staffing they will add one full-time nurse plus part-time hours. They currently have one eight-hour shift uncovered seven days a week, which equals 56 hours plus four additional hours on Saturday and Sunday. That adds up to 64 hours of additional registered nurse time that needs to be added. This would be in terms of full-time equivalents; 1.6 FTEs and they would be able to cover 24/7. I have been generally impressed with the quality of the nursing staff hired and was informed by the nurse who has been on site the longest period of time that in his several years on site this is the best group of nurses they have ever had on site.

RECOMMENDATIONS: Complete the remaining hours of registered nursing so that coverage achieves 24/7.

MENTAL HEALTH FINDINGS: This area of the Settlement Agreement has shown measurable improvement. There are currently two mental health professionals and a psychiatrist. A registered nurse has been identified to assist the mental health team when needed and monitoring referrals, medication order transcription and laboratory studies. This service is not yet fully organized; however, with the very recent addition of the mental health coordinator I anticipate rapid and continued improvement in the quality and quantity of services available to the inmates at GGACF in the near future.

While on site, I had the opportunity to review the resumes for the new hires and ensure that licenses for Dr. Sang and Ms. Murray were current. As mentioned earlier, a third mental health professional position is open and recruiting is ongoing.

RECOMMENDATIONS: None at this time. Once policies are adopted facility should complete an annual staffing analysis and those analyses and plans will be reviewed by this monitor.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: There has been rotation of assignment of correctional officers who work in the medical area. As far as we are aware, there have been no additional officers added and this has had its most significant impact with regard to access to offsite services for which four patients in the last two weeks have had to be rescheduled. This was either due to officer availability or van availability. We have identified previously that officer escort onsite will be required less when the exam rooms built in each housing unit are refurbished and appropriately equipped. We are pleased to note that the effort to accomplish this has begun and we visited the L and K housing units where the process has progressed the furthest. We also visited the G housing unit and in detention both A, B, C and D. The detention housing units were least advanced and L and K were most advanced. I will list the requirements for each housing unit exam room. They are as follows:

1. An air conditioner that is functioning. 2. About 4-6 inches of privacy screen on the windows from the bottom of the window up. 3. An exam table with necessary paper. 4. A large wastebasket in which the used paper can be placed. 5. A desk and two chairs. 6. A sink which includes functioning hot water. 7. Soap. 8. Hand sterilizer. 9. A full set of tiles on the floors which were especially a problem in the detention area rooms. 10. A complete set of ceiling tiles. 11. A redo of the cleaning process so that sanitation is adequate. 12. Cabinetry with a lock on it which can house medical supplies.

RECOMMENDATIONS: 1. Provide sufficient officer staffing and transport vehicle so that rescheduling can be eliminated. 2. Refurbish and supply all housing unit exam rooms according to the requirements listed in the
above findings.

MENTAL HEALTH FINDINGS: There is no progress on this front due to the lack of submission of an adequate and an approved training curriculum by the monitor. Given the absence of any mental health programming plan, it remains impossible for the facility to determine what the adequate number of correctional officers are to properly supervise prisoners serious mental health needs.

RECOMMENDATIONS: None at this time. Once policies are adopted facility should complete an annual staffing analysis and those analyses and plans will be reviewed by this monitor.

l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

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MEDICAL FINDINGS: I have listed the areas that I expect to see quality improvement activities at the time of our next visit. Those include the intake process, including the intake screen and health assessment as well as sick call and medication management and I am expecting to see documentation of QI activities in these four areas by the time of our June visit.

RECOMMENDATIONS: Perform documented QI activities with regard to the above listed service areas.

MENTAL HEALTH FINDINGS: Until policies are approved, trained to, and implemented this provision cannot be met. It is reported that since our last visit there still have been no meetings of the Medical Administration Committee or the Quality Improvement Committee. Hence, there were no meeting minutes available to review.

RECOMMENDATIONS: Essential monthly or quarterly management meetings should be occurring regardless of whether a draft policy has been adopted. Although it is useful for the medical director to be present this should not be an essential component blocking communication between medical staff and other department leaders. Failure to implement these critical committees delays essential communication between administration and medical and remains a major deficiency.

m. Adequate dental care;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have looked at and approved the oral care policy for which we are awaiting the DOJ comments and the completion of the process. I met with the dentist during this visit and discussed with him access, which he indicates has improved. We do not yet have documentation of this.

RECOMMENDATIONS:

1. The HSA should track both the availability of the dentist as well as the availability of custody escorts under the QI program.
2. The dental program should report to the QI program the number of scheduled patients and the numbers who arrive and the reason for non-arrival of patients.
3. The dental program should track the number of extractions as well as the number of restorations performed each month.
4. Develop adequate dental policies, procedures and protocols.

MENTAL HEALTH FINDINGS: defer to Dr. Shansky’s report.

RECOMMENDATIONS: defer to Dr. Shansky’s report.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have seen a draft policy. We do believe an important part of the QI program is for an external review of all deaths to be performed by a non-involved physician in direct care to the patient.

The Territory has not complied with the terms of the Settlement Agreement which require notification of the Monitor and United States upon any inmate death. At least one inmate died in January 2015, but that fact was not brought to the Monitor and United States’ attention as required. Instead, the Territory only confirmed the death in May 2015, in response to the United States’ inquiry in April 2015, which based on the United States’ independent document review. The monitoring team has requested but not yet received documentation relating to this death.

RECOMMENDATIONS: Make an arrangement with an external physician to perform an educational mortality review on all deaths.

MENTAL HEALTH FINDINGS: However, as stated in V.1.k, there has been another case of complicated aggressive behavior and management issues which has generated no documented comprehensive combined internal investigation or review by security and health services. Cases like this would benefit from routine special management meetings or even discussion in a monthly Medical Administration Committee meeting, per provision V.i.l, but none of these are in place.

RECOMMENDATIONS: The clinical directors, newly hired Director of Nursing and Health Services Administrator should develop mechanisms to identify and review all cases of mortality and serious morbidity as part of the Quality Improvement process. These reviews should also include security leadership.

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: My understanding is medical staff are to round twice weekly in order to insure access to services and to assess the potential for decompensation. I have not reviewed the segregation logbooks. I will begin at my next visit.

RECOMMENDATIONS: The Director of Nursing should, on a monthly basis, monitor the segregation logbook to insure that registered nurse rounds have been completed.

MENTAL HEALTH FINDINGS As of the time of this visit, no rounds by any health staff have been performed in segregated units. However, Ms. Charles assured me that as of May 2015, the mental health coordinator would be completing and documenting weekly rounds. A registered nurse will begin doing medical rounds twice a week as of April 21, 2015.

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RECOMMENDATIONS: The mental health coordinator will keep documentation of weekly

rounds and this provision will be monitored at the time of the next site visit.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: There is no change in the findings for this provision since the baseline visit. Inmates with serious mental illness continued to be housed on a long-term basis in disciplinary segregation units. This reviewer also observed three inmates with serious mental illnesses being housed in locked cells for vulnerabilities secondary to their mental illnesses in a general population detainee unit. These inmates are allowed congregant out-of-cell unstructured time for two hours each evening.

Two of the three inmates appear to have developmental disabilities while the third appeared to be actively hallucinating and responding to internal stimuli. A chart review indicated that these three men all carried diagnosis of the major serious mental illness and were receiving antipsychotic medications. All three were housed in cells with no radios or reading material. One man known to eat plastic cups was noted to have the debris of several Styrofoam cups on the floor of his cell. Another inmate was actively smoking a cigarette that he states he had made from toilet paper. The smoke in his cell was so acrid that it was difficult to interview him beyond a few seconds without withdrawing from the cell. The prison is a smoke-free facility with no fire suppression system in place and yet no officer accompanying us requested that the inmate extinguish his makeshift cigarette, which is contraband. The third inmate told me that during his time out of cell he smokes cigarettes in the common area. During the day, while locked in his cell, he attempts to beg cigarettes from other inmates who are circulating within the dayroom area. None of these inmates had any access to structured mental health programming yet clearly would meet criteria for residential treatment placement with the requirements of a minimum of 10 hours of structured therapeutic activities per week. These men are currently only receiving services at an outpatient level of care that is insufficient to meet their treatment needs and only allowed out of cell time two hours per day (a requirement for SMI in segregation) despite the fact that they are not in administrative or disciplinary segregation, but rather protective custody because of their vulnerabilities.

Similarly, some inmates with serious mental illnesses continue to reside in segregation units because of the lack of availability of any other housing designed to meet both their security and mental health treatment needs.

The medical case manager attended a segregation meeting that should be occurring monthly since January but there is not documentation to support the regularity of these meetings. In reviewing her notes from all meetings that have occurred, any chart referencing a mental health need was reviewed. For one inmate there were two notes that he needed to be seen by the psychiatrist but the medical record does not document that either comment resulted in a visit.

RECOMMENDATIONS:

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1. As per the provisions of this Settlement Agreement, inmates with serious mental illnesses should not be placed in isolation. However, it is also noted that the facility lacks any specialized programming unit to adequately accommodate the treatment needs of the seriously mentally ill population and is unable to currently provide any relief to the mentally ill inmates in segregation who require heightened programming and structure. The latter however does not relieve the Bureau of that obligation to develop, in a timely manner, the necessary treatment programs and housing requirements for these inmates. The lack of programming and appropriate housing has been an issue identified by this monitor for the past year and half. The Bureau of Corrections needs to develop a corrective action plan with specific recommendations for capital improvements and dates to remedy this deficiency.
2. As discussed with the mental health staff, a record should be maintained in order to prove that the practice of weekly mental health rounds in segregated units on the detainee and prison side.
3. During the time that inmates remain in segregation with serious mental illnesses, mental health staff should be aware that these inmates be offered a minimum of 10 hours a week of unstructured out of cell time by security. In addition, mental health staff is encouraged to develop supportive group or individual therapeutic activities, generally recommended being a minimum of 10 hours per week per inmate in order to support the inmate’s mental state as well as assist inmates in acquiring skills to move them off the segregated status and sustain themselves in the general population setting.
4. Medical services needs to ensure that communications regarding inmate needs gathered in administrative or other meetings be formally entered on to a referral sheet to the clinic for improved follow up.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: Without a policy requiring input by mental health into the disciplinary process and a form to communicate with the disciplinary committee, mental health will not be notified regarding disciplinary reports and therefore, cannot provide input.

RECOMMENDATIONS:

1. GGACF should develop a form which can be sent to the Mental Health Coordinator, completed by mental health staff and submitted to the disciplinary committee. The committee can use the same form to communicate back to the mental health staff outcome of the hearing proceeding.
2. GGACF needs to develop an effective policy and process to provide mental health review and input into the disciplinary process.
3. Mitigating factors discovered by the mental health professional must be considered by the disciplinary committee.
4. Mental health services should track the effectiveness of their input in mitigating sanctions or

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terminating sanctions as appropriate.

5. Alternative housing and treatment services are an essential component in diverting seriously

mentally ill inmates committing infractions due to their impaired judgment and mental

processing. Again, it is recommended that GGACF provide appropriate staffing and housing

alternatives for this population. (See V.1.p.)

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MEDICAL FINDINGS: We have discussed some progress made in the preparation for housing unit exam rooms to be appropriately equipped, cleaned and sanitized. The section k medical findings on officer staffing includes a description of what is needed. Additionally, nurses are now performing sick call in a room with only a desk and chairs. The room in the clinic area must be equipped with appropriate exam table, other examination supplies as well as, at a minimum, hand sanitation liquids.

RECOMMENDATIONS: 1. Complete the requirements found in the medical findings regarding officer staffing. 2. Appropriately equip the clinic space in which nurses are now performing sick call.

MENTAL HEALTH FINDINGS: The psychiatrist and MHP are using private offices in the treatment building. However, once the medical director and other medical providers are on-site running clinics, space may yet again be an issue.

RECOMMENDATIONS: Appropriate sound private office space with reasonable visibility by security staff needs to be made available to the psychiatrist and to any mental health professionals that are hired providing services in the medical treatment building.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: Based on chart review, there remains a need for updated treatment plan, some of which have not been changed since 2013. However some of the difficulty may be due to the lack of mental health professional staff. Now that there are two new members to the team there should be improvement in the quality and quantity of treatment plans.

RECOMMENDATIONS:

1. Based on policy developed protocol treatment plan should be updated at set frequencies based on inmate need and changing conditions in the inmate status. It is strongly recommended that supervisory review occur to ascertain the appropriateness and completeness of the treatment plans generated.

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2. When indicated, in-service training on treatment plan development is recommended to ensure

consistency between staff members in developing measurable objectives to marked

improvement in those inmates followed by the mental health team.

(ii) adequate mental health programs for all prisoners with serious mental illness;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous visit.

MENTAL HEALTH FINDINGS: There remain serious deficiencies in meeting the requirements of this provision. As noted earlier with the hiring of additional mental health staff, approximately 5 weekly outpatient groups are being offered as well as an increased number of individual face-to-face encounters. However, the service has not yet had time to organize itself to develop and implement a comprehensive facility-wide treatment program.

RECOMMENDATIONS:

1. The mental health team will need to develop a global treatment menu designed to meet the needs of inmates at different levels of housing and treatment needs.

2. Group programming should be designed to meet the clinical needs of individuals who should be assigned to those programs based on their needs assessment on their individual treatment plan.

(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: The psychiatrist continues to do an excellent job in obtaining vital signs including girth at the time of each visit.

Review of 3/5 records were available of those inmates on psychiatric medications that ordinarily would require blood testing and level analysis indicated a need for improvement in the ordering and tracking of these studies. No chart that fell in this category demonstrated adverse effects if studies had not yet been obtained.

A total of 38 inmates are currently receiving psychotropic prescriptions. Of these 68% were on antipsychotic medication and 73% of that group were receiving long-term injectable preparations. There is an unexpectedly low percentage of individuals being treated with antidepressant medication (16%).

There is no formal policy in place or protocol to establish laboratory practice guidelines for the psychiatrist to follow and for the Quality Improvement Process to track.

RECOMMENDATIONS: USVI BOC should develop its own set of practice guidelines to be used system-wide.

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Please refer to the following previously provided suggested guidelines (these are not standards,

simply suggestions).

LABORATORY GUIDELINES:

Lithium: 1. Initial (within 3 months of initiating drug) 2. U/A 3. CBC 4. SMAC 5. TSH 6. EKG if over 40 7. Level every one to two weeks after reaching dose of =/> 600 mg day until level stabilizes. 8. Once a plateau is reached levels should be obtained q 4 months.

Tricyclic antidepressants: 1. Initial same as above except a U/A is not required 2. Level every 6 months or sooner if clinically indicated (Dose exceeds daily recommended
dose, etc.)

Atypical Neuroleptics: 1. At least quarterly weights, HgA1C and fasting lipids q six months especially for Clozaril,
and Zyprexa. 2. AIMS (Assessment of Involuntary Movement Symptoms) initially and q 6 months

Anticonvulsants (Depakote, Tegretol): 1. Hepatitis screen within last three months 2. SMAC 3. CBC with platelet count 4. Monitor levels of Tegretol and Depakene until within a therapeutic range

Chronic use: 1. Level q six months 2. Follow up LFT’s for Depakene

Beta blockers 1. Initial vital signs and follow up pulse and BP whenever dose is changed

Benzodiazepines 2. Baseline vital signs 3. Random UDS q 3-6 months or whenever clinically indicated

Psychostimulants 1. Baseline vital signs 2. Random UDS q 3months 3. Consider TSH whenever clinically appropriate.

Other reference sources on:

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1. practice algorithms include the American Psychiatric Association’s Practice Guidelines at www.psych.org; http://www.urmc.rochester.edu/psychiatry/links/practice-guidelines.aspx
2. AIMS http://www.cqaimh.org/pdf/tool_aims.pdf

(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.

MENTAL HEALTH FINDINGS: No change since the sixth report.

Correctional officers at GGACF should be commended for continuing to comprehensively complete behavioral checklists to initiate referrals for mental health services.

RECOMMENDATIONS:

1. Continue to utilize the Behavioral Checklist process. 2. Conduct a facility quality improvement morbidity review that can be submitted to the
monitoring team for review.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous visit.

MENTAL HEALTH FINDINGS: As noted above, there has been no change in this area since the sixth report.

There continues to be no improvement in this area. Inmates with serious mental health issues continue to be maintained in segregation and isolation (in the case of one individual) due to the lack of appropriate housing, programming, and coordination with security and classification.

RECOMMENDATIONS:

1. Facility leadership continues to fail to include critical medical and mental health staff in decisions regarding housing and programming of the seriously ill inmates. In addition, observations at the time of this visit indicate an ineffective or nonexistent system of communication by the facility leadership to health services leadership. It is strongly recommended that the Warden’s office establish weekly communication meetings between the critical health services leadership (Health Services Administrator, Medical Director, Psychiatric Director, Director of Nursing, etc.) and that the Health Services Administrator coordinate monthly Medical Administration Committee (MAC) meetings occur, documented by minutes and attendance sign in sheets.

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VI. FIRE AND LIFE SAFETY


Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment. Draft policies and procedures were completed by the monitoring team in the area of Fire and Life Safety by the December 31, 2014 deadline and were provided to both parties.

FINDINGS: The Territory provided this Monitor draft Fire Safety policies and procedures during the July 2014 onsite technical assistance visit. However, during that visit the Fire Safety consultant advised the Monitor that he had revised these policies and would thereafter provide them. The monitor reported in his previous reports that he had not yet received revised policy drafts despite making a written request. The revised policies and procedures were not provided to the monitoring team during or after the December 2014 monitoring visit. However, the monitoring team completed a draft version of the GGACF Fire Safety policies and procedures and provided them to both parties by the December 31, 2014 deadline. The finalization, approval, staff training and implementation of these policies and procedures remains vital.

Inadequate housing unit staffing levels and contraband control practices continue to enable inmates to ignite various materials in the housing units as evidenced by our April 2015 inspection of the housing units. During this inspection, I observed lit wicks and smoke emanating from them in several housing units. Supposedly, inmates use the smoke from the lit wicks to ward off insects. However, aside from the contraband problem stemming from the use of wicks, it also creates fire hazards. It appears that staff have relented to the use of lit wicks by inmates and do not prohibit their use. Cigarette butts were observed on the ground in the recreation yard for the Gulf housing unit.

The automatic fire detection and suppression system remains inoperable, inadequate staffing levels and contraband control leaves housing units deleteriously under-controlled and -monitored, inmates apparently have undetected and interrupted access to items to ignite materials, and inmates obviously have no inhibition about igniting materials.

During this monitoring visit, it did not appear that there were any reported fires in the housing units. However, due to the ease by which inmates can access fire ignition sources and given the state of disrepair with the facility electrical system, i.e., exposed electrical wiring and heavy fire loads in the inmate cells, this area remains volatile from a fire and life safety perspective.

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During our inspection, I also observed exposed electrical wiring throughout various areas of the

Facility, including the kitchen, housing units, maintenance shops and electrical rooms. In the

kitchen I observed boxes stacked in the dry storage area nearly up to the ceiling (should be

stacked no higher than 30 inches below the ceiling). This was an identical finding from our last report.1 These findings, in addition to previous findings, reveal the urgent need to develop and

implement a comprehensive fire safety program at GGACF.

The BOC did not renew the contract with the Fire Safety Inspector; however, they have assigned Officer Samuel to perform the fire safety duties for GGACF. Although Officer Samuel appears to be qualified in performing fire safety duties, he also is required to perform other duties associated with GIST. Officer Samuel reported that the VI Fire Marshal has not come to the facility to conduct a fire safety walk-thru, but is expected to do so shortly. The previous contract Fire Safety Inspector had reported that the facility provided copies of the Fire Evacuation Plans to the VI Fire Marshal; however, those evacuation plans only addressed the housing units. Furthermore, there is still no documentation available to demonstrate that even those limited evacuation plans were approved by the VI Fire Marshall. The fire evacuation diagrams within the Facility remain woefully outdated and offer no assurance that they would be effective in routing staff and inmates from a fire or smoke related emergency. In fact, some diagrams do not outline the appropriate route. A comprehensive fire evacuation plan that that would incorporate all areas and buildings within the confines of GGACF and the contents of the overall fire safety program, such as the fire safety policies and procedures, still needs to be developed and provided to the VI Fire Marshal for review.

Staff reported and documents reflect that the BOC is trying to secure an MOU or MOA with the VI Fire Service for helping GGACF come into compliance with the fire safety provisions of the SA. However, it must be expressed that the BOC/GGACF are the primary entities for demonstrating compliance with the fire safety provisions of the Settlement Agreement.

RECOMMENDATIONS: Previous recommendations remain appropriate. Additionally, the Monitor continues to request the reports for all drills and exercises conducted. It is also imperative that when the GGACF Fire Safety Program and the Fire Safety Plan are finalized and that they be provided to the Fire Marshal and with a copy to the Monitor.

1. Finalize and implement fire safety policies once approved and according to the Monitor’s schedule.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all locations
where staff would need to search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate supervision
and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security.

1 There does not seem to be a system in place for ensuring that the respective GGACF department heads receive our monitoring reports in a timely manner, if ever; therefore, they are incapable of providing follow-up actions. For example, the current Fire and Life Safety Officer had only received our report a few days prior to our on-site visit.

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7. Additional part-time fire safety officers should be selected from the officer corps, trained, and

participate in the administration of a comprehensive fire safety program. It is unrealistic to

expect one expert to develop and oversee such a complex program.

8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of

occupied structures, taking particular note of fire risks and hazards, document and report those

findings to administration for timely and appropriate corrective action.

9. The fire inspection program is now detailed in the draft fire safety policies and procedures that

the monitor provided to the parties, and they should become a fundamental element of pre-and

in-service training once policies and procedures are finalized, approved, and implemented.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Almost Identical to previous Monitor’s reports, we found that the Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, cell and housing unit sprinklers are non-functional and regularly used by inmates to support personal clotheslines. The primary fire detection and suppression system was designed to automatically detect and extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates. The only way to alert staff and inmates of a fire or smoke hazard is to use hand-held air horns that are located in the control rooms of the housing units. During this inspection, a maintenance officer had a difficult time locating the hand-held air horn that was found in a drawer in the maintenance office.

Adequate supplies of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures. However, in reviewing the housing unit logs for 9A between January 1, 2015 and April 2, 2015, I noted entries in the log book whereby there was no fire extinguisher available between January 17, 2015 and approximately March 10, 2015. It also appears that there was no fire extinguisher in unit 9B between January 17, 2015 and February 21, 2015.

GGACF staff continue to indicate that sprinkler heads may be replaced in the “newer” buildings at some point in 2015. During our last inspection, we were provided with a letter, dated November 24, 2014, directed to the Department of Interior from the BOC Director requesting to allocate funding to aid in the replacement of the fire suppression system and for refurbishing the Kitchen at GGACF. However, the scope of work for the fire suppression system seems to only include the purchase and installation of fire sprinkler heads and related parts in areas of the Facility where there is a fire sprinkler system, but does not seem to address the need to install a fire sprinkler system such as in the old housing units where there is no fire sprinkler system. This needs to be clarified. The estimated cost for the fire sprinkler heads and related parts is approximately $89,700.00. Moreover, GGACF plans to continue to house individuals in the “older” buildings, and has no plans to update or install fire suppression equipment in those buildings. As reported in earlier monitoring reports, GGACF will never come into

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compliance with these provisions if that remains the case. The acting BOC Director informed

us that a grant with the Department of Interior has been approved for renovating the Main

Control Center and related electronics, including fire and life safety improvements. The bid for

this work is scheduled for bid with 30 days, according to the BOC acting Director. During our

June 2015 inspection, it would be helpful to review the scope of work to be performed

associated with this bid project.

During this inspection we also observed that medical department does not have emergency lighting and only 2 of the 5 manual smoke alarms had batteries. Also, in H housing unit, the emergency lights are inoperable due to lack of batteries.

RECOMMENDATIONS:

1. Refer to recommendations above (a). 2. Consider purchasing fire safety program software from NFPA and/or the American Correctional
Association to assist in program development and monitoring. 3. Continue to support fire safety officer.

c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. GGACF staff indicated that fire drills have not been conducted on a regular basis. The newly appointed Fire Safety Officer reported that the plan is to conduct fire drills in at least two (2) areas of the facility during each quarter. It is laudable that the new Fire Safety Officer plans to start addressing the necessity to conduct regular fire drills. As an example of the lengthy lapses in conducting fire drills, we were informed that in X-Dorm, the last fire drill occurred in 2012. Furthermore, staff and inmates confirmed that fire drills are not conducted on a regular basis. As reported in earlier Monitor reports, it is unclear when, if ever, full fire drills are conducted. The failure of GGACF staff to conduct fire drills on a regular basis of all facility areas continues to put inmates at risk of injury or death, should a fire break out that cannot be suppressed by the hand-held fire extinguishers present in the officer control pods of housing units.

Confusion still remains surrounding emergency key management. For example, some housing units had the emergency key to the fire exit doors available in housing control center. However, in another housing unit we were informed that the emergency key to the fire exits had been removed and taken to another area of the facility. Also, in the housing units that have cell slider doors (Units L and K); the tool used for opening cell doors is not readily available. We were informed by security staff that the emergency tool to manually open these doors is kept in the maintenance shop and tool room. However, there was no emergency tool located in the tool room. There was an emergency tool in a cabinet in the maintenance supervisor’s office, but it uncertain how quickly this emergency tool could be accessed, especially after normal working hours and on weekends. There needs to be a clear and concise understanding by all security

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staff as to where the facility emergency keys are kept as well as having the tool to open the cell

slider doors readily available.

Emergency keys are not appropriately marked and identifiable by touch. A system for marking and identifying all emergency keys that match the proper door locking mechanism needs to be developed and systematically implemented.

During this inspection we also observed that the cells in the intake area, which at times houses juveniles or high level protective custody prisoners, have padlocks on the cell doors. This practice, coupled by the fact that when inmates are housed in these cells where there is not constant and direct supervision, or a functioning smoke alarm system or fire sprinkler system puts the prisoners at a high risk of harm.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement a valid and reliable emergency key system as described above. Train
and drill staff as discussed on system use. 3. Develop emergency key and locking mechanism inspection and reporting system as discussed
above. 4. Implement competency-based staff training as discussed above. 5. Exercise fire safety program using onsite, scenario-based drills; include community responders
in exercise planning and exercise events. 6. Send the training officer and part-time fire safety officers to the National Fire Institute, National
Emergency Training Center, Emmetsburg, MD for additional training.

d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell;
and; (ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Almost identical to our previous monitoring reports, documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance.

There is not a written preventative maintenance program or a regular security inspection program in place for checking that cell locks are functional and are not jammed from the inside or outside of the cell, nor a system for ensuring that all facility remote locking cell mechanisms are functional. During this monitoring visit we observed evidence of inmates compromising the cell locks by inserting various materials in the locking mechanisms. We also observed numerous housing unit grills whereby the locking mechanism was inoperable and the grills left open.

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There is also no position for a full-time locksmith at the facility. The part-time locksmith is

only contracted for 75 days per year, thus the Maintenance Supervisor has to assume the duty

of working on the locking system as well as supervising the Maintenance Department which is

a daunting task. We also observed that the R&D entrance doors are still inoperable from

previous monitoring visits.

RECOMMENDATIONS: Same as above.

1. Refer to previous recommendations for this provision. 2. Also refer to recommendations related to security provisions, contraband, and inmate
manipulation of cell door locking systems. 3. Repair all remote cell locking notification technology.

e. Testing of all staff regarding fire and life safety procedures;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Although the previous Fire Safety Inspector reported that he was involved in training staff on fire and life safety procedures, we were unable to ascertain its’ validity because as stated in the previous reports and in our current site visit, no records have been provided to verify that all staff have been trained and tested on safety procedures. It is also unclear if the newly appointed Fire Safety Officer duties will include testing of staff regarding fire and life safety procedures.

RECOMMENDATIONS:

1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
2. Provide this Monitor documentation evidencing compliance with this Provision.

f. Reporting and notification of fires, including audible fire alarms;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The fire reporting and notification system remains inoperable as reported in previous Monitor reports. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a hand-held air horn to alert inmates’ evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. As identified in previous Monitor reports and consistent with this inspection, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.

During our previous monitoring visit we observed that GGACF has had the necessary equipment for installing a manual fire alert notification system stored in an office for about two (2) years. It appears that in order to install this system, the facility needs to provide the necessary electrical components. However, in light of the acting BOC Director’s comments

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regarding the fire safety upgrades as noted previously in this report, a fire notification system

is contemplated in the project.

RECOMMENDATIONS:

1. Install and routinely test the stored file alert notification system without delay 2. See previous fire safety recommendations

g. Evacuation of prisoners threatened with harm resulting from a fire;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously stated, the fire evacuation policies have not been approved and full scale evacuation drills are not conducted.

RECOMMENDATIONS:

1. Refer to previous recommendations for this provision. 2. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.

h. Fire suppression;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as previously stated. There is no functional fire suppression system, with the exception of the kitchen’s cooking area. Also, as noted previously in this report, fire extinguishers are not always readily available.

RECOMMENDATIONS:

1. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.
2. Repair the automatic fire detection, notification, and suppression system. 3. Replace cell sprinklers with tamper proof mechanisms. 4. Monitor staff response to fires, ensure they comply with basic fire safety principles, and
implement appropriate staff corrective action as needed.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The requirements for this provision are addressed in the draft Fire and Life Safety Policies and procedures that were provided to the parties in December 2014. Once approved, staff must be trained on them and they need to be fully implemented.

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RECOMMENDATIONS:

1. Finalize, approve, and implement relevant policies and procedures.

2. The comprehensive fire safety program development must involve health care leadership to

ensure that policies and procedures include adequate provisions for timely medical and

mental health response to persons injured during a fire event.

3. Medical and mental health staff should be appropriately trained in relevant fire safety

program components and drilled quarterly to ensure compliance with program response

requirements.

4. Policy components involving medical and mental health staff should provide for their safety

and security when involved in fire incident responses.

5. Qualified medical staff should participate in the development of fire program training topic

that involves burns and smoke inhalation concerns. Qualified mental health staff should

participate in the development of training related to critical incident recovery and emotional

injury and recovery.

j. Control of highly flammable materials.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Many inmate cells contain considerable personal property, thus creating a fire and safety risk. Flammable storage areas/cabinets in the Carpentry shops do not appear to be properly vented. The Monitor provided a draft policy and procedure dealing with the Control of Chemicals, Flammables, Toxic and Caustic Materials to the parties which substantially addresses this provision.

RECOMMENDATIONS: Same as above.

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VII. ENVIRONMENTAL HEALTH AND SAFETY


Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;
FINDINGS: Documentation in the form of logbooks and memorandum was provided during this monitoring visit that demonstrated ongoing efforts of GGACF officials and maintenance staff to assess, improve, and monitor facility sanitation and hygiene. Draft policies were provided to this Monitor for review prior to the Court ordering the monitoring team to write draft operational policies. The Monitoring team reviewed and further revised these policies and procedures and provided them to both parties in December 2014. Yet, these policies and procedures were not finalized and approved by GGACF officials in accordance with the courtordered March 30, 2015 deadline.

Again, however, housekeeping and sanitation plans will not meet compliance with this Provision without adequate staffing levels as previously stated.

During our review of the Maintenance Department we observed that the Maintenance Supervisor maintains preventative maintenance schedules for various components of the GGACF physical plant, including the emergency generator.
However, during this inspection we continued to observe inoperable doors and grills, inoperable showers, mold in showers, non-functioning water fountains, plumbing leaks, security fencing breaches and cluttered electrical and mechanical rooms.

RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.

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5. Develop a mold control/mitigation plan that includes routine inspection and cleaning

activities. Control access to related cleaning chemicals and train staff and inmates in the

proper use and storage of those chemicals.

6. Develop and implement a sanitation management plan that monitors and mitigates sanitation

problems and hazards.

7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this

program are trained in proper cleaning methods and use of materials and chemicals. Ensure

mattress storage areas are sanitary at all times.

8. Repair all housing/cell windows to prevent penetration by insects.

b. Adequate ventilation throughout the facility;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated). In housing unit 9 D we encountered an inmate locked in his cell who was visibly mentally ill and verified by the assigned officer. We observed other inmates in front of his cell arguing about a portable fan the inmate had in his cell. Apparently the fan belonged to another inmate who had lent it to this inmate and they were trying to get it back from him. A security supervisor verified that the fan did not belong to the mentally ill inmate and gave it back to the rightful owner. However, I observed that the cell where the inmate was housed was very hot, had no ventilation and the cell window had minimal airflow capability. We were informed that the inmate was homeless and could not afford a fan on his own, and the Territory does not provide fans to indigent inmates—even those who have a mental illness. The mentally ill inmate is also only allowed about one (1) hour of out-of-cell time on a daily basis. These are unacceptable living conditions for any prisoner and particularly for a mentally ill prisoner.

Most of the housing unit exhaust fans remain inoperable.

During our previous inspection the Monitoring team was provided with a draft proposal regarding a Detailed Energy Audit conducted by Energy Systems Group, dated November 10, 2014. This proposal includes measures to retrofit the lighting system, the air conditioning system, the PV Panels and for conducting plumbing upgrades at the Facility at an estimated cost of approximately $8,425,106.69. However, during this inspection we were informed by the acting BOC Director that there is no long term plan to address the ventilation issues. Certainly upgrades are necessary for the continued operation of GGACF.

RECOMMENDATIONS:

1. Timely complete an air quality assessment performed by a qualified provider. 2. Implement necessary improvements that reduce housing area and cell temperatures and
increase air flow.

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3. Medical and mental health staff should monitor all inmates for heat and airflow-related

health risks. All inmates in segregation or who are locked in their cells should be monitored

by medical and mental health staff for signs of health conditions.

4. Train all staff in detecting and responding to health conditions related to heat and air

circulation contributors.

5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and

air quality readers. Require regular monitoring and recording of readings and take timely

action to mitigate environmental conditions that create health risks caused by those

conditions.

6. Medical and mental health professionals should closely monitor inmates being administered

medications that are adversely affected by high body temperatures and take appropriate steps

to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Attention to lighting repair and replacement remains positive. However, security staff are allowing inmates/detainees to cover their cell lights, which is creating a fire hazard.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and internal
illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness. 6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that
impedes good visibility from the cell door window. 7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are
reliably operational.

d. Adequate pest control for housing units, medical units, and food storage areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Very little change since previous inspections. This provision remains in Partial Compliance but no decline in performance was found. Identical to our previous inspection, we noted that the overhead door to the storage area of the Kitchen is not properly sealed and rodents and vermin can easily infiltrate the Kitchen. Inmates in the housing units complained of mosquitos. Some inmates have lit “wicks” made, apparently, of toilet paper on their cell windows and floor, hoping that the smoke will deter mosquitoes. We also observed missing or broken screens on many facility windows.

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The BOC has contact with a private vendor (Oliver Exterminating of St. Croix) to provide pest

control services at GGACF.

The Monitoring Team developed a draft Vermin and Pest Control Policy and Procedure that was provided to both parties in December 2014. Yet, these were not finalized and approved in accordance with the court-ordered March 30, 2015 deadline.

RECOMMENDATIONS: Previous recommendations remain appropriate

1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.

e. Prisoner and clinic staff access to hygiene and cleaning. supplies;

ASSESSMENT: PARTIAL COMPLIANCE – No substantive improvement from previous assessment.

FINDINGS: There was no substantive improvements from previous assessments. Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies. However, there were a number of inmate complaints in the Housing Units claiming they do not have sufficient quantities of cleaning materials to properly sanitize the showers. We observed that many inmate showers are in deplorable condition both from a sanitary standpoint, including mold problems and physical plant deterioration.

The Monitor provided the parties with draft policies and procedures for this area of Environmental Health and Safety. Yet, these were not finalized and approved in accordance with the court-ordered March 30, 2015 deadline. RECOMMENDATIONS:

1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Continue to provide adequate supply of these personal care items in control pods or housing
units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in their cells
and living areas.

This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: NON COMPLIANCE – No substantive improvement from previous assessment.

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FINDINGS: No substantive change from previous assessment.
There is no formal sanitation plan or protocols covering compliance with neither this Provision nor a formal training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling bio-hazardous materials, provided and instructed on the proper use of bio-protective clothing and supplies, and supervisors must closely monitor biohazard clean-ups. Remaining in Partial Compliance with this Provision can jeopardize the health of staff and inmates.
Spill clean-up kits were available in the medical area.
RECOMMENDATIONS:
1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for biohazard safety and exposure control; B. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all bio-waste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a bio hazardous control program that involves regular inspections of all potential contamination areas.
2. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
3. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.
g. Mattress care and replacement;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: I did not see this area to be problematic during this monitoring visit. There were no inmate complaints regarding their mattresses and the ones I inspected were adequate. However, GGACF staff have not yet substantially addressed the Monitor’s previous recommendations as listed below, including mattress care.
RECOMMENDATIONS:

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1. Refer to previously discussed sanitation recommendations. 2. Issue clean and usable mattresses to all inmates. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and contraband,
cleaned and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance
requirements.

h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: No substantive change since previous assessment. Implementation of approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff that supervise inmates and are allowed to handle these chemicals must be properly trained in that role and those responsibilities. This has yet to occur.

The Monitor provided the parties with a draft Control of Chemicals, Flammables, Toxic and Caustic Materials policy and procedure and incorporates this Provision. Yet, these were not finalized and approved in accordance with the court-ordered March 30, 2015 deadline.

RECOMMENDATIONS:

1. Finalize, approve, and implement relevant policies and procedures. 2. Develop comprehensive control plans for cleaning supplies and chemicals, chemical
inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs. 3. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols. 4. This provision can advance to Substantial Compliance once related policies, procedures and plans are approved and implemented according to the Agreement.

i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As previously reported, housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports and found during this monitoring visit, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets, and dry these items in their cells using clotheslines anchored to fire sprinkler heads, walls, window frames, bunks, etc. We also observed worn out linens and dirty linen in many inmate cells.

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The Monitor provided a draft Inmate/Detainee Clothing, Bedding, and Linen Supplies policy and procedure to both parties in December 2014 that addresses the requirements of this Provision. Yet, these were not finalized and approved in accordance with the court-ordered March 30, 2015 deadline.

RECOMMENDATIONS:

1. Finalize, approve, and implement relevant policies and procedures. 2. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks. 3. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells. 4. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of
bedding. 5. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management
plan that governs total laundry operations. 6. Develop specific policies and procedures for handling, containing, and washing contaminated
clothing, linens, and mattresses. 7. Consider replacing all wood laundry carts made of non-absorbing materials that can be sanitized
and completely cleaned. Discontinue the practice of moving laundry on carts that has not been cleaned and sanitized. 8. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing should be exchanged with clean items twice per week at minimum, sheets and towels once per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health. 9. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets. 10. Staff and inmates involved in the laundry work program should be properly trained and supervised. 11. Laundry equipment should reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;

ASSESSMENT: NONCOMPLIANCE
FINDINGS: During our previous inspection, Territory officials reported the initiation of a major project to repair and clean-up the kitchen area. A scope of work for the project was submitted to the BOC Director on July 11, 2014. During this inspection, the acting BOC Director reported that the BOC received a federal grant last year for approximately $400,000.00 for GGAC kitchen improvements, but also included an outside project. The acting Director reported that he was trying to reorganize the grant disbursement to be used only for GGACF.

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The physical plant of the Kitchen remains in a state of substantial deterioration as does the food

service equipment. We found the flooring to be substandard with numerous broken tiles

resulting in standing water and unable to properly clean and sanitize it. From our previous

inspection, some minor repairs were made to the floor area in the dishwashing room. The

dishwasher has not being working properly for a lengthy period of time. We observed plumbing

leaks throughout the Kitchen. We observed inoperable ovens. There is an inoperable walk-in

refrigerator that is unsanitary, along with a foul smell. There is no hot water in the male and

female inmate bathrooms to properly clean their hands. There was an additional hand washing

sink located outside the bathrooms that did have hot water, but it took a lengthy amount of time

for the water to get hot. Paper towels present on the first day of our visit were missing the next.

Food temperatures are not routinely taken of prepared food. The kitchen doors are not rodent

proof. We found residue of rust in the ice that is provided to the housing units. We observed

evidence of mold and rust in various areas of the Kitchen. There is no master inventory of the

utensils and dangerous implements. New items/utensils are not properly labeled. We observed

particles of ceiling tiles falling off in the dining room. However, the staff reported that the

inmate dining room is no longer used for inmates to eat in.

RECOMMENDATIONS:

1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with nationally recommended allowance for basic nutrition; F. Prohibitions of using food as a disciplinary measure; G. Involvement of independent outside sources to verify food service facilities and equipment meet government safety codes; H. Prescribes regular cleaning schedules including routine deep cleaning; I. Provide written utensil control methods similar to those used by the tool shop; J. Accident prevention program; K. Personal and environmental sanitation requirements; L. Food temperature monitoring and records keeping; M. Adequate health protections for all staff and inmates including health screens and prohibitions against working in the kitchen when ill; N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that all bathrooms and wash basins are consistently supplied with antibacterial soap and hot water; O. All areas and equipment related to food preparation, distribution, and storage require frequent inspection to ensure they are sanitary, operational, and safe;

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P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit; between 140

and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the final rinse. The person

conducting inspections should be a qualified food service inspector;

Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit, refrigerated foods

are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees Fahrenheit or below, unless

national or state codes specify otherwise;

R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit and cold

foods at approximately 41 degrees Fahrenheit;

S. Supervisory food service staff should monitor food service operations to ensure that that

cooking, cooling, and food temperatures and delivery meet established requirements;

3. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care.
4. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented.
5. Policies and procedures developed should include controls for the use of caustic, toxic, and hazardous materials used in the kitchen. Material Safety Data Sheets should be posted conspicuously.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No improvement was again observed in the housing units during this assessment with the exception of X-Dorm.

The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lock down. Access to drinkable water is generally available during the “out of cell” periods but inmates must rely on the presence and actions by officers following lock down. Inmates have no access to drinkable water when there are no officers on the units to provide it and water from cell-sinks is considered not safe for drinking. Inmates have consistently complained of seeing particles of rust in the ice that is provided to the housing units. As noted earlier in this report, we observed evidence of rust particles in the ice in the kitchen that was going to be used for housing unit distribution.

In X-Dorm we had been reporting a consistent problem regarding the lack of drinking water for this unit. However, GGACF officials have addressed this problem by installing portable water bottles in the dorm.

RECOMMENDATIONS:

1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable access to safe drinking water.
2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING


Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This Monitor has repeatedly requested, since September 2013, all pre-service and in-service training curricula and related documents. The Territory has not provided any such material.
During this visit this Monitor examined a Training notebook provided by a corrections recruit. This recruit indicated the contents of the notebook included all materials for the basic training program provided to recruits. The contents of this notebook included the following subject matter:
1. Employee Handbook 2. Sexual Harassment 3. BOC General Orders (which were out of date) 4. Outdated Rules and Regulations 5. Staff Dress Code 6. Outdate SOPs 7. Mental Illness (reportedly taught by an unqualified instructor) 8. The 1986 Consent Decree (which is no longer relevant to compliance with the current
Agreement) 9. Two very outdated civil cases 10. Information on body searches and classification 11. The current consent Agreement 12. Suicide Prevention (reportedly taught by an unqualified instructor)
The recruit training program will require extensive and comprehensive revision if this notebook accurately represents the core basic training program. A comprehensive list of basic training topics was previously provided to the Territory for consideration. Additionally, only fully qualified instructors should be authorized to teach pre-service and in-service training courses.
RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Implement training policies and curricula once approved. 2. Provide this Monitor and DOJ all requested training documents.

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b. Pre-service training for all new employees;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.

RECOMMENDATIONS: Previous Recommendations Remain Appropriate

1. Provide the Monitor with all pre-service training curricula and lesson plans for all staff.

c. Periodic in-service training and retraining for all employees following their completion of pre-service training;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.


RECOMMENDATIONS: Previous Recommendations Remain Appropriate


1. Provide Monitor with all in-service training curricula and lesson plans for all staff as requested.

d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above.


RECOMMENDATIONS: Previous Recommendations Remain Appropriate


1. Provide the Monitor all training program curricula and completion of training reports. 2. Provide the Monitor with documentation on how compliance with this provision is being
met. 3. Develop a basic spread sheet that allows the Monitor to clearly determine the following:
 Total authorized staff per category (correctional, supervisory, civilian, contract, etc.)  YTD actual staffing levels per category, preferably by month  Number and percentage of current staff in each category who have completed required
pre and in-service training, per month

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IX. IMPLEMENTATION


1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.
FINDINGS: This Monitor completed and issued a revised Schedule as directed by the Court. Policy and procedure drafts were provide to the Territory on 12/31/14 as directed by the Court. This schedule has since become obsolete as a result of the Territory missing deadlines. The schedule will be revised in collaboration with the parties.
2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.
FINDINGS: Same as above.
3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.
FINDINGS: Virtually all policies drafts submitted by the Territory for review and comment were rejected by USDOJ and this Monitor as incomplete. Moreover, the Territory missed critical courtordered deadlines for finalizing policies and procedures. As a result, policies and procedures have yet to be approved for training and implementation, rendering the latest court-ordered implementation schedule obsolete. The Territory intends to retained professional assistance to finalize and resubmit all deficient policies.
4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.

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FINDINGS: There have been no semiannual impact evaluations submitted by the Territory.

The reports submitted do not include evaluation of progress.

5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.

FINDINGS: Same as number 3

6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.

FINDINGS: The recent Status Report largely provides inadequate information to reliably assess or evaluate progress toward compliance. The information provided does not link progress to compliance. Thus, following the last status conference, the Court ordered “that Defendants’ sixth status report and similar future status reports filed with the Court shall include the expected progress on each item discussed at the preceding status conference with the Court together with the actual progress made by Defendants with regard to each item.” ECF. No. 882 at 2.

7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.

FINDINGS: The Territory fails to promptly notify this Monitor and USDOJ of inmate deaths and injuries requiring emergency medical attention. A review of emergency room transfer logs reflect several transfers of inmates sustaining injuries but not notification was provided as required. Also, during the April 2015 onsite tour, the United States discovered an inmate death in January 2015 that had not been reported by the Territory. This Monitor has requested from the Territory additional information and records about these instances but has yet to be provided that information.

8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.

FINDINGS: Generally speaking, most of the various administrative and operational records provided evidence continued noncompliance with this Agreement. Production of requested records is relatively slow and sometimes incomplete. In some cases, housing unit logbooks have gone missing or been destroyed. This Monitor believes, however, that the document production process is improving with new BOC administration and compliance team.

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9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.

FINDINGS: The Monitor and monitoring team were provided adequate access to the facility during this visit. Yet, staff could not find the requested Supervisor’s Logbook for January 15, 2015, to February 27, 2015, and the Territory still has not submitted requested training records.

10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.

FINDINGS: The Monitor believes that USDOJ continues to experience significant difficulty in receiving timely written responses to questions as required. The USDOJ requested information about the housing and supervision of juveniles and the use of the intake unit at the facility. The Territory’s written response conflicts with facility documentation.

X. Monitoring

D.1. Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.

FINDINGS: This Monitor complied with this requirement before conducting the Baseline visit in September 2013. This Monitor continues to provide the parties this information prior to, during, and following each onsite assessment.

D.2. Monitoring Access: With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility and Detention Center, all facility non-privileged records, prisoners' medical and mental health records, staff members, and prisoners, Defendants will direct all employees to cooperate fully with the Monitor, Reasonable advance notice must be provided to the Bureau of Corrections prior to conducting any on-site compliance reviews. Other than as expressly provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. All nonpublic information obtained by the Monitor will be maintained in a confidential manner.

FINDINGS: The Monitor has consistently provided reasonable advance requests for documents and information that are essential for carrying out his duties required and authorized within this

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Agreement. As previously discussed in this and previous reports, the Monitor (and the USDOJ

for that matter) continues to experience significant delays in receiving requested documents and

information and has not received some requested documents at all.

APPENDIX A
 ASSESSMENT METHODOLOGY

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.
Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Pre­ visit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.
Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.
1. Description of how the Monitor will assess compliance with each of the Compliance Measures.
In general, compliance assessment will include the following activities:
A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring.

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E. On-site tours of grounds, perimeter security barriers, perimeter access control and

entrance points, all external security technology and methods, building and structural

exteriors, roofs, and utility systems.

F. On-site tours of all buildings, housing units, special environments, health care facilities,

receiving and discharge areas, segregation units, all cell areas, food service and storage

areas, utility closets and chases, utility technology and systems, fire prevention and

suppression systems, life safety locations and equipment, other interior areas and location

relevant to determine compliance.

G. Examination of all security equipment and systems used for perimeter, external, structural,

internal, and special security operations purposes.

H. Examination of health care equipment, supplies, materials, technology and other material

methods and processes used for inmate health care assessment, diagnosis, treatment

planning, treatment (long and short-term), follow-up, and discharge planning.

I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other

motorized vehicle used for correctional operations purposes.

J. Examination of any and all available records, data, and/or information relevant to

compliance and compliance monitoring not limited to the following:

 Administration

 Budget

 Personnel

 Operations

 Training

 Facility construction, renovation, repairs, and maintenance

 Equipment, supplies, and materials

 Inmate case files

 Medical and mental health screenings, assessments, evaluations, diagnoses, treatment

plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

 Labor contracts

 Incident reports and logs

 Evidence / contraband reports and logs

 Use of force incidents and logs

 Inmate grievances and disciplinary records and actions

 Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

 Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

 Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (noncompliance, partial compliance, and substantial compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail

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Association, National Commission of Correctional Health Care, American Psychiatric

Association, American Nursing Association, ASIS International, National Fire Protection

Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other

nationally accepted standards for compliance assessment and management. Additionally, specific

measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall

be followed. The following compliance management terms are suggested for assessment and

compliance monitoring:

 Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
 Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.
 Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or consumer satisfaction).
 Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of consumer satisfaction, a performance indicator might be: “the percentage of consumers who state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 On-site visits, tours, meetings, individual and group meetings and interviews  Collection and examination of electronic, paper, and photographic records, information,
and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)
  Online media information
  Online public records
  Electronic and standard mailing of information
  Email communication and phone consultations 


3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s

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desire to assist the Territory in developing records and information methods and processes that

yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it

is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for assessments and monitoring include the following.
A) Corrections Information:
1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility.

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18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry

to the facility or during their stay in the facility.

19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which

ones are vacant.

20. Reports and data showing turnover information and statistics for security, medical, mental

health, and other staff positions budgeted and authorized for the previous 36 months.

21. Any staffing improvement plan, applications for technical assistance, and Territory budget

proposals/authorizations to address staffing shortfalls.

22. Facility maintenance requests and work orders for the past 12 months.

23. Records and/or lists of physical improvements, repairs, and renovation completed to

correct security problems and deficiencies over the past 36 months.

24. Past 36 months of agency budgets.

25. List and contact information for any and all community vendors who provide services of

any kind to GGACF and contracts or professional services agreement authorizing those

services.

26. List and contact information for community regulatory agencies who inspect, review,

approve, and/or provide consultation to the GGACF i.e., health inspections, fire

inspections, etc., and any inter-local agreements involved in these services.

B) Medical and Mental Health Information:

27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of
their records. 31. To the extent not provided above, the policies and procedures governing medical and
mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers, including
on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to include
health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD
testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets.

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S SEVENTH ASSESSMENT REPORT

Page 97 of 98

Settlement Agreement

43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to

include in the log presenting complaint, name, date of request, date triaged, and disposition)

and chronic illness appointments for the past two (2) months.

44. A copy of the nursing protocols.

45. To the extent not provided above, a copy of any training documentation for security and 


medical staff on policies and procedures and emergency equipment.


46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location.

47. To the extent not provided above, external and internal reviews or studies of medical or mental

health services including needs assessments and any American Correctional Association and

National Commission on Correctional Healthcare reports.

48. List of all inmates placed in restraints, and all inmates receiving mental health treatments,

under suicide watch, or taking psychotropic drugs.

49. Current mental health case list including inmate name, number, diagnosis, date of intake, last

psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed

only by counseling staff with last appointment date and follow-up appointment.

50. Documentation reflecting any training that facility staff have received on suicide


prevention, including certificates and training materials.


51. All documents related to the any suicide occurring within the past year.

52. List of all persons on warfarin, Plavix, digoxin.

C) Suicide Prevention Information:

53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms

utilized for the identification of suicide risk and mental illness.
 55. Any suicide prevention training curriculum regarding pre-service and in-service staff 

training, as well as any handouts.
 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and 

investigative reports of all inmate suicide victims within the past three years.
 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications for the
past year. 66. A description of medical and mental health’s involvement/input into the disciplinary process
and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.

It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

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Golden Grove Adult Correctional Facility & Detention Center St. Croix, Virgin Islands

MONITOR’S SEVENTH ASSESSMENT REPORT

Page 98 of 98

Settlement Agreement

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 932 Filed: 09/11/15 Page 1 of 99
United States Virgin Islands
GOLDEN GROVE 
 ADULT CORRECTIONAL FACILITY 

EIGHTH COMPLIANCE MONITORING REPORT

2013 Federal Court Settlement Agreement In re: United States of America v. The Territory of the Virgin Islands (86/265)
Submitted September 11, 2015 Kenneth A. Ray, M.Ed., Monitor

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 Page 2 of 99

“Dripping water hollows out 
 stone, not through force but 
 through persistence.” - Ovid


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Topic

Kenneth A. Ray, MEd, Monitor TABLE OF CONTENTS

Page

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

3

Purpose……………………………………………………………………………..

4

Executive Summary & Findings Overview………………………………..……

6

Section IV. Safety and Supervision Compliance ………………………………

7

Section V. Medical and Mental Health Care Compliance …………………….

42

Section VI. Fire and Life Safety …………………………………………………

71

Section VII. Environmental Health and Safety ………………………………… 79

Section VIII. Training ……………………………………………………………. 88

Section IX / X. Implementation / Monitoring…………………………………… 90

APPENDIX A 
 Compliance Assessment Methodology ……………………………………………. 
 94

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PURPOSE
The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) as a tool to assist U.S. Virgin Island officials in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.
EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW
The eighth onsite compliance monitoring assessment was conducted June 8-11, 2015. A focused and productive Court status conference was held on Thursday, June 11th, 2015. Prior to this site visit, the Monitor coordinated communication between the Parties and monitoring team in preparation for the onsite assessment.
This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.
Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:
“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) partial compliance, and (3) noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”
Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing this final report.

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The Monitor will advance each provision as certain levels of compliance progress are clearly demonstrated by the Territory. Generally speaking, the Monitor will advance provisions from noncompliance to partial compliance when compliance efforts demonstrate the following:

1. Policies, procedures, protocols, and/or plans required of a provision are properly approved in accordance with this Agreement;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented. Implementation includes evaluation that implemented policies, procedures, and training are performing within the expectation of this Agreement.

Provisions are eligible to advance from partial to substantial compliance when efficacious assessment and evaluation of implemented policies, procedures, protocols, plans, etc. quantitatively and/or qualitatively evidence: 1) that implementation efforts are producing outcomes intended in the Agreement and 2) that implementation outcome performance is reliable (assessments and evaluations evidence consistency in producing outcomes intended in the Agreement). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately demonstrated using appropriate compliance evaluation methods and measures, this Monitor will and has reversed a compliance rating when the evidence supports doing so.

This assessment found reasonable cause for the Monitor to reverse one provision from Partial Compliance to Non Compliance. Classification provision IV.F.1.e. is herein reversed due to a continued lack of quality management in various reporting systems necessary for adequately tracking and evaluating performance outcomes. Consequently, overall assessment ratings are slightly lower from the previous assessment. 111 (92.5%) of the 120 Provisions are now rated in Noncompliance; Nine (7.5%), Partial Compliance; and, none are rated in Substantial Compliance. The score card below shows current compliance ratings.

GGACF EIGHTH COMPLIANCE ASSESSMENT SCORE CARD

Areas of Compliance Per Agreement
IV. Safety and Security V. Medical, Mental Health Suicide Prevention VI. Fire and Life Safety VII. Environmental Health and Safety VIII. Training Total Substantive Provisions Percent Compliance

Total Provisions
59 36 10 11 4 120 100%

Non Compliance
56 36 10 5 4 111 92.5%

Partial Compliance
3 0 0 6 0 9 7.5%

Substantial Compliance
0 0 0 0 0 0 0%

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EIGHTH ASSESSMENT FINDINGS OVERVIEW:
This assessment was very well coordinated and attended by GGACF staff and officials. Territory and GGACF participants were prompt, collaborative, and attentive throughout this visit. These participants seemed open and transparent with regard to answering questions posed by the monitoring team and USDOJ attorneys. The participation and contributions of all visit participants exceeded that of previous onsite assessments and deliberately benefited visit outcomes. As noted in the discussion below, however, the Monitor was unable to conduct a complete assessment of several provisions because the Territory did not provide requested documents.
Although overall progress remains at a very slow pace, significant traction has been achieved with regard to establishing new compliance implementation schedules. All health care-related policies and procedures have been approved and training on many of those regulations has commenced. The Territory’s adherence to the new security policy development schedule is been unstable and remains not compliant. Under the schedule, the Territory was to have submitted all policies to the Monitor and USDOJ for review and comment by August 21. As of August 26, however, the Territory had submitted 12 of the 18 required policies. The Territory has not submitted any new policies since July 31, when it informed the Monitor and USDOJ that CCA was not able to work on policies at the previously agreed upon schedule. USDOJ has provided comprehensive comments to all policies except one, and the Territory has submitted four revised policies for further review by the Monitor and USDOJ. Full approval and adoption of all security-related policies and procedures is scheduled for October 30, 2015. The schedule for policy training is forthcoming.

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IV. SAFETY AND SUPERVISION
As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:
a. Development of housing units of security levels appropriately stratified for the
 classification of the prisoners in the institution, see also Section IV.F. re: Classification
 and Housing of Prisoners; 

ASSESSMENT: NONCOMPLIANCE
FINDINGS: On July 24, 2015, the Territory submitted to the monitoring team and USDOJ draft policies, procedures, and related forms pertaining to housing unit security levels that include stratification for the classification of prisoners. The stratification “matrix” includes all housing units and classification designations. Final approval and implementation of these policies and procedures is pending review.
The Territory’s greatest challenge in ensuring prisoner safety and security remains ensuring adequate and consistent housing unit staffing levels, consistent prisoner supervision and monitoring, and staff supervision. The best written policies and procedures are to no avail without sufficient staff and staff supervision to them out. For example, examination of the Incident logs, incident reports, Evidence (Contraband Logs), Daily Staffing Rosters, and interviews with inmates and staff continue to report the active presence of very serious and dangerous safety and security risks and adverse events. Prisoners, and staff for that matter, remain unreasonably expose to actual and potential risk of harm by serious staffing level shortages resulting in inadequate housing unit staffing and prisoner supervision and control.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Apply the approved Housing Stratification matrix as designed and with previously recommended revisions. Specifically, previous recommendations involved making physical and

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programmatic changes to Kilo (K) unit so as to eliminate insolated conditions of mentally ill inmates. 2. Review current population to verify accurate risk/need classification levels and housing, reclassify and appropriately house as indicated by review process findings. 3. Refer to IV.F. regarding specific classification and housing policy recommendations.
b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Revised Post Orders that comport with this Agreement and draft policies and procedures have not been submitted for review and approval as of yet. However, the Warden previously issued written directives to shift supervisors requiring inspections of all housing units each shift and to document those inspections on Shift Supervision Rounds form. This form lists all facility areas to be inspected by supervisors each shift, including housing units, intake areas, non-housing unit buildings, visiting, medical, chapel, kitchen, etc. There are “Date” and “Comments/Concerns” columns to record this information. The bottom of the form provides clear and direct instructions for supervisors to conduct rounds. These instructions denote areas requiring daily (per shift) and weekly (per shift) rounds. All housing units, medical, Receiving and Discharge, and Roving Patrol areas require supervisors to conduct daily inspection rounds. The instructions also direct supervisors to:
x Sign and/or ensure that the officer sign in (RED INK) is preferred x Talk to staff and inmates in each area visited and note any major concerns/issues x Account of these items while on post: Post Order Manual, suicide cut-down tool, flashlight
operational, radio operational, telephone operational, logbook completion, officers’ view into the cells not obstructed x Ensure: High sanitation level, Officers have tools to perform duties, keys secure, etc. x Any deficiencies should be indicated that addresses [resolves] the issue
Examination of Shift Supervisor Rounds forms for May 2015 provided by the Territory cannot verify consistent or accurate compliance with the Warden’s directive because many of the forms appear to be incomplete and inconsistently completely among supervisors. Many of the daily inspection forms denote “ Nothing new report” while other completed forms record numerous problems and issues involving inoperable sally port doors and equipment, specific repairs needed, plumbing leaks, and most troubling, “no officer was present when checked [in detention visiting].”
Shift Supervision Rounds inspections reports can be a valuable tool for monitoring compliance with the Warden’s directive, monitoring facility safety and security, and ensuring supervisors monitor the performance and behavior of staff. However, these findings seem to indicate that upper management does not review these forms for quality compliance purposes but should.
Examination of Supervisor Logs and Shift Rosters continue to evidence continued non-compliance with requiring at least one officer is assigned to each occupied housing unit. These records document

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supervisors finding housing units without officers for the entire shift, and officers reporting late to housing unit assignments, and “extreme staff shortage”. Staff shortages are routinely reported in Shift Rosters as the primary cause for overtime with as many as 75 percent of a shift working overtime.
This Monitor requested all completed Shift Rosters for May 2015. Territory officials provided “what [they] had”, which included only 37 reports. However, there should have been 93 reports for May based on 31 days x 3 shifts per day. Unfortunately, assessment of staffing levels was limited to an incomplete set of reports. This assessment was further complicated by GGACF using at least three different shift staffing forms which did not completely match. Nonetheless, this document examination revealed virtually all shifts had staff shortages, officers reporting late to work, and/or housing units not staffed.
Shift staffing levels was analyzed similarly to analyses shown in previous reports. However, actual shift rosters were used rather than abstracting staffing data from supervisor logs. Shift rosters, overall, appear to provide slightly more reliable information but even these documents are very problematic for assessing compliance. Nonetheless, these documents provide sufficient data to calculate reasonably reliable staffing levels.
Shift staffing rosters provided by the Territory for May 2015 were examined and analyzed. Documents were provided to assess 25 of a possible 31 work days and 35 out of a possible 93 work shifts. (31 days x three shifts per day). Shift rosters were not provided for six work days and 58 work shifts. Additionally, two shift roster reports were excluded for the analysis due to documentation errors. Therefore, only 81 percent of possible work days and 38 percent of possible work shifts could be including in this analysis.
As noted in previous reports, this analysis determined that occupied housing units continue to operate either understaffed or without staff. For example, A Dorm operated with one officer for only 25 of the 35 reported shifts. The remaining ten shifts were staffed by .33 or .5 officers. This is because the shift reports indicate that those officers were assigned to other housing units (RSAT and/or Intake) during the reported shifts. No officer was reportedly assigned to A Dorm on the 10p-6a shift for May 15. Concomitantly, RSAT and Intake units appear to have operated without adequate staffing levels for most shifts assessed. This is particularly concerning because Intake has held vulnerable populations such as juveniles. Other housing units reportedly operating with inadequate or no staff include:
G Unit, 5/3, 10p-6a; 5/21, 10p-6a H Unit, 5/3, 10p-6a; 9A Unit, 5/21, 10p-6a 9C Unit, 5/16, 10p-6a 9D Unit, 5/17, 6a-2p ACF R/D, 5/3, 10p-6a
Additionally, these records also appear to evidence that staff are frequently late to work and/or depart before the end of shift.

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Although these shift document seem to indicate marginal improvement in staffing, this analysis is unable to reliably determine these improvements due to continued documentation problems:
1. At least three (3) different shift roster document forms are used 2. The forms are inconsistently filled out 3. Many are incomplete 4. Many shifts are missing for the month being assessed 5. Legibility problems 6. Not all posts are on the rosters, some rosters use different post terms, some include posts not
included in other rosters
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Immediately correct documentation problems shown above. 2. Rapidly implement the NIC Staffing Analysis recommendations. 3. Complete the draft staffing, as required under the Agreement that reflects the NIC Staffing
Analysis and provides concrete steps for hiring sufficient staff. 4. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff
working overtime have adequate time away from the facility before returning to work to ensure they are adequately rested. 5. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics. 6. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm. 7. Subsequent to policy and procedure development and revisions, conduct a complete review of existing specific and general post orders to ensure they are: A. post specific; B. accurately represent post staffing needs and post resources needed to operate the post safely
and consistently; C. are numbered, cross-referenced with policies/procedures, and formatted in a manner that
makes them easy to interpret and apply; D. maintained at each post, kept current, and easily accessible; E. regularly reviewed, revised, updated; F. consistently enforced; G. known to staff through pre-service, in-service, and ongoing training. 8. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues are detected and resolved in a timely manner. 9. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.
And,
10. GGACF upper management must monitor compliance with any written instructions to subordinate supervisors if compliance with such orders are expected to be followed. 11. Create and implement one, standardized, shift staffing form for supervisors to accurately record shift staffing levels.

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c. Communication to and from corrections officers assigned to housing units (i.e. 
 functional radios); and 

ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: All officers (including recruits) require functional radios in their possession at all times while assigned duties within the security perimeter. Compliance with this requirement helps to ensure safety of staff and prisoners. However, prisoners and staff are exposed to extreme danger when all on-duty staff are not assigned radios.
This danger is no better demonstrated than on June 4, 2015 in Unit 9a when an inmate was brutally assaulted and stabbed by two other inmates.1 In this incident, an inmate physically took the unit cell door keys from one of the two housing unit officers, out-ran both officers to the victim’s cell, unlocked the cell and with an inmate, and commenced beating and stabbing the victim. The two unit officers radioed for help but did not physically attempt to stop the assault at the victim’s cell and only verbally ordering the two assailants to stop. An examination of the incident video reveals a third officer, who this Monitor was told was a recruit, stood without a radio in the dayroom observing the incident transpire. Ultimately, other officers arrived to stop the assault but not until the victim suffered multiple stab wounds.
This incident could have resulted in even more serious harm or death to this inmate, the two housing unit officers, and possibly the recruit. This recruit was not wearing a radio and was helpless to assist his fellow officers by calling for assistance if needed. Not ensuring that ALL staff assigned to housing units are required to carry function radios is a very dangerous practice.
RECOMMENDATIONS: Previous recommendations remain appropriate...
1. Finalize, approve, and implement all related policies and procedures. 2. Timely repair and replace nonfunctioning radio and telephone communications equipment
throughout the facility, and add additional communications equipment where indicated. 3. The Monitor will continue to review radio equipment inventories and functionality during each
onsite assessment. 4. Ensure adequate supply of radio batteries to enable officers to carry radios on their person at all
times. The GGACF Warden did issue written directives to all staff requiring compliance with this recommendation. 5. Ensure all persons carrying radios are fully trained to understand and operate all radio functions proficiently.
d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
1 GGACF Incident Number 06-0047-15-IR and Housing Unit Video obtained from GGACF Officials.

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(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and
(ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Staffing levels remain demonstrably and deleteriously inadequate. Shift Staffing reports evidence constant understaffing in housing units and patrols. Contraband detection and prevention efforts are substantively ineffective due to staffing shortages and evidenced by documented constant high levels of dangerous weapons inmates possess and use to violently attack others, drugs and alcohol, and nuisance items found throughout housing units.
Current staffing levels make it literally impossible to ensure that officers make all required rounds per shift while also attempting to monitor prisoner flow for contraband and supervise prisoners not locked in their cells. Supervisor Shift Rounds reports examined for May 2015 cannot verify adequate housing unit inspections and staff supervision. However, Shift Rosters report shifts having only one on-duty supervisor at times, making it impossible for a lone supervisor to inspect all housing units and security areas, monitor staff, and respond to various scheduled and unscheduled duties and events.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations regarding Post Orders. 2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff
and inmate safety and security, and according to inmate risks and needs. 3. Create a schedule for regular rounds by medical and mental health care staff for each shift to
ensure that special needs inmates (suicidal, mentally ill, medically infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff. 4. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. The supervisory rounds forms should be filled out at the end of each round and collected in a central location and submitted to the Monitor and USDOJ on a monthly basis. 5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.

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B. Contraband

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Contraband detection and prevention efforts are substantively ineffective due to staffing shortages and evidenced by documented constant high levels of dangerous weapons inmates possess and use to violently attack others, drugs and alcohol, and nuisance items found throughout housing units. Interviews with GGACF Gang Intelligence Search Team (GIST) staff during this visit reveal only four to five contraband shakedowns per month due to staffing shortages. Organized and routine contraband searching should occur on a daily basis by each housing unit officer as well as several times per week by the GIST staff. Housing unit officers must thoroughly search all inmates and items entering and leaving their units, routinely inspect all cells in their units, and constantly and vigilantly monitor prisoner behavior for affertive attempts to conceal and/or transfer contraband.

Examination of incident reports and Evidence Collection Logs (April 16-July 5, 2015) again demonstrate that prisoners have relatively unfettered access to contraband. The following contraband was confiscated – sometimes before violence, sometimes following an assault:

GGACF Contraband Seizures
1. Days Reporting 2. Weapons (Knives, Shanks) 3. Cell Phones 4. Drugs, Alcohol, Paraphernalia 5. Handcuff Key 6. Money
Assessment Period Totals Confiscations Per Day Rate

6th Report (10/3-
12/3/2014
60 21 32 9 0 3
65 1.08

7th Report 12/25/2014
4/15/2015
111
28
16
11
1
3
59 0.53

8th Report (4/16/-
7/15/2015
80 10 21 3 0 0
34 0.43

Combined Total
251 59 69 23 1 6
158 0.63

Contraband detection and prevention relies primarily on housing unit officers complying with basic security policies and supervisor instruction. However, such compliance does not appear consistent, assuming supervisors are providing consistent supervising and holding staff accountable. For example, the Shift Supervision reporting process mandates supervisors to ensure that officers can “view into cells”. This is a basic security procedure that helps to control contraband as well as ensure prisoner safety and security. However, this visit again found cells with blocked cell-door windows and linens being used by prisoners to completely obstruct officer sight into cells. This chronic security neglect can only exist when 1) officers are not

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following basic security tenants and/or, 2) officers are not in control of housing units, and/or 3) supervisors are not making rounds and/or 4) supervisors are making rounds but not ensuring compliance with this policy, and 5) chronic staff deficiencies preventing staff from conducting timely and consistent prisoner supervision and control.
Deficient contraband control contributes to extant physical prisoner-on-prisoner and prisoneron-staff assaults. The June 4, 2015 inmate stabbing previously discussed is one serious example but it is not the exception. On May 15, 2015 in Unit 9B at approximately 4:00 pm, a prisoner stabbed another prisoner in the back during a fight. A “weapon was recovered” and the victim was transported to the hospital for care.2
Adequate staffing levels, vigilant adherence to contraband and prisoner security policies by officers, proper training, and diligent staff monitoring and supervision is the minimum requisite for successful implementation of new policies and procedures.
RECOMMENDATIONS:
1. Implement the new policy according to the terms of this Agreement once approved. 2. Ensure supervisors comply with supervision rounds requirements. 3. Ensure corrections officers comply with contraband control and related security policies and
protocol.
b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to B.a. above.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Continue positive efforts in searching people before entering the facility. 2. A “stop and check” protocol for inspecting staff packages after initial entry into the facility must
be developed and implemented. 3. Provide handheld metal detectors for contraband inspections at facility entry points and as
needed for on-campus inspection. 4. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods and
process during the 8th onsite tour and assessment. 5. Train supervisors to provide on-the-job-training (OJT) and staff mentoring in the areas of
adequate searches, contraband prevention and control, and basic inmate supervision and security.
2 May 15 2015, 4:29pm Notification of Serious Incident and reports provided by BOC counsel.

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c. Detection of contraband within Golden Grove, through processes including: (i) supervison of prisoners in common areas, the kitchen, shops, laundry, clinical,
 and other areas of Golden Grove to which prisoners may have access; 
 (ii) pat-down search, metal detector, and other appropriate searches of prisons
 coming from areas where they may have had access to contraband, such as intake, 
 returning
 from visitation or returning from the kitchen, shops, laundry, or clinic; 
 (iii) regular and random search of physical areas in which contraband may be 
 hidden or placed, such as cells and common areas where prisoners have access (e.g.
 clinic, kitchen, dayrooms, storage areas, showers); 

ASSESSMENT: NONCOMPLIANCE
FINDINGS: Also refer to above Contraband findings and discussion.
GGACF cannot consistently nor adequately provide necessary levels of prisoner supervision in any area of the campus with existing staffing levels. This is evidenced by the previously discussed examination of Evidence Collection logs and incident reports. This Monitor observed during this visit no pat-down searching of ANY prisoner entering or leaving housing units and none of the housing units are equipped with metal detectors as previously recommended and required in paragraph ii above. GIST staff confirmed during this visit that regular and random searches are very infrequent but sorely needed. Official GGACF documents evidence that dangerous weapons, drugs and alcohol, cell phones, and nuisance contraband remains accessible to prisoners.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to above, expand application of recommendation to provision c (i-iii) above. 2. See recommendations regarding staffing levels. 3. Ensure inmates are systematically and consistently searched each time they enter and exit
maintenance shop areas, kitchen areas, and any area and/or building containing items that can be used as contraband. 4. Always search prisoners each time they enter and exit housing units. 5. Always search all containers entering and exiting the facility, buildings, and housing units.
d. Confiscation and preservation as evidence/destruction of contraband; and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No change was found since previous reports. Above Contraband Provision findings and discussion adequately support no change in this assessment rating.
RECOMMENDATIONS: Previous recommendations remain appropriate.
Review and implement relevant recommendations for Contraband above, specifically B1a.

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1. Continue to ensure staff access to appropriate equipment and supplies needed to safely
 collect and preserve contraband while maintaining evidentiary integrity.

2. Continue to ensure adequacy of chain-of-custody methods and procedures. 3. Develop a Uniformed Incident Reporting system (discussed further in this report) that

provides cross-referencing and continuity between all reports and logs involving detection 
 and confiscation of contraband. 
 4. Develop and implement a continuous quality improvement (CQI) protocol to evaluate 
 adherence to Contraband policies and procedures and reporting.

e. Admission procedures and escorts for visitors to the facility.
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Front desk admission security checks seem improved. Monitoring team briefcases were searched before each daily visit and we were required to empty our pockets. However, monitoring team members were not consistently escorted by security personnel to and from each area inspected. For example, on June 9th when Mr. Romero and a USDOJ attorney were not escorted during a tour of X-Dorm and A-Dorm. Additionally, Dr. Stellman, mental health monitor, reported that she was escorted by a recruit officer. This particularly troubling considering the previous discuss regarding a recruit officer not responding to the inmate assault incident. The primary purpose for these escorts is to ensure the safety of the monitoring team. However, if a recruit officer will not or cannot respond to an inmate assault incident, how will or could a recruit officer provide adequate security to the monitoring team? Additionally, the monitoring team was consistently provided identification for each day of this visit. This practice may not be as consistent as it appeared, however, according to Shift Rosters and the Shift Supervisor Rounds Report.
First, very low staffing levels logically suggest GGACF is forced to prioritize duty assignments to where security protection needs are greatest – the housing units and prisoner locations. Second, none of the different Shift Roster forms show “Visitation” as a post for recording staffing levels. Third, the May 11, 2015 2pm-1-pm Shift Supervisor Rounds Report documents “No officer was present [in Detention Visitation] when checked”. Finally, most of these Reports recorded no inspection information for Detention Visitation.
Based on these findings, this Monitor found insufficient evidence demonstrating Partial Compliance with this Provision.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Continue to ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.
3. Implement document quality improvement protocols to improve reliability of the two supervisor reporting systems used for this assessment to aid in demonstrating compliance.

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C. General Security
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facilityspecific policies designed to promote the safety and security of prisoners and that include the following:
a. Clothing that prisoners and staff are required or permitted to wear and/or possess;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Prisoners continue to be allowed to wear personal “street” clothes in and out of the housing units. Several prisoners were observed wearing non-correctional attire in day rooms, their cells, and in the yard. The Territory’s most recent prisoner escape involved the prisoner wearing personal clothing to facilitate the escape. This incident alone seems sufficient to have motivated GGACF to fully comply with this provision.
Some on-duty security staff were observed wearing unmarked clothing and some wore unmarked lightweight jackets that covered their uniforms. Unlike specialized law enforcement staff, there is no value or understandable purpose in allowing uniformed security staff to wear unmarked clothing or to wear personal attire that covers portions of their uniforms. The security officer uniform is specifically marked to provide clear and obvious awareness of the presence of a security officer. As such, a marked security officer uniform should never be obscured.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Require inmates to wear issued institutional clothing ONLY. 2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform
policies and inmates who refuse to comply with those policies. 3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and
appropriate corrective action with staff who refuse to do so. 4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’
classification/status. 5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges and
changes in an inmate’s classification and/or status. 6. Consider developing a correctional industry for making uniforms onsite. 7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband and
weapons. 8. Mark all uniforms with highly visible letters/numbers.
b. Identification that prisoners, staff, and visitors are required to carry and/or display;
ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Refer to previous findings and discussions pertaining to B.a, C.1.a. In addition, come prisoners were again observed either not wearing identification or not properly displaying their identification if it was being worn.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure staff compliance with this provision. 2. Ensure adequate supplies for making identification cards. 3. Regularly audit identification card inventory and maintain proper controls to prevent
inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories. 4. Consistently enforce identification card policies and procedures.
c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Previously requested training documents demonstrating completion of staff training on this subject matter have not been provided to this Monitor. Additionally, some of the Shift Supervisor Rounds reports for May 2015 show several inoperable locking mechanisms throughout the facility stating:
x Detention R&D: “Sally Ports remain inoperable along with Exits and Entrances” x K Unit: “Sally ports are inoperable” x 9 D: “Unit entrance gate needs to be repaired” x X Dorm: “A fence should be put up to separate inmates from detainees”
Inconsistent and incomplete use of these reports makes it very difficult to use these documents as a credible sources to advancing this Provision, and it is logical that compliance with this Provision is frustrated by inadequate maintenance staffing levels.
Doors into housing units were routinely observed to be unlocked and open.
During an interview with the Maintenance Supervisor he reiterated previous concerns and frustrations about locking maintenance. He stated that he makes locking system repairs a top priority but is inadequately staffed to maintain a locking system repair and preventive maintain program that is always timely and consistent.
However, even with an adequate locking system maintenance program, prisoners will continue to gain dangerous access to each other until security staff consistently practice good key control.3 RECOMMENDATIONS: Previous recommendations remain appropriate.
3 The June 4, 2015 stabbing incident previous discussed resulted from the prisoner taking cell keys from the hand of an officer.

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1. Provide Monitor requested training records showing a 95 percent minimum successful completion rate.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement. 5. Continue to ensure staff are adequately trained in the proper use of mechanical and/or electronic
locking systems according to their post assignments. 6. Consistently sanction inmates for attempting to manipulate or manipulating any security locking
system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked. 9. Replace or upgrade existing unit control panels to provide for remote electronic locking and
unlocking of unit and cell doors. 10. Improve video surveillance of internal areas by placing cameras in all housing units and inmate
locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations. 13. Consistently enforce security locking policies and procedures with staff and inmates.
d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft policies and procedures have been developed. However, these policies and procedures cannon, ultimately, demonstrate compliance until GGACF has sufficient staffing levels to ensure compliance. This is because these policies and procedures require a much higher level of routine attention to all housing unit locking mechanisms by housing unit officers and supervisors.
RECOMMENDATIONS: Previous recommendations remain appropriate...
1. Employ and maintain adequate Maintenance staffing levels. 2. As requested in the previous two reports, develop an “all-locks” maintenance plan for review
with the Monitor. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number, lock type, condition, etc.

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3. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.
e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This Monitor examined 15 staff personnel folders during this visit. These documents are maintained in the Administration Building located in a separate building located on the GGACF campus. This document examination found various deficiencies in the personnel folders reviewed:
x Missing verification of training documentation x No application and/or background investigation record x Missing criminal background-check documentation x No uniformity of folder content, disorganization x Incomplete documentation regarding disciplinary action (i.e. notification of policy violation
with no other information regarding disciplinary process or case disposition) x Employer/reference background forms missing or not completed x Missing Personal History statements x Pre-service psychological assessments found in some folders but not others x Missing fingerprint records x Incomplete military status questionnaire
The folders examined were very disorganized and inconsistently maintained. I found no evidence of periodic supervisory review of these records for early staff intervention purposes. Keeping pre-service staff psychological assessment results in the general personal folder is a questionable practice. These records should be considered medical documents pertaining to psychological fitness for service and highly confidential. Additionally, information contained in these documents are is considered “need to know” and should be kept and secured separate from general personnel folders. Psychological findings, however, can be important for assessing recruit performance and understanding staff motivation. This information is also very useful for recognizing working conditions uniquely stressful to an employee so as to provide additional and/or specialized training and/or supervision to that employee.
RECOMMENDATIONS:
1. The employee folder/record system should be standardized and well organized 2. All folders should contain completed Applicant Personal History Statements, criminal history
check verification documents 3. Medical records should be kept separately from the general personnel folder 4. Training records should be kept in a staff training folder and separate from the training folder

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5. These records should be reviewed periodically for quality assurance purposes and remedial instruction and/or training provide to records staff where indicated.
D. Security Staffing

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As noted in the previous report, the Territory collaborated with the National Institute of Corrections and completed this staffing analysis that incorporated a shift relief factor. This Monitor, in collaboration with the parties, provided a draft staff coverage plan incorporating each security post (i.e. housing units, patrols, supervisors, etc.). Required staffing levels (shift staffing coverage) were determined based on how many staff are required for each post-assignment per shift and multiplied that number by the relief factor of 1.67. This coverage plan establishes the following additional staffing levels:

Security Positions
Security Management TC Command (Lt)
ATC Command (Sgt) Officer
Total Security Staff

Coverage 2015 Budget Plan 3/2015 Authorized

6

6

5

4

13

7

155

117

179

134

Total Additional
Staff Required
0
1
6
38
45

The total additional staffing requirement shown above is in addition to the 2015 budget authorization and does not include currently unfilled positions. As of the previous report, a total of 80 additional security staff were needed (additional and unfilled positions) to comply with staffing requirements of this Agreement. This Monitor is unable to accurately calculate how many total staff are currently required because a current staffing count has not been provided as of the completion of this report.

The Territory has submitted to this Monitor and USDOJ draft policies and procedures required under this Provisions. Those documents are currently in the review process. As discussed in more detail below, the Staffing Plan required under this Agreement remains in draft form and under final revision by the Territory.

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RECOMMENDATIONS:
1. Finalize and approve required policies and procedures. 2. Finalize and approve the required Staffing Plan. 3. Quickly implement the approved staffing plan without delay.
b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Staffing Plan timeline (shown from the previous report below) remains in dispute. USDOJ retains its objection to the seven year time period for filling all positions until the Territory can articulate an acceptable justification or negotiate a shorter timeline, and to the lack of specificity in the Staffing Plan.

VI BOC/ GGACF Hiring Plan

Security Positions

Staffing Plan 3/2015

Security Management

6

TC Command (Lt)

5

ATC Command (Sgt)

13

Officer

155

Total Security Staff

179

Staff Needed
2 3 8 67 80

Year 1
2016
1 1 2 10 14

Year 2
2017
1 1 2 10 14

Year 3
2018
0 1 2 10 13

Year 4
2019
0 0 2 10 12

Year 5
2020
0 0 0 10 10

Year 6
2021
0 0 0 10 10

Year 7
2022
0 0 0 7 7

Total
20162022
2 3 8 67 80

Staff Needed
100% 100% 100% 100% 100%

It is this Monitor’s hope that final approval of the required Staffing Plan can be accomplished before or during the September 2015 onsite assessment visit.

RECOMMENDATIONS: Finalize and implement the required Staffing Plan.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft policies and procedures have been submitted to this Monitor and USDOJ for review and comment.
RECOMMENDATIONS: Finalize and implement required policies and procedures.

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1. Defendants will implement the staffing plan developed pursuant to D.1 . ASSESSMENT: See above

FINDINGS: Refer to previous findings related to staffing analysis and planning. RECOMMENDATIONS: Refer to previous recommendations.

E.

Sexual Abuse of Prisoners.

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As noted in the previous report, the Territory has not completed the required PREA self-audit. PREA draft polices have been submitted to USDOJ and this Monitor for review and comment. However, the Territory has not yet resolved the issue of the 24/7 hotline.
Also as noted in the previous report, a prisoner’s October 20, 2014 complaint of sexual abuse remains not investigated due to the Investigator vacancy according to GGACF officials. Failure to properly investigate and resolve such compliances violates PREA and federal law. However, the Territory has informed this Monitor that this position has been filled and the investigator began working on August 24, 2015. The Territory is encouraged to ensure it fully complies with PREA regardless of whether this vacancy is filled.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements. 3. Appoint a PREA Compliance Coordinator as soon as possible. 4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s PREA
auditor certification training. All costs are covered by USDOJ. 5. Complete the PREA Self-Audit. 6. Review, revise, develop, train, evaluate policies and procedures that include, at a minimum, the
following PREA topics: 7. Fill the Investigator vacancy immediately.

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F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory has yet to provide evidence that the current classification system has been validated. However, draft classification policies and procedures have been submitted to this Monitor and USDOJ for review and comment according to the revised Schedule.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that provide
more accurate and complete guidance for a valid and reliable classification system for nonconvicted and convicted inmate populations. 3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system. 4. Contact USDOJ / NIC for Objective Classification Technical Assistance. 5. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.
b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As stated in F.1.a above.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Inmates should be housed and separated according to reliable classification process as previously discussed.

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2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Settlement Agreement prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Direct mental health staff to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced side lock down units to determine mental health needs and if a different, less punitive housing placement is available.
c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Same findings as noted in the above Classification section. Additionally, the previously reported incident in this report involving a violent inmate-on-inmate stabbing demonstrates how the current inmate classification system is easily and quickly disabled when officers do not maintain control of cell keys, fail to maintain adequate prisoner management, and are not continuously attentive to security duties when prisoners are unsecured in their housing units.
RECOMMENDATIONS:
1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.
d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: See previously discussed classification findings.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to previous classification findings and recommendations. 2. Refer to recommendations related to grievance and disciplinary policies and procedures. 3. Ensure accuracy of monthly disciplinary committee reports. 4. The Territory must correct problems reported in the monthly disciplinary committee reports. 5. Train classification staff to accurately and consistently complete initial and re-classifications
accordingly.

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e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct;
ASSESSMENT: NONCOMPLIANCE (Downgraded from Partial Compliance)
FINDINGS: The current incident reporting system remains inadequate for complying with this provision. As previously noted in this report, the quality of incident reports remains problematic and the incident reporting log system does not consistently capture all reported incidents. Additionally, Disciplinary Committee monthly reports continue to report problems with missing and late submission of incident reports. Interviews with the sergeant responsible for the prisoner discipline program continues to state the same problems with incident reporting practices and quality oversight.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Timely approve and implement policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.
f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Examination of Segregation Review documents for April thru June 2015 continued to evidence noncompliance with this requirement.
Virtually all of these documents fail to include information about what alternatives were discussed and considered for segregation placement when the segregation review process was completed. Additionally, most of the documents examined omit required information about when and/or why the prisoner was placed in segregation, and whether the reasons for being placed in segregation remain valid. Most of the documents fail to record a prisoner’s prospective release from segregation date, and much of the narrative required by staff performing the review is absent. Staff signatures are often missing and/or illegible, and there is routinely no information documented with regard to whether previous follow-up recommendations were accomplished. Many of the documents show that the segregated prisoner “refused” to

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participate in the review process and the document includes not information about the prisoner’s well-being or health status.
This document examination leaves an impression that GGACF officials give little to no priority to ensuring that prisoners held in segregation are provided constitutionally-required attention and care. As noted in previous reports, it continues to appear that prisoners are placed in disciplinary and administrative segregation for excessive time periods and without due process. A comparison of the prisoner mental health case log and segregation log indicates that inmates with mentally illness remain in segregation/isolation for very long time periods. This practice is a direct violation of the conditions of this Agreement and dangerously detrimental to the health of these prisoners and must cease.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Review, revise, develop, train, implement, and evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status.
2. Ensure inmates with special needs are monitored more frequently as indicated by a security and health risk/needs assessment. A routine schedule for conducting these rounds must be regularized and continuously monitored for compliance.
3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
4. Defendants are reminded that segregation should never be used to punish or serve as a treatment for inmates who are mentally ill, and may never be used for inmates with serious mental illness.
5. Improve the quality and completeness of segregation review documentation.
G. Incidents and Referrals
1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:
a. Reporting by staff of serious incidents, including (i) fights; (ii) serious rule violations; (iii) serious injuries to prisoners;

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(iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Examination of Incident Logs and incident reports provided for March through June 2015 demonstrates continued significant and problematic deficiencies with Provision compliance. This examination again found the following document deficiencies:
1. Inconsistent incident report numbers 2. Incomplete reports 3. Page numbers and other basic information missing 4. Reports not being recorded on the incident log 5. Using different incident numbers for each inmate involved in the same incident 6. Using different incident numbers for different officers reporting the same incident 7. Illegibility 8. Missing signatures 9. Inconsistent recording of incident type 10. No recording of incident type 11. Incident, Evidence, and Disciplinary logs don’t cross-reference each other
As stated in previous monitoring reports, the existing incident reporting system must be completely overhauled if it is to provide valid and reliable information from which to evaluate serious events in order to comply with this Provision or any provision requiring accurate and complete incident reporting to assess compliance levels. A simple document quality assurance and compliance accountability process should be implemented and minimally include the following steps:
1. Officer completes an incident report 2. First-line shift supervisor reviews the report for completeness, accuracy, and legibility 3. First-line approves, signs, and forwards reports that meeting requirements above, deficient
reports are immediately returned to the author with specific written and/or verbal instructions for correction 4. Shift commanders should review and approve only reports meeting the requirements in step two 5. Shift commanders should return to reports first-line shift supervisors that fail to meet the above requirements with verbal and/or verbal instructions for correction 6. The chiefs, Security Administrator, Asst. Warden and Warden should review all reports for quality assurance and operational management purposes.

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RECOMMENDATIONS: Previous recommendations remain appropriate
1. Develop protocols for current tracking system to improve data validity and reliability; this document is replete with duplication and misleading entries.
2. Develop a unified incident coding system for valid and reliable information and data collection, reporting, and analysis.
3. Establish regular monthly quality assurance meeting process involving all major department team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity.
4. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol.
5. Require supervisors to carefully review all incident reports for completeness, accuracy, and consistency.
b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular 
 individuals, shifts, units, etc.);

ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous reports, a formal and regular administrative process as indicated remains nonexistent. Effective implementation of this process first requires substantial improvements in the current incident reporting systems and reporting review process. Furthermore, valid and meaningful incident data for tracking and management purposes relies completely on the quality of the incident reporting system, quality compliance monitoring, and timely data management.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations in G.1.a above.
c. Requirements for preservation of evidence; and.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous monitoring reports, the Evidence Log should include incident report numbers to cross-reference incident reports and evidence (i.e. contraband). This revision to the Evidence Log will help to provide efficient and timely matching of incident reports to evidence, and make the Evidence Log a very useful tool for tracking and managing facility incidents for planning, implementation, and evaluation strategic contraband control policies.
RECOMMENDATIONS: Previous recommendations remain appropriate
1. Refer to similar recommendations regarding contraband.

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d. Central tracking of the above incidents.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Central Control officer is the primary keeper of the GGACF incident central training process. The Central Control officer is notified of incidents, issues an incident number and records incidents on the Incident Log. A significant problem with tracking centralization system is that it assigns several consecutive incident numbers to a single incident depending on how many officers are involved. This practice leads to errors in incident and evidence tracking, and impairs using the incident log as an efficient and accurate information / data source.
Each incident should be assigned its own tracking number regardless of how many officers or inmates are involved in a single incident; this method is similar to a law enforcement incident-based reporting system and works very well. It is much more simple and efficient to determine incident volume for a given time period using the last incident number for that time period then having to count every entry on the incident log. Each incident report written by staff for a single incident would contain the same incident number, and all evidence logs/reports, use of force reports/reviews, medical reports, etc. would use the same incident number for tracking and documentation management purposes. The Territory should seriously consider revising its current incident numbering practices as described.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of incident
reporting and data analysis. 3. Implement a quality assurance process that consistently ensures incident log accuracy and
completeness. 2. The policy will provide that reports, reviews, and corrective action be made promptly 

and within a specified period. 

ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously stated, deficiencies in the incident reporting system, lack of reporting quality management, and the vacant Investigator position exacerbate making positive progress with this provision despite the absence of approved policies and procedures.
Prompt incident reporting remains a serious problem. Prisoner Disciplinary Committee reports examined continue to report problems with staff and supervisors using the appropriate incident report form, submitting error free and/or complete incident reports, and/or turning in reports. The Disciplinary Committee sergeant reports she continues to have problems receiving completed reports from which to make reliable disciplinary action decisions.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Include this element in the required policy and procedure. 2. Establish reasonable timeframes as indicated. 3. Develop and implement corrective action protocols to address staff noncompliance with adopted
policies and procedures. 4. Initiate corrective action against supervisors and staff who continually fail to submit and/or
approve deficient, late, or no incident reports as required by policy and this Agreement.
H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:
a. Permissible forms of physical force along a use of force continuum;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory has submitted draft us of force policies and procedures to this Monitor and USDOJ for review and comment. The Territory integrated USDOJ comments into the draft policies. The USDOJ rejected the revised document citing structural and content problems and provided additional comments and recommendations.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize, approve, and implement draft use of force policies and procedures upon approval and once the revised implementation schedule is approved.
2. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
3. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review of document are 1) complete, 2) accurate, and 3) comprehensive.
4. All planned uses of force must be monitored and controlled by an onsite supervisor. 5. GGACF must promptly and thoroughly investigate all inmate complaints of excessive force and
take necessary corrective action to protect inmates and staff.
b. Circumstances under which the permissible forms of physical force may be used;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above. No improvement.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Include this requirement in policy, procedures, and training as discussed in RECOMMENDATIONS H.a. (1A-W) above.
c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: See above findings. 

RECOMMENDATIONS: Previous recommendations remain appropriate. 

1. Include this requirement in policy, procedures, and training as discussed in RECOMMENDATIONS H.a. (1A-W) above.
d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;
ASSESSMENT: NONCOMPLIANCE
FINDINGS:
RECOMMENDATIONS:
1. Include this requirement in policy, procedures, and training as discussed in RECOMMENDATIONS H.a. (1A-W) above.
2. See RECOMMENDATIONS regarding Training Provisions and apply to use of force requirements.
3. Provide this Monitor and DOJ with all current training curricula.
e. Training and certification required before being permitted to carry and use an
 authorized weapon; 

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment. 

FINDINGS: Same as above. No change.
RECOMMENDATIONS:
1. Include this requirement in policy, procedures, and training as discussed in RECOMMENDATIONS H.a. (1A-W) above.

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2. Refer to Training Provision RECOMMENDATIONS and apply to this requirement.
f. Comprehensive and timely reporting of use of force by those who use or witness it;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Use of force reporting remains problematic. Examination of incident reports for this reporting period continue to describe events involving physical force by staff against inmates but required use of force review documents are not completed. This problem was reported in the 7th Report and must be corrected by the Territory.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement supervisory quality improvement review for all reports to ensure accuracy and completeness before approval.
2. As requested in the previous report, the Territory must develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.
3. Comply with Monitor’s request for documents.
g. Supervision and videotaping of planned uses of force; 

ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment. 

FINDINGS: No planned uses of force were reported during this assessment period. However, the
 Territory did not provide proof that GGACF staff had access to video equipment if needed. 

RECOMMENDATIONS:
1. Include this requirement in policy, procedures, and training as discussed in RECOMMENDATIONS H.a. (1A-W) above.
h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No change.

RECOMMENDATIONS: Previous recommendations remain appropriate. 

1. Provide the Monitor documentation of Compliance for this Provision.
i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;

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ASSESSMENT: NONCOMPLIANCE
FINDINGS: No change.
RECOMMENDATIONS:
1. Provide Monitor documentation of Compliance with this Provision.
j. Prompt administrative review of use of force reports for accuracy;
ASSESSMENT: NON COMPLIANCE
FINDINGS: As stated above in (f), this Monitor cannot verify compliance with this provision. Incident reports continue to describe use of force against prisoners with no accompanying use of force review documentation.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.
k. Timely referral for criminal and/or administrative investigation based on review of clear 
 criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE
FINDINGS: According to GGACF officials, the Investigator position remains vacant and the vacancy has not been posted to fill. This position has been open for several months and must be filled without further delay. There appears to have been no administrative investigation and no criminal referral resulting from the November 10, 2014 incident, which was reported in the media and appeared to result in inmate injuries.
RECOMMENDATIONS: Same as above
l. Administrative investigation of uses of force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.

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RECOMMENDATIONS: Same as above
m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above. The Territory did not provide requested documentation necessary for the Monitor to assess compliance with this Provision.
RECOMMENDATIONS:
1. Develop and implement Central Tracking system to include all required elements.
n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above. 

RECOMMENDATIONS: Previous recommendations remain appropriate. 

1. Immediately issue directives to supervisors to complete reviews for all incidents involving use of force. Monitor compliance, correct deficiencies, and document compliance with this provision.
o. Re-training and sanctions against staff for improper uses of force.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Noncompliance with this provision is a cumulative result of noncompliance with the Use of Force section of the Agreement. Re-training and sanctions against staff for improper use of force cannot be appropriately determined without routine and adequate administrative review of force events. Compliance with this provision is contingent upon compliance with the administrative review provision. . RECOMMENDATIONS:
1. Comply with Administrative Review provisions of this Agreement. 2. Develop and prepare to implement remedial use of force training
I. Use of Physical Restraints on Prisoners

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1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:
a. Permissible and unauthorized types of use of restraints; 
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as above. 
 RECOMMENDATIONS: Previous recommendations remain appropriate. 
 1. Implement this policy once approved according to the new schedule. b. Circumstances under which various types of restraint can be used; 
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as above 
 RECOMMENDATIONS:
 1. Same as above. c. Duration of the use of permitted forms of restraints; 
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as above. 
 RECOMMENDATIONS: Same as above. 

d. Required observation of prisoners placed in restraints; ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above. RECOMMENDATIONS: Same as above.
e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and

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ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above.
f. Required termination of the use of restraints .
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above J. Prisoner Complaints
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:
a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The inmate complaint system shows inadequate improvement for advancement to Partial Compliance. An examination of Grievance Log entries after March 26 through June 29, 2015 reveal the log remains incomplete and mostly nonresponsive to inmate complaints.
There were 19 inmate complaints recorded for the date range assessed:
Food Service – 6 Housing Conditions – 2 Medical – 4 Safety – 1 Staff Misconduct – 1 Appeal – 2 Other – 2 Blank – 1
There was no received date and time for one (1) food service complaint or documented responses for more than half (10/19) complaints, mostly (5) for food service complaints. Only seven (7) complaints documented response dates and only three (3) documented dates that responses were returned to prisoners.

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RECOMMENDATIONS: Previous recommendations remain appropriate. 1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking process
to measure and verify program compliance, take timely and appropriate remedial and correction action. 2. Ensure tracking log is consistently completed and accurate. 3. Assign reliable and timely oversight of the inmate complaint process and logs to a staff person who will provide the process consistent, dedicated, and comprehensive attention. 4. Develop a valid and reliable tracking a quality management statistical report for monitoring inmate and facility needs and problems. 5. Ensure staff are available during onsite visits to allow this Monitor to adequately assess this Provision.
b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated above, examination of the grievance log shows missing data entries indicating untimely or no investigation of prisoner’s complaints related to safety or health care. Additionally, the grievance log studied shows equally problematic responsivity to inmate complaints involving disciplinary action, food service, and housing conditions.
It is not possible to assess timeliness or prioritization of complaints required under this provision due to grievance log document quality and inconsistencies. Most of the response (back to the prisoner) dates are missing in most of the response summary information. This document demonstrates that prisoner health and safety complaints are not investigated timely or prioritized in practice.
RECOMMENDATIONS: Same as above
c. Corrective action taken in response to complaints leading to the identification of violations any departmental policy or regulation, including the imposition of appropriate discipline ainst staff whose misconduct is established by the investigation of a complaint;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same finding related to administrative and use force investigations and reviews.
RECOMMENDATIONS: Refer to administrative and use of force investigation review
1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.
d. Centralized tracking of records of prisoner complaints, as well as their disposition; and

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ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above, and:
1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.
e. Periodic management review of prisoner complaints for trends and individual and systemic issues.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Similar to administrative investigations, use of force and incident reviews, this process remains essentially nonexistent.
RECOMMENDATIONS: Same as above.
1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. 
 Use data from those reviews to identify patterns of individual staff and inmate problems, 
 as well as systemic problems in need of correction. 

K. Administrative Investigations
1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:
1. Timely, documented interviews of all staff and prisoners involved in incidents;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Investigator position remains vacant and administrative investigations cannot be performed.

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RECOMMENDATIONS: Same as previous report
1. Fill the vacant investigator position. 2. Supervisory/management staff must be consistently held appropriately accountable for
adherence to agency rules, regulations, policies, and procedures. 3. The November 2014 housing unit riot must be thoroughly investigated and reviewed to prevent
similar future events and to improve organizational planning, response, and management of these types of major incidents.
2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc..) and attempt to resolve inconsistencies between witness statements;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS:
1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling,
preserving, and maintaining administrative investigation evidence, information, data, etc.
3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No substantive change since previous visit.
RECOMMENDATIONS:
1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.
4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and
ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Examination of the CV provided by the Territory of the recently hire Investigator infers this person is well qualified, but specific documentation of pre-service and in-service training was not apparent. Additionally, training on the new Use of Force policy would be pending final approval of the policy currently in draft-review status.
RECOMMENDATIONS: Fill the currently vacant Chief Investigator position immediately.
1. Finalize, approve, and implement relevant policies and procedures. 2. Create a formal pre- and in-service training program to train staff who are involved in initial
and/or administrative investigation. 3. Provide adequate training of investigative staff on topics in areas of incident scene investigation
and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc. 4. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management. 5. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities. 6. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review upon his/her appointment.
5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No change from previous Report.
RECOMMENDATIONS: Previous recommendations remain appropriate...
1. Finalize, approve, and implement relevant policies and procedures. 2. Review and revise current regulations on staff disciplinary actions and penalties to ensure
completeness and efficacy. 3. Integrate the information in the above into the administrative policies and procedures previously
discussed. 4. Record and maintain onsite records of staff misconduct investigative reports and determinations. 5. Protect the integrity and confidentiality of these staff records, control access to records, provide
a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff. 6. Provide training to supervision staff in the appropriate use of this information for purposes of staff supervision, counseling, discipline, promotion, etc. 7. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE 

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: NONCOMPLIANCE, pending completion of training prior to our report being submitted to the court.
MEDICAL FINDINGS: Progress continues to be made with regard to intake screening. The policies have been submitted and reviewed and approved by this monitor. There was introductory training; however, the formal training has yet to be completed. We would hope that this training is completed and proper documentation is submitted to the monitor before this report is sent out.
The staffing at the present insures RN availability to perform the screening Monday through Sunday from 8:00 a.m. until midnight. Therefore, the only shift uncovered by registered nurses is from midnight to 8:00 a.m. seven days per week. Two nurses have been identified who are qualified and are in the process of being hired to complete the staffing. When that staffing is completed there will be 24 hours a day, seven days a week at least one registered nurse onsite availability. As referred to previously, there was some introductory training and we were informed that the head nurse does review performance with the nurses and provides feedback regarding the quality of the performance.
We reviewed the records of seven intakes who entered within the prior two months before our visit. Only one record lacked an intake screen. In that record, there was documentation that the patient refused to participate in the intake screen. Two weeks later he did agree and this resulted in a negative screen, including both his vital signs and his TB skin test. We did not find in the record documentation of daily offering of the intake screen with refusal by the inmate. In fact, it was not clear that this had occurred. The six other records did include completed intake screens, including one patient identified with a history of recent suicidal ideation who was seen by the psychiatrist two days later. However, on the day of the intake screen the psychiatrist was called and placed the patient on suicide watch. After the psychiatrist completed her assessment the patient was released from suicide watch. We also found a record of a patient who entered and did not have the screen completed until two days later. Finally, one patient was screened who had a history of seizures and admitted to currently taking medications, but these were not listed.

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The performance on the intake screen is consistent with noncompliance. However, if the formal training has not been documented as having occurred prior to the release of our report, it will have to be an assessment of noncompliance related to the training.
Patient #1 S.A. This is a 23-year-old who entered the facility on 5/1/15 and refused the intake screen. Finally on May 14, he agreed to the intake screen and was found to have normal vital signs, a negative TB skin test and a negative screen. The same day as his intake screen he also received a health assessment. There was no daily documentation of the offering of the intake screen nor the refusal by the patient from May 1 through May 14.
Patient #2 J. N. This is a 28-year-old who arrived on 5/2/15. He provided a history of physical and psychological abuse and a history of recent suicidal ideation. He was assessed as an acuity level 1 and, appropriately, the psychiatrist was called. The psychiatrist initiated suicide watch and then saw the patient when she was onsite two days later. At that time the watch was discontinued. He also had a health assessment the same day.
Patient #3 K. R. This is a 27-year-old who arrived on 5/9/15. It is not clear why his intake screen was not performed until 5/11, since, although he arrived on a Saturday, nurses were available to complete the screen both on Saturday and Sunday. His screen revealed a peanut allergy and headaches. He had normal vital signs. He had no chronic medical problems; however, he has a history of schizophrenia as well as bipolar disorder. He also had a history of tremulousness for two days. He was listed as an acuity level 1 because of his psychiatric problems and his mental health assessment was completed the same day as his medical screen.
Patient #4 A. P. This is a 26-year-old who arrived on 4/6/15. His screen revealed a history of seizures, although the most recent seizure occurred four years earlier. He gave a history of being on medications but there were no details such as the name of the medication, the dosage, the frequency or, for that matter, the pharmacy. He was listed as an acuity level 2 but was released the following day.
RECOMMENDATIONS:
1. Complete the training on the policy. 2. Complete the filling of the RN positions on the midnight to 8:00 a.m. shift seven days a week. 3. The head nurse should continue to provide feedback to the nurses performing the nurse screen
regarding their performance and a special emphasis should be given to daily documentation of offering of the intake screen for patients who refuse.
MENTAL HEALTH FINDINGS: Nursing staff continue to perform intake mental health screenings in a timely fashion, within 24 hours of intake. Positive mental health findings do initiate referral to the mental health staff by security and medical intake screeners. The mental health intake screening components have been integrated into the form. The policy has been reviewed by all

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parties. The health services administrator has trained on the draft policies and there is now an approved formal schedule to complete final training on all health policies.
RECOMMENDATIONS:
1. Complete final training on health policy. 2. Track data to support evidence of successful implementation of the policy and demonstrate
adequacy of the quality of the screening process.
b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: Most of the records we reviewed were patients who were released early. In the few records that should have had physical assessments, the performance was problematic. We are very encouraged by the soon-to-be addition of the new Medical Director beginning. In fact, we talked to her over the phone and the following day met her at the facility. We were impressed with her, as she appeared both knowledgeable and committed. She had previously worked in the system about seven years prior to our visit. Several nurses had worked with her previously and were universally enthusiastic about her return. She indicated that she is committed to be fully engaged and intends to work full-time for the correctional system. She committed to three days onsite at Golden Grove and two days a week at the St. Thomas facility. In a few records of patients who have been in the system a long period of time, I have seen assessments performed by her and have been favorably impressed. We would expect and hope that she will bring stability, predictability and leadership to the clinical side of the medical program. The former Medical Director, whose contract was allowed to lapse, has been on site inconsistently and unpredictably, which created problems for both the patients and the staff. Examples of problematic health assessments follow.
Patient #1 This is a 27-year-old who arrived on 5/9/15 but had his intake screen on 5/11. He indicated no chronic problems except mental health problems. He complained of tremulousness times 2 days and was assessed as acuity level 1 based on mental health issues and he had both a mental health screen and assessment on 5/11. His health assessment was performed three days later, but despite normal vital signs including blood pressure he was assessed as having hypertension.
Patient #2 This is a 23-year-old who arrived on 5/7/15 late at night and had his nurse screen on 5/8. He entered with a history of asthma and a peak flow was performed, which was 325. He was listed as an acuity level 1 for medical reasons but he should have been listed as an acuity level 2. He was referred for a chronic care visit. His TB skin test was negative and his health assessment was performed one day after intake. However, there was no adequate asthma history. He was found to have wheezing bilaterally and the rescue inhaler was ordered to be given four times per day rather than as needed. There was also no order for a chronic care follow-up visit. The rescue inhaler frequency of use is used by clinicians to determine how well-controlled the disease is. Ordering the rescue inhaler to be used four times a day whether or not it is needed is incorrect practice.

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RECOMMENDATIONS:
1. The Medical Director position was filled in August.
MENTAL HEALTH FINDINGS: Ms. Murray, the Mental Health Coordinator, has been tracking
 completion of psychosocial assessments via an intake log, which she has developed. She described her
 current process as pulling the daily booking records to verify whether new intakes are still on site. The
 nurse will complete the initial screening within 24 hours and the mental health assessment will be
 performed within 48 hours (first business day for weekend bookings). If there is an urgent need the 
 nurses will notify the psychiatrist any time of day for bridging orders on medications and other
 instructions. Nurses utilize the same acuity scale as used for general medical health screenings. Level 
 I is urgent/emergent and level II is routine.

A copy of the assessment log tracking intakes was reviewed from the end of April through the month 
 of May, 2015. Twenty-seven (27) inmates were booked into the facility during that timeframe. Eight 
 detainees did not receive an initial mental health evaluation because they were quickly released from 
 the facility. One inmate’s assessment was delayed due to security issues. Assessments were
 completed within the required timeframes.

The service continues to develop new mental health and psychiatric assessment forms that will better
 guide this process. In the time being, they are documenting their assessments and initial plan in the
 medical record.

RECOMMENDATIONS: 1. This monitor remains available to assist GGACF in developing standardized mental health intake
screening, initial behavioral health evaluation, and progress note forms for implementation in the coming months. 2. Technical assistance is also always available and encouraged regarding development of treatment programs at the facility. 3. Continue to track inmates entering the facility and monitor time from admission, screening, and initial psychosocial assessment. In addition, referrals to the psychiatrist should be monitored for time to completion.
c. Prisoners' timely access to and provision of adequate medical and mental health care for
 serious chronic and acute conditions, including prenatal care for pregnant prisoners; 

ASSESSMENT: NONCOMPLIANCE pending completion of training prior to the release of our Eighth Report.
MEDICAL FINDINGS: We have used this section to address medical sick call, focusing on the 
 acute part of the section. A separate section deals with chronic care needs. The sick call log was 
 more conscientiously utilized and there were few to no blank spaces. We selected records from the 
 previous month and we are pleased to report that patients were seen timely. There were, however,
 some issues with performance. This is not unexpected in my experience of reviewing correctional 


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health programs. The head nurse has begun to review and discuss with specific nurses issues regarding their performance.
Patient #1 This patient submitted a request on 5/30/15 complaining of bloody stools for one day but he has had it previously. He also complained of a skin abscess on his face. At the time of his sick call visit he was found to have a significantly elevated blood pressure of 140/112. The physician was called and the patient was sent to the ER to have not only the hypertension addressed but also the facial abscess and the gastrointestinal problem. The ER records were available but had not been placed into the medical record. There has been no follow-up with a clinician.
Patient #2 This is a 50-year-old who complained of a toothache on 5/14/15. The nursing assessment contained no pain scale, no description of the nature of the pain, but did describe a minor swelling in the right lower jaw. This patient was provided over-the-counter medications and referred to the dentist. We were told the dentist saw the patient; however, there was no note in the medical record.
Patient #3 This patient also complained of tooth pain on 5/21/15. This was after the patient had seen the dentist. Again, there was no dental note in the chart. There was documentation that a phone order for antibiotics and Motrin had been given, but there was no order in the medical record. On the other hand, the medication administration record revealed that medications had been received. For all phone orders there must be a written order in the medical record.
Patient #4 This patient complained on 5/21/15 that his head was hurting and he was seen the next day. The history did not describe the severity, the location, what relieved, what exacerbated it, etc. The patient also had drainage from a lesion on his head. The nurse never obtained a culture from the drainage. The case was discussed with Dr. Park but we could not find a note written by him.
RECOMMENDATIONS: 1. Continue to instruct staff on the need to conscientiously complete the sick call log. 2. Continue to provide counseling feedback to nurses regarding their performance in the sick call
process. This feedback should include both positive reinforcement and constructive, corrective discussions. 3. Insure documentation of all phone orders as well as assessments.
MENTAL HEALTH FINDINGS: The mental health service has been maintaining a follow-up log for psychiatric visits. Even individuals who have no medications ordered are tracked on an as-needed basis. The current log contains 54 names with 46 being active clients. The service has developed a mental health statistical report that lists the names of every inmate or detainee currently followed by the service and inmates currently housed on the mainland or in hospital. That list contains a total of 64 names with 11 individuals in other prisons or in hospital. In reviewing the psychiatric chronic care visits, a few records demonstrated some opportunities for improvement as follows:

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1. A 22-year-old male who arrived at the facility at the end of April was seen the following day by the psychiatrist for complaints that people could read his thoughts. He was diagnosed as Psychosis Not Otherwise Specified and was started on an antipsychotic medication. He was scheduled to return within one month. It is recommended that inmates unknown to the service or who present with recent onset of significant symptomatology should have follow-up scheduled at least within 10 to 14 days of initiating a new regimen of medication, particularly for a psychotic disorder. This inmate developed a common neuromuscular side effect in reaction to the antipsychotic medication and was actually seen four days after initiation of medication because of that complaint. He was seen again by the psychiatrist on May 14, 2015, with a return to clinic noted as two weeks. At the time of this review on June 10, 2015, he had not yet been seen again. Issue: 1. Initial follow up was too far in the future; 2. Additional follow up was delayed.
2. A 26-year-old male was seen for tongue movements while on an antipsychotic medication that can precipitate these findings as a potentially permanent side effect. Medications were ordered for the inmate but no formal Abnormal Involuntary Movements Survey was completed, which has been recommended to be done by this reviewer a minimum of semiannually for all inmates on antipsychotic medications. Issue: The AIMS score allows for detailed documentation of the location and severity of the emerging movement disorders for future comparison for improvement or worsening of symptoms.
3. Chart reviews completed this visit again indicate a high frequency of the assignment of the diagnosis Psychosis, Not Otherwise Specified or Drug-Induced Psychosis, which is often attributed to acute intoxication by an unknown substance. Dr. Sang has been ordering some urine drug screens, which have been helpful in documenting the presence of an illicit substance. Issue: See recommendation 2.
RECOMMENDATIONS: 1. Moving forward, a variety of quality indicators regarding services should be developed and
maintained to aid the staff in ongoing quality improvement reviews as well as provide proof of practice for the monitoring team and any other Bureau, independent agency or accrediting reviews.
2. It is recommended that the Medical Administration Committee, once formed and active, begin to address the security issue of access to substances that are inducing psychotic conditions that then require psychiatric services. This monitor has noted the odor of marijuana in multiple units during each auditing visit, including the prison side segregation unit. Although, during this visit this finding was less apparent and hopefully represents benefit from recent security inspections.
d. Continuity, administration, and management of medications that address (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical
and mental health needs;

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ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: We again spent some time with the pharmacist whose contract arrangements are apparently stable. The pharmacy area has been reorganized and we witnessed the presence of new pharmacy supplies for packaging the medications. The current arrangements at Golden Grove do not comply with the Pharmacy Practice Act, and the pharmacist has a plan in which she would be present onsite part-time to facilitate the correct packaging of the medications. The monitor had a discussion with her as to whether her plan would achieve compliance with the Pharmacy Practice Act. This is an area that needs to be discussed further. We did discuss if she could, whether she was onsite or at home, review the prescriptions and create the labels for the medications. From home, she would connect through an electronic system and be able to review the medications timely. However, commonwealth law requires an onsite pharmacist for proper dispensing. This is problematic and it is this issue that remains to be addressed.
We also observed medication administration with regard to the morning pass in the housing units. The regular LPN who performed the administration generally performed well, as did the officer who demonstrated respect for the inmates while at the same time insisting on the inmates adequately acquitting their responsibilities in the medication process. However, their first responsibility is to provide an ID card or wristband so that the nurse can correctly identify the patient. This did not happen at all. Secondly, they must bring a container filled with water in order to appropriately ingest the medication in front of the nurse. When this did not happen, the officer appropriately insisted and the patients complied. Finally, the last element is that the patients are expected to open their mouths after ingestion in order to demonstrate that the medication has been swallowed. The officer did insist on this, but the frequency with which the inmates appeared to be unaware of this requirement was extremely problematic. This must be done not only when the medical monitor is observing medication pass but it also must be done at every medication pass. The warden should issue a memo that describes to the inmates the rules for participation in the medication process. The rules include appropriate identification, providing a container filled with water for the process and opening their mouths for inspection after ingestion.
The nurse in this instance knew all the patients quite well and they clearly knew her. A few needed to be reminded to bring the cup of water to the door or to the gate. However, several inmates were surprised at the mouth check and two refused. If an inmate does not comply with the requirements of the medication process then the clinician should be notified and consideration be given to discontinuing the medication.
The nurse did document in a timely manner after the medication was administered on the medication administration records. This is an improvement from prior visits.
RECOMMENDATIONS: 1. The warden should issue a letter in which she lists the rules for participation in the medication
process. Those must include: (1) identification by official means; (2) presenting a cup with water in it when one interacts with the nurse; and (3) facilitating visual inspection of the mouth after ingestion. Noncompliance with the rules can result in nonparticipation in the medication process. 2. Assign a consistent officer to accompany the nurse on the medication pass, whether it is mornings or evenings.

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3. Provide either a card or a wristband that allows correct official identification for the inmates. 4. Continue to improve the pharmacy arrangements so that it is possible to comply with the Pharmacy
Practice Act. 5. The Director of Nursing should monitor the performance of the medication administration process
as part of the quality improvement program.

MENTAL HEALTH FINDINGS: 100% of all MARS for the current month were inspected on June 9, 2015, for completeness. Eighteen (18) inmates currently receiving psychiatric medications demonstrated issues that were of significant concern. Rather than list each chart separately, a general summary will be given. On June 2 and June 3, multiple patients did not receive Cogentin, a medication frequently utilized to treat the common neuromuscular side effects of antipsychotic medications.

On further investigation, it was discovered that there are major pharmacy supply issues reportedly related to late payments to Diamond Pharmacy, as well as an extremely high cost for medications supplied. In an e-mail from Diamond Pharmacy to the Health Services Administrator on May 5, 2015, it was noted that the Bureau of Corrections was in arrears by a total of $351,000. Even in taking into account the fact that this number may represent pharmacy costs for both St. Thomas and St. Croix, this total cost seems incredibly high considering the small number of people at Golden Grove Adult Correctional Facility who are currently receiving medications. Apparently, the pharmacy had refused to supply additional medications until partial payment was received, which resulted in the on-site pharmacy being out of stock of Cogentin.

Another problem identified in this review was notation of frequent refusal of medications by multiple inmates that did not result in any written notification to the clinicians treating these individuals. An example of this miscommunication is a very recent notation by the psychiatrist when seeing an inmate that his medication compliance was fair. Yet, the inmate had refused every dose of medication for the entire first third of the month of June. This same pattern was noted with inmates receiving general medical medications for the management of conditions such as hypertension.

There is no specific section in this agreement that deals with the risk of heat intolerance caused by many psychoactive and general medical pharmaceutics. These medications generally disrupt the body’s ability to perspire as a cooling mechanism and increase the chance of heat stroke, and rarely death. While on site, an Ambient Weather WS-HE01 Handheld Heat Stress Index, Dew Point Monitor with Temperature, Humidity Meter was used to measure the temperature and heat index in several units at approximately 4 PM on 6/8/15, with an outside temperature of 89.9 degrees Fahrenheit (Heat index of 99.9). Some units had multiple readings taken in different parts of the common area (Dayroom).

Unit L (prison segregation) L K (housing for medically fragile and some mentally ill inmates)

Cell 7
Dayroom Dayroom

Temperature (Fahrenheit) 90.8
90 89.8

Heat Index 99.5
98 98.7

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K

Dayroom

91.7

G (general Dayroom

90.9

pop)

G

Dayroom

89.2

H

Dayroom

89.5

9B

Dayroom

91

9B

8

90.9

9B

9

90.7

9B

TV room

90.5

9B

17*

90.4

A (detention Dayroom

90.4

segregation)

105.6 101.8
98 98.5 99.9 100.3 100.4 99.9 99.6 100.1

*B17 was an upper corner cell that was currently unoccupied. Due to the lack of ventilation, it was noted that the heat index of 99.6, although equal to or lower than the other readings, was totally intolerable.

RECOMMENDATIONS: 1. The service needs to quickly implement reliable use of the medication refusal form to allow nursing
staff to notify clinicians of any significant pattern of medication refusal so that prompt attention and counseling can be provided to their patients prior to any clinical decompensation. This process should also be tracked through quality improvement project to ensure that it is appropriately implemented. 2. The Bureau of Corrections should continue its efforts to identify more cost-effective suppliers of medications and make every effort to avoid lapses in providing prescribed medications to its inmates. 3. GGACF should develop a heat risk policy and ensure that all inmates have access to plentiful supplies of water and ventilation methods at all times. A list of inmates on medications that have heat related risks should be maintained and these inmates should have access to ice and water when the heat index indicates an elevated risk of heat related illnesses.

e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: These medical record policy has been approved and training was completed on August 3rd as scheduled. We have seen some improvement in the organization of the records. However, we did find documents that should have been filed but had not yet been filed. Over the long term, the move to an electronic record would be appropriate and necessary.

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RECOMMENDATIONS:
1.Complete the training with regard to the policies and procedures.
 2.Continue to improve the organization of the medical records. 
 3.Improve the timeliness of medical document filing.
 4.Begin to develop plans to implement an electronic record.

ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Maintenance of the mental health record continues to show benefit from the time of our early visits. However, charts remain in need of organization. Multiple records were noted to have documents which were not filed in chronological order. Some charts continue to remain disorganized with significant numbers of loose documents in the folder.
RECOMMENDATIONS: 1. Once all records are appropriately organized and filed, a quality improvement tool needs to be
developed to track compliance with this provision. 2. The mental health records should be scrutinized in organizing chronological fashion.
f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick-call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for this provision. However, these policies and procedures were approved and training was completed by most of the medical staff on July 28, 2015.
RECOMMENDATIONS: See letter (c) findings and recommendations.
MENTAL HEALTH FINDINGS: Ms. Randolph, the RN assigned to the mental health team, described the general process for mental health sick call. A registered nurse will triage the request and then hand it to the Mental Health Coordinator. When a request is triaged as emergent or urgent the registered nurse will call the psychiatrist directly and later notify Ms. Murray. Ms. Murray also triages sick call requests prior to determining who should see the inmate and within what time frame. A most interesting finding in reviewing sick call requests was that in the past six weeks there were a total of 17 requests entered into the log. For the prior 15 weeks there were only eight. It is calculated that this represents more than a 500% increase in requests for service. Speculatively, this is most likely attributed to the increased availability of programming and mental health staff. This increase is regarded as a very positive finding.
A review of the sick call log from April 22, 2015 until the present time (a review of all records since our prior audit) was completed on June 8, 2015, with Ms. Randolph. Seventeen (17) records were

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reviewed. All inmates who had submitted a sick call request received a face-to-face triage by a registered nurse within 24 hours, an excellent practice which exceeds national standards. Mental health staff also saw individuals who were referred within 24 hours and the response was appropriate in addressing the complaints and requests from the inmates.
This reviewer identified an additional inmate who had submitted a sick call request but whose name was not entered in the sick call log.
RECOMMENDATIONS: 1. Discrepancies between entries in the medical and mental health sick call logs need to be corrected
so that both logs are accurate. Accuracy is essential in both ensuring that inmate needs are identified and resolved in a timely fashion as well as providing accurate data for quality improvement efforts.
f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: We interpret this as referring to a chronic care list and an ability to track the sequence of visits. In this area, progress has been made in developing lists for patients with each disease. We were provided with a list which, although we did not perform a thorough analysis, did appear accurate. There is also a newly assigned chronic care nurse who will be working with the chronic care patients. We reviewed nine records of patients who are enrolled in the chronic care program. All records contain problems. These problems included incorrect assessment of the degree of control, incorrect scheduling of the urgency of follow up based on the degree of control, delays in enrolling in the chronic care program as well as incomplete assessments by the clinicians. We will provide a sample of these types of problems.
Patient #1 This is a 77-year-old patient with prostate cancer, asthma and hypertension and status post pacemaker implantation. His initial hypertension visit was in July 2014, and his last chronic care visit was 5/21/15. The initial visit was not in the record we looked at. This patient is on three antihypertensive medications, aspirin as well as medication for hyperlipidemia. At his last visit, his blood pressure was 178/100 and the hypertension was correctly assessed as poor control. However, he was given a follow-up visit in 90 days. This should have been 30 days or sooner.
Patient #2 This is a 61-year-old patient whose baseline visits for hypertension and diabetes occurred in January of this year and his follow-up visit occurred in March of this year. He was assessed as having both his diabetes and his hypertension in fair control. Due to a low blood sugar his meds were stopped. He also should have been followed much more closely, as he was given a 90-day follow up visit and this patient should have been seen much more frequently until his condition was under better control.

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Patient #3 121043 This is a 67-year-old patient with diabetes and hypertension. He had a baseline visit in July 2014. His most recent follow-up visit was in May 2015. However, at first we could not locate the May follow-up visit. After we located the document, it lacked an appropriate disease specific history for each disease. Only the hypertension was addressed at this visit and that was assessed as fair control, but the follow up was in three months rather than within 60 days.
Patient #4 930306 This is a 52-year-old with diabetes type 2 and hyperlipidemia. He had his baseline assessment in April 2014, and his most recent follow-up visit was in January 2015. In October, his hemoglobin A1c result was 7.2%. He has not had any lipid studies in over six months and he should have a repeat hemoglobin A1c. He also has not had an eye or a foot exam.
This program will await the hiring of the new Medical Director who can provide more appropriate clinical decision making.
RECOMMENDATIONS: 1. Have the Medical Director review the chronic care policy and guidelines so that she is familiar with
the program. She is certainly capable and should modify it consistent with her clinical judgment. 2. Have the chronic care nurse insure that the guidelines will be followed by working with the clinician
and reviewing the records and notifying the Medical Director when particular consultations or tests require ordering.
MENTAL HEALTH FINDINGS: The mental health clinic continues to maintain a tracking log for all patients followed by Dr. Sang that appears to be up-to-date during this review. The current log tracks all items critical for ensuring predictable and reliable patient follow up.
RECOMMENDATIONS: 1. It is my understanding that the Mental Health Coordinator plans on also adding a tracking
log for general counseling services, which hopefully will be in place by the time of the next site visit.
f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: See f (ii).
RECOMMENDATIONS: See f (ii).
MENTAL HEALTH FINDINGS: See section V.s.1.
Dr. Shansky for items v, vi, g. and h.

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f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide firstaid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;
ASSESSMENT: NONCOMPLIANCE, although training was completed on these policies July 28, 2015.
MEDICAL FINDINGS: We continue to find medical response bags in the housing units. However, the documentation that the response bags are checked twice daily is problematic. If everything is complete, a checkmark should be made and if something is missing, an X should be documented; the item written in that was missing should also be replaced. We found in a few housing units that staff were using an X to mark bags that were completely filled. Also, in many housing units the bags were inconsistently reviewed, as evidenced by the documentation. Our understanding is that medical and custody should review the bags simultaneously twice a day. It would be helpful to use breakaway plastic strips that if in place indicate that the bag has not been used and therefore it is still filled. We have been told by nursing staff that they tend to bring the health care unit emergency bag to the housing units because that has been historically their custom. That can continue; however, when there are simultaneous incidents in two different housing units, the second incident will require the use of the housing unit emergency bag.
We also reviewed five emergency care records that were sent offsite. The five records revealed one in which the clinician assessment was incomplete and two in which there was no follow-up visit by a clinician after return from the hospital. Those records follow.
Patient #1 R. R. M. This patient was sent to have a carotid Doppler exam on 5/11/15. The cardiologist found an abnormality and sent the patient to the emergency room without documenting an exam. The patient was followed up by a physician in June without any diagnosis.
Patient #2 E. S. This is a 25-year-old who on 4/22/15 complained of chest pain during an intake history and physical. The physician obtained an electrocardiogram which was abnormal and therefore he sent the patient to the hospital. At the hospital, the abnormality was determined to be old and the diagnosis was a variant of costochondritis. The patient was treated symptomatically but no follow up occurred.
Patient #3 B. D. This is a 28-year-old who on 3/3/15 complained of chest pain and was seen on a sick call visit by a nurse and referred to the emergency room after an EKG which demonstrated an abnormality. This patient was seen in the ER and provided treatment, specifically a steroid injection, but the patient was never followed up by a clinician at the facility.

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RECOMMENDATIONS:
1. Complete the training of officers regarding the identification of emergency medical and mental health crises.
2. Custody and medical should work together to facilitate improved monitoring of the medical emergency bags in the housing units.
3. The person who is responsible for retrieval of emergency offsite documents should also insure scheduling of follow-up visits.
4. The facility should initiate drills or at least critically review actual incidents identifying both positive aspects of performance as well as opportunities for improvement.
MENTAL HEALTH FINDINGS: Defer to Dr. Shansky’s report
RECOMMENDATIONS: None
f. (v) adequate and timely referral to specialty care;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: There is a log being maintained; however, we had concerns about the accuracy, which we shared with the offsite service coordinator. One of the first records we reviewed in the log indicated that the patient had not only received the service but also that the report had been returned and the follow-up visit had occurred. In fact, none of this was accurate. We discussed with the offsite service coordinator the need to maintain an accurate and comprehensive log so that the QI program’s monitoring would be facilitated. We have been told that the computer link with the hospital has been set up. We did not have the opportunity to assess its use. However, it did appear that many reports are now more commonly available. This is clearly a step forward. Both the unscheduled service coordinator and the scheduled offsite service coordinator should be able to use that computer to retrieve reports not returned from the hospital with the patient.
We reviewed 10 records of patients sent offsite for scheduled consultations or procedures. The most common problem we found was an absence of a clinician follow-up visit or delays in obtaining services. This was particularly true for CT scans, and we were informed that the hospital CT scanner was broken. This basically compromises access to CT scans for the facility. We have been told that the hospital scanner has been repaired and we would therefore expect that the services should be available more timely. Specific cases that we reviewed will be described below.
Patient #1 An order was written for his infectious diseases consultation on 12/3/14. This is an ongoing consultation and the appointment was for 4/28/15. The visit demonstrated good control, although there was no CD4 count. The patient was given a six-month return visit, but there has been no clinician follow up. This is particularly striking since the patient’s blood pressure was significantly elevated upon return. That blood pressure should have been followed up.

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Patient #2 This prisoner’s visit to urology was ordered on 2/25/15. The appointment was scheduled for 4/27. The patient was unable to obtain the visit because, prior to the visit, a CT scan had been ordered and the hospital scanner was broken. This delayed his access and continues to delay his access to urologic services.
Patient #3 This patient had an order for a gynecologic appointment on 3/25/15. The appointment was scheduled for 10:00 a.m. This was for a procedure in the gyn office which did occur, but there has been no clinician follow up since her return to the facility. This particular procedure may cause complications and in this instance the procedure was not accomplished, although the gynecologist made an attempt and it was not accomplished due to abnormal anatomic variation. This should have been discussed with the patient.
RECOMMENDATIONS: 1. The scheduled offsite service coordinator should insure the accuracy of the maintenance of the
log. 2. The computer link to the hospital should be utilized to retrieve documents that are not returned
with the patient. 3. Once the documents have been obtained, the scheduled offsite service coordinator should schedule
follow-up visits with the clinician so that the clinician documents a discussion of the findings and plan.
f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above
ASSESSMENT: NONCOMPLIANCE, training on Hospital and Specialty Care policies and procedures was completed on July 23, 2015.
MEDICAL FINDINGS: This has been discussed under f (v).
RECOMMENDATIONS: This has been discussed under f (v).
MENTAL HEALTH FINDINGS: Defer to Dr. Shansky’s report
RECOMMENDATIONS: None
g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: This item is completely under the purview of the Medical Director and is one of the responsibilities that she has inherited. She should review and make any changes or additions to the current guidelines and policy

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RECOMMENDATIONS:
1. The new Medical Director should review and modify the clinical guidelines developed for intoxication and detoxification as she feels appropriate.
MENTAL HEALTH FINDINGS: Defer to Dr. Shansky’s report
RECOMMENDATIONS: None
h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: This item requires two things. One is training for the staff, which has been planned, and two, the identification of an infection control nurse who will be responsible for and oversee the program. It would be useful for the designated nurse to attend an infection control training program, usually provided at a hospital. The Director of Nursing can identify the best available program for the designated nurse to attend.
RECOMMENDATIONS:
1. The training needs to be completed and documented as such for the staff. 2. The designated infection control nurse should be sent for appropriate training, especially as it relates to the role of the infection control nurse in the patient care setting.
MENTAL HEALTH FINDINGS: Defer to Dr. Shansky’s report
RECOMMENDATIONS: None
i. Adequate suicide prevention, including:
(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: Suicide prevention is a critical component of any mental health service due to the high risks of serious morbidity and mortality should there be a lapse in these procedures. Policy review is currently complete and the policies have been formally approved and adopted. Training for all staff including security will not begin until early 2016. Medical staff, based on chart review, is providing adequate support to inmates identified and placed on suicide watch. However, there are significant obstacles for the facility to provide adequate 24-hour safety monitoring for these inmates. Until such time as training and implementation is complete, this provision will remain rated as noncompliant (with rare exception) as compliance requires a multidisciplinary effort.

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The few charts reviewed supported immediate referral and rapid evaluation by a mental health professional. The officers continue to complete behavioral checklist referrals and this is maintained in a log by the Mental Health Coordinator. There have been nine such referrals since April 21, 2015 and six of these were reviewed on-site. All six referrals received prompt evaluation within 24 hours by mental health professional and appropriate referrals to the psychiatrist when indicated.
RECOMMENDATIONS:
1. Continue to monitor and review future behavioral health checklist referral tracking logs. 2. Because security staff have not yet been trained with an approved curriculum for suicide
prevention, this provision remains noncompliant. However, it is recognized that the security staff does an excellent job completing these forms when behavioral problems are identified.
(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Currently there is insufficient documentation or data to demonstrate constant observation of inmates until they are evaluated by a qualified mental health professional.
RECOMMENDATIONS: 1. The facility will need to develop a means of documenting whether or not an inmate is maintained
on constant observation until the time of the evaluation in order to demonstrate compliance with this provision. 2. Currently, documentation is scattered between an observation form and hit-or-miss notations in the officers’ unit log. Implement approved Log of Suicide Watch (PCO) Rounds. 3. Once implemented, these should be reviewed by mental health staff regularly to ensure security’s compliance with the policy.
(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: A suicide risk assessment instrument is now in place and was utilized for the two cases reviewed.
RECOMMENDATIONS:
1. Continue to utilize the suicide risk assessment tool and develop quality assurance data to demonstrate compliance with this provision.

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(iv) readily available, safely secured, suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: All housing units will be toured during the September 2015 monitoring visit to assess compliance with this provision.
RECOMMENDATIONS: (v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Currently the monitor has not yet received nor approved an adequate training curriculum, however it is forthcoming based on the training schedule. Therefore, this provision remains noncompliant.
RECOMMENDATIONS: 1. A complete training curriculum on suicide prevention needs to be forwarded to the monitors for
review and approval. 2. Complete training for all staff on suicide prevention and particularly use of cut down tools to
security staff.
(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;
ASSESSMENT: NONCOMPLIANCE -
MENTAL HEALTH FINDINGS: There has been no change reported in this area. A training schedule was adopted at the end of this site visit, which will begin February 1, 2016, and be completed no later than July 31, 2016.
RECOMMENDATIONS: 1. GGACF will submit their curriculum for training officers and health staff in suicide prevention for
approval by the monitoring team. 2. The facility will complete a training by July 31, 2016 for all staff. 3. Effectiveness of the training will need to be demonstrated by the use of competency measuring
tools and follow-up quality improvement studies. Development of curricula and measures of effectiveness of the training were provided by the Monitor.
(vii) availability of suicide resistant cells;
ASSESSMENT: NONCOMPLIANCE - No Substantive Improvement from Previous Visit.

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MENTAL HEALTH FINDINGS: 7th Report: By inspection, GGACF continues to operate without any suicide resistant cells. Inmates requiring close observation are housed in the regular housing units. That placement would require that inmates be placed on constant observation. However, even when inmates have been listed as on suicide watch in the past, it has been noted that observation occurred on an intermittent and unpredictable schedule, if at all.
Construction of a small infirmary and suicide prevention housing area within the medical treatment building has come to a halt reportedly due to finances and relocation of inmate workers to off-site facilities (the latter as a remedy to improve inmate officer staffing ratios).
8th Report: No change. The absence of a suicide resistant cell and adequate supervision remains a serious deficiency.
RECOMMENDATIONS:
1. GGACF is encouraged to urgently complete renovations in the infirmary in order to provide 
 appropriate and safe suicide and close observation cells. As expressed in the last 2 reports, all 
 measures should be taken to provide adequate space within the cell, suicide resistant sinks and 
 commodes and the absence of any protruding objects within the cell that would facilitate the 
 placement of a ligature. Please refer to all of the detailed RECOMMENDATIONS in the 
 Monitor's fifth assessment report regarding the configuration and structure of suicide resistant 
 housing.

2. Security staff will need to be present in the infirmary to monitor inmates on suicide prevention 
 24 hours per day.

3. Whenever an inmate is housed in the infirmary a nurse must be present 24 hours a day to 
 complete the required monitoring of the patient every shift.

(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: The Mental Health Coordinator is maintaining a log that tracks suicide watches. Since the time of our last site visit two inmates have been placed on suicide watch and one inmate was listed as receiving chemical restraints. All three records were thoroughly reviewed.
1. Inmate 1 is a 26-year-old male who placed a sick call request complaining of auditory and visual hallucinations. He was seen that same day by the psychiatrist, who placed him on constant observation with 15 min. documentation on suicide level I. This inmate was seen daily by the psychiatrist until released from suicide watch two days later. He was assigned to a weekly group as part of his follow-up. He was also seen by the psychiatrist one week after being removed from suicide watch. A suicide risk assessment form was also utilized by the medical staff. And he was seen by nursing and behavioral health. Security staff only documented safety reviews hourly on the first day of suicide watch between the hours of 1500 and 2100. There were no further entries in the security logs whatsoever. When the C unit log was reviewed it was noted that while the inmate was supposed to be on constant 1:1 observation, he was allowed to go out to the rec yard with six other

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inmates. The officers’ log also contains no mention that the inmate was on suicide watch between May 18 and May 20, 2015.
2. Inmate 2 is a 25-year-old male who was placed on suicide watch at the end of April. He was seen daily by the psychiatrist, who proceeded to step him down through the suicide observation levels. The registered nurse documented in her progress note that she notified the officer to maintain a 15 min. watch on the individual. Review of the security documentation indicates that 15 min. documented staggered watches were not completed. There are lapses of up to one hour between entries. In addition entries were only entered on April 30, 2015, between midnight and 12:48 PM. The inmate was placed on watch at 4:30 PM April 29, 2015, released on April 30, 2015 at 1:45 PM. In addition, despite being placed on suicide watch at 4 PM on April 29, 2015, the first documented 15 min. check was at midnight.
3. Neither inmate on suicide watch received adequate monitoring by security, which is a serious deficiency. Most correctional systems will require constant 1:1 observation of any inmate on a safety watch whenever the inmate is housed in a non-suicide resistant cell. This rule applies even when the inmate is on a lower level of watch. At GGACF, inmates are not only in hazardous cells but they are not being adequately observed.
RECOMMENDATIONS: 1. Complete the process of training on suicide prevention and observation policy, implementation
and monitoring. 2. System wide training for this provision will be the last of the medical trainings offered because
security must also be included. However, the facility is strongly urged to consider a method to ensure that inmates placed on suicide watch between now and the time training is completed are adequately supervised and that this supervision is documented according to policy.
(ix) procedures to assure implementation of directives from a mental health professional regarding:
(1)the confinement and care of suicidal prisoners; (2)the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: This area of the Settlement Agreement has shown measurable improvement. There are currently two mental health professionals and a psychiatrist. A registered nurse has been identified to assist the mental health team with medication order transcription and laboratory order review.
Ms. Murray, the Mental Health Coordinator, has been busy organizing the service. Under her direction new programming, monitoring, and data collection has been initiated. This will be discussed under a later provision.

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While on site, we were notified that a third mental health professional has been identified and has completed the application process. However, this person has not been hired at this time, which appears to be a human resource department issue. The new Medical Director was hired.
Communication among the medical and mental health team appears good. The mental health coordinator meets daily with her team and the psychiatrist. Ms. Murray also meets weekly with the Health Services Administrator and Director of Nursing. Medical staff have a monthly meeting (that does not always occur). There is an agenda and sign-in sheet, but no minutes. The Health Services Administrator also attends a weekly meeting with the Warden and the Warden's team; however, this meeting addresses mostly security concerns.
The Health Services Administrator has been waiting for the medical director to arrive before initiating medical administration meetings and quality improvement meetings.
RECOMMENDATIONS: 1. Efforts should be made to bring the third mental health professional position online so that all
inmates can receive the required initial mental health assessment and treatment programs can be fully implemented. 2. Once there is a full complement of mental health staff, a meaningful staffing analysis can be completed in 6-12 months to determine if additional staff is needed to complete the mission of the service.
j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: The medical program requires an administrative assistant to assist the Administrator as well as the Director of Nursing and others in the leadership team as well as at least 1.4 FTE RN hours to insure that the night shift is covered by an RN seven days a week. It is our understanding that nurses have been identified and the process has been initiated for their hire.
RECOMMENDATIONS:
1. Fill the nursing hours to complete 24/7 RN staffing.
k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: Although access clearly has improved, as evidenced by my direct observations as well as statements from medical staff, the training has not yet occurred and therefore the findings cannot be advanced towards substantial compliance.

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RECOMMENDATIONS:
1. Complete the officer training. 2. Stabilize the officer assignments for those officers posted to assist medical and enable them to be
trained on the particular aspects of their assignments.
MENTAL HEALTH FINDINGS: No change since the 7th report.
Given the absence of sufficient mental health programming, it remains impossible for the facility to determine what the adequate numbers of correctional officers are to properly supervise prisoners’ serious mental health needs.
RECOMMENDATIONS:
1. No change from baseline assessment. GACCF will need to develop approved training tools and curricula. These will be presented to the monitoring team for approval and then training and implementation.
l. A protocol for periodic assessment of the facility's compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: The medical program is now capable of studying processes with regard to parameters like timeliness or continuity. The professional performance of nursing can be also assessed by the head nurse. The overall clinical professional performance is the responsibility of the new Medical Director. With regard to timeliness of services and nursing appropriateness, I would like to see studies that document data looking at timeliness of intake and sick call as well as professional performance on intake and sick call. In addition, I would like to see continuity with regard to both unscheduled and scheduled offsite services with regard to primary care clinician follow-up visits.
RECOMMENDATIONS: 1. As described above, the QI program should present data to me at my next visit looking at the
intake process, the sick call program and the scheduled and unscheduled offsite services.
MENTAL HEALTH FINDINGS:
Continuous Quality Improvement polices have been approved and training was completed August 24-26, 2015. It is reported that since our last visit there still have been no meetings of the Medical Administration Committee or the Quality Improvement Committee. Hence, there were no meeting minutes available to review.

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RECOMMENDATIONS:
1. Essential monthly or quarterly management meetings should be occurring. Although it is useful for the medical director to be present, this should not be an essential component blocking communication between medical staff and other department leaders. Failure to implement these critical committees delays essential communication between administration and medical and remains a major deficiency.
m. Adequate dental care;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: We did find improvements, especially in access to services. About 90% of scheduled appointments are being seen. For this, custody and the dental program should be commended. Less than 10% of the total appointments resulted in unexcused no-shows. This is a significant improvement. We have also looked at the ratio of extractions to restorations, which currently has a ratio of about 10 to 4. We encourage programs to attempt to achieve, if possible, a 1 to 1 ratio.
RECOMMENDATIONS:
1. Continue to monitor the access by documenting scheduled versus seen and the reasons why not seen.
2. Report the number of restorations each month as well as the number of extractions, with a goal of getting closer to 1 to 1.
MENTAL HEALTH FINDINGS: Dental hygiene is important for good mental health. However, this vulnerable population may be overly reluctant to seek oral care even when in pain. It is very important that GGACF health care services are proactive in monitoring the dental hygiene of this population.
RECOMMENDATIONS:
1. GGACF officials should ensure protocols are in place and practice that ensure proactive oral health assessment of mentally ill inmates.
n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: We have reviewed the policy, but although there was a recent death, no one has reviewed it. Since the new Medical Director had no role in the care of the patient who died she would be the perfect person to perform a review, which she and I could discuss at our next visit.

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Although this case was in the hospital a long time, the review must focus on care provided at GGACF.
RECOMMENDATIONS:
1. Have the new Medical Director perform a review of the care provided at GGACF for the patient who died.
MENTAL HEALTH FINDINGS: No deaths were reported this quarter or significant mental health morbidities. No change since the 7th Monitor's Report.
RECOMMENDATIONS:
1. The clinical directors, Director of Nursing and Health Services Administrator should develop mechanisms to identify and review all cases of mortality and serious morbidity as part of the Quality Improvement process. These reviews should also include security leadership.
o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: As we understand it, a nurse is making rounds three days a week and mental health is making rounds weekly. This particular element may achieve substantial compliance at the next visit. We would look for consistency of the presence of the medical and mental health staff as well as documentation of cases referred over a period of three months based on those rounds.
RECOMMENDATIONS: 1. Maintain documentation of patients referred for care by either medical or mental health as a result
of the segregation rounds made weekly.
MENTAL HEALTH FINDINGS: Soon after the time of the April 2015 site visit, I was informed that Ms. Murray initiated segregation rounds. While on site, I accompanied the mental health professional while she completed these rounds. It was quite evident that the inmates are accustomed to seeing her on a regular basis. The noise level and chaos within the segregation units was noticeably absent during his rounds. Her rapport with the inmates was excellent and rounds were conducted in a competent and effective manner. Not only did she see inmates on the mental health list, but she also conducted rounds on all segregation inmates as well as any identified mental health caseload inmate who was in special housing or restriction on non-segregation units. Ms. Murray developed a tracking form for these rounds that gives information regarding the inmate's general well-being, condition of his cell, and any specific needs that he or she may have.
A review of the segregated rounds log from June 2, 2015 was completed. Four inmates who received a rating of poor under “appearance and behavior of the inmate” received a chart review. All four were being followed regularly by the psychiatrist. One was attending weekly groups.

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RECOMMENDATIONS:
1. The Mental Health Coordinator will keep documentation of weekly rounds and this provision will be monitored at the time of the next site visit.
p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: There is no change in the findings for this provision since the baseline visit. Inmates with serious mental illness continue to be housed on a long-term basis in disciplinary/administrative segregation units. This reviewer also observed three inmates with serious mental illnesses being housed in locked single cells (protective custody) for vulnerabilities secondary to their mental illnesses in a general population detainee unit. These inmates are allowed congregant out-of-cell unstructured time for two hours each evening. Of note, since our last visit mental health has initiated group therapy at least weekly with these three inmates. During segregation rounds, the mental health professional and I visited these men who all seemed calmer, better organized, and clearly enjoying the programming provided to them.
There is currently no formal enhanced programming for seriously mentally ill inmates in isolation or segregation. However, Mr. Rosas has been able to include some of these inmate in his general group therapy sessions held in the medical treatment building. The facility has moved forward in initiating renovations to the group room on the segregation units. Once these are completed it is hoped that mental health will be able to do a variety of activities with inmates housed in these areas.
RECOMMENDATIONS:
1. As per the provisions of this Settlement Agreement, inmates with serious mental illnesses may not be placed in isolation. The Bureau of Corrections needs to develop a corrective action plan with specific recommendations for capital improvements and dates to remedy this deficiency.
2. During the time that inmates remain in segregation with serious mental illnesses, mental health staff should be aware that these inmates be offered a minimum of 10 hours a week of unstructured outof-cell time by security. In addition, mental health staff is encouraged to develop supportive group or individual therapeutic activities, generally recommended being a minimum of 10 hours per week per inmate in order to support the inmate’s mental state as well as assist inmates in acquiring skills to move them off the segregated status and sustain themselves in the general population setting.
3. Medical services needs to ensure that communications regarding inmate needs gathered in administrative or other meetings be formally entered onto a referral sheet to the clinic for improved follow up.
q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations

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and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: No change in practice since the 7th report. Currently mental health receives no notifications when an inmate is placed on disciplinary status.
RECOMMENDATIONS: 1. GGACF should develop a form that can be sent to the Mental Health Coordinator, completed by
mental health staff and submitted to the disciplinary committee. The committee can use the same form to communicate back to the mental health staff the outcome of the hearing proceeding. 2. GGACF needs to develop an effective policy and process to provide mental health review and input into the disciplinary process. 3. Mitigating factors discovered by the mental health professional must be considered by the disciplinary committee. 4. Mental health services should track the effectiveness of their input in mitigating sanctions or terminating sanctions as appropriate. 5. Alternative housing and treatment services are an essential component in diverting seriously mentally ill inmates committing infractions due to their impaired judgment and mental processing. Again, it is recommended that GGACF provide appropriate staffing and housing alternatives for this population. (See V.1.p.)
r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: We are seeing some progress in the completion of the examination rooms. However, progress remains very slow. The most advanced rooms were exam rooms in L and K, but even those lacked a few basic elements needed for use. All the other exam rooms were substantially behind with regard to both equipment and basic supplies like soap, wastebaskets, sink hook-ups, etc. Additionally, the infirmary is fairly close to completion. Two rooms should be made suicide-proof, the dental operatory needs to be moved and appropriately equipped and other relevant equipment needs to be provided for both the pharmacy and medical area. A patient call system needs to be made available.
RECOMMENDATIONS:
1. Complete the exam rooms in all of the housing units. 2. Complete the infirmary including suicide-proof rooms, patient-to-nurse call system, pharmacy
equipment and other requirements of the infirmary.

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MENTAL HEALTH FINDINGS: The psychiatrist and MHP are using private offices in the treatment building. However, once the medical director and other medical providers are on-site running clinics, space may yet again be an issue.
Private examination offices are being renovated in all of the housing units on the prison side. Once complete, these will be available for medical sick call and provider encounters. It is also hoped that mental health professionals can access these offices when medical staff is not utilizing them for private individual counseling or psychiatric visits. As mentioned previously, the facility is renovating some of the multipurpose rooms on the segregation units for use by mental health staff for group programming.
RECOMMENDATIONS:
1. Continue with current renovations.
s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: No change since the last site visit but this area of treatment planning is being addressed by the Mental Health Coordinator. Access to care has been addressed under other provisions in this agreement. Documentation of weekly group notes was observed in multiple charts reviewed. Inmates that were interviewed on rounds during this visit also expressed their pleasure with the current groups offered and found them to be of great benefit. Follow up visits noted during chart reviews were timely based on the expected return date documented in the prior note.
Currently, the facility and the island rely on Dr. Sang as the only psychiatrist on St. Croix. GGACF should consider telemedicine as a backup for Dr. Sang during her planned vacations and also for offsite medical consultations. This mode of treatment is well accepted and commonly used in the states, particularly in rural jails and prisons. Besides the obvious benefit of greater access to numerous consultants there are marked reductions in costs due to decreased or absent transportation costs to the facility.
RECOMMENDATIONS:
1. Based on policy and developed protocol, treatment plan should be updated at set frequencies based on inmate need and changing conditions in the inmate status. It is strongly recommended that supervisory review occur to ascertain the appropriateness and completeness of the treatment plans generated.
2. When indicated, in-service training on treatment plan development is recommended to ensure consistency between staff members in developing measurable objectives toward marked improvement in those inmates followed by the mental health team.

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(ii) adequate mental health programs for all prisoners with serious mental illness;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous visit.
MENTAL HEALTH FINDINGS: Mental health is currently providing six groups per week in the facility. There is one group for the female inmates. Weekly segregation rounds are occurring. During performance of the segregation rounds the mental health professional does check the officers’ log books and will schedule individual follow-up when the need is identified. Ms. Drigo, the medical case manager, continues to work with classification on discharge planning. She will notify mental health whenever someone is scheduled to parole from the facility and she will make outside appointments. The medical/mental health service is planning to initiate a needs assessment as soon as a policy is approved.
RECOMMENDATIONS:
1. The mental health team will need to develop a global treatment menu designed to meet the needs of inmates at different levels of housing and treatment needs as discussed in detail in the recommendations in the 7th report regarding required programming for special populations.
2. Group programming should be designed to meet the clinical needs of individuals who should be assigned to those programs based on their needs assessment on their individual treatment plan.
3. The facility should consider how it might create a special population housing unit to make the delivery of services more efficient to those who require enhanced mental health services.
(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: See V.1.c. & d
RECOMMENDATIONS:
(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload; and …
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
MENTAL HEALTH FINDINGS: No change since the 7th report. This will be covered in the upcoming training slated for 2016.
Correctional officers at GGACF should be commended for continuing to comprehensively complete behavioral checklists to initiate referrals for mental health services.

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RECOMMENDATIONS:
1. Continue to utilize the Behavioral Checklist process.
2. Conduct a facility quality improvement morbidity review that can be submitted to the monitoring team for review.
(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: There continues to be no improvement in this area. Inmates with serious mental health issues continue to be maintained in segregation due to the lack of appropriate housing, programming, and coordination with security and classification.
The Warden has established a weekly meeting which does include the Health Services Administrator. Hopefully, this meeting will evolve into an effective forum to develop alternatives for this group of individuals. RECOMMENDATIONS: No change since the 7th report
1. The Health Services Administrator needs to coordinate monthly Medical Administration Committee (MAC) and Quality Improvement meetings, documented by minutes and attendance sign-in sheets. These meetings should include the Warden or her designee.

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VI. FIRE AND LIFE SAFETY 

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from the previous assessment. However, with the assignment of a full-time fire safety officer, there was an incremental improvement in the conducting of monthly fire safety inspections of all areas of the facility and soliciting the expertise of the Fire Safety Marshal to help develop the GGACF fire safety program.
FINDINGS: The Territory reported that they have been working with Corrections Corporation of America (CCA) to help develop the facility policies and procedures. However, at the time of our site visit, the policies and procedures governing Fire Safety had not yet been addressed. Since the visit, the draft policy was sent to the Monitor and United States for review and returned to the Territory for further revisions. The finalization, approval, staff training and implementation of these policies and procedures remains vital.
Inadequate housing unit staffing levels and contraband control practices continue to enable inmates to ignite various materials in the housing units as evidenced by our April 2015 and June 2015 inspections of the housing units. During these inspections, I observed lit wicks and smoke emanating from them in several housing units. Supposedly, inmates use the smoke from the lit wicks to ward off insects. However, aside from the contraband problem stemming from the use of wicks, it also continues to create fire hazards. It appears that staff have relented to the use of lit wicks by inmates and do not prohibit their use. Cigarette butts were again observed on the ground in the recreation yard for the Gulf housing unit.
The automatic fire detection and suppression system remains inoperable, inadequate staffing levels and contraband control leaves housing units deleteriously under-controlled and -monitored, inmates apparently have undetected and uninterrupted access to items to ignite materials, and inmates obviously have no inhibition about igniting materials.
During this monitoring visit, it did not appear that there were any reported fires in the housing units. However, due to the ease by which inmates can access fire ignition sources and given the state of disrepair with the facility electrical system, i.e., exposed electrical wiring and heavy fire loads in the inmate cells, this area remains volatile from a fire and life safety perspective.

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During our inspection, I also observed exposed electrical wiring throughout various areas of the Facility, including the kitchen, housing units and maintenance shops. Maintenance staff addressed the problem with clutter and exposed wiring in the electrical and boiler rooms that I re-inspected from our last site visit. In the kitchen I continue to observe boxes stacked in the dry storage area nearly up to the ceiling (should be stacked no higher than 30 inches below the ceiling). This was an identical finding in our last two reports. These findings, in addition to previous findings, reveal the urgent need to develop and implement a comprehensive fire safety program at GGACF.
Officer Samuel has been assigned as the full-time fire safety for the facility. During the June inspection, Officer Samuel reported that the VI Fire Marshal recently conducted a fire safety walk-thru of the facility. The Territory still has not submitted it to the Monitor and USDOJ. There is still no documentation available to demonstrate that evacuation plans have been approved by the VI Fire Marshall. The fire evacuation diagrams within the Facility remain woefully outdated and offer no assurance that they would be effective in routing staff and inmates from a fire or smoke related emergency. In fact, some diagrams do not outline the appropriate route. On a positive note, Officer Samuel has commenced his systematic inspections of fire safety needs for the facility. A comprehensive fire evacuation plan that that would incorporate all areas and buildings within the confines of GGACF and the contents of the overall fire safety program, such as the fire safety policies and procedures, still needs to be developed and provided to the VI Fire Marshal for review.
Staff reported and documents reflect that the BOC has secured an MOU or MOA with the VI Fire Service for helping GGACF come into compliance with the fire safety provisions of the SA. However, as we reported in our previous report, it must be expressed that the BOC/GGACF are the primary entities for demonstrating compliance with the fire safety provisions of the Settlement Agreement.
RECOMMENDATIONS:
The Monitor continues to request the reports for all drills and exercises conducted. It is also imperative that when the GGACF Fire Safety Program and the Fire Safety Plan are finalized and that they be provided to the Fire Marshal and with a copy to the Monitor and USDOJ.
1. Finalize and implement fire safety policies once approved and according to the Monitor’s schedule.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan. 4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all locations
where staff would need to search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate supervision
and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security.

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7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program.
8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action.
9. The fire inspection program was detailed in the draft fire safety policies and procedures that the monitor provided to the parties, and they should become a fundamental element of pre-and inservice training once policies and procedures are finalized, approved, and implemented. It is anticipated that the new policies and procedures that CCA is helping the BOC develop meet all of the requirements of Settlement Agreement.
b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Almost identical to previous Monitor’s reports, we found that the Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, and cell and housing unit sprinklers are non-functional and regularly used by inmates to support personal clotheslines. The primary fire detection and suppression system was designed to automatically detect and extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates. The only way to alert staff and inmates of a fire or smoke hazard is to use hand-held air horns that are located in the control rooms of the housing units.
Adequate supplies of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures. The Fire Safety Officer has incorporated the inspecting of fire extinguishers in his monthly inspection reports, which is a positive step in improving fire safety.
GGACF staff continue to indicate that sprinkler heads may be replaced in the “newer” buildings at some point in 2015. During previous inspections, we were provided with a letter, dated November 24, 2014, directed to the Department of Interior from the BOC Director requesting to allocate funding to aid in the replacement of the fire suppression system and for refurbishing the Kitchen at GGACF. However, the scope of work for the fire suppression system seems to only include the purchase and installation of fire sprinkler heads and related parts in areas of the Facility where there is a fire sprinkler system, but does not seem to address the need to install a fire sprinkler system such as in the old housing units where there is no fire sprinkler system. This needs to be clarified. The estimated cost for the fire sprinkler heads and related parts is approximately $89,700.00. Moreover, GGACF plans to continue to house individuals in the “older” buildings, and has no plans to update or install fire suppression equipment in those buildings. As reported in earlier monitoring reports, GGACF will never come into compliance with these provisions if that remains the case

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Although it was commendable that the Fire Safety Officer has systematically embarked in identifying fire safety discrepancies and fire safety needs, the resources to correct those deficiencies must be provided. For example, the Monthly Fire Safety Inspection Reports for the month of May 2015 identified missing or non-functional smoke alarms; therefore, funds need to be made available in order to purchase missing smoke alarms and for purchasing adequate stocks of batteries for them.
RECOMMENDATIONS:
1. Refer to recommendations above (a). 2. Consider purchasing fire safety program software from NFPA and/or the American Correctional
Association to assist in program development and monitoring. 3. Continue to support fire safety officer.
c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. In our previous report, GGACF staff indicated that fire drills have not been conducted on a regular basis. The Fire Safety Officer has commenced a process for conducting fire drills. The Fire Safety Officer reported that during the recent inspection by the Local Fire Safety Marshal, a joint fire drill was conducted in Housing Unit 9D. Hopefully the results of this fire drill will be addressed in the June 2015 Fire Marshal’s report. It is laudable that the new Fire Safety Officer has started addressing the necessity to conduct fire drills. The failure of GGACF staff to conduct fire drills on a regular basis of all facility areas continues to put inmates at risk of injury or death, should a fire break out that cannot be suppressed by the hand-held fire extinguishers present in the officer control pods of housing units.
During this site visit it appeared that security staff had a better awareness of emergency key management. In the housing units we inspected, there were emergency keys available. However, this area needs continuous monitoring and staff need to be trained and retrained on a continuous basis on the Key Control Policy and Fire Safety policies once they are approved. In future site visits we will continue to inspect this area of fire safety. In the housing units that have cell slider doors (Units L and K); the tool used for opening cell doors are still not readily available. The Fire Safety Officer and security management should conduct drills to see how prompt these type of cell doors can be manually be unlocked. There needs to be a clear and concise understanding by all security staff as to where the facility emergency keys are kept as well as having the tool to open the cell slider doors readily available and to ensure that staff are trained and retrained on the final Key Control Policy and Fire Safety policies.
Emergency keys are not appropriately marked and identifiable by touch. A system for marking and identifying all emergency keys that match the proper door locking mechanism needs to be developed and systematically implemented.

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During this inspection I inspected the cells in the intake area, which at times houses juveniles or high level protective custody prisoners. We again observed that these cells had padlocks on the cell doors. If this fire safety practice remains, coupled by the fact that when inmates are housed in these cells where there is not constant and direct supervision, or a functioning smoke alarm system or fire sprinkler system, it will continue to put the prisoners at a high risk of harm.
RECOMMENDATIONS:
1. Develop and implement a valid and reliable emergency key system as described above. Train and drill staff as discussed on system use.
2. Develop emergency key and locking mechanism inspection and reporting system as discussed above.
3. Implement competency-based staff training as discussed above. 4. Exercise fire safety program using onsite, scenario-based drills; include community responders
in exercise planning and exercise events. 5. Send the training officer and part-time fire safety officers to the National Fire Institute, National
Emergency Training Center, Emmetsburg, MD for additional training.
d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the
cell; and; (ii) that all facility remote locking cell mechanisms are functional;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Almost identical to our previous monitoring reports, documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance.
There is not a written preventative maintenance program or a regular security inspection program in place for checking that cell locks are functional and are not jammed from the inside or outside of the cell, nor a system for ensuring that all facility remote locking cell mechanisms are functional. Although the maintenance supervisor reported that there has been a decrease on call outs for lock repairs. During this monitoring visit we continue to observe evidence of inmates compromising the cell locks by inserting various materials in the locking mechanisms.4 We also continue to observe numerous housing unit grills whereby the locking mechanism was inoperable and the grills left open. For example, in Housing Units 9A and 9B we observed that all entry grills were open with the exception of the grill leading into the 9A Housing Unit.
4 Further evidencing the problem with inmates/detainees jamming their cell doors, the Hearing Officer in her May 2015 monthly report addressed this problem and concern about inmate/detainees being able get out or in of their cells by tampering or jamming the cell door locks.

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BOC is processing the financial document (purchase order) that must accompany the contract. This should be completed soon. Thereafter, the Director will sign the contract and the contract will then be submitted to the Department of Property & Procurement, Department of Justice and then the Office of the Governor.
RECOMMENDATIONS: Same as above.
1. Also refer to recommendations related to security provisions, contraband, and inmate manipulation of cell door locking systems.
2. Repair all remote cell locking notification technology.
e. Testing of all staff regarding fire and life safety procedures;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Although the previous Fire Safety Officer reported that he was involved in training staff on fire and life safety procedures, we were unable to ascertain its’ validity because as stated in the previous reports and in our current site visit, no records have been provided to verify that all staff have been trained and tested on safety procedures. The new Fire Safety Officer reported that he is in the process of setting up a hands-on training on the fire extinguishers, which is a good start. However, this provision of the SA requires a more comprehensive program for testing of all staff regarding fire and life safety procedures.
RECOMMENDATIONS:
1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
2. Provide this Monitor documentation evidencing compliance with this Provision.
f. Reporting and notification of fires, including audible fire alarms;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The fire reporting and notification system remains inoperable as reported in previous Monitor reports. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a hand-held air horn to alert inmates’ evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. As identified in previous Monitor reports and consistent with this inspection, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.
During our previous monitoring visit we observed that GGACF has had the necessary equipment for installing a manual fire alert notification system stored in an office for about two (2) years. It appears that in order to install this system, the facility needs to provide the

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necessary electrical components. However, in light of the acting BOC Director’s comments regarding the fire safety upgrades, a fire notification system is contemplated in that project.
RECOMMENDATIONS:
1. Install and routinely test the stored file alert notification system without delay.
g. Evacuation of prisoners threatened with harm resulting from a fire;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously stated, the fire evacuation policies have not been approved and full scale evacuation drills are not conducted.
RECOMMENDATIONS:
1. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.
h. Fire suppression;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as previously stated. There is no functional fire suppression system, with the exception of the kitchen’s cooking area.
RECOMMENDATIONS:
1. Develop and implement an annual full scale evacuation exercise that involves community emergency, health, and social services responders.
2. Repair the automatic fire detection, notification, and suppression system. 3. Replace cell sprinklers with tamper proof mechanisms. 4. Monitor staff response to fires, ensure they comply with basic fire safety principles, and
implement appropriate staff corrective action as needed.
i. Medical treatment of persons injured as a result of a fire; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The requirements for this provision are addressed in the draft Fire and Life Safety Policies and procedures that were provided to the parties in December 2014. Unfortunately, however, they were not addressed in the CCA newly revised policy and procedures on Fire and Life Safety that were submitted to the Monitor and USDOJ on July 24. USDOJ returned the

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policy and procedures to the Territory with comments. Once adequately revised and approved, staff must be trained on them and they need to be fully implemented.
RECOMMENDATIONS: 1. Finalize, approve, and implement relevant policies and procedures. 2. The comprehensive fire safety program development must involve health care leadership to
ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 5. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.
j. Control of highly flammable materials.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Many inmate cells contain considerable personal property, thus creating a fire and safety risk. Identical to previous reporting, flammable storage areas/cabinets in the Carpentry shops do not appear to be properly vented.
RECOMMENDATIONS:
1. It is anticipated that the control of highly flammable materials will be addressed in the revised CCA policies and procedures and that staff will be trained on them and that they be fully implemented.

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VII. ENVIRONMENTAL HEALTH AND SAFETY 

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:
a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Documentation in the form of logbooks and memorandum was provided during this monitoring visit that demonstrated ongoing efforts by GGACF officials and maintenance staff to assess, improve, and monitor facility sanitation and hygiene. Cleaning supplies were more readily available in the housing units from previous site visits. Some housing units and cells were cleaner than others and the need to consistently conduct routine and sustained cleaning of all facility areas remains a challenge to GGACF staff.
Again, however, housekeeping and sanitation plans will not meet compliance with this Provision without adequate staffing levels as previously stated.
The Maintenance Supervisor maintains preventative maintenance schedules for various components of the GGACF physical plant, including the emergency generator.
However, during this inspection we continued to observe inoperable doors and grills, inoperable showers, mold in showers, non-functioning water fountains, plumbing leaks and security fencing breaches.
RECOMMENDATIONS:
1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.

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5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.
8. Repair all housing/cell windows to prevent penetration by insects.
b. Adequate ventilation throughout the facility;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated). During this site visit we took random heat index reading of some housing unit dayrooms and cells.
Most of the housing unit exhaust fans remain inoperable. This is especially harmful for inmates unable to afford to purchase fans and inmates with serious mental illness on certain medications.
During previous inspections the Monitoring team was provided with a draft proposal regarding a Detailed Energy Audit conducted by Energy Systems Group, dated November 10, 2014. This proposal includes measures to retrofit the lighting system, the air conditioning system, the PV Panels and for conducting plumbing upgrades at the Facility at an estimated cost of approximately $8,425,106.69. However, during our last inspection we were informed by the acting BOC Director that there is no long term plan to address the ventilation issues. Certainly upgrades are necessary for the continued operation of GGACF.
RECOMMENDATIONS:
1. Timely complete an air quality assessment performed by a qualified provider. 2. Implement necessary improvements that reduce housing area and cell temperatures and
increase air flow. 3. Medical and mental health staff should monitor all inmates for heat and airflow-related
health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions. 4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors. 5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely

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action to mitigate environmental conditions that create health risks caused by those conditions. 6. Medical and mental health professionals should closely monitor inmates being administered medications that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.
c. Adequate lighting in all prisoner housing and work areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Attention to lighting repair and replacement remains positive. However, security staff continue to allow inmates/detainees to cover their cell lights, which is creating a fire hazard. This practice also creates real and potential serious security problems because staff visibility into cells is virtually completely impaired.
RECOMMENDATIONS:
1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and internal
illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness. 6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that
impedes good visibility from the cell door window. 7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are
reliably operational.
d. Adequate pest control for housing units, medical units, and food storage areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Very little change since previous inspections. This provision remains in partial compliance but no decline in performance was found. Identical to our previous inspection, we noted that the overhead door to the storage area of the Kitchen is not properly sealed and rodents and vermin can easily infiltrate the Kitchen. Inmates in the housing units complained of insect presence. Some inmates have lit “wicks” made, apparently, of toilet paper on their cell windows and floor, hoping that the smoke will deter insects. We also observed missing or broken screens on many facility windows.
The BOC has contact with a private vendor (Oliver Exterminating of St. Croix) to provide pest control services at GGACF.
RECOMMENDATIONS:

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1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.
e. Prisoner and clinic staff access to hygiene and cleaning. supplies;
ASSESSMENT: PARTIAL COMPLIANCE – No substantive improvement from previous assessment.
FINDINGS: There was no substantive improvements from previous assessments. Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies. However, similar to previous site visits, there were a number of inmate complaints in the Housing Units claiming they do not have sufficient quantities of cleaning materials to properly sanitize the showers. We observed that many inmate showers are in deplorable condition from a sanitary standpoint, including mold problems and physical plant deterioration. We also observed that some showers have been repaired from our previous site visit.
RECOMMENDATIONS:
1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Continue to provide adequate supply of these personal care items in control pods or housing
units to ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in their cells
and living areas.
f. Cleaning, handling, storing, and disposing of biohazardous materials;
ASSESSMENT: NONCOMPLIANCE – No substantive improvement from previous assessment.
FINDINGS: No substantive change from previous assessment.
There is no formal sanitation plan or protocols covering compliance with neither this Provision nor a formal training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling bio-hazardous materials, provided and instructed on the proper use of bio-protective clothing and supplies, and supervisors must closely monitor biohazard clean-ups. Remaining in noncompliance with this Provision can jeopardize the health of staff and inmates.
In Housing Unit 9D there was a recent serious inmate on inmate stabbing whereby one of the inmates sustained blood loss. During our inspection we noted that even several days following

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this serious incident, the cell and blood residue had not yet been cleaned or the cell sanitized. The delay in cleaning and sanitizing the cell created a bio-hazard risk to staff and inmates.
Spill clean-up kits were available in the medical area.
RECOMMENDATIONS:
1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes: A. OSHA and CDC standards and protocols for biohazard safety and exposure control; B. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal, storage, inspections, and clean-up; C. Staffing and inmate training on the plan and proper handling and disposal of biohazards; D. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all bio-waste; E. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where biological waste and/or spills do and could occur; F. Provide appropriate clean-up apparel and training in the use of that apparel. G. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. H. Develop a bio hazardous control program that involves regular inspections of all potential contamination areas.
2. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
3. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.
g. Mattress care and replacement;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: I did not see this area to be problematic during this monitoring visit. There were no inmate complaints regarding their mattresses and the ones I inspected were adequate. However, GGACF staff have not yet substantially addressed the Monitor’s previous recommendations below.
RECOMMENDATIONS:
1. Refer to previously discussed sanitation recommendations. 2. Issue clean and usable mattresses to all inmates. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and contraband,
cleaned and sanitized.

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5. Maintain reliable records that verify mattress inventories, cleaning and maintenance requirements.
h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No substantive change since previous assessment. Implementation of approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, however, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff that supervise inmates and are allowed to handle these chemicals must be properly trained in that role and those responsibilities. This has yet to occur.
RECOMMENDATIONS:
1. Finalize, approve, and implement relevant policies and procedures. 2. Develop comprehensive control plans for cleaning supplies and chemicals, chemical
inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs. 3. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols. 4. This provision can advance to Substantial Compliance once related policies, procedures and plans are approved and implemented according to the Agreement.
i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously reported, housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports and found during this monitoring visit, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets, and dry these items in their cells using clotheslines anchored to fire sprinkler heads, walls, window frames, bunks, etc. We also continue to observe worn out linens and dirty linen in many inmate cells.
RECOMMENDATIONS:
1. Finalize, approve, and implement relevant policies and procedures. 2. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks. 3. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells. 4. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of
bedding.

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5. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.
6. Develop specific policies and procedures for handling, containing, and washing contaminated clothing, linens, and mattresses.
7. Consider replacing all wood laundry carts made of non-absorbing materials that can be sanitized and completely cleaned. Discontinue the practice of moving laundry on carts that have not been cleaned and sanitized.
8. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing should be exchanged with clean items twice per week at minimum, sheets and towels once per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health.
9. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets.
10. Staff and inmates involved in the laundry work program should be properly trained and supervised.
11. Laundry equipment should reliable and properly maintained.
j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: During previous inspections, Territory officials reported the initiation of a major project to repair and clean-up the kitchen area. A scope of work for the project was submitted to the BOC Director on July 11, 2014. The acting BOC Director reported that the BOC received a federal grant last year for approximately $400,000.00 for GGAC kitchen improvements, but also included an outside project. The acting Director reported that he was trying to reorganize the grant disbursement to be used only for GGACF.
The physical plant of the Kitchen remains in a state of substantial deterioration as does the food service equipment. Repairs were made to the flooring in order to eliminate the problem of standing water. Unlike previous site visits, we did not observe plumbing leaks. Overall, the kitchen was cleaner than from previous site visits. The dishwasher has not being working properly for a lengthy period of time. There is still an inoperable walk-in refrigerator that was cleaned from our previous site visit; however, there is still evidence of roach infestation that staff are trying to address. There is no hot water in the male and female inmate bathrooms to properly clean their hands. There is an additional hand washing sink located outside the bathrooms that did have hot water, but it takes a lengthy amount of time for the water to get hot. There are no documents to prove that food temperatures are routinely taken of prepared food. The kitchen doors are not rodent proof. We observed evidence of mold and rust in various areas of the Kitchen that staff are attempting to address; however, a permanent fix to the problem still needs to be made to the overall structure of the kitchen. There is no master

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inventory of the utensils and dangerous implements. However, the kitchen officer is working 
 on developing a chit check out system for the utensils and dangerous implements. 

RECOMMENDATIONS:
1. Review, revise, develop, train, implement, and evaluate food service program policies and procedures.
2. Ensure policies and procedures include, at minimum, the following elements: A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes; B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision; C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with nationally recommended allowance for basic nutrition; F. Prohibitions of using food as a disciplinary measure; G. Involvement of independent outside sources to verify food service facilities and equipment meet government safety codes; H. Prescribes regular cleaning schedules including routine deep cleaning; I. Provide written utensil control methods similar to those used by the tool shop; J. Accident prevention program; K. Personal and environmental sanitation requirements; L. Food temperature monitoring and records keeping; M. Adequate health protections for all staff and inmates including health screens and prohibitions against working in the kitchen when ill; N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that all bathrooms and wash basins are consistently supplied with antibacterial soap and hot water; O. All areas and equipment related to food preparation, distribution, and storage require frequent inspection to ensure they are sanitary, operational, and safe; P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit; between 140 and 160 degrees Fahrenheit is appropriate if a sanitizer is used on the final rinse. The person conducting inspections should be a qualified food service inspector; Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit, refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees Fahrenheit or below, unless national or state codes specify otherwise; R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit and cold foods at approximately 41 degrees Fahrenheit; S. Supervisory food service staff should monitor food service operations to ensure that that cooking, cooling, and food temperatures and delivery meet established requirements;
3. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care.
4. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented.

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5. Policies and procedures developed should include controls for the use of caustic, toxic, and hazardous materials used in the kitchen. Material Safety Data Sheets should be posted conspicuously.
k. Sanitary and adequate supplies of drinking water.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No major improvement was again observed in the housing units during this assessment with the exception of X-Dorm.
The lack of constant reliable access to drinkable water further prevents GGACF from ensuring
 that inmates live in a healthy environment. Many of the cell sinks were still inoperable and
 inmates rely on officers to provide water before and during lock down. Access to drinkable 
 water is generally available during the “out of cell” periods but inmates must rely on the
 presence and actions by officers following lock down. Inmates have no access to drinkable
 water when there are no officers on the units to provide it and water from cell-sinks is considered
 not safe for drinking. In previous site visits, inmates consistently complained of seeing particles 
 of rust in the ice that is provided to the housing units. Since our last visit this area seems to 
 have improved. However, a long-term solution to the problem still needs to be addressed. 

In X-Dorm we had been reporting a consistent problem regarding the lack of drinking water for this unit. However, since our last site visit GGACF officials have addressed this problem by installing portable water bottles in the dorm.
RECOMMENDATIONS:
1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable access to safe drinking water.
2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:
a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft training policies and procedures remain under review and revision for final
 approval. These documents include required content listed in this provision. 

RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement training policies and curricula once approved. 2. Provide this Monitor and DOJ all requested training documents.
b. Pre-service training for all new employees;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The draft training policies and procedures include requirements for pre-service training for new civilian, correctional, and supervisory/management staff. These documents remain
 under review and revision for final approval.

RECOMMENDATIONS: Finalize and implement approved training policies and procedures.

c. Periodic in-service training and retraining for all employees following their 
 completion of pre-service training; 

ASSESSMENT: NONCOMPLIANCE
FINDINGS: The draft training policies and procedures include requirements for in-service training for new civilian, correctional, and supervisory/management staff. These documents remain under review and revision for final approval.
RECOMMENDATIONS: Same as above.

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d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment. ASSESSMENT: NONCOMPLIANCE FINDINGS: Draft training policies and procedures generally include the required elements of this provisions. These documents remain under review and revision for final approval as scheduled. RECOMMENDATIONS: Implement training policies and procedures once approved.

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IX. IMPLEMENTATION 

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.
FINDINGS: All medical, mental health, and suicide prevention policies and procedures have been approved. A new training schedule was filed with the Court on June 12, 2015 and implemented. On August 3, 2015, the Territory submitted proof of training for Group 1 policies and procedures as schedule.
On June 22, 2015, the new schedule for completion all security policies and procedures was filed with the Court. The Territory appears to remain diligent to its adherence to this schedule but is somewhat dependent on a private contractor who is providing consulting services at no cost to the Territory. A measure of flexibility with completion dates is agreed to by this Monitor and USDOJ so long as all documents are finalized and adopted by the Territory by October 30, 2015. The Monitor will work with the parties to develop a final training schedule for security policies.
2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.
FINDINGS: This Monitor continues to monitor compliance with Court-ordered schedules.
3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.
FINDINGS: As stated above.

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4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all RECOMMENDATIONS for changes to policies, procedures, or training will be provided to the United States and the Monitor.
FINDINGS: There have been no semiannual impact evaluations submitted by the Territory. The reports submitted do not include description evaluation of progress.
5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.
FINDINGS: The Territory has complied with this requirement and has remained dutiful in timely collaboration with USDOJ and this Monitor with regard to policy and procedure modifications.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
FINDINGS: The Territory filed the required quarterly report on June 4, 2015. This report does not describe actions defendants have taken to implement each provision of the Agreement. This report, however, does appear to comply with the Court following the March 5, 2015 status conference. Going forward, the Territory is encouraged to develop a standard document format to describe progress with all provisions of the Agreement. This Monitor remains willing to assist the Territory with this matter if requested.
7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.
FINDINGS: Despite delay in a few notifications and follow-up incident documentation, including the Territory’s failure to provide any documentation as to serious suicide attempts, as required by the policy and requested by the USDOJ on May 12, 2015, there has been marked improvement with this requirement.

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8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.
FINDINGS: The Territory continues to revise and develop new documents to demonstrate compliance with this Agreement. However, quality management of many records remains problematic. These issues, for example, were previously discussed with regard to incident reports, shift rosters, segregation review forms, and the grievance log. The Territory is encourages to implement the Monitor’s recommendations regarding document quality assurance and management. Doing this will significantly support the Territory’s ability to demonstrate compliance.
9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.
FINDINGS: The Territory continues to cooperate in providing timely access to the facility and needed documents as requested.
10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.
FINDINGS: The Territory continues to provide access to requested records.

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X. Monitoring
D.1. Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.
FINDINGS: This Monitor wishes to thank Territory officials for submitting monthly compliance reports, even as the document request grows.
D.2. Monitoring Access: With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility and Detention Center, all facility non-privileged records, prisoners' medical and mental health records, staff members, and prisoners, Defendants will direct all employees to cooperate fully with the Monitor, Reasonable advance notice must be provided to the Bureau of Corrections prior to conducting any on-site compliance reviews. Other than as expressly provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. All nonpublic information obtained by the Monitor will be maintained in a confidential manner.
FINDINGS: The Territory has provided this Monitor and monitoring team full and complete access to GGACF as required under this provision.

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APPENDIX A 
 ASSESSMENT METHODOLOGY 

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.
Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.
Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.
1. Description of how the Monitor will assess compliance with each of the Compliance Measures.
In general, compliance assessment will include the following activities:
A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other
regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members,
either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning.

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I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.
J. Examination of any and all available records, data, and/or information relevant to compliance and compliance monitoring not limited to the following: • Administration • Budget • Personnel • Operations • Training • Facility construction, renovation, repairs, and maintenance • Equipment, supplies, and materials • Inmate case files • Medical and mental health screenings, assessments, evaluations, diagnoses, treatment plans, progress charts and notes, medication logs and records, drug formularies, appointment calendars, invoices, etc. • Labor contracts • Incident reports and logs • Evidence / contraband reports and logs • Use of force incidents and logs • Inmate grievances and disciplinary records and actions • Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other documents and information that support accurate compliance assessment and progress determinations • Employee complaints, grievances, claims, etc. directly or indirectly related to the compliance provisions • Other information required to determine compliance and compliance progress
The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (Noncompliance, Partial Compliance, and Substantial Compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:
• Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
• Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.

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• Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
• Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.
• Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or consumer satisfaction).
• Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of consumer satisfaction, a performance indicator might be: “the percentage of consumers who state that they received the types and amounts of services that they felt they needed.”
2. How information necessary for on and off site assessment work will be gathered.
Monitoring will involve gathering various forms of information both on and off site and not limited to:
• Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
• On-site visits, tours, meetings, individual and group meetings and interviews • Collection and examination of electronic, paper, and photographic records, information,
and data • Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties) • Online media information • Online public records • Electronic and standard mailing of information • Email communication and phone consultations
3. What information the Monitor will require the Defendants to routinely report and with what frequency.
It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.
Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

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Non-exclusive information required for assessments and monitoring include the following.
A) Corrections Information:
1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force
policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months. 23. Records and/or lists of physical improvements, repairs, and renovation completed to correct security problems and deficiencies over the past 36 months. 24. Past 36 months of agency budgets.

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25. List and contact information for any and all community vendors who provide services of any
 kind to GGACF and contracts or professional services agreement authorizing those services. 

26. List and contact information for community regulatory agencies who inspect, review, approve, 
 and/or provide consultation to the GGACF i.e., health inspections, fire inspections, etc., and
 any inter-local agreements involved in these services. 

B) Medical and Mental Health Information:
27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their 

records and mortality review. 
 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy

of their records. 
 31. To the extent not provided above, the policies and procedures governing medical and mental 

health care. 
 32. A staffing roster with titles and status, part time or full time, and if part time, how many hours 

worked per week. 
 33. The staffing schedule for the past two (2) months for nursing and providers, including on-call 

schedules for the same time period. 
 34. Job descriptions for medical staff and copies of current contracts with all medical care

providers, including hospitals, referral physicians, and mental health staff. 
 35. Inter-local professional services agreements with health care providers, companies, to include 

health care policies under which those persons and/or entities provide inmate health care. 
 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD

testing, health assessments, and inmates sent to the emergency room or off-site for 
 hospitalization listing where applicable name, date of service, diagnosis and service provided. 
 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past
 year. 
 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to 
 include in the log presenting complaint, name, date of request, date triaged, and disposition) 
 and chronic illness appointments for the past two (2) months. 
 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and 
 medical staff on policies and procedures and emergency equipment. 
 46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location. 47. To the extent not provided above, external and internal reviews or studies of medical or mental 
 health services including needs assessments and any American Correctional Association and
 National Commission on Correctional Healthcare reports. 
 48. List of all inmates placed in restraints, and all inmates receiving mental health treatments,
 under suicide watch, or taking psychotropic drugs.


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49. Current mental health case list including inmate name, number, diagnosis, date of intake, last 
 psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed 
 only by counseling staff with last appointment date and follow-up appointment. 

50. Documentation reflecting any training that facility staff have received on suicide prevention,
 including certificates and training materials. 

51. All documents related to the any suicide occurring within the past year. 52. List of all persons on warfarin, Plavix, digoxin.
C) Suicide Prevention Information:
53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms utilized

for the identification of suicide risk and mental illness. 
 55. Any suicide prevention training curriculum regarding pre-service and in-service staff training, 

as well as any handouts. 
 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the following 

areas within the past year: first aid, CPR/AED, and suicide prevention. 
 57. The entire case files (institutional, medical and mental health), autopsy reports, and

investigative reports of all inmate suicide victims within the past three years. 
 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or

hospitalization) within the past year. 
 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications for the

past year. 
 66. A description of medical and mental health’s involvement/input into the disciplinary process

and clearance for placement in segregation. 
 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.
It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

 
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United States Virgin Islands
GOLDEN GROVE 
 ADULT CORRECTIONAL FACILITY 

NINTH COMPLIANCE MONITORING REPORT

2013 Federal Court Settlement Agreement In re: United States of America v. The Territory of the Virgin Islands (86/265)
Submitted November 27, 2015 
 Kenneth A. Ray, M.Ed., Monitor 
 Ronald M. Shansky, MD Medical Expert 
 Manual D. Romero, Operations Expert 
 Richard G. Dudley, Jr. MD, Mental Health Expert


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United States Virgin Islands GOLDEN GROVE
ADULT CORRECTIONAL FACILITY NINTH COMPLIANCE MONITORING REPORT
Kenneth A. Ray, MEd, Monitor
TABLE OF CONTENTS

Cover ……………………………………………………………………………… NA

Table of Contents …………………………………………………………………

2

Purpose……………………………………………………………………………..

3

Executive Summary & Findings Overview………………………………..……

3

Section IV. Safety and Supervision Compliance ………………………………

6

Section V. Medical and Mental Health Care Compliance …………………….

42

Section VI. Fire and Life Safety …………………………………………………

74

Section VII. Environmental Health and Safety ………………………………… 81

Section VIII. Training ……………………………………………………………. 90

Section IX / X. Implementation / Monitoring…………………………………… 92
APPENDIX A Compliance Assessment Methodology ……………………………………………. 94

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PURPOSE
The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) assist U.S. Virgin Island officials in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.
EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW
The ninth (9th) onsite compliance monitoring assessment was conducted September 21-24, 2015 and included a focused and productive Court status conference was held on Thursday, September 24, 2015. Prior to this site visit, the Monitor coordinated communication between the parties and monitoring team in preparation for the onsite assessment.
This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.
Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:
“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) partial compliance, and (3) noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”
Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing this final report.

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The Monitor will advance each provision as certain levels of compliance progress are clearly demonstrated by the Territory. Generally speaking, the Monitor will advance provisions from noncompliance to partial compliance when compliance efforts demonstrate the following:
1. Policies, procedures, protocols, and/or plans required of a provision are properly approved in accordance with this Agreement;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented. Implementation includes evaluation that implemented policies, procedures, and training are performing within the expectation of this Agreement.
Provisions are eligible to advance from partial to substantial compliance when efficacious assessment and evaluation of implemented policies, procedures, protocols, plans, etc. quantitatively and/or qualitatively evidence: 1) that implementation efforts are producing outcomes intended in the Agreement and 2) that implementation outcome performance is reliable (assessments and evaluations evidence consistency in producing outcomes intended in the Agreement). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately demonstrated using appropriate compliance evaluation methods and measures, this Monitor will and has reversed a compliance rating when the evidence supports doing so.
ASSESSMENT FINDINGS OVERVIEW:
The Territory’s progress toward compliance with this settlement agreement remains very slow and relatively steady despite setbacks and delays involving completion of scheduled policies and procedures. Although all medical, mental health, and suicide prevention policies and procedures are approved, all other policies and procedures have not received final approval. Delay in the completion of these documents primarily result from the Territory’s limited resources combined with scheduling conflicts with the Territory’s policy development vendor. Nonetheless, the United States and this Monitor have endeavored to consider these issues and have made every effort to maintain a collaborative process in an effort to support the Territory’s progress without seeking court intervention. As a result, the parties have agreed to various schedule changes represented by the Territory as their best effort to comply with the agreement. Concomitantly, the Territory seems intentionally focused toward completion of the documents.
This assessment finds no factual basis to change any of the compliance ratings reported in the previous (8th) monitoring report. For example:
• Training documentation for approved health care-related policies and procedures was not sufficient to demonstrate that 95% of staff required to complete the training did so with a minimum passing score of 80%;
• Security and safety related policies and procedures are not approved; • Security supervisor and officer staffing levels remain inadequate to reliably protect prisoners
and staff from real and potential violence and harm;

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• Security supervisor levels are insufficient to ensure consistent and routine oversight and supervision of staff and housing unit operations;
• Dangerous and nuisance contraband levels remain very high throughout housing units enabling prisoners the ability to violently and seriously harm others;
• Prisoner disciplinary practices continue to impose disparate and excessive punishments; • Prisoners with serious mental illness continue to languish in solitary confinement with little or
no out-of-cell time. Segregation review documentation remains unable to adequately demonstrate the existence of a meaningful and consistent review process; • The prisoner classification system remains invalidated; • The required staffing plan has not been approved or funded; • The fire safety/suppression system remains inoperable; • The incident reporting system, as well as most documentation process, continues to lack a quality management process to reliably record and track incidents; • The inmate complaint system (grievance process) remains untimely, disorganized, and inadequately documented to clearly demonstrate prisoners have reliable access to a meaningful compliant resolution mechanism.

GGACF NINTH COMPLIANCE ASSESSMENT SCORE CARD

Areas of Compliance Per Agreement
IV. Safety and Security V. Medical, Mental Health Suicide Prevention VI. Fire and Life Safety VII. Environmental Health and Safety VIII. Training Total Substantive Provisions Percent Compliance

Total Provisions
59 36 10 11 4 120 100%

Non Compliance
56 36 10 5 4 111 92.5%

Partial Compliance
3 0 0 6 0 9 7.5%

Substantial Compliance
0 0 0 0 0 0 0%

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NINTH MONITORING REPORT GOLDEN GROVE ADULT CORRECTIONAL FACILITY
UNDER DEPARTMENT OF JUSTICE AGREEMENT
IV. SAFETY AND SUPERVISION 

As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:
a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: On July 24, 2015, the Territory submitted to the monitoring team and USDOJ draft policies, procedures, and related forms pertaining to housing unit security levels that include stratification for the classification of prisoners. The stratification “matrix” includes all housing units and classification designations. Corrections Corporation of America (CCA) has been assisting the Territory in the development of policies and procedures. USDOJ has been reviewing and commenting on these policies and procedures. The Monitor and his team have been providing suggestions and recommendations on these policies and procedures at the Parties request. Final approval and implementation of these policies and procedures is pending review.
The Territory’s greatest challenge continues to be in ensuring prisoner safety and security, ensuring adequate and consistent housing unit staffing levels, consistent prisoner supervision and monitoring, and staff supervision. The best written policies and procedures are to no avail without sufficient staff and staff supervision to carry them out. For example, examination of the Incident logs, incident reports, Evidence (Contraband Logs), Daily Staffing Rosters, and interviews with inmates and staff continue to report the active presence of very serious and dangerous safety and security risks and adverse events. As stated in previous reports, prisoners and staff remain dangerously exposed to actual and potential risk of harm due serious staffing level shortages and staff and prisoner supervision and control.
RECOMMENDATIONS: Previous recommendations remain appropriate.

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1. Apply the approved Housing Stratification matrix as designed and with previously recommended revisions. Specifically, previous recommendations involved making physical and programmatic changes to Kilo (K) unit so as to eliminate isolated conditions of mentally ill inmates. 2. Review current population to verify accurate risk/need classification levels and housing, reclassify and appropriately house as indicated by review process findings. 3. Refer to IV.F. regarding specific classification and housing policy recommendations.
b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: GGACF administration requires shift supervisors to complete and submit three forms to document shift staffing levels and supervisor inspections. The following forms are required to be submitted for each of the three daily shifts:
1. Shift Roster 2. Overtime Verification Report 3. Shift Supervisor Rounds (inspection form)
The Shift Roster is intended to record the following information for each of the three shifts:
1. Shift date and time 2. Supervisor names 3. Post (where staff were assigned to work i.e. housing unit, Patrol, etc.) 4. Officer Name 5. Time In (time officer began work assignment) 6. Time Out (time officer departed work assignment) 7. Names of officers working overtime 8. Total number of posts
Shift rosters are important documents for assessing and measuring shift staffing levels, overtime patterns, and compliance with this and related provisions of the agreement. Unfortunately, however, an accurate and reliable assessment of staffing levels is once again impossible because approximately half (49%) of the staffing rosters (including overtime and rounds forms) for the reported period were missing and not provided to the Monitor. The chart below lists dates each month documentation was missing and descriptive data about this ongoing problem.

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June: 1, 2, 3, 5, 6, 7, 8, 9, 10, 17, 23, 24, 25, 26, 27, 28, 29 July: 1, 8, 15, 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 August: 3, 4, 5, 6, 7, 9, 10, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 September: 5, 11, 12, 18, 19
As previously stated, revised Post Orders that comport with this Agreement and draft policies and procedures have not been submitted for review and approval by the United States or this Monitor. The former Warden previously issued written directives to shift supervisors requiring inspections of all housing units each shift and requiring them to document those inspections on Shift Supervision Rounds form. This form lists all facility areas to be inspected by supervisors each shift, including housing units, intake areas, non-housing unit buildings, visiting, medical, chapel, kitchen, etc. There are “Date” and “Comments/Concerns” columns to record this information. The bottom of the form provides clear and direct instructions for supervisors to conduct rounds. These instructions denote areas requiring daily (per shift) and weekly (per shift) rounds. All housing units, medical, Receiving and Discharge, and Roving Patrol areas require supervisors to conduct daily inspection rounds. The instructions also direct supervisors to:
• Sign and/or ensure that the officer sign in (RED INK) is preferred • Talk to staff and inmates in each area visited and note any major concerns/issues • Account of these items while on post: Post Order Manual, suicide cut-down tool, flashlight
operational, radio operational, telephone operational, logbook completion, officers’ view into the cells not obstructed • Ensure: High sanitation level, Officers have tools to perform duties, keys secure, etc. • Any deficiencies should be indicated that addresses [resolves] the issue
Examination of Shift Supervisor Rounds inspection documents for June through September 2015 again found significant problems demonstrating 1) noncompliance with this and related provisions of this Agreement, 2) failure of GGACF supervisors and management staff to monitor and ensure accurate completion of these documents, and 3) lack of a meaningful quality assurance process.
In addition to missing documentation for this assessment period, documentation examined revealed the numerous other problems and deficiencies:
• Only 8 dates had all 3 shift rosters. • Rounds inspection documents did not record the shift except in a very few cases. • Rounds inspection documents were either an exact copy of a previous inspection that had been
copied repeatedly, or inappropriately completed by documenting “nothing new to report” (there is no comparison document nor is this appropriate documentation); and such poor documentation gives the distinct impression rounds were not initiated or completed in these instances.

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• Duplicate copies throughout the date stacks. This is time consuming for the reviewer, wasteful to the printer, and draws attention to management’s lack of attention to detail.
• Legibility of documentation is sometimes a problem. • Lack of signatures on several of the documents. On at least one occasion the overtime verification
document had no signature at all, no date, etc. • Missing dates, cut off dates and shifts due to poor copy technique. • At least one Roster lacked any documentation in the column for Time Out. • July 7 was a troublesome stack, with 2 staff rosters for the 6-2 shift, different people assigned,
same units, and same shift. Along with this, the 6-2 shift OT Verification also presented with 2 documents with different people, similar times. It is noted that on one of the rosters and one of the OT verification for the 6-2 shift, the date July 7 had been written atop the date July 5.
This document examination seems to clearly demonstrate extant noncompliance with this provision. More importantly, this document review confirms for this Monitor that there remains virtually no management oversight process in place to accurately verify whether supervisor rounds are being either consistently performed or performed as directed by the previous Warden.
Examination of Supervisor Logs, Housing Unit Logs and Shift Rosters continue to evidence continued non-compliance with requiring that at least one officer is assigned to each occupied housing unit. These records document supervisors finding housing units without officers for the entire shift, officers reporting late to housing unit assignments, and “extreme staff shortage.” Staff shortages are routinely reported in Shift Rosters as the primary cause for overtime, with as many as 75 percent of a shift working overtime. The staff shortage and lack of supervision is exemplified in the IT supervisor’s July 2015 monthly report whereby he reported that in May 2015 a camera was not working in Gulf Unit. He reported that “In May inmates managed to enter the Officer’s station in Gulf Unit, climb up into the ceiling, remove a cover from a connection box and cut the wires leading to the cameras. The wires were patched, but one of the cameras shorted out and was destroyed. This left the unit with only one functioning camera.”
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Immediately correct documentation problems shown above. 2. Use a standardize Shift Roster form that includes ALL locations and designate “CLOSED” for all
locations that are out of service. 3. Rapidly implement the NIC Staffing Analysis recommendations. 4. Complete the draft staffing, as required under the Agreement that reflects the NIC Staffing
Analysis and provides concrete steps for hiring sufficient staff. 5. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff
working overtime have adequate time away from the facility before returning to work to ensure they are adequately rested. 6. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics. 7. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm.

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8. Subsequent to policy and procedure development and revisions, conduct a complete review of existing specific and general post orders to ensure they are: a. post specific; b. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; c. are numbered, cross-referenced with policies/procedures, and formatted in a manner that makes them easy to interpret and apply; d. maintained at each post, kept current, and easily accessible; e. regularly reviewed, revised, updated; f. consistently enforced; g. known to staff through pre-service, in-service, and ongoing training.
9. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues are detected and resolved in a timely manner.
10. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs. 11. GGACF upper management must monitor compliance with any written instructions to subordinate
supervisors if compliance with such orders are expected to be followed. 12. Create and implement one, standardized, shift staffing form for supervisors to accurately record
shift staffing levels.
c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: All officers (including recruits) require functional radios in their possession at all times while assigned duties within the security perimeter. Compliance with this requirement helps to ensure safety of staff and prisoners. However, prisoners and staff are exposed to extreme danger when all onduty staff are not assigned radios.
During this inspection, we observed that officers assigned to housing units and other areas of the facility had functional hand-held radios.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize, approve, and implement all related policies and procedures. 2. Timely repair and replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated. 3. The Monitor will continue to review radio equipment inventories and functionality during each onsite assessment. 4. Ensure adequate supply of radio batteries to enable officers to carry radios on their person at all times. The GGACF Warden did issue written directives to all staff requiring compliance with this recommendation. 5. Ensure all persons carrying radios are fully trained to understand and operate all radio functions proficiently.

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d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and (ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Despite the fact the Shift Roster documents prevented accurate assessment of staffing levels for this reporting period, the Monitor was able to determine that staff remains inadequate. This is because 1) staffing levels are not equivalent with the requirements determined by the Staffing Analysis, 2) housing units continue to operate without staff, and 3) overtime remains extremely high.
Shift Staffing reports continue to evidence constant understaffing in housing units and patrols. Contraband detection and prevention efforts are substantively ineffective due to staffing shortages and evidenced by documented constant high levels of dangerous weapons inmates possess and use to violently attack others, drugs and alcohol, and nuisance items found throughout housing units.
Identical to previous reporting, current staffing levels make it literally impossible to ensure that officers make all required rounds per shift while also attempting to monitor prisoner flow for contraband and supervise prisoners not locked in their cells. Supervisor Shift Rounds reports examined for June through September cannot verify adequate housing unit inspections and staff supervision. However, Shift Rosters report shifts having only one on-duty supervisor at times, making it impossible for a lone supervisor to inspect all housing units and security areas, monitor staff, and respond to various scheduled and unscheduled duties and events.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations regarding Post Orders. 2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff and
inmate safety and security, and according to inmate risks and needs. 3. Create a schedule for regular rounds by medical and mental health care staff for each shift to ensure
that special needs inmates (suicidal, mentally ill, medically infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff. 4. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. The supervisory rounds forms should be filled out at the end of each round and collected in a central location and submitted to the Monitor and USDOJ on a monthly basis.

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5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.
B. Contraband
Defendants will develop and submit to USDOJ and the Monitor for review and approval facilityspecific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The movement and presence of nuisance and dangerous contraband remains seemingly unfettered by GGACF management staff efforts to control it. Weapons, cell phones, and drugs remain at the top for contraband confiscations and present the highest risk for staff and inmates. The chart below shows volume of contraband confiscations for 2015.

2015

Unauthorized

Cell

Drug

Handcuff

Weapons

Drugs

Alcohol Electronics & Money

Tobacco Ttl

Phones

Paraphernalia

Key

Tools

January

3

2 3

1

1

10

February

3

2 2

1

3

2

13

March

7

8 2

2

1

1

1

22

April

2

8 1

1

1

5

18

May

1

1

June

8

8 2

1

19

July

1

1

August

4

6 2

1

1

14

September 2

2 1

5

Totals: 31

36 13

4

2

11

3

1

2

103

% Seizures 30% 35% 13%

4%

2%

11%

3% 1% 2% 100%

Weapons confiscated included pocket and combat knives, razors, a box cutter and machete; drugs, marijuana and crack cocaine; various cell phones, drug paraphernalia; unspecified money, alcohol, handcuff key, tobacco; and, a variety of unauthorized electronic devices and tools. The chart and graph below further illustrate this contraband activity.

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High levels of dangerous and nuisance contraband can only exist at GGACF when 1) officers are not 
 consistently and routinely following basic security tenants, 2) officers are not in control of housing units,
 3) supervisors are not making consistent and adequate rounds of housing units, 4) supervisors are making 
 rounds but not ensuring compliance with this policy, and 5) chronic staff deficiencies preventing staff
 from conducting timely and consistent prisoner supervision and control. 
 Adequate staffing levels, vigilant adherence to contraband and prisoner security policies by officers,
 proper training, and diligent staff monitoring and supervision is the minimum requisite for successful 
 implementation of new policies and procedures. 
 RECOMMENDATIONS: Previous recommendations remain appropriate.
 1.Implement the new policy according to the terms of this Agreement once approved. 
 2.Ensure supervisors comply with supervision rounds requirements. 
 3.Ensure corrections officers comply with contraband control and related security policies and protocol. 
 b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison; ASSESSMENT: NONCOMPLIANCE FINDINGS: Refer to B.a. above. 
 It should be noted that GGACF lobby entrance security includes a more comprehensive search process.


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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement the new policy according to the terms of this Agreement once approved. 2. Ensure supervisors comply with supervision rounds requirements. 3. Ensure corrections officers comply with contraband control and related security policies and protocol. 4. Continue positive efforts in searching people before entering the facility. 5. A “stop and check” protocol for inspecting staff packages after initial entry into the facility must be
developed and implemented. 6. Provide handheld metal detectors for contraband inspections at facility entry points and as needed for
on-campus inspection. 7. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods and process
during the 8th onsite tour and assessment. 8. Train supervisors to provide on-the-job-training (OJT) and staff mentoring in the areas of adequate
searches, contraband prevention and control, and basic inmate supervision and security.
c. Detection of contraband within Golden Grove, through processes including: 

(i) supervison of prisoners in common areas, the kitchen, shops, laundry, clinical, and other
 areas of Golden Grove to which prisoners may have access; 
 (ii) pat-down search, metal detector, and other appropriate searches of prisons coming from 
 areas where they may have had access to contraband, such as intake, returning
 from visitation or returning from the kitchen, shops, laundry, or clinic; 
 (iii) regular and random search of physical areas in which contraband may be hidden or placed, 
 such as cells and common areas where prisoners have access (e.g. 
 clinic, kitchen, dayrooms, storage areas, showers); 

ASSESSMENT: NONCOMPLIANCE
FINDINGS: Also refer to above contraband findings and discussion.
GGACF cannot consistently nor adequately provide necessary levels of prisoner supervision in any area of the campus with existing staffing levels. This is evidenced by the previously discussed examination of Evidence Collection logs and incident reports. The Monitoring team observed during this visit no patdown searching of ANY prisoner entering or leaving housing units. None of the housing units are equipped with metal detectors as previously recommended and required in paragraph ii above. GIST staff confirmed again during this visit that regular and random searches are very infrequent but sorely needed. Official GGACF documents evidence that dangerous weapons, drugs and alcohol, cell phones, and nuisance contraband remains accessible to prisoners.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to above, expand application of recommendation to provision c (i-iii) above. 2. See recommendations regarding staffing levels.

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3. Ensure inmates are systematically and consistently searched each time they enter and exit maintenance shop areas, kitchen areas, and any area and/or building containing items that can be used as contraband.
4. Always search prisoners each time they enter and exit housing units. 5. Always search all containers entering and exiting the facility, buildings, and housing units.
d. Confiscation and preservation as evidence/destruction of contraband; and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No change was found since previous reports. Above Contraband Provision findings and discussion adequately support no change in this assessment rating.
RECOMMENDATIONS: Previous recommendations remain appropriate.
Review and implement relevant recommendations for Contraband above, specifically B1b.
e. Admission procedures and escorts for visitors to the facility.
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Front desk admission security checks seem improved. On a positive development, the new Director had a walk-through metal detector installed at the main staff and visitor entrance to the facility.
Monitoring team briefcases were searched before each daily visit and we were required to empty our pockets. Additionally, the monitoring team was consistently provided identification for each day of this visit. This practice may not be as consistent as it appeared, however, according to Shift Rosters and the Shift Supervisor Rounds Report.
First, very low staffing levels logically suggest GGACF is forced to prioritize duty assignments to where security protection needs are greatest – the housing units and prisoner locations. Second, none of the different Shift Roster forms show “Visitation” as a post for recording staffing levels.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Continue to ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.
3. Implement document quality improvement protocols to improve reliability of the two supervisor reporting systems used for this assessment to aid in demonstrating compliance.

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C. General Security
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility specific policies designed to promote the safety and security of prisoners and that include the following:
a. Clothing that prisoners and staff are required or permitted to wear and/or possess;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Prisoners continue to be allowed to wear personal “street” clothes in and out of the housing units. Several prisoners were observed wearing non-correctional attire in day rooms, their cells, and in the yard.
We continue to observe that some on-duty security staff were wearing unmarked clothing and some wore unmarked lightweight jackets that covered their uniforms. Security staff reported having to purchase their uniforms (including shirts, pants, and shoes) themselves; one staff member reported receiving only one official shirt 3-4 years ago. Security staff also reported not receiving expected yearly allowances for clothing maintenance. Unlike specialized law enforcement staff, there is no value or understandable purpose in allowing uniformed security staff to wear unmarked clothing or to wear personal attire that covers portions of their uniforms. The security officer uniform is specifically marked to provide clear and obvious awareness of the presence of a security officer. As such, a marked security officer uniform should never be obscured.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Require inmates to wear issued institutional clothing ONLY. 2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform
policies and inmates who refuse to comply with those policies. 3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and
appropriate corrective action with staff who refuse to do so. 4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’
classification/status. 5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges and
changes in an inmate’s classification and/or status. 6. Consider developing a correctional industry for making uniforms onsite. 7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband and
weapons. 8. Mark all uniforms with highly visible letters/numbers.

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b. Identification that prisoners, staff, and visitors are required to carry and/or display;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to previous findings and discussions pertaining to B.a, C.1.a. In addition, some prisoners were again observed either not wearing identification or not properly displaying their identification if it was being worn. During the onsite visit, the monitoring team and the USDOJ were given and required to wear visitor badges.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure staff compliance with this provision. 2. Ensure adequate supplies for making identification cards. 3. Regularly audit identification card inventory and maintain proper controls to prevent inappropriate
acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories. 4. Consistently enforce identification card policies and procedures.
c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Previously requested training documents demonstrating completion of staff training on this subject matter have not been provided to this Monitor. Additionally, some of the Shift Supervisor Rounds reports and Housing Unit Logs, as well as direct observation during our visit show several inoperable locking mechanisms throughout the facility stating:
• Detention R&D: “Sally Ports remain inoperable along with Exits and Entrances” • K Unit: June 23/24, 2015 an officer reported that around 5:00 am an inmate in cell #8 could not be
let out because the cell door could not be opened. It appears that the cell door was not unlocked until around 9:06 am. The responding maintenance person indicated that he does not do locks and was not trained to open any locks. • Housing Unit slider doors inoperable. • Housing Unit Sally Port doors inoperable
Inconsistent and incomplete use of these reports makes it very difficult to use these documents as a credible sources to advancing this provision, and it is logical that compliance with this provision is frustrated by inadequate maintenance staffing levels. The Director is working with Human Resources and Budget staff to permanently expand the work hours of the contract locksmith, which should result in better upkeep of locking mechanisms. It was encouraging that after many months of noting inoperable

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Sally Port gates and other deficiencies with doors in R&D that they were finally being addressed and most of them already repaired, with the exception one entrance door.
However, even with an adequate locking system maintenance program, prisoners will continue to gain dangerous access to each other until security staff consistently practice good key control.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Provide Monitor requested training records showing a 95 percent minimum successful completion rate.
2. Repair/replace all broken locks and keys. 3. Develop, revise, implement, audit lock/key inventory. 4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality,
detection of tampering, and timely repair/replacement. 5. Continue to ensure staff are adequately trained in the proper use of mechanical and/or electronic
locking systems according to their post assignments. 6. Consistently sanction inmates for attempting to manipulate or manipulating any security locking
system or device. 7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked. 9. Replace or upgrade existing unit control panels to provide for remote electronic locking and
unlocking of unit and cell doors. 10. Improve video surveillance of internal areas by placing cameras in all housing units and inmate
locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems. 11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms. 12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations.
d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft policies and procedures are in the process of being developed. However, these policies and procedures cannot, ultimately, demonstrate compliance until GGACF has sufficient staffing levels to ensure compliance. This is because these policies and procedures require a much higher level of routine attention to all housing unit locking mechanisms by housing unit officers and supervisors.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Employ and maintain adequate Maintenance staffing levels. 2. As requested in the previous two reports, develop an “all-locks” maintenance plan for review by
the Monitor and incorporation into policies and procedures. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date

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repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number, lock type, condition, etc. 3. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.
e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This assessment did not review whether corrective action had been take regarding problems found in GGACF personnel folders during the previous visit. These issues will be reviewed during the December 2015 site visit. The problems identified during the previous visit included:
• Missing verification of training documentation • No application and/or background investigation record • Missing criminal background-check documentation • No uniformity of folder content, disorganization • Incomplete documentation regarding disciplinary action (i.e. notification of policy violation with no
other information regarding disciplinary process or case disposition) • Employer/reference background forms missing or not completed • Missing Personal History statements • Pre-service psychological assessments found in some folders but not others • Missing fingerprint records • Incomplete military status questionnaire
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. The employee folder/record system should be standardized and well organized 2. All folders should contain completed Applicant Personal History Statements, criminal history check verification documents 3. Medical records should be kept separately from the general personnel folder 4. Training records should be kept in a staff training folder and separate from the training folder 5. These records should be reviewed periodically for quality assurance purposes and remedial instruction and/or training provide to records staff where indicated.

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D. Security Staffing
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:
a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in the previous report, the staffing analysis that included a calculated shift relief factor was completed but the staffing plan remains in development by the Territory. During the September 2015 compliance tour, the Monitor and parties set a deadline of December 31, 2015 for approval of the staffing plan. This is because the Territory stated that it needed additional time in order for the new BOC Director to research and revise the staffing plan. The Monitor and parties have agreed to set a late December deadline for submission of the Staffing Plan.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize and approve required policies and procedures. 2. Finalize and approve the required Staffing Plan. 3. Quickly implement the approved staffing plan without delay.
b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in D.1.a above, the staffing analysis was completed but the staffing plan has not yet been approved. Once the Plan and related policies and procedures are approved and implemented, this provision could be advance to Partial Compliance.
RECOMMENDATIONS: Previous recommendations remain appropriate.
4. Finalize and approve required policies and procedures. 5. Finalize and approve the required Staffing Plan. 6. Quickly implement the approved staffing plan without delay.

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c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory has submitted the final policy for the Monitor and USDOJ’s review.
RECOMMENDATIONS: Once approved, implement required policies and procedures.
1. Defendants will implement the staffing plan developed pursuant to D.1 .
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to previous findings related to staffing analysis and planning.
RECOMMENDATIONS: Finalize, fund, and implement staffing plan.
E. Sexual Abuse of Prisoners.
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As noted in the previous report, the Territory has not completed the required PREA selfaudit. PREA draft polices have been submitted to USDOJ and this Monitor for review and comment. The Territory has resolved the 24/7 hotline. The Territory contacted the National PREA Resource Center to seek resources in reviewing the PREA policy and training program that will go along with it. The PREA National Resource Center has agreed to provide the training.
Also as noted in the previous reports, a prisoner’s October 20, 2014 complaint of sexual abuse remains not investigated due to the Investigator vacancy according to GGACF officials. Failure to properly investigate and resolve such compliances violates PREA and federal law. However, the Territory has hired Mr. Jim Warren to serve as the Chief Inspector for both GGACF and St. Thomas. Mr. Warren reports directly to the Director which is an acceptable reporting structure for investigations. Mr. Warren is also supervising the GIST officers. Mr. Warren has an extensive background in law enforcement. Mr. Warren is in the process of developing the office of Chief Inspector as well as working on old cases involving GGACF and St. Thomas. The Director is also in the process of hiring an additional investigator for the agency. When the Office is fully developed, it should be capable of conducting required investigations of staff and prisoner sexual misconduct which is a major component of the PREA regulations. The Monitor is encouraged by these developments. Furthermore, several GGACF staff were recently trained on the fundamentals of PREA using approved NIC curriculum.

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 Page 22 of 101

RECOMMENDATIONS: Previous recommendations remain appropriate.
1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements. 3. Appoint a PREA Compliance Coordinator as soon as possible. 4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s PREA auditor
certification training. All costs are covered by USDOJ. 5. Complete the PREA Self-Audit. 6. Fill additional investigator position.
F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facilityspecific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory is in the process of validating the current classification system. During this visit, James Austin, Classification Expert, was working in St. Thomas in reviewing and refining their classification system. Territory staff reported that he will also be assisting GGACF staff with their classification system and ultimately in the validation process, which is very encouraging. Draft classification policies and procedures have been submitted to this Monitor and USDOJ for review and comment according to the revised Schedule.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Complete an empirical validation of the current classification instrument(s). 2. Review, revise, develop, train, implement, and evaluate policies and procedures that provide more
accurate and complete guidance for a valid and reliable classification system for nonconvicted and convicted inmate populations.

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3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system.
4. Contact USDOJ / NIC for Objective Classification Technical Assistance. 5. Ensure classification staff are well-trained in classification protocols and routinely monitor
classification documents for accuracy.
b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As stated in F.1.a above. Additionally, we continue to note the housing of mixed classifications of prisoners in housing units and cells, including maximum security inmates being housed in the same cell as minimum security inmates. This practice significantly deviates from industry standards and violates the Agreement and related legal requirements.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Settlement Agreement prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Mental health staff must continue to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced side lock down units to determine mental health needs and direct mental health staff to determine if a different, less punitive housing placement is available.
4. c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Same findings as noted in the above Classification section. During the September 2015 compliance tour, we observed housing unit doors left open and/or unlocked, and prisoner movement outside of assigned housing units with little or no supervision.
RECOMMENDATIONS:
1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.

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d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: See previously discussed classification findings.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations related to grievance and disciplinary policies and procedures. 2. Ensure accuracy of monthly disciplinary committee reports. 3. The Territory must correct problems reported in the monthly disciplinary committee reports. 4. Train classification staff to accurately and consistently complete initial and re-classifications
accordingly.
e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The current incident reporting system remains inadequate for complying with this provision. As previously noted in this report, the quality of incident reports remains problematic and the incident reporting log system does not consistently capture all reported incidents. Additionally, Disciplinary Committee monthly reports continue to report problems with missing and late submission of incident reports. Interviews with the sergeant responsible for the prisoner discipline program continues to state the same problems with incident reporting practices and quality oversight.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Timely approve and implement policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.

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f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Examination of Segregation Review documents from June through September continue to evidence noncompliance with this requirement.
Virtually all of these documents fail to include information about what alternatives were discussed and considered for segregation placement when the segregation review process was completed. During the visit, the monitor and GGACF discussed necessary revisions to the segregation review form to capture this information. Additionally, most of the documents examined omit required information about when and/or why the prisoner was placed in segregation, and whether the reasons for being placed in segregation remain valid. Most of the documents fail to record a prisoner’s prospective release from segregation date, and much of the narrative required by staff performing the review is absent. Staff signatures are often missing and/or illegible, and there is routinely no information documented with regard to whether previous follow-up recommendations were accomplished. Many of the documents show that the segregated prisoner “refused” to participate in the review process and the document includes not information about the prisoner’s well-being or health status.
This document examination leaves an impression that GGACF officials give little to no priority to ensuring that prisoners held in segregation are provided constitutionally-required attention and care. As noted in previous reports, it continues to appear that prisoners are placed in disciplinary and administrative segregation for excessive time periods and without due process. A comparison of the prisoner mental health case log and segregation log indicates that inmates with mentally illness remain in segregation/isolation for very long time periods. This practice is a direct violation of the conditions of this Agreement and dangerously detrimental to the health of these prisoners and must cease immediately. In addition, we received reports that sometimes prisoners in segregation are not let out of the cell at all during the day, because of a shortage of officers to supervise. The monitoring team recorded a heat index of 105.2 F at 4:50 pm in the segregation cell of a prisoner who reported not being allowed out of the cell previously due to lack of officers.
As noted in previous reports, it continues to appear that prisoners are placed in disciplinary and administrative segregation for excessive time periods and without due process. Although there has been a reduction in the number of mentally ill inmates in segregation/isolation, a comparison of the prisoner mental health case log and segregation log indicates that there are at least some inmates with mentally illness that remain in segregation/isolation for very long time periods. This practice is a direct violation of the conditions of this Agreement and dangerously detrimental to the health of these prisoners and must cease.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Review, revise, develop, train, implement, and evaluate segregation housing policies to a) minimize segregation time, b) provide adequate opportunities for out-of-cell time for inmates, c) ensure regular and consistent monitoring by medical and mental health staff, d) ensure inmate hygiene is maintained

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 Page 26 of 101
while housed in segregation, and e) develop a tracking log for documenting segregation housing conditions of confinement and inmate status. 2. Continue to ensure inmates with special needs are monitored frequently as indicated by a security and health risk/needs assessment. A routine schedule for conducting these rounds must be continuously monitored for compliance. 3. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision. 4. Defendants are reminded that segregation should never be used to punish or serve as a treatment for inmates who are mentally ill, and may never be used for inmates with serious mental illness. 5. Improve the quality and completeness of segregation review documentation.
G. Incidents and Referrals
1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:
a. Reporting by staff of serious incidents, including: (i) fights; (ii) serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: The previous report documents the following continued problems with incident reporting and log quality management:
1. Inconsistent incident report numbers 2. Incomplete reports 3. Page numbers and other basic information missing 4. Reports not being recorded on the incident log 5. Using different incident numbers for each inmate involved in the same incident 6. Using different incident numbers for different officers reporting the same incident 7. Illegibility 8. Missing signatures 9. Inconsistent recording of incident type 10. No recording of incident type

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11. Incident, Evidence, and Disciplinary logs don’t cross-reference each other
Incident reports and logs for March 3 through October 12, 2015 were examined to determine whether improvement to document quality was achieved. This examination found no substantive improvement since the September 2013 Baseline Report.
Continued problems with incident logs:
There were 89 incident log entries for the time period examined. There were no corresponding incident reports found for 24 of these log entries. The logs contained incomplete and illegible entries, missing information, entries that were out of chronological sequence, and some incident numbers that did not follow a logical flow. For example, an entry dated 10/2 has an ID number of 10-0023. An entry dated 10/3 has ID number 10-0103. It is not likely that 80 incidents occurred within 24 hours.
Continued problems with incident reports:
There were a total of 65 incident reports that correlated with 89 incident log entries (there may be multiple reports per same incident number, but those were all counted as only one (1) reported incident). An additional 30 incident reports were not list on the incident log. Continued problems with incident reports include:
• Duplicates • Errors in incident numbers • Missing names/names in error • Illegible handwriting • Blanks (e.g., date, incident numbers, reason for submitting report, etc.)
As stated in previous monitoring reports, the existing incident reporting system must be completely overhauled if it is to provide valid and reliable information from which to evaluate serious events in order to comply with this Provision or any provision requiring accurate and complete incident reporting to assess compliance levels. A simple document quality assurance and compliance accountability process should be implemented and minimally include the following steps:
1. Officer completes an incident report 2. First-line shift supervisor reviews the report for completeness, accuracy, and legibility 3. First-line approves, signs, and forwards reports that meeting requirements above, deficient reports
are immediately returned to the author with specific written and/or verbal instructions for correction 4. Shift commanders should review and approve only reports meeting the requirements in step two 5. Shift commanders should return to reports first-line shift supervisors that fail to meet the above requirements with verbal and/or verbal instructions for correction 6. The chiefs, Security Administrator, Asst. Warden and Warden should review all reports for quality assurance and operational management purposes.
RECOMMENDATIONS: Previous recommendations remain appropriate


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1. Develop protocols for current tracking system to improve data validity and reliability; the Incident Log document is replete with duplication and misleading entries.
2. Develop a unified incident coding system for valid and reliable information and data collection, reporting, and analysis.
3. Establish regular monthly quality assurance meeting process involving all major department team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity.
4. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol.
5. Require supervisors to carefullyreview all incident reports for completeness, accuracy, and consistency.
b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);
ASSESSMENT: NONCOMPLIANCE
FINDINGS: A regular administrative process required under this provision has not yet been formalized. Such a process first requires wholesale improvements in incident reporting systems and reporting review process. Furthermore, valid and meaningful incident data for tracking and management purposes relies completely on the quality of the incident reporting system, quality compliance monitoring, and timely data management. It is imperative that GGACF management staff implement a measurable document quality assurance and management process for the incident reporting system.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations in G.1.a above.
c. Requirements for preservation of evidence; and.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous monitoring reports, the Evidence Log should include incident report numbers to cross-reference incident reports and evidence (i.e., contraband). This revision to the Evidence Log will help to provide efficient and timely matching of incident reports to evidence, and make the Evidence Log a very useful tool for tracking and managing facility incidents for planning, implementation, and evaluation strategic contraband control policies.
RECOMMENDATIONS: Previous recommendations remain appropriate
1. Refer to similar recommendations regarding contraband.

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d. Central tracking of the above incidents.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Findings described in G.1.a adequately articulate continued problems found with the incident central tracking and logging system.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to previous recommendations regarding incident reporting and tracking. 2. Consider implementation of an electronic jail management system for centralization of incident
reporting and data analysis. 3. Implement a quality assurance process that consistently ensures incident log accuracy and
completeness.
2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously stated, deficiencies in the incident reporting system, lack of reporting quality management, and the vacant Investigator position exacerbate making positive progress with this provision despite the absence of approved policies and procedures.
Prompt incident reporting remains a serious problem. Prisoner Disciplinary Committee reports examined continue to report problems with staff and supervisors using the appropriate incident report form, submitting error free and/or complete incident reports, and/or turning in reports. Prisoners continue to receive inordinate amounts of disciplinary segregation that is unprecedented in contemporary corrections ranging from a few days to over 500 days. The Monitor is encouraged by the discussions he has had with both parties regarding Mental Health involvement in the inmate disciplinary process. The Monitor was somewhat puzzled to hear from the Disciplinary Sergeant that overall detainees receive harsher disciplinary sanctions that sentenced prisoners. Hopefully, the revised Inmate Disciplinary policies and procedures will address this concern.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Include this element in the required policy and procedure. 2. Establish reasonable timeframes as indicated. 3. Develop and implement corrective action protocols to address staff noncompliance with adopted
policies and procedures. 4. Initiate corrective action against supervisors and staff who continually fail to submit and/or approve
deficient, late, or no incident reports as required by policy and this Agreement.

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H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:
a. Permissible forms of physical force along a use of force continuum;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory previously submitted revised draft use of force policies and procedures to this Monitor and USDOJ for review and comment. The USDOJ rejected the revised document citing structural and content problems and provided additional comments and recommendations. The Territory submitted a revised draft on November 13, 2015, and the USDOJ’s comments to that draft are due November 30, 2015.
The monitoring team brought up the concern regarding an entry in the L-Unit log book (Log Book dated June 3, 2015 at page 197) whereby an inmate claimed he was spitting up blood due to been assaulted by GIST officers during a shakedown around July 29, 2015. Certainly, this allegation should receive prompt attention and investigation by the Chief Inspector.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize, approve, and implement draft use of force policies and procedures upon approval and once the revised implementation schedule is approved.
2. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
3. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review of document are 1) complete, 2) accurate, and 3) comprehensive.
4. All planned uses of force must be monitored and controlled by an onsite supervisor. 5. GGACF must promptly and thoroughly investigate all inmate complaints of excessive force and take
necessary corrective action to protect inmates and staff.
b. Circumstances under which the permissible forms of physical force may be used; 

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As noted above, the draft policy has not yet been approved and implemented. 

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Implement policy and procedures once approved.

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c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: See above findings. 

RECOMMENDATIONS: Implement policy and procedures once approved. 

d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The training program cannot be revised to meet this requirement until the new policy is approved. This Monitor and USDOJ also must first receive, review, and approve preservice and annual training curricula.
RECOMMENDATIONS:
1. Implement new policy once approved. 2. Provide this Monitor and DOJ with all current training curricula.
e. Training and certification required before being permitted to carry and use an authorized weapon;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above.
f. Comprehensive and timely reporting of use of force by those who use or witness it;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Problems with incident reporting make it very difficult to assess whether events involving force are being properly reported. For example, incident report 07019015 (07/20/15) documents “Taser” was involved in this incident. However, the narrative is virtually illegible and no use of force review document was provided. Making this incident even more confusing is the fact that administrative documents clearly state no use of force events occurred during the month of July 2015. Again, GGACF management must take intentional steps to improve the quality and accuracy of incident reporting and documentation.

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RECOMMENDATIONS: Previous recommendations remain appropriate. 1. Implement supervisory quality improvement review for all reports to ensure accuracy and
completeness before approval. 2. As requested in the previous report, the Territory must develop a use of force tracking log that
includes elements to verify that reports are submitted complete and timely. 3. Comply with Monitor’s request for documents.
g. Supervision and videotaping of planned uses of force; ASSESSMENT: NONCOMPLIANCE FINDINGS: No planned uses of force were reported during this assessment period. However, the Territory did not provide proof that GGACF staff had access to video equipment if needed. RECOMMENDATIONS: Implement policy once approved.
h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers; ASSESSMENT: NONCOMPLIANCE FINDINGS: No change.
 RECOMMENDATIONS: Previous recommendations remain appropriate.
 1. Provide the Monitor documentation of Compliance for this Provision. 

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries; ASSESSMENT: NONCOMPLIANCE FINDINGS: No change. RECOMMENDATIONS: 1. Provide Monitor documentation of Compliance with this Provision.
j. Prompt administrative review of use of force reports for accuracy; ASSESSMENT: NON COMPLIANCE

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FINDINGS: As stated above in (f), this Monitor cannot verify compliance with this provision. Incident reports continue to describe use of force against prisoners with no accompanying use of force review documentation.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.
k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This policy has not been approved and a formal process for complying with this provision has not been developed.
RECOMMENDATIONS: Implement policy once approved
l. Administrative investigation of uses of force; 

ASSESSMENT: NONCOMPLIANCE 

FINDINGS: Same as above. 

RECOMMENDATIONS: Implement policy once approved.

m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above. No central tracking system has been developed by GGACF officials; this system will not be of much value unless and until quality assurance managements measures, as previously discussed, are in place and determined to be effective.
RECOMMENDATIONS:
1. Develop and implement Central Tracking system to include all required elements.

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n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This policy draft remains under review.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Immediately issue directives to supervisors to complete reviews for all incidents involving use of force. Monitor compliance, correct deficiencies, and document compliance with this provision.
o. Re-training and sanctions against staff for improper uses of force.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Noncompliance with this provision is a cumulative result of noncompliance with the Use of Force section of the Agreement. Re-training and sanctions against staff for improper use of force cannot be appropriately determined without routine and adequate administrative review of force events. Compliance with this provision is contingent upon compliance with the administrative review provision.
RECOMMENDATIONS:
1. Comply with Administrative Review provisions of this Agreement. 2. Develop and prepare to implement remedial use of force training.
I. Use of Physical Restraints on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:
a. Permissible and unauthorized types of use of restraints; 

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. 

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Implement this policy once approved according to the new schedule.

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b. Circumstances under which various types of restraint can be used; ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above RECOMMENDATIONS: 1. Same as above. c. Duration of the use of permitted forms of restraints; 
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as above. 
 RECOMMENDATIONS: Same as above. 
 d. Required observation of prisoners placed in restraints;
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as above. 
 RECOMMENDATIONS: Same as above. e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above. RECOMMENDATIONS: Same as above. f. Required termination of the use of restraints . ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above. RECOMMENDATIONS: Same as above

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J. Prisoner Complaints

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The inmate complaint system remains problematic based on an examination of grievance log entries from July 20 through October 5, 2015. Additionally, the log records no receipt of any grievance between June 29th and July 20th. It seems very unlikely that prisoners submitted no grievance during this time period based on previously recorded submission patterns, as well as prisoner reports of frequently filling out grievances. For example, one prisoner advised Mr. Romero, Monitor’s operations expert, that he had not been able to obtain a attorney visit for six months but had submitted numerous requests and grievances. This further demonstrates GGACF’s compliance with this provision and how noncompliance violates this prisoner’s access to the court.

Approximately 50 prisoner complaints were processed during this reporting period. The log documents responses to prisoner compliance in approximately 76% (38) of these complaints:

Classification

Ttl Received

Appeal

3

Food Service

7

Housing Conditions

2

Medical

8

Other

14

Safety

4

Staff Conduct

12

Totals 50

Response Documented
1 6 1 4 10 4 12 38

Response Rate 33% 86% 50% 50% 71% 100% 100% 76%

As described in previous reports, the time between receipt of a prisoner compliance and response to the prisoner can take several days to weeks in some instances. Additionally, many of the recorded responses do not describe the actual response to the prisoner but instead only what GGACF will do to deal with the complaint i.e. “…will look into the matter.”

USDOJ provided extensive comments to the Territory’s draft prisoner complaints policy on October 29, 2015. Among other things, USDOJ reported that the draft policy continued to lack provisions required by the Settlement Agreement (including provisions regarding corrective

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action and evaluation of trends and individual and systemic issues), and that comments previously submitted by USDOJ to an earlier draft in March 2015 had not been addressed. Under the current schedule, the Territory’s revised draft is due to the Monitor and USDOJ on December 4, 2015.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking process to measure and verify program compliance, take timely and appropriate remedial and correction action.
2. Ensure tracking log is consistently completed and accurate. 3. Assign reliable and timely oversight of the inmate complaint process and logs to a staff person
who will provide the process consistent, dedicated, and comprehensive attention. 4. Develop a valid and reliable tracking a quality management statistical report for monitoring
inmate and facility needs and problems. 5. Ensure staff are available during onsite visits to allow this Monitor to adequately assess this
Provision.
b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The grievance log cannot demonstrate compliance with this provision for several reasons:
1. The “Type” column is intended to prioritize a complaint as “emergency” or “normal”. However, this column is often blank.
2. Response to “emergency” complaints can range from zero (0) to nine (9) days. 3. Descriptions of prisoner complaints often do not support designating the complaint as an
emergency. 4. Response often do not articulate what, if any, emergency (or even urgent) actions were taken
to resolve the complaint.
The inmate complaint system remains problematic and unreliable. The grievance log is inconsistently maintained and confusing on its face. This issue has been discussed with GGACF management officials at each site visit with little or no substantive improvement accomplished to date. The Monitor and USDOJ were assured by GGACF management this matter would be corrected but records consistently demonstrate otherwise.
RECOMMENDATIONS: Same as above
c. Corrective action taken in response to complaints leading to the identification of violations any departmental policy or regulation, including the imposition of appropriate discipline ainst stastaff whose misconduct is established by the investigation of a complaint;

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ASSESSMENT: NONCOMPLIANCE
FINDINGS: Documentation provided is inadequate for assessing compliance with this provision. The description of the prisoner complaint system discussed above is also suggestive of noncompliance with this provision.
RECOMMENDATIONS:
1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.
d. Centralized tracking of records of prisoner complaints, as well as their disposition; and 

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Same as above. 

RECOMMENDATIONS: Same as above, and:

1. Develop and implement a formal andreliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.
e. Periodic management review of prisoner complaints for trends and individual and systemic issues.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Similar to administrative investigations, use of force and incident reviews, this process remains essentially nonexistent.
RECOMMENDATIONS: Same as above.
1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. Use data from those reviews to identify patterns of individual staff and inmate problems, as well as systemic problems in need of correction.

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K. Administrative Investigations
1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:
1. Timely, documented interviews of all staff and prisoners involved in incidents;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Investigator (Chief Inspector) position was filled and the Director is in process of filling another investigator position. However, it will take some time for the Office of the Chief Inspector to be fully developed and fully functional. However, these are certainly steps in the right directions. Also, please refer to the discussion/findings noted in paragraph E-1 of this report.
RECOMMENDATIONS: Same as previous report
1. Fill the vacant investigator position. 2. Supervisory/management staff must be consistently held appropriately accountable for adherence to
agency rules, regulations, policies, and procedures. 3. The November 2014 housing unit riot must be thoroughly investigated and reviewed to prevent
similar future events and to improve organizational planning, response, and management of these types of major incidents.
2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc.) and attempt to resolve inconsistencies between witness statements;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS:
1. Same as above. 2. Develop, as part of these, methods for adequate collection, recording, handling, labeling, preserving,
and maintaining administrative investigation evidence, information, data, etc.

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3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No substantive change since previous visit, but with the creation of the Chief Inspector’s Office it is expected that this area of the Settlement Agreement will advance in compliance ratings in future inspections.
RECOMMENDATIONS:
1. Refer to previous findings regarding information tracking systems and methods. 2. Ensure tracking system maintains salient facts and information to support systematic
administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.
4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Examination of the CV provided by the Territory of the recently hire Investigator infers this person is well qualified, but specific documentation of pre-service and in-service training is still not apparent. Additionally, training on the new Use of Force policy would be pending final approval of the policy currently in draft-review status.
RECOMMENDATIONS:
1. Fill the currently vacant Investigator position as soon as possible. 2. Finalize, approve, and implement relevant policies and procedures. 3. Create a formal pre- and in-service training program to train staff who are involved in initial and/or
administrative investigation. 4. Provide adequate training of investigative staff on topics in areas of incident scene investigation and
appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc. 5. Provide training for administrative/leadership in the areas of administrative investigation oversight, coordination, and management. 6. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities. 7. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review upon his/her appointment.

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5. Disciplinary action of anyone determined to have engaged in misconduct at
 Golden Grove. 

ASSESSMENT: NONCOMPLIANCE
FINDINGS: No change from previous Report.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize, approve, and implement relevant policies and procedures. 2. Review and revise current regulations on staff disciplinary actions and penalties to ensure
completeness and efficacy. 3. Integrate the information in the above into the administrative policies and procedures previously
discussed. 4. Record and maintain onsite records of staff misconduct investigative reports and determinations. 5. Protect the integrity and confidentiality of these staff records, control access to records, provide a
process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff. 6. Provide training to supervision staff in the appropriate use of this information for purposes of staff supervision, counseling, discipline, promotion, etc. 7. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE

Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: Once again, there has been an improvement in the performance of the intake screen. The policy, with regard to intake screening, has been reviewed and approved by the monitor. Formal training has been completed and testing has occurred. It is our perception that all of the required staff have been trained and that they have successfully completed the post-test exam. However, a summary document needs to be sent to the monitor for his review.
There has been no change in the RN staffing since our last visit. That is, onsite there are sufficient numbers of nurses to perform appropriately the intake screen each day, Sunday through Saturday from 8:00 a.m. until midnight. There remains a gap of RN coverage between midnight and 8:00 a.m., seven days a week. The Territory is actively recruiting and we would hope that by the time of our December visit, a complete set of staff are in place to provide timely nurse intake screens.
We did identify a systemic problem, in that several patients arriving in the evening did not have their intake screen until the following day, including several that did not receive the intake screen until the following afternoon. It is not completely clear why this delay occurred. However, the nursing staff informed us since there is no appropriate space available in the intake area, the detainees must be escorted to the clinic. Custody partly confirmed this. Commonly, there is an absence of escort officers and this is the major reason for the delay. We discussed this problem with the Director and the Associate Director, and we accompanied the Associate Director to the intake area. A small room was identified that could be used by the nurse, sitting behind a half door, to quietly interview the detainee sitting less than a foot away. In order for this to be established, however, the door must be created. The bottom half of the door should be a collapsible shelf to benefit the nurse while documenting during intake and assist in obtaining the blood pressure. Once this room is established, there will be no further need for an escort officer to assist in the movement of detainees for the intake screening process.
We found a second record in which the inmate entered the facility on July 10 but did not obtain his intake screen until July 24. The nurses informed us that each morning they run a report from the offender tracking system that lists the names of individuals who have entered the system. However, this inmate’s

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name did not appear on this report until two weeks later, when they obtained the screen. There was an effort while we were onsite to identify when the entries were initially made into the offender tracking system but thus far, the timing of the data entry has not yet been determined.
We reviewed 10 records of detainees who entered the system during the months of June, July and August. Beyond the delays, we felt that the quality of the nursing performance had in fact improved. Even the assessment and application of the acuity scale had improved, and the results of the tuberculosis skin tests were all in the record.
We did clarify our interpretation of the new recommendations from the Centers for Disease Control with regard to determining a positive skin test. Although for the lower risk individual the definition of a positive test has been elevated from 10 mm to 15 mm, it is our view that, by definition, individuals entering a correctional facility come from the highest risk population and therefore the old definition of 10 mm induration should continue to be utilized. Below are some examples of health records reviewed.
Patient #1 This patient entered the facility on 7/10/15; however, his nursing screen was not completed until 7/24/15. His screen included a history of a gunshot wound affecting his rib cage in October 2014. His TB test was negative but he also complained of an upper eyelid redness and chronic back pain. He did see a physician, who completed the health assessment on 8/5. This delay was related to a paucity of physician hours in July.
Patient #2 This patient arrived on 8/25/15 in the early morning, but did not have his nurse screen until 8/26. His skin test was read as positive at 15 mm; however, on 9/2, his chest x-ray was read as negative. He did report a history of night sweats. I reviewed with the Director of Nursing that when the nurses perform the reading of the tuberculosis skin test and identify a positive skin test, they should immediately query the patient with the positive skin test about the presence of TB symptoms.
Patient #3 This patient entered the facility at 5:48 p.m. on 7/25/15, but did not receive his nurse screen until 3:45 p.m. on 7/26. He had a history of both asthma and hypertension. He did receive a peak flow test, which revealed a rate of 300 mm. Otherwise, his vital signs were normal and he was listed as an acuity 2. His TB skin test was also negative. This patient was not seen by a physician until 9/5 (due to the absence of physician hours) and there was no effort, either by the nursing staff or by the physician, to indicate the need for monitoring his blood pressure.
RECOMMENDATIONS: 1. Complete the revisions to the space identified within the intake area so that the nurse intake screen
will no longer be dependent on the availability of escort officers. 2. Complete the filling of the RN positions on the midnight to 8:00 a.m. shift, seven days a week. 3. Assume that all inmates entering the system are designated as high risk and therefore utilize the
definition of a positive test as 10 mm or greater of induration. 4. When the nursing staff identifies a positive skin test, insure that they query the patient with the
positive test regarding TB symptoms and document in the medical record.

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5. Continue to run reports from the offender tracking system in order to identify recent entries into the system.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: For the most part, nursing staff continue to perform intake screenings, which include a section on mental health, within 24 hours of intake into the facility (see above noted medical findings). However, looking only at screenings with positive mental health findings, there were two case exceptions identified during this site visit. In one case, the intake screening was delayed for approximately 2 weeks; the reported reason for this delay was that for some reason, the inmate wasn’t entered into the ‘smart jail’ system; and I was told that the smart jail system is at least one of the ways that inmates in need of an intake screening are identified. In the second case, the intake screening was delayed because no corrections officer was available to accompany the inmate to the health unit so that he could be screened.
A positive finding on the mental health section of the intake screen does prompt an immediate referral to the mental health staff for a full mental health assessment. Positive findings on the mental health screen correlate fairly well with positive findings during the course of the fuller mental health assessment, meaning that there are only a small number of false positives on the mental health intake screen. However, it appears that some of those in need of mental health treatment or at least monitoring by mental health staff are being missed during the mental health intake screening process. For example, there are inmates who are later referred to mental health by corrections officers using the ‘behavioral checklist’, and now that mental health assessments are being performed on all new inmates, some additional number of inmates who were not previously identified at intake are being picked up through this process. Although the reasons for these false negatives at intake are still being explored, at least preliminarily it appears that there are several reasons. For example, it at least appears that there is some subset of new admissions that are either unwilling or unable to reveal mental health issues during the intake screening process, and, for example, the intake screening process does not appear to capture new inmates with severe trauma histories and associated clinically significant trauma-related mental health difficulties that render them at high risk of deterioration while incarcerated. However, the inmates should be captured during the mental health assessment that is conducted within three days of the admission.
RECOMMENDATIONS: 1. Track data to support evidence of successful implementation of the policy and demonstrate adequacy
of the quality of the screening process. 2. Given that the availability of corrections officers to transport inmates at least appears to still be a
problem, consideration should be given to identifying a private space in the intake area for the nurses to perform intake screenings so that new inmates don’t have to be transported to the medical unit for intake screenings. 3. Continue to examine cases where an inmate with a negative mental health screen is later identified as an inmate in need of mental health services, and then explore options for altering the mental health screening process so as to minimize the number of such false negative mental health screenings. 4. Consider including a few questions in the mental health section of the intake screen designed to uncover any significant history of trauma. 5. Assure that the mental health training that will be eventually provided to corrections officers helps them to appreciate the importance of their use of the ‘behavioral checklist’ and enhances their ability to use the ‘behavioral checklist’

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6. Continue the practice of completing mental health assessments on all new admissions.
b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: During this past visit, there was a Medical Director for the entire visit. For the months of June, July and most of August, there was no dependable physician/Medical Director presence. Therefore, the finding of noncompliance. The Medical Director started in late August, is on-call, and works 3 days a week at the facility.
Patient #1 This patient arrived on 7/15/15 and was screened on 7/16. This was a case where there was a delay in the medical screen. He had a history of sickle cell trait. His TB skin test was negative but he was listed as an acuity 2. He was released on 8/21, more than a month later, without having had a health assessment.
Patient #2 This patient arrived on 7/28/15 with a history of asthma and appeared to be symptomatic. He had a peak flow of 360 and a TB skin test of 12 mm. He was released on 8/10 without ever having had an initial assessment or an initial chronic disease encounter. His 12 mm skin test was not considered positive. If the program follows our recommendations, in the future a 12 mm induration will be considered a positive skin test.
RECOMMENDATIONS: 1. The Medical Director should provide feedback to the Director of Nursing and the nursing staff regarding the appropriateness of the assigned acuity level. 2. The new Medical Director has planned to be onsite three days per week. This leaves a gap that should be filled by a clinician at least one day per week so that the health assessments are not unnecessarily delayed. Therefore, some additional hours of clinician services should be added. 3. The Medical Director should consider a strategy in which she can document both a health assessment and an initial chronic clinic visit for individuals who enter with common chronic medical diseases.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As was reported in the last monitoring report, a ‘psychosocial assessment intake log’ has been developed to track when intake screenings and initial mental health assessments are performed. A review of this log revealed that initial mental health assessments were performed the day of or the day after the mental health unit received the intake screening, unless, of course, the inmate had been released. Therefore, in cases where inmates did not receive an initial mental assessment with 72 hours of intake, the delay was due to a delay in performing the intake screening and/or in sending the results of that screening to mental health staff.
As noted above, initial mental health assessments are now being performed on all new admissions. However, there are inmates who were initially incarcerated prior to the time that the current type of initial mental health assessment was being performed; some of those inmates are on the mental health treatment

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list and some are not; and the mental health staff is currently trying to complete mental health assessments on such inmates.
The ‘psychosocial assessment intake log’ also indicates if and when, following the initial mental health assessment, a referral was made to the psychiatrist, as well as the reason for such a referral. Although the log does not indicate when referred inmates were actually evaluated by the psychiatrist, at least a sampling of charts indicates that psychiatric evaluations were usually performed in a timely manner. Exceptions to this occur when the psychiatrist, who is part-time, is not at the facility; in such cases, the psychiatrist is consulted over the telephone; but there is no mechanism, such as video conferencing, that would allow her to actually perform evaluations when she is off-site, which is of particular concern when the inmate’s status is noted as urgent.
The initial mental health assessment form and samplings of its use were also reviewed. This review revealed that the initial mental health assessment is quite complete, except for an adequate assessment of any history of serious trauma and the presence of any resultant clinically significant trauma-related symptoms and developmental difficulties.
There does appear to be a small number of inmates who refuse to undergo an initial mental health assessment or are unwilling or unable to fully cooperate with such an assessment. There is no clear policy or procedure for dealing with such situations, and this is especially critical with regard to those who totally refuse to be assessed.
RECOMMENDATIONS: 1. Continue to track inmates entering the facility and monitor time from admission, screening, and
initial psychosocial assessment. In addition, referrals to the psychiatrist should be monitored for time to completion, and this information should be included on the ‘psychosocial assessment intake log’. 2. As noted above, continue performing initial mental health assessments on all new inmates, and continue efforts to perform such assessments on those who entered the facility prior to the time the current initial mental health assessments were being performed. 3. Develop a video conferencing mechanism that would allow the psychiatrist to perform psychiatric evaluations from an off-site location. 4. Expand the initial mental health assessment to include more about an inmate’s trauma history and any associated clinically significant trauma-related symptoms, including developmental difficulties. The monitor has begun discussing this with the mental health team and remains available for further consultation on this issue. 5. Develop a protocol or procedure for responding to inmates who refuse to engage in an initial mental health assessment. Here, too, the monitor is available for consultation on this issue.
c. Prisoners' timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;
ASSESSMENT: NONCOMPLIANCE, in part related to lack of availability of clinician resources to whom nurses can refer patients to be seen in a timely manner.
MEDICAL FINDINGS: We have used this section to address medical sick call, focusing on the acute part of the section. A separate section deals with chronic care needs. The sick call log was consistently utilized and we are pleased to report that a nurse generally saw patients timely. As we understand, two

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housing unit exam rooms contain exam tables that have been used by nursing staff to perform sick call. Other patients must continue to be escorted to the medical clinic until all housing units have appropriate exam space. There were some identified problems with nursing performance. However, this is to be expected and should improve with ongoing feedback. Problems identified included the absence of vital signs, the absence of documentation of a note, the identification of an abnormal vital sign that was never rechecked, the assessment listed by a nurse as “altered comfort,” which is not a nursing diagnosis and, of course, the problem of lack of availability of clinician resources for timely follow up. We reviewed the records of 15 patients who had requested services for sick call over the prior three months.
Patient #1 This patient is a 46-year-old male with a history of gunshot wound to the chest, arm and groin and subsequent neuropathy. On 8/24/15, he complained of wisdom tooth pain that was 10 out of 10 on a pain scale. He was seen by a nurse who did not perform vital signs although did perform a good history and physical assessment. He returned on 9/1, but we could not find a nursing note. We discussed with the Director of Nursing the need for nurses to keep lists of patients they saw each day so a supervising nurse could review records to insure that the documentation was appropriate.
Patient #2 This patient is a 26-year-old female who requested sick call on 8/31/15 and was seen on 9/2. The patient’s vital signs were normal but the pulse rate was 111 and there was no effort to recheck this abnormal pulse rate.
Patient #3 This patient is a 25-year-old male who on 7/3/15, requested attention for neck pain and knee pain. He also indicated he had pain in his fingers, knees and neck and the pain scale was 7 out of 10. The vital signs were normal but the nursing assessment was “altered comfort.” This is not appropriate and in order to be a nursing diagnosis, it must include alteration in comfort as it relates to an organ system or a specific body part.
Patient #4 This patient is a 38-year-old male who on 8/20/15, complained of shortness of breath related to his asthma. His respirations were increased at 22 per minute, his pulse rate was 104 and his blood pressure was 141/91. Peak flow measurement was not obtained. However, two nebulization treatments were provided. The response from the physician who was called was not consistent with the latest acute asthma treatment recommendations.
RECOMMENDATIONS: 1. Complete the equipping of the housing unit exam rooms so that nurses and physicians are able to
see patients in the housing unit exam rooms. 2. The Director of Nursing needs to continue to review the notes of the nurses and provide feedback
as to how they can improve their performance. 3. An emphasis on peak flow measurements for patients with asthma should be initiated with the
nursing staff.
ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: The ‘mental health follow-up log’ was reviewed. This log list all detainees and inmates who are on the mental health caseload; their psychiatric diagnosis; whether they have been on a suicide watch, placed in restraints or placed in seclusion; the date of their last psychiatric evaluation; any prescribed psychotropic medications; and the scheduled date for follow-up. The log lists 56 detainees and inmates who are housed at the facility, and 16 who are housed off island. Two questions emerged from this review. The first relates to the fact that the time between the last psychiatric evaluation and the next scheduled follow-up varied from approximately 2 months to 4 months. Given that the standard is about 3 months between evaluations, even for chronically ill but stabilized persons, 4 months between evaluations seems like a long period of time. It at least appears that those scheduled to have 2 months between evaluations were deemed to need closer monitoring. However, it was unclear, based on a review of a sampling of records, whether those deemed to need such closer monitoring actually needed to be evaluated even more frequently than every 2 months. This is of particular concern because it wasn’t at all clear whether or not mental health staff, who see the inmates more frequently, are charged with reporting any difficulties with medication (i.e., compliance, efficacy and any adverse effects) to the psychiatrist. The second question relates to the fact that there were inmates and detainees listed on the log as suffering from major Axis 1 psychiatric disorders for which treatment with psychopharmacologic agents is indicated, yet were not on such medication. Exploration of this revealed that these inmates and detainees refused to take medication, but there is no clear protocol or procedure for dealing with inmates and detainees who need but refuse to take medication. This is particularly troubling because as a result, at least some of those inmates are being held in seclusion, unmedicated and acutely ill.
The ‘behavioral checklist/sick call log’ was also reviewed. This log lists all inmates for which a ‘behavioral checklist’ or a ‘sick call request’ was completed, the nature of the complaint, the date the form was received, the date the social work assessment was performed, if/when a referral to the psychiatrist was made, the date of any requested psychiatric evaluation, and the date for any required follow-up. Quite a few of these inmates are also on the mental health case load. This raises the question of whether or not these inmates are being seen frequently enough, and/or whether or not the therapeutic interventions being employed are adequate. These questions need further exploration. Others are not on the mental health case load and were apparently identified by the ‘behavioral checklist’ or their own request for services. At least one of the inmates in this group was initially referred via a ‘behavioral checklist’. And although he was evaluated and scheduled for a follow-up, he returned via a ‘sick call request’ multiple times prior to the scheduled follow-up visit. Cases such as this one also must be reviewed with an eye towards assessing the efficacy of treatment and/or how frequently visits should be scheduled.
Non-psychopharmacologic treatment options have been expanded. There are now quite a few weekly group therapy sessions, and individual sessions can be scheduled for those who evidenced particular difficulties in a group session and/or are otherwise found to be in need of an individual session. It is expected that once the additional expected mental health staff person is hired, treatment options will be further expanded. This monitor attended two group therapy sessions, both of which were quite good. In both cases, participants were totally engaged. I learned that there were inmates who wanted to be placed on the mental health caseload so that they could attend groups, which would at least suggest that the word on the units is that the groups are a good thing. Although the group therapy program covers a wide range of issues, there are at least three types of groups that are not yet available. These include a psychoeducational group, focused on helping those with major mental health disorders learn about their disorders and how to best participate in the management of their disorder; a dual-diagnosis group,

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focused on those with a substance abuse disorder and another major mental health disorder; and a support group for those with a history of exposure to severe trauma(s).
This monitor also met individually with a sampling of inmates who are on the mental health caseload. A couple of them had questions or concerns about their medication that need to be addressed. Of greater concern were the inmates seen who have refused medication and remain acutely ill, some of whom were being held in seclusion.
RECOMMENDATIONS: 1. Moving forward, a variety of quality indicators regarding services should be developed and
maintained to aid the staff in ongoing quality improvement reviews as well as provide proof of practice for the monitoring team and any other Bureau, independent agency or accrediting body. 2. It has been previously recommended that the Medical Administration Committee, once formed and active, begin to address the security issue of access to substances that can induce psychotic conditions that then require psychiatric services. This monitor did not notice the previously reported odor of marijuana in housing units during this auditing visit. Hopefully this represents a substantial improvement on this issue. 3. The question of how frequently psychiatric follow-up sessions should be scheduled should be reviewed. Similarly, the question of how frequently inmates and detainees on the mental health case load need to be seen should be reviewed. 4. Continue to expand non-psychopharmacologic treatment options as noted above. 5. Develop a protocol or procedure for responding to inmates for whom psychopharmacologic intervention is indicated but yet refuse to take medication. This is especially important for those inmates who are being held in seclusion because they are so severely mentally ill. This monitor is available for consultation on the development of such a protocol or procedure.
d. Continuity, administration, and management of medications that address 
 (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;
MEDICAL FINDINGS: We visited the medication area and availed ourselves of the opportunity to meet with the pharmacist who is in charge of the area. She has implemented a system in which patients with chronic diseases have their medications individually dispensed based on the prescription requirements. Thus, patients with hypertension on metoprolol twice a day have a series of small Ziploc bags dispensed with the labeled medication on it. It is our understanding that for new orders as patients come in, the program utilizes an offsite pharmacy to dispense the medications. Thus, nursing staff no longer are involved in dispensing and labeling medications. This is consistent with pharmacy practice acts around the United States, so there continues to be progress with regard to this particular issue. On the other hand, since our last visit there was a substantial gap in access to physician services. This gap stretched from June 1 through most of August and therefore the assessment has to be noncompliance. This impacts timely responses to orders for medications and laboratory tests as well as timely and routine physician review of medications and clinical practices as well as review for known side effects of

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medications. We do not believe there is yet an organized strategy to insure discharge medications are always available to meet patient health needs.
We also observed medication administration with regard to the morning med pass in most of the housing units. A nurse accompanied by an officer now performs this. However, we are disappointed to report that there has been regression with regard primarily to, in our view, custody responsibilities. We observed patients in lockdown who were surprised when told that the lights in their rooms must be on when receiving medications. Patients were also surprised at the request to bring a container of water to their doorway. Furthermore, most of the inmates were surprised that not only did they have to ingest the medications with water or some liquid, but also that after ingestion they were required to cooperate with a mouth inspection. The latter two things were true for not only inmates housed in lockdown status but also true for patients in the general population. Several patients refused to cooperate with a mouth check when I also requested it of them and several inmates refused to ingest water at the time of the ingestion. If a program wants to discourage the availability of medication contraband, it thus requires lights to be on in the cells, official identification by a wristband or an identification card, simultaneous ingestion with water, and a mouth check after ingestion. These are the requirements for detainees and inmates to participate in the medication program in all correctional institutions. All inmates should be fully aware of these rules. They, of course, have a choice to participate or not in medication services, but they must all follow all of these rules if they do participate. Not only should custody administration inform the inmates and detainees of these requirements but also this should be written into the post orders of the officer whose assignment is to accompany the medication nurse. I was also informed that it is quite common for an officer trainee to be given this assignment. In my experience, when these rules are consistently and predictably enforced, there are no problems with the inmates. The use of trainees virtually guarantees problems with enforcement of these rules.
The medication nurse did perform reasonably well given the circumstances. At my request, she also documented after completing each housing unit medication pass. She also inspected the emergency bag available in each housing unit.
RECOMMENDATIONS: 1. The Medical Director should review this section and develop a methodology in order to document
compliance with the elements in this section. 2. Custody leadership should inform the inmates/detainees of the rule requirements to participate in
the medication program. 3. Custody leadership should insure that the post order for the officer that accompanies the medication
nurse clearly stipulates these rules and the officer’s role in enforcing these rules. 4. The Director of Nursing with the Medical Director should develop a system to insure
documentation of the provision of release medications for the population that is released. 5. Officer trainees should not be assigned the responsibility of accompanying the medication nurse. 6. The Director of Nursing should monitor the performance of the medication administration process
as part of the quality improvement program.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: See the discussion on medication administration in the housing units under medical findings.

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As noted above, the time between medication reviews is quite variable, and this needs to be reviewed.
There were two types of medication compliance issues identified that raise two different issues. The first, as noted above, is related to those who totally refuse to take medication and therefore remain untreated. There is absence of a protocol or procedure for responding to those inmates. The other relates to those who periodically refuse to take their prescribed medication and whether or not the psychiatrist is informed of this lack of full compliance in a timely manner. In prior monitoring reports it has been noted that psychiatrist has not been notified about such lack of full compliance, in writing, in a timely manner. As the new mental health monitor, it is difficult for me to determine how much improvement there has been in this regard. I found cases where the psychiatrist believed there was full compliance when that was not the case. This clearly impacts the psychiatrist’s review of the efficacy and safety of medications prescribed.
Although the psychiatrist reports periodic review for known side effects of medications, due to time constraints, the extent to which this is documented was not confirmed by a review of charts. However, this monitor will do such a review during the next monitoring visit. Also to be explored during the next monitoring visit is the extent to which other mental health staff have been trained to recognize medication adverse effects, and how any such recognized adverse effects are reported to the psychiatrist.
The breadth and depth of the formulary for psychopharmacologic agents continues to be an issue. Although this monitor is well aware of the need to consider cost-containment and cost-effectiveness, it has been well-established that although all of the various medications in any particular class of psychopharmacologic agents might be equally as effective, none of them is equally as effective in all individuals. Therefore, having only one or two agents from any given class of medications compromises efficacy for some patients. The same is known/operative with regard to safety, especially when one examines the adverse effect profile of some of the newer versus many of the older psychopharmacologic agents. While one way of managing concerns about cost is to limit the breadth and depth of the formulary, including mostly the older medications, a far better way of managing such cost concerns would be to focus on a better/more cost-effective purchasing plan for medication.
During the visit, this monitor did not review any charts for inmates who had been released after having been on the mental health caseload. The Territory’s mental health team, however, informed this monitor that inmates who are released receive a sufficient supply of medication. This monitor is currently unable to determine whether or not such inmates were given a sufficient supply of medication upon their release. This will be explored during the next monitoring visit.
The issue of the high climate temperatures on the units as a particular concern to those taking psychopharmacologic agents (and other medications) that cause heat intolerance has been discussed in prior monitoring reports. To date, it does not appear that anything has been done to address this issue. However, it is my understanding that at least options are being considered, and those will be discussed in another section of this monitoring report.
RECOMMENDATIONS: 1. The use of the medication refusal forms to allow nursing staff to notify clinicians of any significant
pattern of medication refusal and the review of such forms by prescribing clinicians should be tracked. It may also be helpful to have a place on the form where the prescribing clinician can sign, indicating that the form has been seen and reviewed.

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2. The Bureau of Corrections should continue its efforts to identify more cost-effective suppliers of medications and make every effort to avoid lapses in providing prescribed medications to its inmates.
3. GGACF should develop a heat risk policy and ensure that all inmates have access to plentiful supplies of water and ventilation methods at all times. A list of inmates on medications that have heat-related risks should be maintained, and these inmates should have access to ice and water when the heat index indicates an elevated risk of heat-related illnesses.
4. Regular assessment for medication adverse effects should be well-documented, and through training, such efforts should be expanded to involve all mental health staff in the identification of medication adverse effects.
e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: The medical record policy has been approved and the training has occurred. We did find, however less frequently, documents that were either filed late or filed in the wrong section. Consistent with practice in the community, we believe the availability of an electronic record would greatly facilitate an improvement in care. We have talked with an IT company with whose work we are familiar and who indicated that there could be available to the Territory a substantial discount in cost of such an electronic record.
RECOMMENDATIONS: 1. Continue to improve the organization of the medical records, including the timeliness and
appropriateness of medical document filing. 2. Begin to explore plans to implement an electronic record.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: There continues to be progress in organizing the mental health record for each inmate within his/her larger medical record. However, while doing chart reviews, there were still charts where some of the mental health record was filed in the wrong place, at least based on the medical records format that was provided to this monitor.
The revision to the approved ‘treatment plan’ form is a work in progress. Based on discussions with the mental health staff, it will hopefully soon reflect a multi-disciplinary approach to treatment planning, with a clear indication of which interventions are focused on addressing which problems. However, the concept of treatment planning will have to be expanded to include planned approaches to addressing those who have refused treatment.
A discussion was held regarding how much information about an individual’s participation in a group therapy session should be included in his/her medical record, and the extent to which such entries increase one’s understanding of how that individual is doing upon simply reading his/her medical record. As the number and nature of group therapy sessions expands, and as the number of other non­ psychopharmacologic interventions increases, this issue will be even more relevant.

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RECOMMENDATIONS:
1. When all records are appropriately organized and filed, a quality improvement tool needs to be developed to track compliance with this provision.
2. The mental health records should be organized chronologically. 3. The approved ‘treatment plan’ form needs further development, and should be expanded to describe
planned interventions for those who have refused medication or other important therapeutic interventions. 4. The charting of group therapy sessions and other non-pharmacologic interventions requires further consideration.
f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to: (i) adequate sick call procedures with timely medical triage and physician review along with the logging, tracking ad timely responses to requests by qualified medical and mental health professionals;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for this provision. It must be emphasized that the absence of timely physician services was a major contributor to this assessment
RECOMMENDATIONS: See letter (c) findings and recommendations.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The ‘sick call log’ and sick call procedures have already been discussed, and as noted above, the response to sick call requests is consistently timely and complete. However, it should also be noted that the number of sick call requests for mental health continues to increase. Previously, it has been speculated that this increase is most likely attributed to the increased availability of mental health staff and programming. While this is likely a factor, it is also quite likely that those who were not receiving mental health services have heard from those who are receiving services that real help is available. This would also contribute to the increase in the number of those seeking services. Such discussions might also decrease the stigma that was associated with seeking mental health services, and may further contribute to the increase in the number of those seeking services.
RECOMMENDATIONS: 1. See section ‘1c’ findings and recommendations.
f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE.

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MEDICAL FINDINGS: We interpret this as referring to a chronic care list and an ability to track the sequence of visits. Again, we were provided a list and we did use it to review several records. We reviewed 10 records of patients seen by the chronic care physician. We identified the following types of problems: lengthy delays between follow-up visits, absence of following significant abnormal test results, inadequate subjective information compiled, and inadequate timeliness of follow up and lack of documentation of the assessment of disease control. Finally, there were several patients for whom the finding of fair or poor control did not result in a documented effort to improve the disease control.
Patient #1 This patient entered the facility in August 2014, with hypertension, depression and chronic paranoid delusions. His baseline chronic care visit was 9/5/14, and he was then seen in October of 2014, but not seen again until April 2015. On his baseline visit, there were several positive symptoms described but all of them lacked any detailed elaboration. In October, his hypertension was assessed as being in good control with a three-month follow up. However, he was not seen until six months later. One of his visits lacked any documented date. Also, in February 2015, his blood sugar was 190, but there was no effort to follow up with regard to this item.
Patient #2 This patient is a 44-year-old patient with hypertension, hyperlipidemia and bipolar disorder. His baseline was in November 2013, and he was next seen in October 2014, 11 months later. Subsequently, he was seen in March 2015, and then again in June. At his June visit, he complained of headaches but there was no documentation as to location, intensity or any associated signs or symptoms. There was no assessment of the degree of control of his hypertension at this visit.
Patient #3 This patient is a 63-year-old patient with hypertension and low back pain whose baseline visit was in November 2013, and his next visit was in October 2014. His blood pressure was 137/92 and his pulse was 110, but there was no change in regimen. Thyroid studies were done and interpreted as normal. His most recent visit was in March 2015, where the blood pressure was assessed as fair control, but there were no changes to the regimen. A 90-day follow up was ordered, but this has not occurred.
Patient #4 This patient is a 69-year-old with hypertension whose baseline visit was in January 2015. Although his blood pressure was 190/100, he was not seen in the chronic care program until 9/23/15, where fortunately his blood pressure had been lowered to 146/93.
Patient #5 This patient is a 47-year-old with hypertension and chronic left leg pain along with schizophrenia. His baseline assessment was not completed. His initial blood pressure was 148/98 and assessed correctly as fair control. He had a subsequent visit not dated in documentation. The blood pressure was 172/89, consistent with poor control, but there was no change in regimen.
Patient #6 This patient is a 43-year-old patient with asthma. His baseline is undated but probably took place in May 2015. His vital signs were normal but there was no peak flow measurement and he has not been seen since.

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RECOMMENDATIONS: 1. We understand that the Medical Director will be seeing all of the chronic care patients, which we feel
will substantially improve the quality of services. 2. The chronic care nurse should work closely with the Medical Director, insuring that all asthmatics
have a peak flow measurement, all diabetics and hypertensives have the appropriate laboratory tests available at the time of the visit and insure that the follow up is consistent with the level of disease control.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, the ‘mental health follow-up log’ has been carefully maintained and is up to date. See Section ‘1c’ for further discussion of the ‘mental health follow-up log’.
RECOMMENDATIONS: 1. See section ‘1c’ for recommendations regarding the ‘mental health follow-up log’ 2. In the last monitoring report, it was noted that it was the understanding of the monitor that the
Mental Health Coordinator plans on also adding a tracking log for general counseling services, which hopefully will be in place by the time of the next site visit. Although a log of group therapy sessions was reviewed by this monitor, the development of such a treatment log for all non­ psychopharmacologic interventions continues to be a recommendation.
f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;
ASSESSMENT: NONCOMPLIANCE.

MEDICAL FINDINGS: See f (ii).

RECOMMENDATIONS: See f (ii).

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: See sections ‘1b’, ‘1c’, ‘1d’, and ‘1f’ sub-sections i and ii 

RECOMMENDATIONS: 

See sections ‘1b’, ‘1c’, ‘1d’, and ‘1f’ sub-sections i and ii
f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;
ASSESSMENT: NONCOMPLIANCE

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MEDICAL FINDINGS: We found it difficult to track onsite emergency services because they were logged in the sick call log but they were walk-ins. It would be preferable for them to be logged along with unscheduled offsite services so that the log contains both onsite and offsite services, relatively few of which require the patient to be sent offsite and the majority of which begin as onsite services, even when they are sent offsite. We did find medical response bags in the housing units; however, there was inconsistency in the documentation of checking the bags twice daily. It appeared that most commonly, it was not documented that bags were checked, especially on the weekends. We understand that the medication nurses have the responsibility to check these bags. Occasionally, the availability of the key to access the bags was not completely understood by the housing unit officer. This needs improvement as well. We discovered that some of the contents of the bags had expired.
We also became aware of the fact that since the Medical Director has started to be onsite regularly, one or two patients were sent out without notifying her. These occurred after midnight. In our discussion with the Medical Director, she clearly would like to be called before such patients are sent out. There is a possibility that a send out could be avoided based on her assessment and recommendations. The Warden assured us that staff would be notified of the requirement to contact her even when there are no nursing staff available on site.
We reviewed four records of patients sent offsite. In none of the records was there a timely follow-up visit with a clinician. This is not surprising given the absence of predictable physician availability until the Medical Director began. Although there were offsite service documents available, chart review of one patient with an episode of chest pain reveals the hospital never mentioned performing an electrocardiogram. The following patient records were reviewed.
Patient #1 This patient is a 49-year-old male with a history of gunshot wound and angina, who was sent to the ER on 8/4/15 for chest pain. He apparently walked into the clinic at 9:42 a.m. complaining of left-sided chest pain that he reported to be 8 out of 10 on the pain scale. Although his vital signs were normal, there was a nurse assessment and the patient was sent to the emergency room. Although the documents from the emergency room were available, they did not mention an electrocardiogram and there was no physician follow up.
Patient #2 This patient is a 43-year-old male with a history of reflux disease. On 8/17/15, he complained of abdominal pain. Although there was no nurse on site, the patient was sent to the emergency room without contacting the Medical Director, who had already begun her employment at the facility. The patient returned about 2:35 a.m. The patient was released later that day. The emergency room report was present.
Patient #3 This patient is a 43-year-old male with a history of hypertension, hyperlipidemia and reflux disease who at 3:45 p.m. on 6/1/15 complained of black tarry stools and a facial abscess. He was assessed by a nurse and sent to the emergency room. The stool was not tested onsite. The emergency room did test the stools and they were negative for blood. They did address the facial abscess, for which they performed an incision and drainage. There has been no physician follow up.

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RECOMMENDATIONS: 1. Custody must make it clear to all correctional officers that before a patient is sent out emergently, the
Medical Director must be contacted for her final decision. 2. The Director of Nursing should establish a system to insure that the offsite service documents are
available (which does appear to be working) and when they are available, the patient’s name should be placed on the list to be followed up with the Medical Director. 3. Emergency onsite care should be tracked in the same log as the offsite care or in a separate log for emergency onsite services.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: See medical findings and recommendations.
In addition, as noted above, when the psychiatrist is off-site, her ability to respond to emergencies is severely compromised by the lack of some type of video conferencing capability. At present, she is virtually always available for a telephone consultation, but of course, the quality of that consultation depends on the quality of the information presented to her. With video conferencing capability, she would be able to actually see and speak to the inmate directly, thereby substantially increasing the quality of an emergency assessment, and in turn, the appropriateness of an emergency intervention.
RECOMMENDATIONS: 1. Develop video conference capability that would allow the psychiatrist to assess inmates who are in
urgent need of an assessment even when she is off site.
f. (v) adequate and timely referral to specialty care;
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: There is a medical log that appears to be significantly more accurate than during our prior visit. We reviewed 12 records of patients who received consultation services or procedures, such as colonoscopies or CT scans. Again, the biggest problem was the frequent absence of clinician follow-up related to the unavailability of physician services until the Medical Director began. In almost all instances, the reports were available.
Patient #1 This patient is a 35-year-old male with hypertension, a history of a positive TB skin test and bipolar disorder. On 9/17/15, he was scheduled to have a CT scan of his head, ordered on 9/7. The CT scan was completed; however, there was no physician follow-up visit.
Patient #2 This patient is a 64-year-old male who was scheduled for a visit with a nephrologist on 9/16/15 as a follow up to a June visit. He has stage 3 chronic kidney disease secondary to HIV infection. He is a complicated patient for whom the Medical Director and I discussed the need for a one-page summary that accurately describes his conditions.

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Patient #3 This patient is a 75-year-old male with hypertension and type 2 diabetes who was scheduled for an xray of his right hand on 6/26/15. The x-ray was performed on 7/1, and reviewed two weeks later by the cardiologist on 7/15. Again, there has been no follow-up visit.
Patient #4 This patient is a 55-year-old male with hypertension who was scheduled for a CT scan of his abdomen on 9/18/15. The CT report was in the chart but there has been no follow-up visit.
Patient #5 This patient is a 58-year-old male with HIV disease, hyperlipidemia and spinal stenosis. On 8/21/15, he was scheduled for an outpatient communicable disease clinic visit and although he did have a CD4 count of 334, there was no viral load report in the medical record. He needs follow up with the Medical Director as soon as is feasible.
Patient #6 This patient is a 31-year-old male with a history of gunshot wound to the right thigh and a history of bladder repair. He was scheduled for a neurology appointment on 8/26/15 but this clinic was delayed due to lack of availability of territorial plane tickets. This is an unacceptable reason for delayed services.
Patient #7 This patient is a 60-year-old male with hypertension and prostate enlargement. He saw urology on 7/27/15 and diagnosed with chronic prostatitis. He has a history of a diagnosis of a sarcoma with regard to a scrotal mass. He has had no recent follow up with the primary care provider since his urology visit.
RECOMMENDATIONS: 1. The scheduled offsite service coordinator should insure there are follow up visits with the Medical
Director once the offsite service reports are available. 2. The Medical Director’s visit with the patient should document a discussion of the findings and
plan with regard to the offsite service.
f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: This provision received noncompliance due to the absence of adequate physician resources, which we expect will be corrected by our next visit. This has also been discussed under f (v).
RECOMMENDATIONS: This has been discussed under f (v).
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: With regard to mental health, adequate follow-up care and treatment after return from referral for outside diagnosis and treatment is facilitated by the fact that the facility’s

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psychiatrist is also the psychiatrist at the hospital. Notwithstanding this fact, care must be given to formally referencing emergency assessments performed and treatment given at the hospital, and the linking of that to follow-up care and treatment.
RECOMMENDATIONS: Refer to medical findings and recommendations.
g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: We did review the approved intoxication and detoxification policy. It does appear reasonable. The new Medical Director will have to provide specific training based on the policy and we were not aware of any cases where the assessment on intake resulted in an assessment of potential intoxication or detoxification problems.
RECOMMENDATIONS: 1. The Medical Director should provide training to the nursing staff with regard to the
implementation of the monitoring system. 2. Once training has been provided, we presume that the nurses will utilize the CIWA and COWS
assessment forms.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: See medical findings and recommendations.
In addition, it is important to note that there is a substantial sub-set of individuals suffering from substance abuse difficulties who also suffer from some other major psychiatric difficulty. Such other major psychiatric difficulties may be evident while the individual is intoxicated and/or they may become evident during detoxification. In either case, these other major psychiatric difficulties may have to be addressed. Medical staff persons who are managing intoxicated inmates and those undergoing detoxification must be able to rapidly consult with mental health staff and integrate mental health interventions into the treatment process when such is indicated.
RECOMMENDATIONS: 1. Assure the integration of mental health staff into the assessment and treatment of intoxicated inmates and those undergoing detoxification when there is evidence that the inmate is also suffering from other major psychiatric difficulties.
h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.
ASSESSMENT: NONCOMPLIANCE. This item requires training for the staff and the identification of an infection control nurse who will be responsible for overseeing the program.
MEDICAL FINDINGS: The training of the nursing staff and the oversight of the training of the officers should be the responsibility of the Medical Director. The issue that we raised with regard to intake

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related to the potential change in definition of a positive TB skin test. We strongly recommend that the more conservative definition of a positive skin test, defined as 10 mm of induration, be retained because the population seen is such a high-risk population.
RECOMMENDATIONS: 1. The training of medical staff and correctional staff should be conducted under the direction of the Medical Director. She may choose to do this herself or designate someone who she adequately trains.
MENTAL HEALTH FINDINGS: Defer to Dr. Shansky’s report
RECOMMENDATIONS: None.
i. Adequate suicide prevention, including: (i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate metal health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, a review of the ‘behavioral checklist/sick call log’ revealed that those referred to mental health by either mechanism were rapidly evaluated by the mental health staff, and when indicated, rapidly referred to and then evaluated by the psychiatrist. Of course, what this log doesn’t reveal is how quickly corrections officers identified serious mental health needs and then completed a ‘behavioral checklist’, which is the other key element in addressing this issue.
A more detailed review of one inmate referred via a ‘behavioral checklist’ for suicidal ideation demonstrated the mental health unit’s rapid and full response to such an emergency, but raised other concerns. In this case, an inmate not previously known to mental health became suicidal and cut both wrists after he was placed in disciplinary segregation about a month prior to his scheduled release date. Although he was rapidly evaluated and placed on an appropriate level of suicide watch, there was no evidence that his mental health status was taken into consideration when making decisions about disciplinary actions and/or the use of segregation, and mental health staff reported that they were not at all involved in these decisions. The parties and monitoring team had a conference call regarding the Territory’s draft policy regarding inmate discipline and, among other things, the role of mental health staff. Under the current schedule, the Territory’s revised draft policy is due December 4, 2015, and the parties and monitoring team will hold another conference call on the policy on either December 10 or 11.
RECOMMENDATIONS: 1. Continue to monitor and review future behavioral health checklist referral tracking logs. 2. Because security staff have not yet been trained with an approved curriculum for suicide prevention,
this provision remains noncompliant. It is recognized that despite not having been trained, the security staff does an excellent job completing these forms when behavioral problems are identified. However, there should also be an assessment of how early in the process of the emergence of suicidal ideation or other mental health emergency that such difficulties are identified by security staff. 3. Mechanisms for better integrating information from mental health staff into the decision-making process regarding disciplinary actions and the use of segregation must be developed.

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(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Currently, there is insufficient documentation or data to demonstrate constant observation of inmates until they are evaluated by a qualified mental health professional.
RECOMMENDATIONS: 1. The facility will need to develop a means of documenting whether or not an inmate is maintained on
constant observation until the time of the evaluation in order to demonstrate compliance with this provision. 2. Currently, documentation is scattered between an observation form and hit-or-miss notations in the officers’ unit log. Implement approved Log of Suicide Watch (PCO) Rounds. 3. Once implemented, these should be reviewed by mental health staff regularly to ensure security’s compliance with the policy.
(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;
ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: A suicide risk assessment instrument is in place and being utilized. 

RECOMMENDATIONS: 
 1. Continue to utilize the suicide risk assessment tool and develop quality assurance data to demonstrate
compliance with this provision.
(iv) readily available, safely secured, suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Although suicide cut-down tools are in place and safely secured, it is not at all clear that they are readily available (i.e., can be quickly enough retrieved from their location to be useful in the event of a suicide attempt). Based on questioning security staff, it is not clear that all security staff are familiar with their use.
RECOMMENDATIONS: 1. Assure that rapid access to cut-down tools is possible.

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(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, it is not clear that all security staff are familiar with the use of cut-down tools and other suicide prevention emergency interventions.
RECOMMENDATIONS: 1. Complete training for all staff on suicide prevention, including training for security staff on the use
of cut-down tools, followed by an assessment of competency to employ such suicide prevention efforts.
(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: A training schedule was previously adopted, with training scheduled to begin on 1 February 2016, and scheduled to be completed by 31 July 2016.
RECOMMENDATIONS: 1. GGACF will submit their curriculum for training officers and health staff in suicide prevention for
approval by the monitoring team. 2. The facility will complete this training by July 31, 2016 for all staff. 3. Effectiveness of the training will need to be demonstrated by the use of competency measuring tools
and follow-up quality improvement studies.
(vii) availability of suicide resistant cells;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: There is still no suicide resistant cell(s). As was noted in the last monitoring report, there is an area in the infirmary that has been earmarked for conversion into a suicide prevention housing area, but the transformation of those cells into suicide resistant cells has not yet occurred. Therefore, inmates placed on the highest levels of suicide watch are still kept on regular housing units, with the expectation that they will have the constant observation by security staff that is required to assure their safety there. However, based on a review of available observation records, such constant observation could not be confirmed, and it at least appears that observation continues to be intermittent and unpredictable at its best.
RECOMMENDATIONS: 1. GGACF is encouraged to urgently complete renovations in the infirmary in order to provide
appropriate and safe suicide and close observation cells. As expressed in the last 3 reports, all measures should be taken to provide adequate space within the cell, suicide resistant sinks and commodes and the absence of any protruding objects within the cell that would facilitate the

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placement of a ligature. Please refer to all of the detailed recommendations in the Monitor's fifth assessment report regarding the configuration and structure of suicide-resistant housing. 2. Even when suicide-resistant cells are available, security staff will still need to be present in the suicide prevention housing area to monitor inmates on suicide prevention 24 hours per day. Appropriate logs for documenting security staff monitoring will have to be developed, maintained and then reviewed for compliance with policy and procedures. 3. Even when suicide-resistant cells are available, a nurse will have to be present in the suicide prevention housing area 24 hours a day to complete the required monitoring of the patient every shift. These records will also have to be reviewed for compliance with policy and procedures 4. Until such time that the proposed suicide prevention housing area has been fully renovated and become operational, security staff must provide constant observation of inmates placed on the highest levels of suicide watch, and document that such constant observation is taking place. Such documentation should be reviewed for compliance with policy and procedures.
(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The medical/mental health records and a log maintained by the mental health coordinator clearly track and provide information obtained from ongoing evaluations regarding indications for the various levels of suicide watch ordered. A review of medical/mental health records and the tracking log indicates that the protocol for the mental health supervision of actively suicidal inmates is clear, consistent with current standards of medical practice, and carefully followed. However, as noted above (in section vii), it is impossible to document the extent to which security staff is providing the level of observation required to ensure the safety of inmates placed on suicide watch, and it at least appears that the level of observation by security staff continues to be intermittent and unpredictable at its best.
RECOMMENDATIONS: 1. Complete the process of training on suicide prevention and observation policy, implementation and
monitoring. 2. System-wide training for this provision will be the last of the medical trainings offered because
security must also be included. However, the facility is strongly urged to consider a method to ensure that inmates placed on suicide watch, between now and the time training is completed, are adequately supervised and that this supervision is documented according to policy.
(ix) procedures to assure implementation of directives from a mental health professional regarding:
(1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: As noted above (under section viii), the protocol for the ongoing mental health evaluation of suicidal inmates and the care of such inmates, including their placement on and removal from suicide watch, is being carefully followed by the mental health staff. Furthermore, a review of their work in this regard indicates that clinical decisions have been consistently appropriate, both during the period of an inmate’s active suicidality and during the prescribed period of follow-up after an active level of suicidality has remitted. However, there continues to be concern about the implementation of directives that result from the evaluation and the development of care plans for suicidal inmates when such directives must be implemented by staff outside of the mental health unit.
RECOMMENDATIONS: 1. Assure that appropriate mechanisms are in place to facilitate the notification of all medical staff,
especially nursing staff, of mental health directives and care plans for suicidal inmates; monitor the effectiveness of such mechanisms for notification; and monitor the implementation of the directives that nursing and any other medical staff are responsible for. 3. Assure that appropriate mechanisms are in place to facilitate the notification of security staff of mental health directives and care plans for suicidal inmates; monitor the effectiveness of such mechanisms for notification; and monitor the implementation of the directives that security staff are responsible for.
j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: With the addition of the Medical Director, only the midnight shift between midnight and 8:00 a.m. seven days a week is currently vacant. We do know that the Bureau is actively recruiting and we anticipate that this hiring can be completed and the staff in place prior to our next visit. We also recognize that the effort made to rectify the situation of the Health Care Administrator has been successful. With the Medical Director in place, the only medical position remaining is that of nursing hours (eight hours per day) to complete the RN staffing.
RECOMMENDATIONS: 1. Fill the nursing hours to complete 24/7 RN staffing.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: At present, the mental health staff includes the mental health coordinator (Ms. Murray, LCSW), a part time psychiatrist (Dr. Sang), a mental health counselor (Mr. Rosas, MHC), and at least a substantial amount of time of one of the nurses (Ms. Randolph, RN).
At least one additional staff person is required to address all of the provisions of this agreement. It is my understanding that an additional mental health counselor has been identified and is somewhere in the process of negotiation and/or review by human resources, but it remains unclear to me if and/or when this additional staff person might actually start working.

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RECOMMENDATIONS: 1. Fill the currently available slot for an additional mental health staff person as quickly as possible. 2. As mental health staff continue efforts to address all of the provisions of this agreement, staffing
analyses should continue to assure adequate staffing of the mental health unit.
k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: There still are problems with regard to intake and sick call and dental services related to adequate available officer staffing.
RECOMMENDATIONS: 1. Complete the officer training. 2. Stabilize the officer assignments for those officers posted to assist medical and enable them to be
trained on the particular aspects of their assignments.
MENTAL HEALTH FINDINGS: As per medical findings.
RECOMMENDATIONS: As per medical recommendations.
l. A protocol for periodic assessment of the facility’s compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: The medical program now has a dedicated Medical Director in place who can provide leadership for the quality improvement program. The Medical Director should especially focus on professional performance, both by the nursing staff as well as the additional physician who adds the extra day on site. With regard to timeliness of services, the program committee should look at these with regard to each major service, such as intake, sick call, chronic care, unscheduled services and scheduled offsite services.
RECOMMENDATIONS: 1. As described above, the QI program should present data to me at my next visit looking at the intake
process, the sick call program and the scheduled and unscheduled offsite services.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Except for the exceptions noted above, the mental health team is now collecting adequate data that can be used to assess compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious mental health

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conditions. When the above noted exceptions are addressed, the team will also have the data required to assess the overall quality of services provided, and thereby identify any policies or procedures that need to be revised in order to assure quality mental health service delivery.
Given the now ready availability of such data, the current focus should be on the development of a meaningful periodic review of this data for compliance with policies and procedures, and the development of an approach for employing this data to assess overall quality of mental health care.
It must be noted however that quality assurance with regard to mental health care is not entirely under the control of the mental health staff. For example, assuring the safety and adequate care of suicidal inmates requires the availability of suicide-resistant cells and monitoring by security staff. In addition, the appropriate care of many of the seriously mentally ill inmates who are amenable to treatment requires access to a unit designed for inmates with such special needs that would allow for enhanced mental health programming, and those who refuse treatment require a mechanism to obtain treatment for them.
RECOMMENDATIONS: 1. The mental health staff should develop compliance reports that indicate any failures to comply with
developed policies and procedures, and the result of investigations into the reasons any such failures to comply occurred. 2. The mental health team should also assess the overall quality of the mental health services provided, with an eye towards identifying, developing, and implementing any quality improvements that should be made. 3. Monthly or quarterly management meetings with medical staff and other department leaders should be occurring. Mental health staff should be using these meetings as an opportunity to continue to raise quality assurance issues that are not totally under their control. Raising such issues and any identified approaches to addressing such issues should be documented in the minutes of these management meetings.
m. Adequate dental care;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: We found two types of problems with regard to dental access. First of all, the dental staff had problems being available based on the ability of the Bureau to timely purchase tickets on flights that would allow them to be available for the full day. This needs to be rectified and should be addressed by the Health Service Administrator. The second issue has been some slippage with regard to officer escorts, so that the percent available has recently been as low as 60% of scheduled appointments.
RECOMMENDATIONS: 1. Continue to monitor the access to dental care by documenting scheduled versus seen, and the reasons
why not seen. 2. Report the number of restorations each month as well as the number of extractions, with a goal of
getting closer to 1:1.
ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: As was noted in prior monitoring reports, mentally ill inmates, especially those suffering from serious yet untreated mental illness, may not focus on their need for dental services and therefore not seek the dental services that they require, even if they are in pain. Therefore, GGACF health, mental health and dental services must be proactive in monitoring the dental hygiene of this vulnerable population.
RECOMMENDATIONS: 1. GGACF officials should ensure protocols are in place and practices that ensure proactive oral health
assessment of mentally ill inmates.
n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;
ASSESSMENT: NONCOMPLIANCE. No substantive improvement from previous assessment.
MEDICAL FINDINGS: Now that there is a Medical Director in place, all deaths and any significant hospitalizations that may be problematic must be reviewed per this policy.
RECOMMENDATIONS:
1. Have the new Medical Director perform a review of the care provided at GGACF for the patient who died.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Although there were no inmate deaths to review, there was a serious suicide attempt, which was made by an inmate who had not been on the mental health caseload prior to the attempt. However, there was no morbidity review of the suicide attempt to determine such things as whether or not underlying mental health difficulties had been missed and if so why; whether or not clinically significant suicidal ideation could have been identified prior to the actual suicide attempt; and whether or not there were any other issues raised by this case, such as the process by which decisions are made to place an individual in segregation. The suicide attempt also had not been previously reported to the Monitor and USDOJ as required by the Settlement Agreement, notwithstanding repeated USDOJ requests for that information.
RECOMMENDATIONS:
1. The clinical directors, Director of Nursing and Health Services Administrator should develop mechanisms to identify and review all cases of mortality and serious morbidity as part of the Quality Improvement process. These reviews should also include security leadership.
2. When such reviews result in the identification of issues that need to be addressed (whether they be a failure to comply with policies and procedures, or the possible inadequacy of existing policies and procedures), a plan for corrective action should be developed.

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o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;
ASSESSMENT: NONCOMPLIANCE MEDICAL FINDINGS: As we understand it, a nurse is making rounds three days per week and documenting in the medical record for those patients who have issues that require the nurse to address. We would like to be able to facilitate our review of this item by the nursing and mental health staff identifying names of people and the date seen for which they wrote a note in the medical record.
RECOMMENDATIONS: 1. Maintain documentation of patients referred for care by either medical or mental health as a result
of the segregation rounds made weekly.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: There is currently weekly mental health rounding in isolation/segregation cells performed by Mr. Rosas, and monthly mental health rounding in isolation/segregation cells performed by Ms. Murray. In both cases, all inmates in isolation/segregation are seen – not just those on the mental health caseload – and there are logs kept for both sets of rounding that indicate when the inmate was seen, the inmate’s general well-being, the condition of the inmate’s cell, and any specific mental health needs that the inmate might have.
Although on this monitoring visit I was unable to accompany Mr. Rosas or Ms. Murray on these rounds, I plan to do this the next monitoring visit. My focus will be on the assessment of the impact of isolation/segregation on the inmate’s mental health status; the development of a recommended plan for any inmates whose mental health has been adversely impacted upon by isolation/segregation, including recommendations with regard to whether or not they should continue to be placed in isolation/segregation; and the appropriateness and feasibility of any such developed plan. However, it should be noted that the prior monitor did accompany Ms. Murray on her rounds, and noted that the rounds were conducted in a “competent and effective manner”.
RECOMMENDATIONS: 1. The Mental Health Coordinator will keep documentation of weekly and monthly rounds. 2. This provision will be more closely monitored at the time of the next site visit as described above.
p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Despite this prohibition, there are still inmates with serious mental illness who are being held in isolation/segregation, and some of them have been held in isolation/segregation for many, many years. The seriously mentally ill inmates being held in isolation/segregation fall into several sub-groups, each of which raises different issues/concerns.

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First of all, there are seriously mentally ill inmates who are not receiving any type of mental health treatment because they have reportedly refused such treatment, and as a result they continue to be acutely psychotic and/or otherwise seriously mentally ill. At issue for this subgroup is the documentation by mental health staff (during the rounding process) of their mental status and their need for an intervention other than locking them in isolation/segregation, and a clear protocol for addressing the mental health needs of such inmates.
There is another group of seriously mentally ill inmates who are in treatment, but reportedly are being held in isolation/segregation because, despite treatment, they continue to be too vulnerable to be placed in general population. In other words, they are reportedly being protected by being placed in isolation/segregation. These inmates are allowed two hours/day of congregant out-of-cell unstructured time and at least some of them are also now participating in the new group therapy program. However, to date, there is no planned housing alternative that would provide protection for such inmates, such as an open unit for this population of patients and others who might require similar protections. There is also no enhanced programming for seriously mentally ill inmates that would be a therapeutically sound alternative to locking them in isolation/segregation for the overwhelming majority of the day.
Then there is the group of seriously mentally ill inmates who are in isolation/segregation as a disciplinary sanction. As discussed below, there is no evidence that the mental health status of these inmates was considered when reviewing their disciplinary infraction and/or when deciding whether or not isolation/segregation was the most appropriate response to their disciplinary infraction.
RECOMMENDATIONS: 1. As per the provisions of this Settlement Agreement, inmates with serious mental illnesses may not be
placed in isolation. This infraction should be repeatedly documented during the rounds of isolation/segregation cells performed by the mental health staff, and corrective action taken. 2. For those seriously mentally ill inmates who refuse treatment, the mental health staff needs to opine as to whether or not such inmates are a sufficient danger to themselves or others that they would require isolation/segregation. In addition, a protocol must be developed for that subset of inmates that are a danger to themselves or others, focused on attempting to get them to voluntarily accept treatment and outlining steps that should be taken for those who ultimately continue to refuse treatment. 3. With regard to those seriously mentally ill inmates who are currently in isolation/segregation for their own protection, the Bureau of Corrections needs to develop a corrective action plan with specific recommendations for capital improvements that will provide a more appropriate housing unit for such inmates, with dates to remedy this deficiency. In addition, once an alternative to the isolation/segregation of such inmates has been developed, mental health staff will need to develop enhanced programming for them. 4. With regard to those seriously mentally ill inmates with an alleged disciplinary infraction, see the next section of this report. 5. During the time that inmates with serious mental illnesses remain in segregation, mental health staff should be aware that these inmates should be offered a minimum of 10 hours a week of unstructured out-of-cell time by security. Additionally, mental health staff is encouraged to develop supportive group or individual therapeutic activities, generally recommended being a minimum of 10 hours per week per inmate in order to support the inmate’s mental state as well as assist inmates in acquiring skills to move them off the segregated status and sustain themselves in the general population setting. 6. Mental health staff need to repeatedly raise all of these concerns during management and administrative meetings as a reminder to all levels of staff that these concerns must be addressed.

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q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Such a review by and/or consultation with mental health staff does not occur.
RECOMMENDATIONS: 1. GGACF needs to develop an effective policy and process to provide mental health review and input
into the disciplinary process. 2. Mental health staff must be prepared to quickly assess inmates with alleged disciplinary infractions,
with an eye towards determining whether or not the alleged infraction was likely a product of any mental illness that the inmate might be suffering from, and the likely impact of potential sanctions on the inmate’s mental health status. 3. GGACF should develop a form that can be sent to the Mental Health Coordinator, completed by mental health staff and submitted to the disciplinary committee, which outlines the findings of the mental health assessment. The committee can use the same form to communicate back to the mental health staff the outcome of the hearing proceeding. 4. Mitigating factors discovered by the mental health professional must be considered by the disciplinary committee. 5. Mental health services should track the effectiveness of their input in mitigating sanctions or terminating sanctions as appropriate. 6. Alternative housing and treatment services are an essential component in diverting seriously mentally ill inmates committing infractions due to their impaired judgment and mental processing. 7. Again, it is recommended that GGACF provide appropriate staffing and housing alternatives for this population. (See V.1.p.)
r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: There is some improvement with regard to the availability of the exam rooms within the housing units. Two rooms in housing units are now ready for use. They each need additional chairs; otherwise, they are fully ready. One room is being used both by the nurse who does sick call as well as by the medication nurse. There are six rooms that require exam tables, of which we were told should be available the week after our visit. On the other hand, we did not observe any work being completed with regard to the remaining issues in the infirmary.

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RECOMMENDATIONS: 1. We strongly recommend that the Medical Director and Health Services Administrator jointly
develop a plan to expedite the completion of the infirmary renovations and the implementation of the dental and mental health rooms as well as medical patient rooms. 2. Complete the exam rooms in all of the housing units.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The renovation of examination offices on each of the housing units has been virtually completed. It is presumed that mental health staff will have access to these offices for individual sessions with inmates and psychiatric visits when other medical staff are not utilizing them, but the logistics of this (such as scheduling and the availability of keys to those offices) will have to be worked out. However, the renovation of space for other mental health programming still needs to be completed, such as the renovation of multipurpose rooms on the segregation units so that the space can be used for mental health programming; the renovation of cells in the infirmary to make them suicide-resistant; and the identification of space for an expanded group therapy program.
RECOMMENDATIONS: 1. Continue with current renovation plans. 2. Continue to assess the need for additional space for developing mental health programming.
s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Most of the issues related to the timely, current, and adequate development of mental health treatment plans have already been discussed under other provision of this agreement. In summary, at the next monitoring visit I will be reviewing the revised treatment plan document; reviewing records and logs to assess the timely completion of treatment plans; review treatment plans to determine to what extent they were developed by the mental health treatment team as a whole, and to what extent they were reviewed with and understood by the inmate/patient; and reviewing the relationship between the information obtained during the assessment process and the treatment plan in order to assess the adequacy of the treatment plan with regard to the inmates presenting problems.
It must again be noted that this monitor recognizes that the adequacy of treatment plans might at times be compromised by some of the above noted problems that are outside of the control of mental health staff. When this is the case, this monitor will expect to see any such required compromises noted in the treatment plan, so as to make it clear that there is a more appropriate intervention that is simply not currently available.
RECOMMENDATIONS: 1. Based on policy and developed protocol, treatment plans should be updated at set frequencies based
on inmate need and changing conditions in the inmate status. It is strongly recommended that supervisory review occur to ascertain the appropriateness and completeness of the treatment plans generated.

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2. When indicated, in-service training on treatment plan development is recommended to ensure consistency between staff members in developing measurable objectives toward marked improvement in those inmates followed by the mental health team.
(ii) adequate mental health programs for all prisoners with serious mental illness;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As has been already noted above, mental health programming has been expanded to include various group therapy programs. Although I have recommended the expansion of the group therapy program, it is clear that the existing program has already proven itself to be quite beneficial to many of the inmates in need of mental health services.
As noted above, enhanced programming for seriously mentally ill inmates, especially those currently in isolation (both while they remain in isolation and even when a suitable alternative to isolation has been developed), must be developed. In addition, a step-wise program of interventions for those who refuse treatment must be developed and implemented.
RECOMMENDATIONS: 1. The mental health team will need to develop a global treatment menu designed to meet the needs of
inmates at different levels of housing and treatment needs. 2. Group programming should be designed to meet the clinical needs of individuals who should be
assigned to those programs based on their needs assessment and their individual treatment plan. 3. The facility should consider how it might create a special population housing unit that would provide
a safe housing alternative to vulnerable mentally ill inmates and make the delivery of services more efficient to those who require enhanced mental health services. 4. Those who refuse needed treatment must be further assessed to determine if they are a danger to themselves or others; this assessment should be used to determine whether or not they require placement in isolation/segregation and whether or not a court intervention should be obtained that would require them to undergo treatment; and all the while, efforts should continue to convince such inmates to voluntarily accept treatment.
(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: For the most part, the medical records indicate that the psychiatrist is monitoring inmates for medication adverse effects, but a more routine way of reporting such monitoring might simplify chart reviews performed for the purpose of quality assurance. However, a review of the records at least appears to indicate that the psychiatrist is not always totally aware of the extent to which an inmate has been compliant with the medication as prescribed. It is not clear from the records that inmates have consistently given ‘informed’ consent for such treatment. Additionally, it does not appear that other medical and mental health staff have been charged with the responsibility for also monitoring for medication adverse effects, and/or trained to assume such a responsibility.

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RECOMMENDATIONS: 1. Assure communication between nursing staff and the psychiatrist with regard to inmate compliance
with psychotropic medication orders. 2. Confirm the obtaining of ‘informed consent’ for medication in the medical records or consider a
special form for this purpose. 3. Assure that medical and mental health staff are trained to suspect the presence of psychotropic
medication adverse effects and report such a suspicion to the psychiatrist in a timely manner.
(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Although this training has not yet occurred, correctional staff are completing the ‘behavioral checklists’ and making referrals for mental health services for both inmates who are already on the mental health services caseload and those who are not. Hopefully, this training will also help security staff better appreciate the role that mental health staff should be playing in decisions regarding the addressing of disciplinary matters, the review of situations where there was use of force, the use of isolation/segregation, and the classification of inmates. . RECOMMENDATIONS: 1. Continue to utilize the Behavioral Checklist process. 2. Finalize and present mental health training for security staff. 3. Improve the incorporation of information obtainable from mental health assessments into security
decision-making and review regarding disciplinary matters, the review of situations where there was use of force, the use of isolation/segregation, and the classification of inmates. 4. Conduct a facility quality improvement morbidity review that can be submitted to the monitoring team for review.
(v) ceasing to place seriously mentally ill prisoners in segregated housing or lock-down as a substitute for mental health treatment.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, seriously mentally ill inmates continue to be placed in isolation/segregation. Most such inmates are not receiving adequate mental health services, and some of them are not receiving any mental health services at all.
RECOMMENDATIONS: 1. The Health Services Administrator needs to coordinate monthly Medical Administration Committee
(MAC) and Quality Improvement meetings, documented by minutes and attendance sign-in sheets. This issue should be an important agenda item for such meetings. These meetings should include the Warden or the Warden’s designee in order to assure that plans for addressing this issue take all aspects of the problem into consideration.

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VI. FIRE AND LIFE SAFETY 

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from the previous assessment. However, with the assignment of a full-time fire safety officer, we continue to see incremental improvement in the conducting of monthly fire safety inspections of all areas of the facility and soliciting the expertise of the Fire Safety Marshal to help develop the GGACF fire safety program. The monthly fire safety inspections are conducted in a consistent manner and deficiencies are being identified. However, corrective action on noted deficiencies needs to be addressed. We noted fire related fire safety discrepancies dating back to May 2015 that have not yet been corrected.
FINDINGS: The Territory reported that they have been working with Corrections Corporation of America (CCA) to help develop the facility policies and procedures. Since the last visit, the draft policy was sent to the Monitor and United States for review and returned to the Territory for further revisions. The Territory has since revised and policy and returned the same to the Monitor and Unites States for review. The finalization, approval, staff training and implementation of these policies and procedures remains vital Inadequate housing unit staffing levels and contraband control practices continue to enable inmates to ignite various materials in the housing units as evidenced by our September 2015 inspection of the housing units. During these inspections, I continue to observe lit wicks and smoke emanating from them in several housing units. Supposedly, inmates use the smoke from the lit wicks to ward off insects. However, aside from the contraband problem stemming from the use of wicks, it also continues to create fire hazards. It appears that staff have relented to the use of lit wicks by inmates and do not prohibit their use.
The automatic fire detection and suppression system remains inoperable, inadequate staffing levels and contraband control leaves housing units deleteriously under-controlled and unmonitored, inmates apparently have undetected and uninterrupted access to items to ignite materials, and inmates obviously have no inhibition about igniting materials.
During this monitoring visit, it did not appear that there were any reported fires in the housing units. However, due to the ease by which inmates can access fire ignition sources and given the state of disrepair with the facility electrical system, i.e., exposed electrical wiring and heavy fire loads in the inmate cells, this area remains volatile from a fire and life safety perspective.
During our inspection, I also observed exposed electrical wiring in various areas of the Facility, including the kitchen, housing units and maintenance shops. In the kitchen I continue to observe boxes stacked in

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the dry storage area nearly up to the ceiling (should be stacked no higher than 30 inches below the ceiling). This was an identical finding in our last three reports. These findings, in addition to previous findings, reveal the urgent need to develop and implement a comprehensive fire safety program at GGACF.
Officer Samuel has been assigned as the full-time fire safety for the facility. There is still no documentation available to demonstrate that evacuation plans have been approved by the VI Fire Marshall. The fire evacuation diagrams within the Facility remain woefully outdated and offer no assurance that they would be effective in routing staff and inmates from a fire or smoke related emergency. In fact, some diagrams do not outline the appropriate route. On a positive note, Officer Samuel continues to conduct his systematic inspections of fire safety needs for the facility. A comprehensive fire evacuation plan that that would incorporate all areas and buildings within the confines of GGACF and the contents of the overall fire safety program, such as the fire safety policies and procedures, still needs to be developed and provided to the VI Fire Marshal for review.
Staff reported and documents reflect that the BOC has secured an MOA with the VI Fire Service for helping GGACF come into compliance with the fire safety provisions of the SA. However, as we reported in our previous reports, it must be expressed that the BOC/GGACF are the primary entities for demonstrating compliance with the fire safety provisions of the Settlement Agreement.
RECOMMENDATIONS: The Monitor continues to request the reports for all drills and exercises conducted. It is also imperative that when the GGACF Fire Safety Program and the Fire Safety Plan are finalized and that they be provided to the Fire Marshal and with a copy to the Monitor and USDOJ.
1. Finalize and implement fire safety policies once approved and according to the agreed schedule. 2. Repair/replace/install fire detection and suppression systems throughout the entire campus and
structures. 3. Train all staff on this plan. 4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all locations where
staff would need to search for or evacuate people. 5. Conduct and document quarterly fire drills for all shifts and document those activities. 6. Officials must continue to critically review staffing levels to ensure adequate inmate supervision and
flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security. 7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program. 8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action. 9. The fire inspection program was detailed in the draft fire safety policies and procedures that the monitor provided to the parties, and they should become a fundamental element of pre-and inservice training once policies and procedures are finalized, approved, and implemented. It is anticipated that the new policies and procedures that CCA is helping the BOC develop meet all of the requirements of Settlement Agreement.

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b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Almost identical to previous Monitor’s reports, we found that the Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, and cell and housing unit sprinklers are non-functional. We noted an improvement in the housing units whereby inmates were not using the fire sprinklers to support personal clotheslines. The primary fire detection and suppression system was designed to automatically detect and extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates. The only way to alert staff and inmates of a fire or smoke hazard is to use hand-held air horns that are located in the control rooms of the housing units.
Adequate supplies of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures. The Fire Safety Officer has incorporated the inspecting of fire extinguishers in his monthly inspection reports, which is a positive step in improving fire safety.
GGACF staff continue to indicate that sprinkler heads may be replaced in the “newer” buildings at some point in 2015. During previous inspections, we were provided with a letter, dated November 24, 2014, directed to the Department of Interior from the BOC Director requesting to allocate funding to aid in the replacement of the fire suppression system and for refurbishing the Kitchen at GGACF. During this inspection, the Director gave us an update on progress in these areas. For example, the scope of work for the kitchen is now more defined. They are in the process of receiving a cost estimate for exhaust and blower fans for the housing units, among other important capital projects. However, the scope of work for the fire suppression system seems to only include the purchase and installation of fire sprinkler heads and related parts in areas of the Facility where there is a fire sprinkler system, but does not seem to address the need to install a fire sprinkler system such as in the old housing units where there is no fire sprinkler system. This needs to be clarified. Moreover, GGACF plans to continue to house individuals in the “older” buildings, and has no plans to update or install fire suppression equipment in those buildings. As reported in earlier monitoring reports, GGACF will never come into compliance with these provisions if that remains the case.
Although it was commendable that the Fire Safety Officer has systematically embarked in identifying fire safety discrepancies and fire safety needs, the resources to correct those deficiencies must be provided. For example, the Monthly Fire Safety Inspection Reports for the month of July and August 2015 identified missing or non-functional smoke alarms; therefore, funds need to be made available in order to purchase missing smoke alarms and for purchasing adequate stocks of batteries for them.
RECOMMENDATIONS: 1. Refer to recommendations above (a).

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2. Consider purchasing fire safety program software from NFPA and/or the American Correctional Association to assist in program development and monitoring.
3. Continue to support fire safety officer.
c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. In our previous report, GGACF staff indicated that fire drills have not been conducted on a regular basis. The Fire Safety Officer has commenced a process for conducting fire drills. It is laudable that the Fire Safety Officer is addressing the necessity to conduct fire drills. The failure of GGACF staff to conduct fire drills on a regular basis of all facility areas continues to put inmates at risk of injury or death, should a fire break out that cannot be suppressed by the hand-held fire extinguishers present in the officer control pods of housing units.
During this site visit it appeared that security staff had a better awareness of emergency key management. With a few exceptions, staff were able to open emergency doors with keys. In the housing units we inspected, there were emergency keys available. However, this area needs continuous monitoring and staff need to be trained and retrained on a continuous basis on the Key Control Policy and Fire Safety policies once they are approved. In future site visits we will continue to inspect this area of fire safety. In the housing units that have cell slider doors (Units L and K) the tool used for opening cell doors are still not readily available. Staff are using a long screw driver for this purpose. A special tool for opening these doors manually is now available, but staff have not been trained on the proper use of the tool. The Fire Safety Officer and security management should conduct drills to see how prompt these type of cell doors can be manually be unlocked. There needs to be a clear and concise understanding by all security staff as to where the facility emergency keys are kept as well as having the tool to open the cell slider doors readily available and to ensure that staff are trained and retrained on the final Key Control Policy and Fire Safety policies.
Emergency keys are not appropriately marked and identifiable by touch. A system for marking and identifying all emergency keys that match the proper door locking mechanism needs to be developed and systematically implemented.
RECOMMENDATIONS: 1. Develop and implement a valid and reliable emergency key system as described above. Train and
drill staff as discussed on system use. 2. Develop emergency key and locking mechanism inspection and reporting system as discussed above. 3. Implement competency-based staff training as discussed above. 4. Exercise fire safety program using onsite, scenario-based drills; include community responders in
exercise planning and exercise events. 5. Send the training officer and part-time fire safety officers to the National Fire Institute, National
Emergency Training Center, Emmetsburg, MD for additional training.

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d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of
 the cell; and; 
 (ii) that all facility remote locking cell mechanisms are functional;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Almost identical to our previous monitoring reports, documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance.
There is not a written preventative maintenance program or a regular security inspection program in place for checking that cell locks are functional and are not jammed from the inside or outside of the cell, nor a system for ensuring that all facility remote locking cell mechanisms are functional. During this monitoring visit we were pleased to observe no evidence of inmates compromising the cell locks by inserting various materials in the locking mechanisms. We did, however continue to observe numerous housing unit grills whereby the locking mechanism was inoperable and the grills left open.
RECOMMENDATIONS: Same as above. 1. Also refer to recommendations related to security provisions, contraband, and inmate manipulation
of cell door locking systems. 2. Repair all remote cell locking notification technology.
e. Testing of all staff regarding fire and life safety procedures;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No records have been provided to verify that all staff have been trained and tested on safety procedures. The new Fire Safety Officer reported that some hands-on training on the fire extinguisher still needs to be addressed. However, this provision of the Settlement Agreement requires a more comprehensive program for testing of all staff regarding fire and life safety procedures.
RECOMMENDATIONS: 1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF
officials should create a statistical report showing percentages of staff who have and have not completed required testing. 2. Provide this Monitor documentation evidencing compliance with this Provision.
f. Reporting and notification of fires, including audible fire alarms;
ASSESSMENT: NONCOMPLIANCE

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FINDINGS: The fire reporting and notification system remains inoperable as reported in previous Monitor reports. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a hand-held air horn to alert inmates’ evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. As identified in previous Monitor reports and consistent with this inspection, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.
The new Director reported that he is prioritizing the installation of a fire alert notification system.
RECOMMENDATIONS: 1. Install and routinely test the stored file alert notification system without delay.
g. Evacuation of prisoners threatened with harm resulting from a fire;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously stated, the fire evacuation policies have not been approved and full scale evacuation drills are not conducted.
RECOMMENDATIONS: 1. Develop and implement an annual full scale evacuation exercise that involves community
emergency, health, and social services responders.
h. Fire suppression;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as previously stated. There is no functional fire suppression system, with the exception of the kitchen’s cooking area.
RECOMMENDATIONS: 1. Develop and implement an annual full scale evacuation exercise that involves community emergency,
health, and social services responders. 2. Repair the automatic fire detection, notification, and suppression system. 3. Replace cell sprinklers with tamper proof mechanisms. 4. Monitor staff response to fires, ensure they comply with basic fire safety principles, and implement
appropriate staff corrective action as needed.
i. Medical treatment of persons injured as a result of a fire; and
ASSESSMENT: NONCOMPLIANCE

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FINDINGS: The requirements for this provision need to be addressed in the final Fire and Life Safety Policies and procedures. Once the policies and procedures are approved, staff must be trained on them and they need to be fully implemented.
RECOMMENDATIONS: 1. Finalize, approve, and implement relevant policies and procedures. 2. The comprehensive fire safety program development must involve health care leadership to ensure
that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event. 3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements. 4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses. 5. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.
j. Control of highly flammable materials.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Many inmate cells contain considerable personal property, thus creating a fire and safety risk. However, it appears that that this issue is being addressed by the new Director by purchasing bins for prisoners to store their personal belongings. Identical to previous reporting, flammable storage areas/cabinets in the Carpentry shops do not appear to be properly vented.
RECOMMENDATIONS: 1. It is anticipated that the control of highly flammable materials will be addressed in the revised CCA
policies and procedures and that staff will be trained on them and that they be fully implemented.

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VII. ENVIRONMENTAL HEALTH AND SAFETY 

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:
a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Documentation in the form of logbooks and memorandum was provided during this monitoring visit that demonstrated ongoing efforts by GGACF officials and maintenance staff to assess, improve, and monitor facility sanitation and hygiene. Cleaning supplies were more readily available in the housing units. Some housing units and cells were cleaner than others and the need to consistently conduct routine and sustained cleaning of all facility areas remains a challenge to GGACF staff.
Again, however, housekeeping and sanitation plans will not meet compliance with this Provision without adequate staffing levels as previously stated.
The Maintenance Supervisor maintains preventative maintenance schedules for various components of the GGACF physical plant, including the emergency generator. The emergency generator has been problematic for some time. The Maintenance Supervisor has ordered a radiator to repair it.
However, during this inspection we continued to observe inoperable doors and grills, inoperable showers, mold in showers, non-functioning water fountains and plumbing leaks. The new Director has started to address the perimeter of the facility and security fencing needs.
RECOMMENDATIONS: 1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water
for inmates. 2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and
linens. 3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per
week. 4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene,
adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.

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5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.
8. Repair all housing/cell windows to prevent penetration by insects.
b. Adequate ventilation throughout the facility;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated). During this site visit we took random heat index reading of some housing unit dayrooms and cells. The heat indices remain unacceptably high. For example, in the common area of Unit 9B, the heat index was 107.6 F at 3.25 pm, with a large fan blowing. Heat indices of 110.9 F, 111.6 F, and 109.4 F were measured in Unit 9A.
Most of the housing unit exhaust fans remain inoperable. This is especially harmful for inmates unable to afford to purchase fans and inmates with serious mental illness on certain medications. One indigent inmate, who has been diagnosed with “mental retardation/schizophrenia” and is taking Haldol and Cogentin, continued to be held in segregation without a fan in his cell. This inmate also did not have a fan during the June 2015 site visit. We recorded the heat index in his cell during this visit as 103.6 F. We were informed that he had been given a fan after the June 2015 visit, but somehow had managed to sell the fan to another inmate for a cigarette butt, despite being locked in his cell and despite the fact that the fan is too large to fit through the cell window or food port.
The new Director is prioritizing the installation of exhaust and blowers fans for the housing units.
RECOMMENDATIONS: 1. Timely complete an air quality assessment performed by a qualified provider. 2. Implement necessary improvements that reduce housing area and cell temperatures and increase air
flow. 3. Medical and mental health staff should monitor all inmates for heat and airflow-related health risks.
All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions. 4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors.

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5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions.
6. Medical and mental health professionals should closely monitor inmates being administered medications that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.
c. Adequate lighting in all prisoner housing and work areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Attention to lighting repair and replacement remains positive. However, security staff continue to allow inmates/detainees to cover their cell lights, which is creating a fire hazard. However, we did note improvement in this area from previous inspections.
RECOMMENDATIONS: 1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all
required internal and external perimeters, housing areas, support services structures and areas. 2. Maintain an ongoing lighting repair log that evidences repair activities. 3. Ensure rapid repair and replacement of inoperable lighting, add additional external and internal
illumination where indicated by a comprehensive security lighting needs assessment. 4. Provide for adequate staffing levels to support lighting plan and maintenance. 5. Increase illumination in all occupied cells for improved security and inmate wellness. 6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that
impedes good visibility from the cell door window. 7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are reliably
operational.
d. Adequate pest control for housing units, medical units, and food storage areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Very little change since previous inspections. This provision remains in partial compliance but no decline in performance was found. Identical to our previous inspection, we noted that the overhead door to the storage area of the Kitchen is not properly sealed and rodents and vermin can easily infiltrate the Kitchen. Inmates in the housing units complained of insect presence. Some inmates continue lighting “wicks” made, apparently, of toilet paper on their cell windows and floor, hoping that the smoke will deter insects. We also observed missing or broken screens on many facility windows.
The BOC has contact with a private vendor (Oliver Exterminating of St. Croix) to provide pest control services at GGACF.

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RECOMMENDATIONS: 1. Review, revise, develop, train, implement, evaluate environmental pest control policies and
procedures that provide for both incidental and scheduled pest control inspections and mitigation. 2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed
for requirements of those activities. 3. Replace all missing and broken unit and cell window screens to prevent access by insects.
e. Prisoner and clinic staff access to hygiene and cleaning supplies;
ASSESSMENT: PARTIAL COMPLIANCE FINDINGS: There was no substantive improvement from previous assessments. Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies. However, similar to previous site visits, there were a number of inmate complaints in the Housing Units claiming they do not have sufficient quantities of cleaning materials to properly sanitize the showers. We observed that many inmate showers are in deplorable condition from a sanitary standpoint, including mold problems and physical plant deterioration. We also observed that some showers have been repaired from our previous site visit.
RECOMMENDATIONS: 1. Ensure that all inmates have access to hygiene products upon admission to the facility. 2. Continue to provide adequate supply of these personal care items in control pods or housing units to
ensure timely exchange of use-for-new products. 3. Prohibit inmates from bartering these supplies and from hoarding empty containers in their cells and
living areas.
f. Cleaning, handling, storing, and disposing of biohazardous materials;
ASSESSMENT: NONCOMPLIANCE – No substantive improvement from previous assessment.
FINDINGS: No substantive change from previous assessment.
There is no formal sanitation plan or protocols covering compliance with this Provision; nor is there a formal training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling bio-hazardous materials, provided and instructed on the proper use of bio-protective clothing and supplies, and supervisors must closely monitor biohazard clean-ups. Remaining in noncompliance with this Provision can jeopardize the health of staff and inmates.
Spill clean-up kits were available in the medical area.
RECOMMENDATIONS: 1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive
bio-hazard control plan that includes: 2. OSHA and CDC standards and protocols for biohazard safety and exposure control;

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3. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal, storage, inspections, and clean-up;
4. Staffing and inmate training on the plan and proper handling and disposal of biohazards; 5. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all bio­
waste; 6. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations where
biological waste and/or spills do and could occur; 7. Provide appropriate clean-up apparel and training in the use of that apparel. 8. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas
to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility. 9. Develop a bio hazardous control program that involves regular inspections of all potential contamination areas. 10. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies. 11. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.
g. Mattress care and replacement;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: I did not see this area to be problematic during this monitoring visit. There were no inmate complaints regarding their mattresses and the ones I inspected were adequate. However, GGACF staff have not yet substantially addressed the Monitor’s previous recommendations below.
RECOMMENDATIONS: 1. Refer to previously discussed sanitation recommendations. 2. Issue clean and usable mattresses to all inmates. 3. Complete a full inventory of non-usable mattresses and remove them from the supply. 4. Do not issue mattresses to inmates until after properly inspected for damage and contraband, cleaned
and sanitized. 5. Maintain reliable records that verify mattress inventories, cleaning and maintenance requirements.
h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No substantive change since previous assessment. Implementation of policies and procedures, once approved, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, however, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff that supervise inmates and are allowed to handle these chemicals must be properly

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trained in that role and those responsibilities. This has yet to occur. In addition, Material Safety Data Sheets had not been updated, as recommended during the June 2015 compliance tour. The Territory has, however, drafted a chemical control policy for review by the Monitor and the United States
RECOMMENDATIONS: 1. Finalize, approve, and implement relevant policies and procedures. 2. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections,
inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs. 3. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols. 4. This provision can advance to Substantial Compliance once related policies, procedures and plans are approved and implemented according to the Agreement.
i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously reported, housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports and found during this monitoring visit, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets. However, we did not observe inmates drying these items in their cells using clotheslines anchored to fire sprinkler heads, walls, window frames, bunks, etc. This was a positive development. We also continue to observe worn out linens and dirty linen in many inmate cells.
RECOMMENDATIONS: 1. Finalize, approve, and implement relevant policies and procedures. 2. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks. 3. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells. 4. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of bedding. 5. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan
that governs total laundry operations. 6. Develop specific policies and procedures for handling, containing, and washing contaminated
clothing, linens, and mattresses. 7. Consider replacing all wood laundry carts made of non-absorbing materials that can be sanitized and
completely cleaned. Discontinue the practice of moving laundry on carts that have not been cleaned and sanitized. 8. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing should be exchanged with clean items twice per week at minimum, sheets and towels once per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health.

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9. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets.
10. Staff and inmates involved in the laundry work program should be properly trained and supervised. 11. Laundry equipment should reliable and properly maintained.
j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The new Director reported his plans to refurbish the Kitchen with the necessary capital improvements is underway. This is a very positive development. In addition, the Territory drafted the food services policy and provided the same to the Monitor and the United States for review.
The physical plant of the Kitchen remains in a state of substantial deterioration as does the food service equipment. Repairs were made to the flooring in order to eliminate the problem of standing water. Overall, the kitchen was cleaner than it was during previous site visits, with the exception of the floor drains. The dishwasher has not been working properly for some time. Apparently the dishwasher needs a door.
There is still an inoperable walk-in refrigerator that was cleaned from our previous site visit; however, there is still evidence of roach infestation that staff are trying to address. During the inspection of the Kitchen, I observed a mouse darting from the cooking area into the inoperable walk-in refrigerator.
There is still no hot water in the male and female inmate bathrooms to properly clean their hands. There is an additional hand washing sink located outside the bathrooms that did have hot water, but it takes a lengthy amount of time for the water to get hot.
There are no documents to prove that food temperatures are routinely taken of prepared food. However, staff reported that the food service vendor recently provided training to staff on kitchen sanitation, food temperature control, among other food related topics. Further, the Territory indicated that staff will commence documenting food temperatures in October 2015.
The kitchen doors are not rodent proof. We observed evidence of mold and rust in various areas of the Kitchen that staff is attempting to address; however, a permanent fix to the problem still needs to be made to the overall structure of the kitchen. There is no master inventory of the utensils and dangerous implements. However, the kitchen officer is still working on finalizing a chit check out system for the utensils and dangerous implements. Facility staff reported that they are also in the process of purchasing the needed food service equipment to ensure that food remains at proper temperatures at feeding time. The Facility purchased the needed food service equipment, which includes thermal trays and storage warmer bags. The food warmers are located in the housing units.

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RECOMMENDATIONS: 1. Review, revise, develop, train, implement, and evaluate food service program policies and
procedures. 2. Ensure policies and procedures include, at minimum, the following elements:
A. Meals that are nutritionally balanced, well-planned, and prepared and served in a manner that meets established health and safety codes;
B. An adequate number of qualified food service employees and supervisors needed to monitor program quality and inmate worker supervision;
C. Special menus that comply with various medical and religious needs and requirements; D. Maintain accurate accounting records; E. That menus are reviewed at least annually by a qualified dietitian to ensure meals comply with
nationally recommended allowance for basic nutrition; F. Prohibitions of using food as a disciplinary measure; G. Involvement of independent outside sources to verify food service facilities and equipment meet
government safety codes; H. Prescribes regular cleaning schedules including routine deep cleaning; I. Provide written utensil control methods similar to those used by the tool shop; J. Accident prevention program; K. Personal and environmental sanitation requirements; L. Food temperature monitoring and records keeping; M. Adequate health protections for all staff and inmates including health screens and prohibitions
against working in the kitchen when ill; N. Requirements for daily monitoring of staff and inmate cleanliness practices, and that all
bathrooms and wash basins are consistently supplied with antibacterial soap and hot water; O. All areas and equipment related to food preparation, distribution, and storage require frequent
inspection to ensure they are sanitary, operational, and safe; P. Water temperature on final dishwasher rinse should be 180 degrees Fahrenheit; between 140 and
160 degrees Fahrenheit is appropriate if a sanitizer is used on the final rinse. The person conducting inspections should be a qualified food service inspector; Q. Stored shelf goods are maintained at 45 degrees to 80 degrees Fahrenheit, refrigerated foods are 35 to 40 degrees Fahrenheit, and frozen foods at 0 degrees Fahrenheit or below, unless national or state codes specify otherwise; R. Food temperatures for hot foods should range between 135-140 degrees Fahrenheit and cold foods at approximately 41 degrees Fahrenheit; S. Supervisory food service staff should monitor food service operations to ensure that that cooking, cooling, and food temperatures and delivery meet established requirements; 3. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care. 4. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented. 5. Policies and procedures developed should include controls for the use of caustic, toxic, and hazardous materials used in the kitchen. Material Safety Data Sheets should be posted conspicuously.

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k. Sanitary and adequate supplies of drinking water.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No major improvement was again observed in the housing units during this assessment with the exception of X-Dorm.
The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Similar to previous reporting, many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lock down. Access to drinkable water is generally available during the “out of cell” periods but inmates must rely on the presence and actions by officers following lock down. Inmates have no access to drinkable water when there are no officers on the units to provide it, and water from cell-sinks is considered not safe for drinking. In previous site visits, inmates consistently complained of seeing particles of rust in the ice that is provided to the housing units. Since our last two visits this area seems to have improved. However, a long-term solution to the problem still needs to be addressed.
In X-Dorm we had been reporting a consistent problem regarding the lack of drinking water for this unit. However, since our last two site visit GGACF officials have addressed this problem by installing portable water bottles in the dorm.
RECOMMENDATIONS: 1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable
access to safe drinking water. 2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:
a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft training policies and procedures remain under review and revision for final approval. These documents must include the required content listed in this provision.
Training curricula and training has been conducted for the approved health care-related policies and procedures. However, documentation has not yet been provided to this Monitor that demonstrates 95% of required staff completed all training with minimum passing score of 80%.
RECOMMENDATIONS: Previous recommendations remain appropriate. 1. Implement training policies and curricula once approved. 2. Provide this Monitor and United States all requested training documents.
b. Pre-service training for all new employees;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The draft training policies and procedures include requirements for pre-service training for new civilian, correctional, and supervisory/management staff. These documents remain under review and revision for final approval.
RECOMMENDATIONS: Finalize and implement approved training policies and procedures.
c. Periodic in-service training and retraining for all employees following their completion of preservice training;
ASSESSMENT: NONCOMPLIANCE

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FINDINGS: The draft training policies and procedures include requirements for in-service training for new civilian, correctional, and supervisory/management staff. These documents remain under review and revision for final approval. RECOMMENDATIONS: Same as above.
d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.
ASSESSMENT: NONCOMPLIANCE FINDINGS: Draft training policies and procedures generally include the required elements of this provisions. These documents remain under review and revision for final approval as scheduled. RECOMMENDATIONS: Implement training policies and procedures once approved.

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IX. IMPLEMENTATION 

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.
FINDINGS: As previously stated, Territory progress toward compliance remains very slow but intentional.
2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.
FINDINGS: This Monitor continues to monitor compliance with Court-ordered schedules.
3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.
FINDINGS: As stated above.
4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all RECOMMENDATIONS for changes to policies, procedures, or training will be provided to the United States and the Monitor.
FINDINGS: There have been no semiannual impact evaluations submitted by the Territory. The reports submitted do not include description evaluation of progress.

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5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.
FINDINGS: The Territory has complied with this requirement and has remained dutiful in timely collaboration with USDOJ and this Monitor with regard to policy and procedure modifications.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
FINDINGS: The Territory’s status reports remain anemic for describing progress. During the September 24th status conference the court instructed the Territory to include in its status report all provisions of the agreement and to notate any progress toward compliance with each.
7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.
FINDINGS: The Territory provides monthly medical emergency reports and notifications required under this requirement. However, follow-up documentation should be made more timely. In addition, during the September compliance tour, the Monitor discovered through document review that a serious suicide attempt had occurred. The Territory had not informed either the Monitor or USDOJ of this attempt, as required by the policy.
8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.
FINDINGS: The Territory continues to revise and develop new documents to demonstrate compliance with this Agreement. However, quality management of many records remains problematic. These issues include, for example, incident reports, shift rosters, segregation review forms, and the grievance log. The Territory is encouraged to implement the Monitor’s recommendations regarding document quality

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assurance and management. Doing this will significantly support the Territory’s ability to demonstrate compliance.
9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.
FINDINGS: The Territory continues to cooperate in providing access to the facility and needed documents as requested.
10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.
FINDINGS: The Territory continues to provide access to requested records.

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X. Monitoring 

D.1. Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.
FINDINGS: This Monitor wishes to thank Territory officials for submitting monthly compliance reports, even as the document request grows.
D.2. Monitoring Access: With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility and Detention Center, all facility non-privileged records, prisoners' medical and mental health records, staff members, and prisoners, Defendants will direct all employees to cooperate fully with the Monitor, Reasonable advance notice must be provided to the Bureau of Corrections prior to conducting any on-site compliance reviews. Other than as expressly provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. All nonpublic information obtained by the Monitor will be maintained in a confidential manner.
FINDINGS: The Territory has provided this Monitor and monitoring team full and complete access to GGACF as required under this provision.

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APPENDIX A 
 ASSESSMENT METHODOLOGY 

This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.
Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.
Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.
1. Description of how the Monitor will assess compliance with each of the Compliance Measures.
In general, compliance assessment will include the following activities:
A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or other regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community members, either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning.

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I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other

motorized vehicle used for correctional operations purposes.

J. Examination of any and all available records, data, and/or information relevant to

compliance and compliance monitoring not limited to the following:

•

Administration

•

Budget

•

Personnel

•

Operations

•

Training

•

Facility construction, renovation, repairs, and maintenance

•

Equipment, supplies, and materials

•

Inmate case files

•

Medical and mental health screenings, assessments, evaluations, diagnoses,

treatment plans, progress charts and notes, medication logs and records, drug formularies,

appointment calendars, invoices, etc.

•

Labor contracts

•

Incident reports and logs

•

Evidence / contraband reports and logs

•

Use of force incidents and logs

•

Inmate grievances and disciplinary records and actions

•

Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other

documents and information that support accurate compliance assessment and progress

determinations

•

Employee complaints, grievances, claims, etc. directly or indirectly related to the

compliance provisions

•

Other information required to determine compliance and compliance progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (Noncompliance, Partial Compliance, and Substantial Compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

• Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
• Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.

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• Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
• Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.
• Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or consumer satisfaction).
• Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of consumer satisfaction, a performance indicator might be: “the percentage of consumers who state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and off site assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and off site and not limited to:

•

Communications with Territory and U.S. Department of Justice Officials as

authorized in the Order

•

On-site visits, tours, meetings, individual and group meetings and interviews

•

Collection and examination of electronic, paper, and photographic records,

information, and data

•

Photographs taken during inspections (not to be used in any report without expressed

written agreement of both parties)

•

Online media information

•

Online public records

•

Electronic and standard mailing of information

•

Email communication and phone consultations

3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for assessments and monitoring include the following.

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A) Corrections Information:
1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's Use of Force policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months. 23. Records and/or lists of physical improvements, repairs, and renovation completed to correct security problems and deficiencies over the past 36 months. 24. Past 36 months of agency budgets. 25. List and contact information for any and all community vendors who provide services of any kind to GGACF and contracts or professional services agreement authorizing those services.

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26. List and contact information for community regulatory agencies who inspect, review, approve, and/or provide consultation to the GGACF i.e., health inspections, fire inspections, etc., and any inter-local agreements involved in these services.
B) Medical and Mental Health Information:
27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of their records. 31. To the extent not provided above, the policies and procedures governing medical and mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers, including oncall schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to include health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment. 46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location. 47. To the extent not provided above, external and internal reviews or studies of medical or mental health services including needs assessments and any American Correctional Association and National Commission on Correctional Healthcare reports. 48. List of all inmates placed in restraints, and all inmates receiving mental health treatments, under suicide watch, or taking psychotropic drugs.

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49. Current mental health case list including inmate name, number, diagnosis, date of intake, last psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed only by counseling staff with last appointment date and follow-up appointment. 50. Documentation reflecting any training that facility staff have received on suicide prevention, including certificates and training materials. 51. All documents related to the any suicide occurring within the past year. 52. List of all persons on warfarin, Plavix, digoxin.
C) Suicide Prevention Information:
53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and investigative reports of all inmate suicide victims within the past three years. 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric medications for the past year. 66. A description of medical and mental health’s involvement/input into the disciplinary process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.
It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 960-1 Filed: 03/08/16 Page 1 of 133
United States Virgin Islands
GOLDEN GROVE ADULT CORRECTIONAL FACILITY TENTH COMPLIANCE MONITORING REPORT
AMDENDED 03/07/2016
2013 Federal Court Settlement Agreement In re: United States of America v. The Territory of the Virgin Islands (86/265)
Submitted February 21, 2016
Kenneth A. Ray, M.Ed., Monitor Ronald M. Shansky, MD Medical Expert Manual D. Romero, Operations Expert Richard G. Dudley, Jr. MD, Mental Health Expert

Case: 1:86-cv-00265-WAL-GWC Document #: 960-1 Filed: 03/08/16 Page 2 of 133 2 of 133

United States Virgin Islands GOLDEN GROVE ADULT CORRECTIONAL FACILITY
TENTH COMPLIANCE MONITORING REPORT
AMDENDED 03/07/2016
Kenneth A. Ray, MEd, Monitor
TABLE OF CONTENTS

Cover ………………………………………………………………………………

NA

Table of Contents …………………………………………………………………

2

Purpose……………………………………………………………………………..

3

Executive Summary & Findings Overview………………………………..……

3

Section IV. Safety and Supervision Compliance ………………………………

11

Section V. Medical and Mental Health Care Compliance …………………….

63

Section VI. Fire and Life Safety …………………………………………………

103

Section VII. Environmental Health and Safety …………………………………

111

Section VIII. Training …………………………………………………………….

121

Section IX / X. Implementation / Monitoring……………………………………

123

APPENDIX A Compliance Assessment Methodology …………………………

127

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PURPOSE
The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) assist U.S. Virgin Island officials in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.
EXECUTIVE SUMMARY & ASSESSMENT OVERVIEW
The this onsite compliance monitoring assessment was conducted December 14-17, 2015 and included a focused and productive Court status conference was held on Wednesday, December 16, 2015. Prior to this site visit, the Monitor coordinated communication between the parties and monitoring team in preparation for the onsite assessment.
This Settlement Agreement contains six (6) Sections. Each section contains a number of specific and measureable compliance requirements (Provisions). Combined, these six sections contain 130 provisions; 120 of these represent five (5) primary substantive sections while ten (10) provisions are contained within only one section, Section X. Implementation.
Each provision of this Agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:
“In his or her reports, the Monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) partial compliance, and (3) noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor's report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor's findings.”
Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing this final report.

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The Monitor advances each Provision once substantive progress is clearly demonstrated by the Territory:
1. policies, procedures, protocols, and/or plans required of a provision are properly approved in accordance with this Agreement;
2. the above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. those documents are adequately and effectively implemented. Implementation includes evaluation demonstrating that implemented policies, procedures, and training are measurably performing within the outcome expectations of this Agreement.
A Provision advances from noncompliance to partial compliance when 1) required policies and procedures for the Provision are approved by the Monitor, United States, and the Territory, 2) when 95% of staff required to be trained on the policies and procedures have done so with a minimum passing score of 80%, 3) the policies and procedures are fully implemented, and 4) the Territory objectively and measurably demonstrates implementation effectiveness. A Provision advances from partial to substantial compliance when continued valid and reliable evaluation of implemented policies, procedures, protocols, plans, etc. clearly justifies advancement. Justification is based on quantitatively and/or qualitatively evidence: 1) that implementation efforts are producing measurable outcomes intended in the Agreement, and 2) that outcome performance is valid and reliable (performance evaluations are likely to produce consistent and sustainable compliance.). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately demonstrated using appropriate compliance evaluation methods and measures, this Monitor will and has reversed a compliance rating when the evidence supports doing so.
Some Provisions overlap. For example, many medical, mental health, and suicide prevention Provisions involve independent compliance assessment and scoring by both of the Monitor’s medical and mental health experts. Such Provisions are advanced to the next level when both experts advance the Provision. The Provision, however, remains at the lowest compliance score when the experts’ scores differ.
During the December site visit, the Monitor spent a significant amount of time with the Territory and United States revising the Territory’s draft security policies. Accordingly, some areas below were not assessed during the December site visit, but will be assessed during the March site visit.
ASSESSMENT FINDINGS OVERVIEW:
Ten (10 / 28%) of 36 Medical/Mental Health Provisions advanced from NONCOMPLIANCE to PARTIAL COMPLIANCE. This assessment determined the Territory has accomplished

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requisite completion of policies and procedures, staff training, and implementation of these Provisions:
V 1. a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
V 1. b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission
V 1. e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;
V 1. f. (i) adequate sick call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals
V 1. f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;
V 1. f. (v) adequate and timely referral to specialty care V f. (vi) adequate follow-up care and treatment after return from referral for outside
diagnosis or treatment V 1. (iii) timely suicide risk assessment instrument by a qualified mental-health
professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions V 1.s. (i) Mental health care and treatment, including: timely, current, and adequate
treatment plan develop and implementation V 1.s. (iii) adequate psychotropic medication practices, including monitoring for side
effects and informed consent
Additionally, the Territory, United States, and Monitor continued to actively collaborate on final approval of all security and safety-related policies and procedures as directed by the Court. Some of these documents remain in various stages of final approval except for twelve that were approved on December 16, 2015 while onsite during this compliance assessment. The following policies and procedures required under this Agreement have been approved by the United States and the Monitor:
1. IV. A.1.c.-d., C.1.a-d: Supervision of Inmates/Detainees 2. IV.B.1.a., IV.B.1.b, IV.B.1.e.:Visitation 3. IV. B.1. a.-e.: Mail Policy 4. IV.D.1-2: Security Staffing Policies (not including Staffing Plan) 5. IV.E.1: PREA 6. IV.K.1: Administrative Investigations & Staff Discipline 7. VI.1.a-j: Fire & Life Safety Plan 8. VII.1.a-c, e, f, k: EHS Maintenance 9. VII.1.d: Pest Control 10. VII. 1.g. & i: Inmate Bedding & Clothing

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11. VII.1.h: Chemical Control 12. VII. 1.j Food Service

The value of the collaborative process cannot be understated. Despite numerous deviations from the compliance Schedule, active collaboration has consistently demonstrated its utility in the completion and approval of several high-quality and contemporary medical, mental health, suicide prevention, safety and security policies and procedures. The process has proven instrumentally beneficial in achieving measurable progress with certain training requirements, resolving disputes, and reaching mutually amical clarification of performance expectations when appropriate.

There are now 19 Provisions in Partial Compliance, 101 in Non-Compliance, and none in Substantial Compliance. Except for the ten (10) health care Provisions that advanced to Partial Compliance, all Provisions retain compliance ratings reporting in the 9th Compliance Report. The updated scorecard below quantifies compliance as of this assessment:

GGACF 10th Compliance Scorecard

Areas of Compliance Per Agreement

Total

Non

Partial

Provisions Compliance Compliance

IV. Safety and Security

59

56

3

V. Medical, Mental Health Suicide Prevention

36

26

10

VI. Fire and Life Safety

10

10

0

VII. Environmental Health and Safety

11

5

6

VIII. Training

4

4

0

Total Substantive Provisions Percent Compliance

120

101

19

100%

84%

16%

Substantial Compliance
0 0 0 0 0 0 0%

Provisions that failed to advance do so for the following reasons:
 All security and safety-related policies, procedures, and Staffing Plan are not approved;  Security supervisor and officer staffing levels remain inadequate to reliably protect
prisoners and staff from real and potential violence and harm.  Security supervisor levels are insufficient to ensure consistent and routine oversight and
supervision of staff and housing unit operations.  Dangerous and nuisance contraband levels remain very high throughout housing units
enabling prisoners the ability to violently and seriously harm others.  Prisoner disciplinary practices are inconsistent and continue to impose disparate and
excessive punishments.  Prisoners with serious mental illness continue to remain in solitary confinement statuses
with little or no out-of-cell time. Segregation review documentation remains unable to adequately demonstrate the existence of a meaningful and consistent review process.  The prisoner classification system has not been validated.  The fire safety/suppression system remains inoperable.

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 A qualified training program does not exist to adequately train staff in the full implementation of this Agreement.
 The incident reporting system, as well as most documentation process, continues to lack a quality management process to reliably record and track incidents.
 The inmate complaint system (grievance process) remains untimely, disorganized, and inadequately documented to clearly demonstrate prisoners have reliable access to a meaningful compliant resolution mechanism.
 The administrative investigation process remains under-development but has not yet demonstrated requisite progress to advance.
 Reported PREA-related complaints by prisoners are not investigated consistently and resolved in a timely manner according to PREA requirements.
 Food services program capital improvements have not been completed.  Facility hygiene and sanitation conditions remain deficient.

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Serious Security Breaches Evidencing Continued Noncompliance, Real and Potential Harm to GGACF Staff, Civilians, and the Community
Serious security breaches within GGACF continue to occur and seem unfettered by management efforts to improve security practices. Both of the incidents discussed here strongly support justification that several Provisions of this Agreement are not showing compliance progress. The incidents highlight the chronic risks and dangers of inadequate staffing, excessive use of overtime, lax security practices, and staff noncompliance with standard security policies, inmate classification, and contraband control. Additionally, the lack of timeliness in administrative investigations following an incident is troubling. Both of these incidents were easily preventable if basic security practices were followed consistently and proper staff supervision and training maintained.
Incident 1: On 10/20/15 at approximately 0200 hours, an inmate being held in unit 9C escaped from the facility and was captured in the community at approximately 1000 hours the same day. The escape was discovered at approximately 0745 hours and confirmed at approximately 0819 hours. The inmate had not been noticed missing from his cell for approximately six (6) hours. The investigation report completed by VIBOC on December 24, 2015 states that the escape resulted from several security management breakdowns, before and during the actual incident. The second incident described hereafter evidences continued security management failures involving the same inmate, even after this incident.
According to the investigation report and my review of Shift Rosters for 10/18-20/15, the officer assigned to 9C had worked approximately 12 hours preceding the incident and another 8 hours from 1351 to 2201 hours on 10/18. It is quite likely that this officer was mentally fatigued before starting the second consecutive 8-hr. shift on 10/19/15.
The investigation report states that the inmate opened his unsecured cell door at approximately 0200 hours on 10/20/15. The cell door was reportedly previously opened at approximately 2000 hours on 10/19/15 to provide water to inmates. The report states the inmate exited his cell at about 0200, walked down the upper tier stairway, crawled past the enclosed officer’s station, untied the fence and slid through the inner security door. The inmate was able exit the outer security door at housing unit 9D, the adjacent housing unit. The inmate then climbed thru an internal fence opening and climbed onto the fenced walkway, and eventually escaped from the facility. The report states the inmate was wearing civilian clothing, which was also a contributing factor to the previous escape involving the alleged sexual assault of a community member.
According to the report, the inmates in 9C were secured in their respective cells (locked down) at approximately 1800 hours by the housing unit officer. At 2000 hours, the same officer unlocked cell doors to provide water to inmates and reportedly re-secured all of the doors. At approximately 2210, the officer involved was authorized to leave the housing unit for a break to return at 2300 hours. The officer reports making cell checks thereafter until 0545. However, during the officer’s break, no cell checks were made.

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The 10/20/15 escape investigation report states this prisoner escaped from 9C around 0200. However, the November monthly classification housing record, provided by the Territory, documents he was placed in disciplinary segregation (9A-11) on 06/20/15 with an 11/24/15 classification review that recommended no housing status change. The December 2015 classification housing record documents the same 9A housing location and placement date with a 12/23/15 review date and no status change. These records don’t seem to comport with him being in 9C on 10/20/15, which is after his 6/20/15 placement in 9A and before both segregation reviews indicating he remained there until at least 12/23/15. An examination of classification housing records did not show this inmate on any segregation records for June through October 2015. The December 17, 2015 count sheet shows him in 9A lockdown, which seems consistent with the December 23 classification review record. However, his 12/23/15 review is a Segregation Review form, not a Classification Review. This record shows he was placed in 9A13 on 10/20/15, following his escape, which is inconsistent with previous records showing a 06/20/15 placement. The January classification housing record does not show this inmate in a disciplinary or administrative segregation status. I is also possible the 10/20/15 segregation placement date was incorrectly recorded.
In brief, this incident demonstrates a collapse of physical and operational security management for the following reasons:
1. The prisoner was able to exit his secured cell door in plain sight and exit the 9C building and campus without begin detected. It is more likely than not that the inmate’s cell door was not properly secured either due to 1) a faulty locking mechanism, 2) manipulation of the lock by the inmate, or 3) the officer failed to properly check the door during each welfare check of the inmates in 9C.
2. A basic welfare check involves actual visual observation and accounting of each prisoner each time the check is made. Proper welfare checks are intended to detect escape attempts and missing inmates. The inmate was not found missing until several hours following his escape.
3. Security gates and doors were easily opened and closed by the inmate without detection.
4. The inmate topped the fence and covered walkway and exited the facility campus without detection.
5. No provisions were required by supervisors during the officer’s break to ensure welfare checks were conducted.
6. Inmates continue to be allowed to wear civilian clothing.
7. Housing unit security doors and gates continue to be left unlocked despite written directives by management to keep doors and gates secured.

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8. Inadequate staffing levels force the use of excessive amounts of overtime while leaving housing units not staffed by officers.
9. All of the issues listed above have been reported in this Monitor’s previous reports, but not adequately corrected.
10. Classification and housing records do not appear to be consistent based on an examination of several documents recording this inmate’s housing placements.
Incident 2: On 12/15/15, during the Monitoring visit, the inmate in the above case was involved in another serious security management breakdown in the GGCF medical building. This inmate was left unsecured and unattended by a security officer to allegedly use the bathroom. However, the inmate entered an office, accosted and made physical contact with one of the United States DOJ attorneys. Fortunately, Dr. Dudley was in the same office and the inmate stopped. The attorney involved was very shaken by the incident.
In brief, this incident demonstrates a collapse of physical and operational security management for the following reasons:
1. An inmate with a recent history of escape was not properly secured with restraints while in the medical building.
2. A lack of adequate physical security barriers and locked doors facilitated the inmate’s undetected access to inner officer areas.
3. Lax security practices allowed a high-risk inmate to move freely about the medical building without proper security escort and constant supervision.
4. A lone security officer assigned to the medical building is deleteriously insufficient to provide adequate control and supervision when prisoners are in the building for medical services.

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TENTH MONITORING REPORT GOLDEN GROVE ADULT CORRECTIONAL FACILITY
UNDER DEPARTMENT OF JUSTICE AGREEMENT
IV. SAFETY AND SUPERVISION
As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control-related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.
A. Supervision
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:
a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft Classification policies and procedures that include housing unit stratification have not yet been approved. However, approval and implementation of required policies and procedures will improve the Territory’s ability to ensure institutional, staff and inmate safety and security in the interim. This problem is caused in part from inadequate security staffing levels needed to operate housing units that were recently closed. Ironically, these facilities were closed to improve security staffing levels in housing units that remained occupied by prisoners. Several prisoners were transferred to the mainland under housing contracts with other correctional facilities. This allowed the Territory to redeploy security staff assigned to the closed housing units to prisoner-occupied facilities. This action does seem to have generally improved housing unit security staffing levels but concomitantly eliminated the Territory’s ability to fully comply with the intended outcomes of this Provision.
Examination of housing unit count sheets and onsite housing unit tours demonstrate continued ineffectiveness of prisoner classification and stratification practices. General population housing units are forced to operate as segregation units. Some prisoners are required to remain in lockdown status only for lack of adequate housing capacity to keep separate certain prisoner classifications i.e. gangs, under-protection, etc. The Monitor understands the conundrum the

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Territory faces to resolve this aspect of noncompliance. However, this problem, like inadequate staffing levels, will instrumentally impair gaining compliance with this Agreement until fully resolved. Adequate housing capacity is a basic function of effective and compliant prisoner classification and stratification practices. Adequate security staffing levels are necessary to ensure adequate housing capacity is properly staffing, prisoners monitored and supervised.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Attain approval for required policies and procedures.
2. Train staff on approved policies and procedures.
3. Implement policies and procedures.
4. Identify appropriate alternatives to implement and maintain compliant classification and housing stratification practices.
5. Increase staffing
6. Ensure adequate and routine monitoring of housing units by shift supervisors.
b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This draft policy has not been approved. Final Post Orders have not been disseminated for this Provision. Examination of Supervisor Logs, Housing Unit Logs and Shift Rosters continue to evidence continued non-compliance.
The daily shift rosters is the primary record used by this Monitor to assess compliance with this Provision. Rosters are to be submitted to the Monitor on a monthly basis. Officers’ work assignments are recorded on these rosters. Submission rates are improving but remain noncompliant.
This Monitor studied these records for 1) completeness, 2) legibility, 3) consistency, and 4) accuracy to determine document reliability for assessing compliance. The Territory submitted shift roster sets to this Monitor for November thru December, 2015. Approximately 97% of shift rosters were submitted for November and December. Records are audited for each of the three 24/7 shifts to determine validity and reliability of compliance assessment determinations. The table below shows record submission compliance rates for November and December:
Monthly Shift Rosters Sets Audit

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Year / Month Shift Rosters
1st Shift ( 10p-6a) 2nd Shift (6a-2p) 3rd Shift ( 2p-10p)
Score Over- Time Report
1st Shift ( 10p-6a) 2nd Shift (6a-2p) 3rd Shift ( 2p-10p)
Score Supervisor Inspection Report
1st Shift ( 10p-6a) 2nd Shift (6a-2p) 3rd Shift ( 2p-10p)
Score GGACF Score

2015 Nov 93% 97% 100% 97%
90% 97% 100% 96%
93% 97% 100% 97% 96%

Dec 100% 100% 100% 100%
100% 100% 90% 97%
100% 97% 97% 98% 98%

Score 97% 98% 100% 98%
95% 98% 95% 96%
97% 97% 98% 97% 97%

180 shift roster records were studied to measure compliance with this provision. Hand-count of officer housing unit assignments indicates one (1) officer was assigned to housing units at least 95% of all shifts for the 61 days (183 shifts) examined. These documents did record some shifts where two housing units were staffed with one (1) officer. Additional, officer duty times (on to off duty time) showed times when officers were late to work but this analysis was unable to determine whether other officers were held over to remain in the housing unit until their relief arrived.

Supervisor and housing log entries continue to evidence staff shortages and absence of supervision. Examples of staffing and housing unit supervision problems documented in the log books include:

1. 10/9/15, 0630hrs: Officer on duty documents that he/she is the only office on duty in 9A which is on lockdown and will not be entering the unit, but will continue to observe from the office. Another officer did not show until 0815 to assist with breakfast (9A Log Book pg. 84).

2. 10/15/15, 0620hrs: Officer documents that he/she is the only officer on duty in 9A when he/she arrived to work on the unit, and will monitor the Unit through the window and will not travel the Unit alone (9A Log Book, pg. 105).

3. 10/16/15, 0730hrs: officer documents that there is only one officer on duty in the lockdown unit. A second CO was present during breakfast but left after breakfast was served (9A Log Book, pg. 111).

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4. 10/21/15, 0750hrs: An officer once again documents only one officer on duty in 9A, and will not be conducting ay floor movement until another officer reports to help (9A Log Book, pg. 129).
5. 10/21/15, 1052hrs: An officer documents that he/she did not have contact with SGT Graham who reported that a check was made on the dorm and all appeared to be normal (9A Log Book, pg. 129).
6. 10/30/15, 0840hrs: An officer documents that only one officer on duty, and therefore, will not be conducting showers or recreation until another CO arrives to assist. At 0922 GIST officers enter to perform dormitory check (9A Log Book, pg. 166).
This is totally unacceptable for both inmate and officer safety. Another example was noted in the log book for housing unit 9C whereby on October 25, 2015 an officer makes an entry indicating that due to shortage of staff the Lieutenant conducted a unit check via telephone. This is also an unacceptable method of supervision.
NOTE ADDED 03/07/2016: One January 31, 2016, this Monitor requested in writing clarification about a November 11, 2015 Shift Overtime Report; the Monitor’s emailed request to the Territory stating the following:
“Hi, Shari – this is request clarification about shift staff and request contract housing records
First, the November 11, 2015 2p-10p Overtime Verification Document has 23 names suggesting overtime was used for most posts virtually the entire shift. Can you clarify why so many regular shift staff didn’t show up for work. Second, I am requesting copies of all current contracts for housing GGACF prisoners and monthly invoices since transferring prisoners offisland. Thank you. Ken”
The Territory responded to this request of the Monitor on 02/22/16 as follows:
“Good Day Mr. Ray,
In response to your February 4, 2016 inquiry about the 23 officers working overtime.
I spoke to Warden Trotter and she provided the below response to your inquiry.
Good Afternoon Bonnie,

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Lt. Francis was the supervisor on November 11, 2015. Instead of noting the officers working overtime on shift, she annotated special assignments officers and their normal post if they were at the facility past their normal work hours. The ones highlighted on the Overtime Verification Sheet are the officers on special assignments who worked over on their post. On the roster itself, I noted in pink (the time) the officers who are assigned to 1400/2200 that worked on November 11, 2015. There were a total of 11 personnel working overtime for the 1400/2200 shift not 23. Two of them were supervisors, OIC Sheppard and Lt. Francis.
Note: I forgot to highlight Detention R&D and ACF as special assignments, but both officers were working overtime. I hope this helps. Please see the attachment below.”
The Monitor’s request above was made in good faith and with the specific intention of ensuring the accuracy of 10th Monitor Report. Overtime-use calculations in the first filing of the 10th Report were based on documents from the Territory representing shift staffing levels and use of overtime to supplement staffing shortages. This Monitor relied on the face value of the 11/11/2015 2pm-10pm Shift Overtime Verification document for these calculations. This official record clearly records that 23 officers worked overtime, primarily due to staffing shortages at specific GGACF locations. However, the Territory’s 02/22/2016 response to the Monitor’s 01/31/16 request was after the filing of the 10th Report. As a result, the overtime calculations below are inaccurate in so much as there were reportedly 11, not 23, officers working overtime on 11/11/2015 2pm-10pm shift. Although this difference of 12 officers does not change the Monitor’s repeated concerns about facility safety and security relative to excessive overtime use, it does call into question the veracity the Monitor’s interpretations of any record provided by the Territory for monitoring purposes. This, combined with the Territory’s history of delayed and incomplete submission of requested documents, continues to significantly hamper the monitoring process and the effective management of the monitoring budget.
Overtime calculations below have not been amended as a result of the Territory’s clarification of overtime used on 11/1/15. To do so would require significant and costly data work and recalculation by this Monitor. Therefore, there is no change to this section of the report as shown below.
Shift rosters, Overtime Verification records, and Supervisor Shift logs continue to document enormous amounts of overtime required to operate the facility and housing units. It is typical to see shift supervisors note that shifts are “extremely short staffed” on shift rosters and log entries. Entire shifts are sometime held over to cover the next shift because of inadequate staffing levels. Examination of daily overtime records show that overtime was required for each of the 61 day reporting period. The number of officers and supervisors working overtime per day averaged over 27 and ranged from 16 to 41. The tables below shows these statistics.

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Officers & Supervisors working OT Per Day

Days

61

Mean

27.0984

Median

28.0000

Mode

28.00

Minimum

16.00

Maximum

41.00

The chart and graph below illustrates how often (# of Days) 16 to 41 officers and supervisors worked overtime.

An average of 25 officers, range 4 to 38, worked overtime per day. The graph below shows how often (Number of Days OT Worked) the range of 4 to 38 officers per day worked overtime. For example, one (1) day required four (4) officers to work overtime up to ten (10) days requiring 25 officers to work overtime and so on.

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Only five (5 / 8.2%) of the 61 days did not require overtime for shift supervision. For the 56 days involving use of overtime for shift supervision, the number of supervisors working overtime ranged from 1 to 4 per day. The graph below shows how often (Number of Days OT Worked) the range of 1 to 4 supervisors per day worked overtime.
This assessment period involved 183 shifts (3 shifts per day x 61 days). Examination of overtime use per shift found similarly troubling use of overtime. Only seven (7 / 3.8%) of the 183 shifts did not require use of overtime for officers or supervisors. The number of officers and supervisors working overtime ranged from 1 to 23 per shift, approximate average of nine (9). 176 (96%) of the 183 shifts required correctional officer overtime. The graph below shows the number of shifts requiring officers and supervisors to work overtime. For example, one (1) shift required one (1) officer or supervisor working overtime up to 28 shifts requiring overtime from nine (9) officers and supervisors.

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The number of correctional officers working overtime ranged from 1 to 23 per shift, averaging approximately nine (9).
However, overtime requirements per shift were much less for supervisors. 106 (60%) of the 183 shifts did not report overtime for supervisors. When overtime was reported, the number of supervisors working overtime ranged from 1 to 3 per shift, approximately 1.5 per shift.

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These findings cannot be interpreted that overtime usage ensured adequate staff coverage during the period assessed. To the contrary, overtime usage has not demonstrated compliance with staffing levels required in the Staffing Analysis Report. Additionally, GGACF reported overtime levels continue to expose staff and inmates to real and potential harm. Excessive Overtime must be curtailed! Excessive overtime is contraindicated for ensuring an alert and health correctional workforce. Extant scientific literature on this subject reports serious and detrimental effects of excessive overtime on safety and employee health. Excessive overtime can reduce employee alertness, significantly contribute to work safety errors, and cause and/or exacerbate employee medical problems. Such detrimental performance outcomes place staff and inmates at greater risk of harm while contributing to excessive use off-days by employees, which can be inferred by facility records. Excessive overtime is self-perpetuating. Employees are forced to work excessive overtime, they become exhausted and are less effective on the job and/or are absent. Reduced employee effectiveness increases performance error rates and facility risks. Work absences require use of overtime to staff the facility. GGACF correctional officers and supervisors are the backbone of the facility’s security program. However, that backbone is being weakened by excessive use of overtime. This weakening of the security program will likely not be repaired until sufficient security staff are employed. The most effective policy implementation or training program will never improve compliance substantially without sufficient staffing levels.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Immediately correct documentation problems shown above.
2. Use a standardize Shift Roster form that includes ALL locations and designate “CLOSED” for all locations that are out of service.
3. Rapidly implement the NIC Staffing Analysis recommendations.
4. Complete the draft staffing, as required under the Agreement that reflects the NIC Staffing Analysis and provides concrete steps for hiring sufficient staff.
5. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff working overtime have adequate time away from the facility before returning to work to ensure they are adequately rested.
6. Create a fast-track basic officer training program that ensures recruits are adequately trained on salient correctional topics.
7. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm.
8. Subsequent to policy and procedure development and revisions, conduct a complete review of existing specific and general post orders to ensure they are: a. post specific; b. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; c. are numbered, cross-referenced with policies/procedures, and formatted in a manner that makes them easy to interpret and apply; d. maintained at each post, kept current, and easily accessible; e. regularly reviewed, revised, updated; f. consistently enforced; g. known to staff through pre-service, in-service, and ongoing training.
9. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues are detected and resolved in a timely manner.
10. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.
11. GGACF upper management must monitor compliance with any written instructions to subordinate supervisors if compliance with such orders are expected to be followed.

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12. Create and implement one, standardized, shift staffing form for supervisors to accurately record shift staffing levels.
c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Policies and procedures required for this Provision have been approved. All officers (including recruits) require functional radios in their possession at all times while assigned duties within the security perimeter. Compliance with this requirement helps to ensure safety of staff and prisoners. However, prisoners and staff are exposed to extreme danger when all on duty staff are not assigned radios.
During this inspection, with some exceptions, we observed that officers assigned to housing units and other areas of the facility had functional hand-held radios. When the monitoring team visited A Dorm, the officer on duty informed the monitor that he does not wear his radio at all times, but instead keeps it at the desk, even when he is in the housing unit. This practice should stop.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement the approved policies and procedures.
2. Timely repair and replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
3. The Monitor will continue to review radio equipment inventories and functionality during each onsite assessment.
4. Ensure adequate supply of radio batteries to enable officers to carry radios on their person at all times. The GGACF Warden did issue written directives to all staff requiring compliance with this recommendation.
5. Ensure all persons carrying radios are fully trained to understand and operate all radio functions proficiently.

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d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and (ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: Officer and supervisor staffing levels remain detrimentally insufficient to meet this requirement. It is impossible for current staffing levels to adequately perform these compliance requirements. Officers and supervisors are daily tasked with a plethora of duties and responsibilities. Officers are ill prepared and unable to perform safe and security rounds when they are the only person assigned to a housing unit. Although officers do so to the limited extend possible, doing so places the officer and prisoners at extreme personal risk. An officer should never be required to conduct housing unit rounds without a back-up officer observing them and able to quickly provide assistance when needed. Incident reports have demonstrated serious assaults on officers working alone in housing units, housing unit keys being taken from an officer by and inmate, and very slow officer response to inmate-on-inmate assaults due to inadequate staffing levels. Contraband control efforts are severely impaired because inadequate staffing levels impair regular cell searches by insufficient numbers of on-duty housing officers.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations regarding Post Orders.
2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff and inmate safety and security, and according to inmate risks and needs.
3. Create a schedule for regular rounds by medical and mental health care staff for each shift to ensure that special needs inmates (suicidal, mentally ill, medically infirm, vulnerable, etc.) are monitored more frequently and by qualified health care staff.
4. Create a schedule for supervisory rounds, by shift, to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. The supervisory rounds forms should be filled out at the end of each round and collected in a central location and submitted to the Monitor and USDOJ on a monthly basis.

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5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.
B. Contraband
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:
a. Clear definitions of what items constitute contraband;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Drafted policies include definition of what items constitute contraband but additional revisions are required before approval by the United States and this Monitor is attained.
The movement and presence of nuisance and dangerous contraband continues to remain rampant within GGACF based on examination of somewhat reliable contraband log documents. Contraband confiscation records examined document continued presence of weapons, drugs, cell-phones, money, and nuisance items. Complete assessment of contraband control progress was impaired by records provided by the Territory to the Monitor on 01/15/2016. The Evidence Room (contraband) Log contains 19 contraband confiscation entries. Entries include weapons, drugs, cell phones, and money. Date entries for confiscated items were not recorded in the appropriate column and the dates seem out of sequence with other log records. The 2015 dates recorded begin with March, then April, then June, October, December, then January 2016. However, similar entry dates are recorded on other records. The Monitor is unable to reliably interpret this record but can conclude that contraband remains very problematic. The document in question also evidences GGACF management has yet to engage effective document quality control or assurance practices. The Monitor will return to include descriptive analysis of contraband activity once valid and reliable documents are consistently provided by the Territory.
The parties have held several conference calls to discuss the draft Contraband Policy, as well as the list of allowable property. Although the Territory has agreed, after discussion with the United States, to allow newspapers and books at the facility, the Territory apparently has banned local newspapers from the facility. The parties are continuing to discuss this policy.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1.Implement the new policy according to the terms of this Agreement once approved.

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2.Ensure supervisors comply with supervision rounds requirements.
3.Ensure corrections officers comply with contraband control and related security policies and protocol.
b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to B.a. above.
It should be noted that GGACF lobby entrance security included a more comprehensive and somewhat more consistent search process during our previous inspection than this one. During this inspection we noted that the walk-through metal detector was not operable and searches were inconsistently conducted. The Mail policy has been fully approved.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement the new policy and procedures.
2. Ensure supervisors comply with supervision rounds requirements.
3. Ensure corrections officers comply with contraband control and related security policies and protocol.
4. Continue positive efforts in searching people before entering the facility.
5. A “stop and check” protocol for inspecting staff packages after initial entry into the facility must be developed and implemented.
6. Provide handheld metal detectors for contraband inspections at facility entry points and as needed for on-campus inspection.
7. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods and process during the 11th onsite tour and assessment.
8. Train supervisors to provide on-the-job-training (OJT) and staff mentoring in the areas of adequate searches, contraband prevention and control, and basic inmate supervision and security.

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c. Detection of contraband within Golden Grove, through processes including:
(i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinical, and other areas o Golden Grove to which prisoners may have access; (ii) pat-down search, metal detector, and other appropriate searches of prisons coming from areas where they may have had access to contraband, such as intake, returning from visitation or returnin from the kitchen, shops, laundry, or clinic; (iii) regular and random search of physical areas in which contraband may be hidden or placed, suc as cells and common areas where prisoners have access (e.g. clinic, kitchen, dayrooms, storage areas, showers);
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Also refer to above contraband findings and discussion.
GGACF remains unable to provide necessary levels of prisoner supervision in any area of the campus with existing staffing levels. This is evidenced by the previously discussed examination of Evidence Collection logs, Supervisor Logs, and Shift Rosters. The Monitoring team again observed during this visit no pat down searching of ANY prisoner entering or leaving housing units. None of the housing units are equipped with metal detectors as previously recommended and required in paragraph ii above. GIST staff confirmed again during this visit that regular and random searches are very infrequent but sorely needed. Official GGACF documents evidence that dangerous weapons, drugs and alcohol, cell phones, and nuisance contraband remains accessible to prisoners.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to above, expand application of recommendation to provision c (i-iii) above.
2. See recommendations regarding staffing levels.
3. Ensure inmates are systematically and consistently searched each time they enter and exit maintenance shop areas, kitchen areas, and any area and/or building containing items that can be used as contraband.
4. Always search prisoners each time they enter and exit housing units.
5. Always search all containers entering and exiting the facility, buildings, and housing units.

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d. Confiscation and preservation as evidence/destruction of contraband; and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No change was found since previous reports. Above Contraband Provision findings and discussion adequately support no change in this assessment rating.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Review and implement relevant recommendations for Contraband above, specifically B1b.
2. Implement a continuous quality improvement program (CQI) for the Evidence Log to ensure the record is valid, reliable, and supports effective compliance monitoring.
e. Admission procedures and escorts for visitors to the facility.
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: The Visitation policy has been approved.
Front desk admission security checks were inadequate and inconsistent. The walk-through metal detector that was in place during our previous inspection was now inoperable. Monitoring team briefcases were searched before each daily visit, but we were not required to consistently empty our pockets. The monitoring team was consistently provided identification for each day of this visit.
First, very low staffing levels logically suggest GGACF is forced to prioritize duty assignments to where security protection needs are greatest – the housing units and prisoner locations. Second, none of the different Shift Roster forms show “Visitation” as a post for recording staffing levels.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Continue to ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.
3. Implement document quality improvement protocols to improve reliability of the two supervisor reporting systems used for this assessment to aid in demonstrating compliance.

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C. General Security
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility specific policies designed to promote the safety and security of prisoners and that include the following:
a. Clothing that prisoners and staff are required or permitted to wear and/or possess;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Inmate Clothing policy has been approved.
Prisoners continue to be allowed to wear personal “street” clothes in and out of the housing units. Several prisoners were again observed wearing non-correctional attire in day rooms, their cells, and in the yard.
We continue to observe that some on-duty security staff were wearing unmarked clothing and some wore unmarked lightweight jackets that covered their uniforms. Security staff reported having to purchase their uniforms (including shirts, pants, and shoes) themselves. Security staff also reported not receiving expected yearly allowances for clothing maintenance.
Unlike specialized law enforcement staff, there is no value or understandable purpose in allowing uniformed security staff to wear unmarked clothing or to wear personal attire that covers portions of their uniforms. The security officer uniform is specifically marked to provide clear and obvious awareness of the presence of a security officer. As such, a marked security officer uniform should never be obscured. This problem continues to be documented in the GGACF Security Administrator’s monthly reports for at least 90 days.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Require inmates to wear issued institutional clothing ONLY.
2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform policies and inmates who refuse to comply with those policies.
3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and appropriate corrective action with staff who refuse to do so.
4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’ classification/status.

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5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges and changes in an inmate’s classification and/or status.
6. Consider developing a correctional industry for making uniforms onsite.
7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband and weapons.
8. Mark all uniforms with highly visible letters/numbers.
b. Identification that prisoners, staff, and visitors are required to carry and/or display;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to previous findings and discussions pertaining to B.a, C.1.a. In addition, some prisoners were again observed either not wearing identification or not properly displaying their identification if it was being worn. During the onsite visit, the monitoring team and the USDOJ were given and required to wear visitor badges.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure staff compliance with this provision.
2. Ensure adequate supplies for making identification cards.
3. Regularly audit identification card inventory and maintain proper controls to prevent inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories.
4. Consistently enforce identification card policies and procedures.
c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;
ASSESSMENT: NONCOMPLIANCE - Noted some improvement from previous assessment.
FINDINGS: Previously requested training documents demonstrating completion of staff training on this subject matter have not been provided to this Monitor. Additionally, some of the Shift Supervisor Rounds reports and Housing Unit Logs, as well as direct observation during our visit show several inoperable locking mechanisms in various areas of the facility. However, it should be noted that on a positive note, doors that had been previously identified

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as inoperable in the sally port area, detention housing and R&D have been repaired. The slider grills/gates in the L and K units remain inoperable.
Inconsistent and incomplete use of these reports makes it very difficult to use these documents as a credible sources to advancing this provision, and it is logical that compliance with this provision is frustrated by inadequate maintenance staffing levels. The Director reported that the locksmith position is now a permanent position, but they still need to resolve an insurance issue.
However, even with an adequate locking system maintenance program, prisoners will continue to gain dangerous access to each other until security staff consistently practice good key control. A log book entry, for example, reported that the Alpha Unit officer station was left open and unsecured (Supervisor Log Book, 09/15/15, pg. 225. RECOMMENDATIONS: Previous recommendations remain appropriate. 1. Provide Monitor requested training records showing a 95 percent minimum successful
completion rate.
2. Repair/replace all broken locks and keys.
3. Develop, revise, implement, audit lock/key inventory.
4. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality, detection of tampering, and timely repair/replacement.
5. Continue to ensure staff are adequately trained in the proper use of mechanical and/or electronic locking systems according to their post assignments.
6. Consistently sanction inmates for attempting to manipulate or manipulating any security locking system or device.
7. Secure access to keys and electronic locking control panels. 8. Keep security doors locked.
9. Replace or upgrade existing unit control panels to provide for remote electronic locking and unlocking of unit and cell doors.
10. Improve video surveillance of internal areas by placing cameras in all housing units and inmate locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems.
11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms.

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12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations.
d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The policies and procedures that address this provision have been finalized and now staff need to be training on them and they need to be implemented. However, these policies and procedures alone cannot ultimately demonstrate compliance until GGACF has sufficient staffing levels to ensure compliance. This is because these policies and procedures require a much higher level of routine attention to all housing unit locking mechanisms by housing unit officers and supervisors.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Employ and maintain adequate Maintenance staffing levels.
2. As requested in the previous two reports, develop an “all-locks” maintenance plan for review by the Monitor and incorporation into policies and procedures. The plan should include a complete inventory of all locks, locking mechanisms, date lock found non-functional, date of repair /replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located – (Perimeter gate, housing unit 9A, cell #, emergency door, etc.), and lock number, lock type, condition, etc.
3. Establish a deadline for developing and implementing the lock plan to include policies, procedures, training, and continuous quality assurance.
e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention,
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This assessment did not review whether corrective action had been take regarding problems found in GGACF personnel folders . GGACF hired a new Human Resources Manager who is responsible for the organization of personnel records. These issues

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will be reviewed during the March 2016 site visit. The problems identified during the previous visit included:
• Missing verification of training documentation • No application and/or background investigation record • Missing criminal background-check documentation • No uniformity of folder content, disorganization • Incomplete documentation regarding disciplinary action (i.e. notification of policy
violation with no other information regarding disciplinary process or case disposition) • Employer/reference background forms missing or not completed • Missing Personal History statements • Pre-service psychological assessments found in some folders but not others • Missing fingerprint records • Incomplete military status questionnaire
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. The employee folder/record system should be standardized and well organized.
2. All folders should contain completed Applicant Personal History Statements, criminal history check verification documents.
3. Medical records should be kept separately from the general personnel folder.
4. Training records should be kept in a staff training folder and separate from the training folder. These records should be reviewed periodically for quality assurance purposes and remedial instruction and/or training provide to records staff where indicated.
D. Security Staffing
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:
a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;
ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Contents of the proposed Staffing Plan remain in dispute. The plan lacks specific detail to provide complete direction and guidance for its implementation. The parties and Monitor are continuing to discuss these issues. Among other things, the Monitor and United States are troubled by the requirement in the Staffing Plan that incoming officers sign a contract mandating that they remain with the BOC for at least three years or they will not receive a favorable recommendation for future employers.
The correctional culture is coercive enough not to add a sour flavor to the job just to attain employment. And such language is negative versus a positive measure for recruitment and maintaining the workforce. Better pay and less overtime in the aggregate will do much more to reduce staff stress, error, and performance. Recruiting employees from the mainland will likely not attract much interest simply do to pay, compared to cost of living. For example, this Monitor provided very brief research to Territory officials that compared mainland and VI salaries for correctional officers. The data were adjusted for cost of living difference. These comparisons showed conservable differences in salaries that were well above the Territory’s current and proposed correctional officer salaries. Again, this research was very brief to simply encourage Territory officials to include a variety of options for recruiting staff.
The plan also lacks provisions related to officer pay. This matter has been referred to the court for resolution and is pending final disposition. Extant subject matter literature seems to suggest that salary increases combined with other improvements with job satisfaction could help to stabilize the Territory’s job force. A reasonable raise combined with prescriptive positive administrative/operational (i.e., better training) changes could promote better recruitment and retention outcomes.
The Monitor conducted a limited and brief salary survey comparing St. Croix’s reported cost of living with the starting and top salaries for several mainland agencies. Based on the provisional results, the Monitor concluded that the Territory could have a very difficult time recruiting from the mainland.
The staffing analysis remains a provisional document for verifying actually staffing requirements. This is because the Territory did not provide the NIC analysis requested data to estimate actual net annual work hours. This estimate requires quantifying actual staff work hours required to operate all GGACF posts and all hours staff were off duty for various reasons i.e. sick, days off, vacation, etc. In the absence of these data points the analyst used national net annual work hour estimates to determine staffing levels. A staffing reanalysis may be required should full implementation of the staffing plan fail to yield adequate staffing levels to safety operate the facility.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement the approved policy
2. Attain approval for and implement the required Staffing Plan

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b. A security staffing plan, with timetables, to implement the results of the security staffing analysis; and
ASSESSMENT: NONCOMPLIANCE FINDINGS: As stated in D.1.a above. RECOMMENDATIONS: As stated above
c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove's staffing analysis and security staffing plan.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The staffing policy and procedure has been approved by the United States and this Monitor, but not the Staffing Plan. RECOMMENDATIONS: As stated above
1. Defendants will implement the staffing plan developed pursuant to D.1 .
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to previous findings related to staffing analysis and planning. RECOMMENDATIONS: Finalize, fund, and implement staffing plan.
E. Sexual Abuse of Prisoners.
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As noted in the previous reports, the Territory has not completed the required PREA self-audit. PREA policies and procedures have been submitted to USDOJ and this Monitor and they have been finalized and approved. The Territory has resolved the 24/7 hotline. The Territory has initiated a Memorandum of Understanding (MOU) with the USVI

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Police Department to conduct criminal investigations of sexual misconduct at GGACF. It was unclear, however whether or not this MOU has been signed by both entities.
Mr. James Warren is charged with the duty to conduct administrative investigations of sexual misconduct at GGACF. Mr. Warren reported that he is working on a PREA related investigation that was reported in November 2015. We were unable to examine three (3) PREA-related allegations because as of January 14, 2016 we had not yet been provided with all information or administrative investigations regarding these alleged incidents. However, on January 15, 2016, Counsel for Defendant’s provided us with copies of two (2) PREA related investigations. One of those investigations was responsive to a request made by the Monitor to Defendant’s on January 6, 2016. The second investigation appears to have the same date regarding one (1) of the requested investigations, but it does not appear to that it was the one requested by the Monitor. Nevertheless, we reviewed the two (2) provided investigations. One of the investigations involved an allegation of sexual harassment made by an inmate against an officer in May 2015. The Investigator found this allegation to be “unfounded”. Although it is commendable that BOC staff commenced the process of conducting investigations with the appointment of the Chief Inspector, this investigation exemplifies the past inattention by GGACF to act upon allegations of sexual misconduct. The second investigation does not appear to the one the Monitor requested, but nevertheless we also reviewed this investigation. This investigation involved an inmate-on-inmate allegation of alleged sexual advances. In this investigation, the Chief Inspector found the allegation to be sustained. However, there is no indication in the investigation as to what the recommended corrective action will be or any referral to other GGACF staff or the Director of Corrections for corrective action. The Chief Inspector conducted timely investigations of both of these cases from the time he was assigned to investigate them as requested by the Director of Corrections. However, it appears that the investigations were assigned to the Chief Inspector only after repeated requests for the investigation reports by the Monitor. For example, one PREA-related incident allegedly occurred on September 9, 2015, but was not received by the Chief Inspector for investigation until January 8, 2016. The PREA investigation regarding the May 2015 incident also was not referred to the Chief Inspector for investigation until January 8, 2016. The Monitor requested both investigation reports during the December 2015 site visit, and again by email on January 6, 2016.
It should also be noted that during our previous site visit we requested that an investigation be undertaken regarding the alleged allegation by an inmate of excessive force by a GIST officer on July 29, 2015. It does not appear that such investigation has been launched.
Facility staff reported that following our last inspection WTS Consultant Services provided general training to staff and inmates on PREA. Staff training was conducted on 9/29 & 10/2/15 according to training rosters provided. However, these rosters are difficult to interpret due to slopping entries. Additionally, these records do not document that 95% of staff required to complete this training did so with a passing score of 80% or better. We reviewed the course presentation by WTS and found it to be adequate. This is a good start and the process should continue as GGACF officials implement their PREA policies and procedures. Additionally,

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Mr. Warren reported that he took an on-line PREA Investigations Course. This initiative will also benefit the process for conducting sexual misconduct related investigations.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements. 3. Appoint a PREA Compliance Coordinator as soon as possible.
4. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s PREA auditor certification training. All costs are covered by USDOJ.
5. Complete the PREA Self-Audit.
6. Fill additional investigator position slated for a 6/16 hire date, according to the Territory.
F. Classification and Housing of Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:
a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security-needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner's charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Territory is still in the process of validating the current classification system. Apparently James Austin, Classification Expert is continuing to work with the Territory on the process. Draft classification policies and procedures have been submitted to this Monitor and USDOJ for review and comment according to the revised Schedule.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Complete an empirical validation of the current classification instrument(s).
2. Review, revise, develop, train, implement, and evaluate policies and procedures that provide more accurate and complete guidance for a valid and reliable classification system for non-convicted and convicted inmate populations.
3. Consider requesting assistance from the National Institute of Corrections for assistance in this process and the development of an objective classification system.
4. Contact USDOJ / NIC for Objective Classification Technical Assistance.
5. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.
b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from previous assessment.
FINDINGS: As stated in F.1.a above. Additionally, we continue to note the housing of mixed classifications of prisoners in housing units. During this review we did not examine whether or not this mixing also includes the housing of maximum security inmates in the same cell as minimum security inmates. During our next review we will examine this phenomena in more detail as classification policies and procedures are implemented and staff trained on them. This practice significantly deviates from industry standards and violates the Agreement and related legal requirements.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Settlement Agreement prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Mental health staff must continue to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced side lock down units to determine mental health needs and direct mental health staff to determine if a different, less punitive housing placement is available.

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c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;
ASSESSMENT: NONCOMPLIANCE – Minor improvement noted, but not yet substantive or sustained
FINDINGS: Same findings as noted in the above Classification section. During the December 2015 compliance tour, we observed some housing unit doors being left open and/or unlocked, and prisoner movement outside of assigned housing units with little or no supervision.
RECOMMENDATIONS:
1. Refer to previously discussed security-related findings and recommendations. 2. Refer to previously discussed classification-related findings and recommendations.
d. The development and implementation of a system to re-classify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: See previously discussed classification findings.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations related to grievance and disciplinary policies and procedures. 2. Ensure accuracy of monthly disciplinary committee reports. 3. The Territory must correct problems reported in the monthly disciplinary committee
reports.
4. Train classification staff to accurately and consistently complete initial and reclassifications accordingly.

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e. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The current incident reporting system remains inadequate for complying with this provision. As previously noted in this report, the quality of incident reports remains problematic and the incident reporting log system does not consistently capture all reported incidents. Additionally, Disciplinary Committee monthly reports continue to report problems with missing and late submission of incident reports. Interviews with the sergeant responsible for the prisoner discipline program continues to state the same problems with incident reporting practices and quality oversight.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Timely approve and implement policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of the incident reporting system as discussed above 6. Assign additional staff to GIST as described above.
f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Segregation-related (Special Housing) policies and procedures remain working products and yet approved. The new segregation review form was implemented during the December 2015 onsite assessment, but review documentation remains deficient.
Assessment of this Provision involves examination and cross-referencing of these primary records. December 2015 records were examined for this assessment:

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1. Segregation review records 2. Housing unit count sheets to determine prisoners assigned segregation/lockdown status
requiring regular reviews. 3. Chronic care records to identify medical/mental health needs of prisoners in
segregation/lockdown living conditions.
Document quality examination found marginal improvement but important problems continue. For example, some of segregation review records failed to record date the prisoner was placed into segregation or reason (discipline, administrative, etc.). Some records failed record that an inmate was seriously mentally ill. Some documents failed to meaningfully complete certain sections of the form. For example, writing “valid” to item 1 (VIII) does not meaningfully respond to the question, which asks “Are there reasons for circumstances for placement in Segregation still valid?” The question asks for “reasons” and a narrative explanation should be provided. Similarly, VII 2 asks for a description of what alternatives [to segregation] were discussed and considered for placement. “N/A” is not an appropriate response. This section should describe alternatives discussed and how those alternatives were ruled out or not accepted. Another review document (BOC101160, 12/23/15) states the prisoner was not present during the review. This record fails to record the prisoner’s current segregation status, if the prisoner had been seen by an RN in the past two weeks or mental health professional in the past week (items I, III, IV). Additionally, none of the ten prisoner needs and wellness questions (item V) were answered. However, the segregation committee remarks about the prisoner there is “no apparent distress”, “Spoke with detainee appears in good health but didn’t say much”, and “refused to be interviewed”. All of these sections should have been completed whether or not the prisoner participated in the interview. This can be accomplished by reviewing records maintained in the officers’ station. All segregation review records must answer all questions regardless of whether or not a prisoner participants in the process. These documents are important and valuable quality assurance records used to demonstrate compliance with this Provision, policies and procedures.
GGACF housing unit count sheets recorded that 227 prisoners were in custody on 12/17/15; 35 (15%) were in a segregation/lock down status on 12/17/15. These 35 prisoners were housed in units 9A (13), 9C (9), 9D (4), and Lima (9). A 15% daily segregation rate seems extraordinarily and dangerously high compared to local, state, and federal rates. On an average day, up to 4.4% of state and federal inmates and 2.7% of jail (detention) inmates were held in segregation. The GGACF daily segregation rate, therefore, ranges from approximately 3.5 to almost 7 times higher than compared rates. Similarly, the amount of time GGACF prisoners are held in a segregation status seems extremely high. Fifty percent (50%) of these prisoners have remained in segregation for more than nine months. Approximately a third for more than 18 months. Four prisoners, including a seriously ill prisoner, has remained segregated from two to over four years. The table below shows prisoner lengths of stay for the in segregation.
The table that follows shows descriptive statistics for GGACF segregation.

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GGACF Prisoners in Segregation/Lock Down on 12/17/15

Prisoner Reason Days Months Years Months in Segregation

1 Administrative 1617 53.9 4.4 Time Spent

Pri s oners

2 Discipline 1422 47.4 3.9 1-3 Months

5.00

3 Administrative 927 30.9 2.5 4-6

3.00

4 Discipline

765 25.5 2.1 7-9

3.00

5 Not Recorded 589 19.6 1.6 10-18

3.00

6 Discipline

541 18.0 1.5 19-25

2.00

7 Administrative 485 16.2 1.3 26-30

1.00

8 Administrative 312 10.4 0.9 > 30

2.00

9 Administrative 276 9.2 0.8

10 Discipline

261 8.7 0.7

11 Administrative 236 7.9 0.6

12 Discipline

203 6.8 0.6

13 Discipline

143 4.8 0.4

14 Discipline

120 4.0 0.3

15 Discipline

93 3.1 0.3

16 Discipline

87 2.9 0.2

17 Discipline

76 2.5 0.2

18 Discipline

64 2.1 0.2

19 Discipline

41 1.4 0.1

% 26.32% 15.79% 15.79% 15.79% 10.53% 5.26% 10.53%

Segregation review forms were provided for 20 (57%) of the 35 segregated prisoners. Records provided could not verify that segregation reviews were performed for all segregation prisoners as shown in the table below:

12/17/15 Count Sheets
9A 9C 9D Lima Totals

Lock Down Count
13 9 4 9 35

December Seg Reviews
Provided 11 4 0 5 20

% Seg Reviews
85% 44% 0% 56% 57%

Although review forms record important information about prisoner health and hygiene status, the form does not provide information from which to determine whether opportunities for outof-cell time were adequate. Form section V question 5 asks if the prisoner received at one hour of recreation each day. Section V was completed for 17 of the 20 records; all 17 review documents recorded the prisoners stated they had received one hour of recreation daily. Provision of adequate out-of-cell time cannot be determine by the current segregation review form. This form should be revised specifically determine opportunities to out-of-cell time between reviews was adequate.

Examination of completed segregation of for this assessment period found several documentation problems. Some of the documents were not accurately completed, some failed

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to adequately document inmate needs and alternatives to segregation, some documentation contained important inconsistencies. The following records reviewed illustrate these problems:
Overall, the segregation review process and documentation has improved marginally compared to previous assessments. Particular attention should be devoted to ensuring all documents are accurately completed. The Warden should approved and sign only segregation review documents (or any record for that matter) that are complete and accurate.
The number of prisoners being held in segregation and the length of time prisoners spend so confined is very troubling. The scientific literature regarding segregation continues to document the seriously harmful effects of prisoner solitary confinement on their medical, psychological, and social wellbeing. Research has also demonstrated that some prisoners held in segregation for long periods of time are more likely to recidivate after release and commit violence in the community as products of segregation. GGACF officials must develop constitutionally-sound and healthy alternatives to current segregation practices.
RECOMMENDATIONS: Review, revise, develop, train, implement, and evaluate segregation housing policies to:
1. Minimize time in segregation.
2. Provide adequate opportunities for out-of-cell time for inmates.
3. Ensure regular and consistent monitoring by medical and mental health staff. 4. Ensure inmate hygiene is maintained while housed in segregation.
5. Track and document (log) segregation housing conditions of confinement and inmate status.
6. Continue to ensure inmates with special needs are monitored frequently as indicated by a security and health risk/needs assessment. A routine schedule for conducting these rounds must be continuously monitored for compliance.
7. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
8. Defendants are reminded that segregation should never be used to punish or serve as a treatment for inmates who are mentally ill, and may never be used for inmates with serious mental illness.
9. Improve the quality and completeness of segregation review documentation.

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G. Incidents and Referrals
1. Defendants will develop and submit to USDOJ for review and approval facilityspecific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:
a. Reporting by staff of serious incidents, including: (i) fights; (ii) serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;
ASSESSMENT: NONCOMPLIANCE -
FINDINGS: Examination of incident logs and reports for October through December 2015 continue to warrant management implementation of better documentation quality control and accountability methods. Incident reporting deficiencies discussed in previous compliance reports remain unresolved by GGACF management:
1. Inconsistent incident report numbers 2. Incomplete reports 3. Page numbers and other basic information missing 4. Reports not being recorded on the incident log 5. Using different incident numbers for each inmate involved in the same incident 6. Using different incident numbers for different officers reporting the same incident 7. Illegibility 8. Missing signatures 9. Duplicate records 10.Inconsistent recording of incident type 11.No recording of incident type 12.Incident, Evidence, and Disciplinary logs don’t cross-reference each other 13.Blanks (e.g., date, incident numbers, reason for submitting report, etc.)
As stated in previous monitoring reports, the existing incident reporting system must be completely overhauled if it is to provide valid and reliable information from which to meaningfully evaluate serious events in order to comply with this Provision or any provision

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requiring accurate and complete incident reporting to assess compliance levels. A simple document quality assurance and compliance accountability process should be implemented and minimally include the following steps:
1. Officer completes an incident report 2. First-line shift supervisor reviews the report for completeness, accuracy, and legibility 3. First-line approves, signs, and forwards reports that meeting requirements above, deficient
reports are immediately returned to the author with specific written and/or verbal instructions for correction 4. Shift commanders should review and approve only reports meeting the requirements in step two 5. Shift commanders should return to reports first-line shift supervisors that fail to meet the above requirements with verbal and/or verbal instructions for correction 6. The chiefs, Security Administrator, Asst. Warden and Warden should review all reports for quality assurance and operational management purposes.
RECOMMENDATIONS: Previous recommendations remain appropriate
1. Develop protocols for current tracking system to improve data validity and reliability; the Incident Log document is replete with duplication and misleading entries.
2. Develop a unified incident coding system for valid and reliable information and data collection, reporting, and analysis.
3. Establish regular monthly quality assurance meeting process involving all major department team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity.
4. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol.
5. Require supervisors to carefully review all incident reports for completeness, accuracy, and consistency.

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b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Records were not provided by GGACF management staff to demonstrate compliance that this process exists. A regular administrative process required under this provision has not yet been formalized. Such a process first requires wholesale improvements in incident reporting systems and reporting review process. Furthermore, valid and meaningful incident data for tracking and management purposes relies completely on the quality of the incident reporting system, quality compliance monitoring, and timely data management. It is imperative that GGACF management staff implement a measurable document quality assurance and management process for the incident reporting system.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations in G.1.a above.
c. Requirements for preservation of evidence; and.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous monitoring reports, the Evidence Log should include incident report numbers to cross-reference incident reports and evidence (i.e., contraband). This revision to the Evidence Log will help to provide efficient and timely matching of incident reports to evidence, and make the Evidence Log a very useful tool for tracking and managing facility incidents for planning, implementation, and evaluation strategic contraband control policies.
RECOMMENDATIONS: Previous recommendations remain appropriate
1. Refer to similar recommendations regarding contraband.
d. Central tracking of the above incidents.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Findings described in G.1.a adequately articulate continued problems found with the incident central tracking and logging system.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to previous recommendations regarding incident reporting and tracking.
2. Consider implementation of an electronic jail management system for centralization of incident reporting and data analysis.
3. Implement a quality assurance process that consistently ensures incident log accuracy and completeness.
2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Prompt event reporting, investigation, and resolution remains problematic. Deficiencies in the current incident reporting and management process must be improved before other measures intended to gain compliance with this Provision will matter.
Examination of various records evidence problems in compliance. For example, the required management review of a use of force incident occurring on 10/29/15 was not completed until 11/13/15. Despite this incident involving relatively low-level force and without injury to any person, the management review and final disposition should have been much timelier. This problem is also demonstrated in the inmate complaints (grievance log). Times from inmate complaint to final resolution of the complaint are often unreasonably lengthy, if recorded at all. Administrative investigation reports also demonstrate lack of promptness. For example, this Monitor requested investigative documents for several serious complaints and events occurring over the past six months. Responses to this request included investigation documents dated weeks following the events.
Related draft policies and procedures include specified timelines for incident reviews and resolution. This problem can be easily corrected by GGACF management implementing those timeframes before these policies receive final approval.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Include this element in the required policy and procedure.
2. Establish reasonable timeframes as indicated.
3. Develop and implement corrective action protocols to address staff noncompliance with adopted policies and procedures.

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4. Initiate corrective action against supervisors and staff who continually fail to submit and/or approve deficient, late, or no incident reports as required by policy and this Agreement.
H. Use of Force by Staff on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or re-training of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:
a. Permissible forms of physical force along a use of force continuum;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The required policies and procedures remain in final draft form pending further review before being approved by the United States and this Monitor. These documents contain the elements required in this Provision.
Examination of incident reports and monthly management reports provided found three use of force (UOF) events, one each for October, November, and December 2015. Required supervisory review records were provided for the October and November incidents. The October management record was not provided to this Monitor as previously requested and the December management report recorded there were no UOF incidents, which differs from the review of December incident reports. The November management report documents the one incident reported that month.
October 29, 2015 UOF incident report involved officers using only physical force to control a prisoner while confiscating contraband from him. The incident report indicates officers “grabbed, shoved, and punched” the prisoner to overcome passive resistance and to prevent the prisoner for getting too close to officers and leaving his cell. The incident report does not state whether the prisoner was injured but a nurse was summoned to assess for medical needs. The prisoner denied need for medical care. The incident report appears to have been accurately completed. However, the required supervisor review was not completed until 11/13/15, two weeks post incident. Examination of this review form indicates necessary revisions. The form does not include “punching” as a force option but should. The reviewer also referred this incident for administrative investigation due to the prisoner’s allegation of excessive force. These investigative records will be requested and examined. This incident, at present, seems to involve justified use of force.

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November 18, 2015 UOF incident report involved the use of an electronic control weapon (ECW), Taser, to gain compliance of a prisoner to confiscate contraband from his person. Related incident reports document the prisoner failed to fully comply with officers’ instructions to place his hands on his bunk while they were attempting to search him. Officers report the prisoner put his hands in his waistband and he was stunned once with the Taser to gain his compliance. The “Primary” officer’s report of this incident is incomplete and inaccurate. Boxes on the report form for recording force was involved were not completed. On its face, the report would not be noticed as an incident involving force. This speaks further about document quality improvement concerns discussed in the Incident Reporting section of this report. A review of the Incident Commander’s Review/Critique report shows additional problems with this incident and document accuracy issues. For UOF clarification purposes, this Monitor reviewed the medical departments Chronic Care Log to determine whether use of ECW may be contraindicated for this prisoner; the prisoner involved was not on the log.
December 29, 2015 UOF incident report involved and officer “tussling” with a prisoner while attempting to confiscate contraband from him. The report is very short and fails to clearly articulate what type of force was used by the officer. This would not be considered a UOF incident if the officer simply grabbed the contraband away from the prisoner. However, this is a reportable force incident if tussling involved any physical force against the prisoner to gain control of the contraband or control of the prisoner. Again, this incident report demonstrates incident reporting quality assurance deficiencies; incident reports should be clearly written so as to leave no question about incident facts.
The commander review of this incident concludes that this incident complied with GGACF policy, procedure, and training. However, the incident report fails to adequately document justification for ECW force. It is also very troubling that this review reports there were no medical staff on duty when the decision was made to use ECW. The incident report fails to articulate this situation requiring emergent UOF. The safety literature on Taser has empirically determined that this weapon can contribute to serious injury and death under certain circumstances. Use of Taser (or an ECW) is discouraged when medical staff are not readily available, except in circumstances when its use is absolutely necessary to prevent the real, present, and imminent danger of physical harm to others or escape. Additionally, this reviewer cannot accurately conclude this incident complied with policies and procedures when the incident report was not accurately completed. This Monitor has requested for review video recordings and Taser data for this incident.
The use of force reporting, review process, and program remains noncompliant. These findings also provide a pertinent object lesson with regard to gaining Partial Compliance even after required policies and procedures are properly implemented according to the Agreement. These findings would prevent a Partial Compliance rating or would result in a Partial Compliance rating being returned to Noncompliance. Effective quality assurance management practice can help prevent this from happening.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize, approve, and implement draft use of force policies and procedures upon approval and once the revised implementation schedule is approved.
2. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
3. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review of document are 1) complete, 2) accurate, and 3) comprehensive.
4. All planned uses of force must be monitored and controlled by an onsite supervisor. 5. GGACF must promptly and thoroughly investigate all inmate complaints of excessive force
and take necessary corrective action to protect inmates and staff.
6. Strictly prohibit ECD use except to for emergency situations requiring that level of force to prevent imminent physical harm to staff, the inmate, or other inmates.
b. Circumstances under which the permissible forms of physical force may be used;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As noted above, the draft policy has not yet been approved and implemented. RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement policy and procedures once approved.
c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: See above findings. RECOMMENDATIONS: Implement policy and procedures once approved.

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d. Pre-service training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The training program cannot be revised to meet this requirement until the new policy is approved. This Monitor and USDOJ also must first receive, review, and approve preservice and annual training curricula.
RECOMMENDATIONS:
1. Implement new policy once approved.
2. Provide this Monitor and DOJ with all current training curricula.
e. Training and certification required before being permitted to carry and use an authorized weapon;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above.
f. Comprehensive and timely reporting of use of force by those who use or witness it;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Reliability in the incident reporting system is inadequate to determine whether reports are completed and submitted on a timely basis. Some of the reports examined lack requisite comprehensiveness to comply with this Provision.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement supervisory quality improvement review for all reports to ensure accuracy and completeness before approval.
2. As requested in the previous report, the Territory must develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.
3. Comply with Monitor’s request for documents.

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g. Supervision and videotaping of planned uses of force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No planned uses of force were reported during this assessment period. However, the Territory did not provide proof that GGACF staff had access to video equipment if needed.
RECOMMENDATIONS: Implement policy once approved.
h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No change.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Provide the Monitor documentation of Compliance for this Provision.
i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The November 2015 incident reports medical staff were not available during the use of the Taser. However, qualified medical staff should have been available, as previously stated. Under the circumstances reported, medical staff should have performed a post-incident assessment for Taser burns and latent injuries. The prisoner denied medical need in the October 2015 incident. No injuries were reporting during the December 2015 “tussling” event. None of the records report photographic documentation of whether there were injuries.
RECOMMENDATIONS:
1. Provide Monitor documentation of Compliance with this Provision.

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j. Prompt administrative review of use of force reports for accuracy;
ASSESSMENT: NON COMPLIANCE
FINDINGS: The November UOF incident previously described demonstrates noncompliance with this Provision. A two week interval between a UOF incident and review does not meet this requirement. Additionally, the reviews examined demonstrates deficiencies in review accuracy as discussed.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure that supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.
k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as discussed above in this set of Provisions.
RECOMMENDATIONS: Implement policy once approved
l. Administrative investigation of uses of force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Implement policy once approved.

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m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above. No central tracking system has been developed by GGACF officials; this system will not be of much value unless and until quality assurance managements measures, as previously discussed, are in place and determined to be effective.
RECOMMENDATIONS:
1. Develop and implement Central Tracking system to include all required elements.
n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This policy draft remains under review.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Immediately issue directives to supervisors to complete reviews for all incidents involving use of force. Monitor compliance, correct deficiencies, and document compliance with this provision.
o. Re-training and sanctions against staff for improper uses of force.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Noncompliance with this provision is a cumulative result of noncompliance with the Use of Force section of the Agreement. Re-training and sanctions against staff for improper use of force cannot be appropriately determined without routine and adequate administrative review of force events. Compliance with this provision is contingent upon compliance with the administrative review provision.

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RECOMMENDATIONS: 1. Comply with Administrative Review provisions of this Agreement. 2. Develop and prepare to implement remedial use of force training. I. Use of Physical Restraints on Prisoners
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:
a. Permissible and unauthorized types of use of restraints; ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above. RECOMMENDATIONS: Previous recommendations remain appropriate. 1. Implement this policy once approved according to the new schedule. b. Circumstances under which various types of restraint can be used; ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above RECOMMENDATIONS: 1. Same as above.
c. Duration of the use of permitted forms of restraints; ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as above. RECOMMENDATIONS: Same as above.

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d. Required observation of prisoners placed in restraints;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above. RECOMMENDATIONS: Same as above.
e. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above.
f. Required termination of the use of restraints .
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above
J. Prisoner Complaints
1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies so that prisoners can report, and facility management can timely address, prisoners' complaints in an individual and systemic fashion. Such policies will include the following:
a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The parties and this Monitor remain engaged in the final review and approval process for these policies and procedures. The draft documents include language to provide prisoners confidential access and reporting of complaints, and assistance for prisoners of communication and cognitive disabilities and/or impairments.

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The existing prisoner complaint (grievance) system remains problematic for ensuring meaningful, timely, and consistent response and resolution of prisoner complaints. This is determined by examination of the current GGACF Grievance Log for October – December 2015. This log demonstrates marginal but insufficient improvement compared to previously reported findings.

The log records 49 prisoner complaints for the period assessed. Prisoner complaints involving an array of issues, including: food service (11), prisoner work issues (5), complaints about staff conduct (9), medical concerns (1), housing conditions (1), and “other” (22). The table below quantifies prisoner complaints assessed:

GGACF Prisoner Grievances Recorded - October - December 2015

Issue / Month

Oct

Nov

Dec

N

%

Food Service

3

2

6

11

22%

Work Issues

3

1

1

5

10%

Staff Conduct

9

0

0

9

18%

Medical

0

1

0

1

2%

Housing Conditions

0

0

1

1

2%

Other

6

8

8

22

45%

Totals 21

12

16

49 100%

& 43%

24%

33%

Log document quality remains deficient for effectively managing and tracking prisoner complaints. Accurate and complete recording of prisoner complaints requires consistent entry of specific information about a complaint on the log. Accurate and complete entry of this information in the log allows GGACF management the ability to track complaints by prisoner and ensure whether complaint resolution is meaningful and timely.

Examination of the 49 logged complaints found 38 of the required entries were missing. Information missing on the log included the prisoner BOC# (1), date complaint was received (1), time complaint was received (6), response to complaint date (10), the date the response was returned to the prisoner-complainant (10), and descriptive response to the complaint (10). There were 38 missing information elements for the 49 complaints logged for this review period. The table below quantifies missing information for the complaints logged:

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GGACF Prisoner Grievance Log - October - December, 2015

Compliance Information Omitted

Oct Nov

Dec

BOC#

1

0

0

Date Received

0

0

1

Time Received

0

3

3

Classification

0

0

0

Type

0

0

0

Date Forwarded

0

0

0

Response DueDate

0

0

0

Response Date

2

3

5

Date Returned to Inmate

2

3

5

Summary

0

0

0

Response

2

3

5

Totals

7

12

19

Missing Information / Complaint Ratio 0.33

1.00

1.19

Ttl %

1

2.6%

1

2.6%

6 15.8%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

10 26.3%

10 26.3%

0

0.0%

10 26.3%

38 100.0%

0.78

This document quality problem appears to have increased from October to December 2015. The ratio of missing information to recorded complaints grew from .33 (1 error in 3 complaints) to 1.19 (more than 1 error per complaint recorded). These document quality problems have been repeatedly reported and discussed with GGACF management staff. These findings echo document and process quality assurance and accountability problems described elsewhere in this and previous compliance reports.

The grievance log seems to demonstrate a decrease in the time interval from receipt of a prisoner complaint to the date when a response is returned to the prisoner. However, document quality problems do not allow for a definitive conclusion.

GGACF appears to use a seven (7) day interval from receipt of a complaint to when a response is to the prisoner. These time intervals were analyzed by subtracting dates logged for when complaints were received from when response were due. Thirty-eight (39/80%) of the 49 complaints logged included dates required for this analysis.

Response-time compliance analysis findings:

 39 (80%) of the 49 prisoner complaint records were usable for this analysis  15 (38%) of the usable records recorded responses beyond required due dates  Usable records decreased from October to December, 90% to 69% respectively  Late responses decreased from October from 63% late response to zero (0) in
December

The table below describes analysis findings:

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GGACF Prisioner Complaint Response Timeliness Analysis

Response Lateness

Oct

Nov

Dec Total

Total Records

21

12

16

49

Usable Records

19

9

11

39

% Usable Records

90%

75%

69%

80%

Late Responses

12

3

0

15

% Late Responses

63%

33%

0%

38%

Late Days

1-3

9

2

0

11

4 - 7

0

0

0

0

8 - 10

1

0

0

1

11 - 15

0

0

0

0

> 15

2

1

0

3

Total 12

3

0

15

The grievance log requires entering a narrative response to prisoner complaints; no responses were recorded for 10 of the 49 records. Narratives recorded are very brief and seem to describe what the responder will do or did about the complaint. Many of the response descriptions do not consistently or clearly describe the response that was actually provided to a prisoner who filed a complaint. The log does not adequately record or describe whether or how a complaint is finally resolved but should. Below are some specific examples of this observation:

Logged Prisoner Complaint Summary
10/1/5 - Inmate stated he was suspended from work in the kitchen without a copy of complaint & a proper investigation filed against him due to complaint made against him by cook. 10/1/15 - request Officer not be allowed to be present around his meals because officer have spit and masturbated in his food. On August 23, 2015 stated that he was going to urinate in his tea. This is an ongoing problem and he will file a law suit for violation of detainee rights. 10/30/15 - Inmate said he was charged and placed in lockdown but charges were dismissed. He wanted to know where he was deem a threat to the facility.

Logged Response to Prisoner Complaint 10/26/15 - Response: Inmate case reference his termination from the kitchen was forward to the chief Investigator for further review.
10/13/15 - Chief stated inmate Complaint was forward to the Chief Investigator for further investigation
11/4/15 - Chief will make an inquiry as to the reasons inmate was deemed a threat to the institution and will let him know by 11/6/15

RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking process to measure and verify program compliance, take timely and appropriate remedial and correction action.
2. Ensure tracking log is consistently completed and accurate.

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3. Assign reliable and timely oversight of the inmate complaint process and logs to a staff person who will provide the process consistent, dedicated, and comprehensive attention.
4. Develop a valid and reliable tracking a quality management statistical report for monitoring inmate and facility needs and problems.
5. Ensure staff are available during onsite visits to allow this Monitor to adequately assess this Provision.
b. Timely investigation of prisoners' complaints, prioritizing those relating to safety, medical and/or mental health care;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Notwithstanding previously described omissions in required log information, there have been significant delays in investigating serious prisoner complaints. This is partly due to the delays in filling the Investigator vacancy. It is also the result of GGACF not prioritizing such complaints to ensure timely complaint resolution. This problem appears to be improving with the hiring of a qualified investigator.
1. The “Type” column is intended to prioritize a complaint as “emergency” or “normal”. However, this column is often blank.
2. Response to “emergency” complaints can range from zero (0) to nine (9) days. 3. Descriptions of prisoner complaints often do not support designating the complaint as an
emergency. 4. Response often does not articulate what, if any, emergency (or even urgent) actions were
taken to resolve the complaint.
The inmate complaint system remains problematic and unreliable. The grievance log is inconsistently maintained and confusing on its face. This issue has been discussed with GGACF management officials at each site visit with little or no substantive improvement accomplished to date. The Monitor and USDOJ were assured by GGACF management this matter would be corrected but records consistently demonstrate otherwise.
RECOMMENDATIONS: Same as above

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c. Corrective action taken in response to complaints leading to the identification of violations any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Documentation provided is inadequate for assessing compliance with this provision. The description of the prisoner complaint system discussed above is also suggestive of noncompliance with this provision.
RECOMMENDATIONS:
1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.
d. Centralized tracking of records of prisoner complaints, as well as their disposition; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above, and:
1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.
e. Periodic management review of prisoner complaints for trends and individual and systemic issues.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Similar to administrative investigations, use of force and incident reviews, this process remains essentially nonexistent.

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RECOMMENDATIONS: Same as above.
1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. Use data from those reviews to identify patterns of individual staff and inmate problems, as well as systemic problems in need of correction.
K. Administrative Investigations
1. Defendants will develop and submit to USDOJ for review and approval facilityspecific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:
1. Timely, documented interviews of all staff and prisoners involved in incidents;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Investigator (Chief Inspector) position was filled prior to our last inspection. The Chief Inspector reported that two (2) additional positions have been created for investigators. Both of those investigators will be interchangeable between GGACF and the St. Thomas Facility. Furthermore, the Territory informed the Monitor that one of these two investigator positions has been hire and begins work on 3/16. However, it will take some time for the Office of the Chief Inspector to be fully developed and fully functional. These are certainly steps in the right directions. Also, please refer to the discussion/findings noted in paragraph E-1 of this report.
RECOMMENDATIONS: Same as previous report
1. Fill the vacant investigator positions.
2. Supervisory/management staff must be consistently held appropriately accountable for adherence to agency rules, regulations, policies, and procedures.
3. The November 2014 housing unit riot must be thoroughly investigated and reviewed to prevent similar future events and to improve organizational planning, response, and management of these types of major incidents.

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2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc.) and attempt to resolve inconsistencies between witness statements;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS:
1. Same as above.
2. Develop, as part of these, methods for adequate collection, recording, handling, labeling, preserving, and maintaining administrative investigation evidence, information, data, etc.
3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No substantive change since previous visit, but with the creation of the Chief Inspector’s Office and with the ultimate addition of investigators, it is expected that this area of the Settlement Agreement will advance in compliance ratings in future inspections. We are encouraged that the Territory is taking steps to develop and implement a credible investigatory component as previously noted in this report.
RECOMMENDATIONS:
1. Refer to previous findings regarding information tracking systems and methods.
2. Ensure tracking system maintains salient facts and information to support systematic administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.

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4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Examination of the CV provided by the Territory of the Investigator infers this person is well qualified, but specific documentation of pre-service and in-service training is still not apparent. Additionally, training on the new Use of Force policy will be essential to the investigative process and expectations regarding the use of force.
RECOMMENDATIONS:
1. Fill the currently vacant Investigator positions as soon as possible.
2. Finalize, approve, and implement relevant policies and procedures.
3. Create a formal pre- and in-service training program to train staff who are involved in initial and/or administrative investigation.
4. Provide adequate training of investigative staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
5. Provide training for administration/leadership staff in the areas of administrative investigation oversight, coordination, and management.
6. Develop and implement, as an adjunct to these policies and procedures, an “Investigators Manual” that provides guidance to staff responsible for oversight and investigative activities.
7. Provide the Monitor qualification documents for the newly appointed Chief Investigator for review upon his/her appointment.
5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No change from previous Report.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Finalize, approve, and implement relevant policies and procedures.
2. Review and revise current regulations on staff disciplinary actions and penalties to ensure completeness and efficacy.
3. Integrate the information in the above into the administrative policies and procedures previously discussed.
4. Record and maintain onsite records of staff misconduct investigative reports and determinations.
5. Protect the integrity and confidentiality of these staff records, control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
6. Provide training to supervision staff in the appropriate use of this information for purposes of staff supervision, counseling, discipline, promotion, etc.
7. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE
Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners' medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for self-injurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: With regard to the policies and procedures, all of the medical policies have been approved and training has been provided to more than 95% of the staff, and those staff have scored better than 80% on a post-training exam. It is interesting to note that as we reviewed records we did find some issues in each of those three areas, although overall, there has been significant progress since our September visit. This is the first visit to find a stable onsite Medical Director who is committed and invested in the outcomes of her patients.
With regard to the intake policy and procedure, the staffing does not yet allow 24/7 coverage by registered nurses. At best, nurses are onsite until usually between 8:00 a.m. and midnight, thus leaving a minimum of eight hours and sometimes longer without the presence of a registered nurse. We also continued to find delays in the completion of the nurse screen for up to 20 or more hours from the time of entry to the facility. All of the records we reviewed of patients entering the facility since our last monitoring visit did have nurse screens completed by a registered nurse within the first 24 hours. However, it was more common than not that patients waited between 12 and 20 hours for that screen to be completed. We also reviewed a record of a patient who had their nurse screen on Day 1 and had their practitioner exam on Day 2, but the inmate’s booking information was not entered into the computer system until Day 3. We addressed this with the Director of the Bureau of Corrections. We were told that this delay occurred as a result of classification staff not being onsite on weekends. In my experience, since the booking process is in fact a 24/7 process, there should always be staff onsite who can enter newly booked inmates or detainees into the offender tracking system. The Director indicated he would look into the reasons why this delay was occurring.
Although the timeliness requirement includes no later than 24 hours after booking, the expectation is that the process will be completed within four hours of the booking the inmate. It is a liability for both the patient and the Territory to have a person sitting onsite in the intake area

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while the program has no understanding of his medical issues. The nurse intake screen should be viewed as analogous to the fingerprinting for custody. Thus, the nurse intake screen is the medical fingerprint for each inmate, allowing the jurisdiction to know not only the inmate’s criminal background but also their medical needs.
We also reviewed a record of a patient who, when entering, appeared to be receiving methadone maintenance and yet this was not addressed. We discussed this case with the Medical Director. Since the facility is not licensed to provide methadone maintenance, there are two options to consider. One option would be to have the program in which the patient was enrolled to provide methadone on a daily basis by bringing the methadone to the facility. A more likely option is for the methadone program to recommend a detoxification regimen to be provided at the facility until the patient is released.
We also reviewed the tuberculosis screening program and generally found it satisfactory. However, in patients identified as having a positive skin test at the time of reading by the nurse, she/he should re-query questions with the patient with regard to acute TB symptoms and then document this in the record, for example, “The patient denies cough, weight loss, night sweats or coughing up blood.” Overall, there has been improvement in the quality and completion of nurse intake screening. Enabling registered nurses onsite around the clock should, along with review and feedback by the head nurse, result in improved performance.
Patient #1 This patient is a 23-year-old who arrived at the facility on 11/14/15, which was a Saturday. The patient had insomnia, bipolar disorder, claustrophobia and asthma. He was listed as a priority 1 due to mental health issues. He was seen by Ms. Murray (the mental health coordinator) on 11/17 for a complete mental health screen.
Patient #2 This patient is a 49-year-old who arrived at the facility on 11/18/15, and his screen was on 11/19. He arrived on a Thursday at 3:50 p.m., but his intake screen was not done until the following day. He was also seen by a physician on 11/19.
Patient #3 This patient is a 55-year-old female who arrived at the facility on 11/12/15 at 6:08 p.m. She had her screen on 11/13 at 3:10 p.m. The patient was identified as having PTSD and depression and was classified as a priority 1 because of mental health issues. She was seen by mental health staff within the first week.

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RECOMMENDATIONS:
1. Fill the registered nurse positions so that there is 24/7 registered nurse-staffing onsite.
2. When nurses identify a patient with a positive TB skin test, they should re-query the patient regarding acute TB symptoms.
3. The Medical Director should discuss with the methadone maintenance program a regimen that allows satisfactory detoxification from methadone while the patient is incarcerated.
4. The Director must arrange for booking to be entered into the computer at the beginning of the intake process.
5. The goal for completion of the nurse intake screen must be within four hours of the entry into the offender tracking system of the booking information.
6. Complete the training and post-test examinations for relevant medical staff with regard to the infection control policy, the intoxication and detoxification policy as well as the discharge planning policy.
MENTAL HEALTH FINDINGS: See above noted medical findings as they relate to the timeliness of the intake screenings and plans to now perform these screenings in the intake facility.
As noted in the last report, it appears that there is a subset of new admissions who are either unwilling or unable to reveal a history of serious mental health difficulties and/or current mental health difficulties at intake, but who then do reveal such during the initial mental health assessment, which is currently being performed on all new admissions. Although there are likely various reasons why this occurs, there is concern that the perceived lack of privacy afforded by performing intake screenings in the intake facility (vs. a private room in the medical facility) might make it even more difficult for some new admissions to reveal any significant mental health difficulties during the intake screening process. Therefore, we will continue to carefully monitor for this.
RECOMMENDATIONS:
1. Track data to support evidence of successful implementation of the policy and demonstrate adequacy of the quality of the screening process.
2. Continue to examine cases where an inmate with a negative mental health screen is later identified as an inmate in need of mental health services, and then explore options for altering the mental health screening process (be it the content and/or the conditions under which it is performed) so as to minimize the number of such false negative mental health screenings.
3. Assure that the mental health training that will eventually be provided to corrections officers helps them to appreciate the importance of their use of the ‘behavioral checklist’ and

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enhances their ability to use the ‘behavioral checklist’, given that the ‘behavioral checklist’ is one of the ways to identify inmates who are suffering from mental health problems that were not identified at intake.
4. Continue the practice of completing mental health assessments on all new admissions.
b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: As we understand it, Dr. Callwood, the Medical Director, is onsite Monday through Wednesday and Dr. Park has filled in when he has been available. Our understanding is that another physician has been identified who is very interested in working Thursdays and Fridays, which would provide sufficient coverage for more timely intake history and physicals. We understand this position has been filled as an employee v. a contractor.
Patient #1 This patient is a 34-year-old who arrived at the facility on 11/3/15 with a history of seizure disorder. He had his intake screen that day and he was assessed as acuity 2, but he did not receive his physical exam until six days later. At the time of the exam, he complained of chest pain and the history obtained was insufficient.
Patient #2 This patient is a 25-year-old who arrived at the facility on 10/22/15 and was screened on 10/23 at 11:00 a.m. He had a history of asthma and his peak flow was 400. He was an acuity 1 and was seen by the physician that day, but there was no mention of the asthma and no follow-up chronic care visit.
RECOMMENDATIONS:
1. Pursue a contract for additional physician hours so that the history and physical can be provided timely.
2. The Medical Director should provide feedback to the Head Nurse with regard to the appropriateness of the acuity level assignment from the nurse screen.
3. The Medical Director should develop a procedure that insures a timely initial chronic care visit based on disease control. If the patient meets disease control criteria of good control, the initial chronic care visit must be no later than 3-4 weeks; if the patient meets the criteria of fair control, no more than 2 weeks, and if the patient meets the disease control criteria of poor control, no more than 1 week for the scheduled initial chronic disease visit.

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MENTAL HEALTH FINDINGS: As was noted in the prior report, the ‘psychosocial assessment intake log’ indicates that initial mental health assessments are being performed on all new admissions the day of or the day after the mental health unit received the intake screening. Therefore, comprehensive mental health assessments are being performed well within three days of admission, except in cases where there was a delay in performing the intake screening, or a delay in sending the results of the intake screening to mental health staff.
Psychosocial assessments are now also being performed on inmates who entered the facility prior to the time when such assessments were being performed on all new admissions, with the initial focus being on completing assessments on inmates who are currently on the mental health caseload.
As recommended, the ‘initial mental health assessment form’ has been expanded to include a more rigorous assessment of any history of serious trauma, especially violent trauma, and the presence of any resultant clinically significant trauma-related symptoms and/or developmental difficulties, especially those that might render the inmate subject to deterioration and/or behavioral difficulties while incarcerated.
Also as recommended, the ‘psychosocial assessment intake log’ has been modified to include the date when inmates who are referred to see the psychiatrist actually see the psychiatrist. A review of this modified log reveals that those inmates who are referred to the psychiatrist generally see her in a timely manner. However, as previously noted, a timely face-to-face evaluation by the psychiatrist is not always possible due to the fact that the psychiatrist, who is part-time, is not always at the facility; when the psychiatrist is not at the facility, she is contacted by telephone for a consultation. However, the availability of video conferencing would allow her to actually perform an evaluation when she is offsite, which would be particularly helpful in cases where the inmates’ status is noted as urgent. We understand the Territory has begun the process of installing Tele-psychiatry (VSEE). It has been installed on one of the exam room computers. The Territory is in the process of installing the system on other computers, including Dr. Callwood and Dr. Sang’s personal computers.
RECOMMENDATIONS:
1. Continue to track inmates entering the facility and monitor time from admission to screening to initial psychosocial assessment, and to initial psychiatric assessment for those referred for an initial psychiatric assessment.
2. Continue performing initial mental health assessments on all new inmates, and continue efforts to perform such assessments on those who entered the facility prior to the time the current initial mental health assessments were being performed.
3. Develop a video conferencing mechanism that would allow the psychiatrist to perform psychiatric evaluations from an offsite location.
4. To the extent that the initial psychosocial assessment fails to identify any inmates with serious mental health difficulties (later picked up as a result of a referral to mental health by

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way of a ‘behavioral check list’), explore for factors that might have contributed to the failure of the initial assessment process to identify that inmate’s mental health needs.
5. Develop a protocol or procedure for responding to inmates who refuse to engage in an initial mental health assessment.
c. Prisoners’ timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;
ASSESSMENT: NONCOMPLIANCE (Partial Compliance for Medical, Non Compliance for Mental Health)
MEDICAL FINDINGS: We have used this section to address medical sick call, focusing on the acute part of the section. A separate section deals with chronic care needs.
The sick call log was consistently utilized and again we are able to report that a nurse generally saw the patients timely; most patients were seen by a nurse on the same day as receipt of the request. The exam rooms in the housing areas, according to staff and our own tour, have been completed and are available for appropriate use. In some records, we found insufficient subjective data obtained and in other records insufficient objective data obtained.
Patient #1 This patient is a 21-year-old who arrived at the facility on 9/3/13. On 11/19/15, he complained of painful urination. His vital signs were normal and no urinalysis was done, we were told, because the appropriate equipment was not available. This patient was seen by a physician and appropriate treatment was provided.
Patient #2 This patient is a 35-year-old with a history of hypertension, bipolar disorder and seizure disorder along with hypertriglyceridemia. On 11/23/15, he complained of chest pain. Among the elements that are considered necessary for a history with regard to chest pain are things that make the chest pain worse or things that make the chest pain better, and these were absent from the history.
Patient #3 This patient is a 25-year-old who arrived at the facility on 12/2/14. The patient presented with a history of asthma. On 11/9/15, he complained of shortness of breath and a chest cold for two days. He also complained of wheezing at night. His peak flow rate was 350. The patient was provided nebulization treatment; however, there was no post-treatment peak expiratory flow rate documented in the record. The peak flow is appropriate in order to objectively quantify the improvement after treatment.

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RECOMMENDATIONS:
1. The head nurse should provide feedback with regard to the nursing professional performance with regard to sick call.
2. Implement a procedure such that nurses by protocol always obtain a pre and post nebulization treatment peak expiratory flow rate.
3. Most of the nurse sick call should be completed within the housing unit exam rooms. This will require transporting the medical records to the housing unit exam rooms.
MENTAL HEALTH FINDINGS: As noted in the last report, the ‘mental health follow-up log’ lists all detainees and inmates who are on the mental health caseload, their psychiatric diagnosis, whether they have been on a suicide watch, placed in restraints or placed in seclusion, the date of their last psychiatric evaluation and any prescribed psychotropic medications, and the scheduled date for a follow-up psychiatric evaluation. Given the exciting development of nonpsychopharmacologic therapeutic interventions, these will also be noted on the follow-up log.
As recommended, the frequency of psychiatric follow-up visits has been reviewed, with a focus on whether or not at least some inmates were being seen frequently enough. As a result, the time between psychiatric follow-up visits has been reduced to a time period that is well within the standard.
Much thought has been given to the development of a clear protocol for inmates with major Axis I psychiatric disorders, for which treatment with psychopharmacologic agents is indicated but who either totally refuse to take medication or are not fully compliant with medication. With further exploration of the problem, examples of various types of situations were identified. For example, Patient #1 suffers from schizophrenia and is on lots of medication. He periodically refuses to take his medication, but usually when asked the next day he will take his medication. If such a patient refuses oral medication too frequently, IM medication would be considered. Patient #2 also suffers from schizophrenia. He has consistently refused to take medication and gets extremely angry when it is suggested that he take medication. Otherwise, he isn’t a threat to himself or others and does not present a management problem, and so he has not been forced to take medication. In contrast, Patient #3, who also totally refuses to take medication, threatens staff and is otherwise a major management problem. Therefore, steps need to be taken to go to court to force treatment. Patient #4 represents a subset of those who refuse to take psychotropic medication in that he also refuses to take medication for other chronic and potentially lifethreatening medical conditions. Going to court to force treatment should be an effort made by both the mental health unit and the medical unit. Therefore, a clear protocol for those who are not fully compliant with medication and those who totally refuse to take medication must recognize these different patient types.
As previously noted, the ‘behavioral checklist/sick call log’ lists all inmates for which a ‘behavioral checklist’ or a ‘sick call request’ was completed, the nature of the complaint, the date the form was received, the date the social work assessment was performed, if/when a referral to the psychiatrist was made, the date of any requested psychiatric evaluation, and the date for any

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required follow-up. In addition to tracking all of this information, the information contained in this log also helps in efforts to monitor the efficacy of the initial assessment process (to the extent that it identifies inmates who were not previously found to have clinically significant mental health needs), and helps to monitor the efficacy of the treatment provided (to the extent the it identifies inmates who are already on the mental health case load who are continuing to have significant difficulty despite receiving treatment – for example, as noted above, this information helped to identify the fact that some patients needed to be seen more frequently than they were being seen).
The non-psychopharmacologic treatment options continue to be an extremely helpful and very popular service provided by the mental health unit, especially the group therapy program. As was recommended, the possible addition of a ‘psychoeducational group’, focused on helping those with major mental health disorders learn about their disorders and how to best participate in the management of their disorder; a ‘dual-diagnosis group’, focused on those with a substance abuse disorder and another major mental health disorder; and a ‘support group for those with a history of exposure to severe trauma(s)’ is being explored.
It is important to again note that the fuller implementation of non-psychopharmacologic treatment options requires filling the remaining mental health staff positions, completing the renovation of space where group therapy, etc. will be done, and the timely availability of corrections staff to transport inmates to and from group therapy sessions, etc.
In addition, it appears that the mental health staff is unaware of the work that has been done to develop PREA policies and procedures, and they are therefore unclear about their role in the implementation of PREA policy and procedures. Although this monitor initiated discussion with the mental health staff about all of this, it became clear that a more complete review of PREA and PREA policies and procedures must be provided to mental health staff before staff can become clear about their expected roles and responsibilities and prepare to assume those roles and responsibilities. We understand The Territory has begun the process of getting the staff acquainted with the policy ahead of any training. It has been provided to the staff and portions of the policy relevant to mental health have been highlighted for ease of reference.
RECOMMENDATIONS:
1. Moving forward, a variety of quality indicators regarding services should be developed and maintained to aid the staff in ongoing quality improvement reviews as well as provide proof of practice for the monitoring team and any other Bureau, independent agency or accrediting body.
2. Continue to expand non-psychopharmacologic treatment options, which will include addressing some of the impediments to such an expansion noted above.

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3. Formalize the protocol or procedure for responding to inmates for whom psychopharmacologic intervention is indicated but yet refuse to take medication. This is especially important for those inmates who are being held in seclusion because they are not receiving treatment despite the fact that they are so severely mentally ill.
4. Take the above noted necessary steps to help mental health staff understand their expected roles and responsibilities with regard to PREA and prepare to assume those roles and responsibilities.
d. Continuity, administration, and management of medications that address (i) timely responses to orders for medications and laboratory tests; (ii) timely and routine physician review of medications and clinical practices (iii) review for known side effects of medications; and, (iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: There is a Medical Director on-site three days a week. We were told that from the time of ordering to the time of receipt by the patient, the process is working timely. However, there have been no quality improvement studies that document such timeliness. In addition, the Medical Director has not yet begun to review the use of medications, particularly by practitioners other than herself. Finally, we came across a patient with both medical and mental health issues who was released from court, returned to the jail and was released from the jail without ever receiving any of the regimen for medical and mental health problems. We were told that this occurred because when patients are released from court, custody does not notify the medical department so it can review the record, obtain any necessary medications and, if possible, arrange for post-release appointments. Two of the elements that could be studied and documented have not yet begun to be implemented and therefore the current assessment of noncompliance.
The new Medical Director has arranged for a different pharmacy and has reworked the contract with the pharmacist so that the pharmacist is predominantly monitoring the medication program and ensuring that the program minimizes the possibility of errors and complies with Territorial law.
During this visit, we observed the medication administration during the morning medication pass in several of the housing units. The officer who accompanied the nurse did an excellent job of ensuring that patients identified themselves. They brought water to the medication administration, the patients swallowed the medication with water and they cooperated in the post-ingestion mouth check. However, there was still one patient who did not swallow water either during the ingestion or immediately after, and did not cooperate with the mouth check. This behavior violates the rules of receiving medication, rules that have been provided to the inmates. The inmate has a right to refuse any and all medication, but they do not have a right to determine the rules under which the

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administration occurs. Therefore, we indicated that the particular inmate in question needs to be counseled such that he will not receive medication if he does not comply with the rules. He must ingest water at the time of administration or immediately thereafter and participate in a mouth check. Also, the nurse performing the medication administration brought all the patient medications together for each housing unit and they were not easily separated by patient. We indicated that the carrying container should include a vehicle to better organize the patient medications so that she can be certain that each patient appropriately receives the correct and complete regimen. We understand the GGACF Warden issued on or about 12/8/15 a directive to all security staff and management a directive mandating specific procedures for complying with the pill call process. This directive was re-issued on 2/21/16. This process will be assessed again during the 11th onsite visit.
RECOMMENDATIONS:
1. The medical program should work with custody so that there is a procedure that arranges for a timely notification of patients soon to be released by the courts. This is necessary so that the medical department, once notified, can review the medical record and arrange for the patient to receive any medications and appointments necessary for successful reentry before they depart the facility.
2. The QI program should, with the Medical Director and Head Nurse, perform a study of a sample of orders provided by clinicians and track the time of the order along with the time of receipt. For the overwhelming majority of orders, the requirement is that receipt should occur within 24 hours.
3. The inmate who refused to follow the medication rules needs to be counseled that he will no longer be provided medication if he does not comply with the rules.
4. The nurses should be provided a carrying container that allows segregation of each patient’s regimen within a particular cluster, e.g., housing unit. The Head Nurse should work with the nursing staff and the administrator to create such a methodology.
5. An electronic medication administration record will facilitate more accurate completion of the process and can be provided with several electronic records.
MENTAL HEALTH FINDINGS: See the discussion under medical findings with regard to medication administration.
As noted above, with more frequent visits, the timely and routine physician review of medications and clinical practices is much improved. The review for known side effects of medications is documented, and now with more frequent visits, such reviews are also timelier.
See also above discussion about medication noncompliance and the formalization of a protocol to address such.

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During this monitoring visit, there was a much more detailed discussion about and review of discharge planning, especially with regard to providing inmates with a sufficient supply of medication upon discharge. This review revealed that there are inmates with very serious mental health difficulties who were being treated while incarcerated, but who were released without any medication. It at least appears that, for the most part, such inmates went to court and were released, then returned to the facility for their belongings but mental health wasn’t notified that they were leaving the facility. Therefore, there was no chance to give them a supply of medication to use until they could begin treatment on the outside. This was particularly troubling, given that at least 3 of those released during the last monitoring period had previously evidenced symptoms such as auditory hallucinations and/or dramatic swings in their mood, at times accompanied by suicidal ideation. In at least one case, the psychiatrist had recommended long-term psychiatric placement upon release, a plan that could also not be implemented given that the mental health unit was not notified of his release.
This impediment to discharge planning and providing those being released with an adequate supply of medication was discussed with the administration, and options for addressing those impediments were explored. Whether or not any of those options are selected and implemented, and whether or not such implementation results in improved discharge planning will have to be determined at the time of the next site visit.
RECOMMENDATIONS:
1. The use of the medication refusal forms to allow nursing staff to notify clinicians of any significant pattern of medication refusal and the review of such forms by prescribing clinicians should be tracked. It may also be helpful to have a place on the form where the prescribing clinician can sign, indicating that the form has been seen and reviewed.
2. GGACF should develop a heat risk policy and ensure that all inmates have access to plentiful supplies of water and ventilation methods at all times. A list of inmates on medications that have heat-related risks should be maintained, and these inmates should have access to ice and water when the heat index indicates an elevated risk of heat-related illnesses.
3. GGACF should develop a heat risk policy and ensure that all inmates have access to plentiful supplies of water and ventilation methods at all times. A list of inmates on medications that have heat-related risks should be maintained, and these inmates should have access to ice and water when the heat index indicates an elevated risk of heat-related illnesses.
4. Regular assessment for medication adverse effects is well-documented, but through training such efforts should be expanded to involve all mental health staff in the identification of medication adverse effects.
5. The above noted impediments to the implementation of a discharge plan must be addressed so that inmates who are released receive an adequate supply of medication and a thoughtful referral to an appropriate treatment program/facility.

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e. Maintenance of adequate medical and mental health records, including records, results, and orders received from off-site consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: The medical record policy has been approved and the training and posttest and post-training examinations have been provided to the monitor. The filing errors have been substantially reduced. We have talked about the value of an electronic record so that records do not have to be carried to the housing units and multiple people can access completely legible records simultaneously.
RECOMMENDATIONS:
1. Continue to improve the organization of the medical records, including the timeliness and appropriateness of medical document filing.
2. Continue to explore the implementation of an electronic record.
MENTAL HEALTH FINDINGS: While doing chart reviews, it became clear that the organization of the mental health section of the medical records is much improved. As recommended, these records now also include all of the various therapeutic interventions that each inmate is receiving, including non-pharmacologic interventions.
As recommended, revisions to the ‘treatment plan’ reflect a multi-disciplinary approach to treatment planning, with a clearer indication of which interventions are focused on addressing which problems. What remains to be added to the treatment plan is a planned approach to addressing those who have refused treatment.
RECOMMENDATIONS:
1. Now that mental health records are appropriately organized and filed, a quality improvement tool needs to be developed to track compliance with this provision.
2. The mental health records should be organized chronologically.
3. The approved ‘treatment plan’ form needs further development, and should be expanded to describe planned interventions for those who have refused medication or other important therapeutic interventions.

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f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to:
(i) adequate sick call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: This item was dealt with under letter (c), including recommendations for this provision. It must be emphasized that not only have the policies and procedures been approved, training provided and the exams passed by the staff, but also there is now stability in onsite coverage by the Medical Director.
RECOMMENDATIONS: See letter (c) findings and recommendations.
MENTAL HEALTH FINDINGS: The ‘sick call log’ and sick call procedures have already been discussed above, and a review of the log indicates that the response to sick call requests is consistently timely and complete.
RECOMMENDATIONS:
1. See section ‘1c’ FINDINGS and RECOMMENDATIONS.
f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: We interpret this area as referring to a chronic care list and an ability to track the sequence of visits. Although the policies have been approved, training has occurred, and sufficient staff have passed the post-training tests, this area is clearly the farthest from substantial compliance. We reviewed five records of patients whose names were on the chronic care list. However, our review of all five records was sufficiently problematic such that we realized this program needs to be completely reworked. The medical monitor expects to spend some time with the new Medical Director providing technical assistance on how to best implement this area. Among the problems were records in which the problem list inside the medical record did not contain the problem for which the chronic disease program was following the patient. We also found a record in which, although the patient gave a history of a problem, was never confirmed by laboratory tests, although such confirmation should be easily available. We also found a significant number of records in which the initial chronic care visit was delayed, sometimes beyond 60 or 90 days. We also found records in which, after the initial chronic care visit, the patient was not seen in the appointed timeframe nor was there any explanation in the record. We also found records in which mandatory laboratory tests were not ordered as well as chronic care forms not appropriately completed. Some of the deficiencies in the documentation included inadequate subjective

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information, inadequate objective information, lack of assessment of degree of control and sometimes inappropriate plans for the degree of control. We believe this program provides the biggest challenge for the new Medical Director.
Patient #1 This patient entered the facility with a history of lupus erythematosus; however, this diagnosis was not on the problem list. In addition, there were no laboratory tests to confirm that diagnosis.
Patient #2 This patient arrived at the facility in February 2004, with a history of hypertension, hyperlipidemia, glaucoma and bipolar disorder. His most recent visit was six months earlier, in June 2015. At that last visit, neither the hypertension nor the hyperlipidemia nor the glaucoma were addressed. Rather, the only documentation addressed a headache and cerumen in the ear canal. There was no mention of blood pressure control or hyperlipidemia control. There were no blood studies for hyperlipidemia.
Patient #3 This patient had a blank problem list despite his history of angina. He had an initial chronic disease visit in August 2015, but there was no assessment of degree of control and no lipid studies. This patient has not been seen since.
Patient #4 This is a 77-year-old patient with a history of prostate cancer, asthma and hypertension. He has been seen once a year on follow-up forms. He never had an initial chronic disease database completed. His last chronic disease visit was in September 2013, where it was ordered that the patient be seen again in two weeks. He has not been seen since.
Patient #5 This is a 44-year-old patient who arrived at the facility in December 2011 with type 2 diabetes, hypertension, hyperlipidemia and mental health issues. He had his initial chronic disease visit form completed in April 2014, but other than family history, everything else is blank. He was seen once in 2014 and twice in 2015. His most recent chronic disease visit was in October 2015. He was assessed as being in fair control for his diabetes and in good control for his hypertension. He was scheduled to be seen in November for his diabetes but this never occurred.
In summary, this program needs to be started anew, with an understanding of how to create and appropriately document chronic disease follow up.

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RECOMMENDATIONS:
1. The Medical Director and the medical monitor should discuss the chronic disease program in its entirety with a plan evolving to rebuild the chronic disease program.
2. A chronic disease nurse should work closely with the Medical Director to insure that all patients have received the necessary diagnostic test per the required guidelines.
MENTAL HEALTH FINDINGS: As noted above, the ‘mental health follow-up log’ has been carefully maintained and is up-to-date. All patients on the mental health case load are consistently being seen and receiving treatment at appropriate intervals except those who have refused treatment; all modalities of treatment including group therapy sessions and other counseling services are logged; and the therapeutic interventions being employed appear to be appropriate.
RECOMMENDATIONS:
1. See section ‘1c’ for recommendations regarding the ‘mental health follow-up log’. 2. As the ‘treatment plan’ is expanded to include all services and the therapeutic goal(s) for each
intervention, the development of an integrated treatment log for all interventions continues to be a recommendation.
f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;
ASSESSMENT: NONCOMPLIANCE (Partial Compliance for Medical, Non Compliance for Mental Health)
MEDICAL FINDINGS: See f (ii).
RECOMMENDATIONS: See f (ii).
MENTAL HEALTH FINDINGS: See sections ‘1b’, ‘1c’, ‘1d’, and ‘1f’ subsections i and ii
For clarity, it should be noted that the primary issue that is holding mental health back here is the development and implementation of a clear protocol for seriously mentally ill patients who refuse treatment. This will be a major focus during the next monitoring visit.
RECOMMENDATIONS: See sections ‘1b’, ‘1c’, ‘1d’, and ‘1f’ sub-sections i and ii

Case: 1:86-cv-00265-WAL-GWC Document #: 960-1 Filed: 03/08/16 Page 79 of 133 79 of 133
f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide firstaid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental-health crises;
ASSESSMENT: NONCOMPLIANCE (Partial Compliance for Medical, Non Compliance for Mental Health).
MEDICAL FINDINGS: We reviewed five records of patients who were listed in the unscheduled service log as needing unscheduled services, most of whom were ultimately sent offsite. The process for providing emergency care breaks down after hours when, we are told, that officers call the Head Nurse who then calls the Medical Director. She decides to send out the patients. We believe her ability to triage patients advanced once the Territory completes implementation of the tele-health system. We did find that both onsite and offsite unscheduled services were documented in the same log. We also toured the housing units and inspected the emergency bags. We were pleased to find that all bags were well-maintained and had been reviewed on a daily basis by medical staff. There has been an improvement in notification to the Medical Director of identified emergencies. Most patients had the offsite service documents filed in the record and initialed as having been reviewed and, in addition, most saw the doctor upon return within a few days. However, there can be improvement in the timeliness of retrieval of offsite service documents; we found a record in which the offsite service document was reviewed and initialed by a nurse only. We were informed that four days after the patient returned, the patient was released and the document was retrieved after release. We indicated to the Medical Director that the nurse should initial that document and explain that this was received post-release and that is why the physician had not reviewed it.
Patient #1 This patient is a 35-year-old with hypertension, bipolar disorder, seizure disorder and hypertriglyceridemia who arrived on 11/23/15. He was sent out due to chest pain and his offsite service report was available, but not until the patient was released, about four days later. The nurse initialed it without indicating on the report that it had been received after release.
RECOMMENDATIONS:
1. Continue to aggressively pursue offsite service documents so that they are retrieved as timely as possible for use by the Medical Director.
2. The Medical Director should utilize actual cases to review and discuss with the nursing staff with regard to what was performed well and what items could be improved.

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MENTAL HEALTH FINDINGS: See medical findings and recommendations. Also, correctional staff have not been adequately trained to recognize and timely respond to emergency medical and mental-health crises. Partial Compliance can be achieved following requisite staff training and evidence-based demonstration of policy compliance.
RECOMMENDATIONS:
1. Develop video conference capability that would allow the psychiatrist to assess inmates who are in urgent need of an assessment even when she is off site.
2. The training of all staff in recognizing mental health emergencies has not yet occurred but should move forward as planned
f. (v) adequate and timely referral to specialty care;
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: We reviewed eight records of patients sent offsite for scheduled offsite services. We used the log to determine which records to select. All records we utilized had these services provided since our last monitoring visit. Of the eight records we reviewed, a few records did not have a follow-up visit with the primary care clinician after the offsite service. The offsite service documents were usually obtained, although some not timely. Overall, this service has improved since our last visit. However, it is still in partial compliance.
Patient #1 This is a 25-year-old with asthma. On 10/23/15, he was referred for a soft cystic mass on his left forearm. He was seen on 12/3 with a diagnosis of a fatty tumor to be excised at the hospital. He was then sent for surgery on 12/11, but that operative report is still pending. He was seen in chronic care clinic for his asthma on 12/15. He was not seen after the initial diagnostic visit with the surgeon.
Patient #2 This is a 24-year-old with asthma, who received an order for a dermatologist on 11/26/15. His appointment was on 12/10. However, the dermatology note by the dermatologist does not indicate what the regimen was for this patient. The Medical Director will have to contact the dermatologist and she will follow this patient.

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RECOMMENDATIONS:
1. The Medical Director must ensure that following a scheduled offsite service there is a follow-up visit onsite with herself or another practitioner.
2. The offsite service coordinator should ensure that offsite service documents are accessed timely.
f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: The relevant policy is Hospital and Specialty Care, which is included with the Group 1 policies. Medical/Mental Health staff were trained on this in July 2015 and documentation provided to the US and monitor on 8/3/15. The Territory met the 95%/80% requirement. The master training list was provided to the Territory and the Monitor on 12/15/15. In addition, we identified a case of a patient who entered the facility on methadone maintenance but this was not provided, nor was the problem addressed. We discussed our recommendations encouraging the Medical Director to work with the local methadone maintenance program to, at a minimum, receive a recommended regimen that should be followed for detoxification.
RECOMMENDATIONS: This has been discussed under f (v).
MENTAL HEALTH FINDINGS: With regard to mental health, adequate follow-up care and treatment after return from referral for outside diagnosis and treatment is facilitated by the fact that the facility’s psychiatrist is also the psychiatrist at the hospital. Notwithstanding this fact, care must be given to formally referencing emergency assessments performed and treatment given at the hospital, and the linking of that to follow-up care and treatment.
A somewhat related issue is the availability of up-to-date information for inmates being admitted upon a transfer from St. Thomas or the Federal Prison in Puerto Rico. Reportedly, there tends to be delays in entering such transfers into the ‘smart jail’ system, and as a result there is a period of time when mental health staff doesn’t even know that they are at the facility. How much, if any, information mental health staff receives about such transfers (with regard to whether or not they suffer from mental health difficulties) requires further exploration.
RECOMMENDATIONS: Refer to medical findings and recommendations.

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g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: The training with regard to this policy and procedure has not been completed. In addition, we identified a case of a patient who entered the facility on methadone maintenance but this was not provided, nor was the problem addressed. We discussed under recommendations encouraging the Medical Director to work with the local methadone maintenance program to, at a minimum, receive a recommended regimen that should be followed for detoxification.
RECOMMENDATIONS:
1. Complete the training and examinations on this area.
2. The Medical Director is to obtain recommendations from the methadone maintenance program on a regimen for detoxification.
MENTAL HEALTH FINDINGS: See medical findings and recommendations.
The monitor remains concerned about the management of the subset of individuals suffering from substance abuse difficulties who also suffer from some other major psychiatric difficulty, and whether that other major psychiatric difficulty is evident while the individual is intoxicated and/or becomes evident during detoxification. In either case, it is well recognized that with such patients, the management of substance abuse difficulties and such other mental difficulties must be done in an integrated and coordinated way if interventions are to be effective.
RECOMMENDATIONS:
1. Assure the integration of mental health staff into the assessment and treatment of intoxicated inmates and those undergoing detoxification when there is evidence that the inmate is also suffering from other major psychiatric difficulties.
h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: This item still requires training of the nursing staff and oversight of the training of the officers, which should be accomplished by the Medical Director. We have previously discussed with regard to intake the recommendation to ensure that nurses re-query patients regarding active TB symptoms when they find a positive skin test. This should be documented in the record. We also strongly recommend a program regarding skin

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infections and the control of MRSA. This has historically been problematic in correctional settings. It is important to track both culture-proven and presumptively treated MRSA infections. Accomplishing this must be done through notification to the designated infection control nurse who keeps track of and reports monthly the number of presumptively treated and the number of culture-proven cases each month.
RECOMMENDATIONS:
1. Train the nursing staff so that when they identify a positive TB skin test they are to requery the patient regarding acute TB symptoms and document this in the record.
2. A program should be established to report monthly both presumptively treated as well as culture-proven skin infections.
MENTAL HEALTH FINDINGS: Defer to Dr. Shansky’s report
RECOMMENDATIONS: None.
i. Adequate suicide prevention, including: (i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate metal health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As was noted in prior reports, reviews of ‘behavioral checklists’, sick call requests, and the ‘behavioral checklist/sick call log’ indicate that there continues to be clear corrections officer referrals and inmate self-referrals for suicide concerns and other serious mental health concerns. These documents and records also indicate an immediate response to these referrals by the mental health unit. However, what is difficult to determine is how quickly corrections officers identified serious mental health needs and then completed a ‘behavioral checklist’, which is the other key element in addressing this issue. Therefore, as training of corrections officers on suicide prevention and other mental health emergencies continues, such training should also focus on identifying problems as early as possible (i.e., if possible, when deterioration begins/before a full crisis occurs).

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RECOMMENDATIONS:
1. Continue to monitor and review future behavioral health checklist referral tracking logs.
2. Because all staff have not yet been trained with an approved curriculum for suicide prevention, this provision remains noncompliant. It is recognized that despite not having been trained, the security staff does an excellent job completing these forms when behavioral problems are identified. However, there should also be an assessment of how early in the process of the emergence of suicidal ideation or other mental health emergency that such difficulties are identified by security staff.
(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: During this monitoring period, six (6) suicide watch charts were reviewed but only one of those charts showed a monitoring log was initiation. There was one clear case where an inmate was placed on Level One suicide watch by the mental health unit, which includes monitoring every 15 minutes. The order was documented in the inmate’s mental health record. It was also noted in the ‘Unit Log’, but another entry in the Unit Log seemed to indicate, at least initially, that the supervisor was unaware of the order and/or that other officers who should have been notified were not notified. Although the suicide watch was ordered for at least 6 days, and apparently even more than that, there was only one other mention of this in the Unit Log, and that mention did not include the level ordered or the required frequency of monitoring. It simply stated that the inmate was on suicide watch and needed to be monitored. There was no indication in the Unit Log that the inmate was monitored at all, and there has been no production of a separate observation form for this inmate for this monitor’s review.
Given the above noted, this monitor can only conclude that at minimum, there is insufficient documentation or data to demonstrate any constant observation of inmates until they are evaluated by a qualified mental health professional and insufficient documentation or data to demonstrate any observation of inmates consistent with the level of suicide watch ordered after an inmate is evaluated. Of course, this lack of documentation or data raises the question of whether or not observation is occurring at all.
RECOMMENDATIONS:
1. The facility will need to develop a means of documenting whether or not an inmate is maintained on constant observation until the time of the evaluation in order to demonstrate compliance with this provision. Similarly, the facility will need to develop a means of documenting whether or not an inmate is being observed consistent with the level of suicide watch ordered following an evaluation by mental health.

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2. Currently, documentation is scattered between an observation form and hit-or-miss notations in the officers’ unit log. Implement approved Log of Suicide Watch (PCO) Rounds.
3. Once implemented, these should be reviewed by mental health staff regularly to ensure security’s compliance with the policy.
(iii) timely suicide risk assessment instrument by a qualified mental-health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;
ASSESSMENT: PARTIAL COMPLIANCE
MENTAL HEALTH FINDINGS: A well-developed suicide risk assessment instrument is in place and being utilized as indicated. Staff have been trained on the approved policy and procedure.
RECOMMENDATIONS:
1. Continue to utilize the suicide risk assessment tool and develop quality assurance data to demonstrate compliance with this provision. Ensure required annual training is completed as required.
(iv) readily available, safely secured, suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Although suicide cut-down tools are in place and safely secured, it is not at all clear that they are readily available (i.e., can be quickly enough retrieved from their location to be useful in the event of a suicide attempt). It is also not clear that all security staff are familiar with their use. Additionally, all correctional staff have not been trained on the approved policy but training has commenced, according to the Territory.
RECOMMENDATIONS:
1. Assure that rapid access to cut-down tools is possible.
2. Complete training.
3. Demonstrate compliance with approved policy following completion of requisite training.

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(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: See above section on cut-down tools
RECOMMENDATIONS:
1. Complete training for all staff on suicide prevention, including training for security staff on the use of cut-down tools, followed by an assessment of competency to employ such suicide prevention efforts.
(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Training has commenced but has not been completed.
RECOMMENDATIONS:
1. The facility proposed to complete this training by July 31, 2016 for all staff.
2. Effectiveness of the training will need to be demonstrated by the use of competency measuring tools and follow-up quality improvement studies.
(vii) availability of suicide resistant cells;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The plan to create suicide resistant cells in the medical facility that was previously presented to this monitor has not been implemented. This monitor has now been told that a suicide resistant cell was being created in the intake area; it is the understanding of the monitor that the decision to move on that was at least in large part based on the fact that there was always a corrections officer there who could monitor an inmate on suicide watch. However, it is unclear to this monitor whether this is only a temporary measure until staffing levels increase or whether it has been decided to move the location of the suicide resistant cell, despite the fact that such a relocation complicates the ability of mental health staff (and medical staff) to provide evaluation, monitoring and treatment services to suicidal inmates.

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RECOMMENDATIONS:
1. GGACF is encouraged to urgently complete renovations in order to provide appropriate and safe suicide and close observation cells. Ideally, such cells would be in the infirmary. As expressed in the last 3 reports, all measures should be taken to provide adequate space within the cell, suicide resistant sinks and commodes, and ensure the absence of any protruding objects within the cell that would facilitate the placement of a ligature. Please refer to all of the detailed recommendations in the Monitor's fifth assessment report regarding the configuration and structure of suicide-resistant housing.
2. Even when suicide-resistant cells are available, security staff will still need to be present in the suicide prevention housing area to monitor inmates on suicide prevention 24 hours per day. As noted above, appropriate logs for documenting security staff monitoring will need to be developed, maintained and then reviewed for compliance with policy and procedures.
3. Even when suicide-resistant cells are available, a nurse must be present in the suicide prevention housing area 24 hours a day to complete the required monitoring of the patient every shift. These records will also need to be reviewed for compliance with policy and procedures
4. Until such time that the proposed suicide prevention housing area has been fully renovated and operational, security staff must provide constant observation of inmates placed on the highest levels of suicide watch, and document that such constant observation is taking place. This documentation should be reviewed for compliance with policy and procedures.
(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The medical/mental health records and a log maintained by the mental health coordinator clearly track and provide information obtained from ongoing evaluations regarding indications for the various levels of suicide watch ordered. A review of medical/mental health records and the tracking log indicated that the protocol for the mental health supervision of actively suicidal inmates is clear, consistent with current standards of medical practice, and carefully followed. However, as noted above (in section vii), it is impossible to document the extent to which security staff is providing the level of observation required to ensure the safety of inmates placed on suicide watch, and it at least appears that the level of observation by security staff continues to be intermittent and unpredictable at its best.

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RECOMMENDATIONS:
1. Complete the process of training on suicide prevention and observation policy, implementation and monitoring.
2. System-wide training for this provision will be the last of the medical trainings offered because security must also be included. However, the facility is strongly urged to consider a method to ensure that inmates placed on suicide watch, between now and the time training is completed, are adequately supervised and that this supervision is documented according to policy.
(ix) procedures to assure implementation of directives from a mental health professional regarding: (1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above (under section vii), the protocol for the ongoing mental health evaluation of suicidal inmates and the care of such inmates, including their placement on and removal from suicide watch, is being carefully followed by the mental health staff. Furthermore, a review of their work in this regard indicates that clinical decisions have been consistently appropriate, both during the period of an inmate’s active suicidality and during the prescribed period of follow-up after an active level of suicidality has remitted. However, there continues to be concern about the implementation of directives that result from the evaluation and the development of care plans for suicidal inmates when such directive must be implemented by staff outside of the mental health unit.
RECOMMENDATIONS:
1. Assure that appropriate mechanisms are in place to facilitate the notification of all medical staff, especially nursing staff, of mental health directives and care plans for suicidal inmates; monitor the effectiveness of such mechanisms for notification; and monitor the implementation of the directives that nursing and any other medical staff are responsible for.
3. Assure that appropriate mechanisms are in place to facilitate the notification of security staff of mental health directives and care plans for suicidal inmates; monitor the effectiveness of such mechanisms for notification; and monitor the implementation of the directives that security staff are responsible for.
j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.

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ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: The staffing currently consists of four RNs who cover roughly 8:00 a.m. to between 8:00 p.m. and midnight, seven days a week. However, there is between 8 and 12 hours per day not covered by onsite RN staff. This situation is likely to get worse before it gets better, in that one of the existing RN staff has accepted another job. The fillin physician for the Medical Director has been problematic, but we understand this positions has been filled by a staff physician. It is up to the administration to arrange for matriculation of this physician. With the additional nursing and the fill-in physician, the medical staffing will be complete.
RECOMMENDATIONS:
1. Fill the nursing hours to complete 24/7 RN staffing.
MENTAL HEALTH FINDINGS: At present, the mental health staff includes the mental health coordinator (Ms. Murray, LCSW), a part time psychiatrist (Dr. Sang), a mental health counselor (Mr. Rosas, MHC), and at least a substantial amount of time from one of the nurses (Ms. Randolph, RN).
At least one additional staff person is required to address all of the provisions of this agreement. It was the understanding of this monitor that there was, in fact, a line for another mental health counselor; but this monitor has recently discovered that steps still need to be taken to actually fund that line. It is the understanding of this monitor that a prior candidate for that line had been identified, but since there was no movement in hiring that candidate, the candidate finally took another position. It is the understanding of this monitor that now another candidate has been identified, and given how difficult it can be to find qualified mental health professionals to do this work, hopefully the line will be funded quickly enough so that candidate will not also be lost.
RECOMMENDATIONS:
1. Fund and the fill the slot for an additional mental health staff person as quickly as possible.
2. As mental health staff continue efforts to address all of the provisions of this agreement, staffing analyses should continue to assure adequate staffing of the mental health unit.
k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE

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MEDICAL FINDINGS: We were told that delays in accomplishing the computerized booking were in fact related to inadequate numbers of classification officers. In addition, whether it is the assignment of officers or the overall numbers, this program has been handicapped by officer availability even to escort nursing staff to accomplish the nursing intake screen. Also, when the officer in the medical clinic functions as the officer assisting the medication administration process, the medical program as well as mental health are closed down until that officer returns. There must be available at least two officers in the building in order to perform the escort service while someone remains in the medical clinic building to provide security for occupied infirmary beds as well as for outpatient traffic.
RECOMMENDATIONS:
1. Ensure sufficient staffing to accomplish all of the health care services in a timely fashion.
2. Ensure that trainees are not assigned the medical function with regard to medication administration or running the building.
MENTAL HEALTH FINDINGS: As per medical findings.
RECOMMENDATIONS: As per medical recommendations.
l. A protocol for periodic assessment of the facility’s compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: The medical program now has a dedicated Medical Director in place who is providing leadership for the quality improvement program. She has begun by reviewing the chronic disease program, which she identified as problematic with regard to timeliness of visits, performance of professionals and compliance with disease guidelines. We intend to work with her on expanding the quality improvement program to include all of the services provided.
RECOMMENDATIONS:
1. The Medical Director and the medical monitor should discuss elements to be implemented in the quality improvement program.

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MENTAL HEALTH FINDINGS: Except for the exceptions noted above, the mental health team is now collecting adequate data that can be used to assess compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious mental health conditions. When the above noted exceptions are addressed, the team will also have the data required to assess the overall quality of services provided, and thereby identify any policies, procedures or practices that need to be revised in order to assure quality mental health service delivery.
Given the now ready availability of such data, the current focus should be on the development of a meaningful periodic review of this data for compliance with policies and procedures, and the development of an approach for employing this data to assess overall quality of mental health care.
It must be noted however that quality assurance with regard to mental health care is not entirely under the control of the mental health staff. For example, assuring the safety and adequate care of suicidal inmates requires the availability of suicide-resistant cells and monitoring by security staff. For example, the management of dual-diagnosis patients (with substance abuse difficulties and another major psychiatric illness) and the development of a plan to address patients with both mental health and other medical conditions who refuse treatment requires the cooperation of/coordination with the medical unit. In addition, the appropriate care of many of the seriously mentally ill inmates who are amenable to treatment requires access to a unit designed for inmates with such special needs that would allow for enhanced mental health programming, and those who refuse treatment require a mechanism to obtain treatment for them instead of placing them in segregation, which in some cases will involve the courts.
RECOMMENDATIONS:
1. The mental health staff should develop compliance reports that indicate any failures to comply with developed policies and procedures, and the result of investigations into the reasons any such failures to comply occurred.
2. The mental health team should also assess the overall quality of the mental health services provided, with an eye towards identifying, developing, and implementing any quality improvements that should be made.
3. Monthly or quarterly management meetings with medical staff and other department leaders should be occurring. Mental health staff should be using these meetings as an opportunity to continue to raise quality assurance issues that are not totally under their control. The raising of such issues and any identified approaches to addressing such issues should be documented in the minutes of these management meetings.
m. Adequate dental care;
ASSESSMENT: NONCOMPLIANCE (Partial Compliance for Medical, Non Compliance for Mental Health)

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MEDICAL FINDINGS: We continue to find that access to dental services were subject to availability of airplane tickets for the dental staff. When the dental assistant/hygienist is unavailable, the dentist does not provide services. Within the month of November, there were three weeks in which the dental assistant was not able to be present onsite. This clearly is not acceptable. The officer escorting issue also needs to be resolved. It is not acceptable if health services are shut down while the only officer in the building is pulled to escort patients to the building.
RECOMMENDATIONS:
1. Fix the problem of transporting the dental staff to GGACF.
2. Provide sufficient officers such that access is unimpeded.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted in prior monitoring reports, mentally ill inmates, especially those suffering from serious yet untreated mental illness, may not focus on their need for dental services and therefore not seek the dental services that they require, even if they are in pain. Therefore, GGACF health, mental health and dental services must be proactive in monitoring the dental hygiene of this vulnerable population.
RECOMMENDATIONS:
1. GGACF officials should ensure protocols are in place and practices that ensure proactive oral health assessment of mentally ill inmates.
n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents in which a prisoner was at high risk for death within 30 days of the incident triggering the review;
ASSESSMENT: NONCOMPLIANCE.
MEDICAL FINDINGS: There is a Medical Director in place but neither deaths nor hospitalizations have yet been reviewed by her. This is an area that the medical monitor will discuss with her. Advancing this Provision may include review of a mock mortality review per a scenario-based event that involves all elements of this Provision and the approved policy and procedure. RECOMMENDATIONS:
1. Have the new Medical Director perform a review of the care provided at GGACF for the patient who died.

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MENTAL HEALTH FINDINGS: Similar to Medical Findings
RECOMMENDATIONS:
1. The clinical directors, Director of Nursing and Health Services Administrator should develop mechanisms to identify and review all cases of mortality and serious morbidity as part of the Quality Improvement process. These reviews should also include security leadership.
2. When such reviews result in the identification of issues that need to be addressed (whether failure to comply with policies and procedures or the possible inadequacy of existing policies and procedures), a plan for corrective action should be developed.
3. The incidences that prompt such a review and the review and its outcomes should be shared with the monitor.
o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: Although we do believe a nurse has been making rounds in segregation three days per week, we have not been able to receive a list of patients who were seen in the segregation on the rounds for which problems have been identified and treatment provided.
RECOMMENDATIONS:
1. Maintain a list of patients seen each day in segregation for whom the patient was seen either by the nurse or for whom a note was written.
MENTAL HEALTH FINDINGS: As previously reported, there is weekly mental health rounding in isolation/segregation cells performed by Mr. Rosas, and monthly mental health rounding in isolation/segregation cells performed by Ms. Murray. In both cases, all inmates in isolation/segregation are seen – not just those on the mental health caseload – and there are logs kept for both sets of rounding that indicate when the inmate was seen, the inmate’s general well-being, the condition of the inmates’ cell, and any specific mental health needs that the inmate might have.
During this monitoring visit, this monitor accompanied Mr. Rosas on his rounds, and found that he was clearly quite familiar with each inmate; that the inmates were familiar with him; and that the rounds were conducted in a competent and effective manner. Although this monitor did not yet accompany Ms. Murray on her rounds, this monitor discussed the rounding process quite extensively with Ms. Murry, and as previously noted, the prior

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monitor did round with her and found that her rounds were also conducted in a competent and effective manner.
The primary focus of this monitoring visit was the meaningful integration of the information gathered and the mental health opinions rendered (based on that information and all other available information about each inmate) into the larger segregation review process. This involved two activities. The first was meetings with the mental health staff to discuss what role they should be playing in the larger segregation review process. More specifically, in addition to offering their findings, they should, for example, be making recommendations for addressing any mental health issues that might have contributed to such a placement, recommending therapeutic interventions for those adversely impacted upon by such isolation or segregation, and/or even recommending more appropriate alternative placements, regardless of whether or not any such recommendations are currently implementable (i.e., if only to repeatedly establish the need for such alternatives). During those discussions, it was clear that mental health staff had such recommendations, but had been reluctant to put such recommendations forward given current limitations. The second activity was meeting with security staff and the ultimate revision of the ‘isolation/segregation review form’, so as to begin the process of more meaningful integration of information from the mental health unit into the segregation review process. The second activity was meeting with security staff and the ultimate revision of the ‘isolation/segregation review form’, so as to begin the process of more meaningful integration of information from the mental health unit into the segregation review process.
RECOMMENDATIONS:
1. The Mental Health Coordinator will continue to keep documentation of weekly and monthly rounds, and will keep documentation of information provided and recommendations offered during the monthly isolation/segregations review process.
2. Monitor how mental health recommendations made during the monthly isolation/segregation review process are integrated into and impact on the monthly isolation/segregation review process.
3. Continue to document the need for certain alternative therapeutic interventions (most of which have been noted in other sections of this report) that would allow many mentally ill inmates to be removed from segregation, and continue to advocate for the provision of such interventions.
p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;
ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: As has been noted in prior monitoring reports, despite this prohibition, that there are still inmates with serious mental illness who are being held in isolation/segregation, and some of them have been held in isolation/segregation for many, many years. The seriously mentally ill inmates being held in isolation/segregation fall into several sub-groups, each of which raises different issues/concerns.
First of all, there are seriously mentally ill inmates who are not receiving any type of mental health treatment because they have reportedly refused such treatment, and as a result they continue to be acutely psychotic and/or otherwise seriously mentally ill. Two of the issues discussed above are particularly relevant for this subgroup – they are (1) the documentation by mental health staff (during the rounding process) of their mental health status and their need for an intervention other than locking them in isolation/segregation, and (2) a clear protocol for addressing the mental health needs of inmates who refuse treatment.
There is a second group of seriously mentally ill inmates who are in treatment, but reportedly are being held in isolation/segregation because, despite treatment, they continue to be too vulnerable to be placed in general population. In other words, they are reportedly being protected by being placed in isolation/segregation. These inmates are allowed two hours/day of congregant out-of-cell unstructured time and at least some of them are also now participating in the group therapy program. However, to date there is no planned housing alternative that would provide protection for this group of inmates, such as an open unit for this population of patients and others who might require similar protections. Therefore, there is also no opportunity to develop enhanced programming for seriously mentally ill inmates that would be a therapeutically sound alternative to locking them in isolation/segregation for the overwhelming majority of the day.
Then there is the group of seriously mentally ill inmates who are in isolation/segregation as a disciplinary sanction. As discussed below, there is no clearly documented evidence that the mental health status of most of these inmates was considered when reviewing their disciplinary infraction and/or when deciding whether or not isolation/segregation was the most appropriate response to their disciplinary infraction.
See also the above section on isolation/segregation rounds and the isolation/segregation review process.
RECOMMENDATIONS:
1. As per the provisions of this Settlement Agreement, inmates with serious mental illnesses may not be placed in isolation. This infraction should be repeatedly documented during the rounds of isolation/segregation cells performed by the mental health staff, and corrective action taken.
2. For those seriously mentally ill inmates who refuse treatment, the mental health staff needs to opine as to whether or not such inmates are a sufficient danger to themselves or others that they would require isolation/segregation. In addition, a protocol must be developed for that subset of inmates that are a danger to themselves or others, focusing

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on attempting to get them to voluntarily accept treatment and outlining steps that should be taken for those who ultimately continue to refuse treatment.
3. With regard to those seriously mentally ill inmates who are currently in isolation/segregation for their own protection, the Bureau of Corrections needs to develop a corrective action plan with specific recommendations for capital improvements that will provide a more appropriate housing unit for such inmates, with dates to remedy this deficiency. In addition, once an alternative to the isolation/segregation of such inmates has been developed, mental health staff will need to develop enhanced programming for them.
4. With regard to those seriously mentally ill inmates with an alleged disciplinary infraction, see the next section of this report.
5. During the time that inmates with serious mental illnesses remain in segregation, mental health staff should be aware that these inmates should be offered a minimum of 10 hours per week of unstructured out-of-cell time by security. Additionally, mental health staff is encouraged to develop supportive group or individual therapeutic activities, generally recommended being a minimum of 10 hours per week per inmate in order to support the inmate’s mental state as well as assist inmates in acquiring skills to move them off the segregated status and sustain themselves in the general population setting whenever possible.
6. Mental health staff need to repeatedly raise all of these concerns during management and administrative meetings as a reminder to all levels of staff that these concerns remain and must be addressed. In such management meetings there should be a particular focus on issues that clearly relate to security concerns, space allocation, and other above noted issues that are under the control of those outside of the mental health unit.
q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS A discussion between the monitors, mental health staff, security staff, and corrections administrators regarding this issue was also a major focus of this monitoring visit. Several issues emerged.
This monitor noted that mental health input should be occurring right from the beginning of the disciplinary review process versus an add-on after the disciplinary review process is completed and a sanction has been given. Corrections noted that when a disciplinary charge is filed, and the inmate appears to have some mental health issues, a behavioral checklist is or could be completed and sent to mental health, and mental health could begin to perform

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an evaluation. It was also noted that if the inmate was already on the mental health caseload (which could be provided to the appropriate corrections administrator) mental health could be notified even if there were no obvious indications that the inmate’s mental illness might have contributed to the disciplinary infraction, and mental health staff could begin to perform an evaluation specifically related to the disciplinary charge.
The more difficult issue that emerged was to what extent any mental health findings or opinions might impact on the disciplinary review process and the sanctions levied. The issue became such that even if some subset of inmates charged with a disciplinary infraction might be diverted to mental health or even given a lesser sanction than placement in isolation/segregation, it is yet to be determined who can make that decision and when could such a decision be made (i.e. can this decision be made without going through the entire disciplinary review process, especially in instances where the inmate’s mental health status might make it difficult for him/her to adequately participate in/defend him/her-self during that process?).
Given the above, it would at least appear to this monitor that although there may be movement toward allowing some comment by mental health as part of the disciplinary review process, it is not at all clear how any information or opinion from mental health will be incorporated into the process and impact, if at all, on the sanctions levied.
It should also be noted here that another/related issue impacts on all of this, and that is what at least appears to be the lack of a range of disciplinary sanctions other than isolation/segregation that may be more appropriate for lower level infractions, regardless of the inmate’s mental health status.
RECOMMENDATIONS:
1. GGACF should continue to work on the development of an effective policy and process to provide mental health review and input into the disciplinary process.
2. Mental health staff must be prepared to quickly assess inmates with alleged disciplinary infractions, with an eye toward determining whether or not the alleged infraction was likely a product of any mental illness that the inmate might be suffering from, and the likely impact of potential sanctions on the inmate’s mental health status.
3. GGACF should develop a form that can be sent to the Mental Health Coordinator, completed by mental health staff and submitted to the disciplinary committee, which outlines the findings of the mental health assessment. The committee can use the same form to communicate back to the mental health staff the outcome of the hearing proceeding.
4. Mitigating factors discovered by the mental health professional must at least be considered by the disciplinary committee.
5. Mental health services should track the effectiveness of their input in mitigating sanctions or terminating sanctions as appropriate.

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6. Alternative housing and treatment services are an essential component in diverting seriously mentally ill inmates committing infractions due to their impaired judgment and mental processing.
7. Again, it is recommended that GGACF provide appropriate staffing and housing alternatives for this population. (See V.1.p.)
r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: Progress has been made in that the exam rooms have been completed. The area that remains to be addressed is the infirmary area in the medical clinic building. We would like to see a plan for what yet remains to be accomplished in that building.
RECOMMENDATIONS:
1. Please provide us a plan with specific timelines of the remaining elements to be completed in the infirmary area with a timeframe for completion.
MENTAL HEALTH FINDINGS: The renovations of the examination offices on each of the housing units has been completed. It is the understanding of this monitor that mental health staff have access to these offices for individual sessions with inmates and psychiatric visits when other medical staff are not utilizing them, but the logistics of this (such as scheduling, the availability of keys, etc.) remains unclear.
However, the renovation of space already designated for mental health programming remains incomplete, thus such space can still not be put into use. These designated spaces include the renovation of multipurpose rooms on the segregations units so that the space can be used for mental health programming, the above noted renovation of cells to make them suicide-resistant (including the newly identified cell in the intake unit), and the renovation of space for the already expanded group therapy program.
RECOMMENDATIONS:
1. Continue with current renovation plans as quickly as possible.
2. Continue to assess the need for additional space for developing mental health programming.
s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan develop and implementation:

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ASSESSMENT: PARTIAL COMPLIANCE
MENTAL HEALTH FINDINGS: The issues related to the timely, current, and adequate development of mental health treatment plans have already been discussed under other provisions of this agreement. As this monitor continues to review charts/mental health records during subsequent monitoring visits, this monitor will continue to review treatment plans, with regard to their timely completion, whether or not they were developed by the mental health treatment team as a whole, to what extent they were reviewed with and understood by the inmate/patient, and the relationship between the information obtained during the assessment process and the treatment plan in order to assess the adequacy of the treatment plan with regard to the inmates presenting mental health problems.
It must again be noted that this monitor recognizes that the adequacy of treatment plans might, at times, be compromised by some the above noted problems that are outside of the control of mental health staff. When this is the case, this monitor will expect to see any such required compromises noted in the treatment plan, so as to make it clear that there is a more appropriate intervention that is simply not currently available. Therefore, a treatment plan might note, for example, that a patient will be switched to a specific, more appropriate modality of treatment when such become available.
RECOMMENDATIONS:
1. Based on policy and developed protocol, treatment plans should be updated at set frequencies based on inmate need and changing conditions in the inmate status. It is strongly recommended that supervisory review occur to ascertain the appropriateness and completeness of the treatment plans generated.
2. When indicated, in-service training on treatment plan development is recommended to ensure consistency between staff members in developing measurable objectives toward marked improvement in those inmates followed by the mental health team.
(ii) adequate mental health programs for all prisoners with serious mental illness;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As has been previously noted, mental health programming has been expanded to include various group therapy sessions and individual sessions as needed. Although I have recommended the expansion of the group therapy program, it is clear that the existing program has already proven itself to be quite beneficial to many of the inmates in need of mental health services. It is also clear that individual sessions have been judiciously used to help inmates in need of additional support.
As noted above, enhanced programming for seriously mentally ill inmates, especially those currently in isolation (both while they remain in isolation and even when a suitable

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alternative to isolation has been developed), must be developed. In addition, a stepwise program of interventions for those who refuse treatment must be formalized and fully implemented.
RECOMMENDATIONS:
1. The mental health team will need to develop a global treatment menu designed to meet the needs of inmates at different levels of housing and treatment needs.
2. Group programming should be designed to meet the clinical needs of individuals who should be assigned to those programs based on their needs assessment and their individual treatment plan.
3. The facility should consider how it might create a special population housing unit that would provide a safe housing alternative to vulnerable mentally ill inmates and make the delivery of services more efficient to those who require enhanced mental health services.
4. Those who refuse needed treatment must be further assessed to determine if they are a danger to themselves or others. This assessment should be used to determine whether or not they require placement in isolation/segregation and whether or not a court intervention should be obtained that would require them to undergo treatment; and all the while, efforts should continue to convince such inmates to voluntarily accept treatment.
(iii) adequate psychotropic medication practices, including monitoring for side effects and informed consent;
ASSESSMENT: PARTIAL COMPLIANCE
MENTAL HEALTH FINDINGS: Most of the issues related to this finding have been addressed in earlier sections of this report, but a few additional comments, including updates from the last report, need to be raised.
Communication between staff regarding medication compliance seems to be quite good, which has made monitoring of medication adverse effects and efficacy a more consistently meaningful process. All of this is well-documented in the medical records. However, it remains the opinion of this monitor that all mental health staff and nursing staff should be trained to look for possible major medication adverse effects – while even with training, staff would not be expected to diagnose medication adverse effects. Such training might help them suspect adverse effects and report their concern to the psychiatrist, and in so doing, the psychiatrist might see an inmate earlier than scheduled and thereby intervene more quickly.

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RECOMMENDATIONS:
1. Continue to ensure communication between nursing staff and the psychiatrist with regard to inmate compliance with psychotropic medication orders.
2. Confirm the obtaining of ‘informed consent’ for medication in the medical records or consider a special form for this purpose.
3. Assure that medical and mental health staff are trained to suspect the presence of psychotropic medication adverse effects and report such a suspicion to the psychiatrist in a timely manner.
(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Although training on this issue has not yet been fully completed, correctional staff are completing the ‘behavioral checklists’ and making referrals for mental health services for both inmates who are already on the mental health services caseload and those who are not. There are multiple potential benefits of this training, including the earlier identification of mental health difficulties (i.e., the identification of symptoms that precede a more full deterioration); even better use of/improved communication by way of the ‘behavioral checklist’; increased understanding of the various ways that different types of mental illness can impact on an individual’s ability to function; and an increased appreciation for taking an inmate’s mental health difficulties into consideration when making important decisions concerning the inmate (such as classification/placement, the planned use of force, the use of isolation/segregation, disciplinary decisions, etc.).
Given the above noted, it also seems reasonable to at least discuss whether or not there is some ongoing way to provide feedback to corrections officers who complete a ‘behavioral checklist’, with the goal of continuing the learning process and further increasing their appreciation for the difficulties encountered by inmates with mental illness, while still preserving some sense of privacy for the inmate.
RECOMMENDATIONS:
1. Continue to utilize the Behavioral Checklist process.
2. Finalize and present mental health training for security staff.

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3. Improve the incorporation of information obtainable from mental health assessments into security decision-making and review regarding disciplinary matters, the review of situations where there was use of force, the use of isolation/segregation, and the classification of inmates.
4. Consider a more formal process for providing feedback to security staff who complete a behavioral Checklist, regarding how helpful their effort to complete the checklist has been and also regarding any suggestions mental health might have that would help security staff better management and otherwise interact with the individual.
5. Conduct a facility quality improvement morbidity review that can be submitted to the monitoring team for review.
(v) ceasing to place seriously mentally ill prisoners in segregated housing or lockdown as a substitute for mental health treatment.
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, seriously mentally ill inmates continue to be placed in isolation/segregation. Most such inmates are not receiving adequate mental health services, and some of them are not receiving any mental health services at all.
In addition, it has come to my attention that there is a related problem, and that is the placement of juveniles in what is essentially isolation/segregation. This is related in that although a juvenile might not be mentally ill, it has been well-documented that the immature level of development in all spheres (including immaturity with regard to brain development) renders juveniles extremely vulnerable to the development of clinically significant mental health difficulties when placed in isolation/segregation. In addition, at least at Golden Grove, the few juveniles who are placed here end up being placed on a unit of their own, and although it is not an isolation/segregation unit, they are, in fact, essentially isolated and segregated. Therefore, this is another issue that needs to be further explored and addressed.
RECOMMENDATIONS:
1. The Health Services Administrator needs to coordinate monthly Medical Administration Committee (MAC) and Quality Improvement meetings, documented by minutes and attendance sign-in sheets. This issue should be an important agenda item for such meetings. These meetings should include the Warden or the Warden’s designee in order to assure that plans for addressing this issue take all aspects of the problem into consideration.

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VI. FIRE AND LIFE SAFETY
Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:
a. An adequate fire safety program with a written plan reviewed by the Local Fire Marshal;
ASSESSMENT: NONCOMPLIANCE - No substantive improvement from the previous assessment. However, with the continued assignment of a full-time fire safety officer, we continue to see incremental improvement in the conducting of monthly fire safety inspections of all areas of the facility and soliciting the expertise of the Fire Safety Marshal to help develop the GGACF fire safety program. The monthly fire safety inspections are conducted in a consistent manner and deficiencies are being identified. However, corrective action on noted deficiencies needs to be addressed. We continue to note fire and life safety discrepancies dating back to May 2015 that have not yet been corrected.
FINDINGS: The Territory continued working with Corrections Corporation of America (CCA) to help develop the facility fire and life safety related policies and procedures. The fire and life safety policies and procedures have been finalized and approved and now require that staff be trained on them and that they be implemented.
Staff training and implementation of these policies and procedures remains vital. Inadequate housing unit staffing levels and contraband control practices continue to enable inmates to ignite various materials in the housing units as evidenced by our December 2015 inspection of the housing units. During these inspections, I continue to observe the smell of smoke in several housing units.
The automatic fire detection and suppression system remains inoperable, inadequate staffing levels and contraband control leaves housing units deleteriously under-controlled and unmonitored, inmates apparently have undetected and uninterrupted access to items to ignite materials, and inmates obviously have no inhibition about igniting materials.
During this monitoring visit, it did not appear that there were any reported fires in the housing units. However, due to the ease by which inmates can access fire ignition sources and given the state of disrepair with the facility electrical system, i.e., exposed electrical wiring and heavy fire loads in the inmate cells, this area remains volatile from a fire and life safety perspective.

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During our inspection, I also observed exposed electrical wiring in various areas of the Facility, including the kitchen, housing units and maintenance shops. In the kitchen I continue to observe boxes stacked in the dry storage area nearly up to the ceiling (should be stacked no higher than 30 inches below the ceiling). This was an identical finding in our previous reports. These findings, in addition to previous findings, reveal the urgent need to develop and implement a comprehensive fire safety program at GGACF.
Officer Samuel has continued to serve as the full-time fire safety for the facility. There is still no documentation available to demonstrate that evacuation plans have been approved by the VI Fire Marshall. The fire evacuation diagrams within the Facility remain woefully outdated and offer no assurance that they would be effective in routing staff and inmates from a fire or smoke related emergency. In fact, some diagrams still do not outline the appropriate route. On a positive note, Officer Samuel continues to conduct systematic inspections of fire safety needs for the facility. A comprehensive fire evacuation plan that would incorporate all areas and buildings within the confines of GGACF and the contents of the overall fire safety program, such as the finalized and approved fire safety policies and procedures, needs to be provided to the VI Fire Marshal for review.
Staff reported and documents reflect that the BOC has secured an MOA with the VI Fire Service for helping GGACF come into compliance with the fire safety provisions of the SA. However, as we reported in our previous reports, it must be expressed that the BOC/GGACF are the primary entities for demonstrating compliance with the fire safety provisions of the Settlement Agreement.
RECOMMENDATIONS:
The Monitor continues to request the reports for all drills and exercises conducted. It is also imperative that when the GGACF Fire Safety Program and the Fire Safety Plan are finalized and that they be provided to the Fire Marshal and with a copy to the Monitor and USDOJ.
1. Implement the approved fire safety policies.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan.
4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all locations where staff would need to search for or evacuate people.
5. Conduct and document quarterly fire drills for all shifts and document those activities.

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6. Officials must continue to critically review staffing levels to ensure adequate inmate supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security.
7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program.
8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely and appropriate corrective action.
9. The fire inspection program was detailed in the draft fire safety policies and procedures that the monitor provided to the parties, and they should become a fundamental element of preand in-service training once policies and procedures are finalized, approved, and implemented.
b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Almost identical to previous Monitor’s reports, we found that the Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, and cell and housing unit sprinklers are non-functional. We noted an improvement in the housing units whereby inmates were not using the fire sprinklers to support personal clotheslines; however, we did note that some inmates were using makeshift clotheslines in other areas of their cells. The primary fire detection and suppression system was designed to automatically detect and extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates. The only way to alert staff and inmates of a fire or smoke hazard is to use hand-held air horns that are located in the control rooms of the housing units.
Adequate supplies of handheld fire extinguishers were found in housing units, kitchen areas, the medical unit, and shops. All devices were tagged showing current inspections and all gauges showed positive pressures. The Fire Safety Officer has incorporated the inspecting of fire extinguishers in his monthly inspection reports, which is a positive step in improving fire safety. However, as the approved fire and life safety policies and procedures are implemented, GGACF staff must start taking deliberate steps in addressing discrepancies that are identified by the Fire Safety Officer.

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The Director of Corrections reported the Fire Department will be conducting an evaluation of the newer housing units to identify fire and life safety related discrepancies. However, it does not appear that a plan is underway to fully address the fire sprinkler system for the entire facility. The scope of work for the kitchen is now more defined, the Director of Corrections reported the funding has been secured and the renovation project is going out to bid as well as the project for installing exhaust and blower fans in the housing units. Moreover, GGACF plans to continue to house individuals in the “older” buildings, and has no plans to update or install fire suppression equipment in those buildings. As reported in earlier monitoring reports, GGACF will never come into compliance with these provisions if that remains the case.
Although it is commendable that the Fire Safety Officer has systematically embarked in identifying fire safety discrepancies and fire safety needs, the resources to correct those deficiencies must be provided. For example, the Monthly Fire Safety Inspection Reports for the months of October, November 2015 continue to identify missing or non-functional smoke alarms and inoperable emergency lights dating back to May 2015; therefore, funds need to be made available in order to purchase missing smoke alarms and for purchasing adequate stocks of batteries for them. We were informed that the Fire Safety Officer now reports to the Physical Plant Manager, which may better help to resolve maintenance related discrepancies more promptly.
RECOMMENDATIONS:
1. Refer to recommendations above (a).
2. Consider purchasing fire safety program software from NFPA and/or the American Correctional Association to assist in program development and monitoring.
3. Continue to support fire safety officer.
c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. In our previous reporting, GGACF staff indicated that fire drills have not been conducted on a regular basis. The Fire Safety Officer had commenced a process for conducting fire drills; however, documents evidencing this process were not made available during this reporting period.
During this site visit it appeared that security staff continue to have a better awareness of emergency key management. With a few exceptions, staff were able to identify emergency

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keys. In the housing units we inspected, there were emergency keys available. However, this area needs continuous monitoring and staff need to be trained and retrained on a continuous basis on the Key Control Policy and Fire Safety policies and procedures. In future site visits we will continue to inspect this area of fire safety. The Fire Safety Officer and security management should conduct drills to see how prompt cell doors can be manually be unlocked
Emergency keys are not appropriately marked and identifiable by touch. A system for marking and identifying all emergency keys that match the proper door locking mechanism needs to be developed and systematically implemented.
RECOMMENDATIONS:
1. Develop and implement a valid and reliable emergency key system as described above. Train and drill staff as discussed on system use.
2. Develop emergency key and locking mechanism inspection and reporting system as discussed above.
3. Implement competency-based staff training as discussed above.
4. Exercise fire safety program using onsite, scenario-based drills; include community responders in exercise planning and exercise events.
5. Send the training officer and part-time fire safety officers to the National Fire Institute, National Emergency Training Center, Emmetsburg, MD for additional training.
d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell;
and; (ii) that all facility remote locking cell mechanisms are functional;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Almost identical to our previous monitoring reports, documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance.
The Maintenance policy has been approved. However, there is not a written preventative maintenance program or a regular security inspection program in place for checking that cell locks are functional and are not jammed from the inside or outside of the cell, nor a system for ensuring that all facility remote locking cell mechanisms are functional. During this monitoring

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visit we were pleased to observe little evidence of inmates compromising the cell locks by inserting various materials in the locking mechanisms. We did, however continue to observe housing unit grills whereby the locking mechanism was inoperable and the grills left open. We also noted improvement in other housing units where the entry door locks and doors had been repaired and were functional such as in detention housing.
RECOMMENDATIONS: Same as above.
1. Also refer to recommendations related to security provisions, contraband, and inmate manipulation of cell door locking systems.
2. Repair all remote cell locking notification technology.
e. Testing of all staff regarding fire and life safety procedures;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No records have been provided to verify that all staff have been trained and tested on safety procedures. The Fire Safety Officer reported that some hands-on training on the fire extinguisher is occurring. However, this provision of the Settlement Agreement requires a more comprehensive program for testing of all staff regarding fire and life safety procedures.
RECOMMENDATIONS:
1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
2. Provide this Monitor documentation evidencing compliance with this Provision.
f. Reporting and notification of fires, including audible fire alarms;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The fire reporting and notification system remains inoperable as reported in previous Monitor reports. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a hand-held air horn to alert inmates’ evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. As identified in previous Monitor reports and consistent with this inspection, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.

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The Director of Corrections reported that he has asked the Fire Department to conduct an evaluation of the facility for fire and life safety discrepancies. RECOMMENDATIONS: 1. Install and routinely test the stored file alert notification system without delay.
g. Evacuation of prisoners threatened with harm resulting from a fire;
ASSESSMENT: NONCOMPLIANCE FINDINGS: The fire evacuation policies and procedures have been approved and now staff must be trained on them and implemented to include full scale evacuation drills. RECOMMENDATIONS: 1. Develop and implement an annual full scale evacuation exercise that involves community
emergency, health, and social services responders.
h. Fire suppression;
ASSESSMENT: NONCOMPLIANCE FINDINGS: Same as previously stated. There is no functional fire suppression system, with the exception of the kitchen’s cooking area. RECOMMENDATIONS: 1. Develop and implement an annual full scale evacuation exercise that involves community
emergency, health, and social services responders. 2. Repair the automatic fire detection, notification, and suppression system. 3. Replace cell sprinklers with tamper proof mechanisms. 4. Monitor staff response to fires, ensure they comply with basic fire safety principles, and
implement appropriate staff corrective action as needed.

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i. Medical treatment of persons injured as a result of a fire; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The requirements for this provision are addressed in the final and approved Fire and Life Safety policies and procedures. The next step is to ensure that staff are trained on them and they need to be fully implemented.
RECOMMENDATIONS:
1. Implement approved policies and procedures.
2. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event.
3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements.
4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses.
5. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.
j. Control of highly flammable materials.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Many inmate cells still contain considerable personal property, thus creating a fire and safety risk. During our previous site visit, the Director indicated that they would be purchasing bins for prisoners to store their personal belongings; however, this initiative has not yet been accomplished. Identical to previous reporting, flammable storage areas/cabinets in the Carpentry shops do not appear to be properly vented.
RECOMMENDATIONS:
1. It is anticipated that staff will be trained on the approved policies and procedures concerning the control of highly flammable materials as well as implementing them.

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VII. ENVIRONMENTAL HEALTH AND SAFETY
Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:
a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Documentation in the form of logbooks and memorandum was provided during this monitoring visit that demonstrated ongoing efforts by GGACF officials and maintenance staff to assess, improve, and monitor facility sanitation and hygiene. Cleaning supplies were more readily available in the housing units. Some housing units and cells were cleaner than others and the need to consistently conduct routine and sustained cleaning of all facility areas remains a challenge to GGACF staff.
Again, however, housekeeping and sanitation plans will not meet compliance with this Provision without adequate staffing levels as previously stated.
The Maintenance Supervisor maintains preventative maintenance schedules for various components of the GGACF physical plant, including the emergency generator. The emergency generator has been problematic for some time. However, the Maintenance Supervisor reported that the necessary parts to repair the emergency generator had arrived in the Island during our site visit.
The Director of Corrections reported that one of his next priorities will be to address the issue of non-functional drinking fountains in the housing units.
RECOMMENDATIONS:
1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.

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3. Laundry exchanges of clean, institution issued linens and clothing, should occur at least twice per week.
4. Replace, repair, and install working shower heads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.
8. Repair all housing/cell windows to prevent penetration by insects.
b. Adequate ventilation throughout the facility;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated).
As reported earlier in this report, the Director of Corrections is prioritizing the project for the installation of exhaust and blowers fans for the housing units.
RECOMMENDATIONS:
1. Timely complete an air quality assessment performed by a qualified provider.
2. Implement necessary improvements that reduce housing area and cell temperatures and increase air flow.

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3. Medical and mental health staff should monitor all inmates for heat and airflow-related health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions.
4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors.
5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions.
6. Medical and mental health professionals should closely monitor inmates being administered medications that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.
c. Adequate lighting in all prisoner housing and work areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Attention to lighting repair and replacement remains positive. However, some security staff continue to allow inmates/detainees to cover their cell lights, which is creating a fire hazard.
RECOMMENDATIONS:
1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services structures and areas.
2. Maintain an ongoing lighting repair log that evidences repair activities.
3. Ensure rapid repair and replacement of inoperable lighting, add additional external and internal illumination where indicated by a comprehensive security lighting needs assessment.
4. Provide for adequate staffing levels to support lighting plan and maintenance.
5. Increase illumination in all occupied cells for improved security and inmate wellness.
6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that impedes good visibility from the cell door window.

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7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are reliably operational.
d. Adequate pest control for housing units, medical units, and food storage areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Very little change since previous inspections. This provision remains in partial compliance but no significant decline in performance was found. Identical to our previous inspection, we noted that the overhead door to the storage area of the Kitchen is not properly sealed and rodents and vermin can easily infiltrate the Kitchen. Inmates in the housing units complained of insect presence. We also observed missing or broken screens on many facility windows.
The BOC has a contract with a private vendor (Oliver Exterminating of St. Croix) to provide pest control services at GGACF. It does not seem that the contract provides for individual cell extermination, but perhaps it should. In one of the housing units (K-Unit), an inmate reported the presence of cockroaches in his cell. I inspected this cell and there did appear to be evidence of cockroach infestation, however, the cell was also unsanitary and contained many food items, food particles and debris.
RECOMMENDATIONS:
1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.
e. Prisoner and clinic staff access to hygiene and cleaning supplies;
ASSESSMENT: PARTIAL COMPLIANCE FINDINGS: There was no substantive improvement from previous assessments. Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies. However, similar to previous site visits, there were a number of inmate complaints in the Housing Units claiming they do not have sufficient quantities of cleaning materials to properly sanitize the showers. We observed that many inmate showers are in deplorable condition from a sanitary standpoint, including mold problems and physical

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plant deterioration. We also observed that some showers have been repaired from our previous site visit.
RECOMMENDATIONS:
1. Ensure that all inmates have access to hygiene products upon admission to the facility.
2. Continue to provide adequate supply of these personal care items in control pods or housing units to ensure timely exchange of use-for-new products.
3. Prohibit inmates from bartering these supplies and from hoarding empty containers in their cells and living areas.
f. Cleaning, handling, storing, and disposing of biohazardous materials;
ASSESSMENT: NONCOMPLIANCE – No substantive improvement from previous assessment.
FINDINGS: No substantive change from previous assessment.
There is no formal sanitation plan or protocols covering compliance with this Provision; nor is there a formal training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling bio-hazardous materials, provided and instructed on the proper use of bio-protective clothing and supplies, and supervisors must closely monitor biohazard clean-ups. Remaining in noncompliance with this Provision can jeopardize the health of staff and inmates.
Spill clean-up kits were available in the medical area.
RECOMMENDATIONS:
1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive bio-hazard control plan that includes:
a. OSHA and CDC standards and protocols for biohazard safety and exposure control; b. Written and enforced procedures and protocols for biohazard handling; cleaning, disposal,
storage, inspections, and clean-up; c. Staffing and inmate training on the plan and proper handling and disposal of biohazards; d. Consistently maintain adequate supplies of feminine hygiene products and disposal bags
for all bio-waste; e. Locate adequate supplies of bio-hazard disposal and clean-up supplies in or at all locations
where biological waste and/or spills do and could occur;

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f. Provide appropriate clean-up apparel and training in the use of that apparel.
2. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio-products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility.
3. Develop a bio hazardous control program that involves regular inspections of all potential contamination areas.
4. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
5. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.
g. Mattress care and replacement;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: The related policy has been approved by the United States and the Monitor. I did not see this area to be problematic during this monitoring visit. There were no inmate complaints regarding their mattresses and the ones I inspected were adequate. However, GGACF staff have not yet substantially addressed the Monitor’s previous recommendations below.
RECOMMENDATIONS:
1. Refer to previously discussed sanitation recommendations.
2. Issue clean and usable mattresses to all inmates.
3. Complete a full inventory of non-usable mattresses and remove them from the supply.
4. Do not issue mattresses to inmates until after properly inspected for damage and contraband, cleaned and sanitized.
5. Maintain reliable records that verify mattress inventories, cleaning and maintenance requirements.

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h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No substantive change since previous assessment. Implementation of the approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff that supervise inmates and are allowed to handle these chemicals must be properly trained in that role and those responsibilities. This has yet to occur. In the area of Material Safety Data Sheets, we did note an improvement in that facility staff have prepared notebooks that contain material safety data sheets and are being circulated to various areas of the facility including the housing units.
RECOMMENDATIONS:
1. Implement approved policies and procedures.
2. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring, and property control logs.
3. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.
4. This provision can advance to Substantial Compliance once related policies, procedures and plans are approved and implemented according to the Agreement.
i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously reported, housing unit/cell inspection and inmate interviews found no substantive improvement. As stated in previous reports and found during this monitoring visit, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets. Unfortunately, unlike our previous site visit, during this visit we observed inmates drying these items in their cells using clotheslines anchored to walls, window frames, bunks, etc. This was a negative development from our previous site visit and in large part, is exacerbated by the lack

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of staff presence in the housing unit and lack of supervision. We also continue to observe worn out linens and dirty linen in many inmate cells.
RECOMMENDATIONS:
1. Implement approved policies and procedures.
2. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks.
3. Cease the practice of allowing inmates to dry clothing on make-shift clotheslines in their cells.
4. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of bedding.
5. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.
6. Consider replacing all wood laundry carts made of non-absorbing materials that can be sanitized and completely cleaned. Discontinue the practice of moving laundry on carts that have not been cleaned and sanitized.
7. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet and blanket. Clothing should be exchanged with clean items twice per week at minimum, sheets and towels once per week at minimum. Blankets should be exchanged monthly at minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health.
8. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets.
9. Staff and inmates involved in the laundry work program should be properly trained and supervised.
10. Laundry equipment should reliable and properly maintained.

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j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Director of Corrections reported that funding has been secured to refurbish the Kitchen and they are in the bidding process. This is a very positive development. In addition, the food services policies and procedures have been finalized and approved.
The physical plant of the Kitchen remains in a state of substantial deterioration as does the food service equipment. Overall, the kitchen was clean. The dishwasher is still not working properly.
There is still an inoperable walk-in refrigerator that was cleaned from our previous site visits; however, there is still evidence of insect and rodent infestation that staff are trying to address. It appears that part of the scope for the kitchen refurbishing project will be the permanent removal of all inoperable and useable food service equipment.
During this inspection I did note that there was hot water in men’s bathroom.
The kitchen doors are not rodent proof. We observed evidence of mold and rust in various areas of the Kitchen that staff is attempting to temporarily address; however, a permanent fix to the problem still needs to be made to the overall structure of the kitchen. The kitchen officer is still working on finalizing a chit check out system for the utensils and dangerous implements.
RECOMMENDATIONS:
1. Implement approved policies.
2. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care.
3. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented.
4. Policies and procedures developed should include controls for the use of caustic, toxic, and hazardous materials used in the kitchen. Material Safety Data Sheets should be posted conspicuously.
5. Timely complete planned renovations to the kitchen and food service support areas.

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k. Sanitary and adequate supplies of drinking water.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No major improvement was again observed in the housing units during this assessment with the exception of X-Dorm.
The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Similar to previous reporting, many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lock down. Access to drinkable water is generally available during the “out of cell” periods but inmates must rely on the presence and actions by officers following lock down. Inmates have no access to drinkable water when there are no officers on the units to provide it, and water from cellsinks is considered not safe for drinking. In previous site visits, inmates consistently complained of seeing particles of rust in the ice that is provided to the housing units. During this visit there were some complaints regarding contaminated ice with rust and particles. A long-term solution to the problem still needs to be addressed through the installation of refrigerated water fountains in the housing units.
In X-Dorm we had been reporting a consistent problem regarding the lack of drinking water for this unit. However, since our last three site visit GGACF officials have addressed this problem by installing portable water bottles in the dorm.
RECOMMENDATIONS:
1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable access to safe drinking water.
2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING
Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:
a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft training policies and procedures remain under review and revision for final approval. These documents must include the required content listed in this provision.
At least 95% of health care staff have been trained on most of the approved health care-related policies and procedures but achieving a minimum passing score of 80%. All security-related policies and procedures have not yet been approved nor has any training curricula been approved for this purpose. The Territory is currently engaged in procuring a vendor to develop training curricula and provide training for these purposes.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement training policies and curricula once approved.
2. Provide this Monitor and United States all requested training documents.
b. Pre-service training for all new employees;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The draft training policies and procedures include requirements for pre-service training for new civilian, correctional, and supervisory/management staff. These documents remain under review and revision for final approval.

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RECOMMENDATIONS: Finalize and implement approved training policies and procedures.
c. Periodic in-service training and retraining for all employees following their completion of preservice training;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The draft training policies and procedures include requirements for in-service training for new civilian, correctional, and supervisory/management staff. These documents remain under review and revision for final approval. RECOMMENDATIONS: Same as above.
d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Draft training policies and procedures generally include the required elements of this provisions. These documents remain under review and revision for final approval as scheduled.
RECOMMENDATIONS: Implement training policies and procedures once approved.

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IX. IMPLEMENTATION
1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants ("TCCs"), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.
FINDINGS: The schedule is in place for completion of required policies and procedures. The parties have adjusted this schedule by mutual agreement but all security-related policies are not yet completed; training and implementation schedules are pending. Training has been completed on most health care policies and the implementation process is underway.
2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.
FINDINGS: This Monitor continues to monitor compliance with Court-ordered schedules. Additionally, this Monitor continues to support schedule revises when those revisions result from collaboration and mutually agreement between the parties. This Monitor continues to participate in resolution of disputes as requested.
3. Defendants will implement every policy, procedure, plan, training, system, and other item required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.
FINDINGS: All health care-related policies and procedure are in the implementation process. Several approved security-related policies and procedures were provided to the Monitor and United States. The Monitor and the Parties continue to collaborate in finalizing the balance of outstanding policies. We have participated in several policy-related phone conferences during this assessment period. These activities have been exceptionally productive for finalizing draft policies and procedures. Disputes involving the Territory’s proposed Staffing Plan has been submitted to the court for resolution.

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4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.
FINDINGS: There have been no semiannual impact evaluations submitted by the Territory. The reports submitted do not include descriptive analysis of progress. The monitor has provided the Territory assistance in identifying and analyzing appropriate data for evaluation while onsite, during conference calls, and in compliance reports.
5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days' notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.
FINDINGS: This Monitor has no evidence at this time to believe the Territory is not complying with this requirement.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement, Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
FINDINGS: The Territory filed its Eighth Status Report 12/10/15 (ECF 945-1). This report documents status representations stated during the 12/16/15 conference. Content of this report articulates progress toward compliance with the Agreement in several more areas than contained in previous status reports. Unfortunately, this report was filed about 30 days early and likely omits progress occurring during that period. Nonetheless, this status report shows improvement in Territory’s progress documentation efforts.
7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.
FINDINGS: The Territory notifies this Monitor and the United States of serious events as they occur and provides related records either with those notifications or upon request. Additionally,

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the Territory submits monthly incident reports and medical emergency logs to this Monitor and the United States for examination. Additional information and records are typically provided by the Territory as requested but receipt of those records can be untimely on occasion. Timelier responses would improve the efficiency of routine monitoring and compliance reporting.
8. Defendants shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the Monitor and USDOJ at all reasonable times for inspection and copying. In addition, Defendants shall also provide all documents not protected by the attorney-client or work product privilege reasonably requested by USDOJ. The parties will discuss a protective order for other documents over which Defendants may claim privilege.
FINDINGS: The Territory continues to provide requested compliance-related information and records. Occasionally, documents requested during onsite visits are provided post-visit due to GGACF resource limitations. Providing documents timelier would improve the efficiency of the monitoring process. Some documents appear to contain incorrect information. For example, a chronic care log sent to the Monitor and United States in January 2016, contains repeated references to housing units that have been closed and a prisoner who is no longer at the facility. The Territory acknowledged that the document contained errors, but as of February 18, 2016, the Territory has not submitted a corrected document for the Monitor and United States to review.
9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove's staff.
FINDINGS: The Territory continues to cooperate in providing access to the facility and needed documents as requested.
10. Excluding on-site tours, within 30 days of receipt of written questions from USDOJ concerning Defendants' compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.
FINDINGS: The Territory continues to provide access to requested records.

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X. Monitoring
D.1. Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.
FINDINGS: This Monitor wishes to thank Territory officials for submitting monthly compliance reports, even as the document request grows.
D.2. Monitoring Access: With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility and Detention Center, all facility non-privileged records, prisoners' medical and mental health records, staff members, and prisoners, Defendants will direct all employees to cooperate fully with the Monitor, Reasonable advance notice must be provided to the Bureau of Corrections prior to conducting any on-site compliance reviews. Other than as expressly provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. All nonpublic information obtained by the Monitor will be maintained in a confidential manner.
FINDINGS: The Territory has provided this Monitor and monitoring team full and complete access to GGACF as required under this provision.

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APPENDIX A - ASSESSMENT METHODOLOGY
This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.
Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Previsit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.
Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and off site assessment work will be gathered; and, 3) what information the Monitor will require the defendants to routinely report and with what frequency.
1. Description of how the Monitor will assess compliance with each of the Compliance Measures.
In general, compliance assessment will include the following activities:
A. Discussions and meetings with facility officials, staff, providers, and inmates. B. Discussions and meetings with community agency officials providing inspection or
other regulatory oversight of GGACF. C. Discussion and meetings with officials and staff of contract providers and community
agencies who provide services within and/or for GGACF and inmates held in its custody. D. Discussions and meetings with other pertinent staff, personnel, and community
members, either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring. E. On-site tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems. F. On-site tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance. G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes. H. Examination of health care equipment, supplies, materials, technology and other material methods and processes used for inmate health care assessment, diagnosis,

Case: 1:86-cv-00265-WAL-GWC Document #: 960-1 Filed: 03/08/16 Page 128 of 133 128 of 133

treatment planning, treatment (long and short-term), follow-up, and discharge

planning.

I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any

other motorized vehicle used for correctional operations purposes.

J. Examination of any and all available records, data, and/or information relevant to

compliance and compliance monitoring not limited to the following:

•

Administration

•

Budget

•

Personnel

•

Operations

•

Training

•

Facility construction, renovation, repairs, and maintenance

•

Equipment, supplies, and materials

•

Inmate case files

•

Medical and mental health screenings, assessments, evaluations, diagnoses,

treatment plans, progress charts and notes, medication logs and records, drug

formularies, appointment calendars, invoices, etc.

•

Labor contracts

•

Incident reports and logs

•

Evidence / contraband reports and logs

•

Use of force incidents and logs

•

Inmate grievances and disciplinary records and actions

•

Policies, procedures, protocols, guidelines, post-orders, logs, memos, and

other documents and information that support accurate compliance

assessment and progress determinations

•

Employee complaints, grievances, claims, etc. directly or indirectly related

to the compliance provisions

•

Other information required to determine compliance and compliance

progress

The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (Noncompliance, Partial Compliance, and Substantial Compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance assessment and management. Additionally, specific measures articulated in the

Case: 1:86-cv-00265-WAL-GWC Document #: 960-1 Filed: 03/08/16 Page 129 of 133 129 of 133
Order of the Court dated May 14, 2013 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:
• Compliance Control: Implies activities designed and intended to inspect and reject defective or deficient performance, processes, services, equipment, etc. when applied.
• Compliance Assurance: Implies activities designed and intended to identify performance and services that assure compliance when applied.
• Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
• Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.
• Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or consumer satisfaction).
• Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of consumer satisfaction, a performance indicator might be: “the percentage of consumers who state that they received the types and amounts of services that they felt they needed.”
2. How information necessary for on and off site assessment work will be gathered.
Monitoring will involve gathering various forms of information both on and off site and not limited to:  Communications with Territory and U.S. Department of Justice Officials as
authorized in the Order  On-site visits, tours, meetings, individual and group meetings and interviews • Collection
and examination of electronic, paper, and photographic records, information, and data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)  Online media information  Online public records  Electronic and standard mailing of information  Email communication and phone consultations
3. What information the Monitor will require the Defendants to routinely report and with what frequency.
It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and

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information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.
Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in both previously reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.
Non-exclusive information required for assessments and monitoring include the following.
A) Corrections Information:
1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility's policies and procedures manual(s), including the facility's
Use of Force policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate Disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers work day. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff.

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17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility.
18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility.
19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant.
20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months.
21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls.
22. Facility maintenance requests and work orders for the past 12 months. 23. Records and/or lists of physical improvements, repairs, and renovation completed to
correct security problems and deficiencies over the past 36 months. 24. Past 36 months of agency budgets. 25. List and contact information for any and all community vendors who provide
services of any kind to GGACF and contracts or professional services agreement authorizing those services. 26. List and contact information for community regulatory agencies who inspect, review, approve, and/or provide consultation to the GGACF i.e., health inspections, fire inspections, etc., and any inter-local agreements involved in these services.
B) Medical and Mental Health Information:
27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both
their records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or
a copy of their records. 31. To the extent not provided above, the policies and procedures governing medical
and mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how
many hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers,
including on-call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical
care providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies,
to include health care policies under which those persons and/or entities provide inmate health care.

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36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided.
37. A list of all persons with chronic illness listing name, location, and name of chronic illness.
38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the
past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of the nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment. 46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location. 47. To the extent not provided above, external and internal reviews or studies of medical or mental health services including needs assessments and any American Correctional Association and National Commission on Correctional Healthcare reports. 48. List of all inmates placed in restraints, and all inmates receiving mental health treatments, under suicide watch, or taking psychotropic drugs. 49. Current mental health case list including inmate name, number, diagnosis, date of intake, last psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed only by counseling staff with last appointment date and follow-up appointment. 50. Documentation reflecting any training that facility staff have received on suicide prevention, including certificates and training materials. 51. All documents related to the any suicide occurring within the past year. 52. List of all persons on warfarin, Plavix, digoxin.
C) Suicide Prevention Information:
53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other
forms utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in
the following areas within the past year: first aid, CPR/AED, and suicide prevention.

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57. The entire case files (institutional, medical and mental health), autopsy reports, and investigative reports of all inmate suicide victims within the past three years.
58. List of all serious suicide attempts (incidents resulting in medical treatment and/or hospitalization) within the past year.
59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year 65. A list of any use of force associated with the administration of psychiatric
medications for the past year. 66. A description of medical and mental health’s involvement/input into the disciplinary
process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three
years.
It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 1 of 9

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

Plaintiff,

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, et al., )

Defendants.

)

_________________________________________ )

Civil No. 86/265

UNITED STATES’ NOTICE OF OBJECTIONS TO STAFFING PLAN AND REQUEST FOR A STATUS CONFERENCE
The United States respectfully requests that this Court set a status conference with the parties and the Monitor, Mr. Kenneth Ray, to discuss the United States’ objections to the Staffing Plan. Based on the Territory’s representation that it needed additional time to revise the Staffing Plan, the parties agreed during the September 2015 compliance tour to a deadline of December 31, 2015, for approval of the Staffing Plan. See Ninth Compliance Monitoring Report at 20 (Nov. 30, 2015) (Dkt. No. 944). After several discussions with the Monitor and United States, the Territory submitted its final Staffing Plan on December 30, 2015. See Exhibit A. The parties held an hour-long conference call with the Monitor that afternoon. The United States voiced its continuing concerns with the Staffing Plan. During the conference call, the Monitor recommended that the United States file objections and seek a status conference with the Court, because judicial intervention might be necessary to ensure adequate staffing—a prerequisite to the Territory’s ability to comply with the provisions of the Settlement Agreement.1

1

The Monitor also noted that staffing impacts civil rights and public safety. See also

Ninth Compliance Monitoring Report at 6 (Nov. 30, 2015) (Dkt. No. 944) (“[P]risoners and staff

remain dangerously exposed to actual and potential risk of harm due [to] serious staffing level

shortages and staff and prisoner supervision and control.”); Monitor’s Fourth Assessment Report

Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 2 of 9

FIRST OBJECTION:

THE STAFFING PLAN DOES NOT ADDRESS OFFICER PAY.

The Monitor has reported that “[t]he single most salient issue that I can see based on my

39 years in this business, as well as the literature reviews that I did . . . , is pay.” 6/11/15 Tr. at

102:9-12. During the December 2015 status conference, the Monitor identified officer salaries

as one of the two issues that pose the greatest obstacles to compliance, and noted that the issue of officer salaries impacts recruitment, morale, motivation, and attrition.2 There appear to be at

least two pay-related issues. First, the Bureau of Corrections does not have pay parity with other

local law enforcement agencies, which has resulted in its losing recruits to the Virgin Islands

Police Department. See 6/11/15 Tr. at 71:12-15; 9/25/14 Tr. at 14:13-16, 15:10-14 (Director

Wilson: “[O]ur correctional officers are woefully underpaid. They’re the lowest paid safety

officers in the Territory. . . . [I]t impacts our morale. It impacts the supreme core. And I think

sometimes it may drive an otherwise honest person to do something to make some money on the

side.”); 4/28/14 Tr. at 31:9-10. Second, the Territory allegedly owes back pay to current officers.

at 17 (Sept. 2, 2014) (Dkt. No. 843) (“Shifts continue to operate without a supervisor onsite and/or the assistance of off-site supervision. An extreme example of this problem is evidenced on May 11, 2014, the day before the escape. Investigation and incident reports for this escape document that the on-duty supervisor called the Assistant Warden for assistance due to that shift having a severe staffing shortage. Reports indicated that the Assistant Warden not only refused to provide this supervisor with any assistance to mitigate the staffing shortage, but reportedly told the requesting supervisor, ‘. . . you are on your own . . .’ This supervisor, having worked in excess of 20 consecutive hours, ultimately abandoned his or her post, reporting fatigue and concerns about an existing chronic disease being exacerbated by situational stress and no meal breaks during the shift. Incident reports also revealed that no other supervisors or leadership staff were available for assistance. This means that there were no officers or supervisors conducting adequate rounds in housing units during that shift, as required by this provision. The Territory’s failure to meet this requirement resulted in a serious security breach, and the alleged revictimization of a community member.”).

2

The court hearing was held on December 16, 2015. The United States ordered a

transcript of the hearing on December 18, 2015, and expects to receive the transcript in January.

2

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See 6/11/15 Tr. at 71:16-25; 9/25/14 Tr. at 15:7-8.3 During the December 2015 compliance tour, the United States continued to receive reports from officers that they are not receiving the salary they are supposed to receive based on years of service; that they are unable to support a family on their current salary; and that, as a result, they are forced to work a number of overtime shifts. Officers reported that the high number of overtime shifts has led to stress, exhaustion, decreased morale, and little time to spend with family. The United States also received reports that some officers are actively looking for better paying employment.
Nonetheless, the Territory’s final Staffing Plan contains no provisions that address the salary issue.4 During the conference call on December 30, 2015, the Monitor suggested that some form of judicial intervention may be necessary to resolve the salary issue. See also 6/11/15 Tr. at 20-21 (Monitor’s request that the Court “establish[] a deadline to raise the wages of these correctional officers”). Without specific deadlines and documentation, the Monitor said, no progress will be made on this issue. Even if the Territory cannot commit to raising officer pay and paying any outstanding back pay by a date certain, the Staffing Plan provides no discussion of any steps that the Territory plans to take to address the serious salary issue, including, as the Monitor suggested during the conference call, a salary survey.

3

On August 25, 2015, the United States requested the pay scale for Golden Grove

employees. A copy of the document produced to the United States by the Territory on

September 21, 2015, is attached as Exhibit B.

4

There is one provision that states: “With respect to retention efforts, in either 2012 or

2013, the former Director, Julius Wilson went before the Legislature of the Virgin Islands and

requested funds to increase the corrections officers’ salaries. The Legislature appropriated about

$2 million; however, there were no funds available to satisfy this appropriation.” Exhibit A at 6.

During the December 30, 2015 conference call, the Territory stated that a one-time sum of $1.9

million has been allocated to the Bureau of Corrections for officer pay. The Territory did not

know how that money would be allocated, however, and acknowledged that it is not a permanent

solution.

3

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SECOND OBJECTION: THE STAFFING PLAN DOES NOT PROVIDE SUFFICIENT DETAIL REGARDING RECRUITMENT AND RETENTION EFFORTS.
The Staffing Plan also does not provide sufficient information about recruitment and
retention efforts, and remains more retrospective than prospective. See Exhibit A at 4-6
(discussing “Past Recruitment/Retention Efforts”). The United States is especially concerned
about ensuring that the Staffing Plan details expected activities in 2016. The Staffing Plan lists
four “Recruitment/Retention Efforts Being Considered”:
• Continue discussions and potential memorandum of understanding prohibiting other law enforcement agencies from recruiting BOC cadets while in the POST Academy.
• Draft and implement an employment contract mandating that all incoming officer [sic] remain with the BOC for at least three years or else the [sic] will not receive a favorable recommendation for future employers.
• Exploring collaboration with the Department of Education (DOE) to assist with the development of corrections curricula/program to implement in all public high school for students to prequalify.
• Career Incentive Program to include relocation costs. Exhibit A at 6.5 However, the Staffing Plan provides little information about each effort “being
considered,” and gives no timeline for completion. The second bullet point also seems likely to
impede recruitment efforts; it is not a positive measure for recruiting and maintaining the
workforce.

5

A draft Staffing Plan submitted by the Territory on December 22, 2015, also included a

bullet point for “Restructuring the hiring process.” See Exhibit C at 6. It is not clear whether

this provision was inadvertently omitted from the Staffing Plan submitted on December 30,

2015, which was intended to make only a few minor revisions. See Exhibit D at 1-2.

Nonetheless, that bullet point lacks the requisite specificity. It is not clear whether that bullet

point was intended to address the parties’ discussion and discussion with the Court at the last

status conference about the need to streamline the hiring process to avoid unnecessary delays.

4

Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 5 of 9
The Staffing Plan contains two tables—one showing “different recruitment means” and another showing “[o]ther possible recruitment medium.” See Exhibit A at 11. Little information is provided of the latter, including when that “medium” will be completed. And the Staffing Plan states that “four (4) correction officers per fiscal year” will be recruited through such mediums. Id. That does not account for the twelve officers that, according to the Staffing Plan, must be hired each fiscal year to meet the Plan’s five-year goal. See id. at 10.
The tables at the end of the Staffing Plan also lists several “strategies” that relate to recruitment:
1.1 Initiate an online recruitment protocol 1.2 Revise the steps for completing the pre-employment process . . . . 3.1 Expand the Correction Officer recruiting plan 3.2 Establish an agency-wide, incentive-based recruiting program 3.3 Recruit within the territory with a cross section of recruiters from target populations 3.4 Recruit outside of the territory with a cross section of recruiters representing target programs 3.5 Increase advertisement for Correction Officers within the territory and outside of the territory See Exhibit A at 20-24. Again, however, the Staffing Plan provides little information about each strategy, and no timeline is given for completion—the “Completion Date” for 1.1, 3.1, 3.2, 3.3, 3.4, and 3.5 is listed as “Ongoing.” Id. The “Completion Date” for 1.2 is listed as “July 2009,” id. at 20, and the “Status” of 3.2 is listed as “Done,” id. at 23. During the conference call on December 30, 2015, the Monitor suggested some additional, specific avenues for recruitment efforts by identifying for the Territory publications
5

Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 6 of 9

that corrections professionals read. The Monitor cautioned, however, that corrections

professionals may be reluctant to apply once they see the offered salary and cost of living in

St. Croix.

THIRD OBJECTION:

THE STAFFING PLAN DOES NOT PROVIDE THE NECESSARY SPECIFICITY OVERALL OR EXPLAIN THE RELATIONSHIP BETWEEN THE PLAN’S STRATEGIES AND TIMEFRAME FOR COMPLETION.

Overall, the Staffing Plan lacks requisite specificity as to who will do what, and by when.

During the December 30, 2015 conference call, the Monitor stated that language in the Staffing

Plan, such as “being considered” and “[e]xploring collaboration,” see Exhibit A at 6, evidenced a

hesitance to commit. Moreover, items in the tables at the end of the Staffing Plan lack specific

completion dates. See id. at 20-24. In addition to the provisions discussed under the Second

Objection, above, the Staffing Plan contains language such as: “BOC will strive to work towards

the implementation of Direct Supervision.” Exhibit A at 9. It is unclear what that means. The

Staffing Plan must set forth a specific supervision model and lay out how that model will be

implemented. As the United States stated during its discussions with the Territory and Monitor

during the December 2015 compliance tour, the United States supports implementation of a

direct supervision model. Because there currently are not enough officers to implement this

model, the United States recommended that the Territory phase the model in over time, starting

with housing units with a problematic history. If the Territory chooses to pursue that course, the phase-in should be detailed in the Staffing Plan.6

6

The Monitor, during the December 2015 compliance tour, noted that the housing units

are very hot, and that officers may not be able to stay in the units at all times, as the direct

supervision model requires. Accordingly, it is critical that the Territory lower the temperature in

the housing units to acceptable levels. See Ninth Compliance Monitoring Report at 82 (Nov. 30,

2015) (Dkt. No. 944) (“During this site visit we took random heat index reading[s] of some

housing unit dayrooms and cells. The heat indices remain unacceptably high.”). Of course, the

temperature in the units also places inmates at an unacceptable risk. See id. (“Most of the

6

Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 7 of 9

Finally, the Staffing Plan states that “BOC will revisit the staffing levels after three years to see whether the goals of the staffing plan are being met in a five (5) year period verses over the originally suggested seven (7) year period.” Exhibit A at 10. The December 22, 2015, version of the Staffing Plan also said: “and whether additional years should be added to this Plan.” See Exhibit C at 10. The United States recognizes that the Territory made this revision in response to the United States’ grave concern that seven years is simply too long to wait for the facility to be adequately staffed, particularly given the October 2015 escape and other ongoing serious incidents placing inmates, staff, and the St. Croix community at continued risk of harm. Although the United States agrees that the Territory should revisit staffing levels before the fiveyear mark, the Territory also will need to revisit its recruitment and retention strategies to determine whether additional strategies need to be implemented.
* * * * * On the Monitor’s recommendation, the United States respectfully requests that the Court schedule a status conference to discuss its objections to the Territory’s Staffing Plan. The United States is hopeful that, in the meantime, the parties and Monitor can finally resolve the Second and Third Objections.7 The Monitor, however, has stated that judicial intervention likely will be necessary to adequately resolve the First Objection, that the Staffing Plan cannot wait any longer to be finalized, and that he intends to recommend to the Court specific forms of intervention regarding the issue of officer pay.

housing unit exhaust fans remain inoperable. This is especially harmful for inmates unable to afford to purchase fans and inmates with serious mental illness on certain medications.”).

7

The Monitor also has requested that the Territory update the Staffing Matrix. See Exhibit

D at 1. According to the Monitor, “[s]taffing levels shown on the [existing] matrix won’t likely

resolve access to care and building security problems” in the Treatment Building that were

discovered during the December 2015 site tour. Id. In addition, at the United States’ request, the

Territory is checking whether its table of hirings and separations is current.

7

Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 8 of 9

DATED this 31st day of December, 2015 Washington, District of Columbia
ANGELA P. TYSON-FLOYD Assistant United States Attorney United States Attorney’s Office 1108 King Street, Suite 201 Christiansted, Virgin Islands 00841 (340) 773-3920 (340) 773-1407 (fax)

Respectfully submitted,
VANITA GUPTA Principal Deputy Assistant Attorney General Civil Rights Division
ROBERT MOOSSY Deputy Assistant Attorney General Civil Rights Division
JUDITH C. PRESTON Acting Chief
LAURA L. COON Special Litigation Counsel
s/ Rita K. Lomio MARLYSHA MYRTHIL RITA K. LOMIO Trial Attorneys United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW Washington, DC 20530 (202) 353-1279 (202) 514-0212 (fax)

8

Case: 1:86-cv-00265-WAL-GWC Document #: 949 Filed: 12/31/15 Page 9 of 9
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that on December 31, 2015, I electronically filed the foregoing
using the CM/ECF system, which will send electronic notification to the following:
CAROL THOMAS-JACOBS Civil Division Chief V.I. Department of Justice Office of the Attorney General GERS Building, 2nd Floor 34-38 Kronprindensens Gade St. Thomas, VI 00802 Telephone: (340) 774-5666 Email: cjacobs@doj.vi.gov
SHARI N. D’ANDRADE Assistant Attorney General V.I. Department of Justice Office of the Attorney General 6040 Estate Castle Coakley Christiansted, VI 00820 Telephone: (340) 773-0295 Fax: (340) 773-1425 Email: sdandrade@doj.vi.gov
JOSEPH A. DIRUZZO, III Fuerst Ittleman David & Joseph, PL 1001 Brickell Bay Drive, 32nd Floor Miami, FL 33131 Telephone: (305) 350-5690 Email: jdiruzzo@fuerstlaw.com
Respectfully submitted,
/s Rita K. Lomio Rita K. Lomio Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, DC 20530 (202) 353-1279 (202) 514-0212 (fax)

Case: 1:86-cv-00265-WAL-GWC Document #: 949-1 Filed: 12/31/15 Page 1 of 26
EXHIBIT A

Case: 1:86-cv-00265-WAL-GWC Document #: 949-1 Filed: 12/31/15 Page 2 of 26
GOVERNMENT OF THE VIRGIN ISLANDS U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020 S
BUREAU OF CORRECTIONS
SEVEN YEAR RECRUITMENT PLAN

2015 - 2020

“SECURITY, CUSTODY, CONTROL”

1

Last revised on 12-14-2015; recently edited on 12-18-2015, 12-30-2015

Rick Mullgrav, Director Designee of BOC

Case: 1:86-cv-00265-WAL-GWC Document #: 949-1 Filed: 12/31/15 Page 3 of 26 U.S. Virgin Islands Bureau of Corrections
Security Staffing & Recruitment Plan 2015 - 2020
SUBJECT: Recruitment Plan
PURPOSE: To establish a comprehensive recruitment program to ensure the Bureau of Corrections complies with state and federal equal employment opportunity and affirmative action guidelines.
RULE: The Government of the Virgin Islands and Bureau of Corrections (BOC) is governed by a strong commitment to equal employment opportunity and affirmative action, and this commitment is clearly expressed in its Recruitment Plan.
The Bureau of Corrections is committed to an environment which promotes equal access to employment opportunities for all employees and applicants and strives for a workforce composition that reflects the diversity of qualified candidates and ensures the safety and security of the Correctional system.
The Bureau of Corrections does not discriminate in any terms or conditions of employment, on the basis of race, creed, color, religion, sex, age, national origin, marital status, sexual orientation, citizenship status, disability or veteran status. The Bureau of Corrections will reasonably accommodate disabled employees and applicants as required by law.
STATEMENT
In an effort to develop an effective recruitment program, the Division of Personnel and the Bureau of Corrections hereby reaffirms and formalizes its commitment to the principle of equal employment opportunity. Furthermore, it has been a longstanding policy of the Division of Personnel and the Bureau of Corrections to employ and promote qualified personnel without discrimination against any employee or applicant for employment because of his or her protected category or any other non-job¬related characteristic.
In developing the recruitment program, The Bureau of Corrections commits to:
 Recruiting, hiring, training, and promoting persons in all job classifications without regard to their protected category, or any other non-job-related characteristic.
 Ensuring decisions regarding selections and promotions are in accordance with equal employment opportunity, personnel rules and regulations and collective bargaining agreement requirements by imposing only valid, job-related requirements for such promotions.
 Ensuring all personnel actions relating to compensation, benefits, transfers, terminations, training, and educational attainment are administered in a nondiscriminatory and expedited manner.
 Conduct annual assessments to determine whether any adjustments are needed in accordance to the standards stipulated in the staffing plan.

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Case: 1:86-cv-00265-WAL-GWC Document #: 949-1 Filed: 12/31/15 Page 4 of 26 U.S. Virgin Islands Bureau of Corrections
Security Staffing & Recruitment Plan 2015 - 2020
SECTION I – RESPONSIBITILITY
To ensure the Recruitment Plan is carried out through a good faith effort, the Bureau of Corrections has established various levels of responsibility to both direct and oversee its recruitment efforts.
The Human Resources Manager has been designated as the official responsible for the Bureau of Corrections recruitment efforts. The Human Resources Manager is responsible for monitoring recruitment efforts, providing equal opportunity training, and recommending the use of outside resources, where applicable to ensure the successful implementation of the plan. The Human Resources Manager also provides a critical link to the Government’s Division of Personnel for human resource support.
Individual managers and supervisors are responsible for ensuring that their employment decisions comply with principles embodied in the Bureau of Corrections Recruitment Plan and all applicable Collective Bargaining Agreements, local laws, federal laws, and Bureau of Corrections Policies and Regulations.
SECTION II - DISSEMINATION OF POLICY
The Recruitment Plan and policies related to equal employment opportunities are considered to be open records, available for public inspection. In addition, the Bureau of Corrections will take proactive steps to ensure the public and other key stake holders know about the Bureau of Corrections recruitment program. Some of the methods used to inform the public are:
1. Internal Dissemination
a. The Recruitment Plan will be provided to each Department Director.
b. The statement that The Bureau of Corrections is an EEO/AA employer will be documented in the Employee Handbook.
c. The Human Resources Manager and each Department Director will stress the importance of the Recruitment Plan in meetings with employees.
d. The Recruitment Plan will be explained thoroughly in employee orientation and management training programs.
e. The Recruitment Plan will be made available to any interested individual upon request and on the Bureau of Corrections website. Employees will be made aware of its existence and the benefits available to them.
2. External Dissemination
a. All appropriate publications and printed materials will state the shortened version of the institution's Mission and Recruitment philosophy: "The Bureau of Corrections is an Equal Employment Opportunity and Affirmative Action Employer." The statement will be placed on all letterhead, envelopes, business cards or invitations.

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

b. The Bureau of Corrections will regularly provide written information to schools, universities, employment organizations, veteran's groups, groups concerned with promoting the field of Corrections, etc.

c. Recruitment information (including videos and other electronic media), position announcements, and advertising will contain the Bureau of Correction's mission and philosophy statement.

SECTION III - RESPONSIBILITY FOR IMPLEMENTATION

The Human Resources Manager of the Bureau of Corrections is responsible for the implementation and administration of the Recruitment Plan. As the chief administrator of the Recruitment Plan, the Human Resources Manager has delegated to the department directors, managers, and supervisors the authority and responsibility for carrying out this plan at each corresponding level. Each of these individuals is expected to commit himself/herself to the Recruitment Plan's success.

As specified in the Recruitment Plan, the Human Resources Manager is charged with the administrative responsibility for ensuring compliance in employment activities. In fulfilling these responsibilities, the Human Resources Manager will:

1. Serve as liaison between the Bureau of Corrections and outside regulatory/ enforcement agencies;

2. Prepare, review, and ensure all hiring and promotions prior to job offers being extended, for compliance purposes;

3. Review qualifications of all employees to ensure that minorities and women are given full opportunities for transfers and promotions.

4. Disseminate recruitment plan to all employees annually.

The Human Resources Manager and Department Directors of the Bureau of Corrections will:

1. Assist in identifying problem areas and establishing division or departmental objectives.

2. Work with schools, universities, employment organizations, veteran's groups, groups concerned with promoting the field of Corrections, etc.

3. Review and affirm on an annual basis the manpower needs of the Bureau of Corrections to ensure the recruitment practices are still relevant in principles and institutional plan of affirmative action.

4. Encourage all officers to participate in all the Bureau of Corrections sponsored community, educational and social activities.

SECTION IV- PAST RECRUITMENT/RETENTION EFFORTS

Division of Personnel

Division of Personnel is the recruiting agent for the V.I. Government and recruits through:

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020
 Advertises via their website, press releases, on-line newspaper advertisements, radio announcements, and newspaper advertisements about the Correction Officer’s entrance examinations quarterly schedules.
 In an effort to increase the pool of candidates, the Division of Personnel established a waiver from the entrance examination for applicants with degrees (e.g. associate, bachelor, and master level) from accredited institutions and military veterans who have served full military service with an honorable or general discharge.
In addition to local recruitment, the Division of Personnel has recruited from outside of the territory:  Military Career Expo (08/2013 - 11/2013) – recruited veterans in the states of Virginia, Maryland, North Carolina, Texas & Florida  USVI Alliance, Inc. Career Expo in Atlanta (May 21-22, 2014)
New media campaign: in collaboration with the Department of Tourism, launched a joint campaign on 11/12/15 aimed at recruiting Virgin Islanders and others living in the mainland United States with high school diplomas to relocate to the Virgin Islands. This campaign includes a website, social media and online newspaper sources.
Department of Labor
 Hosted a job fair on St. Croix on June 22, 2015.
Bureau of Corrections
Job Recruitment Efforts:
BOC participated in job/career fairs that targeted candidates between the ages of 21-45.
 Law Enforcement Career Day: BOC participated in this event starting from 2012-2015. The event was held at the University of the Virgin Islands and was open to college students and the general public. Other local/federal law enforcement agencies as well as public/private employers participated in the event.
 Hero2Hired Career and Education Fair: BOC participated in this event in 2013. The event was sponsored by the VI National Guard and was open to all services members, spouses, veterans and retirees. Other local/federal law enforcement agencies as well as public/private employers participate in the event.
Career Incentives Program:
BOC and the officer’s Union has established a Career Incentive Program to offering pay differentials to classified corrections officers as a reward for furthering their education in fields which are related to the performance by the correction officer of present or possible future official duties with BOC. Each corrections officer is eligible to receive a pay differential equal to a percentage of his/her base compensation in accordance with the following schedule:
 Three percent (3%) increase for ten (10) semester hour credits or its equivalent in quarter units earned toward a baccalaureate or associate degree;

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020
 A six percent (6%) increase for twenty-five (25) semester hour credits or its equivalent in quarter units earned toward a baccalaureate or an associate degree;
 A ten percent (10%) increase for forty (40) semester hour credits or its equivalent in quarter units earned toward a baccalaureate or an associate degree;
 A fifteen percent (15%) increase for an associate degree;  A twenty (20%) percent increase for a baccalaureate degree;  A twenty-five (25%) percent increase for a post graduate degree.
Recruitment/Retention Efforts Being Considered:
 Continue discussions and potential memorandum of understanding prohibiting other law enforcement agencies from recruiting BOC cadets while in the POST Academy.
 Draft and implement an employment contract mandating that all incoming officer remain with the BOC for at least three years or else the will not receive a favorable recommendation for future employers.
 Exploring collaboration with the Department of Education (DOE) to assist with the development of corrections curricula/program to implement in all public high school for students to prequalify.
 Career Incentive Program to include relocation costs.
With respect to retention efforts, in either 2012 or 2013, the former Director, Julius Wilson went before the Legislature of the Virgin Islands and requested funds to increase the corrections officers’ salaries. The Legislature appropriated about $2 million; however, there were no funds available to satisfy this appropriation.

SECTION V – STAFFING AND POSTS Below are tables that prioritize the posts based on, among other things, population and high levels of violence: Primary Posts (Mandatory Posts): 1 Central Control 2 X Dorm 3 Treatment Building (Medical Infirmary) 4 9/B & Kilo—Special Management and Mentally Ill 5 L & 9A-Lockdown 6 G & H/ 9C &9D 7 R&D/RSAT/A-Dorm 8 I & J - Closed

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Case: 1:86-cv-00265-WAL-GWC Document #: 949-1 Filed: 12/31/15 Page 8 of 26 U.S. Virgin Islands Bureau of Corrections
Security Staffing & Recruitment Plan 2015 - 2020 Secondary Posts: 1 ACF and Detention 2 East Tower and West Tower 3 Roving Patrol, Patrol 4 Education, Recreation, Visit, Kitchen, Transportation 5 Warehouse, Car Repair shop and tool room 6 Main Entrance Security Point
Please refer to the Staffing Matrix as to corrections officers for each post (see Appendix A).

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

SECTION VI - STAFFING ANALYSIS

Prison Rape Elimination Act Staffing Analysis

(a) The agency shall ensure that each facility it operates shall develop, document, and make its best efforts to comply on a regular basis with a staffing plan that provides for adequate levels of staffing, and, where applicable, video monitoring, to protect inmates against sexual abuse. In calculating adequate staffing levels and determining the need for video monitoring, facilities shall take into consideration:

(1) Generally accepted detention and correctional practices;

(2) Any judicial findings of inadequacy;

(3) Any findings of inadequacy from Federal investigative agencies;

(4) Any findings of inadequacy from internal or external oversight bodies;

(5) All components of the facility’s physical plant (including “blind-spots” or areas where staff or inmates may be isolated);

(6) The composition of the inmate population;

(7) The number and placement of supervisory staff;

(8) Institution programs occurring on a particular shift;

(9) Any applicable State or local laws, regulations, or standards;

(10) The prevalence of substantiated and unsubstantiated incidents of sexual abuse; and

(11) Any other relevant factors.

(b) In circumstances where the staffing plan is not complied with, the facility shall document and justify all deviations from the plan.

(c) Whenever necessary, but no less frequently than once each year, for each facility the agency operates, in consultation with the PREA coordinator required by § 115.11, the agency shall assess, determine, and document whether adjustments are needed to:

(1) The staffing plan established pursuant to paragraph (a) of this section;

(2) The facility’s deployment of video monitoring systems and other monitoring technologies; and

(3) The resources the facility has available to commit to ensure adherence to the staffing plan.

(d) Each agency operating a facility shall implement a policy and practice of having intermediate-level or higherlevel supervisors conduct and document unannounced rounds to identify and deter staff sexual abuse and sexual harassment. Such policy and practice shall be implemented for night shifts as well as day shifts. Each

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agency shall have a policy to prohibit staff from alerting other staff members that these supervisory rounds are occurring, unless such announcement is related to the legitimate operational functions of the facility.
Security Staffing Analysis
A staffing analysis was conducted by Rod Miller, National Institute of Corrections Consultant, in July 2014, which identified all housing, special and split posts, a coverage plan, staffing levels requirement as well as various recommendations for the improvement of security and overall operations to include (see Appendix 1):
1. BOC will strive to work towards the implementation of Direct Supervision. An officer will be in each dayroom at all times—no exceptions. Coverage will enable this by providing three officers in each 2-unit building at all times. Two officers would be providing direct supervision and making rounds in the housing units; the third would be operating the control room and monitoring all movement in and out of the unit. The proposed plan will provide staffing to conduct searches of inmates whenever they return to a housing unit, as well as random searches of cell.
2. Reduction of inmate population in order to provide the best optimum security staff levels through “reverse engineer” the plan, calculating staff reductions that could be realized by reducing the number of inmates housed. The Bureau relocated some offenders to off-island facilities, thereby reducing the offender population and closing two (2) housing units. This closure reduced staffing demands by 4 security staff per shift 4 therefore, reducing by an average of 12 security officers per shift.
3. Change on shift schedule based on the peak time/level of activities during peak time period of the day. The changes from 8-4, 4-12, & 12-8 shift schedules to 6-2; 2-10; 10-6 shift schedules. These changes provide the increase level of offender supervision during offender movements during peak hours of operations. Change of shift schedule has also resulted in reduction in overtime worked due to absenteeism (e.g. scheduled leave, leave without pay).

With the implementation of the above- mentioned changes and the reduction of housed inmates and shift schedules, the Bureau revisited the Coverage Plan and developed a Staff/Post Matrix as of 12/14/15, which indicates the revised level of staffing requirements based on the current posts.
Moreover, funding is available for 18 correction officer positions for fiscal year 2016.
VI GGGACF STAFF/POST MATRIX – 12/14/2015

Security Positions Security Management TC Command (Lt) ATC Command (Sgt) Officer Total Security Staff

Intended Staffing
Plan 2015
6 5 13 155
179

Actual Staffing
as of 12/14/15
4 2 5 95
106

2015 Budget Authorized
4 3 5 117
129

2016 Budget Authorized
5 3 7 117
132

Staff Needed
2 3 8 60 73

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Based on the Staffing Plan dated July 2014, and the Staff/Post Matrix dated December 2015, the level of staffing has increased from 165.6 to 179 (due to security management post added) security staff needed for operations. The Bureau of Corrections and the Division of Personnel are committed to meeting the demands and begin the recruitment and employment efforts to acquire the additional corrections officers to meet the staffing levels of Staff/Post Matrix.

The Bureau proposes the staffing plan be implemented over a five (5) fiscal year period to be able to effectively recruit and retain officer while taking into consideration the replacement of officers due to attrition and retirement. BOC will revisit the staffing levels after three years to see whether the goals of the staffing plan are being met in a five (5) year period verses over the originally suggested seven (7) year period.

VI BOC/ GGACF Hiring Plan
Security Positions
Security Management TC Command (Lt) ATC Command (Sgt) Officer Total Security Staff

Staffing Plan as 12/2015
4 2 5 95
106

Staff Needed (vacancies)
2 3 8 60
73

Year 1
F2016
1 1 2 12 16

Year 2
F2017
1 1 2 12 16

Year 3
F2018
0 1 2 12 15

Year 4
F2019
0 0 2 12 14

Year 5
F2020
0 0 0 12 12

Total
20162020
2 3 8 60 73

Staff Needed
100% 100% 100% 100% 100%

The chart below shows target staffing levels by security position 2016-2020:

VI BOC/ GGACF Hiring Plan
Security Positions
Security Management % Staffing
TC Command (Lt) % Staffing
ATC Command (Sgt) % Staffing
Officer % Staffing
Total Security Staff % Staffing

Overall Staffing Required
6
5
13
155
179

Actual Staffing
as of 12/14/15
4 67%
2 40%
5 38% 95 61% 106
59%

Year 1
F2016
5 83%
3 60%
7 54% 107 68% 122
68%

Year 2
F2017
6 100%
4 80%
9 69% 119 74% 138
77%

Year 3
F2018
5 100%
11 85% 131 81% 153
85%

Year 4
F2019
13 100% 143 87% 167
93%

Year 5
F2020
155 100% 179
100%

Total
20162020
6 5 13 155 179

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

The Bureau of Corrections is committed to recruit at least four (4) correction officers per fiscal year through different mediums.
The chart below shows the different recruitment means to increase staffing pool F2016-F2020:

Measurable Job Fairs Sponsored: Outcomes

# of Sponsored Job Fairs per Fiscal Year

Date of Job Fair

# of Job Fairs Anticipated Participation

# of Anticipated Registered
Recruits

# of Actual Recruits

Division of Personnel
The University of the Virgin Islands Albert A. Sheen Campus
Bureau of Corrections Recruitment Program Department of Labor

2

Pending – STT &

2

STX

3

4/6/2016 – STX;

3

4/2016 – STT; &

10/2016 – STT

2

6/15/2016 - STT

2

& STX

2

7/2016 – STT &

2

STX

45

TBD

30

TBD

40

TBD

40

TBD

30

TBD

40

TBD

Other possible recruitment medium:
Measurable Other Recruitment Efforts Outcomes
Post Vacancies on Department of Labor “VIEWS” website

# of Interested

# of

Candidates Candidates

Fiscal Year Considered

TBD

TBD

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Hiring/Separation for the BOC for the past six years (2009-2015)

New Hires & Separations:

Employee's

Last Name

First Name

√

√

√

√

√

√

√

√

√

√

√

√

√

√

2015
05/11/2015 05/11/2015 05/11/2015 05/11/2015

2014

01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014

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Hire Dates

2013

2012

2011

N O

H I R E S

T

2010

2009

Separation Date

Reason for separation

Employed

In the Academy

Employed

In the Academy Dismissed from the Academy

Dismissed from the Academy

04/25/2014 Dismissed from the Academy

Employed

Employed 03/19/2014

Dismissed from the Academy

Employed

09/08/2015

Resigned

Dismissed from the Academy

Employed 09/08/2014 05/08/2014

Resigned Resigned

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's

Last Name

First Name

2015

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

2014 01/27/2014
12/0 8/2014 12/0 8/2014 12/0 8/2014 12/0 8/2014 12/0 8/2014 12/0 8/2014 12/0 8/2014

2013

Hire Dates 2012 H I S

Y E A R
3/5/2013 3/5/2013

2011

2010 2009

10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011

Separation Date

Reason for separation

Employed Employed Employed Employed 12/15/2014 Employed Employed Employed
5/29/2014 Employed 8/9/2013 3/10/2014 Employed 7/5/2012 9/12/2012 4/3/2013 Employed 8/16/2012 7/28/2013

Dismissed from the Academy Transferred to VIPD Transferred to VIPD In the Academy In the Academy
In the Academy Resigned
In the Academy
Rehired Rehired Resigned
Resigned Resigned
Resigned Resigned Resigned
Resigned Resigned

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

2014

2013

Hire Dates 2012

2011 7/5/2011 7/5/2011 7/5/2011 7/5/2011 7/5/2011 7/5/2011 7/6/2011 7/5/2011 7/5/2011 3/7/2011 3/7/2011 3/7/2011 3/7/2011 3/7/2011 3/7/2011

2010 2009
2/16/2010 2/16/2010 2/16/2010 2/16/2010 2/16/2010

Separation Date
Employed Employed 5/27/2012 10/24/2011 Employed 10/31/2011
11/9/2011 1/26/2011 6/20/2011 10/3/2013 2/4/2013 Employed 5/27/2014 10/31/2011
9/10/2012 Employed Employed 2/21/2015

Reason for separation
Deceased Resigned
Dismissed Pending dismissal
Resigned Resigned Dismissed Dismissed Resigned
Resigned Dismissed Dismissal pending Resigned
deceased

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

2014 2013

√ √

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Hire Dates 2012 2011

2010

2009

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

6/21/2010

6/21/2010

6/21/2010

6/21/2010

6/21/2010

6/21/2010

6/24/2010

6/21/2010 6/21/2010

Separation Date
Employed 8/12/2015 2/26/2014 4/23/2012
8/17/2015 Employed 8/30/2012 Employed 2/14/2013 8/11/2014 3/12/2015
Employed 3/9/2012 Employed 1/29/2013 Employed 8/21/2014
06/25/2010 5/30/2011

Reason for separation
Resigned Dismissed Resigned Dismissal pending Resigned
Resigned
Dismissed Resigned Dismissed No show
Dismissal
Resigned
Resignation Resignation Resignation Dismissal pending

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √ √ √ √ √

2014 2013

√ √

√ √ √ √ √ √ √ √

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Hire Dates 2012 2011

2010

2009

6/21/2010

6/21/2010

11/8/2010

11/8/2010

11/8/2010

11/8/2010

11/15/2010

11/8/2010

11/8/2010

11/8/2010

11/8/2010

11/8/2010

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

6/22/2009

6/22/2009

Separation Date
employed employed 5/5/2014
12/6/2012 employed 06/03/2011 10/6/2012 6/20/2013 6/3/2011 employed employed
employed 10/8/2012
8/29/2012 employed employed 4/4/2013 10/7/2013 3/24/2013 11/10/2014

Reason for separation
Resigned No Show Resigned Resigned Resigned Dismissed Resigned
Resigned Dismissed Resigned
Resigned Dismissed Resigned Dismissed

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √

2014 2013

Hire Dates

2012

2011

2010

2009 6/122/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009

Separation Date

Reason for separation

8/29/2012 employed employed employed employed
employed 8/13/2012

Resigned
Resigned Resigned

Year 2015 2014 2013 2012 2011 2010 2009

Breakdown by Year
Hires 4 18 2 0 25 39 20

Separations 5 13 11 9 9 2 0

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Applicant Tracking & Pass/Failure Report

# District

Exam Title

Company

Applicants Registered

Applicants Exam Date Tested Passed Waived

Law Enforcement

Officer/Corrections

5 STX

Officer

TABE

72

1/16/2009

37

5

0

Law Enforcement

Officer/Corrections

6 STX

Officer

TABE

94

3/24-4/3/2009

53

10

2

Law Enforcement

Officer/Corrections

7 STX

Officer

TABE

96

6/22-29/2009

47

6

4

8

STX Corrections Officer

CPS

105

11/14/2009

60

9

3

9

STX Corrections Officer

CPS

10 STX Corrections Officer

CPS

11 STX Corrections Officer

CPS

12 STX Corrections Officer

CPS

61

3/6/2010

34

12

4

3 resent

192

8/6/2010

110

13

7

1 transfer

1 resent

50

11/20/2010

34

7

6

3 resent

71

3/15-18/11

47

3

7

18

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

# District 13 STX 14 STX 15 STX 16 STX 17 STX 18 STX

Exam Title
Corrections Officer
Corrections Officer
Corrections Officer
Corrections Officer
Corrections Officer
Corrections Officer

Company CPS

Applicants Registered
125

Applicants

Exam Date

Tested

Passed

7/11-22/11

1 resent

78

13

Waived 11

CPS

82

11/2-7/11

52

5

1

1 resent

CPS

115

12/18-27/12

42

2

10

10/01/12 -

CPS

199

09/30/13

72

7

24

10/01/13 -

CPS

74

09/30/14

27

5

15

10/01/14 -

CPS

214

09/30/15

94

11

32

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Goal: To develop and implement a comprehensive fully integrated human resources system that will facilitate professional development, improved performance and ensure recruitment and the placement of civilian and sworn staff by 2015 while supporting the overall mission of the Bureau of Corrections.

Objective #1: The Bureau will recruit, hire, train and promote employees to implement a staffing plan that includes, relief factor and contingency plans, at levels to ensure a safe, secure, and humane environment for the Bureau’s employees, inmates, and visitors

STRATEGIES 1.1 Initiate an online recruitment protocol
1.2 Revise the steps for completing the preemployment process;
1.3. Develop and implement tracking mechanisms to alert Correction Officers who have arrived at age 55 to take annual examination; 1.4. Develop and implement tracking mechanisms to alert Supervisors of outstanding performance evaluations; 1.5. Design and implement a revised sworn staff and civilian staff performance appraisal system aligned with the Bureau of Corrections performance standards and completion of the individualized professional development plan; 1.6. Design and implement an instrument to track professional development and aligning training to test data;

Status

START DATE Ongoing

2016 2016
2015

COMPLETION DATE
Ongoing
July 2009
Ongoing

PERSONNEL RESPONSIBLE
Director of MIS - Vacant (Marsyvn David, System Programmer) Human Resources Manager (Yvonne Lawrence) Division of Personnel (Milton Potter, Director Designee) Human Resources Manager (Yvonne Lawrence) Administrative Services Staff - HR (Lynette Barnes, Eliza Joshua, Erica Smith) Human Resources Manager (Yvonne Lawrence)

OUTCOMES Division of Personnel Website
An outline of the new hiring process
A tracking mechanism to alert Correction Officers;

2016 2016
2016

Director of MIS - Vacant (Marsyvn David, System Programmer) Human Resources Manager (Yvonne Lawrence)
Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Division of Personnel (Milton Potter, Director Designee) Unions Warden (Mildred Trotter) Director of Training, Vacant (Yvonne Lawrence) Human Resources Manager (Yvonne Lawrence)

A tracking mechanism to alert Supervisors;
Measurable improvement in performance;
An instrument to monitor professional development achievements and deficits;

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

1.7. Revise and update HR policy and procedures manual;

In Progress 2015

Ongoing

1.8. Provide training to personnel of the revised and updated policy and procedures
1.9. Ensure Correction Officer compensation is comparable with other law enforcement positions

May 2015

Ongoing

October 2015 Ongoing

Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Staff Division of Personnel (Milton Potter, Director Designee Office of Collective Bargaining (Acting Chief Negotiator Joss Springette, Esq.) – for review purposes Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Training Staff (Yvonne Lawrence and Deborah Samuel) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Collective Bargaining (Acting Chief Negotiator Joss Springette, Esq.)

Written policies and standard operational procedures;
Training Schedule
New Corrections Officer contract

Objective #2: To increase the number of Correction Officers through hiring, promotions, education and professional development.

STRATEGIES 2.1. Conduct Staffing Analysis to include Upper-Management (Warden, Assistant Warden, Chief), Mid-level Management (Lieutenants), First-Line Supervisors (Sergeants) and Line Staff (Correction Officers) 2.2. Establish minimum staffing levels for Custody (ACA standard for Inmate/Staff Ratio/Security Posts)

STATUS

START DATE July 2014
March 2015

COMPLETION DATE
July 2014
March 2015

PERSONNEL RESPONSIBLE
Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Chief (Shern Morris, Calvin Herbert) NIC Technical Consultant (Rod Miller) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Chiefs (Shern Morris, Calvin Herbert) Human Resources Manager (Yvonne Lawrence)

OUTCOMES
Staffing Analysis completed and submitted to Monitor, USDOJ, and Federal Court Staffing Matrix

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

2.3. Develop system and format for Documenting:
 Daily/Shift Staffing reports delineating Correction Officer’s assignments at mandatory posts
 Monthly Staffing Reports  Staffing deficiencies notification process

Implemented Ongoing

Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Chiefs (Shern Morris, Calvin Herbert) Shift Supervisor Human Resources Manager (Yvonne Lawrence)

Standardize Forms & Reports

2.4. Develop a long-term (5yr) Hiring Plan
 Target number of new hires (corrections officers) - Entrance examination administered every three (3) months; - On average 12 candidates successfully passing entrance exam and complete Bureau of Corrections pre-employment process to include criminal background investigation and hired per year - Over a five (5) year period we will be able to maintain the staffing plan as outlined by the Staffing Analysis. - Currently we have 106 security staff members. - Our goal is acquired a total of 179 security staff members which means we are in need of 73 new officers - Our plan is to meet this goal in 2020 after which time we will only be replacing officers due to 10% attrition and 3% retirement for the duration of the five (5) year plan.

March 2015

 Advertise and post vacancies  Establish timelines for interviews, job
offers, start date, training 2.5. Prepare line item Budget for Personnel

In progress

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September 2020
To be

Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette hansen) Human Resources Manager (Yvonne Lawrence) Warden (Mildred Trotter) Office of Management & Budget (Nellon Bowry, Director Designee) Division of Personnel (Milton Potter, Director Designee) Office of the Governor (Kenneth E. Mapp, Governor)

Hiring Plan

Director, BOC (Rick Mullgrav), Assistant

Annual Budget

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

(5yrs) 2.6. Secure Funding for Staffing Plan

submitted February of each fiscal year
Ongoing

Director, BOC (Everette Hansen) Human Resources Manager (Yvonne Lawrence) Office of Management & Budget (Nellon Bowry, Director Designee) Legislature of the VI (Neville James, (President) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Human Resources Manager (Yvonne Lawrence) Office of Management & Budget (Nellon Bowry, Director Designee) Legislature of the VI (Neville James, (President) Office of the Governor (Kenneth E. Mapp, Governor)

Annual Budget

Objective #3: To increase the number of Correction Officers hired on an annual bases in the Bureau of Corrections through recruitment initiatives

STRATEGIES 3.1. Expand the Correction Officer recruiting plan;

STATUS

START DATE

3.2. Establish an agency-wide, incentive-based Done recruiting program

3.3. Recruit within the territory with a cross section of recruiters from target programs;

In Progress Ongoing

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COMPLETION DATE
On going
On going
On going

PERSONNEL RESPONSIBLE
Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Public Information Officer (Juel Anderson) Division of Personnel (Milton Potter, Director Designee) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Division of Personnel (Milton Potter, Director Designee); Human Resources Manager (Yvonne Lawrence); Office of Collective Bargaining (Acting Chief Negotiator Joss Springette, Esq.) Office of Management & Budget (Nellon Bowry, Director Designee) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen)

OUTCOMES Increased number due to the increased programs
Increase candidate pool with a built-in on the job mentor
Increased number due to the increased

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

3.4. Recruit outside of the territory with a cross In Progress section of recruiters representing target programs;
3.5. Increase advertisement for Correction Officers within the territory and outside of the territory;

On going Ongoing

Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Public Information Officer (Juel Anderson) Division of Personnel (Milton Potter, Director Designee) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Human Resources Manager (Yvonne Lawrence) Public Information Officer (Juel Anderson) Division of Personnel (Milton Potter, Director Designee) Human Resources Manager (Yvonne Lawrence) Division of Personnel(Milton Potter, Director Designee)

programs
Increased number due to the increased programs
Increase applicant pool by 15% per year;

Objective #4: To establish a new succession plan for Correction Officers to meet the needs of the Bureau of Corrections.

STRATEGIES 4.1. Conduct a needs assessment to determine the impending changes in staffing due to retirement. 4.2. Develop and implement a succession plan based on the needs assessment.
4.3 Develop an Employee Satisfaction Survey

STATUS In Progress Done

START DATE January 2016
June 2016
2016

COMPLETION DATE
March 2016
2017
2016

PERSONNEL RESPONSIBLE
Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Division of Personnel (Milton Potter, Director Designee) Division of Personnel (Milton Potter, Director Designee) Human Resources Manager (Yvonne Lawrence)

OUTCOMES Data from needs assessment Identifying Gaps in service and personnel Staffing and professional development plan that aligns needs based, with the projected personnel separations from workforce. Establish a base line on the employee morale

4.4 Develop relocation incentives for interisland and mainland recruits.

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Office of Management & Budget

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

4.5 Review Career Incentives Program

Division of Personnel (Milton Potter, Director Designee & Office of Management & Budget

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Case: 1:86-cv-00265-WAL-GWC Document #: 949-2 Filed: 12/31/15 Page 1 of 3
EXHIBIT B

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Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 1 of 26
EXHIBIT C

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 2 of 26
GOVERNMENT OF THE VIRGIN ISLANDS U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020 S
BUREAU OF CORRECTIONS
SEVEN YEAR RECRUITMENT PLAN

2015 - 2020

“SECURITY, CUSTODY, CONTROL”

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Rick Mullgrav, Director of BOC

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 3 of 26 U.S. Virgin Islands Bureau of Corrections
Security Staffing & Recruitment Plan 2015 - 2020
SUBJECT: Recruitment Plan
PURPOSE: To establish a comprehensive recruitment program to ensure the Bureau of Corrections complies with state and federal equal employment opportunity and affirmative action guidelines.
RULE: The Government of the Virgin Islands and Bureau of Corrections (BOC) is governed by a strong commitment to equal employment opportunity and affirmative action, and this commitment is clearly expressed in its Recruitment Plan.
The Bureau of Corrections is committed to an environment which promotes equal access to employment opportunities for all employees and applicants and strives for a workforce composition that reflects the diversity of qualified candidates and ensures the safety and security of the Correctional system.
The Bureau of Corrections does not discriminate in any terms or conditions of employment, on the basis of race, creed, color, religion, sex, age, national origin, marital status, sexual orientation, citizenship status, disability or veteran status. The Bureau of Corrections will reasonably accommodate disabled employees and applicants as required by law.
STATEMENT
In an effort to develop an effective recruitment program, the Division of Personnel and the Bureau of Corrections hereby reaffirms and formalizes its commitment to the principle of equal employment opportunity. Furthermore, it has been a longstanding policy of the Division of Personnel and the Bureau of Corrections to employ and promote qualified personnel without discrimination against any employee or applicant for employment because of his or her protected category or any other non-job¬related characteristic.
In developing the recruitment program, The Bureau of Corrections commits to:
 Recruiting, hiring, training, and promoting persons in all job classifications without regard to their protected category, or any other non-job-related characteristic.
 Ensuring decisions regarding selections and promotions are in accordance with equal employment opportunity, personnel rules and regulations and collective bargaining agreement requirements by imposing only valid, job-related requirements for such promotions.
 Ensuring all personnel actions relating to compensation, benefits, transfers, terminations, training, and educational attainment are administered in a nondiscriminatory and expedited manner.
 Conduct annual assessments to determine whether any adjustments are needed in accordance to the standards stipulated in the staffing plan.

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Security Staffing & Recruitment Plan 2015 - 2020
SECTION I – RESPONSIBITILITY
To ensure the Recruitment Plan is carried out through a good faith effort, the Bureau of Corrections has established various levels of responsibility to both direct and oversee its recruitment efforts.
The Human Resources Manager has been designated as the official responsible for the Bureau of Corrections recruitment efforts. The Human Resources Manager is responsible for monitoring recruitment efforts, providing equal opportunity training, and recommending the use of outside resources, where applicable to ensure the successful implementation of the plan. The Human Resources Manager also provides a critical link to the Government’s Division of Personnel for human resource support.
Individual managers and supervisors are responsible for ensuring that their employment decisions comply with principles embodied in the Bureau of Corrections Recruitment Plan and all applicable Collective Bargaining Agreements, local laws, federal laws, and Bureau of Corrections Policies and Regulations.
SECTION II - DISSEMINATION OF POLICY
The Recruitment Plan and policies related to equal employment opportunities are considered to be open records, available for public inspection. In addition, the Bureau of Corrections will take proactive steps to ensure the public and other key stake holders know about the Bureau of Corrections recruitment program. Some of the methods used to inform the public are:
1. Internal Dissemination
a. The Recruitment Plan will be provided to each Department Director.
b. The statement that The Bureau of Corrections is an EEO/AA employer will be documented in the Employee Handbook.
c. The Human Resources Manager and each Department Director will stress the importance of the Recruitment Plan in meetings with employees.
d. The Recruitment Plan will be explained thoroughly in employee orientation and management training programs.
e. The Recruitment Plan will be made available to any interested individual upon request and on the Bureau of Corrections website. Employees will be made aware of its existence and the benefits available to them.
2. External Dissemination
a. All appropriate publications and printed materials will state the shortened version of the institution's Mission and Recruitment philosophy: "The Bureau of Corrections is an Equal Employment Opportunity and Affirmative Action Employer." The statement will be placed on all letterhead, envelopes, business cards or invitations.

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

b. The Bureau of Corrections will regularly provide written information to schools, universities, employment organizations, veteran's groups, groups concerned with promoting the field of Corrections, etc.

c. Recruitment information (including videos and other electronic media), position announcements, and advertising will contain the Bureau of Correction's mission and philosophy statement.

SECTION III - RESPONSIBILITY FOR IMPLEMENTATION

The Human Resources Manager of the Bureau of Corrections is responsible for the implementation and administration of the Recruitment Plan. As the chief administrator of the Recruitment Plan, the Human Resources Manager has delegated to the department directors, managers, and supervisors the authority and responsibility for carrying out this plan at each corresponding level. Each of these individuals is expected to commit himself/herself to the Recruitment Plan's success.

As specified in the Recruitment Plan, the Human Resources Manager is charged with the administrative responsibility for ensuring compliance in employment activities. In fulfilling these responsibilities, the Human Resources Manager will:

1. Serve as liaison between the Bureau of Corrections and outside regulatory/ enforcement agencies;

2. Prepare, review, and ensure all hiring and promotions prior to job offers being extended, for compliance purposes;

3. Review qualifications of all employees to ensure that minorities and women are given full opportunities for transfers and promotions.

4. Disseminate recruitment plan to all employees annually.

The Human Resources Manager and Department Directors of the Bureau of Corrections will:

1. Assist in identifying problem areas and establishing division or departmental objectives.

2. Work with schools, universities, employment organizations, veteran's groups, groups concerned with promoting the field of Corrections, etc.

3. Review and affirm on an annual basis the manpower needs of the Bureau of Corrections to ensure the recruitment practices are still relevant in principles and institutional plan of affirmative action.

4. Encourage all officers to participate in all the Bureau of Corrections sponsored community, educational and social activities.

SECTION IV- PAST RECRUITMENT/RETENTION EFFORTS

Division of Personnel

Division of Personnel is the recruiting agent for the V.I. Government and recruits through:

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020
 Advertises via their website, press releases, on-line newspaper advertisements, radio announcements, and newspaper advertisements about the Correction Officer’s entrance examinations quarterly schedules.
 In an effort to increase the pool of candidates, the Division of Personnel established a waiver from the entrance examination for applicants with degrees (e.g. associate, bachelor, and master level) from accredited institutions and military veterans who have served full military service with an honorable or general discharge.
In addition to local recruitment, the Division of Personnel has recruited from outside of the territory:  Military Career Expo (08/2013 - 11/2013) – recruited veterans in the states of Virginia, Maryland, North Carolina, Texas & Florida  USVI Alliance, Inc. Career Expo in Atlanta (May 21-22, 2014)
New media campaign: in collaboration with the Department of Tourism, launched a joint campaign on 11/12/15 aimed at recruiting Virgin Islanders and others living in the mainland United States with high school diplomas to relocate to the Virgin Islands. This campaign includes a website, social media and online newspaper sources.
Department of Labor
 Hosted a job fair on St. Croix on June 22, 2015.
Bureau of Corrections
Job Recruitment Efforts:
BOC participated in job/career fairs that targeted candidates between the ages of 21-45.
 Law Enforcement Career Day: BOC participated in this event starting from 2012-2015. The event was held at the University of the Virgin Islands and was open to college students and the general public. Other local/federal law enforcement agencies as well as public/private employers participated in the event.
 Hero2Hired Career and Education Fair: BOC participated in this event in 2013. The event was sponsored by the VI National Guard and was open to all services members, spouses, veterans and retirees. Other local/federal law enforcement agencies as well as public/private employers participate in the event.
Career Incentives Program:
BOC and the officer’s Union has established a Career Incentive Program to offering pay differentials to classified corrections officers as a reward for furthering their education in fields which are related to the performance by the correction officer of present or possible future official duties with BOC. Each corrections officer is eligible to receive a pay differential equal to a percentage of his/her base compensation in accordance with the following schedule:
 Three percent (3%) increase for ten (10) semester hour credits or its equivalent in quarter units earned toward a baccalaureate or associate degree;

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020
 A six percent (6%) increase for twenty-five (25) semester hour credits or its equivalent in quarter units earned toward a baccalaureate or an associate degree;
 A ten percent (10%) increase for forty (40) semester hour credits or its equivalent in quarter units earned toward a baccalaureate or an associate degree;
 A fifteen percent (15%) increase for an associate degree;  A twenty (20%) percent increase for a baccalaureate degree;  A twenty-five (25%) percent increase for a post graduate degree.
Recruitment/Retention Efforts Being Considered:
 Continue discussions and potential memorandum of understanding prohibiting other law enforcement agencies from recruiting BOC cadets while in the POST Academy.
 Draft and implement an employment contract mandating that all incoming officer remain with the BOC for at least three years or else the will not receive a favorable recommendation for future employers.
 Exploring collaboration with the Department of Education (DOE) to assist with the development of corrections curricula/program to implement in all public high school for students to prequalify.
 Career Incentive Program to include relocation costs.  Restructuring the hiring process.
With respect to retention efforts, in either 2012 or 2013, the former Director, Julius Wilson went before the Legislature of the Virgin Islands and requested funds to increase the corrections officers’ salaries. The Legislature appropriated about $2 million; however, there were no funds available to satisfy this appropriation.
SECTION V – STAFFING AND POSTS
Below are tables that prioritize the posts based on, among other things, population and high levels of violence:
Primary Posts (Mandatory Posts):
1 Central Control
2 X Dorm
3 Treatment Building (Medical Infirmary)
4 9/B & Kilo—Special Management and Mentally Ill
5 L & 9A-Lockdown
6 G & H/ 9C &9D
7 R&D/RSAT/A-Dorm

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Security Staffing & Recruitment Plan 2015 - 2020 8 I & J - Closed Secondary Posts: 1 ACF and Detention 2 East Tower and West Tower 3 Roving Patrol, Patrol 4 Education, Recreation, Visit, Kitchen, Transportation 5 Warehouse, Car Repair shop and tool room 6 Main Entrance Security Point
Please refer to the Staffing Matrix as to corrections officers for each post (see Appendix A).

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

SECTION VI - STAFFING ANALYSIS

Prison Rape Elimination Act Staffing Analysis

(a) The agency shall ensure that each facility it operates shall develop, document, and make its best efforts to comply on a regular basis with a staffing plan that provides for adequate levels of staffing, and, where applicable, video monitoring, to protect inmates against sexual abuse. In calculating adequate staffing levels and determining the need for video monitoring, facilities shall take into consideration:

(1) Generally accepted detention and correctional practices;

(2) Any judicial findings of inadequacy;

(3) Any findings of inadequacy from Federal investigative agencies;

(4) Any findings of inadequacy from internal or external oversight bodies;

(5) All components of the facility’s physical plant (including “blind-spots” or areas where staff or inmates may be isolated);

(6) The composition of the inmate population;

(7) The number and placement of supervisory staff;

(8) Institution programs occurring on a particular shift;

(9) Any applicable State or local laws, regulations, or standards;

(10) The prevalence of substantiated and unsubstantiated incidents of sexual abuse; and

(11) Any other relevant factors.

(b) In circumstances where the staffing plan is not complied with, the facility shall document and justify all deviations from the plan.

(c) Whenever necessary, but no less frequently than once each year, for each facility the agency operates, in consultation with the PREA coordinator required by § 115.11, the agency shall assess, determine, and document whether adjustments are needed to:

(1) The staffing plan established pursuant to paragraph (a) of this section;

(2) The facility’s deployment of video monitoring systems and other monitoring technologies; and

(3) The resources the facility has available to commit to ensure adherence to the staffing plan.

(d) Each agency operating a facility shall implement a policy and practice of having intermediate-level or higherlevel supervisors conduct and document unannounced rounds to identify and deter staff sexual abuse and sexual harassment. Such policy and practice shall be implemented for night shifts as well as day shifts. Each

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020
agency shall have a policy to prohibit staff from alerting other staff members that these supervisory rounds are occurring, unless such announcement is related to the legitimate operational functions of the facility.
Security Staffing Analysis
A staffing analysis was conducted by Rod Miller, National Institute of Corrections Consultant, in July 2014, which identified all housing, special and split posts, a coverage plan, staffing levels requirement as well as various recommendations for the improvement of security and overall operations to include (see Appendix 1):
1. BOC will strive to work towards the implementation of Direct Supervision. An officer will be in each dayroom at all times—no exceptions. Coverage will enable this by providing three officers in each 2-unit building at all times. Two officers would be providing direct supervision and making rounds in the housing units; the third would be operating the control room and monitoring all movement in and out of the unit. The proposed plan will provide staffing to conduct searches of inmates whenever they return to a housing unit, as well as random searches of cell.
2. Reduction of inmate population in order to provide the best optimum security staff levels through “reverse engineer” the plan, calculating staff reductions that could be realized by reducing the number of inmates housed. The Bureau relocated some offenders to off-island facilities, thereby reducing the offender population and closing two (2) housing units. This closure reduced staffing demands by 4 security staff per shift 4 therefore, reducing by an average of 12 security officers per shift.
3. Change on shift schedule based on the peak time/level of activities during peak time period of the day. The changes from 8-4, 4-12, & 12-8 shift schedules to 6-2; 2-10; 10-6 shift schedules. These changes provide the increase level of offender supervision during offender movements during peak hours of operations. Change of shift schedule has also resulted in reduction in overtime worked due to absenteeism (e.g. scheduled leave, leave without pay).

With the implementation of above- mentioned changes and the reduction of housed inmates and shift schedules, the Bureau revisited the Coverage Plan and developed a Staff/Post Matrix as of 12/14/15, which indicates the revised level of staffing requirements based on the current posts.
Moreover, funding is available for 18 correction officer positions for fiscal year 2016.
VI GGGACF STAFF/POST MATRIX – 12/14/2015

Security Positions Security Management TC Command (Lt) ATC Command (Sgt) Officer Total Security Staff

Intended Staffing
Plan 2015
6 5 13 155
179

Actual Staffing
as of 12/14/15
4 2 5 95
106

2015 Budget Authorized
4 3 5 117
129

2016 Budget Authorized
5 3 7 117
132

Staff Needed
2 3 8 60 73

9

Last revised on 12-14-2015; recently edited on 12-18-2015

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 11 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Based on the Staffing Plan dated July 2014, and the Staff/Post Matrix dated December 2015, the level of staffing has increased from 165.6 to 179 (due to security management post added) security staff needed for operations. The Bureau of Corrections and the Division of Personnel are committed to meeting the demands and begin the recruitment and employment efforts to acquire the additional corrections officers to meet the staffing levels of Staff/Post Matrix.

The Bureau proposes the staffing plan be implemented over a five (5) fiscal year period to be able to effectively recruit and retain officer while taking into consideration the replacement of officers due to attrition and retirement. BOC will revisit the staffing levels after three (3) years to determine whether the goals of the staffing plan are being met in a five (5) year period and whether additional years should be added to this Plan.

VI BOC/ GGACF Hiring Plan
Security Positions
Security Management TC Command (Lt) ATC Command (Sgt) Officer Total Security Staff

Staffing Plan as 12/2015
4 2 5 95
106

Staff Needed (vacancies)
2 3 8 60
73

Year 1
F2016
1 1 2 12 16

Year 2
F2017
1 1 2 12 16

Year 3
F2018
0 1 2 12 15

Year 4
F2019
0 0 2 12 14

Year 5
F2020
0 0 0 12 12

Total
20162020
2 3 8 60 73

Staff Needed
100% 100% 100% 100% 100%

The chart below shows target staffing levels by security position 2016-2020:

VI BOC/ GGACF Hiring Plan
Security Positions
Security Management % Staffing
TC Command (Lt) % Staffing
ATC Command (Sgt) % Staffing
Officer % Staffing
Total Security Staff % Staffing

Overall Staffing Required
6
5
13
155
179

Actual Staffing
as of 12/14/15
4 67%
2 40%
5 38% 95 61% 106
59%

Year 1
F2016
5 83%
3 60%
7 54% 107 68% 122
68%

Year 2
F2017
6 100%
4 80%
9 69% 119 74% 138
77%

Year 3
F2018
5 100%
11 85% 131 81% 153
85%

Year 4
F2019
13 100% 143 87% 167
93%

Year 5 F2020
155 100% 179
100%

Total
20162020
6 5 13 155 179

10

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Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 12 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

The Bureau of Corrections is committed to recruit at least four (4) correction officers per fiscal year through different mediums.
The chart below shows the different recruitment means to increase staffing pool F2016-F2020:

Measurable Job Fairs Sponsored: Outcomes

# of Sponsored Job Fairs per Fiscal Year

Date of Job Fair

# of Job Fairs Anticipated Participation

# of Anticipated Registered Candidates

# of Actual Recruits

Division of Personnel
The University of the Virgin Islands Albert A. Sheen Campus
Bureau of Corrections Recruitment Program Department of Labor

2

Pending – STT &

2

STX

3

4/6/2016 – STX;

3

4/2016 – STT &

10/2016 – STT

2

6/15/2016 - STT

2

& STX

2

7/2016 – STT &

2

STX

45

TBD

30

TBD

40

TBD

40

TBD

30

TBD

40

TBD

The corrections officer examination period is January 25-29, 2016.

Other possible recruitment medium:

Measurable Other Recruitment Efforts Outcomes

# of Interested

# of

Candidates Candidates

Fiscal Year Considered

Vacancies Posted with Department of Labor

TBD

TBD

11

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Hiring/Separation for the BOC for the past six years (2009-2015)

New Hires & Separations:

Employee's

Last Name

First Name

√

√

√

√

√

√

√

√

√

√

√

√

√

√

2015
05/11/2015 05/11/2015 05/11/2015 05/11/2015

2014

01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014 01/27/2014

12

Last revised on 12-14-2015; recently edited on 12-18-2015

Hire Dates

2013

2012

2011

N O

H I R E S

T

2010

2009

Separation Date

Reason for separation

Employed

In the Academy

Employed

In the Academy Dismissed from the Academy

Dismissed from the Academy

04/25/2014 Dismissed from the Academy

Employed

Employed 03/19/2014

Dismissed from the Academy

Employed

09/08/2015

Resigned

Dismissed from the Academy

Employed 09/08/2014 05/08/2014

Resigned Resigned

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 14 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's

Last Name

First Name

2015

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

Hire Dates

2014

2013

2012

01/27/2014

H

I

S

12/0 8/2014

12/0 8/2014

12/0 8/2014

Y

12/0 8/2014

E

12/0 8/2014

A

12/0 8/2014

R

12/0 8/2014

3/5/2013

3/5/2013

2011

2010 2009

10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011 10/17/2011

Separation Date

Reason for separation

Employed Employed Employed Employed 12/15/2014 Employed Employed Employed
5/29/2014 Employed 8/9/2013 3/10/2014 Employed 7/5/2012 9/12/2012 4/3/2013 Employed 8/16/2012 7/28/2013

Dismissed from the Academy Transferred to VIPD Transferred to VIPD In the Academy In the Academy
In the Academy Resigned
In the Academy
Rehired Rehired Resigned
Resigned Resigned
Resigned Resigned Resigned
Resigned Resigned

13

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Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 15 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

2014

2013

Hire Dates 2012

2011 7/5/2011 7/5/2011 7/5/2011 7/5/2011 7/5/2011 7/5/2011 7/6/2011 7/5/2011 7/5/2011 3/7/2011 3/7/2011 3/7/2011 3/7/2011 3/7/2011 3/7/2011

2010 2009
2/16/2010 2/16/2010 2/16/2010 2/16/2010 2/16/2010

Separation Date
Employed Employed 5/27/2012 10/24/2011 Employed 10/31/2011
11/9/2011 1/26/2011 6/20/2011 10/3/2013 2/4/2013 Employed 5/27/2014 10/31/2011
9/10/2012 Employed Employed 2/21/2015

Reason for separation
Deceased Resigned
Dismissed Pending dismissal
Resigned Resigned Dismissed Dismissed Resigned
Resigned Dismissed Dismissal pending Resigned
deceased

14

Last revised on 12-14-2015; recently edited on 12-18-2015

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 16 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

2014 2013

√ √

15

Last revised on 12-14-2015; recently edited on 12-18-2015

Hire Dates 2012 2011

2010

2009

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

2/16/2010

6/21/2010

6/21/2010

6/21/2010

6/21/2010

6/21/2010

6/21/2010

6/24/2010

6/21/2010 6/21/2010

Separation Date
Employed 8/12/2015 2/26/2014 4/23/2012
8/17/2015 Employed 8/30/2012 Employed 2/14/2013 8/11/2014 3/12/2015
Employed 3/9/2012 Employed 1/29/2013 Employed 8/21/2014
06/25/2010 5/30/2011

Reason for separation
Resigned Dismissed Resigned Dismissal pending Resigned
Resigned
Dismissed Resigned Dismissed No show
Dismissal
Resigned
Resignation Resignation Resignation Dismissal pending

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 17 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √ √ √ √ √

2014 2013

√ √

√ √ √ √ √ √ √ √

16

Last revised on 12-14-2015; recently edited on 12-18-2015

Hire Dates 2012 2011

2010

2009

6/21/2010

6/21/2010

11/8/2010

11/8/2010

11/8/2010

11/8/2010

11/15/2010

11/8/2010

11/8/2010

11/8/2010

11/8/2010

11/8/2010

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

2/23/2009

6/22/2009

6/22/2009

Separation Date
employed employed 5/5/2014
12/6/2012 employed 06/03/2011 10/6/2012 6/20/2013 6/3/2011 employed employed
employed 10/8/2012
8/29/2012 employed employed 4/4/2013 10/7/2013 3/24/2013 11/10/2014

Reason for separation
Resigned No Show Resigned Resigned Resigned Dismissed Resigned
Resigned Dismissed Resigned
Resigned Dismissed Resigned Dismissed

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 18 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Employee's Last Name First Name 2015 √ √ √ √ √ √ √ √

2014 2013

Hire Dates

2012

2011

2010

2009 6/122/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009 6/22/2009

Separation Date

Reason for separation

8/29/2012 employed employed employed employed
employed 8/13/2012

Resigned
Resigned Resigned

Year 2015 2014 2013 2012 2011 2010 2009

Breakdown by Year
Hires 4 18 2 0 25 39 20

Separations 5 13 11 9 9 2 0

17

Last revised on 12-14-2015; recently edited on 12-18-2015

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 19 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Applicant Tracking & Pass/Failure Report

# District

Exam Title

Company

Applicants Registered

Applicants Exam Date Tested Passed Waived

Law Enforcement

Officer/Corrections

5 STX

Officer

TABE

72

1/16/2009

37

5

0

Law Enforcement

Officer/Corrections

6 STX

Officer

TABE

94

3/24-4/3/2009

53

10

2

Law Enforcement

Officer/Corrections

7 STX

Officer

TABE

96

6/22-29/2009

47

6

4

8

STX Corrections Officer

CPS

105

11/14/2009

60

9

3

9

STX Corrections Officer

CPS

10 STX Corrections Officer

CPS

11 STX Corrections Officer

CPS

12 STX Corrections Officer

CPS

61

3/6/2010

34

12

4

3 resent

192

8/6/2010

110

13

7

1 transfer

1 resent

50

11/20/2010

34

7

6

3 resent

71

3/15-18/11

47

3

7

18

Last revised on 12-14-2015; recently edited on 12-18-2015

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

# District 13 STX 14 STX 15 STX 16 STX 17 STX 18 STX

Exam Title
Corrections Officer
Corrections Officer
Corrections Officer
Corrections Officer
Corrections Officer
Corrections Officer

Company CPS

Applicants Registered
125

Applicants

Exam Date

Tested

Passed

7/11-22/11

1 resent

78

13

Waived 11

CPS

82

11/2-7/11

52

5

1

1 resent

CPS

115

12/18-27/12

42

2

10

10/01/12 -

CPS

199

09/30/13

72

7

24

10/01/13 -

CPS

74

09/30/14

27

5

15

10/01/14 -

CPS

214

09/30/15

94

11

32

19

Last revised on 12-14-2015; recently edited on 12-18-2015

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 21 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

Goal: To develop and implement a comprehensive fully integrated human resources system that will facilitate professional development, improved performance and ensure recruitment and the placement of civilian and sworn staff by 2015 while supporting the overall mission of the Bureau of Corrections.

Objective #1: The Bureau will recruit, hire, train and promote employees to implement a staffing plan that includes, relief factor and contingency plans, at levels to ensure a safe, secure, and humane environment for the Bureau’s employees, inmates, and visitors

STRATEGIES 1.1 Initiate an online recruitment protocol
1.2 Revise the steps for completing the preemployment process;
1.3. Develop and implement tracking mechanisms to alert Correction Officers who have arrived at age 55 to take annual examination; 1.4. Develop and implement tracking mechanisms to alert Supervisors of outstanding performance evaluations; 1.5. Design and implement a revised sworn staff and civilian staff performance appraisal system aligned with the Bureau of Corrections performance standards and completion of the individualized professional development plan; 1.6. Design and implement an instrument to track professional development and aligning training to test data;

Status

START DATE Ongoing

2016 2016
2015

COMPLETION DATE
Ongoing
July 2009
Ongoing

PERSONNEL RESPONSIBLE
Director of MIS - Vacant (Marsyvn David, System Programmer) Human Resources Manager (Yvonne Lawrence) Division of Personnel (Milton Potter, Director Designee) Human Resources Manager (Yvonne Lawrence) Administrative Services Staff - HR (Lynette Barnes, Eliza Joshua, Erica Smith) Human Resources Manager (Yvonne Lawrence)

OUTCOMES Division of Personnel Website
An outline of the new hiring process
A tracking mechanism to alert Correction Officers;

2016 2016
2016

Director of MIS - Vacant (Marsyvn David, System Programmer) Human Resources Manager (Yvonne Lawrence)
Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Division of Personnel (Milton Potter, Director Designee) Unions Warden (Mildred Trotter) Director of Training, Vacant (Yvonne Lawrence) Human Resources Manager (Yvonne Lawrence)

A tracking mechanism to alert Supervisors;
Measurable improvement in performance;
An instrument to monitor professional development achievements and deficits;

20

Last revised on 12-14-2015; recently edited on 12-18-2015

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

1.7. Revise and update HR policy and procedures manual;

In Progress 2015

Ongoing

1.8. Provide training to personnel of the revised and updated policy and procedures
1.9. Ensure Correction Officer compensation is comparable with other law enforcement positions

May 2015

Ongoing

October 2015 Ongoing

Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Staff Division of Personnel (Milton Potter, Director Designee Office of Collective Bargaining (Acting Chief Negotiator Joss Springette, Esq.) – for review purposes Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Training Staff (Yvonne Lawrence and Deborah Samuel) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Collective Bargaining (Acting Chief Negotiator Joss Springette, Esq.)

Written policies and standard operational procedures;
Training Schedule
New Corrections Officer contract

Objective #2: To increase the number of Correction Officers through hiring, promotions, education and professional development.

STRATEGIES 2.1. Conduct Staffing Analysis to include Upper-Management (Warden, Assistant Warden, Chief), Mid-level Management (Lieutenants), First-Line Supervisors (Sergeants) and Line Staff (Correction Officers) 2.2. Establish minimum staffing levels for Custody (ACA standard for Inmate/Staff Ratio/Security Posts)

STATUS

START DATE July 2014
March 2015

COMPLETION DATE
July 2014
March 2015

PERSONNEL RESPONSIBLE
Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Chief (Shern Morris, Calvin Herbert) NIC Technical Consultant (Rod Miller) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Chiefs (Shern Morris, Calvin Herbert) Human Resources Manager (Yvonne Lawrence)

OUTCOMES
Staffing Analysis completed and submitted to Monitor, USDOJ, and Federal Court Staffing Matrix

21

Last revised on 12-14-2015; recently edited on 12-18-2015

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

2.3. Develop system and format for Documenting:
 Daily/Shift Staffing reports delineating Correction Officer’s assignments at mandatory posts
 Monthly Staffing Reports  Staffing deficiencies notification process

Implemented Ongoing

Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Chiefs (Shern Morris, Calvin Herbert) Shift Supervisor Human Resources Manager (Yvonne Lawrence)

Standardize Forms & Reports

2.4. Develop a long-term (7yr) Hiring Plan
 Target number of new hires (corrections officers) - Entrance examination administered every three (3) months; - On average 12 candidates successfully passing entrance exam and complete Bureau of Corrections pre-employment process to include criminal background investigation and hired per year - Over a five (5) year period we will be able to maintain the staffing plan as outlined by the Staffing Analysis. - Currently we have 99 security staff members. - Our goal is acquired a total of 179 security staff members which means we are in need of 73 new officers - Our plan is to meet this goal in 2020 after which time we will only be replacing officers due to 10% attrition and 3% retirement for the duration of the five (5) year plan.

March 2015

 Advertise and post vacancies  Establish timelines for interviews, job
offers, start date, training 2.5. Prepare line item Budget for Personnel

In progress

22

Last revised on 12-14-2015; recently edited on 12-18-2015

September 2022
To be

Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette hansen) Human Resources Manager (Yvonne Lawrence) Warden (Mildred Trotter) Office of Management & Budget (Nellon Bowry, Director Designee) Division of Personnel (Milton Potter, Director Designee) Office of the Governor (Kenneth E. Mapp, Governor)

Hiring Plan

Director, BOC (Rick Mullgrav), Assistant

Annual Budget

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 24 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

(7yrs) 2.6. Secure Funding for Staffing Plan

submitted February of each fiscal year
Ongoing

Director, BOC (Everette Hansen) Human Resources Manager (Yvonne Lawrence) Office of Management & Budget (Nellon Bowry, Director Designee) Legislature of the VI (Neville James, (President) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Human Resources Manager (Yvonne Lawrence) Office of Management & Budget (Nellon Bowry, Director Designee) Legislature of the VI (Neville James, (President) Office of the Governor (Kenneth E. Mapp, Governor)

Annual Budget

Objective #3: To increase the number of Correction Officers hired on an annual bases in the Bureau of Corrections through recruitment initiatives

STRATEGIES 3.1. Expand the Correction Officer recruiting plan;

STATUS

START DATE

3.2. Establish an agency-wide, incentive-based Done recruiting program

3.3. Recruit within the territory with a cross section of recruiters from target programs;

In Progress Ongoing

23

Last revised on 12-14-2015; recently edited on 12-18-2015

COMPLETION DATE
On going
On going
On going

PERSONNEL RESPONSIBLE
Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Public Information Officer (Juel Anderson) Division of Personnel (Milton Potter, Director Designee) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Division of Personnel (Milton Potter, Director Designee); Human Resources Manager (Yvonne Lawrence); Office of Collective Bargaining (Acting Chief Negotiator Joss Springette, Esq.) Office of Management & Budget (Nellon Bowry, Director Designee) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen)

OUTCOMES Increased number due to the increased programs
Increase candidate pool with a built-in on the job mentor
Increased number due to the increased

Case: 1:86-cv-00265-WAL-GWC Document #: 949-3 Filed: 12/31/15 Page 25 of 26
U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

3.4. Recruit outside of the territory with a cross In Progress section of recruiters representing target programs;
3.5. Increase advertisement for Correction Officers within the territory and outside of the territory;

On going Ongoing

Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Public Information Officer (Juel Anderson) Division of Personnel (Milton Potter, Director Designee) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Human Resources Manager (Yvonne Lawrence) Public Information Officer (Juel Anderson) Division of Personnel (Milton Potter, Director Designee) Human Resources Manager (Yvonne Lawrence) Division of Personnel(Milton Potter, Director Designee)

programs
Increased number due to the increased programs
Increase applicant pool by 15% per year;

Objective #4: To establish a new succession plan for Correction Officers to meet the needs of the Bureau of Corrections.

STRATEGIES 4.1. Conduct a needs assessment to determine the impending changes in staffing due to retirement. 4.2. Develop and implement a succession plan based on the needs assessment.
4.3 Develop an Employee Satisfaction Survey

STATUS In Progress Done

START DATE January 2016
June 2016
2016

COMPLETION DATE
March 2016
2017
2016

PERSONNEL RESPONSIBLE
Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Director, BOC (Rick Mullgrav), Assistant Director, BOC (Everette Hansen) Warden (Mildred Trotter) Human Resources Manager (Yvonne Lawrence) Division of Personnel (Milton Potter, Director Designee) Division of Personnel (Milton Potter, Director Designee) Human Resources Manager (Yvonne Lawrence)

OUTCOMES Data from needs assessment Identifying Gaps in service and personnel Staffing and professional development plan that aligns needs based, with the projected personnel separations from workforce. Establish a base line on the employee morale

4.4 Develop relocation incentives for interisland and mainland recruits.

24

Last revised on 12-14-2015; recently edited on 12-18-2015

Office of Management & Budget

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U.S. Virgin Islands Bureau of Corrections Security Staffing & Recruitment Plan 2015 - 2020

4.5 Review Career Incentives Program

Division of Personnel (Milton Potter, Director Designee & Office of Management & Budget

25

Last revised on 12-14-2015; recently edited on 12-18-2015

Case: 1:86-cv-00265-WAL-GWC Document #: 949-4 Filed: 12/31/15 Page 1 of 3
EXHIBIT D

Case: 1:86-cv-00265-WAL-GWC Document #: 949-4 Filed: 12/31/15 Page 2 of 3

From: Sent: To:
Subject: Attachments:

Kenneth Ray [ken@rjsjusticeservices.com] Wednesday, December 30, 2015 2:24 PM 'Shari D'Andrade'; Lomio, Rita (CRT); Myrthil, Marlysha (CRT); Coon, Laura (CRT); Njoku, Anthony (CRT); 'Kenneth Ray' RE: Cross Walk with changes Security Post Staffing from VI 031615.xlsx

Thank you, Shari – note the attach staffing matrix referred to in the Plan remains unattached. It’s format requires updating and we need to discuss treatment building staffing issues revealed during the recent visit. Staffing levels shown on the matrix won’t likely resolve access to care and building security problems discovering then. Looking forward to discussing this further. Ken

P.O. Box 1481 Ashland, KY 41105
606.694.3031 ken@rjsjusticeservices.com
“Dedication to Public Safety and Community Wellness”
From: Shari D'Andrade [mailto:Shari.D'Andrade@doj.vi.gov] Sent: Wednesday, December 30, 2015 1:46 PM To: Rita Lomio <Rita.Lomio@usdoj.gov>; Marlysha Myrthil <Marlysha.Myrthil@usdoj.gov>; Laura Coon <Laura.Coon@usdoj.gov>; Anthony Njoku <Anthony.Njoku@usdoj.gov>; Kenneth Ray <ken@rjsjusticeservices.com> Subject: Fwd: Cross Walk with changes
See below and attached.
Sent from my iPhone
Begin forwarded message:
From: "Yvonne Lawrence" <ylawrence@boc.vi.gov> To: "Shari D'Andrade" <Shari.D'Andrade@doj.vi.gov> Subject: Cross Walk with changes
Greetings Shari,
Please find some changes that was overlooked in the prior submission.

Cross Walk of changes

Old

New

Page

1

Case: 1:86-cv-00265-WAL-GWC Document #: 949-4 Filed: 12/31/15 Page 3 of 3

Other possible recruitment medium:

Post Vacancies on Department of Labor p. 11
“VIEWS” website

Vacancies Posted with Department of Labor
Objective #2: 2.4. Develop a long‐term (7yr) Hiring Plan
 Target number of new hires (corrections officers) - Entrance examination administered every three (3) months; - On average 12 candidates successfully passing entrance exam and complete Bureau of Corrections pre‐ employment process to include criminal background investigation and hired per year - Over a seven (7) year period we will be able to maintain the staffing plan as outlined by the Staffing Analysis. - Currently we have 99 security staff members. - Our goal is acquired a total of 179 security staff members which means we are in need of 73 new officers - Our plan is to meet this goal in 2020 after which time we will only be replacing officers due to 10% attrition and 3% retirement for the duration of the seven (7) year plan.

2.4. Develop a long‐term (5yr) Hiring Plan
 Target number of new hires (corrections officers)
- Entrance examination administered every three (3) months;
- On average 12 candidates successfully passing entrance exam and complete Bureau of Corrections pre‐ employment process to include criminal background investigation and hired per year
- Over a five (5) year period we will be able to maintain the staffing plan as outlined by the Staffing Analysis.
- Currently we have 106 security staff members.
- Our goal is acquired a total of 179 security staff members which means we are in need of 73 new officers
- Our plan is to meet this goal in 2020 after which time we will only be replacing officers due to 10% attrition and 3% retirement for the duration of the five (5) year plan.

p. 22

2.5. Prepare line item Budget for Personnel (7yrs)

Prepare line item Budget for Personnel (5yrs)

p. 22

Yvonne D. Lawrence, MS HRM
Human Resources Manager
VI Bureau of Corrections 81A & B Krondprindsens Gade Franklin Building 3rd Floor, Room 304 St. Thomas, U.S. Virgin Islands 00802
Phone: (340) 715‐7575 Fax: (340) 774‐5878
2

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 954 Filed: 02/02/16 Page 1 of 2

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, )

et al.,

)

)

)

Defendants.

)

__________________________________________)

Civil Action No. 1986-0265

Attorneys: Jonathan M. Smith, Esq., Laura L. Coon, Esq., Rita K. Lomio, Esq., Sharon I. Brett, Esq., Marlysha Myrthil, Esq., Washington, D.C. Angela Tyson-Floyd, Esq., St. Croix, U.S.V.I.
For the United States

Shari N. D’Andrade, Esq., St. Croix, U.S.V.I.
For Defendants

ORDER

THIS MATTER comes before the Court on the United States’ “Notice of Objections to

Staffing Plan and Request for a Status Conference” (Dkt. No. 949), Defendants’ Response thereto

(Dkt. No. 951), and the United States’ Reply (Dkt. No. 952). In the Notice, the United States raises

three objections to the Staffing Plan submitted by Defendants on December 30, 2015: (1) the

Staffing Plan does not address the salary of corrections officers; (2) the Staffing Plan does not

provide sufficient detail regarding recruitment and retention of corrections officers; and (3) the

Case: 1:86-cv-00265-WAL-GWC Document #: 954 Filed: 02/02/16 Page 2 of 2

Staffing Plan does not provide specificity or explain the relationship between the strategies

proposed therein and the timeframe for completion. (See Dkt. No. 949).

In its Reply, the United States withdraws its request for a status conference on its second

and third objections to the Staffing Plan, but maintains that a status conference is still necessary to

resolve its first objection to the Staffing Plan—i.e., the Staffing Plan’s failure to address the salary

of corrections officers. (See Dkt. No. 952 at 1, n.1).

UPON CONSIDERATION of the foregoing, and the entire record herein, it is hereby

ORDERED that a hearing on the United States’ first objection to Defendants’ Staffing

Plan shall be held on March 17, 2016 at 1:30 p.m. in STX Courtroom 1, immediately before the

status conference currently scheduled in this matter; and it is further

ORDERED that any individuals deemed necessary by Defendants to respond to questions

regarding the salary of corrections officers shall appear in person at the hearing; and it is further

ORDERED that the individuals appearing in person shall include Acting Chief Deputy

Attorney General Joseph Ponteen and Emile Henderson, Esq., Chief Legal Counsel to the

Governor of the Virgin Islands.

SO ORDERED.

Date: February 2, 2016

_______/s/________ WILMA A. LEWIS Chief Judge

2

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 970 Filed: 03/18/16 Page 1 of 3

DISTRICT COURT OF THE VIRGIN ISLANDS DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

)

v.

)

)

TERRITORY OF THE VIRGIN ISLANDS, )

et al.,

)

)

)

Defendants.

)

__________________________________________)

Civil Action No. 1986-0265

Attorneys: Jonathan M. Smith, Esq., Laura L. Coon, Esq., Rita K. Lomio, Esq., Sharon I. Brett, Esq., Marlysha Myrthil, Esq., Washington, D.C. Angela Tyson-Floyd, Esq., St. Croix, U.S.V.I.
For the United States

Shari N. D’Andrade, Esq., St. Croix, U.S.V.I.
For Defendants

ORDER

THIS MATTER came before the Court for a Status Conference on March 17, 2016. At the

Status Conference, the Court heard oral argument on the following three issues: (1) the transfer of

prisoners from the Golden Grove Adult Correctional Facility to off-island facilities; (2) the United

States’ “Motion to Compel Production of Documents and Enforce Settlement Agreement” (Dkt.

No. 964); and (3) the United States’ objection to the Staffing Plan submitted by Defendants on

December 30, 2015—i.e., the Staffing Plan’s failure to address the salary of corrections officers.

For the reasons stated on the record at the Status Conference, it is hereby

Case: 1:86-cv-00265-WAL-GWC Document #: 970 Filed: 03/18/16 Page 2 of 3
ORDERED that the United States’ “Request for Documents and Information Related to Prisoner Transfer” (Dkt. No. 965-2) and any associated actions are STAYED pending further Order of the Court; and it is further
ORDERED that the United States shall have up to and including March 31, 2016 within which to file a brief explaining how the transfer of prisoners from the Golden Grove Adult Correctional Facility to off-island facilities, and any associated monitoring or other review of the conditions at those facilities, are properly within the scope of this action, and as to off-island monitoring, within the jurisdiction of this Court; and it is further
ORDERED that the United States’ brief on the transfer of prisoners shall include an analysis of how the inclusion in this case of the prisoner transfer issues is consistent with the Prison Litigation Reform Act, and falls within the scope of the Findings of Fact and Conclusions of Law adopted by the Court and the Settlement Agreement entered in this case; and it is further
ORDERED that Defendants shall have up to and including April 14, 2016 within which to file a response; and it is further
ORDERED that the United States shall have up to and including April 21, 2016 within which to file a reply; and it is further
ORDERED that the United States’ “Motion to Compel Production of Documents and Enforce Settlement Agreement” is DENIED WITHOUT PREJUDICE;1 and it is further
ORDERED that the parties shall jointly prepare a letter to Mr. Eugene Irish, Vice President of the Seafarers International Union, signed by Attorney General Claude Walker, explaining with specificity the critical importance—to the Virgin Islands Bureau of Corrections and its compliance
1 At the Status Conference, the Court advised the parties that the United States and/or the Monitor may revise their request for production of documents. However, the request must be properly tailored to documentation and information necessary to the monitoring of Defendants’ implementation of the Settlement Agreement entered in this case.
2

Case: 1:86-cv-00265-WAL-GWC Document #: 970 Filed: 03/18/16 Page 3 of 3

with, and fulfillment of, the terms of the Settlement Agreement entered in this case—of pay parity

between corrections officers and other local law enforcement officers; and it is further

ORDERED that Defendants shall send the letter to Vice President Irish and file it with the

Court no later than March 21, 2016; and

While recognizing that this Order does not bind the Legislature of the Virgin Islands but

pertains only to the actions of Defendants, it is further

ORDERED that Defendants shall have up to and including April 7, 2016 within which to

file an amended Staffing Plan that includes the estimated timeframe, subject to action by the

Legislature of the Virgin Islands, within which corrections officers at the Virgin Islands Bureau of

Corrections are expected to receive the retroactive increase in their salaries.

SO ORDERED.

Date: March 18, 2016

________/s/________ WILMA A. LEWIS Chief Judge

3

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 974-1 Filed: 03/22/16 Page 1 of 2
TTHHEE UUNNIITTEEDD SSTTAATTEESS VVIIRRGGIINN IISSLLAANNDDSS
DDEEPPAARRTTl>MlEENNTT OOFF JJUUSSTTIICCEE OOFFFFIrCCEE OOFF TTHHEE AATTTTOORRNNEEYY GGEENNEERRAALL

CCLLAAUUDDEE EEAARRLL WWAALLKKEERR,, EESSQQUUIIRREE AATTTtOORRNNtE:YY GGEENNEERRAALL

MMaarrcchh 2222, 2200116

EEuugene IIrish Vice PPresident SSeafarers IInntteernational Union UUnnited SShopping PPllaza, BBay #24 CChhrristiansted, SSt. CCroix, VVI 0000820
Re: Correction Offfflicceers AAggrreement -— BBuureau ofCCoorrrections
Dear Mr,. Irish:
On or about August 31, 2012, the Territory of the Virgin Islands., on behalf of the Bureau of Corrections and its operations of the Golden Grove Adult Correctional Facility and Detention Center, entered into a Settlement Agreement with the United States of America, through its United States Department of Justice. As part of this Agreement, the Bureau of Corrections is required to develop and implement staffing plan which will serve to improve its recruitment and retention efforts.
Over the years, adequate compensation for Correction Officers has been identified as a majorr impediment to attractingg and retaining individuals at the Bureau. In an effort to beginn addressing the staffingg issues, Governor Kenneth L.. Mapp,, onn Februaryy 24,, 2016, submitted Billll No. 331-03200 to the 331l5t Legislature off thee Virgin Islands, requesting thatt an additional $S2,.469.,363.,000 be appropriated from the General Fund to the Bureau of Corrections.. These funds will be used to implement salary increasseess for employeeeess of the Bureaauu off Correctioonn,, thereby placciinngg them on the prrooppeerr salarryy steppss,, inn accordannccee witthh thee curreenntt bargainniinngg agreement. AddddiittiioonnaalLlly,, thhee Govveerrnnoorr haass publiclyy expressedd hiiss beliieeff thaatt aa starttiinngg salarryy off $24,5000.,0000 for a Correctiioonn Officeerr iss too loww.. Likewisee,, thee Independdeenntt Monitor overseeinngg complianccee with thee SSeettlement Agreementt hass identifieedd thee staffingg issuuee att Goldeenn Grovvee ass ann “"emergeennccyy”".. Thereeffoorree,, giveenn thaatt thhee tiimmee iiss rippee ffor negotiaattiioonnss oonn aa neeww colleccttiivvee bbaarrggaaiinniinngg agreeeemmeenntt foorr thhee empllooyyeeeess aatt thhee Burreeaauu offCorreeccttiioonnss,, iitt iiss evideenntt tthhaatt aallll ppaarrttiieess arree pprreesseenntteedd wwiitthh aa uunniiqquuee oppoorrttuunniittyy too prrooppeerrllyy adddrreessss tthhee peerrssiisstteenntt conncceerrnnss abboouutt aann apprroopprriiaattee leevveell off ppaarriittyy bbeettwweeeenn tthhee salaarriieess foorr corrrreeccttiioonn offffiicceerrss aanndd otthheerr laaww ennffoorrcceemmeenntt ppeerrssoonnnneell..
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:I-lI4.—.:n3So KI{IIUOoNrPoI;It'IINUDNSmfimNsSs nL.i\oOnE•. GGEEKRSS 1I1liIi.UOO.,., 22NSII)) FFI.IO.OOOHil•. SSTT.. TThUOOM!>AIASS, . UUS.S, .VViW11O01INN ‘ISSIIA.ANNOOfSO (010800022•· ((3:)4.10.0)) 77774·.,.(·I500(0I0•· FFAAXX((n0-4to0)) 7777•I-•1—--00717100 (00 0.10-0 (C‘s.\sSTTuL:I! (COOAAKKlEI.Y CY. · DllrE.sSlIoCl'NO' UCUNHTTEllmi 1f1h,1.l)l0o. ,•· CC[IIIIlIf:IISSTTIIAANSHTTIr.0O, . SSTT.. (C11R0O1 IXX. , IUT.SS. . VVr.i1iIo0i1NS IISfoIO.ls..N ANnOsfil 00008022C)0• ' ((:n1.4I0-o)) ‘7v7s— 3-n0e20or:,0;•· FFAAXX ((o0.i•-.o,0)) 717733—-144221n

Case: 1:86-cv-00265-WAL-GWC Document #: 974-1 Filed: 03/22/16 Page 2 of 2
Letltltter 1to0 Euggetnnet Irish Corrretctlions Officetrs Agretetmtennt
Buureau orf CCoorrrreetciitOioDnSs
rla’age. Z2
of Corrections will be addressed in relation to the Territoryy’'s desire to expeditiously satisfy the terms and conditions of the Settlement Agreement.
In light of the initial financial moves by the Governor, coupled with his intention to demolish and to rebuild some of the housing and related structures at the Golden Grove Facility, the time is now to further accelerate compliance with, and fulfillment of the terms of the Settlement Agreement, and to arrive at a place where the Bureau of Corrections actively protects the constitutional rights of all individuals in its custody. The Attorney General of the Virgin Islands, as a signatory to the Settlement Agreement, remains committed to assuring that all is done for the best interest of the Territory and People of the Virgin Islands. To this end, you may feel free to contact me if you have any concerns or suggestions as to how we can move forward.
La
Claude Earl Walker, Esquire Attorney General

 
 Case: 1:86-cv-00265-WAL-GWC Document #: 979 Filed: 06/01/16 Page 1 of 131
United States Territory of the Virgin Islands Golden Grove Adult Correctional Facility Settlement Agreement
1:86-cv-00265-WAL-GWC

Court-Appointed Independent Monitor’s Eleventh
Compliance Report
Submitted Mary 29, 2016

Dr. Kenneth A. Ray, DBH, MEd Court-Appointed Independent Monitor

Dr. Ronald M. Shansky, MD Corrections Medicine

Mr. Manual D. Romero Corrections Operations &
Safety

Dr. Richard Dudley, Jr., MD Corrections Mental Health

GG!CF Monitor’s Eleventh Compliance Report

Page 1 of 131

Case: 1:86-cv-00265-WAL-GWC Document #: 979 Filed: 06/01/16 Page 2 of 131
United States Territory of the Virgin Islands
 Golden Grove Adult Correctional Facility
 Settlement Agreement

1:86-cv-00265-WAL-GWC
Court-Appointed Independent Monitor’s
 Eleventh 

Compliance Report

Submitted Mary 29, 2016

Dr. Kenneth A. Ray, DBH, MEd
 Court-Appointed Independent Monitor


Dr. Ronald M. Shansky, MD Corrections Medicine

Mr. Manual D. Romero, BS Corrections Operations & Safety

Dr. Richard Dudley, Jr., MD Corrections Mental Health

GG!CF Monitor’s Eleventh Compliance Report

Page 2 of 131

Case: 1:86-cv-00265-WAL-GWC Document #: 979 Filed: 06/01/16 Page 3 of 131
Court-Appointed Independent Monitor’s
 Eleventh Compliance Report

Table of Contents


Contents Cover Pages Table of Contents Purpose & Methods Revise Scorecard & Progress Measurement Brief Summary & Scorecard Agreement Sections & Subsections 1 IV Safety & Supervision…………………………………………………………..
IV.A. Supervision………………………………………………………………. IV.B. Contraband………………………………………………………………. IV.C. General Security………………………………………………………… IV.D. Security Staffing………………………………………………………… IV.E. Sexual Abuse of Prisoners…………………………………………….. IV.F. Classification & Housing……………………………………………….. IV.G. Incidents & Reporting………………………………………………….. IV.H. Use of Force by Staff on Prisoners…………………………………… IV.I. Use of Restraints on Prisoners…………………………………………. IV.J. Prisoner Complaints…………………………………………………….. IV.K. Administrative Investigations………………………………………….. 2 V. Medical & Mental Health………………………………………..……………. 3 VI. Fire & Life Safety……………………………………………………………… 4 VII. Environmental Conditions………………………………………………….. 5 VIII. Training………………………………………………………………………… 6 IX. Implementation………………………………………………………………… 7 X. Monitoring………………………………………………………………………..

Page NA 3 4 5 8
10-131 10 11 18 24 28 31 33 37 40 48 50 53 56 98 106 116 122 125

Appendix A: Assessment Methodology

126

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Case: 1:86-cv-00265-WAL-GWC Document #: 979 Filed: 06/01/16 Page 4 of 131

PURPOSE

The Monitor intends this report to serve three primary goals: 1) assess, measure, and determine progress toward partial and substantial compliance with all provisions of the Settlement Agreement; 2) assess compliance progress relative to previous assessments; and 3) assist U.S. Virgin Island officials in developing action plans to systematically develop, prioritize, implement, and evaluate policies, procedures, and administrative and operational changes and improvements that ensure consistent substantial compliance with the Agreement and the provision of constitutional care and custody of prisoners incarcerated at the Golden Grove Adult Correctional Facility & Detention Center, St. Croix, Virgin Islands.
EXECUTIVE SUMMARY AND ASSESSMENT OVERVIEW
This onsite compliance monitoring assessment was conducted March 14-17, 2016, and included a focused and productive Court status conference, which was held on Thursday, March 17, 2015. Prior to this site visit, the Monitor coordinated communication between the parties and monitoring team in preparation for the onsite assessment.
This Settlement Agreement contains six (6) sections. Each section contains a number of specific and measurable compliance requirements (Provisions). Combined, these six sections contain 133 provisions (sections IV-IX); 123 of these represent five (5) primary substantive sections and their respect sub-sections (IV-VIII), while ten (10) provisions are contained within only one section, Section IX. Implementation. The five substantive sections include:

Agreement Sections & Subsections
1 IV Safety & Supervision IV.A. Supervision IV.B. Contraband IV.C. General Security IV.D. Security Staffing IV.E. Sexual Abuse of Prisoners IV.F. Classification & Housing IV.G. Incidents & Reporting IV.H. Use of Force by Staff on Prisoners IV.I. Use of Restraints on Prisoners IV.J. Prisoner Complaints IV.K. Administrative Investigations
2 V. Medical & Mental Health 3 VI. Fire & Life Safety 4 VII. Environmental Conditions 5 VIII. Training
Total Provisions

Substantive Provisions
61 4 5 5 4 1 6 5 15 6 5 5 36 11 11 4 123

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Case: 1:86-cv-00265-WAL-GWC Document #: 979 Filed: 06/01/16 Page 5 of 131
Each provision of this agreement was evaluated using defined standards stated in Section G. Compliance Assessments. This assessment followed the required protocols and evaluated each provision according to the three standards stated below from the Agreement:
“In his or her reports, the monitor will evaluate the status of compliance for each relevant provision of the Agreement using the following standards: (1) Substantial Compliance; (2) partial compliance, and (3) noncompliance. In order to assess compliance, the Monitor will review a sufficient number of pertinent documents to accurately assess current conditions; interview all necessary staff; and interview a sufficient number of prisoners to accurately assess current conditions. The Monitor will be responsible for independently verifying representations from Defendants regarding progress toward compliance and for examining supporting documentation, where applicable. Each Monitor’s report will describe the steps taken to analyze conditions and assess compliance, including documents reviewed, individuals interviewed, and the factual basis for each of the Monitor’s findings.”
Each provision was evaluated and rated with regard to 1) policy and procedure formulation and 2) implementation. The Monitor and monitoring experts provided recommendations for each provision found not in compliance with the Agreement. A draft assessment report was provided to the Parties for review and comment as required, and reasonable consideration was given to those comments in completing this final report.
The Monitor advances each Provision once substantive progress is clearly demonstrated by the Territory:
1. Policies, procedures, protocols, and/or plans required of a provision are properly approved in accordance with this Agreement;
2. The above documents are promulgated and staff are adequately trained on those documents and related performance expectations; and,
3. Those documents are adequately and effectively implemented. Implementation includes evaluation demonstrating that implemented policies, procedures, and training are measurably performing within the outcome expectations of this Agreement.
A Provision advances from noncompliance to partial compliance when 1) required policies and procedures for the Provision are approved by the Monitor, United States, and the Territory; 2) when 95% of staff required to be trained on the policies and procedures have done so with a minimum passing score of 80%; 3) the policies and procedures are fully implemented, and 4) the Territory objectively and measurably demonstrates implementation effectiveness. A Provision advances from partial to substantial compliance when continued valid and reliable evaluation of implemented policies, procedures, protocols, plans, etc. clearly justifies advancement. Justification is based on quantitative and/or qualitative evidence: 1) that implementation efforts are producing measurable outcomes intended in the Agreement, and 2) that outcome performance is valid and reliable (performance evaluations are likely to produce consistent and sustainable compliance). The entire Agreement is eligible for termination once all provisions have reached and maintained substantial compliance for a minimum of 12 consecutive months. Although this Monitor will not withhold substantial compliance rating where advancement is adequately demonstrated using appropriate compliance evaluation methods and measures, this Monitor will and has reversed a compliance rating when the evidence supports doing so.

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Case: 1:86-cv-00265-WAL-GWC Document #: 979 Filed: 06/01/16 Page 6 of 131

Some Provisions overlap. For example, many medical, mental health, and suicide prevention Provisions involve independent compliance assessment and scoring by both of the Monitor’s medical and mental health experts. Such Provisions are advanced to the next level when both experts advance the Provision. The Provision, however, remains at the lowest compliance score when the experts’ scores differ.
Revised Compliance Scorecard:
As “scorecard” has been used since the 2013 Baseline assessment to numerically measure compliance progress. A revised scorecard is used for this and future reports. The scorecard will use a point system and color-coding to represent the Monitor’s compliance ratings as defined in this Agreement. The three defined compliance ratings are assigned a point value and color to more accurately measure and visualize compliance progress toward dismissal of the Agreement. The chart below shows point values and color-codes used for each compliance rating required under this Agreement.

Non-

Non-compliance indicates that Defendants have not met most

Compliance or all of the components of the Agreement

Red

0

Partial Compliance

Partial Compliance indicates that Defendants achieved compliance on some of the components of the relevant provision of the Agreement, but significant work remains.

Yellow 1

Substantial Compliance

Substantial Compliance indicates that Defendants have achieved compliance with most or all components of the relevant provision of the Agreement.

Green 2

Sustained Compliance

Sustained compliance is not defined in the Settlement Agreement per se. It is used to rate a Provision that has maintained Substantial Compliance for one (1) year, 12 consecutive months. The Agreement shall terminate when Defendants achieve Substantial Compliance with all substantive provisions of this agreement and maintain that compliance level for one (1) year, 12 consecutive months.

Blue 3

Additionally, a re-audit of the Agreement determined there are 123 substantive provisions versus 120 as previously report. The monitoring team has assessed and reporting on all provisions; this Monitor inadvertently combined three provisions and simply miscounted the number of provisions.

Measuring Progress toward Dismissal of the Agreement

The new scorecard is used in other CRIPA cases by this Monitor and has shown to be very effective for simply and accurately tracking and visualizing compliance progress for dismissal purposes. Defendants and plaintiffs in similar CRIPA cases found this method helpful for self-

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monitoring their progress and compliance status. The United States accepted this method and continues to use it in one case in which this Monitor manages.
There are 123 substantive provisions in this Agreement. The agreement can be dismissed once all 123 provisions have reached and maintained Substantial Compliance for 12 consecutive months (one year). Each compliance rating is assigned a point value to measure progress toward dismissal:
 NonCompliance – 0 Points  Partial Compliance – 1 Point  Substantial Compliance – 2 Points  Sustained Compliance – 3 Points (a provision has maintained Substantial Compliance for 12
consecutive months)
Dismissal of the Agreement, therefore, requires achievement of 369 points (Sustained Compliance (3 points) for each of the 123 substantive provisions (3 points x 123 provisions = 369 points). The scorecard advances or regresses as compliance improves or declines. The example below is shown for the four (4) Supervision section (IV.A.1-4) provisions. Assessment reports one (1) thru 11 are shown horizontally above provision-ratings and color-coding. The number of provisions in each of the four (includes Sustained Compliance) is shown to track progress from report to report. “Progress Points” are the sum of points using the numeric rating method. Finally, the bottom row shows the percentage of provisions that remain in NonCompliance.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.A. Supervision

1 2 3 4 5 6 7 8 9 10 11

1 IV. A1a: Unit Security Stratification & Management

00 0 0 0 0 0 0 0 0 0

2 IV. A1b: Post Orders & Unit Office/Supervisor Staffing

00 0 0 0 0 0 0 0 0 0

3 IV. A1c: Officer Communications

00 1 1 1 1 1 1 1 1 1

4 IV. A1d(i,ii) Security Rounds All Units & Areas

00 0 0 0 0 0 0 0 0 0

# NonCompliance 4 4 3 3 3 3 3 3 3 3 3

# Partial Compliance 0 0 1 1 1 1 1 1 1 1 1

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 1 1 1 1 1 1 1 1 1

Percent Out of Noncompliance 0% 0% 25% 25% 25% 25% 25% 25% 25% 25% 25%

A similar scorecard is included herein to track and visualize compliance progress of the Agreement, each section and subsection. Graphs will be included in future reports to improve progress visualization.

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Eleventh Assessment Brief Summary
Eleventh Summary & Scorecard
Four (4) Medical/Mental Health provisions advanced from NonCompliance to Partial Compliance as a result of this assessment findings. These provisions include:
1. V.1c: Defined Timely Access/Provision Adequate M/MH Care. 2. V.1d(i,ii,iii, iv): Timely RX Orders & Labs, Timely & Routine Physician Review of RX & Clinical
Practices, Qualified Review of RX for Side Effects, Qualified Review of RX for Side Effects. Sufficient RX Upon Discharge for Serious M/MH Needs. 3. V.1f (iii): Appropriate/Timely Chronic/Acute Care/Follow-up w/Clinical Practice Guidelines. 4. V.1f (iv) (1, 2, 3): Adequate Provision of Emergency Care, Defined Emergency Care Training for Staff.
There was no change in the compliance ratings for all other provisions. This is primarily due to the fact that none of the security-related and operational policies and procedures have been officially approved and implemented by the Territory, but much progress has be made to do so. Currently, virtually all of these policies have been either approved by this Monitor and the United States or are in that process. Additionally, the Territory has selected a well-qualified contractor to develop and implemented the required training curricula for these policies and procedures. This progress is very promising and clearly demonstrates the Territory’s commitment to complying with agree in this regard.
However, and not withstanding this progress, assessment of several medical provisions were found to have regressed somewhat but compliance ratings but will not be decreased for this assessment period. This regression results from two specific causes. First, nurse staff levels declined since the previous assessment and second, the medical director has developed and maintained positive or functional collaboration among and between health care staff and other health care leaders. Combined, these two issues have impaired medical progress and can ultimately result in decreases in several medical ratings if not corrected quickly.
The new Governor, BOC Director and GGACF leadership seem very determined to make the necessary improvements to comply with this agreement. For example, the Governor recently authorized salary increases for all correctional officers and supervisors. A systematic process for implementing these increases is currently underway. This action can improve GGACF staff recruitment and retention while renewing incumbent staff esprit de corps.

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Scorecard

Twenty-three (19%) of the 123 provisions and 14 (39%) of the medical provisions have advance out of NonCompliance; all 23 are in Partial Compliance. Progress toward dismissal of the Agreement is now at 6%, up from 5%.

Agreement Substantive Sections

Compliance Assessment Report Number & Scores

Total Pr ovis ions

1

2

3

4

5

67 8

9

10

IV. Safety & Supervision

61

0 7 8 8 7 643 3 3

V. Medical & Mental Health

36

0 0 0 0 0 0 0 0 0 10

VI. Fire & Life Safety

11

0 0 0 0 0 000 0 0

VII. Environmental Health & Safety

11

0 3 6 5 6 666 6 6

VIII. Training

4

0 0 0 0 0 000 0 0

Agreement Total Provisions: 123

Total Compliance Points Gained: 0 10 14 13 13 12 10 9 9 19

Percent Out of NonCompliance:

0% 8% 11% 11% 11% 10% 8% 7% 7% 15%

Percent Toward Agreement Dismissal: 369

0% 3% 4% 3% 3% 3% 3% 2% 2% 5%

11
3 14 0 6 0
23 19% 6%

A large increase in measurable progress is anticipated once all provisions have been reliably implement.

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COURT-APPOINTED INDEPENDENT MONITOR’S
 ELEVENTH (11th) COMPLIANCE REPORT 

GOLDEN GROVE ADULT CORRECTIONAL FACILITY
 UNDER DEPARTMENT OF JUSTICE AGREEMENT

IV. SAFETY AND SUPERVISION

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV. Safety & Supervision

Total
Provisions 1 2 3 4 5 6 7 8 9 10 11

1 IV.A. Supervision

4

0 0 1 1 1 111 1 1 1

2 IV.B. Contraband

5

0 3 3 3 3 322 2 2 2

3 IV.C. General Security

5

0 0 0 0 0 000 0 0 0

4 IV.D. Security Staffing

4

0 0 0 1 1 100 0 0 0

5 IV.E. Sexual Abuse of Prisoners

1

0 0 0 0 0 000 0 0 0

6 IV.F. Classification & Housing

6

0 0 2 2 1 110 0 0 0

7 IV.G. Incidents & Referrals

5

0 1 1 1 1 000 0 0 0

8 IV.H. Use of Force on Prisoners

15

0 2 1 0 0 000 0 0 0

9 IV.I. Use of Restraints on Prisoners

6

0 0 0 0 0 000 0 0 0

10 IV.J. Prisoner Complaints

5

0 0 0 0 0 000 0 0 0

11 IV.K. Administrative Investigations

5

0 1 0 0 0 000 0 0 0

Total Provisions: 61

# NonCompliance

61 54 53 53 54 55 57 58 58 58 58

# Partial Compliance

0 7 8 8 7 643 3 3 3

# Substantial Compliance

0 0 0 0 0 000 0 0 0

# Sustain Compliance Progress Points
Percent Out of Noncompliance 0%

0 0 0 0 0 000 0 0 0 0 7 8 8 7 643 3 3 3 0% 11% 13% 13% 11% 10% 7% 5% 5% 5% 5%

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Substantive Provisions:
As required by the Constitution, Defendants will take reasonable steps to protect prisoners from harm, including violence by other prisoners. While some danger is inherent in a jail setting, Defendants will implement appropriate measures to minimize these risks including development and implementation of facility-specific security and control related policies, procedures, and practices that will provide a reasonably safe and secure environment for all prisoners and staff.

IV.A. Supervision

Progress Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the four (4) provisions in this section of the Agreement. However, the Territory is commended for not losing Partial Compliance progress nine (9) consecutive assessments for provision A1c; 25% of this section remains out of NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

IV.A. Supervision

1 2 3 4 5 6 7 8 9 10 11

1 IV. A1a: Unit Security Stratification & Management

00 0 0 0 0 0 0 0 0 0

2 IV. A1b: Post Orders & Unit Office/Supervisor Staffing

00 0 0 0 0 0 0 0 0 0

3 IV. A1c: Officer Communications

00 1 1 1 1 1 1 1 1 1

4 IV. A1d(i,ii) Security Rounds All Units & Areas

00 0 0 0 0 0 0 0 0 0

# NonCompliance 4 4 3 3 3 3 3 3 3 3 3

# Partial Compliance 0 0 1 1 1 1 1 1 1 1 1

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 1 1 1 1 1 1 1 1 1

Percent Out of Noncompliance 0% 0% 25% 25% 25% 25% 25% 25% 25% 25% 25%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding supervision of prisoners. These policies will include measures necessary to prevent prisoners from being exposed to an unreasonable risk of harm by other prisoners or staff and must include the following:

a. Development of housing units of security levels appropriately stratified for the classification of the prisoners in the institution, see also Section IV.F. re: Classification and Housing of Prisoners;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory. These policies and procedures well articulate protocols for protecting GGACF prisoners. Successful implementation of these policies and procedures, and achieving their desired outcomes, will ultimately be affected by several factors. These factors include 1) adequate housing and campus security post coverage, 2) timely replacement and repair non-functional locking mechanisms, gate, and doors, 3) implementation

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of consistent, thorough, and routine prisoner and facility searches, 4) timely replacement of electronic security-breach detection systems (i.e. metal detectors), 5) timely, reasonable, and consistent monitoring and supervision of staff compliance with these policies and procedures by GGACF leadership.

Housing stratification is specified in the Classification section and related policies and procedures; Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.

Preventing and controlling unreasonable risk of harm by other prisoners requires GGACF officials to timely detect and prevent overt harmful actions and prisoner neglect. Overt harmful actions by other inmates and staff can involve intentional acts as well as unintentional acts, such and officer failing to properly apply restraints. Prisoner neglect specifically applies to corrections staff who intentionally or inadvertently fail to provide adequate security, care, and/or custody of the general population and special needs/vulnerable populations. For example, GGACF continues to isolate mentally ill prisoners, albeit, considerable progress has been made to increase the health monitoring of this population by GGACF mental health staff. However, these prisoners continue to languish in very dark cells with very little out-of-cell time and positive social interactions. High temperatures in these housing units are contraindicated for certain prescribed psychotropic medications and can create serious health risks for this population. Other examples come from examination of incident reports and logs for December 1, 2015 to March 26, 2016. The BOC Director has selected a vendor to install exhaust fans in the housing to mitigate this environmental concern; the contracting process is currently underway.

Incident reports and logs for this time period clearly demonstrate an urgent need to implement these and other security-related policies and procedures without unreasonable delay. The following safety and security problems reported by this Monitor in previous reports remain a serious and troubling concern per the incident reporting period examined:

 Prisoner threats and assaults of officers  Prisoner-on-prisoner assaults and fights  Door lock tampering by prisoners  Continue presence of dangerous contraband in housing units and cells  Prisoner drug trafficking

Although the movement of some 100 prisoners off-island may somewhat mitigate these high-risk safety and security problems, the concomitant redeployment of security staff cannot substitute for full and consistent implementation of these and the approved classification policies and procedures.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Train staff on approved policies and procedures.

2. Implement policies and procedures.

3. Identify appropriate alternatives to implement and maintain compliant classification and housing stratification practices.

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4. Increase staffing. 5. Ensure adequate and routine monitoring of housing units by shift supervisors.

b. Post orders and first-line supervision of corrections officers in each housing unit (at least one officer per unit) based on an assessment of staffing needs;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.

No post orders were provided to demonstrate compliance with this provisions.

Daily supervisor logs, shift rosters, overtime reports, and supervisor facility inspection documents are used by this Monitor to assist in the assessment of compliance with this provision. These documents record 1) the number of correctional staff working per day per shift and the post they worked, 2) the names and number of security staff and supervisors working overtime per shift, and 3) facility inspections conducted by supervisors per shift. The Territory had not consistently submitted all documents for routine monitoring prior to November 2015 as requested. An audit of document submissions for January 2015 through March 2016 found that 99.6% of the documents were submitted. The table below of audit results from November 2016 thru March 2016 indicated continued positive improvement in the submission of these documents.

Monthly Shift Rosters Sets Audit

Year / Month 2015

2016

Shift Rosters

Nov Dec Jan

Feb

1st Shift ( 10p-6a) 93% 100% 100% 100%

2nd Shift (6a-2p) 97% 100% 100% 97%

3rd Shift ( 2p-10p) 100% 100% 100% 100%

Score 97% 100% 100% 99%

Over- Time Report

1st Shift ( 10p-6a) 90% 100% 100% 100%

2nd Shift (6a-2p) 97% 100% 100% 97%

3rd Shift ( 2p-10p) 100% 90% 100% 100%

Score 96% 97% 100% 99%

Supervisor

Inspection Report

1st Shift ( 10p-6a) 93% 100% 100% 100%

2nd Shift (6a-2p) 97% 97% 100% 97%

3rd Shift ( 2p-10p) 100% 97% 100% 100%

Score 97% 98% 100% 99%

GGACF Score 96% 98% 100% 99%

Standard: 100%

Mar 100% 100% 100% 100%
100% 100% 100% 100%
100% 100% 100% 100% 100%

Score 100% 99% 100% 99.6%
100% 99% 100% 99.6%
100.0% 98.9% 100.0% 99.6% 99.6%

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Correctional officer overtime needed to cover all three shifts at GGACF remained extremely high for January thru most of March 2016. As previously reported, overtime was documented for all days during each month with approximately 26 officers working overtime per day November 2015 thru the first week of March 2016. The average number of officers working overtime per shift was approximately 8 for this period. However, this trend began to decline beginning the second week of March 2016 with approximately 16 officers working overtime per day and 5.5 per shift. Shift supervisor logs continue to report severe staff shortages during these periods. Supervisor overtime showed no significant change since the previous report; supervisor overtime was documented for most days January thru March 2016. The chart below show correctional officer and supervisor trends for November 2016 through March 2016.

GGACF Analysis of CO & Supervisor Overtime Use November 2015 thru March 2016

Year

Month

Da ys i n Month

Da ys Per Month COs Worked OT

Avg Num COs Worki ng OT
Per Da y

Avg Num COs Worki ng OT
Per Shi ft

Da ys Per Month Supervi s ors Worked OT

Avg Num Avg Num Supervi s ors Supervi s ors Worki ng OT Worki ng OT
Per Da y Per Shi ft

2015 Nov 30

30

25.52

8.47

Dec 31

31

25.68

8.48

2016 Jan 31

31

26.90

8.97

Feb 29

29

25.83

8.61

Mar 31

31

18.61

6.20

27

1.85

0.56

29

1.55

0.49

24

1.63

0.42

24

1.29

0.36

25

1.60

0.43

Overtime Use Graphs

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GGACF leadership is encouraged to continue monitor and improve overtime usage and security staffing levels very closely and continuously for staff and prisoner health and safety reasons.

RECOMMENDATIONS:

1. Use a standardized Shift Roster form that includes ALL locations and designate “CLOSED” for all locations that are out of service.

4. Ensure timely and continuous implementation of the staffing plan and staff salary increases.

5. Cease the practice of allowing staff to work high amounts of overtime and ensure that staff working overtime have adequate time away from the facility before returning to work to ensure they are adequately rested.

6. Fast-track completion and implementation of the training plan and policies.

7. Seek Court relief to remove any barriers to rapid remediation of facility safety and security deficiencies that expose people to harm.

8. Subsequent to policy and procedure development and revisions, conduct a complete review of existing specific and general post orders to ensure they are: a. post specific; b. accurately represent post staffing needs and post resources needed to operate the post safely and consistently; c. are numbered, cross-referenced with policies/procedures and formatted in a manner that makes them easy to interpret and apply; d. maintained at each post, kept current, and easily accessible; e. regularly reviewed, revised, updated; f. consistently enforced; g. known to staff through preservice, in-service, and ongoing training.

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9. Develop a plan that provides for regular review of all log books by supervisors to ensure staffing and other unit safety and security issues are detected and resolved in a timely manner.
10. Ensure that all posts are staffed according to post complexity and dynamics, risks and needs.
11. GGACF upper management must monitor compliance with any written instructions to subordinate supervisors if compliance with such orders are expected to be followed.
12. Create and implement a single standardized shift staffing form for supervisors to accurately record shift staffing levels.

c. Communication to and from corrections officers assigned to housing units (i.e. functional radios); and
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Working portable radios were found in each occupied housing unit and with each field officer. However, a few shift supervisor inspection records reported a radio missing that was ultimately replaced. Supervisors are commended for their attention and reporting of these deficiencies.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement the approved policies and procedures.
2. Timely repair and replace nonfunctioning radio and telephone communications equipment throughout the facility, and add additional communications equipment where indicated.
3. The Monitor will continue to review radio equipment inventories and functionality during each onsite assessment.
4. Ensure adequate supply of radio batteries to enable officers to carry radios on their person at all times. The GGACF Warden did issue written directives to all staff requiring compliance with this recommendation.
5. Ensure all persons carrying radios are fully trained to understand and operate all radio functions proficiently.

d. Supervision by corrections officers assigned to cellblocks, including any special management housing units (e.g., administrative or disciplinary segregation) and cells to which prisoners on suicide watch are assigned, including:
(i) conducting of adequate rounds by corrections officers and security supervisors in all cellblocks; and,

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(ii) conducting of adequate rounds by corrections officers and security supervisors in areas of the prison other than cellblocks.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As discussed above. Staffing levels remain inadequate to consistently protect inmates from harm as defined previously.
RECOMMENDATIONS:
1. Refer to recommendations regarding Post Orders.
2. Ensure housing units and cell blocks are consistently staffed at levels required to ensure staff and inmate safety and security, and according to inmate risks and needs.
3. Monitor and ensure continuation of scheduled RNs rounds twice per week; QMHS round once per week.
4. Create a schedule for supervisory rounds by shift to ensure that supervisors routinely inspect general and special housing units to ensure compliance staffing requirements, policy and procedures, and to interview inmates presenting problem conditions. Supervisors should also ensure that all safety and security equipment is present and functional during these inspections and immediately replace any nonfunctional equipment. The supervisory rounds forms should be filled out at the end of each round and collected in a central location and submitted to the Monitor and USDOJ on a monthly basis.
5. Repair all broken lights in housing units and cells, issue flashlights to staff for cell inspections, keep all housing unit doors locked, repair broken control panels to improve unit security.

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B. Contraband

Progress Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the five (5) provisions in this section of the Agreement with three of the five (40%) provisions in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.B. Contraband

1 2 3 4 5 6 7 8 9 10 11

1 IV. B1a: Clear Definitions of Contraband

01 1 1 1 1 0 0 0 0 0

2 IV. B1b: Prevention of Introduction

00 0 0 0 0 0 0 0 0 0

3 IV. B1c(i,ii,iii): Prisoner Supervision, Prisoner Searches, Physical Areas Searching

00 0 0 0 0 0 0 0 0 0

4 IV. B1d: Confiscation, Preservation, Destruction

01 1 1 1 1 1 1 1 1 1

5 IV. B1e: Admission and Escorts of Visitors

01 1 1 1 1 1 1 1 1 1

# NonCompliance 5 2 2 2 2 2 3 3 3 3 3

# Partial Compliance 0 3 3 3 3 3 2 2 2 2 2

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0 Progress Points 0 3 3 3 3 3 2 2 2 2 2
Percent Out of Noncompliance 0% 60% 60% 60% 60% 60% 40% 40% 40% 40% 40%

Substantive Provisions:

1. Defendants will develop and submit to the USDOJ and the Monitor for review and approval facility-specific policies regarding contraband that are designed to limit the presence of dangerous material in the facility. Such policies will include the following:

a. Clear definitions of what items constitute contraband;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been partially completed and approved by this Monitor, the United States, and the Territory. Final resolution of prisoner access to local newspapers is near conclusion. Initially, the Territory opposed allowing prisoner access to the local newspaper due security concerns and imposed a unilateral ban of local newspapers for prisoners. The BOC Director indicated that BOC prisoners can and have used information gained from the local newspaper to maintain awareness of gang activity and criminal charges of other prisoners. This concern is legitimate as it is well known in the corrections industry that prisoners will use information gained from local newspapers for clandestine, sometimes dangerous, purposes. However, the United States rightfully apposed this ban cited constitutional issues prohibiting such a ban.

On April 7, 2016, a conference call was held with the parties and this Monitor. Following a healthy debate and discussion on this issue, the BOC Director proposed policy language intended resolve this matter. The BOC Director has agreed to allow prisoner access to local newspapers under a structured and tightly controlled process. This matter appears to have been amicably resolved between the parties pending final acceptance of the revised policy by this Monitor and the United States.

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Notwithstanding ongoing contraband document quality problems discussed in the previous report, the presence of dangerous and nuisance contraband remains high. Examination of contraband confiscation documents provided by the Territory for December 2015 through March 2016 demonstrate that dangerous and nuisance contraband continues enter the facility and into the hands of prisoners. Data abstracted from confiscation documents suggest a reduction in the volume of contraband, but these data can be positively misleading due to document quality issues and the frequency of facility searches by housing unit officers and the GIST team. No facility or housing unit search activities were observed by the monitoring team during this visit. GIST staff interviewed stated that organized searches are random and occur once or twice monthly. Additionally, current housing unit staffing levels are inadequate to perform routine searches on prisoner cells or prisoners entering and exiting the housing units consistently. Additionally, housing officers are not adequately equipped with electronic metal detection devices to scan prisoners and are, therefore, left to conduct pat-down searches. Pat-down searching is a basic tactic for detecting contraband but is inadequate as the sole method for preventing contraband from entering housing units. The Territory should purchase and distribute at least one electronic hand-held metal detector in each housing unit (not building).
The chart below shows the number of different contraband items confiscated at GGACF for the time periods shown.

Year

Month

Drug

Unauthorized

Handcuff

Weapons Cell Phones Drugs Paraphernalia Alcohol

Electronics & Tools

Money

Key

Tobacco

Ttl

2015 January

3

2

3

1

1

10

February

3

2

2

1

3

2

13

March

7

8

2

2

1

1

1

22

April

2

8

1

1

1

5

18

May

1

1

June

8

8

2

1

19

July

1

1

August

4

6

2

1

1

14

September

2

2

1

5

October

1

2

3

November

7

1

8

December

4

1

6

11

2016 January

6

6

2

3

17

February

1

4

1

6

March

2

4

1

7

Totals: 33

63 19

6

2

13

10

1

5

148

% Seizures

22% 43% 13% 4%

1%

9%

7% 1% 3% 100%

These data suggest that first quarter reported contraband confiscations decreased by a third (15 items) from 2015 to 2016 (45 to 30 respectively). This quarterly comparison is shown in the table below.

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Year

Month

2015
Total 2016
Total

January February March
January February March

Weapons Cell Phones Drugs

Drug

Alcohol

Unauthorized Electronics &

Money Handcuff Tobacco

Ttl

Paraphernalia

Tools

Key

3

2

3

1

1

0

0

0

0

10

3

2

2

1

3

2

0

0

13

7

8

2

0

0

2

1

1

1

22

13

12

7

2

1

5

3

1

1

45

6

6

2

0

0

0

0

3

17

1

4

0

0

1

0

0

0

6

2

4

1

0

0

0

0

0

0

7

3

14 7

2

0

1

00

3 30

There appears to be increases, decreases, and no change in reported contraband confiscations of the items included in this assessment. Most notable is a significant decrease in weapons confiscated (2015, 13; 2016, 3). Other decreases in items confiscated include alcohol (none for 2016), unauthorized electronic devices (5 to 1), money (3 to 0), and handcuff key (1 to 0). There were increases in confiscations of cell phones (12 to 14), and tobacco (1 to 3). No change was reported in drugs confiscated (7 and 7) or drug paraphernalia (2 and 2 items). The graph below illustrates these findings.

Confidence in the veracity of these findings relies patently on the accuracy of reporting and the quality of the reports, both of these conditions remain in question. Additionally, improvement in contraband control at GGACF cannot be inferred by these findings due to reported infrequency of facility and prisoner searches. Nonetheless, these findings seem promising. It is likely that the presence of dangerous and nuisance contraband will be legitimately decreased once housing unit

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staff levels are consistently adequate, staff are trained on these policies and procedures, and supervisors consistently monitor staff to ensure compliance with the policies and procedures.
RECOMMENDATIONS:
1. Implement the new policy according to the terms of this Agreement, once approved.
2. Ensure supervisors comply with supervision rounds requirements.
3. Ensure corrections officers comply with contraband control and related security policies and protocol.
b. Prevention of the introduction of contraband from anyone entering or leaving Golden Grove, through processes including prisoner mail and package inspection and searches of all individuals and vehicles entering the prison;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As discussed above
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement the new policy and procedures.
2. Ensure supervisors comply with supervision rounds requirements.
3. Ensure corrections officers comply with contraband control and related security policies and protocol.
4. Continue positive efforts in searching people before entering the facility.
5. A “stop and check” protocol for inspecting staff packages after initial entry into the facility must be developed and implemented.
6. Provide handheld metal detectors for contraband inspections at facility entry points and as needed for on-campus inspection.
7. Be prepared to thoroughly discuss current vehicle, mail, and package inspection methods and process during the 11th onsite tour and assessment.
8. Train supervisors to provide on-the-job training (OJT) and staff mentoring in the areas of adequate searches, contraband prevention and control, and basic inmate supervision and security.

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c. Detection of contraband within Golden Grove, through processes including:
(i) supervision of prisoners in common areas, the kitchen, shops, laundry, clinical and other areas of Golden Grove to which prisoners may have access;
(ii) pat-down search, metal detector, and other appropriate searches of prisoners coming from areas where they may have had access to contraband such as intake, returning from visitation or returning from the kitchen, shops, laundry or clinic;
(iii) regular and random search of physical areas in which contraband may be hidden or placed, such as cells and common areas where prisoners have access (e.g. clinic, kitchen, dayrooms, storage areas, showers);
ASSESSMENT: NONCOMPLIANCE

FINDINGS: As discussed above.

RECOMMENDATIONS: Previous recommendations remain appropriate.

1. Refer to above, expand application of recommendation to provision c (i-iii) above.
2. See recommendations regarding staffing levels.
3. Ensure inmates are systematically and consistently searched each time they enter and exit maintenance shop areas, kitchen areas, and any area and/or building containing items that can be used as contraband.
4. Always search prisoners each time they enter and exit housing units.
5. Always search all containers entering and exiting the facility, buildings, and housing units.
6. Develop a structured contraband confiscation tracking system routinely assess and monitor confiscations by location, time, date, housing classification, and person.

d. Confiscation and preservation as evidence/destruction of contraband; and

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: As discussed above. Additionally, GGACF management should regularly review the quality and accuracy of contraband confiscation document. As stated in previous reports, the location of the contraband confiscation should be records on the monthly confiscation log.

Additionally, collection and preservation practices are somewhat lax and absent chain of custody protocols to ensure evidence integrity. This possess significant issues for maintaining reliable security and control over seized evidence and contraband needed for reliable criminal and/or prisoner disciplinary purposes. For example, there is no central collection box for such items with custody control protocols. All evidence/contraband seized should be properly marked, bagged,

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boxed and tagged. Standard evidence bags for marking items should be used to properly mark and seal all items that can be bagged.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Review and implement relevant recommendations for Contraband above, specifically B1b.
2. Implement a continuous quality improvement program (CQI) for the Evidence Log to ensure the record is valid, reliable, and supports effective compliance monitoring.
3. Evidence collection and preservation elements of the new policy can be implemented to resolve the issues described above.
4. Obtain standard evidence collection bags/containers.
e. Admission procedures and escorts for visitors to the facility.
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: There seemed to be improvement in access security at the lobby entrance. One officer staffed the desk while another officer searched visitor bags and possessions. However, one officer reported that the walk-through metal detector and X-ray machined were not reliably functional. This is problematic and should be corrected immediately. These are essential security management devices that should consistently remain in good working order and back-up devices should be purchased and available during repair periods to ensure security continuity.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Continue to ensure timely and consistent escorts for the monitoring team and USDOJ officials during all onsite visits.
2. Continue to maintain adequate supplies of visitor identification cards and ensure that all visitors conspicuously wear badges at all times while inside the security perimeter.
3. Implement document quality improvement protocols to improve reliability of the two supervisor reporting systems used for this assessment to aid in demonstrating compliance.
4. Ensure all electronic security-breach detection devices are consistently reliable as indicated above.

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IV.C. General Security

Progress Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the five (5) provisions in this section of the Agreement; all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions IV.C. General Security

Compliance Assessment Report Number & Scores 1 2 3 4 5 6 7 8 9 10 11

1 IV. C1a: Authorized Prisoner & Staff Clothing

00 0 0 0 0 0 0 0 0 0

2 IV. C1b: Prisoner, Staff, Visitor Identification

00 0 0 0 0 0 0 0 0 0

3 IV. C1c: Locking & Unlocking Gates & Doors

00 0 0 0 0 0 0 0 0 0

4 IV. C1d: All Locks Inspections & Maintenance

00 0 0 0 0 0 0 0 0 0

IV. C1e: Staff Preemployment Checks, Tracking, Supervisor

5 Review of Records

00 0 0 0 0 0 0 0 0 0

# NonCompliance 5 5 5 5 5 5 5 5 5 5 5

# Partial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies designed to promote the safety and security of prisoners and that include the following:

a. Clothing that prisoners and staff are required or permitted to wear and/or possess;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Prisoner clothing is adequately addressed in part in the approved Inmate Clothing, Bedding and Linen supplies.

Many of the prisoners were wearing what appeared to be new uniforms. However, some prisoners continue to wear what appears to be personal or “street” clothes in the housing units. The BOC Director stated that prisoners are allowed to wear only BOC issued prison attire; he also stated that he is replenishing prisoner uniforms to ensure compliance with this provision and timely exchange of prisoner uniforms during laundering of the uniforms. Progress toward compliance with this provision appears positive. Progress toward compliance also appears positive as all onduty staff observed by this Monitor wore official GGACF attire. Partial Compliance with this provision is likely once the policies and procedures have been implemented and an adequately compliance evaluation determines that staff application of these policies is consistent.

RECOMMENDATIONS:

1. Require inmates to wear issued institutional clothing ONLY.

2. Take timely and appropriate corrective action with staff who fail to enforce inmate uniform policies and inmates who refuse to comply with those policies.

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3. Ensure that all staff wear their required GGACF uniform at all times, and take timely and appropriate corrective action with staff who refuse to do so.
4. Consider acquiring correctional apparel that provides obvious recognition of the inmates’ classification/status.
5. Ensure there is a consistently sufficient supply of uniforms for regular laundry exchanges and changes in an inmate’s classification and/or status.
6. Consider developing a correctional industry for making uniforms onsite.
7. Select/make uniforms specifically designed to reduce/eliminate places to hide contraband and weapons.
8. Mark all uniforms with highly visible letters/numbers.
b. Identification that prisoners, staff, and visitors are required to carry and/or display;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This Monitor observed no prisoner wearing their official identification cards during this visit. The monitoring team was required to turn-over their driver’s licenses in exchange for GGACF visitor ID each day of the visit.
RECOMMENDATIONS:
1. Ensure staff compliance with this provision.
2. Ensure prisoners comply with this provision.
3. Ensure adequate supplies for making identification cards.
4. Regularly audit identification card inventory and maintain proper controls to prevent inappropriate acquisition of cards. Conduct regular “identification card counts” using methods similar to key control inventories.
5. Consistently enforce identification card policies and procedures. c. Requirements for locking and unlocking of exterior and interior gates and doors, including doors to cells consistent with security, classification and fire safety needs;
ASSESSMENT: NONCOMPLIANCE – Noted some improvement from previous assessment.
FINDINGS: Ongoing lack of adequate facility maintenance staff and timely access to repair and replacement parts continues to create substantial barriers for improvement in progress. Examination of shift supervisor inspection records for this assessment period report inoperable security doors and gates.

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RECOMMENDATONS: Previous recommendations remain appropriate.
1. Repair/replace all broken locks and keys.
2. Develop, revise, implement, and audit lock/key inventory.
3. Regularly inspect keys, locks, and electronic locking systems to ensure reliable functionality, detection of tampering, and timely repair/replacement.
4. Continue to ensure staff are adequately trained in the proper use of mechanical and/or electronic locking systems according to their post assignments.
5. Consistently sanction inmates for attempting to manipulate or manipulating any security locking system or device.
6. Secure access to keys and electronic locking control panels.
7. Keep security doors locked.
8. Replace or upgrade existing unit control panels to provide for remote electronic locking and unlocking of unit and cell doors.
9. Improve video surveillance of internal areas by placing cameras in all housing units and inmate locations, and add additional cameras to monitor external access points to ensure rapid detection of attempts to disable or damage locking devices/systems.
11. Increase perimeter and internal lighting to improve detection of sabotage to locking devices and mechanisms.
12. Supervisor should inspect all locking systems during each shift and report for investigation and/or repair any signs of lock disrepair, malfunctioning, or manipulations.
d. Procedures for the inspection and maintenance of operational cell and other locks in Golden Grove to ensure locks are operational and not compromised by tampering; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory
Refer to previous discussions regarding housing unit staffing levels and overtime regarding the Territory’s abilities and progress toward ensuring housing unit security locking mechanisms.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement approved policies and procedures.
2. Ensure correctional officer and supervisor staffing levels are adequate to regularly and routinely assess and monitor security locking functionality.
3. Employ and maintain adequate Maintenance staffing levels.
4. As requested in the previous two reports, develop an “all locks” maintenance plan for review by the Monitor and for incorporation into policies and procedures. The plan should include a complete inventory of all locks, locking mechanisms, date lock found nonfunctional, date of repair/replacement was completed, and a list of all locks and locking systems taken offline. The plan should include, at a minimum, the following elements and should use an Excel spreadsheet: Where the lock is specifically located (Perimeter gate, housing unit 9A, cell #, emergency door, etc.) and lock number, lock type, condition, etc.
e. Pre-employment background checks and required self-reporting of arrests and convictions for all facility staff, with centralized tracking and periodic supervisory review of this information for early staff intervention.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: This provision was not assessed during the previous visit but will be during the June 2016 onsite assessment.
RECOMMENDATIONS:
1. The employee folder/record system should be standardized and well-organized.
2. All folders should contain completed Applicant Personal History Statements, criminal history check verification documents.
3. Medical records should be kept separately from the general personnel folder.
4. Training records should be kept in a staff training folder and separate from the training folder. These records should be reviewed periodically for quality assurance purposes and remedial instruction and/or training provided to records staff where indicated.

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IV.D. Security Staffing

Progress Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the four (4) provisions in this section of the Agreement. This scorecard is expected to substantively improve upon full implementation of these provisions.

IV.D. Security Staffing

1 2 3 4 5 6 7 8 9 10 11

1 IV. D1a: Staffing Analysis w/Realistic Shift Factor

00 0 1 1 1 0 0 0 0 0

2 IV. D1b: Staffing Analysis-Based Staffing Plan w/Timetables

00 0 0 0 0 0 0 0 0 0

3

IV. D1c: Periodic Review & Amending of Staffing Analysis & Staffing Plan

00 0 0 0 0 0 0 0 0 0

4 IV. D2: Staffing Plan Implementation

00 0 0 0 0 0 0 0 0 0

# NonCompliance 4 4 4 3 3 3 4 4 4 4 4

# Partial Compliance 0 0 1 1 1 1 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 1 1 1 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 25% 25% 25% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies and a staffing plan that provides for adequate staff to implement this Agreement, as well as policies, procedures, and practices regarding staffing necessary to comply with the Constitution that include the following:

a. A security staffing analysis, incorporating a realistic shift factor for all levels of security staff at Golden Grove;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: On March 17, 2016, the court instructed the Territory to file a completed Staffing Plan by April 7, 2016. The Plan was filed as directed by the court, document #976. Additionally, the court instructed the Territory to include in the Plan specific timelines for the authorization and implementation of salary increases for custody staff, which is shown on page six of the Plan. This Monitor considers the file Plan complete and, therefore, approves the Plan for demonstrating progress toward compliance with this provision with one exception pertaining to the staffing analysis.

As stated in previous monitoring reports, the staffing analysis does not reflect accurate security staffing relief factors. This is because the Territory did not provide all data requested by the staffing analyst from the National Institute of Corrections (NIC). GGACF-specific personnel data pertaining to staff time-off was not provided. These data are required to calculate GGACF’s Net Annual Work Hours (NAWH). NAWH includes a comprehensive analysis of staff time off for specified years. The results of the NAWH analysis are plugged into final 24/7 staffing level requirements to determine realistic, GGACF-specific relief factors. The absence of these data required the NIC analyst to base relief factors on national averages rather than relief factors that are realistic to GGACF. Therefore, staff levels in the Plan should not be considered realistic or final. However, the staffing analysis did include all security posts and the approved Plan should be considered a solid basis from which to begin implementation of staffing increases.

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RECOMMENDATIONS:
1. Implement the approved policy. 2. Continue to implement the staffing plan 3. Monitor Plan effectiveness with regard to prisoner population levels, incidents, and other care
and custody work levels. 4. Update the staffing analysis with GGACF-specific NAWH calculations if indicated. 5. This provision can move to Partial Compliance if Plan timelines and staffing outcomes are
achieved as written.
b. A security staffing plan, with timetable, to implement the results of the security staffing analysis; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The Plan delineates implementation guidelines as required and includes timelines for implementation of security staff salary increases. Staff recruitment and retention activities and timelines appear well thought-out but this Monitor is skeptical that the Territory can achieve proposed staffing increases due to 1) the availability of qualified officer candidates, and 2) GGACF’s staff attrition history. The approved salary increases may partially mitigate these two concerns for recruitment and retention. Additional, creative strategies may be required down the road to gain Substantial Compliance with this provision.
The timeline for security staff salary increases was examined. Full implementation of this component of the Plan appears to require approximately 101 days as shown below.

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On April 12, 2016, this Monitor requested clarification from the Territory on the above table stating, “Good afternoon, Shari – I have reviewed the Staffing Plan filed with the court and request some clarification. First, is the timeline below accurate per the Plan’s descriptions... Second, to which correctional officers will the salary increase apply? Thank you for your timely response. Best! Ken”.
On May 6, 2016, the Territory responded to the above request for clarification stating, “Good morning Ken: The Legislature submitted the approved bill to the Governor on or about April 25, 2016. As of May 3, the Governor signed the bill into law and directed the Director of the Division of Personnel ("DOP") to commence the salary implementation process. The increase is for all officers, both rank and file and supervisors. Shari” Based on this clarification from the Territory, it appears that the Territory is fully engaged in the implementation process, somewhere between steps three and four.
The Governor and Territory officials are commended for taking this long-needed step toward improving compliance with this Agreement and the quality of life for correctional staff. This provision can move into Partial Compliance once the Territory can demonstrate that the staffing plan is reasonably achieving compliance based on documented results of an adequate evaluation process.
RECOMMENDATIONS:
1. Continue to implement the Staffing Plan and salary increases as indicated.

c. Policies and procedures for periodic reviews of, and necessary amendments to, Golden Grove’s staffing analysis and security staffing plan.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.
RECOMMENDATIONS:
1. Implement final policies and procedures.

1. Defendants will implement the staffing plan developed pursuant to D.1.
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: The Territory has initiated implementation of the staffing plan.
 RECOMMENDATIONS:
 Continue and monitoring implementation of the staffing plan.

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E. Sexual Abuse of Prisoners

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of one (1) provision. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.E. Sexual Abuse of Prisoners

1 2 3 4 5 6 7 8 9 10 11

1 IV. E1: Substantive PREA Requirements Implemented

00 0 0 0 0 0 0 0 0 0

# NonCompliance 1 1 1 1 1 1 1 1 1 1 1

# Partial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies that incorporate the definitions and substantive requirements of the Prison Rape Elimination Act (PREA) and any implementing regulations.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory. The Territory has resolved the 24/7 hotline issue to ensure prisoner access to confidential, outside reporting of abuse. The Territory has initiated a Memorandum of Understanding (MOU) with the USVI Police Department to conduct criminal investigations of sexual misconduct at GGACF. It was unclear, however, whether or not this MOU has been signed by both entities.

Mr. James Warren is charged with the duty to conduct administrative investigations of sexual misconduct at GGACF. Since our previous site visit, the BOC has hired an additional administrator investigator to assist in conducting administrative investigations and they are in the process of hiring an additional investigator. The investigative team will have responsibility for conducting administrative investigations both at GGACF and the St. Thomas facility. The new investigator is Ms. Angelyna Boyd. The monitoring team interviewed Ms. Boyd and found her to be very welleducated and has a clear understanding of the task at hand with respect to assisting in conducting administrative investigations, including PREA related investigations. Ms. Boyd has already availed herself to an on-line PREA investigations course and plans on further availing herself to additional investigative related trainings.

The BOC Director informed the monitoring team that VIOMB approved the position; it is fully funded. The BOC Director hired the PREA Coordinator, Garvin Simon. Mr. Simon started on May 16, 2016. He completed certain PREA courses trainings; certification of training completion was provided for inspection.

Since our last onsite visit, Mr. Warren reported that he has worked on three (3) PREA related investigations. The monitoring team reviewed those investigations. The completed investigations were promptly investigated by Mr. Warren after they were assigned to him by the Director, as we

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reported in our previous report. However, the dates of the incidents, as reported in the previous Monitor’s report, occurred in May and September 2015. Both of these investigations were adequate. In one of the investigations, Mr. Warren determined it to be unfounded, and the other one was sustained. The monitoring team noted that the sustained investigation did not contain a recommended remedy or final action to be taken by the BOC. We also noted that the investigations do not contain a tracking number. During our exit briefing with BOC staff, we recommended that they should devise a tracking system for all investigations, including the assignment of a tracking number for reference/tracking purposes. The third PREA-related investigation was completed on April 7th. From our discussion with the investigative team, it appeared that the allegation made was credible and was reported by a staff member. It did not appear that the staff member (a contract employee) had been administratively removed from her job assignment upon staff being informed of this alleged PREA-related incident. The contract employee was terminated.
Subsequently, the involved inmate was reportedly transferred to another facility off-island. It should be noted that there must be zero tolerance for any form of sexual misconduct at the facility, and when credible information is obtained that such misconduct may be occurring, the alleged perpetrator should be removed from his/her job assignment until the investigation has been completed and final action taken on the matter. During this monitoring period, the monitoring team was provided with the completed investigations regarding the May 2015 incident and the September 2015 incident, as noted above.
It should also be noted that during our previous site visit we requested that an investigation be undertaken regarding the alleged allegation by an inmate of excessive force by a GIST officer on July 29, 2015. It does not appear that such investigation has been launched.
The BOC has continued to work with outside entities to further advance GGACF’s PREA obligations and to develop a staff and inmate training strategy on the final PREA policies and procedures followed by full implementation.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. GGACF should take advantage of the National PREA Resource Center at http://www.prearesourcecenter.org/, and the National Institute of Corrections at http://nicic.gov/ for qualified information about PREA compliance, training, and other related resources.
2. Review PREA and develop an action plan for the implementation of PREA requirements.
3. BOC officials are encouraged to send at least one qualified staff person to USDOJ’s PREA auditor certification training. All costs are covered by USDOJ.
4. Complete the PREA Self-Audit.
5. Fill additional investigator position slated for a 6/16 hire date, according to the Territory.

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IV.F. Classification and Housing of Prisoners


Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.F. Classification & Housing

1 2 3 4 5 6 7 8 9 10 11

1 IV.F1a: Objective System Annually Validated / Timelines

00 0 0 0 0 0 0 0 0 0

2 IV.F1b: Classified Prisoner Housing/Separation

00 0 0 0 0 0 0 0 0 0

3 IV.F1c: Other Unit Access Prevention System for Prisoners 0 0 0 0 0 0 0 0 0 0 0

4 IV.F1d: Specified Re-Classification System

00 1 1 0 0 0 0 0 0 0

5 IV.F1e: Specified Incident Data Collection/Reporting

00 1 1 1 1 1 0 0 0 0

6 IV.F1f: Regular Review Prisoner Segregation/Out-time

00 0 0 0 0 0 0 0 0 0

# NonCompliance 6 6 4 4 5 5 5 6 6 6 6

# Partial Compliance 0 0 2 2 1 1 1 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 2 2 1 1 1 0 0 0 0

Percent Out of Noncompliance 0% 0% 33% 33% 17% 17% 17% 0% 0% 0% 0%

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the six (6) provisions in this section of the Agreement; all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Substantive Provisions:

1. Defendants will develop and submit to USDOG and the Monitor for review and approval facility-specific policies that will appropriately classify, house, and maintain separation of prisoners based on a validated risk assessment instrument in order to prevent an unreasonable risk of harm. Such policies will include the following:

a. The development and implementation of an objective and annually validated system that classifies detainees and sentenced prisoners as quickly after intake as security needs and available information permit, and no later than 24-48 hours after intake, considering the prisoner’s charge, prior commitments, age, suicide risk, history of escape, history of violence, gang affiliations, history of victimization, and special needs such as mental, physical, or developmental disability;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory. On May 11, 2016, the Territory notified this Monitor that the classification instrument had been validated by its original author, Dr. James Austin. The approved policies and procedures, and the classification instrument account for prisoner classification measures required in this provision. Further discussion about this progress will be provided in the 12th report following review of Dr. Austin’s report by this Monitor.

RECOMMENDATIONS:

1. Provide empirical validation of the current classification instrument(s).

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2. Review, revise, develop, train, implement, and evaluate policies and procedures that provide more accurate and complete guidance for a valid and reliable classification system for nonconvicted and convicted inmate populations.
3. Ensure classification staff are well-trained in classification protocols and routinely monitor classification documents for accuracy.
b. Housing and separation of prisoners in accordance with their classification;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Inmates should be housed and separated according to reliable classification process as previously discussed.
2. Pending completion of a reliable classification process, GGACF officials should use the Incident Log Report and other reliable information sources to target population cohorts for housing and separation that is more consistent with behavioral risks and needs.
3. Comply with the Settlement Agreement prohibiting housing seriously mentally ill inmates in isolation cells or locked-down housing units. Mental health staff must continue to conduct a serious, comprehensive assessment of all prisoners on both the detention and sentenced side lockdown units to determine mental health needs and direct mental health staff to determine if a different, less punitive housing placement is available.
c. Systems for preventing prisoners from obtaining unauthorized access to prisoners in other units;

ASSESSMENT: NONCOMPLIANCE – Minor improvement noted, but not yet substantive or 
 sustained.

FINDINGS: Same as above
RECOMMENDATIONS:
1. Refer to previously discussed security-related findings and recommendations.
2. Refer to previously discussed classification-related findings and recommendations.

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d. The development and implementation of a system to reclassify prisoners, as appropriate, following incidents that may affect prisoner classification, such as prisoner assaults and sustained disciplinary charges/charges dismissed for due process violations;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Refer to recommendations related to grievance and disciplinary policies and procedures.
2. Ensure accuracy of monthly disciplinary committee reports.
3. The Territory must correct problems reported in the monthly disciplinary committee reports.
4. Train classification staff to accurately and consistently complete initial and reclassifications, accordingly.

c. The collection and periodic evaluation of data concerning prisoner-on-prisoner assaults, prisoners who report gang affiliation, the most serious offense leading to incarceration, prisoners placed in protective custody, and reports of serious prisoner misconduct;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No documentation was provided by the Territory to determine the existence of this practice.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Timely approve and implement policies and procedures for the accurate and complete use of the Incident Tracking System.
2. Develop and implement a continuous quality assurance policy and program to ensure that incident reports and logs are consistently accurate and complete.
3. Revise incident report forms to include all essential elements to track incident data in a systematic and unified manner.
4. Establish an incident tracking database to produce and regularly review valid and reliable incident information and data.
5. Revise use of an incident reporting system, as discussed above 6. Assign additional staff to GIST, as described above.

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f. Regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time for prisoners in segregation.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Out-of-cell time remains problematic but is improving. However, lack of adequate staffing and the closure of several housing units pinches the Territory’s options for complying with this provision.
Mentally ill prisoners continue to languish in isolated segregation but there has been some increase in the frequency and duration of out-of-cell time for many of these prisoners. The Territory must redouble its efforts to make further progress for this population. Additionally, some general population and higher-risk prisoners are segregated (locked-down) in their cells for extended periods for disciplinary and protective purposes. For example, due to inadequate housing capacity and staffing levels, out-of-cell time is scheduled to keep rival gang members apart to control violence. Segregation review documents indicated regular in-person assessments and review of these prisoners. However, inadequate housing capacity and/or housing unit staffing levels cannot be the driving reason for these practices.
RECOMMENDATIONS:
1. Minimize time in segregation.
2. Provide adequate opportunities for out-of-cell time for inmates.
3. Ensure regular and consistent monitoring by medical and mental health staff.
4. Ensure inmate hygiene is maintained while housed in segregation.
5. Track and document (log) segregation housing conditions of confinement and inmate status.
6. Continue to ensure inmates with special needs are monitored frequently as indicated by a security and health risk/needs assessment. A routine schedule for conducting these rounds must be continuously monitored for compliance.
7. Develop and implement a monthly segregation housing unit log that tracks lengths of stay and compliance with this provision.
8. Defendants are reminded that segregation should never be used to punish or serve as a treatment for inmates who are mentally ill, and may never be used for inmates with serious mental illness.
9. Improve the quality and completeness of segregation review documentation.

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IV.G. Incident and Referrals

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the five (5) provisions in this section of the Agreement; all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.G. Incidents & Referrals

1 2 3 4 5 6 7 8 9 10 11

1

IV.G1a: Reporting of Ten (10, i-x) Defined Incidents Categories

00 0 0 0 0 0 0 0 0 0

2 IV.G1b: Mgmt. Review of Incidents for Administrative/Criminal Investigations, Incident Trends

01 1 1 1 0 0 0 0 0 0

3 IV.G1c: Preservation of Incident Evidence

00 0 0 0 0 0 0 0 0 0

4 IV.G1d: Centralized Incident Tracking System

00 0 0 0 0 0 0 0 0 0

IV.G2: Prompt Reporting, Reviews, Corrective Action Per 5 Specific Timelines

00 0 0 0 0 0 0 0 0 0

# NonCompliance 5 4 4 4 4 5 5 5 5 5 5

# Partial Compliance 0 1 1 1 1 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 1 1 1 1 0 0 0 0 0 0

Percent Out of Noncompliance 0% 20% 20% 20% 20% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies to alert facility management of serious incidents at Golden Grove so they can take corrective, preventive, individual, and systemic action. Such policies will include the following:

a. Reporting by staff of serious incidents, including: (i) fights; (ii) serious rule violations; (iii) serious injuries to prisoners; (iv) suicide attempts; (v) cell extractions; (vi) medical emergencies; (vii) contraband; (viii) serious vandalism; (ix) fires; and (x) deaths of prisoners;

ASSESSMENTS: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.

There has been marginal improvement in the quality and completeness of written incident reports but continued GGACF supervisor and leadership attention to this issue remains necessary. An examination of incident reports continues to find incomplete reports approved by shift supervisors.

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Additionally, no structure and systematic process for responding to patterns of incidents was provided during this visit.
RECOMMENDATIONS: 1. Develop protocols for current tracking system to improve data validity and reliability; the
Incident Log document is replete with duplication and misleading entries. 2. Develop a unified incident coding system for valid and reliable information and data collection,
reporting, and analysis. 3. Establish regular monthly quality assurance meeting process involving all major department
team leaders to review serious incident reports and recommend evidence-based remedial measures for eliminating/mitigating incident frequency and severity.
4. Train staff in applying adopted policies and use of forms, implement a continuous quality assurance protocol.
5. Require supervisors to carefully review all incident reports for completeness, accuracy, and consistency.
b. Review by senior management of reports regarding the above incidents to determine whether to refer the incident for administrative or criminal investigation and to ascertain and address incident trends (e.g., particular individuals, shifts, units, etc.);
ASSESSMENT: NONCOMPLIANCE FINDINGS: As stated above RECOMMENDATIONS: Previous recommendations remain appropriate. 1. Refer to recommendations in G.1.a above.
c. Requirements for preservation of evidence; and
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: As stated above and in the Contraband section.
 RECOMMENDATIONS: Previous recommendations remain appropriate.
 1. Refer to similar recommendations regarding contraband.

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d. Central tracking of the above incidents.
ASSESSMENT: NONCOMPLIANCE

FINDINGS: The incident logging system is currently the only tracking system used by the Territory. Historically, incident logs have shown to be inaccurate, incomplete, and somewhat confusing to interpret. Similar to the incident report quality, Territory officials are encouraged to give more attention to ensuring the quality of incident logs. Additionally, a more formal incident tracking system must be developed to comply with this provision. Such a tracking system will include specific data to measure incident activities and metrics to assess whether mitigating interventions are effective.
RECOMMENDATIONS:
1. Refer to previous recommendations regarding incident reporting and tracking.
2. Consider implementation of an electronic jail management system for centralization of incident reporting and data analysis.
3. Implement a quality assurance process that consistently ensures incident log accuracy and completeness.
2. The policy will provide that reports, reviews, and corrective action be made promptly and within a specified period.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Refer to previous discussion in this section
RECOMMENDATIONS:
Develop and implement corrective action protocols to address staff noncompliance with adopted policies and procedures.
1. Initiate corrective action against supervisors and staff who continually fail to submit and/or approve deficient, late, or no incident reports as required by policy and this Agreement.

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IV.H. Use of Force by Staff on Prisoners

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the fifteen (15) provisions in this section of the Agreement. A shown in the scorecard below, all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.H. Use of Force by Staff on Prisoners

1 2 3 4 5 6 7 8 9 10 11

1 IV.H1a: Permissible Forms of Physical Force & Use of Force 0 0 0 0 0 0 0 0 0 0 0 Continuum

IV.H1b: Circumstances for Permissible Forms of Physical 2 Force

00 0 0 0 0 0 0 0 0 0

3 IV.H1c: Impermissible Force i.e. Restrained Prisoner, For Verbal Threats, Unnecessary/Excessive Force

00 0 0 0 0 0 0 0 0 0

4 IV.H1d: Defined Competency & Scenario-Based PreService/Annual UOF Training

00 0 0 0 0 0 0 0 0 0

5 IV.H1e: Pre Training/Certification for Authorized Weapons 0 0 0 0 0 0 0 0 0 0 0

6 IV.H1f: Comprehensive/Timely Reporting of UOF by User and Witnesses

01 0 0 0 0 0 0 0 0 0

7 IV.H1g: Supervision & Videotaping of Planned UOF

00 0 0 0 0 0 0 0 0 0

8 IV.H1h: Appropriate Armory Operations and Permitting of Deadly Force at Authorized Posts

00 0 0 0 0 0 0 0 0 0

9

IV.H1i: Prompt Medical Evaluation, TX After UOF, Photographic Documentation of Injuries

00 0 0 0 0 0 0 0 0 0

10 IV.H1j: Prompt Admin Review of UOF Report Accuracy

01 1 0 0 0 0 0 0 0 0

11 IV.H1k: Timely Referral for Criminal/Admin Investigation Per Specified Clear Criteria

00 0 0 0 0 0 0 0 0 0

12 IV.H1l: Admin Investigation of UOF

00 0 0 0 0 0 0 0 0 0

13 IV.H1m: Defined UOF Tracking All UOF, Periodic Evaluation 0 0 0 0 0 0 0 0 0 0 0 for Early Staff Intervention

14 IV.H1n: Specified Supervisory UOF Reviews

00 0 0 0 0 0 0 0 0 0

15 IV.H1o: Staff Re-training / Sanctions as Indicated

00 0 0 0 0 0 0 0 0 0

# NonCompliance 15 13 14 15 15 15 15 15 15 15 15

# Partial Compliance 0 2 1 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 2 1 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 13% 7% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval of facility-specific policies that prohibit the use of unnecessary or excessive force on prisoners and provide adequate staff training, systems for use of force supervisory review and investigation, and discipline and/or retraining of staff found to engage in unnecessary or excessive force. Such policies, training, and systems will include the following:

a. Permissible forms of physical force along a use of force continuum;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.
Examination of incident reports and use of force reviews for this reporting period found no serious use of force events or force events that were not reviewed.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure all force incidents are properly reported and document complete supervisory reviews of all reported force incidents.
2. Implement a continuous quality improvement protocol to ensure all incident reports and supervisory review of documents are 1) complete, 2) accurate, and 3) comprehensive.
3. All planned uses of force must be monitored and controlled by an onsite supervisor.
4. GGACF must promptly and thoroughly investigate all inmate complaints of excessive force and take necessary corrective action to protect inmates and staff.
5. Strictly prohibit electronic control device (ECD) use except for emergency situations requiring that level of force to prevent imminent physical harm to staff, the inmate, or other inmates.

b. Circumstances under which the permissible forms of physical force may be used;
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: As stated above in this section.
 RECOMMENDATIONS: Previous recommendations remain appropriate.
 1. Implement policy and procedures once approved.

c. Impermissible uses of force, including force against a restrained prisoner, force as a response to verbal threats, and other unnecessary or excessive force;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated above in this section.

RECOMMENDATIONS: Implement policy and procedures once approved.


d. Preservice training and annual competency-based and scenario-based training on permitted/unauthorized uses of force and de-escalation tactics;

ASSESSMENT: NONCOMPLIANCE

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FINDINGS: GGACF recruits continue to be trained using the existing training program. This program was previously determined by this Monitor to be inadequate. The new UOF policy and training plan include all elements needed to comply with this provision. However, development the proposed UOF training curriculum is pending. The United States and this Monitor will closely examine draft training documents to ensure compliance with this provision.
RECOMMENDATIONS:
1. Implement approved policies and procedures.
2. Provide this Monitor and USDOJ with the new training curriculum.
3. Continue to monitor staff use of force and efforts to avoid and minimize force use.

e. Training and certification required before being permitted to carry and use an authorized weapon;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As discussed above in this section. Additionally, it was very troubling to learn that certain officers carry electronic control weapons (ECW / stun guns) without documented authorization or training. GIST carries unauthorized ECW flashlights into the facility (in contravention of the new UOF policies) and there was no final resolution onsite of how the Territory was going to prohibit this practice immediately. It appears that GIST would continue to bring and use their own person weapon devices at the facility unchecked. This is a serious finding requiring immediate attention and resolution. Specifically, no weapon of any kind can be authorized at any BOC management level unless such authorization complies with this provision.
RECOMMENDATIONS:
1. Same as above.
2. Comply with this provision without delay.

f. Comprehensive and timely reporting of use of force by those who use or witness it;
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as above.
 RECOMMENDATIONS:
 1. Implement supervisory quality improvement review for all reports to ensure accuracy and
completeness before approval.

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2. As requested in the previous report, the Territory must develop a use of force tracking log that includes elements to verify that reports are submitted complete and timely.
3. Comply with Monitor’s request for documents.
g. Supervision and videotaping of planned uses of force;
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as discussed above.
 RECOMMENDATIONS: Implement policy once approved.

h. Appropriate oversight and processes for the selection and assignment of staff to armory operations and to posts permitting the use of deadly force such as the perimeter towers; ASSESSMENT: NONCOMPLIANCE
 FINDINGS: Same as discussed above.
 RECOMMENDATIONS: Previous recommendations remain appropriate.
 1. Provide the Monitor documentation of Compliance for this Provision.

i. Prompt medical evaluation and treatment after uses of force and photographic documentation of whether there are injuries; ASSESSMENT: NONCOMPLIANCE FINDINGS: RECOMMENDATIONS: 1. Provide Monitor documentation of Compliance with this Provision.
j. Prompt administrative review of use of force reports for accuracy; ASSESSMENT: NONCOMPLIANCE FINDINGS: There were few use of force events documented during this reporting period. These incidents included documentation of administrative reviews but two reviews were submitted late to this Monitor. It is unknown whether these reviews were timely.

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RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Ensure that the supervisor/administrative reviews of incidents involving use of force resolve problems related to reporting accuracy, completeness, and consistency.
2. Provide the Monitor documentation of Compliance with this Provision for ALL previous use of force incidents as requested.

k. Timely referral for criminal and/or administrative investigation based on review of clear criteria, including prisoner injuries, report inconsistencies, and prisoner complaints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Two complaints of excessive force from different prisoners were examined during this assessment period. Both complaints were filed by these prisoners as grievances and both complaints involved the same corrections officer. An administrative investigation was requested for one complaint, no administrative investigation was conducted on the second complaint.

Prisoner excessive use of force complaint not investigated:

Examination of the grievance log found one prisoner use of force complaint recorded for March 23, 2016. The log records March 23rd as the date the complaint was received but the log’s Summary column for this complaint records March 19th as the date the prisoner signed the
compliant. The log does not explain this four-day difference in time. The log also records that this complaint was issued to a GGACF chief for resolution on March 30th for resolution. The stated resolution and return of the findings to the inmate was also recorded as March 30th.

The recorded description of this complaint states, “CO XXXX used excessive force while detainee hands were in handcuff. That officer XXXX stated he will send him to STT where he will be killed”. The recorded chief’s March 30th response states, “Chief XXXX stated that searches are performed for detainee's safety as well as the officers. Searches also include strip searches of detainees. If you feel Officer XXXX harassed you it will be addressed. However, you need to be mindful of your behavior and what you say when you get upset. A cell phone was found also several drugs paraphernalia were found in your cell”.

This March 30th response to this complaint fails to specifically address the excessive force claim except to advise the complaining prisoner that any officer harassment will be addressed “if [the prisoner] feels” the officer harassed him. The chief’s response also seems to blame the alleged excessive on the prisoner by stating, “…you need to be mindful of your behavior and what you say when you get upset.” Assuming the prisoner’s complaint is legitimate, this response essentially informs the inmate that excessive physical force by an officer is justified for verbal abuse of that officer. Assuming the complaint is not legitimate, the chief’s recorded response fails to provide the prisoner with information about how the matter will be investigated and resolved.

Examination of the incident report (#GGACF-03-0037-16-IR) related to this complaint indicates no excessive force was used during this event. The report articulates that this incident involved cell extraction of this prisoner during a cell search by three officers. The report states that this

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inmate was in possession of a broken cell phone and no other contraband. The report also states the prisoner was hand-cuffed and removed from his cell during the cell search then un-cuffed and returned to his cell following the search. The report states the prisoner became verbally abusive and threatening to officer who the prisoner accused of excessive force. Nothing written in this incident report would trigger a use of force investigation or review, nor does the chief’s March 30th response to this allegation deal with the excessive force complaint. It is assumed that no administrative investigation was conducted to determine the veracity of this complaint as such documents were not provided to this Monitor for examination. It appears that this excessive force complaint was not adequately resolved, but informally handled by giving complete deference to the officer(s) reported description of the incident. Although this inference may be incorrect, there were no other documents provided to this monitor to determine otherwise.

It is not uncommon in correctional facilities to incorrectly handle such prisoner complaints in this manner, especially when the complaint involves a troublesome prisoner. However, resolving such a complaint in this manner can expose the jurisdiction and staff to unnecessary and expensive legal actions before the matter is resolved in favor of the defendant. Or, result in serious legal consequences if a court determines that the jurisdiction was deliberatively indifferent to such prisoner complaints as a customary practice.

To fully comply with this provision of the agreement, the Territory must ensure that all prisoner complaints of excessive force are adequately investigated and resolved in a timely manner and well documented.

This incident compels this Monitor to more closely scrutinize all incident reports and inmate complaints for possible excessive force issues.

Prisoner excessive use of force complaint investigated:

On October 28, 2015 a prisoner filed a complaint about excessive force by a corrections officer. This Monitor notified the Territory about this complaint and requested administrative investigation documentation. The Investigative Summary fact sheet records that the investigation was received by the investigator January 8, 2016 and records the investigation was completed January 15, 2016. Administrative investigation documentation was provided to this Monitor January 19, 2016.

This complaint involves a prisoner who alleged being choked by a corrections officer during a verbal altercation with this officer after the prisoner was fired from a work assignment. The investigation report records the complaint was unfounded because the prisoner recanted his allegation and stated no force was used by the officer. The report also records that this inmate apologized to the accused officer and his work assignment was in instated.

The conclusions and final determinations of this case seem appropriate. However, administrative investigation documentation is missing the accused officer’s written statement and documentation of any prisoner disciplinary action taken as a result of the prisoner’s abusive behavior toward the officer or for making a false allegation about excessive use of force. The report should also document whether there were witnesses to the alleged excessive force and their written statements if witnesses were present.

This case demonstrates the need for GGACF leadership to ensure timely and complete administrative investigations. This prisoner complaint was filed on October 28, 2015 and not

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investigated until January 8, 2016 at the request of this Monitor. The investigation was completed seven days after it began, which seems to be an appropriate time period. However, the fact that no investigation was initiated until requested by the monitor is troubling. As indicated in the case discussed previously, GGACF officials must take more proactive and deliberate steps to timely and completely investigate all prisoner complaints of excessive force, even if a vast majority of those complaints are perceived or determine to be false allegations.
RECOMMENDATIONS:
1. Ensure response to prisoner complaints of excessive force are adequately investigated, resolved, and documented.
2. GGACF leadership should routinely monitor all incident reports and inmate complaints to ensure any excessive force complaint is adequate handled.
3. GGACF should serious consider forming a Use of Force Review Committee to review all use of force events and complaints of excessive force.
1. Administrative investigation of uses of force;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As discussed above

RECOMMENDATIONS: As discussed above in this section.


m. Central tracking of all uses of force that records: staff involved, prisoner injuries, prisoner complaints/grievances regarding use of force, and disciplinary actions regarding use of force, with periodic evaluation for early staff intervention;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Documentation of a centralized force tracking system has not been provided to this Monitor by the Territory.
RECOMMENDATIONS:
1. Develop and implement Central Tracking system to include all required elements.

n. Supervisory review of uses of force to determine whether corrective action, discipline, policy review or training changes are required; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: As stated previously in this section. Also, current review process determinations are made by one GGACF administrator. Although this process may seem efficient, the recommended

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review committee method could improve the quality and perceived credibility of final conclusions and determinations. In the alternative, GGACF should consider assigning all use of force incident reviews and prisoner complaints of excessive force to an investigator. This could strengthen the perceived objectively and credibility of final conclusions and determinations.
RECOMMENDATIONS: As stated above.
o. Retraining and sanctions against staff for improper uses of force.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The incidents discussed directly above provide good examples of easily corrected deficiencies in complying with this provision. In the first case, no documentation was provided to determine whether retraining and/or sanctions were warranted. Although, it is very likely that these remedial measures were not indicated for this incident, the lack of adequate documentation prevents this Monitor from making a positive assessment about the Territory’s compliance with this provision, and causes this Monitor concern about the Territory’s use of force control practices.
RECOMMENDATIONS: As previously stated in this provision

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IV.I. Use of Physical Restraints on Prisoners

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the six (6) provisions in this section of the Agreement. As shown in the chart below, all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.I. Use of Restraints on Prisoners

1 2 3 4 5 6 7 8 9 10 11

1 IV.I.1a: Permissible/Unauthorized Types of Restraints

00 0 0 0 0 0 0 0 0 0

2 IV.I.1b: Defined Circumstances for Restrain-Type Uses

00 0 0 0 0 0 0 0 0 0

3 IV.I.1c: Duration of Permitted Restraint Use

00 0 0 0 0 0 0 0 0 0

4 IV.I.1d: Required Observation of Prisoners in Restraints

00 0 0 0 0 0 0 0 0 0

5 IV.I.1e: Restraint Limitations on MI Prisoners, Appropriate

00 0 0 0 0 0 0 0 0

0

Consultation w/MH Staff

6 IV.I.1f: Required Termination of Restraints

00 0 0 0 0 0 0 0 0 0

# NonCompliance 6 6 6 6 6 6 6 6 6 6 6

# Partial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to the USDOJ and the Monitor for review and approval, facility-specific policies to protect against unnecessary or excessive use of physical force/restraints and provide reasonable safety to prisoners who are restrained. Such policies will address the following:

a. Permissible and unauthorized types of use of restraints;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory. Documentation provided by the Territory for this assessment period is inadequate to fully assess this provision. Unfortunately, the excessive force complaint previously discussed is the only record provided to make and assessment.

RECOMMENDATIONS: Same recommendations as stated for Use of Force sections.

b. Circumstances under which various types of restraint can be used;


ASSESSMENT: NONCOMPLIANCE


FINDINGS: As stated above and in the Use of Force sections.


RECOMMENDATIONS: Same as above.
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c. Duration of the use of permitted forms of restraints;
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: As stated above and in the Use of Force sections.
 RECOMMENDATIONS: Same as above.

d. Required observation of prisoners placed in restraints; FINDINGS: As stated above and in the Use of Force sections. RECOMMENDATIONS: Same as above.
c. Limitations on use of restraints on mentally ill prisoners, including appropriate consultation with mental health staff; and ASSESSMENT: NONCOMPLIANCE FINDINGS: As stated above and in the Use of Force sections. RECOMMENDATIONS: Same as above.
f. Required termination of the use of restraints.
 ASSESSMENT: NONCOMPLIANCE
 FINDINGS: As stated above and in the Use of Force sections.
 RECOMMENDATIONS: Same as above.


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J. Prisoner Complaints

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the five (5) provisions in this section of the Agreement. All provisions remain in NonCompliance as shown in the scorecard below. This scorecard is expected to substantively improve upon full implementation of these provisions.

IV.J. Prisoner Complaints

1 2 3 4 5 6 7 8 9 10 11

1 IV.J1a: Defined Complaint System, Confidential Access and 0 0 0 0 0 0 0 0 0 0 0 Reporting, Assistance for C/DD Prisoners

2 IV.J1b: Timely Complaint Investigations/Prioritized for Safety, Medical/MH Care

00 0 0 0 0 0 0 0 0 0

3 IV.J1c: Defined Corrective Action for Staff as Indicated

00 0 0 0 0 0 0 0 0 0

4 IV.J1d: Centralized Complaint System w/ Disposition

00 0 0 0 0 0 0 0 0 0

5

IV.J1e: Periodic Mgmt. Review for Trends/Individual/Systemic Issues

00 0 0 0 0 0 0 0 0 0

# NonCompliance 5 5 5 5 5 5 5 5 5 5 5

# Partial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies so that prisoners can report and facility management can timely address prisoner’s complaints in an individual and systemic fashion. Such policies will include the following:

a. A prisoner complaint system with confidential access and reporting, including assistance to prisoners with cognitive difficulties;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.

In addition to the deficiencies previously discussed in the two excessive use of force complaints, this assessment found marginal improvement in the prisoner complaint system and process. The grievance tracking log appears to be more complete. However, the narrative entries in this record remain inadequate to clearly determine whether complaints are resolved properly, or whether prisoners are consistently informed of a resolution to their complaints.

The inmate grievance coordinator was interview about progress with this provision during this site visit. The coordinator stated that she is not consistently provided documented response to prisoner complaints from staff responsible for submitting those responses. She also stated that some responses are too vague to adequately complete the grievance log. She suggested that GGACF should take a more active role for ensuring the quality response documentation and timeliness.

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RECOMMENDATIONS:
1. Conduct monthly administrative reviews of the inmate complaint reporting and tracking process to measure and verify program compliance, take timely and appropriate remedial and corrective action.
2. Ensure tracking log is consistently completed and accurate.
3. Assign reliable and timely oversight of the inmate complaint process and logs to a staff person who will provide the process with consistent, dedicated, and comprehensive attention.
4. Develop a valid and reliable tracking and quality management statistical report for monitoring inmate and facility needs and problems.
5. Ensure staff are available during onsite visits to allow this Monitor to adequately assess this Provision.
b. Timely investigation of prisoners’ complaints, prioritizing those relating to safety, medical and/or mental health care;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The quality of the grievance tracking log impairs accurate assessment of this provision. Improvement in the quality of this log was discussed and the new Warden agreed to improve the quality of the log for assessment and monitoring purposes. The previously discussed prisoner complaints of excessive force demonstrate the need for GGACF officials to ensure timely investigations of prisoner complaints.
RECOMMENDATIONS: Same as above.
c. Corrective action taken in response to complaints leading to the identification of violations of any departmental policy or regulation, including the imposition of appropriate discipline against staff whose misconduct is established by the investigation of a complaint;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously stated.
RECOMMENDATIONS:
1. Develop quality assurance process to ensure the completeness and accuracy of the Grievance Log documents and processes.

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d. Centralized tracking of records of prisoner complaints, as well as their disposition; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As previously stated
RECOMMENDATIONS: Same as above, and:
1. Develop and implement a formal and reliable centralized tracking system of inmate complaints and grievances that includes necessary complaint information and facts and complaint disposition.
2. Monitor the current tracking system to ensure timely, consistent, and complete administration.
e. Periodic management review of prisoner complaints for trends and individual and systemic issues.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No documentation for assessing compliance with this provision was provided by the Territory. Examination of the grievance log suggests a significant need for improvement in this area.
RECOMMENDATIONS: Same as above, and:
1. Conduct monthly administrative reviews of the inmate complaint/grievance tracking reports. Use data from those reviews to identify patterns of individual staff and inmate problems, as well as systemic problems in need of correction.

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IV.K. Administrative Investigations

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the five (5) provisions in this section of the Agreement. The scorecard below shows that all provisions from in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

IV.K. Administrative Investigations

1 2 3 4 5 6 7 8 9 10 11

1 IV.K.1: Timely Prisoner/Staff Interviews Involved in Incidents

00 0 0 0 0 0 0 0 0 0

2 IV.K1.2: Defined Adequate Investigation Reports, Attempt to 0 0 0 0 0 0 0 0 0 0 0 Resolve Statement Inconsistencies

3 IV.K1.3: Defined Centralized Tracking/Supervisory Review

of Admin Investigations for Systemic/Staff Actions.

00 0 0 0 0 0 0 0 0 0

4 IV.K1.4: Defined Pre/In-Service Investigator Training 5 IV.K1.5: Disciplinary Action for Staff Misconduct

00 0 0 0 0 0 0 0 0 0 01 0 0 0 0 0 0 0 0 0

# NonCompliance 5 4 5 5 5 5 5 5 5 5 5 # Partial Compliance 0 0 0 0 0 0 0 0 0 0 0 # Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0 # Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0
Progress Points 0 1 0 0 0 0 0 0 0 0 0 Percent Out of Noncompliance 0% 20% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

1. Defendants will develop and submit to USDOJ for review and approval facility-specific policies so that serious incidents are timely and thoroughly investigated and that systemic issues and staff misconduct revealed by the investigations are addressed in an individual and systemic fashion. Such policies will address the timely, adequate investigations of alleged staff misconduct; violations of policies, practices, or procedures; and incidents involving assaults, sexual abuse, contraband, and excessive use of force. Such policies will provide for:

1. Timely, documented interviews of all staff and prisoners involved in incidents;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.

The Territory has filled the second investigator position. Examination of the new investigator’s resume provided by the Territory indicates this person has some experience in community corrections investigations involving criminal probationers, but no experience or training regarding administrative investigations or institutional investigations of any kind. The new investigator seems well-educated and enthusiastic. Professional development of the new investigator will involve adequate supervision of her work and additional training on conducting administrative investigations in law enforcement (corrections-specific) settings. A review of this person’s resume and lengthy interview by this Monitor indicates the new investigator can be a positive asset to the Territory’s investigation team and work.

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During previous onsite visit, this Monitor discussed with the Territory and Chief investigator the need to develop and maintain an administrative investigations tracking log. The Territory agreed to this recommendation at that time. No tracking log has yet been developed.
The two administrative investigations previously discussed in the Prisoner Complaints section demonstrate deficiencies found in assessing compliance with this provision. Those deficiencies are easily corrected with proper administrative oversight of the administrative investigation program and additional training of the investigators. The BOC Director issued the new administrative investigation policies and procedures to the investigators for implementation. Although a formal training curriculum for these policies and procedures will be developed, the investigators can being implementing those policies under the supervision of the Director.
RECOMMENDATIONS: Same as previous report.
1. Fill the third investigator position.
2. Provide experienced supervision and necessary training to the new investigator(s).
3. Develop and implement the agreed administrative investigations tracking log.
2. Adequate investigatory reports that consider all relevant evidence (physical evidence, interviews, recordings, documents, etc.) and attempt to resolve inconsistencies between witness statements;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as above.
RECOMMENDATIONS: Same as above, and:
1. Develop, as part of these, methods for adequate collection, recording, handling, labeling, preserving, and maintaining administrative investigation evidence, information, data, etc.
3. Centralized tracking and supervisory review of administrative investigations to determine whether individual or systemic corrective action, discipline, policy review, or training modifications are required;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated above. A central tracking system for administrative investigations has not been developed.

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RECOMMENDATIONS:
1. Refer to previous findings regarding information tracking systems and methods.
2. Ensure tracking system maintains salient facts and information to support systematic administrative decision-making for initiating remedial/corrective actions, staff/inmate discipline where indicated, efficacy of policy, procedure, and/or training and, that supports valid and reliable changes and/or revisions to the process.
4. Pre-service and in-service training of investigators regarding policies (including the use of force policy) and interviewing/investigatory techniques; and
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No documentation was provided to verify whether any such training has been provided to the administrative investigators.
RECOMMENDATIONS:
1. Create a formal pre- and in-service training program to train staff who are involved in initial and/or administrative investigation.
4. Provide adequate training of investigative staff on topics in areas of incident scene investigation and appropriate administrative investigation methods, processes, techniques, legal and ethical issues, etc.
5. Provide training for administration/leadership staff in the areas of administrative investigation oversight, coordination, and management.
6. Develop and implement, as an adjunct to these policies and procedures, an “Investigator’s Manual” that provides guidance to staff responsible for oversight and investigative activities.
7. Provide the Monitor qualification documents for the newly appointed chief Investigator for review upon his/her appointment.
5. Disciplinary action of anyone determined to have engaged in misconduct at Golden Grove.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No documentation of disciplinary action taken against GGACF staff was provided during this assessment. However, BOC has a history of taking disciplinary action to include staff termination and filing criminal charges against staff engaged in regulatory and/or statutory misconduct.

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RECOMMENDATIONS: Continue to:
1. Integrate the information in the above into the administrative policies and procedures previously discussed.
2. Record and maintain onsite records of staff misconduct investigative reports and determinations.
3. Protect the integrity and confidentiality of these staff records, control access to records, provide a process for authorizing legitimate access and review of these records for general reporting purposes, monitoring, and supervision of staff.
4. Provide training to supervision staff in the appropriate use of this information for purposes of staff supervision, counseling, discipline, promotion, etc.
5. As with all training, especially training required for and that supports the monitoring of the Agreement, ensure complete training records are maintained onsite.

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V. MEDICAL AND MENTAL HEALTH CARE
Compliance Summary: As discussed herein, this assessment found factual basis on which to upgrade to Partial Compliance three (3) of the 36 the Monitor’s compliance; these include V.1c (Defined Timely Access/Provision Adequate M/MH Care), V.1d(i,ii,iii,iv) (Timely RX Orders & Labs, Timely & Routine Physician Review of RX & Clinical Practices, Qualified Review of RX for Side Effects, Qualified Review of RX for Side Effects, Sufficient RX Upon Discharge for Serious M/MH Needs), V.1f (iii) (Appropriate/Timely Chronic/Acute Care/Follow-up w/Clinical Practice Guidelines) and, V.1f(iv)(1,2,3) (Adequate Provision of Emergency Care, Defined Emergency Care Training for Staff). This section of the Agreement now has 14 provisions in Partial Compliance, up from ten (10) from the previous assessment, approximately 39% of the provisions in this section are out of NonCompliance. The scorecard below shows revised progress.

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Agreement Section & Substantive Provisions V. Medical & Mental Health
1 V.1a: Adequate Intake for Serious Med/MH by QMMHS 2 V.1b: Comprehensive Initial/Follow-up Assessments by
QMMHS w/in 3 Days of Admission

Compliance Assessment Report Number & Scores

1 2 3 4 5 6 7 8 9 10 11

00 0 0 0 0 0 0 0

1

1

00 0 0 0 0 0 0 0

1

1

3 V.1c: Defined Timely Access/Provision Adequate M/MH Care 0 0 0 0 0 0 0 0 0

0

1

V.1d(i,ii,iii, iv): Timely RX Orders & Labs, Timely & Routine

Physician Review of RX & Clinical Practices, Qualified

4 Review of RX for Side Effects, Qualified Review of RX for

00 0 0 0 0 0 0 0

0

1

Side Effects, Sufficient RX Upon Discharge for Serious M/MH

Ne e ds,

5 V.1e: Defined Prisoner Health Records Adequacy

00 0 0 0 0 0 0 0

1

1

6

V.1f(i): Adequate/Timely Sick-Call, Triage, Physician Review, Logging, Tracking, Responses by QMMHP

00 0 0 0 0 0 0 0

1

1

7 V.1f(ii): Adequate Tracking, Care, Monitoring of Prisoners w/ 0 0

0

0

0

0

0

0

0

1

1

Med/MH Needs.

8 V.1f (iii): Appropriate/Timely Chronic/Acute Care/Follow-up 0 0

0

0

0

0

0

0

0

0

1

w/Clinical Practice Guidelines

9

V.1f(iv)(1,2,3): Adequate Provision of Emergency Care, Defined Emergency Care Training for Staff

00 0 0 0 0 0 0 0

0

1

10 V.1f(v): Adequate/Timely Referral to Specialty Care

00 0 0 0 0 0 0 0

1

1

11 V.1f(vi): Adequate Care/Follow-up After Return From Outside DX or TX

00 0 0 0 0 0 0 0

1

1

12 V.1g: Adequate Care for Alcohol/Drug intoxication/Detox

00 0 0 0 0 0 0 0

0

0

13

V.1h: Infection Control, Guidelines, Precautions, Testing, Monitoring, TX Programs

00 0 0 0 0 0 0 0

0

0

14 V.1i(i): Suicide Prevention - Defined Immediate Referrals Prisoner Suicide or SMI Needs to QMHP/S

00 0 0 0 0 0 0 0

0

0

15 V.1i(ii): Suicide Prevention - Constant Observation Pending 0 0

0

0

0

0

0

0

0

0

0

QMHP Assessment of Supervision Needs

16

V.1i(iii): Timely Suicide Risk Assessment/Instrument by QMHP Not to Exceed 24Hrs of SP Placement

00 0 0 0 0 0 0 0

1

1

17 V.1i(iv): Readily Available, Safety Secured Suicide Cutdown 0 0

0

0

0

0

0

0

0

0

0

Tools

18 V.1i(v): Scenario-Based SP Response &Cutdown Tool Tra ini ng

00 0 0 0 0 0 0 0

0

0

19

V.1i(vi):Suicide Prevention, ID Risk, Instruction & Competency-Based Training

00 0 0 0 0 0 0 0

0

0

20 V.1i(vii): Availability of Suicide Resistant Cells

00 0 0 0 0 0 0 0

0

0

21 V.1i(viii): Protocols/Constant / Close Supervision of Suicidal 0 0

0

0

0

0

0

0

0

0

0

Prisoners as Indicated by Assessed Risk

V.1i(ix)(1,2,3): Assurance of QMHP Directives for Care &

22 confinement, Removal from SP Watch, Follow-Up

00 0 0 0 0 0 0 0

0

0

Assessment at Clinically Appropriate Intervals

23 V.1j: Clinically Adequate Med/MH Staffing Levels, Periodic

00

0

0

0

0

0

0

0

0

0

Staffing Analysis/Plans

24 V.1k: Adequate CO Staffing/Training -ID/Refer/Supervise Prisoners with Serious M/MH Needs

00 0 0 0 0 0 0 0

0

0

25

V.1l: Protocol/Periodic Assessment of Compliance with PPs re ID, Handling, Care of Prisoners w/Med/MH Conditions

0

0

0

0

0

0

0

0

0

0

0

26 V.1m: Adequate Dental Care

00 0 0 0 0 0 0 0

0

0

27 V.1n: Defined Morbidity/Mortality Reviews

00 0 0 0 0 0 0 0

0

0

28

V.1o:Medical/MH Rounding Isolation/Segregation to Provide Access to Care/Avoid Decompensation

0

0

0

0

0

0

0

0

0

0

0

29 V.1p: Defined Isolation SMI Prisoners Prohibited, Regular Re vie w s

00 0 0 0 0 0 0 0

0

0

30 V.1q: QMMHP Review/Consults of Proposed Disciplinary Action MI Prisoners for Specified Determinations

00 0 0 0 0 0 0 0

0

0

31

V.1r: Medical Facilities, Scheduling/Availability of Appropriate/Private Clinical Spaces

00 0 0 0 0 0 0 0

0

0

32 V.1s(i) Mental Health Treatment Timely, Current, Adequate

00

0

0

0

0

0

0

0

1

1

TX Plans and Implementation

33 V.1s(ii): Mental Health Programming for SMI Adequacy

00 0 0 0 0 0 0 0

0

0

34

V.1s(iii): Psychotropic RX Practices/Side Effects Monitoring/Informed Consent Adequacy

00 0 0 0 0 0 0 0

1

1

35 V.1s(iv): Comprehensive CO/Clinical Staff Training on Prisoner MH Needs as Specified

00 0 0 0 0 0 0 0

0

0

V.1s(v): Cease Placement of SMI in Seg Housing or Lock 36 Down as Substitute for MH TX

00 0 0 0 0 0 0 0

0

0

# NonCompliance 36 36 36 36 36 36 36 36 36 29 5

# Partial Compliance 0 0 0 0 0 0 0 0 0 10 14

# Substantial Compliance 0 0 0 0 0 0 0 0 0

0

0

# Sustain Compliance 0 0 0 0 0 0 0 0 0

0

0

Progress Points 0 0 0 0 0 0 0 0 0 10 14

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 28% 39%

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Compliance progress with this section of the Agreement is, however, jeopardized by two primary issues. First, RN staffing levels decreased since the previous assessment due to resignations and slowed re-hiring. Remaining RN staff are working overtime to provide prisoner care but provision of adequate compliance can easily degrade without adequate staffing levels. Second, medical leadership has not established effective interprofessional collaboration with mental health leadership or meaningful integrated care practices. For example, the medical director intentionally failed to involve the mental health director nor the entire mental health clinical team in preparing numerous mentally ill prisoners who were recently transferred off-island. Some of these prisoners suffered from chronic serious mental and chronic diseases and at high risk of psychiatric decompensation. As a result, none of these mentally ill prisoners received adequate pre-transfer consultations with their primary care providers. This is appalling and vividly demonstrates deliberate indifference for the psychiatric suffering and needs of these prisoners. All of these prisoners should have received at least one (1) pre-transfer individual treatment session with Dr. Sang and the clinical team. Additionally, Dr. Sang and the entire MH team should have been requested by the medical director to fully engage the pre-transfer process to ensure all necessary health care information was provided to the receiving transfer facility. The BOC Director was advised of this issue by this Monitor; he seemed noticeable concerned and stated that he would immediately correct any medical leadership issues required to comply with this Agreement and to ensure such issues do not reoccur.
This scorecard is expected to substantively improve upon full implementation of these provisions.
Substantive Provisions.
Defendants shall provide constitutionally adequate medical and mental health care, including screening, assessment, treatment, and monitoring of prisoners’ medical and mental health needs. Defendants also shall protect the safety of prisoners at risk for selfinjurious behavior or suicide, including giving priority access to care to individuals most at risk of harm and who otherwise meet the criteria for inclusion in the target population for being at high risk for suicide.
1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval, facility-specific policies regarding the following:
a. Adequate intake screenings for serious medical and mental health conditions, to be conducted by qualified medical and mental health staff;

ASSESSMENT: PARTIAL COMPLIANCE (Progress has regressed since previous assessment. Compliance rating will be decreased to NONCOMPLIANCE if similar findings exist during the next assessment)

MEDICAL FINDINGS: With regard to policies and procedures in general, all of the medical policies and procedures have been drafted and training is occurring with a focus on the correctional officer training. This will be completed by early July. In addition, more than 95% of

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the medical staff have been tested and have received scores of better than 80%. The training materials were reviewed with regard to infection control, intoxication and detoxification, and discharge planning. With regard to infection control, both the policy and the training materials as well as the exams appear to be consistent with the plans for implementation.

With regard to discharge planning, we suggested some additions to the existing policy based on what is expected to be the process for discharge planning for each of the sentenced inmates as well as for the detainees. Given that there is far more time to perform a more comprehensive discharge planning process for the sentenced inmates (since their release date is known in advance), we only recommended that a clearer distinction be made between the two processes. With regard to the detainee population, where discharge or release is determined at a court hearing, we suggested the procedures to be utilized be clarified in the policy. Therefore, for the detainee population, it will be incumbent on the classification team to immediately notify medical staff responsible for insuring that patients with chronic medical problems leave with a two-week supply of their medications. If this is not possible, at a minimum, a designated pharmacy will contain a prescription for a two-week supply of medication, for which the Bureau of Corrections will pay when the released detainee receives it. In addition, for patients with chronic mental health problems, the nurses can notify mental health staff so that they can participate in the discharge plan for each of their patients. All patients will receive a document that includes contact information for each of the community medical centers as well as mental health centers.

With regard to the intoxication and detoxification policy, we suggested that the Medical Director determine the CIWA or COWS score to which the nurses are mandated to contact the Medical Director in order to guide the nursing staff. This is a common part of jail intoxication policies. These minor additions will be provided to all health care staff as they are formalized.

Since our last visit in December, four of the six registered nurses have departed the program. We believe that a major issue is the lack of competitive compensation. We reviewed 10 intake records of patients who entered between the time of our last visit and the first week of March of this year, 2016. Among those records, we found one record of a patient whose nurse screen was performed approximately 35 hours after his arrival. We also reviewed records of patients whose intake screen occurred 20 hours after arrival, 22 hours after arrival, and 17 hours after arrival. Thus, 40% of the 10 records we reviewed did not have a nurse intake screen for more than 12 hours after they had arrived. For some of these, the shortage of filled RN positions certainly may have contributed to the delays. With the exception of the patient who did not receive his nurse screen for 35 hours, the nine remaining records did contain a nurse screen within the first 24 hours. As I indicated earlier, the goal should be to complete the screen within four hours, and that standard clearly is not being approached.

One patient who had a severe psychiatric disorder missed his injectable antipsychotic medication. When he arrived he was not cooperative. The nurses must document daily that they have seen the patient and offered him to participate in a nurse intake screen. In addition, this patient apparently was uncooperative in relation to the absence of his antipsychotic medication. We were informed that on St. Thomas, as a matter of course, police routinely pick up these patients on the date of their injection and bring them to the clinic. This is to insure that there is no disruption of the antipsychotic medication. Additionally, one patient identified as having a newly positive TB skin test but the patient was released before the chest x-ray was obtained. This information obligates the nursing staff to contact the Department of Health TB control unit to make them aware of this particular patient’s problem. Overall, the quality of the screens was reasonably appropriate.

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However, timeliness of the screen appears to be a problem, with a few occurring after 24 hours and several more than 12 hours after arrival.
Patient #1 This is a 45-year-old who arrived on 12/16/15 at 7:50 a.m. His nurse screen was not until 12/17 at 6:50 p.m. His blood pressure was elevated at 160/100 and at repeat was 170/100. His pulse rate was also elevated at 101. He had a history of gout, coronary artery disease and hypertension. He also had his history and physical on the same day as his intake screen because he was an acuity level 1. However, the history and physical were woefully inadequate. There was no mention of the gout, no mention of the blood pressure issues, and no mention of the stents. He was not referred for chronic medical care and he has not been part of the chronic care program.
Patient #2 This is a 47-year-old who arrived on 12/27/15 at 5:25 p.m. He had his nurse screen on 12/28 at 4:45 p.m., or 23 hours after he arrived for booking. His blood pressure was borderline elevated at 134/96 and he was listed as an acuity level 2. He was seen for his history and physical and his blood pressure was increased at 136/98. He also lacked any referral to the chronic care program or even monitoring of his blood pressure.
Patient #3 This is a 30-year-old who arrived on 1/25/16 at 6:58 p.m. He had his screen on 1/26 at noon, approximately 17 hours later. He reported he had a seizure a day ago. His vital signs were normal. He was assessed as an acuity level 1 and was seen by the physician on the same day as the screen. His blood pressure was recorded as 143/80; however, it is not clear from the record why he was not being followed in the seizure clinic. In talking with the Medical Director, she indicated that during one of his reported seizures, she was able to converse with him, thus raising a question as to whether he was actually having seizures. However, this is not documented in the record in a manner that makes it clear that there is a question as to the validity of his seizure disorder.
Patient #4 This is a 44-year-old who arrived on 2/20/16 at 6:00 p.m. He had a screen performed on 2/21 at 4:00 pm., approximately 22 hours after his arrival. He was found to have a positive TB skin test. However, he was released before a chest x-ray could be performed. Given the fact that this is a newly positive TB skin test, the Department of Health TB control program should have been notified and this should be documented in the record.
Patient #5 This is a 32-year-old who arrived on 1/23/16 at 4:57 p.m. Vital signs showed a blood pressure of 141/84. The screen was done more than a day later. Although the screen was incomplete because of the lack of cooperation of the detainee, there was no documentation of daily offering to complete the screen. This patient has been on long-acting antipsychotic medication injections and apparently missed his injection.
RECOMMENDATIONS: 1. Fill the registered nurse positions, whose vacancies are creating a severe stress on the
remaining two nurses, each of whom is working at least six days a week and at least 10 hours a day. 2. The goal should be to perform the nurse intake screen within four hours of arrival.

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3. When a patient is uncooperative, nurses must document daily offering of the nurse intake screen to the patient until the intake screen is successfully completed.
4. When a patient is found to be newly positive for tuberculosis and is released before the chest x-ray is performed, the Department of Health TB control section must be notified and that notification documented in the medical record.
MENTAL HEALTH FINDINGS: See above noted medical findings as they relate to the timeliness of the intake screenings.
Mental health staff continues to perform initial mental health assessments on all new admissions. Staff is also continuing to note and assess cases where the initial mental health assessment identifies individuals in need of mental health treatment who were not identified as such during the intake screening process.
RECOMMENDATIONS:
1. Track data to support evidence of successful implementation of the policy and demonstrate adequacy of the quality of the screening process.
2. Continue to examine cases where an inmate with a negative mental health screen is later identified as an inmate in need of mental health services, and then explore options for altering the mental health screening process (be it the content and/or the conditions under which it is performed) so as to minimize the number of such false negative mental health screenings.
3. Assure that the mental health training that will eventually be provided to corrections officers helps them to appreciate the importance of their use of the ‘behavioral checklist’ and enhances their ability to use the ‘behavioral checklist’, given that the ‘behavioral checklist’ is one of the ways to identify inmates who are suffering from mental health problems that were not identified at intake.
4. Continue the practice of completing mental health assessments on all new admissions.

b. Comprehensive initial and/or follow-up assessments, conducted by qualified medical and mental health professionals within three days of admission.

ASSESSMENT: PARTIAL COMPLIANCE (Progress has regressed since previous assessment. Compliance rating will be decrease to NONCOMPLIANCE if similar findings exist during the next assessment)

MEDICAL FINDINGS: We have informed the Medical Director that she must review the records of the physicians and discuss the cases with them in order to get improved performance on the quality of the initial history and physical. We found a record of a patient whose history and physical was woefully inadequate. The patient came in with coronary artery problems and a history of coronary stents, an elevated blood pressure and gout, and yet this patient was not referred to the chronic care program. We also identified two other cases with elevated blood pressures that were identified yet no referral occurred to the chronic care program. This is unacceptable care. The Medical Director must review the work of the clinicians and provide counseling and feedback for them. If

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their work does not improve, action must be taken with regard to their providing services. There is a new physician who, beginning April 1, 2016, will be onsite two days per week. The Medical Director should carefully review his work and make sure that the practice is in conformance with the guidelines.

We were also informed that for a period of time, according to the Medical Director close to three months, the laboratory at the local hospital that performs the laboratory services for Golden Grove was having problems and therefore laboratory services were not available. However, she indicated to me that the hospital never closed. This indicates that the hospital had obtained alternate laboratory services that were not provided to inmates. This is completely unacceptable. In order to provide care consistent with reasonable community standards, patients who enter with a variety of diagnostic problems or chronic diseases need to have laboratory testing for either confirmation or monitoring the degree of control. For a program such as this not to have laboratory services available, even for a few days, is not acceptable. The Medical Director is obligated as the professional responsible for the quality of care to insure that laboratory services are accessible either through the local hospital or through an emergency outside contractor. This situation must never be allowed to happen again. I have indicated to the Medical Director that the memorandum of agreement with the local hospital should add a section that obligates the hospital to provide the required services or procedures even if they temporarily use an outside source. The services that they provide to their patients must also be provided to BOC patients.

Patient #1 This is a 42-year-old who arrived on 3/6/16 at 7:18 p.m. The nurse screen was done also on 3/6, and the patient had bipolar disorder and was assigned an acuity level 1 on that basis. Within 24 hours, the patient had the history and physical that demonstrated a blood pressure of 170/96 and 165/94. However, there was no referral to the chronic care program and no follow up.

Patient #2 This is a 47-year-old who had a blood pressure of 134/96 and 136/98; however, the history and physical makes no mention of the elevated blood pressure. There was no referral for either monitoring or for any type of follow up.

Patient #3 This is a 45-year-old who arrived on 12/16/15 and whose nurse screen occurred 35 hours later. The history and physical was done on the same day as the nurse screen, but whereas the nurse screen identified a history of gout, elevated blood pressure and a history of coronary artery disease, this was not identified or mentioned in the history and physical. In addition, there were no laboratory tests to determine whether the problems still persisted nor was there any referral for the chronic care program.

RECOMMENDATIONS:

1. The Medical Director must review the work of both physicians, including the one who has been with the facility for several years, as well as the new physician and provide feedback to them with regard to their performance and where that performance needs to improve.
2. The Medical Director should provide feedback to the head nurse with regard to the appropriateness of the acuity level assignment from the nurse screen.
3. The Medical Director should develop a procedure that insures a timely initial chronic care visit based on disease control. If the patient meets disease control criteria of good control, then the

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initial chronic care visit must be no later than three to four weeks. If the patient meets the criteria of fair control, no more than two weeks, and if the patient meets the disease control criteria for poor control, no more than one week for the scheduled initial chronic disease visit. 4. When there is any service disruption, one of the Medical Director’s responsibilities is to insure that the time of disruption is minimized and that patients have access to the required services as soon as possible. This may require working closely with the Director of Corrections.
MENTAL HEALTH FINDINGS: This most recent review of the ‘psychosocial assessment intake log’ indicates that initial mental health assessments continue to be performed on all new admissions the day of or the day after the mental health unit receives the intake screening. Therefore, comprehensive mental health assessments are continuing to be performed well within three days of admission.
As was previously noted, the ‘psychosocial assessment intake log’ was modified prior to the 10th monitoring visit so as to include information on when the psychiatrist actually saw the subset of new admissions who had been referred to her following their initial mental health assessment (previously, the form had only indicated the date the inmate was referred to the psychiatrist). Therefore, during this 11th monitoring visit, the review of the log also clearly documented that the psychiatrist is performing initial psychiatric evaluations in a timely manner, upon receiving a referral for such an evaluation. However, given that there is only one part-time psychiatrist, the availability of video conferencing/tele-psychiatry for use in emergency situations continues to be important, and the Territory has now provided this to the psychiatrist.
Substantial progress has been made in efforts to perform psychosocial assessments on inmates who entered the facility prior to the time when such assessments were being performed on all new admissions. This is especially the case with regard to inmates who are currently on the mental health caseload. However, this effort has now been disrupted since most of those who were still in need of a psychosocial assessment have been transferred to another facility.
As was also noted in the 10th Monitoring Report, the ‘initial mental health assessment form’ was expanded to include a more rigorous assessment of any history of serious trauma, especially violent trauma, and the presence of any resultant clinically significant trauma-related symptoms and/or developmental difficulties, especially those that might render an inmate vulnerable to deterioration and/or development of behavioral difficulties while incarcerated. That expanded form is now in use, and such trauma-related information is being gathered. It will now be important for the mental health unit to monitor individuals with a significant trauma history so as to determine how best to serve that population so as to keep them as stable as possible.
RECOMMENDATIONS:
1. Continue to track inmates entering the facility and monitor time from admission to screening to initial psychosocial assessment, and to initial psychiatric assessment for those referred for an initial psychiatric assessment.
2. Continue performing initial mental health assessments on all new inmates, and continue efforts to perform such assessments on those who entered the facility prior to the time the current initial mental health assessments were being performed.

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3. To the extent that the initial psychosocial assessment fails to identify any inmates with serious mental health difficulties (later picked up as a result of a referral to mental health by way of a ‘behavioral checklist’), explore for factors that might have contributed to the failure of the initial assessment process to identify that inmate’s mental health needs.
4. Develop a protocol or procedure for responding to inmates who refuse to engage in an initial mental health assessment.

c. Prisoners’ timely access to and provision of adequate medical and mental health care for serious chronic and acute conditions, including prenatal care for pregnant prisoners;
ASSESSMENT: ASSESSMENT: PARTIAL COMPLIANCE (Medical progress has regressed since previous assessment. Compliance rating will be decrease to NONCOMPLIANCE if similar findings exist during the next assessment)
MEDICAL FINDINGS: We have used this section to address medical sick call, focusing on the acuity part of the section. A separate section deals with chronic care needs. The sick call log was consistently utilized, and again we are able to report that either a nurse or occasionally a clinician, that is a physician, saw the patient timely. Most patients continue to be seen by a nurse on the same day as receipt of the request. However, we did identify some quality issues, particularly with regard to one of the practitioners and with regard to nursing in relationship to inadequate history taking. Also, we reviewed the record of a patient seen in February whose note was not in the medical record and later it was discovered in the “to be filed” pile, which apparently extended back through January. We are extremely concerned with the availability of only two RNs, each of them working six days a week and averaging about 10 hours per day. This is not an arrangement that can be sustained. Virtually all of the nurse sick call does occur in the housing unit exam rooms.
Patient #1 This is a 65-year-old, who on 2/23/16 requested services due to swelling of his right foot, which had gone on for a long time. The physician saw him on the same day the slip was submitted. At that time, his blood pressure was 158/91. The rest of the vital signs were normal. His diagnosis was left leg and ankle edema. He did not have a history of high blood pressure. Labs were ordered, which were not in the medical record, and an x-ray was ordered; this also was not available. In addition, the physician did not do anything regarding the elevated blood pressure, not even ordering the blood pressure to be monitored on some regular basis.
Patient #2 This is a 38-year-old who, on 2/14/16, requested services for an earache and a sore throat. A nurse saw him on 2/16, but again the note was not in the record. It was later retrieved from the “to be filed” pile. This note was adequate.
Patient #3 This is a 39-year-old with asthma, hypertension and anemia. On 2/8/16, he requested health services regarding a cough, a headache, and chest pain. The nurse who talked with the doctor saw him the same day, and he was given some medicine. The headache was never addressed by the nurse, although the cough and chest pain were.

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RECOMMENDATIONS:

1. The Medical Director should review the work of the physicians and provide feedback to them with a summary that indicates what number of records were discussed with each physician, the areas of concern, and whether or not a discussion took place.
2. The head nurse should review the work of the nurses and counsel them with regard to areas in need of improvement.

MENTAL HEALTH FINDINGS: A review of the logging of referrals made to the mental health unit via a ‘behavioral checklist’ or self-referral, a review of the ‘sick call log’, and a review of the ‘mental health follow-up log’ reveals that prisoners have timely access to mental health care whether they are already on the mental health caseload or a person newly identified as in need of mental health care. More specifically, evaluations are performed in a timely manner, and any required treatment is initiated as quickly as might be required.

During this monitoring visit, the mental health monitor randomly selected cases from the mental health case load for a more detailed review with regard to the provision of adequate mental health care. The review included a comparison of the information contained in the ‘mental health followup log’ with the information contained in the inmate’s medical/mental health chart, including the ‘treatment plan’ and all records of the provision of therapeutic interventions. In addition, the mental health monitor held a case conference with the entire mental health staff to review and discuss their evaluation and treatment of each of this same set of randomly selected inmates. Several very positive findings emerged from this process.

First of all, the information gathered from each of these sources of information was very complete; the information gathered from each source was consistent with the information gathered from the other sources; and the information gathered demonstrated the provision of well-considered and adequate mental health care.

This review process also revealed that prior recommendations had been further explored and responded to, including recommendations for a review of the frequency of psychiatric follow-up visits, an expansion of the use of non-pharmacologic interventions (such as the group therapy program), and the judicial use of individual sessions. More specifically, the frequency of psychiatric follow-up visits had been increased where appropriate, and now appears to be all the more responsive to the mental health status and treatment needs of each individual inmate, as well as consistent with prevailing standards of practice. The group therapy program has been expanded to include previously recommended groups; the renovation of the group therapy room has been completed, which has made it easier to run a fuller group therapy program; and a new group for inmates who suffer from a combination of intellectual disability and other serious mental health difficulties has clearly helped to better stabilize that population. The judicious use of individual sessions, especially for inmates in crisis and/or for inmates who require more targeted support, has also helped to increase stability for selected inmates.

In addition, this review revealed that mental health staff had significantly increased their focus on the subset of seriously mentally ill inmates who had previously refused treatment or failed to consistently comply with treatment (this group was discussed in the 10th Monitoring Report). Given this finding, the mental health monitor expanded this review to include a similar review of some of the unit’s historically most difficult to manage/most resistant to treatment inmates. This expanded

review revealed that mental health staff had developed individual approaches to each of these

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inmates, often with dramatic results. Some of these results included, for example, the development of an actual connection with some of these inmates who had previously been totally withdrawn and isolative; some had actually begun to communicate with mental health staff in a reasonable and, in some instances, even a meaningful way; some evidenced significant improvements in hygiene and grooming; some had even begun to have increased interaction with other inmates; and for some, there was improved compliance with psychopharmacologic interventions. This expanded review also revealed that mental health staff had given considerable thought to more clearly establishing a point at which inmates should be considered clearly resistant to or non-responsive to reasonable efforts to provide therapeutic interventions, and staff has begun to outline steps that should be taken at that point depending on an inmate’s mental status, behavior and any existing security concerns.

Given the above noted efforts of mental health staff, and the response of the inmates under their care, especially those inmates who had historically been so isolative and unresponsive, the sudden and unexpected (at least for the inmates and the mental health staff) transfer of such a large number of those inmates to another facility was extremely distressing for mental health staff for multiple reasons. More specifically, staff were not given an opportunity to prepare the inmates for such a transfer, which is extremely unfortunate given that mental health treatment is so tied into the relationship between the provider and the recipient of treatment. Staff feared that inmates would feel abandoned by them, especially those inmates who had only recently begun to engage with staff; staff feared that some inmates would feel that staff must have known about the transfer and just didn’t tell them; and of course, staff were concerned that given the way the transfer was managed, it was likely that this would result in a loss of the gains that many of the inmates had made. Staff members were also not given the opportunity to prepare some type of transfer summary for each inmate, which might have at least helped to increase the possibility that there would be some continuity of care, and at least helped to minimize any loss in gains that had been made. Then in addition, staff had no knowledge about the mental health services available at the receiving facilities, including the ethno-cultural competency of those mental health services, and so therefore they had no idea how inmates who had been under their care would be treated.

It is the understanding of this monitor that now, after the fact, mental health staff will have an opportunity to be in contact with providers at the receiving facility to share information on each inmate who was on the mental health caseload. In addition, a teleconference session between mental health staff and each such inmate is being considered, which can hopefully be used to help address any of the above noted issues that might have come up for inmates in response to the abrupt and unexpected disruption of their therapeutic relationships with mental health staff persons.

Making sure that mental health staff are fully aware of their responsibilities under PREA and are prepared to accept those responsibilities continues to be an issue. The monitor discussed this issue again with all involved parties, and the monitor has been assured that appropriate parties will meet with mental health staff to begin addressing this issue.

RECOMMENDATIONS:

1. Moving forward, a variety of quality indicators regarding services should be developed and maintained to aid the staff in ongoing quality improvement reviews as well as provide proof of practice for the monitoring team and any other bureau, independent agency, or accrediting body.

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2. Continue to expand non-psychopharmacologic treatment options, which will include addressing some of the impediments to such an expansion noted above.
3. Formalize the protocol or procedure for responding to inmates for whom psychopharmacologic intervention is indicated yet refuse to take medication. This is especially important for those inmates who are being held in seclusion because they are not receiving treatment despite the fact that they are so severely mentally ill.
4. Take the above noted necessary steps to help mental health staff understand their expected roles and responsibilities with regard to PREA and prepare to assume those roles and responsibilities.

d. Continuity, administration, and management of medications that address:
(i) timely responses to orders for medications and laboratory tests;
(ii) timely and routine physician review of medications and clinical practices;
(iii) review for known side effects of medications; and,
(iv) sufficient supplies of medication upon discharge for prisoners with serious medical and mental health needs;
ASSESSMENT: ASSESSMENT: NONCOMPLIANCE (Medical) PARTIAL COMPLIANCE (Mental Health)
MEDICAL FINDINGS: We were informed that the time of ordering to the time of receipt by the patients is usually within 24 hours. However, there is no data to support this. Also the Medical Director has not yet begun to review the use of medications, particularly by practitioners other than herself. Although there is a discharge planning process, especially for sentenced inmates, there is no data to suggest that the process for detainees is even somewhat effective. We are recommending that a group of stakeholders, including nursing, medical, mental health and custody, including classification, meet in order to both map out the processes that must be implemented and develop a documentation capability such that as people are released from the facility it is documented as to whether or not they have been receiving medications or refusing them.
During this visit, we observed a morning medication pass. Due to the transfer out of approximately 100 sentenced inmates, the med passes in general are shorter. Almost all of the inmates or detainees cooperated with the identification process, bringing water to aid in ingestion and cooperating in the mouth check. The exception was one female who refused the post-ingestion mouth check. We were told that she is a difficult person with a personality disorder and that may have accounted for this behavior. However, she must be counseled regarding the requirements of receiving medication and that if she does not meet the requirements she will not receive the medication.

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We still identified problems with the documentation. The nurse, in order to complete the administration more quickly, waited to enter some of the medications after she completed the entire medication pass. That is not acceptable. She must spend the time when she is in a housing unit to complete the documentation.

RECOMMENDATIONS:

1. The custody and health care leadership should convene a task force, including medical, nursing, mental health, classification and custody working in the release area to map out the sequence of procedures to fully implement the discharge-planning program. Part of this task force’s responsibility is to implement forms such that data may be available to be collected in order to demonstrate that the process is effective.
2. The QI program should, with the Medical Director and head nurse, perform a study of a sample of orders provided by clinicians and then track the time of the order along with the time of the receipt. For the overwhelming majority of orders, the requirement is that receipt should occur within 24 hours.
3. The patient who refused the mouth check post-ingestion must be counseled about the rules that are required for participation in the medication program.
4. The nurses should be provided a carrying container that allows segregation of each patient’s regimen within a particular housing unit.
5. Documentation should occur as close as is feasible to the medication administration.

MENTAL HEALTH FINDINGS: See above medical findings with regard to medication administration.

As noted above, there is now a timely and routine physician/psychiatric review of medications and clinical practices. Treatment logs reflect that the frequency of such reviews is timely and consistent with clinical practice guidelines. Medical records document that inmates are being routinely evaluated for known side effects of medication, and the records also indicate how any identified unacceptable adverse effects were addressed. Medical records and treatment plans also document routine assessment of the efficacy of the medications prescribed as related to target symptoms, and in incidences where efficacy is lacking, document the need for dosage adjustment or a change of medication.

Although the impediments to discharge planning and providing those being released with an adequate supply of medication was raised in the 10th Monitoring Report, these impediments had not been addressed by the time of the 11th monitoring visit. However, during the course of the 11th
monitoring visit, efforts were made to begin to address this issue. Therefore, during the next
monitoring visit it will be important to determine if any real progress has been made in this regard.

RECOMMENDATIONS:

1. The use of the medication refusal forms to allow nursing staff to notify clinicians of any significant pattern of medication refusal and the review of such forms by prescribing clinicians should be tracked. It may also be helpful to have a place on the form where the prescribing clinician can sign, indicating that the form has been seen and reviewed.

2. GGACF should develop a heat risk policy and ensure that all inmates have access to plentiful supplies of water and ventilation methods at all times. A list of inmates on medications that

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have heat-related risks should be maintained, and these inmates should have access to ice and water when the heat index indicates an elevated risk of heat-related illnesses.
3. Regular assessment for medication adverse effects is well-documented, but through training, such efforts should be expanded to involve all mental health staff in the identification of medication adverse effects.
4. The above noted impediments to the implementation of a discharge plan must be addressed so that inmates who are released receive an adequate supply of medication and a thoughtful referral to an appropriate treatment program/facility.

e. Maintenance of adequate medical and mental health records, including records, results, and orders received from offsite consultations and treatment conducted while the prisoner or detainee is in Golden Grove custody;

ASSESSMENT: PARTIAL COMPLIANCE (Medical progress has regressed since previous assessment. Compliance rating will be decrease to NONCOMPLIANCE if similar findings exist during the next assessment)

MEDICAL FINDINGS: During this visit, there were several notes as well as laboratory reports that were delayed more than a month in being filed. In fact, the “to be filed” pile contained documents, both lab reports and encounter notes, dating as far back as January. This is clearly a step backward from the prior site visit. In part, this may have been attributable to a hospital lab problem, but it also may be attributable to the loss of health care staff, which has been dramatic and has compromised potentially many aspects of the health care services program. Clearly, an electronic record in which the laboratory results enter into the electronic record automatically would solve some of these problems.

RECOMMENDATIONS:

1. Fill the vacant nursing positions. 2. Explore the implementation of an electronic record.

MENTAL HEALTH FINDINGS: The organization of the mental health section of inmate charts has continued to improve, and charts are now organized in a consistent manner. Charts are also more complete, in that they include a more detailed treatment plan that clearly indicates the focus, goals and therapeutic objectives of each intervention, and also documented in the chart is evidence all of the various therapeutic interventions that each inmate is receiving, including non-pharmacologic interventions.

RECOMMENDATIONS:

1. Now that mental health records are appropriately organized and filed, a quality improvement tool needs to be developed to track ongoing compliance with this provision.

2. Although the treatment planning process is much improved and better documented, information contained on the approved ‘treatment plan’ form should be expanded to describe planned

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interventions for those who have refused medication or other important therapeutic interventions.
f. Prisoners’ timely access to and the provision of constitutional medical and mental health care to prisoners including but not limited to:
(i) adequate sick call procedures with timely medical triage and physician review along with the logging, tracking and timely responses to requests by qualified medical and mental health professionals
ASSESSMENT: PARTIAL COMPLIANCE (Medical progress has regressed since previous assessment. Compliance rating will be decrease to NONCOMPLIANCE if similar findings exist during the next assessment)
MEDICAL FINDINGS: See letter (c) findings and recommendations.
RECOMMENDATIONS: See letter (c) findings and recommendations.
MENTAL HEALTH FINDINGS: The ‘sick call log’ and sick call procedures have been previously described, and a review of the log indicates that the response to sick call requests is consistently timely and complete.
RECOMMENDATIONS: See section ‘1c’ findings and recommendations.
f. (ii) an adequate means to track, care for and monitor prisoners identified with medical and mental health needs;
ASSESSMENT: PARTIAL COMPLIANCE. Medical progress has regressed since previous assessment. Compliance rating will be decrease to NONCOMPLIANCE if similar findings exist during the next assessment.
MEDICAL FINDINGS: From our intake records, we identified four records of patients that should have been entered into the chronic care program at the time of diagnosis, and as a result of this oversight, the patients had not been appropriately followed up. Needless to say, this is unacceptable. We can indicate that we found some forms filled out by the Medical Director and the documentation in those forms reflects an overall improvement in the chronic care documentation. However, when patients are not enrolled in the chronic care program, even if the Medical Director follows all the enrollees, a void is still created which potentially compromises the outcomes of patients. In addition, for many diseases it is impossible to practice in a manner consistent with written guidelines when laboratory services are unavailable. This problem has been corrected, but it must be prevented and avoided at all costs in the future. Finally, the delay in filing lab reports also compromises the information available to the clinician at the time of the chronic care visit. All of these problems should be corrected by the time of our next visit. To identify patients who should have been enrolled, see the patient description for sections (a) and (b).

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RECOMMENDATIONS:
1. The Medical Director must begin reviewing and counseling the clinicians who perform all of the intake history and physicals, especially insuring that chronic care enrollments do take place. It is impossible to maintain an accurate list when patients have not been enrolled.
2. The program at GGCAF must always have access to laboratory services. Any disruption must be avoided or be minimized to a day or two.
MENTAL HEATLH FINDINGS: As noted above, the ‘mental health follow-up log’ has been carefully maintained and is up-to-date. All patients on the mental health caseload are consistently being seen and receiving treatment at appropriate intervals except those who have refused treatment; all modalities of treatment are logged; and the therapeutic interventions being employed appear to be appropriate.
RECOMMENDATIONS:
1. See section ‘1c’ for recommendations regarding the ‘mental health follow-up log’.
2. As the ‘treatment plan’ is expanded to include all services and the therapeutic goal(s) for each intervention, the development of an integrated treatment log for all interventions continues to be a recommendation.

f. (iii) chronic and acute care with clinical practice guidelines and appropriate and timely follow-up care;
ASSESSMENT: PARTIAL COMPLIANCE MEDICAL FINDINGS: See f (ii). RECOMMENDATIONS: See f (ii) MENTAL HEALTH FINDINGS: See sections ‘1b’, ‘1c’, ‘1d’, and ‘1f’ subsections i and ii RECOMMENDATIONS: See sections ‘1b’, ‘1c’, ‘1d’, and ‘1f’ subsections I and ii.

f. (iv) adequate measures for providing emergency care, including training of staff: (1) to recognize serious injuries and life-threatening conditions; (2) to provide first-aid procedures for serious injuries and life-threatening conditions; (3) to recognize and timely respond to emergency medical and mental health crises;

ASSESSMENT: PARTIAL COMPLIANCE. Medical progress has regressed since previous assessment. Compliance rating will be decrease to NONCOMPLIANCE if similar findings exist during the next assessment. Non-compliance for Mental Health.

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MEDICAL FINDINGS: We reviewed six records of patients listed in the unscheduled service log as having utilized unscheduled services, almost all of whom were sent out to the hospital. The problems that we identified included lab reports not being in the record, offsite service reports not being in the record, as well as the utilization of outdated lab reports when being followed in the chronic care program, and in one instance, failure to order an important laboratory test. These issues tie in with both the laboratory access that we have commented on previously as well as medical record availability of documents in the record.
Patient #1 This is a 31-year-old with a history of seizure disorder after a head injury. On 1/6/16, the Medical Director was called and ordered seizure precautions and a CT scan. This patient had arrived on 10/7 and had his history and physical on 10/10, but the initial history and physical did not enroll him in the seizure chronic care program and he had not been seen since. Clearly, this failure might have been avoided.
Patient #2 This is a 61-year-old who was sent out on 1/8/16 for weakness, vomiting, and lethargy. He had diabetes, hypertension, degenerative joint disease, and diabetic retinopathy along with hypertriglyceridemia. He was sent out in midafternoon on 1/8 and returned on 1/9, also in the afternoon. The physician saw him on 1/11, and ordered new laboratory tests. However, there were no results available from the hospital. The patient was seen on 1/11, noted on a chronic disease form but results were utilized from prior testing months earlier. The hospital report was in the medical record but relevant lab results were not in the hospital document. The diagnosis was vasovagal reaction but there is not a clear basis for this diagnosis.
Patient #3 This is a 23-year-old with asthma, sent out on 1/15/16 for neck stiffness and diaphoresis. He was seen before he was sent out by a physician, who diagnosed tardive dyskinesia and extrapyramidal symptoms. The psychiatrist and the Medical Director were called. There was no ER report available. He was on an antipsychotic medication that tends to cause extraparamydial symptoms, but he had not been given in the same order the antidote to these symptoms. When he returned, he was given that medicine. We were told that when he was at the hospital he failed to sign a release of information form and therefore the hospital has not provided the hospital documents. His signature should not be necessary on a release form in order for the hospital to provide the relevant documents to the caring physicians. A meeting with the hospital needs to take place during which this clarification needs to be discussed and arrangements made so that this breakdown in follow up no longer occurs.
Patient #4 This is a 52-year-old with a history of transient ischemic attacks, vertigo, hypertension, and seizure disorder. On 1/19/16, at about 10:45 a.m. he presented with an apparent seizure. He had been in the facility since March of 2011. He had been followed up in chronic care for two years. The ER report was available but not in the chart. The seizure medicine level was ordered but there is no result available and there has been no follow up blood testing since his return.

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RECOMMENDATIONS:
1. Meet with the hospital and ensure that they understand that they have an obligation to provide hospital documents for those patients that you are clinically responsible for independent of the presence of a signed release form.
2. Ensure that lab and hospital documents are filed timely. 3. Ensure that no breakdown of access for laboratory or other services occurs in the future.
MENTAL HEALTH FINDINGS: Training on mental health policies and procedures is now underway and appears to be going quite well. Partial Compliance can be achieved following requisite staff training and evidence-based demonstration of policy and procedure compliance.
RECOMMENDATIONS:
1. Complete staff training in recognizing mental health emergencies and other mental health policies and procedures.

f. (v) adequate and timely referral to specialty care;
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: We reviewed five records of patients sent to specialists and we found problems with reports being available in the medical record as well as absence of follow up documentation by the physician of counseling of the patient. We had a discussion with the Medical Director regarding whether if a result was normal it was acceptable to have the counseling performed by a nurse. We explained that the only circumstance in which that would be acceptable was if there was a routine screening test performed in the absence of symptoms and the nurse understood the guideline recommendations. However, in other circumstances where the patient had an active symptom, the fact that the report is normal in no way resolves the active symptom. She agreed that those circumstances would require a physician counseling.
Patient #1 This is a 24-year-old with chronic bronchial asthma. On 11/26/15, there was an order for a dermatology consult scheduled for 12/10/15. The consult occurred on 12/10 and this was with a diagnosis of acne for which topical and systemic medications were recommended but no prescriptions were written. There is no note by the Medical Director regarding the basis for the absence of prescriptions.
Patient #2 This is a 64-year-old with high blood pressure and HIV disease with peripheral neuropathy as well as chronic kidney disease and anemia of chronic disease. A dermatology appointment was requested also for this patient and he was seen on 12/10. His CD-4 count improved in February, as did his viral load, which decreased. In this case, there was no sign-off on the consult report and no follow up visit with the physician.

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RECOMMENDATIONS:
1. Ensure that scheduled offsite services result in a follow up visit with a physician in which there is documentation of the results of the consultation as well as a discussion of the findings and plan. The only exception should be when routine screening procedures are performed in the absence of symptoms and the results are normal, then a nurse may document this counseling.
MENTAL HEALTH FINDINGS: Adequate housing and care for prisoners with acute and/or severe mental illness is not available in the Territory. This population is housed on the mainland for care but whether that care is adequate is unknown to this Monitor. It is, there, important for GGACF to maintain regular care status reports from these off-island providers.
RECOMMENDATIONS:
1. Maintain complete and regular care status reports from off-island providers of specialty care provided to prisoners with acute and/or severe mental illness.
f. (vi) adequate follow-up care and treatment after return from referral for outside diagnosis or treatment; See above
ASSESSMENT: PARTIAL COMPLIANCE
MEDICAL FINDINGS: We used this section to document scheduled offsite procedures. We reviewed five records of patients sent offsite for procedures, such as radiology procedures, gastroenterology procedures or cardiac procedures. In three of the five records, we did not find a relevant follow up note.
Patient #1 This is a 55-year-old with hypertension and a lipid disorder. She had a mammogram ordered on 2/9/16 that was done on 2/19. The report came back benign findings but there was no follow up note by anyone.
Patient #2 This is a 38-year-old who was complaining of lower back pain. MRI was done on 2/8/16. The report revealed mild disk bulging throughout the lower back but there has been no follow up with a practitioner.
Patient #3 This is a 60-year-old with diabetes type 2, hypertension, retinopathy, degenerative joint disease, and hypertriglyceridemia. There was an order for a stress test on 1/31/16, and this in fact was completed on 2/3. A report was received 3/1. The stress test was negative except for abnormal heartbeats. This was reviewed by the Medical Director on 3/1, but there has been no follow up visit.

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RECOMMENDATIONS:
1. Ensure timely follow up with documentation of a discussion with the patient of the findings and any plans.
MENTAL HEALTH FINDINGS: Refer to medical findings and recommendations.
RECOMMENDATIONS: Refer to medical findings and recommendations.
g. Adequate care for intoxication and detoxification related to alcohol and/or drugs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: We have no cases to review that demonstrate any implementation of this particular policy. We did comment that the policy should require the Medical Director to set a score that mandates a nurse make contact with a physician. This has not yet occurred. We have as of yet to review any records in which detoxification monitoring has been implemented. We were told that there is an agreement for the local methadone clinic to continue to provide medications for patients when they are brought over there.
RECOMMENDATIONS:
1. Complete the training and examinations on this area. 2. Provide documentation to use of this agreement and add this to the intoxication and
detoxification policy.
MENTAL HEALTH FINDINGS: The monitor remains concerned about the management of the subset of individuals suffering from substance abuse difficulties who also suffer from some other major psychiatric difficulty, whether that other major psychiatric difficulty is evident while the individual is intoxicated and/or becomes evident during detoxification. In either case, it is well recognized that with such individuals, the management of substance abuse difficulties and such other mental health difficulties must be done in an integrated and coordinated way if interventions are to be effective.
RECOMMENDATIONS:
1. Assure the integration of mental health staff into the assessment and treatment of intoxicated inmates and those undergoing detoxification when there is evidence that the inmate is also suffering from other major psychiatric difficulties.
h. Infection Control, including guidelines and precautions and testing, monitoring and treatment programs.
ASSESSMENT: NONCOMPLIANCE

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MEDICAL FINDINGS: This item requires training for the staff and oversight of training of the officers, which will be completed by early July.
We have previously discussed with regard to intake the recommendation to ensure that nurses re-query patients regarding active TB symptoms when they find a positive skin test. This must be documented in the medical record. We did identify a case sited under the intake cases in which the patient was identified as newly positive but there was no documentation at that time of the TB symptom questions.
RECOMMENDATIONS:
1. Complete the training of officer staff. 2. Begin to develop data to be utilized regarding skin infections as well as other common
diseases such as tuberculosis. 3. There should be a quarterly report on infection control matters presented at the quality
improvement meeting.
MENTAL HEALTH FINDINGS: Defer to medical findings and recommendations
RECOMMENDATIONS: None.
i. Adequate suicide prevention, including:
(i) the immediate referral of any prisoner with suicide or serious mental health needs to an appropriate mental health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As was noted in prior reports, reviews of ‘behavioral checklists’, sick call requests, and the ‘behavioral checklist/sick call log’ indicate that there continues to be clear corrections officer referrals and inmate self-referrals for serious mental health concerns, including suicide concerns. These documents and records also indicate an immediate response to these referrals by the mental health unit. However, what is difficult to determine is how quickly corrections officers identified serious mental health needs and then completed a ‘behavioral checklist’, which is the other key element in addressing this issue.
Training of corrections officers on suicide prevention and the identification and management of other mental health emergencies is now underway, and completion of this training is required for this provision to move to the point of partial compliance. This monitor’s discussions with the trainers indicates that the questions asked during the training and the new insights shared by trainees appear to indicate that the training will help corrections officers increase their ability to more quickly identify individuals who are suffering from serious mental health difficulties, including suicide-related difficulties. Once all officers have been trained, the impact of the training on officers can be more fully assessed.

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RECOMMENDATIONS:
1. Continue to monitor and review future behavioral health checklist referral tracking logs.
2. Because all staff have not yet been trained with an approved curriculum for suicide prevention, this provision remains noncompliant. It is recognized that despite not having been trained, the security staff does an excellent job completing these forms when behavioral problems are identified. However, there should also be an assessment of how early in the process of the emergence of suicidal ideation or other mental health emergency that such difficulties are identified by security staff.
(ii) a protocol for constant observation of suicidal prisoners until supervision needs are assessed by a qualified mental health professional;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The monitor reviewed the monitoring log being used by security to document constant observation of prisoners who are suspected to be suicidal until the time that such prisoners are assessed by a qualified mental health professional. The monitor has also not seen any other evidence that such prisoners are, in fact, being constantly observed until they are assessed by a qualified mental health professional.
RECOMMENDATIONS:
1. The facility will need to develop a means of documenting whether or not an inmate is maintained on constant observation until the time of the evaluation in order to demonstrate compliance with this provision. Similarly, the facility will need to develop a means of documenting whether or not an inmate is being observed consistent with the level of suicide watch ordered following an evaluation by mental health.
2. Currently, documentation is scattered between an observation form and hit-or-miss notations in the officers’ unit log. Implement approved Log of Suicide Watch (PCO) Rounds.
3. Once implemented, these should be reviewed by mental health staff regularly to ensure security’s compliance with the policy.
(iii) timely suicide risk assessment instrument by a qualified mental health professional within an appropriate time not to exceed 24 hours of prisoner being placed on suicide precautions;
ASSESSMENT: PARTIAL COMPLIANCE

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MENTAL HEALTH FINDINGS: Staff has been trained on this approved policy and procedure; a welldeveloped suicide risk assessment instrument is in place; and the instrument is being utilized by qualified mental health professionals as indicated in the approved policy and procedure.
A review of the various logs and other records maintained by the mental health unit indicates that individuals referred by security because they are suspected to be suicidal and individuals who are self–referred are assessed by a qualified mental health professional almost immediately, and clearly within 24 hours. A review of randomly selected assessments, coupled with a consultation with the staff person who performed the assessment, indicates that the assessments are clinically sound.
RECOMMENDATIONS:
1. Continue to utilize the suicide risk assessment tool, and continue to review existing logs that demonstrate compliance with this provision with regard to the timeliness of suicide risk assessments.
2. Develop quality assurance data to demonstrate the quality of the suicide risk assessment as that relates to compliance with this provision.
3. Ensure required annual training is completed as required.

(iv) readily available, safely secured, suicide cut-down tools;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Suicide cut-down tools are in place and safely secured. However,
 to consider such tools ‘readily available’, correction officers must know how to quickly retrieve these tools from their location. They must also then learn how to use these tools.
Training of correction officers on this policy is underway, and such training will include the retrieval and use of cut-down tools. Once this training has been completed and corrections officers have been able to demonstrate their skills, this provision can be changed to partial compliance.
RECOMMENDATIONS:
1. Assure that rapid access to cut-down tools is possible.
2. Complete training.
3. Demonstrate compliance with approved policy following completion of requisite training.

(v) instruction and scenario-based training of all staff in responding to suicide attempts, including use of suicide cut-down tools;
ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS:
RECOMMENDATIONS: See above section on cut-down tools. It should also be noted that other issues related to suicide prevention are also included in the training that is currently underway.
1. Complete training for all staff on suicide prevention, including training for security staff on the use of cut-down tools, followed by an assessment of competency to employ such suicide prevention efforts.

(vi) instruction and competency-based training of all staff in suicide prevention, including the identification of suicide risk factors;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: Training has commenced but has not been completed. As noted above, the identification of individuals who might require mental health services as early as possible in the course of their illness is ideal. With regard to suicide prevention, recognizing that individuals are evidencing suicide risk factors might allow for such early intervention, a better treatment outcome, and decreased morbidity. Therefore, the goals of the mental health training should include helping corrections staff to recognize individuals at high risk of becoming suicidal and refer such identified individuals for mental health evaluation and treatment before they actually make some type of suicidal attempt.
RECOMMENDATIONS:
1. The facility proposed to complete this training by July 31, 2016 for all staff.
2. Effectiveness of the training will need to be demonstrated by the use of competency measuring tools and follow-up quality improvement studies.

(vii) availability of suicide-resistant cells;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: The suicide resistant cell in the Intake Area has been essentially completed (there was still a problem with one of the ceiling light fixtures) and will be available for use. It is positioned near the corrections officer who is always posted in the Intake Area, which would allow for whatever level of observation/monitoring by security is required. As previously noted however, this location makes it more difficult for nursing staff and mental health staff to monitor any inmate that is placed there.

The suicide resistant cell in the medical building has not been completed, but it is the understanding of the monitor that there are still plans to complete the renovation of that cell. However, it is also the understanding of this monitor that at present, even if that cell was completed, there is not enough security staff at the facility to monitor a suicidal inmate placed in that cell/in the medical facility.

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It should again be noted here that the provision of a suicide-resistant cell somewhere at the facility where there is a corrections officer posted does not fully address this provision – the availability of a suicide-resistant cell is not particularly helpful in the absence of an ability of staff and otherwise to use the suicide-resistant cell. More specifically, a nurse is also required to be part of the monitoring process; at present, there is also a shortage of nurses; and this shortage of nurses coupled with the fact that a nurse would have to run back-and-forth between intake and the medical building to perform the monitoring is a big issue. Of course in addition, mental health staff also has to repeatedly assess the individual, and that means that a qualified mental health professional must also be running back-and-forth between intake and the medical building.
RECOMMENDATIONS:
1. GGACF is encouraged to complete the renovation of the proposed suicide resistant cell in the medical building. Completing this renovation and addressing security staffing issues will be a fuller and more appropriate response to this provision.
2. Train staff on approved suicide prevention policies and demonstrate proficient use of the suicide resistant cells.
(viii) protocol for the constant supervision of actively suicidal prisoners and close supervision of other prisoners at risk of suicide;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: The medical/mental health records and a log maintained by the mental health coordinator clearly track and provide information obtained from ongoing evaluation of suicidal inmates regarding indications for the various levels of suicide watch ordered. A review of medical/mental health records and the tracking log also indicates that the protocol for the mental health evaluation and supervision of actively suicidal inmates is clear, consistent with current standards of medical/psychiatric practice, and carefully followed.
It has become clear to the monitor that when mental health places an inmate on suicide watch, security is given a ‘mental health/psychiatry observation level sheet’, which notes which risk level the inmate has been placed on and the protocol for that level of risk, including how frequently the inmate is to be observed by security. Mental health also provides security with a ‘special observations monitoring sheet’, which is to be used to document each time the inmate is observed, the corrections officer who did the observation, and the inmate’s behavior at the time of the observation (there is a simple coding system for this right on the form).
Although the monitor has seen a completed ‘mental health/psychiatry observation level sheet’ (which is essentially a medical/psychiatric order for initiation of a suicide watch), the monitor has never seen a completed ‘special observations monitoring sheet’ or any substitute documentation of the monitoring of suicidal inmates by security. Therefore, the monitor has no way of knowing whether any such monitoring has ever occurred.

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RECOMMENDATIONS:
1. Complete the process of training on suicide prevention and observation policy, implementation and monitoring.
2. System-wide training for this provision will be the last of the medical trainings offered because security must also be included. However, the facility is strongly urged to consider a method to ensure that inmates placed on suicide watch, between now and the time training is completed, are adequately supervised and that this supervision is documented according to policy.
(ix) procedures to assure implementation of directives from a mental health professional regarding: (1) the confinement and care of suicidal prisoners; (2) the removal from watch; and (3) follow-up assessments at clinically appropriate intervals;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, the protocol for the ongoing mental health evaluation of suicidal inmates and the care of such inmates, including their placement on and removal from suicide watch, is being carefully followed by the mental health staff and well documented. Furthermore, a review of their work in this regard indicates that clinical decisions have been consistently appropriate, both during the period of an inmate’s active suicidality and during the prescribed period of follow-up after an active level of suicidality has remitted.
However, as also noted above, there continues to be concern about the implementation of directives that result from the evaluation and the development of care plans for suicidal inmates when such directive must be implemented by staff outside of the mental health unit.
RECOMMENDATIONS:
1. Complete the training on suicide/suicide prevention and the training on the policies and procedures specifically related to this issue.
2. Assure that appropriate mechanisms are in place to facilitate the notification of all medical staff, especially nursing staff, of mental health directives and care plans for suicidal inmates; monitor the effectiveness of such mechanisms for notification; and monitor the implementation of the directives that nursing and any other medical staff are responsible for.
3. Assure that appropriate mechanisms are in place to facilitate the notification of security staff of mental health directives and care plans for suicidal inmates; monitor the effectiveness of such mechanisms for notification; and monitor the implementation of the directives that security staff are responsible for.

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j. Clinically adequate professional staffing of the medical and mental health treatment programs as indicated by implementation of periodic staffing analyses and plans.
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: The staffing has dramatically shrunk as a result of two-thirds of the registered nurses departing since our last visit. This has resulted in the remaining two nurses working six days per week, roughly 10 hours a day. This situation is not sustainable. We understand that one of the reasons for departure is adequacy of compensation. We were informed that to work per diem at the Golden Grove facility provides compensation at $24.00 per day. To work at the hospital provides compensation for a registered nurse of $48.00 per day. This doubling of the pay must be mitigated at least to some extent. Leadership of BOC must address this problem.
RECOMMENDATIONS:
1. Fill the nursing hours to complete staffing component.
MENTAL HEALTH FINDINGS: At present, the mental health staff includes the mental health coordinator (Ms. Murray, LCSW), a part time psychiatrist (Dr. Sang), and a mental health counselor (Mr. Rosas, MHC). The prior mental health nurse, Ms. Randolph, RN, is no longer at the facility; she has not been replaced and as noted above, and currently there is an overall shortage of nurses; and so at present, there is more limited support from nursing.
At least one additional staff person is required to address all of the provisions of this agreement. It is the understanding of this psychiatrist that a line has now been created and funded for that additional staff person.
The existing staffing pattern for the mental health treatment program called for this additional staff person to be another MHC. However, as the mental health treatment program has developed, it has become clear that the monitoring, reporting and other administrative responsibilities of the mental health coordinator, coupled with her responsibilities for things like segregation review and performing special assessments for disciplinary cases, etc. have all become so extensive that it leaves her much less time than had been expected to perform other more clinical/direct treatmentrelated duties, such as initial mental health assessment, targeted individual sessions, etc. Given that the mental health coordinator is also the only LCSW on the mental health treatment team, the question has been raised as to whether or not the now available line for another MHC can be used to hire another LCSW or a licensed clinical psychologist, even on a less than full-time basis, who could then assume some of the more clinical/direct treatment-related responsibilities that are now totally carried by the mental health coordinator.
RECOMMENDATIONS:
1. Consider the possibility of using the newly created and funded line for an MHC to instead hire another LCSW or a licensed clinical psychologist, even on a less than full-time basis (i.e., further assess the need for such an alteration in the staffing pattern and explore the possibility and feasibility of making any such alteration in the staffing pattern if it appears to be indicated).

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2. As mental health staff continue efforts to address all of the provisions of this agreement, staffing analyses should continue to assure adequate staffing of the mental health unit.

k. Adequate staffing of correctional officers with training to implement the terms of this agreement, including how to identify, refer, and supervise prisoners with serious medical and mental health needs;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: Very recently, 100 detainees were shipped off the island to facilities in the United States. This occurred one week before our visit and therefore we have no data with regard to its impact. We do believe that there will be additional officers available for escort but we will not be able to ascertain whether that has occurred until our next visit. We were told that there are delays with regard to dental access and sometimes with regard to medical access. We could not determine whether the redeployment has eliminated those delays.
RECOMMENDATIONS:
1. Ensure sufficient staffing to accomplish all of the health care services in a timely fashion.
2. Ensure that trainees are not assigned the medical function with regard to medication administration or running the building.
MENTAL HEATLH FINDINGS: Refer to medical findings
RECOMMENDATIONS: As per medical recommendations.

l. A protocol for periodic assessment of the facility’s compliance with policies and procedures regarding the identification, handling, and care of detainees and prisoners with serious medical and mental health conditions;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We have been informed that there have been no quality assurance/quality improvement activities. We were shown no document reflective of organized activity in this area. We are available to consult with the leadership in providing suggestions on how this may be organized.

RECOMMENDATIONS:

1. We look forward to working with the medical leadership team to develop this program.

MENTAL HEALTH FINDINGS: The mental health unit already maintains a range of logs (described above and in previous monitoring reports) that track and document compliance with many of the provisions of this agreement and many of the specific policies and procedures that have been developed. These logs are available for review and assessment at any time. More

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specifically, these logs document that new admissions are being assessed in a timely manner; that those who are later referred by corrections staff or self-referred for mental health services are being assessed in a timely manner; that mental health emergencies, including those involving suicide attempts and/or suicidal ideations, are being assessed in a timely manner; and that all those who are assessed who also require a psychiatric evaluation receive a psychiatric evaluation in a timely manner. These logs also document what specific mental health services are provided to each inmate who has been placed on the mental health caseload, and how frequently the inmate receives each of the various services; which inmates have been placed on suicide watch, placed in segregation and/or had other difficulties; and how quickly treatment plans are developed and other interventions, directly therapeutic or otherwise, are initiated. Therefore, data is already available and the mechanism is already in place for periodic assessment of issues such as these by the mental health unit and this monitor.

The mental health unit has begun to look at the quality of the referral process and the quality of the various types and levels of assessment by gathering information that would allow for a comparison of the findings of each. The findings will hopefully improve and the significance of the findings will be all the more important once all of the mental health training has been completed. However, it remains to be determined whether or not more information should be gathered and what is the best way to assess the information that is gathered in order to have a meaningful assessment of the quality of referrals and the various types of assessments performed.

Although clinically there is a clear sense that the treatment provided is of good quality, a more formal assessment of the quality of the treatment provided, ranging from the development of a treatment plan to the provision of the various therapeutic interventions, has not been initiated. Outcomes that can be used for such a more formal assessment must be determined; an approach to measurement against such outcomes must be developed; and then a way to document this process so that it can be readily reviewed must be developed. Woven into this process will be the identification of impediments to quality treatment, including those that are outside of the control of the mental health unit, such as the availability of the various types of physical spaces required to provide mental health treatment programs, and the monitoring of suicidal patients by security staff.

The mental health unit will also have to join with other facility staff to develop mechanisms for assessing compliance to certain other provisions of this agreement that mental health plays a role in but are not entirely under the control of the mental health unit. These areas include, for example, segregation review, disciplinary review, etc.

RECOMMENDATIONS:

1. The mental health staff should develop compliance reports that indicate any failures to comply with developed policies and procedures, and the result of investigations into the reasons any such failures to comply occurred.

2. The mental health team should also assess the overall quality of the mental health services provided, with an eye toward identifying, developing, and implementing any quality improvements that should be made.

3. Scheduled regular monthly or quarterly management meetings with medical staff and other department leaders should be occurring consistently. Mental health staff should be using these meetings as an opportunity to continue to raise quality assurance issues that are not

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totally under their control. The raising of such issues and any identified approaches to addressing such issues should be documented in the minutes of these management meetings.

m. Adequate dental care;
ASSESSMENT: NONCOMPLIANCE (Partial Compliance for Medical and Noncompliance for Mental health)
MEDICAL FINDINGS: The pattern of inconsistent escorting continues intermittently to interfere with access. We expect to see that at least 90% of patients scheduled to be seen are in fact seen unless there is a refusal form signed by the prisoner and witnessed by a qualified medical staff person.
RECOMMENDATIONS:
1. Provide sufficient officers such that access is unimpeded.
MENTAL HEALTH FINDINGS: Refer to medical findings.
RECOMMENDATIONS:
1. GGACF officials should ensure protocols are in place and practices that ensure proactive oral health assessment of mentally ill inmates.

n. Morbidity or mortality reviews of all prisoner deaths and of all serious suicide attempts or other incidents which a prisoner was at high risk for death within 30 days of the incident triggering the review;
ASSESSMENT: NONCOMPLIANCE
MEDICAL FINDINGS: There have been no morbidity reviews that we are aware of and since there have been no mortalities we would not expect any but some hospitalizations are worth reviewing and that process has not yet been started.
RECOMMENDATIONS: 1. Have the Medical Director perform a review of the care provided at GGACF for patients who
died or became hospitalized.
MENTAL HEALTH FINDINGS: Refer to medical findings.
RECOMMENDATIONS:
1. The clinical directors, Director of Nursing and Health Services Administrator should develop mechanisms to identify and review all cases of mortality and serious morbidity as part of the Quality Improvement process. These reviews should also include security leadership.

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2. When such reviews result in the identification of issues that need to be addressed (whether failure to comply with policies and procedures or the possible inadequacy of existing policies and procedures), a plan for corrective action should be developed.
3. The incidences that prompt such a review and the review and its outcomes should be shared with the monitor.

o. A protocol for medical and mental health rounding in isolation/segregation cells to provide prisoners access to care and to avoid decompensation;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: Although we do believe a nurse has been making rounds until very recently, three days per week in segregation, we have not been able to receive a list of patients who were seen in the segregation unit on the rounds for which problems have been identified and treatment provided.

RECOMMENDATIONS:

1. Maintain documentation of patients seen each day in segregation, by whom the patient was seen, either by the nurse or for whom a note was written.

MENTAL HEALTH FINDINGS: As previously reported, there is weekly mental health rounding in isolation/segregation cells performed by Mr. Rosas, and monthly mental health rounding in isolation/segregation cells performed by Ms. Murray. In both cases, all inmates in isolation/segregation are seen – not just those on the mental health caseload – and there are logs kept for both sets of rounding that indicate when the inmate was seen, the inmate’s general wellbeing, the condition of the inmate’s cell, and any specific mental health needs that the inmate might have. The goals of this rounding are to identify those in need of mental health services and facilitate their access to mental health care, and to monitor for any mental health impact that isolation/segregation might be having on inmates.

Ms. Murray’s monthly rounding is also in connection with the larger segregation review process. In that regard, the information she brings to the segregation review process is also informed by Mr. Rosas’ weekly rounding and any other information gathered from other mental health staff. During the 10th monitoring visit, the form used for this larger segregation review process was revised, allowing for more detailed input from mental health, including any specific recommendations that mental health might have, particularly with regard to the continued use of segregation for any particular inmate.

During this monitoring visit it was clear that Ms. Murray has now been completing the mental health section of the segregation review form, and listing specific recommendations when indicated. Of particular concern for Ms. Murray and the rest of the mental health team was an inmate who was clearly deteriorating while in segregation, and so they recommended an early termination of his stay in segregation. She also reported that when she has concerns, those concerns are discussed with the other members of the segregation review team during the segregation review process; but her recommendations have never been acted upon; and there

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has never even been any follow-up/feedback offered to her after a monthly review team meeting. It is the understanding of this psychiatrist that these recommendations from mental health, along with the rest of the segregation review form and recommendations of the review team, are to be forwarded to the warden for her review and a final decision. However, during discussions with the warden, she noted that she has never received any such recommendations from mental health to accept or reject, and she noted that she will look into why that has been the case.
RECOMMENDATIONS:
1. The Mental Health Coordinator will continue to keep documentation of weekly and monthly rounds, and will keep documentation of information provided and recommendations offered during the monthly isolation/segregations review process.
2. The Warden will assure that she receives any recommendations from mental health, along with the rest of the input from the segregation review process, so that she can either accept or reject the recommendations, or request additional information.
3. Monitor how mental health recommendations made during the monthly isolation/segregation review process are integrated into and impact on the monthly isolation/segregation review process.
4. Continue to document the need for certain alternative therapeutic interventions (most of which have been noted in other sections of this report) that would allow many mentally ill inmates to be removed from segregation, and continue to advocate for the provision of such interventions.

p. A prohibition on housing prisoners with serious mental illness in isolation, regular review of prisoners in segregation to minimize time in segregation, and provision of adequate opportunities for out-of-cell time of prisoners in segregation;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: As has been repeatedly noted in prior monitoring reports,
despite this patent prohibition, there are still inmates with serious mental illness who are being held in isolation/segregation. Dr. Ray, the Court-Appointed Monitor, has written extensively on this matter in previous reports that includes analyses of segregation conditions and monitoring. Despite noted improvements in the segregation review process, no practices other than a complete elimination of isolation of mentally ill prisoners will comply with this Provision.

Since many of these inmates were included in the mass transfer of inmates to other facilities and are therefore no longer at the facility, the total number of seriously mentally ill inmates in isolation/segregation has decreased. However, there continues to be seriously mentally ill individuals in isolation/segregation, and so this provision has still not been addressed.

The various reasons why there are seriously mentally ill inmates in isolation/segregation has also been repeatedly summarized in prior reports; those reasons remain the same; and so a full discussion of those reason will not be repeated here. However in summary, some are in isolation/segregations because they have refused treatment and are considered to be dangerous;

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some are in isolation/segregation because although involved in treatment, they are considered vulnerable and in need of protection from other inmates; and some are in isolation/segregation due to disciplinary infractions.
Again, it should also be noted that the above noted section on isolation/segregation rounds and the isolation/segregation review process, and the following section on the role of mental health in addressing prisoner disciplinary sanctions are very clearly relevant to this issue of the placing of seriously mentally ill prisoners in isolation/segregation. Therefore, those sections should be reviewed again for the relevance to this issue, especially as they relate to efforts to minimize time in segregation and the success or lack of success of those efforts.
Mental health staff has made considerable efforts to increase opportunities for out-of-cell time for inmates suffering from serious mental health difficulties who are being housed in isolation/segregation, despite the continued absence of renovated space that would readily allow for enhanced programming for such seriously mentally ill individuals. However, the monitor has discovered that security is not consistently supportive of this effort to increase out-of-cell time, despite the fact that demonstrating such an effort is a critical part of the response to several provisions of this agreement. More specifically, for example, many such inmates have been prescribed group therapy, as indicated in their treatment plan. However in some cases, security has allowed them to attend group therapy, while others have not been allowed to attend, and still others are allowed to attend sometimes and yet not allowed to attend at other times. No explanation for this differential treatment has been given to mental health; this monitor was unable to figure out why this has occurred; but in the absence of the articulation of some clearly defined, acute security concern (which does not appear to be the issue), placement in isolation/segregation shouldn’t result in denying an inmate access to prescribed treatment, psychopharmacologic or otherwise.
RECOMMENDATIONS:
1. As per the provisions of this Settlement Agreement, inmates with serious mental illnesses may not be placed in isolation. This infraction should be repeatedly documented during the rounds of isolation/segregation cells performed by the mental health staff, and corrective action taken. This writer intends to request court intervention via Dr. Ray if this practice remains in effect at the next assessment visit.
2. For those seriously mentally ill inmates who refuse treatment, the mental health staff needs to opine as to whether or not such inmates are a sufficient danger to themselves or others that they would require isolation/segregation. In addition, a protocol must be developed for that subset of inmates that are a danger to themselves or others, focusing on attempting to get them to voluntarily accept treatment and outlining steps that should be taken for those who ultimately continue to refuse treatment.
3. With regard to those seriously mentally ill inmates who are currently in isolation/segregation for their own protection, the Bureau of Corrections needs to develop a corrective action plan with specific recommendations for capital improvements that will provide a more appropriate housing unit for such inmates, with dates to remedy this deficiency. In addition, once an alternative to the isolation/segregation of such inmates has been developed, mental health staff will need to develop enhanced programming for them.

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4. With regard to those seriously mentally ill inmates with an alleged disciplinary infraction, see the next section of this report.
5. During the time that inmates with serious mental illnesses remain in segregation, mental health staff should be aware that these inmates should be offered a minimum of 10 hours per week of unstructured out-of-cell time by security. Additionally, mental health staff is encouraged to develop supportive group or individual therapeutic activities, generally recommended being a minimum of 10 hours per week per inmate in order to support the inmate’s mental state as well as assist inmates in acquiring skills to move them officer the segregated status and sustain themselves in the general population setting whenever possible.
6. Security staff should assure that mentally ill inmates housed on isolation/segregation units continue to have access to prescribed mental health treatments, whether they are psychopharmacologic or non-psychopharmacologic interventions. Mental health staff should advise security administrators when inmates are denied such access so that security administration could look into the matter.
7. Mental health staff need to repeatedly raise all of these concerns during management and administrative meetings as a reminder to all levels of staff that these concerns remain and must be addressed. In such management meetings there should be a particular focus on issues that clearly relate to security concerns, space allocation, and other above noted issues that are under the control of those outside of the mental health unit.

q. Review by and consultation with a qualified mental health provider of proposed prisoner disciplinary sanctions to evaluate whether mental illness may have impacted rule violations and to provide that discipline is not imposed due to actions that are solely symptoms of mental illness;

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: During the 10th monitoring visit there was considerable discussion between the monitors, mental health staff, security staff, and corrections administrators regarding this issue.

During those discussions, it was clearly established that there should be mental health input into the disciplinary review process when there is some indication that the prisoner has mental health issues. However, it remained unclear as to how, if at all, such mental health input might be considered and/or how it might actually impact on the disciplinary review process. In addition, it became clear that the apparent lack of a range of disciplinary sanctions other than isolation/segregation further complicates this issue, by essentially limiting the disciplinary decision to isolation/segregation or no disciplinary action, regardless of the inmate’s mental health status.

During this most recent monitoring visit it became clear that there has been absolutely no progress made on this issue. Mental health staff had not been asked for input on any prisoner involved in a disciplinary action, despite the fact that that had at least appeared to be the one issue where there was some consensus. A review of the list of inmates who had disciplinary charges during this most recent period revealed that there were multiple inmates on that list who were also on the

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mental health caseload; during prior discussions, being on the mental health caseload had been considered to be one of the ways to identify the subset of inmates undergoing disciplinary proceedings for whom mental health input should be obtained; but no mental health input was sought for these inmates. During prior discussions, it was also noted that suspicion that an inmate might be suffering from mental health issues, regardless of whether or not such suspected issues were thought to be directly causative of the disciplinary infraction, would be another reason to request mental health input into the disciplinary process; it was decided that in such cases, a ‘behavioral checklist’ would be completed for the inmate, noting that the inmate is now involved in the disciplinary review process; but no disciplinary-related ‘behavioral checklists’ were received during this most recent period. It is impossible to determine exactly why no ‘behavioral checklists’ were filed as part of the disciplinary review process, but options range from there simply were no inmates who were suspected to have mental health issues (presumably including those on the mental health caseload, diagnosed with major psychiatric disorders), to those involved in the disciplinary review process were unable to recognize indicators that an inmate might be suffering from mental health difficulties, to those involved in the disciplinary review process are simply ignoring the need to implement this provision.

It remains to be determined whether or not the mental health training that is currently underway will increase the capacity of those involved in the disciplinary review process to identify the subset of inmates undergoing disciplinary review who might be suffering from mental health difficulties, and increase their understanding of why it is so important to request mental health involvement in the disciplinary review process for such inmates. However, it may very well be that specific training focused on this provision and designed for all of those directly involved in the disciplinary review process – i.e., covering policies, procedures and the knowledge and skills required to at least suspect that an inmate might be suffering from mental health difficulties – will be required.

As noted above, even if those involved in the disciplinary review process increase their capacity to identify the subset of inmates who might be suffering from mental health difficulties, and even if they then seek mental health input for that subset of inmates, what happens next (the other issues noted above) still has to be resolved before there can be any meaningful progress made on this provision.

RECOMMENDATIONS:

1, GGACF should continue to work on the development of an effective policy and process to provide mental health review and input into the disciplinary process.

2. Mental health staff must be prepared to quickly assess inmates with alleged disciplinary infractions, with an eye toward determining whether or not the alleged infraction was likely a product of any mental illness that the inmate might be suffering from, and the likely impact of potential sanctions on the inmate’s mental health status.

3. GGACF should develop a form that can be sent to the Mental Health Coordinator, completed by mental health staff and submitted to the disciplinary committee, which outlines the findings of the mental health assessment. The committee can use the same form to communicate back to the mental health staff the outcome of the hearing proceeding.

4. Mitigating factors discovered by the mental health professional must be at least considered by the disciplinary committee.

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5. Mental health services should track the effectiveness of their input in mitigating sanctions or terminating sanctions as appropriate.
6. Alternative housing and treatment services are an essential component in diverting seriously mentally ill inmates committing infractions due to their impaired judgment and mental processing.
7. Again, it is recommended that GGACF provide appropriate staffing and housing alternatives for this population. (See V.1.p.)

r. Medical facilities, including the scheduling and availability of appropriate clinical space with adequate privacy;

ASSESSMENT: NONCOMPLIANCE

MEDICAL FINDINGS: We were told that the Medical Director has developed a new plan and we performed a walk-thru of the medical area. We have seen that there is a new mental health group room that has been almost completed and is currently being utilized. Other rooms, including dental services, have been reconfigured. There are minor things under the new plan that need to be completed, such as removing doors, providing a plastic boat for the suicide room, replacing the porcelain fixtures with stainless steel, and the reconfiguration of the dental area. We performed a walk-thru with the Warden, who supported all of the changes and indicated that many of these could take place. We also observed the suicide room in the intake area. This has been completed; however, the nurse screening room where the nurse would perform the intake screen has not yet been completed.

RECOMMENDATIONS:

1. Complete all the minor changes that are recommended for the clinic building and complete the nurse screening room in the intake area.

MENTAL HEALTH FINDINGS: As noted above, the renovation of the group therapy room in the medical building has been completed; the renovation was extremely well done; and now the room is in use for group therapy.

As also noted above, the renovation of a cell in intake to make it a suicide-resistant cell has been essentially completed. Although the renovation of this particular cell increases the possibility that security will appropriately monitor/observe inmates on suicide watch, the location of the cell in the intake area makes it difficult for nursing staff and mental health staff to monitor such inmates who are being held there. In contrast, the renovation of the cell in the medical building to make it suicide-resistant remains incomplete.

The renovation of other space designated for mental health programming also remains incomplete and therefore unusable. Of particular concern is the renovation of multipurpose rooms on the segregation units so that the space can be used for expanded mental health programming for seriously mentally ill inmates who are housed there. The completion of this renovation would be

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a significant step towards removing seriously mentally ill inmates from segregation/isolation into a more appropriate setting where they can receive appropriate mental health services. RECOMMENDATIONS: 1. Continue with current renovation plans as quickly as possible. 2. Continue to assess the need for additional space for developing mental health programming.

s. Mental health care and treatment, including: (i) timely, current, and adequate treatment plan development and implementation:

ASSESSMENT: PARTIAL COMPLIANCE

MENTAL HEALTH FINDINGS: As noted above, during this monitoring visit the monitor did a more detailed review of randomly selected inmates on the mental health caseload. This review included a review of each inmate’s treatment plan, the information about each inmate contained on the various treatment logs, and each inmate’s medical/psychiatric record, as well as a discussion of the inmate with all mental health staff in the context of a clinical case conference held by the monitor. The results of that review process have been described above. However, to be clear with regard to this particular provision, the monitor found that treatment plans were well done; plans included a formulation of the inmate’s mental health difficulties and the goals of treatment; therapeutic interventions were linked to particular treatment goals; timelines for the meeting of each goal were noted; and for those who had been in treatment for some time, updates were also included, and where appropriate, the updates also noted any required changes in the treatment plan.

As noted in prior monitoring reports, this monitor recognizes that the adequacy of treatment plans might, at times, be compromised by some of the above noted problems that are outside of the control of mental health staff. When this is the case, this monitor expects to see any such required compromises noted in the treatment plan, so as to make it clear that there is a more appropriate intervention that is simply not currently available at the facility. Therefore, a treatment plan might note, for example, that an inmate will be switched to a specific, more appropriate modality of treatment when such becomes available.

RECOMMENDATIONS:

1. Based on policy and developed protocol, treatment plans should be updated at set frequencies based on inmate need and changing conditions in the inmate status. It is strongly recommended that supervisory review occur to ascertain the appropriateness and completeness of the treatment plans generated.

2. The mental health unit should also continue to use its own case conferences to ensure consistency between staff members in developing measurable objectives toward marked improvement in those inmates followed by the mental health team. Such efforts are important in and of themselves, but they will also be important as the unit continues to develop its capacity to regularly access the overall quality and efficacy of the unit’s efforts

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(ii) adequate mental health programs for all prisoners with serious mental illness;
ASSESSMENT: NONCOMPLIANCE
MENTAL HEALTH FINDINGS: As noted above, mental health programming has been expanded to include considerable non-pharmacologic therapeutic interventions, including the various group therapy sessions and the judicious use of individual sessions as needed. The addition of these interventions has been enormously helpful to many of the inmates who suffer from serious mental illness, and they have also been helpful to many of the ‘less ill’ but still unstable inmates, in that they have been helped to increase their capacity to remain more stable.
However, as also noted above, enhanced programming for seriously mentally ill inmates, especially those who are currently in isolation, continues to be a work in progress. There have been some notable gains with some of these inmates, despite the absence of a specifically developed enhanced program and despite the absence of renovated space where such an enhanced program could be provided. Staff must continue to find creative ways to offer as much programming as possible in the absence of the full facility to do so; staff must begin to plan for the development of a fuller enhanced program so such can put implemented once space is available; and, of course, staff must continue to advocate for the space that they require.
Finally, staff of the mental health unit continue to try to encourage those who have refused treatment to voluntarily accept treatment. Staff also appear to be clear about the fact that some subset of those who have refused treatment will never voluntarily accept treatment, and that some subset of those who will never voluntarily accept treatment meet the criteria for court intervention. However, the monitor continues to urge the mental health unit to distill all of this into a written and actionable policy/procedure. This is at least in part because having such a written policy/procedure that can be shared with other staff at the facility may help in efforts to address many of the problems noted above (such as the placement of seriously mentally ill in isolation/seclusion), and because the increased clarity that it would bring to the understanding of the management of seriously mentally ill individuals is so integral to addressing those problems.
RECOMMENDATIONS:
1. The mental health team will need to develop a global treatment menu designed to meet the needs of inmates at different levels of housing and treatment needs.
2. Group programming should be designed to meet the clinical needs of individuals who should be assigned to those programs based on their needs assessment and their individual treatment plan.
3. The facility should consider how it might create a special population housing unit that would provide a safe housing alternative to vulnerable mentally ill inmates and make the delivery of services more efficient to those who require enhanced mental health services.
4. Those who refuse needed treatment must be further assessed to determine if they are a danger to themselves or others. This assessment should be used to determine whether or not they require placement in isolation/segregation and whether or not a court intervention should

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be obtained that would require them to undergo treatment; and all the while efforts should continue to convince such inmates to voluntarily accept treatment.
(iii) adequate psychotropic medication practices, including monitoring for side effects ad informed consent;
ASSESSMENT: PARTIAL COMPLIANCE
MENTAL HEALTH FINDINGS: Most of the issues related to this finding have been discussed in earlier sections of this report. However, one additional issue should be noted here, and that is that during medical/mental health chart reviews, this monitor did not always find documentation of informed consent for medication. Therefore, mental health staff should make sure to obtain informed consent and make sure that documentation of signed informed consent is included in the chart of all those who are currently taking psychotropic medications.
In addition, it remains the opinion of this monitor that all mental health staff and nursing staff should be trained to look for possible major medication adverse effects. There is no expectation here that mental health staff and nursing staff would begin to diagnose medication adverse effects. Instead, the expectation is that such training might help staff suspect adverse effects and report their concern to the psychiatrist, and upon doing so, the psychiatrist might see an inmate earlier than scheduled and thereby intervene more quickly. Rapid intervention would, of course, decrease the amount of suffering that an inmate might endure; it might decrease the likelihood that an inmate might stop complying with psychopharmacologic interventions because of concerns about/fears of unacceptable adverse effects; and it helps with inmate learning that if he/she participates in treatment, adjustments and changes in medication can be made in response to problems that the inmate reports, which in turn tends to enhance compliance.
RECOMMENDATIONS:
1. Continue to ensure communication between nursing staff and the psychiatrist with regard to inmate compliance with psychotropic medication orders.
2. Confirm the obtaining of ‘informed consent’ for medication in the medical records or consider a special form for this purpose.
3. Assure that medical and mental health staff are trained to suspect the presence of psychotropic medication adverse effects and report such a suspicion to the psychiatrist in a timely manner.
(iv) comprehensive correctional and clinical staff training and a mechanism to identify signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload;
ASSESSMENT: NONCOMPLIANCE

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MENTAL HEALTH FINDINGS: The mental health training that has been developed has been described and discussed in prior monitoring reports. That training is now underway, and it is expected to be completed in July 2016. Once the training has been completed, it will be important to evaluate the extent to which the training reached its goals, some of which are noted below.
As has been previously noted, the ‘behavioral checklist’ is the mechanism available to correctional staff that would allow staff to identify and report signs and symptoms of mental health needs of prisoners not previously assigned to the mental health caseload. Staff has been using the ‘behavioral checklist’, and it is expected that the mental health training that is currently underway will significantly improve their capacity to do so.
It is also hoped that the mental health training will help staff better understand the various ways that different types of mental illness can impact on an individual’s ability to function, and thereby increase their appreciation for taking an inmate’s mental health difficulties into consideration when making important decisions concerning the inmate. Such important decisions might include, for example, classification/placement, the planned use of force, the use of isolation/segregation, and disciplinary decisions.
RECOMMENDATIONS:
1. Continue to utilize the Behavioral Checklist process.
2. Finalize and present mental health training for security staff.
3. Improve the incorporation of information obtainable from mental health assessments into security decision-making and review regarding disciplinary matters, the review of situations where there was use of force, the use of isolation/segregation, and the classification of inmates.
4. Consider a more formal process for providing feedback to security staff who complete a behavioral Checklist, regarding how helpful their effort to complete the checklist has been and also regarding any suggestions mental health might have that would help security staff better manage and otherwise interact with the individual.
5. Conduct a facility quality improvement morbidity review that can be submitted to the monitoring team for review.

(v) ceasing to place seriously mentally ill prisoners in segregated housing or lockdown as a substitute for mental health treatment.

ASSESSMENT: NONCOMPLIANCE

MENTAL HEALTH FINDINGS: Most of the issues related to this provision have been discussed in previous sections of this report. However, it should be noted that the point most specifically related to this provision is the placement of seriously mentally ill inmates in isolation/segregation reportedly for their protection, instead of placing them on a special unit where they can receive the enhanced mental health programming that they require.

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RECOMMENDATIONS:
1. GGACF must cease to place seriously mentally ill prisoners in segregated housing or lockdown as a substitute for mental health treatment.
2. The Health Services Administrator needs to coordinate regular monthly Medical Administration Committee (MAC) and Quality Improvement meetings, documented by minutes and attendance sign-in sheets. This issue should be an important agenda item for such meetings. These meetings should include the Warden or the Warden’s designee in order to assure that plans for addressing this issue take all aspects of the problem into consideration.

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VI. FIRE AND LIFE SAFETY

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the 11 provisions in this section of the Agreement. As shown in the scorecard below, all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

VI. Fire & Life Safety

1 2 3 4 5 6 7 8 9 10 11

1 V.1a: Adequate Fire Safety Program/Plan/Fire Marshall Review

00 0 0 0 0 0 0 0 0 0

V.1b: Adequate Fire Safety Steps / Fireload

2 Maintenance/Equipment Inspections/Alarms/Smoke

00 0 0 0 0 0 0 0 0 0

Detection in all Housing Units

3 V.1c: Defined Comprehensive/Documented Fire Drills/Staff 0 0 0 0 0 0 0 0 0 0 0 Competency

4 V.1d(i): Regular Housing Unit Inspections/Lock Functioning/Repair

00 0 0 0 0 0 0 0 0 0

5

V.1d(ii): Regular Housing Unit Inspections/All Remote Locking Mechanisms Functional

00 0 0 0 0 0 0 0 0 0

6 V.1e: All Staff Tested on Fire Safety Procedures

00 0 0 0 0 0 0 0 0 0

7 V.1f: Reporting/Notification of Fires/Audible Alarms

00 0 0 0 0 0 0 0 0 0

8 V.1g: Prisoner Evacuation as Indicated

00 0 0 0 0 0 0 0 0 0

9 V.1h: Fire Suppression

00 0 0 0 0 0 0 0 0 0

10 V.1i: Medical TX of Persons Injured from Fires

00 0 0 0 0 0 0 0 0 0

11 V.1j: Control of Highly Flammable Materials

00 0 0 0 0 0 0 0 0 0

# NonCompliance 11 11 11 11 11 11 11 11 11 11 11

# Partial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

Defendants will protect prisoners from fires and related hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant, emergency preparedness, and fire and life safety equipment, including the following:

a. An adequate fire safety program with a written plan reviewed by the local Fire Marshal;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No substantive improvement from the previous assessment. However, with the continued assignment of a full-time fire safety officer and the proposed assignment of a fire safety coordinator, we are encouraged that the fire safety program at GGACF will improve. The new fire safety coordinator will be responsible for the fire safety programs at GGACF and St. Thomas. We interviewed and reviewed the CV of the proposed fire safety coordinator, Mr. Charlemagne Davidson, and we determined that he is highly qualified to serve in the capacity of Fire Safety Coordinator. Mr. Davidson has intimate knowledge of the fire safety program at GGACF as well

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as the many challenges that remain in coming into compliance with fire safety provisions of the SA.
We continue to see incremental improvement in the conducting of monthly fire safety inspections of all areas of the facility. The monthly fire safety inspections are conducted in a consistent manner and deficiencies are being identified. However, corrective action on noted deficiencies needs to be addressed. We continue to note fire and life safety discrepancies dating back to May 2015 that have not yet been corrected.
The GGACF Fire and Safety policies and procedures have been finalized and approved by this Monitor. Next steps are for GGACF staff to start training on the policies and to commence a comprehensive implementation process of the fire safety program. Staff training and implementation of these policies and procedures remains vital.
Inadequate housing unit staffing levels and contraband control practices continue to enable inmates to ignite various materials in the housing units, as evidenced by our March 2016 inspection of the housing units. During these inspections I continue to observe the smell of smoke in several housing units.
The automatic fire detection and suppression system remains inoperable; inadequate staffing levels and contraband control leaves housing units deleteriously under-controlled and unmonitored; inmates apparently have undetected and uninterrupted access to items to ignite materials, and inmates obviously have no inhibition about igniting materials.
During this monitoring visit, it did not appear that there were any reported fires in the housing units. However, due to the ease by which inmates can access fire ignition sources and given the state of disrepair with the facility electrical system, i.e., exposed electrical wiring and heavy fire loads in the inmate cells, this area remains volatile from a fire and life safety perspective.
During our inspection, I also observed exposed electrical wiring in various areas of the facility, including the kitchen and housing units. In the kitchen I continue to observe boxes stacked in the dry storage area nearly up to the ceiling (should be stacked no higher than 30 inches below the ceiling). This was an identical finding in our previous reports. These findings, in addition to previous findings, reveal the urgent need to develop and implement a comprehensive fire safety program at GGACF.
There is still no documentation available to demonstrate that evacuation plans have been approved by the VI Fire Marshall. The fire evacuation diagrams within the facility remain woefully outdated and offer no assurance that they would be effective in routing staff and inmates from a fire or smoke related emergency. In fact, some diagrams still do not outline the appropriate route. On a positive note, Officer Samuel has continued to conduct systematic inspections of fire safety needs for the facility. A comprehensive fire evacuation plan that would incorporate all areas and buildings within the confines of GGACF and the contents of the overall fire safety program, such as the finalized and approved fire safety policies and procedures, needs to be provided to the VI Fire Marshal for review. It is also expected that with the assignment of the Fire Safety Coordinator, the fire safety program will be advanced towards compliance.

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RECOMMENDATIONS:
The Monitor continues to request the reports for all drills and exercises conducted. It is also imperative that when the GGACF Fire Safety Program and the Fire Safety Plan are finalized, that they be provided to the Fire Marshal along with a copy to the Monitor and USDOJ.
1. Implement the approved fire safety policies.
2. Repair/replace/install fire detection and suppression systems throughout the entire campus and structures.
3. Train all staff on this plan.
4. Install self-contained breath apparatuses (SCBAs) or an appropriate alternative at all locations where staff would need to search for or evacuate people.
5. Conduct and document quarterly fire drills for all shifts and document those activities.
6. Officials must continue to critically review staffing levels to ensure adequate inmate supervision and flammable contraband control in the housing units, fire detection, response, suppression, evacuation, and incident security.
7. Additional part-time fire safety officers should be selected from the officer corps, trained, and participate in the administration of a comprehensive fire safety program. It is unrealistic to expect one expert to develop and oversee such a complex program.
8. Supervisors should conduct routine, scheduled and unscheduled physical inspections of occupied structures, taking particular note of fire risks and hazards, document and report those findings to administration for timely appropriate corrective action.
9. The fire inspection program was detailed in the draft fire safety policies and procedures that the monitor provided to the parties, and they should become a fundamental element of preand in-service training once policies and procedures are finalized, approved, and implemented.

b. Adequate steps to provide fire and life safety to prisoners including maintenance of reasonable fire loads and fire and life safety equipment that is routinely inspected to include fire alarms, fire extinguishers, and smoke detectors in housing units;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Almost identical to previous Monitor’s reports, we found that the Housing unit fire control panels remain inoperable, the primary fire suppression system remains broken, and cell and housing unit sprinklers are non-functional. We noted an improvement in the housing units whereby inmates were not using the fire sprinklers to support personal clotheslines; however, we did note that some inmates were using makeshift clotheslines in other areas of their cells. The primary fire detection and suppression system was designed to automatically detect and

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extinguish fires within most of the housing areas. However, the older housing units are not equipped with this system. The detection system does not function and the sprinklers are either broken or clogged by inmates. The only way to alert staff and inmates of a fire or smoke hazard is to use handheld air horns that are located in the control rooms of the housing units.
Adequate supplies of handheld fire extinguishers were found in housing units, kitchen areas and medical unit. All devices were tagged showing current inspections and all gauges showed positive pressures. The Fire Safety Officer has incorporated the inspecting of fire extinguishers in his monthly inspection reports, which continues to be a positive step in improving fire safety. However, as the approved fire and life safety policies and procedures are implemented, GGACF staff must start taking deliberate steps in addressing discrepancies that are identified by the Fire Safety Officer and Fire Safety Coordinator.
As noted in previous reports, if GGACF plans to continue to house individuals in the “older” buildings with no plans to update or install fire suppression equipment in those buildings, GGACF will never come into compliance with these provisions.
Although it is commendable that the Fire Safety Officer has systematically embarked in identifying fire safety discrepancies and fire safety needs, the resources to correct those deficiencies must be provided. For example, the Monthly Fire Safety Inspection Reports for the months of January and February 2016 continue to identify missing or non-functional smoke alarms and inoperable emergency lights dating back to May 2015; therefore, funds need to be made available in order to purchase missing smoke alarms and for purchasing adequate stocks of batteries for them.
RECOMMENDATIONS:
1. Refer to recommendations above (a).
2. Consider purchasing fire safety program software from the NFPA and/or the American Correctional Association to assist in program development and monitoring.
3. Continue to support fire safety officer.

c. Comprehensive and documented fire drills in which staff manually unlock all doors and demonstrate competency in the use of fire and life safety equipment and emergency keys that are appropriately marked and identifiable by touch;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Documentation demonstrating compliance with this Provision was not provided during this assessment. In our previous reporting, GGACF staff indicated that fire drills have not been conducted on a regular basis. The Fire Safety Officer had commenced a process for conducting fire drills; however, documents evidencing this process were not made available during this reporting period.

During this site visit it appeared that security staff continue to have a better awareness of emergency key management. With a few exceptions, staff were able to identify emergency keys.

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In the housing units we inspected, we found emergency keys to be available. We conducted a random check of the emergency exit doors in Housing Unit 9-D and noted that security staff were unable to open one these doors. It appeared that the locking mechanism had been sabotaged. This area needs continuous monitoring and staff need to be trained and retrained on a continuous basis on the Key Control Policy and Fire Safety policies and procedures. In future site visits we will continue to inspect this area of fire safety. The Fire Safety Officer and security management should conduct drills to see how promptly cell doors can be manually unlocked.
Emergency keys are not appropriately marked and identifiable by touch. A system for marking and identifying all emergency keys that match the proper door locking mechanism needs to be developed and systematically implemented.
RECOMMENDATIONS:
1. Develop and implement a valid and reliable emergency key system as described above. Train and drill staff as discussed on system use.
2. Develop emergency key and locking mechanism inspection and reporting system as discussed above.
3. Implement competency-based staff training as discussed.
4. Exercise fire safety program using onsite, scenario-based drills; include community responders in exercise planning and exercise events.
5. Send the training officer and part-time fire safety officers to the National Fire Institute, National Emergency Training Center, Emmetsburg, MD for additional training.

d. Regular security inspections of all housing units that include checking: (i) that cell locks are functional and are not jammed from the inside or outside of the cell; and; (ii) that all facility remote locking cell mechanisms are functional;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Almost identical to our previous monitoring reports, documentation demonstrating compliance with this Provision was not provided during this assessment. However, compliance with this Provision and its actualization of its intended outcomes will remain virtually impossible without adequate staffing levels for housing units, supervision, and facility maintenance. It should be noted that the Maintenance Department has addressed a number of locking mechanisms in various areas of the facility, but a more systemic approach needs to be implemented in the housing units whereby the inspection of the locking mechanisms become routine.

The Maintenance policy has been approved. However, there is not a written preventative maintenance program or a regular security inspection program in place for checking that cell locks are functional and are not jammed from the inside or outside of the cell, nor is there a system for ensuring that all facility remote locking cell mechanisms are functional. During this monitoring visit

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we were pleased to again observe little evidence of inmates compromising the cell locks by inserting various materials in the locking mechanisms. We did, however continue to observe housing unit grills whereby the security grills were left open. We also noted improvement in other housing units where the entry door locks and doors had been repaired and were functional.
RECOMMENDATIONS: Same as above.
1. Also refer to recommendations related to security provisions, contraband, and inmate manipulation of cell door locking systems.
2. Repair all remote cell locking notification technology.
e. Testing of all staff regarding fire and life safety procedures;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: No records have been provided to verify that all staff have been trained and tested on safety procedures. The Settlement Agreement requires testing of all staff regarding fire and life safety procedures. The fire safety policies and procedures have been approved and now staff need to be trained on them.
RECOMMENDATIONS:
1. Maintain records proving that staff have been trained and tested on emergency procedures. GGACF officials should create a statistical report showing percentages of staff who have and have not completed required testing.
2. Provide this Monitor documentation evidencing compliance with this Provision.
f. Reporting and notification of fires, including audible fire alarms;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: The fire reporting and notification system remains inoperable as reported in previous Monitor reports. There is no automatic audible fire alarm system at GGACF; each housing unit is issued a handheld air horn to alert inmates’ evacuation. This system may be useless, however, since all cell doors must be opened manually and the central control panels for the housing units remain inoperable. As identified in previous Monitoring reports and consistent with this inspection, the only means of adequately detecting and responding to fire emergencies is having an officer physically present at the scene of the emergency.
RECOMMENDATIONS:
1. Install and routinely test the stored file alert notification system without delay.

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g. Evacuation of prisoners threatened with harm resulting from a fire; ASSESSMENT: NONCOMPLIANCE FINDINGS: The fire evacuation policies and procedures have been approved and now staff must be trained on them and implemented to include full scale evacuation drills. RECOMMENDATIONS: 1. Develop and implement an annual full scale evacuation exercise that involves community
emergency, health, and social services responders.

h. Fire suppression;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Same as previously stated. There is no functional fire suppression system, with the exception of the kitchen’s cooking area.
RECOMMENDATIONS:
1. Develop and implement an annual full scale evacuation exercise that involves community emergency, health and social services responders.
2. Repair the automatic fire detection, notification, and suppression system.
3. Replace cell sprinklers with tamper-proof mechanisms.
4. Monitor staff response to fires, ensure they comply with basic fire safety principles, and implement appropriate staff corrective action as needed.

i. Medical treatment of persons injured as a result of a fire; and

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The requirements for this provision are addressed in the final and approved Fire and Life Safety policies and procedures. The next step is to ensure that staff are trained on them and they need to be fully implemented.

RECOMMENDATIONS:

1. Implement approved policies and procedures.

2. The comprehensive fire safety program development must involve health care leadership to ensure that policies and procedures include adequate provisions for timely medical and mental health response to persons injured during a fire event.

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3. Medical and mental health staff should be appropriately trained in relevant fire safety program components and drilled quarterly to ensure compliance with program response requirements.
4. Policy components involving medical and mental health staff should provide for their safety and security when involved in fire incident responses.
5. Qualified medical staff should participate in the development of fire program training topic that involves burns and smoke inhalation concerns. Qualified mental health staff should participate in the development of training related to critical incident recovery and emotional injury and recovery.
j. Control of highly flammable materials.
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Many inmate cells still contain considerable personal property, thus creating a fire and safety risk. The project of providing bins to all prisoners to store their personal belongings will help alleviate this problem. Identical to previous reporting, flammable storage areas/cabinets in the Carpentry shops do not appear to be properly vented; however, the fire safety staff reported that they will be addressing this issue as they systematically implement the approved Fire and Life Safety policies and procedures.
RECOMMENDATIONS:
1. It is anticipated that staff will be trained on the approved policies and procedures concerning the control of highly flammable materials as well as implementing them.

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VII. ENVIRONMENTAL HEALTH AND SAFETY

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the 11 provisions in this section of the Agreement. As shown in the scorecard below, the Territory has maintained six (6) provisions (55%) out of NonCompliance since the 7th assessment. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

VII. Environmental Health & Safety

1

VII.1a: Housing Plans/Proper Cleaning/Preventative Maintenance Plan/Response to Routine/Emergency Needs

2 VII.1b: Adequate Ventilation Throughout Facility

Compliance Assessment Report Number & Scores 1 2 3 4 5 6 7 8 9 10 11 00 1 0 1 1 1 1 1 1 1 00 0 0 0 0 0 0 0 0 0

3 VII.1c: Adequate Lighting/All Prisoner Housing/Work Areas 0 0 1 1 1 1 1 1 1 1 1

4

VII.1d: Adequate Pest Control for Housing Units, Medical Units/Food Storage

01 1 1 1 1 1 1 1 1 1

5

VII.1e: Prisoner/Clinical Staff Access to Hygiene/Cleaning Supplies

01 1 1 1 1 1 1 1 1 1

6 VII.1f: Cleaning/Handling/Storing/Disposal of Biohazardous 0 0 1 1 1 1 0 0 0 0 0 Materials

7 VII.1g: Mattress Care/Cleaning

00 0 0 0 0 1 1 1 1 1

8

VII.1h: Chemical Control/Supervision of Prisoners Having Chemical Access

01 1 1 1 1 1 1 1 1 1

VII.1i: Laundry Services/Sanitation Providing Adequate

9 Clean Clothing,Underclothing,Bedding at Appropriate

00 0 0 0 0 0 0 0 0 0

Intervals

10 VII.1j: Defined Food Services Safety/ Hygiene/ Temps/ Storage/ Transportation

00 0 0 0 0 0 0 0 0 0

11 VII.1k: Sanitary/Adequate Drinking Water Supply

00 0 0 0 0 0 0 0 0 0

# NonCompliance 11 8 5 6 5 5 5 5 5 5 5

# Partial Compliance 0 3 6 5 6 6 6 6 6 6 6

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 3 6 5 6 6 6 6 6 6 6

Percent Out of Noncompliance 0% 27% 55% 45% 55% 55% 55% 55% 55% 55% 55%

Substantive Provisions:

Defendants will protect prisoners from environmental health hazards by providing constitutionally adequate living conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the physical plant and environment, including the following:

a. Written housekeeping and sanitation plans that outline the proper routine cleaning of housing, shower, and medical areas along with an appropriate preventive maintenance plan to respond to routine and emergency maintenance needs;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Documentation in the form of logbooks and memorandum was provided during this

monitoring visit that demonstrated ongoing efforts by GGACF officials and maintenance staff to

assess, improve, and monitor facility sanitation and hygiene. Cleaning supplies continue to be

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more readily available in the housing units. Some housing units and cells were cleaner than others and the need to consistently conduct routine and sustained cleaning of all facility areas remains a challenge to GGACF staff.
Again, however, housekeeping and sanitation plans will not meet compliance with this Provision without adequate staffing levels, as previously stated.
The Maintenance Supervisor maintains preventative maintenance schedules for various components of the GGACF physical plant, including the emergency generator. The emergency generator had been problematic for some time. However, the Maintenance Supervisor reported that the emergency generator has been repaired and is functional.
Non-functional drinking fountains in the housing units remain of serious concern and have negative implications on inmate health and safety.
RECOMMENDATIONS:
1. Replace, repair, and install reliable sinks in all cells and housing areas that provide safe drinking water for inmates.
2. Prohibit allowing inmates to use toilets, sinks, and described clotheslines for cleaning clothes and linens.
3. Laundry exchanges of clean, institution-issued linens and clothing should occur at least twice per week.
4. Replace, repair, and install working showerheads and plumbing to provide reliable personal hygiene, adhere slip-resistance materials at shower entrance points to reduce fall risks, repair water draining to eliminate standing water in unit and cell floors.
5. Develop a mold control/mitigation plan that includes routine inspection and cleaning activities. Control access to related cleaning chemicals and train staff and inmates in the proper use and storage of those chemicals.
6. Develop and implement a sanitation management plan that monitors and mitigates sanitation problems and hazards.
7. Improve practices involving mattress cleaning and ensure inmates and staff involved in this program are trained in proper cleaning methods and use of materials and chemicals. Ensure mattress storage areas are sanitary at all times.
8. Repair all housing/cell windows to prevent penetration by insects.

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b. Adequate ventilation throughout the facility;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: As stated in previous reports, ventilation throughout all housing units remains troubling. High summer temperatures and humidity make the housing units and cells constantly uncomfortable for breathing. High temperatures and poor ventilation can contribute to and exacerbate pulmonary illness, and potentially jeopardize the health of inmates on psychotropic medications (many such medications can cause harmful reactions when body temperatures are elevated).
The Director of Corrections is prioritizing the project as part of the capital improvement program for GGACF.
RECOMMENDATIONS:
1. Timely complete an air quality assessment performed by a qualified provider.
2. Implement necessary improvements that reduce housing area and cell temperatures and increase air flow.
3. Medical and mental health staff should monitor all inmates for heat and airflow-related health risks. All inmates in segregation or who are locked in their cells should be monitored by medical and mental health staff for signs of health conditions.
4. Train all staff in detecting and responding to health conditions related to heat and air circulation contributors.
5. Install environmental health condition monitoring devices, e.g., temperature, humidity, and air quality readers. Require regular monitoring and recording of readings and take timely action to mitigate environmental conditions that create health risks caused by those conditions.
6. Medical and mental health professionals should closely monitor inmates being administered mediations that are adversely affected by high body temperatures and take appropriate steps to eliminate adverse effects.

c. Adequate lighting in all prisoner housing and work areas;

ASSESSMENT: PARTIAL COMPLIANCE

FINDINGS: Attention to lighting repair and replacement remains positive. However, some security staff continue to allow inmates/detainees to cover their cell lights, which is creating a fire hazard.

RECOMMENDATIONS:

1. Develop a comprehensive campus/facility lighting plan that ensures constant illumination of all required internal and external perimeters, housing areas, support services, structures and areas.

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2. Maintain an ongoing lighting repair log that evidences repair activities.
3. Ensure rapid repair and replacement of inoperable lighting, add additional external and internal illumination where indicated by a comprehensive security lighting needs assessment.
4. Provide for adequate staffing levels to support lighting plan and maintenance.
5. Increase illumination in all occupied cells for improved security and inmate wellness.
6. Prohibit inmates from blocking cell door windows and from erecting anything in their cells that impedes good visibility from the cell door window.
7. Ensure that all emergency lights in housing units (and other occupied areas in the facility) are reliably operational.
d. Adequate pest control for housing units, medical units, and food storage areas;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: Very little change since previous inspections. This provision remains in partial compliance but no significant decline in performance was found. Identical to our previous inspection, we noted that the overhead door to the storage area of the Kitchen is not properly sealed and rodents and vermin can easily infiltrate the Kitchen. Inmates in the housing units complained of insect presence. We also observed missing or broken screens on many facility windows.
The BOC has a contract with a private vendor (Oliver Exterminating of St. Croix) to provide pest control services at GGACF. It does not seem that the contract provides for individual cell extermination, but perhaps it should.
RECOMMENDATIONS:
1. Review, revise, develop, train, implement, evaluate environmental pest control policies and procedures that provide for both incidental and scheduled pest control inspections and mitigation.
2. Ensure that inmates involved in pest control activities are properly trained, equipped, and clothed for requirements of those activities.
3. Replace all missing and broken unit and cell window screens to prevent access by insects.

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e. Prisoner and clinic staff access to hygiene and cleaning supplies;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: There was no substantive improvement from previous assessments. Inspection of housing units, cells, kitchen, and medical areas again show consistent presence of personal hygiene and cleaning supplies. However, similar to previous site visits, there were a number of inmate complaints in the Housing Units claiming they do not have sufficient quantities of cleaning materials to properly sanitize the showers. We observed that many inmate showers are in deplorable condition from a sanitary standpoint, including mold problems and physical plant deterioration. We also observed that some showers have been repaired from our previous site visit.
RECOMMENDATIONS:
1. Ensure that all inmates have access to hygiene products upon admission to the facility.
2. Continue to provide adequate supply of these personal care items in control pods or housing units to ensure timely exchange of use-for-new products.
3. Prohibit inmates from bartering these supplies and from hoarding empty containers in their cells and living areas.

f. Cleaning, handling, storing, and disposing of biohazardous materials;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: There is no formal sanitation plan or protocols covering compliance with this Provision, nor is there a formal training program for staff or inmates on this topic. Staff and inmates must be trained and demonstrate competence in handling biohazardous materials, provided and instructed on the proper use of bio-protective clothing and supplies, and supervisors must closely monitor biohazard clean-ups.

In Housing Unit 9, we observed evidence in prisoner’s cell that had been transferred to the hospital as a result of an apparent altercation with another prisoner. Even though several days had transpired since the incident, the prisoner’s cell was in a state of disarray, unsanitary and still contained blood splatter residue on the floor. This is a serious breach to staff and inmate health safety.

Remaining in noncompliance with this Provision can jeopardize the health of staff and inmates.

Spill clean-up kits were available in the medical area.

RECOMMENDATIONS:

1. Develop, as part of medical infection control policies and facility sanitation plans, a comprehensive biohazard control plan that includes:

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a. OSHA and CDC standards and protocols for biohazard safety and exposure control;
b. Written and enforced procedures and protocols for biohazard handling, cleaning, disposal, storage, inspections, and cleanup;
c. Staffing and inmate training on the plan and proper handling and disposal of biohazards;
d. Consistently maintain adequate supplies of feminine hygiene products and disposal bags for all biowaste;
e. Locate adequate supplies of biohazard disposal and cleanup supplies in or at all locations where biological waste and/or spills do and could occur;
f. Provide appropriate cleanup apparel and training in the use of that apparel.
2. Commence deep cleaning of all housing and cell area walls, floors, showers, and other living areas to remove all dried bio products and waste. Do the same in the kitchen, medical areas, intake, and all washrooms throughout the facility.
3. Develop a biohazardous control program that involves regular inspections of all potential contamination areas.
4. GGACF officials should consult an environmental specialist to assess these conditions and assist them in developing appropriate mitigation plans and policies.
5. This provision can advance to Substantial Compliance once related policies and procedures have been approved and implemented according to the Agreement.

g. Mattress care and replacement;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: The related policy has been approved by the United States and the Monitor. I did not see this area to be problematic during this monitoring visit. There were no inmate complaints regarding their mattresses, and the ones I inspected were adequate, with few exceptions. However, GGACF staff have not yet substantially addressed the Monitor’s previous recommendations below.
RECOMMENDATIONS:
1. Refer to previously discussed sanitation recommendations.
2. Issue clean and usable mattresses to all inmates.

3 Complete a full inventory of non-usable mattresses and remove them from the supply.


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4. Do not issue mattresses to inmates until after properly inspected for damage and contraband, cleaned and sanitized.
5. Maintain reliable records that verify mattress inventories, cleaning, and maintenance requirements.
h. Control of chemicals in the facility, and supervision of prisoners who have access to these chemicals;
ASSESSMENT: PARTIAL COMPLIANCE
FINDINGS: No substantive change since previous assessment. Implementation of the approved policies and procedures, and a quality assurance tracking system will aid in advancing this provision to Substantial Compliance. Although chemical storage appears appropriate, there is no training program for staff or inmates responsible for handling and controlling these chemicals. Additionally, staff that supervise inmates and are allowed to handle these chemicals must be properly trained in that role and those responsibilities. This has yet to occur. As noted in our previous report, staff have developed Material Safety Data Sheets that are contained in notebooks and have been placed in various areas of the facility.
RECOMMENDATIONS:
1. Implement approved policies and procedures.
2. Develop comprehensive control plans for cleaning supplies and chemicals, chemical inspections, inventory control, and inmate training in use of supplies. Ensure adequate record keeping, monitoring and property control logs.
3. Ensure the cleaning chemical control plan is coordinated with medical staff for harmful exposure mitigation, response, and recovery protocols.
4. This provision can advance to Substantial Compliance once related policies, procedures, and plans are approved and implemented according to the Agreement.
i. Laundry services and sanitation that provide adequate clean clothing, underclothing, and bedding at appropriate intervals;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: We found no substantive improvement in this area from our previous site visit. As stated in previous reports and found during this monitoring visit, inmates continue to routinely wash personal and issued clothing in cell sinks and toilets. We observed inmates drying these items in their cells using clotheslines anchored to walls, window frames, bunks, etc. We also continue to observe worn out linens and dirty linens in many inmate cells.

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RECOMMENDATIONS:
1. Implement approved policies and procedures.
2. Cease the practice of allowing inmates to wash personal and issued clothing in toilets and sinks.
3. Cease the practice of allowing inmates to dry clothing on makeshift clotheslines in their cells.
4. Routine and consistent replacement of damaged mattresses, mattress cleaning, cleaning of bedding.
5. Review, revise, develop, train, implement, and evaluate a comprehensive laundry management plan that governs total laundry operations.
6. Consider replacing all wood laundry carts made of nonabsorbent materials that can be sanitized and completely cleaned. Discontinue the practice of moving laundry on carts that have not been cleaned and sanitized.
7. The initial issue of inmate supplies should include, at minimum: one (1) corrections issue shirt/pants, jumpsuit, undergarments, towel, bedding, mattress, sheet, and blanket. Clothing should be exchanged with clean items twice per week at a minimum, sheets and towels once per week at a minimum. Blankets should be exchanged monthly at a minimum. Any clothing, linens or bedding should be changed immediately if they appear damaged and/or unsanitary, or appear to present a risk to health.
8. Ensure that inmate handbooks provide clear rules and information about the laundry program, how to access clothing, linens, and bedding. Cease the practice of allowing inmates to wash clothing in housing unit or cell sinks and toilets.
9. Staff and inmates involved in the laundry work program should be properly trained and supervised.
10. Laundry equipment should be reliable and properly maintained.

j. Safe and hygienic food services, including adequate meals maintained at safe temperatures along with cleaning and sanitation of utensils, food preparation and storage areas, and containers and vehicles used to transport food;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: The Director of Corrections reported that funding has been secured to refurbish the Kitchen and the bidding process was initiated. This is a very positive development. In addition, the food services policies and procedures have been finalized and approved.

The physical plant of the Kitchen remains in a state of substantial deterioration as does the food service equipment. Overall, the kitchen was clean. The dishwasher is still not working properly.

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There is still an inoperable walk-in refrigerator that was cleaned from our previous site visits; however, there is still evidence of insect and rodent infestation that staff are trying to address. It appears that part of the scope for the kitchen refurbishing project will be the permanent removal of all inoperable and non-useable food service equipment.
The kitchen doors are not rodent-proof. We observed evidence of mold and rust in various areas of the Kitchen that staff is attempting to temporarily address; however, a permanent fix to the problem still needs to be made to the overall structure of the kitchen.
The kitchen officer is still working on finalizing a chit checkout system for the utensils and dangerous implements. This has been a lengthy project that requires completion.
RECOMMENDATIONS:
1. Implement approved policies.
2. GGACF officials should review food service requirements promulgated by the National Correctional Association and National Commission on Correctional Health Care.
3. Develop a food service training program that includes inmate and staff training records and ensure that all training is well-documented.
4. Policies and procedures developed should include controls for the use of caustic, toxic, and hazardous materials used in the kitchen. Material Safety Data Sheets should be posted conspicuously.
5. Timely complete planned renovations to the kitchen and food service support areas.

k. Sanitary and adequate supplies of drinking water.

ASSESSMENT: NONCOMPLIANCE

FINDINGS: No major improvement was again observed in the housing units during this assessment with the exception of X-Dorm.

The lack of constant reliable access to drinkable water further prevents GGACF from ensuring that inmates live in a healthy environment. Similar to previous reporting, many of the cell sinks were still inoperable and inmates rely on officers to provide water before and during lockdown. Access to drinkable water is generally available during the “out of cell” periods, but inmates must rely on the presence and actions by officers following lockdown. Inmates have no access to drinkable water when there are no officers on the units to provide it, and water from cell sinks is considered not safe for drinking. In previous site visits, inmates consistently complained of seeing particles of rust in the ice that is provided to the housing units. During this visit there were still some complaints regarding contaminated ice with rust and particles. A long-term solution to the problem still needs to be addressed through the installation of refrigerated water fountains in the housing units.

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In X-Dorm we had been reporting a consistent problem regarding the lack of drinking water for this unit. However, since our last four site visits, GGACF officials have addressed this problem by installing portable water bottles in the dorm. We did note that the assigned officer’s portable drinking fountain was empty.
RECOMMENDATIONS:
1. Develop and implement a corrective action plan that ensures inmates have consistent and reliable access to safe drinking water.
2. Ensure that all inmates are provided consistent access to sanitary drinking water.

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VIII. TRAINING

Compliance Summary: As discussed herein, this assessment found not factual basis on which to change any of the Monitor’s compliance ratings of the four (4) provisions in this section of the Agreement. As shown in the scorecard below, all provisions remain in NonCompliance. This scorecard is expected to substantively improve upon full implementation of these provisions.

Agreement Section & Substantive Provisions

Compliance Assessment Report Number & Scores

VIII. Training

1 2 3 4 5 6 7 8 9 10 11

1 VIII.1a: Defined Staff Training Curricula/Scheduling

00 0 0 0 0 0 0 0 0 0

2 VIII.1b: Pre-Service Training for all New Employees

00 0 0 0 0 0 0 0 0 0

3

VIII.1c: Periodic In-Service Training/Retraining of all Employees Following Pre-Service Training

00 0 0 0 0 0 0 0 0 0

4

VIII.1d: Documentation & Accountability Measures to Ensure Staff Completion of Required Training

0

0

0

0

0

0

0

0

0

0

0

# NonCompliance 4 4 4 4 4 4 4 4 4 4 4

# Partial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Substantial Compliance 0 0 0 0 0 0 0 0 0 0 0

# Sustain Compliance 0 0 0 0 0 0 0 0 0 0 0

Progress Points 0 0 0 0 0 0 0 0 0 0 0

Percent Out of Noncompliance 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Substantive Provisions:

Defendants will take necessary steps to train staff so that they understand and implement the policies and procedures required by this Agreement, which are designed to provide constitutional conditions.

1. Accordingly, Defendants will develop and submit to USDOJ and the Monitor for review and approval facility-specific policies regarding the following:

a. The content (i.e. curricula) and frequency of training of uniformed and civilian staff regarding all policies developed and implemented pursuant to this order;

ASSESSMENT: NONCOMPLIANCE

FINDINGS: Policies and procedures required under this provision have been fully completed and approved by this Monitor, the United States, and the Territory.

Training and implementation for the approved medical and mental health policies and procedures is well underway. GGACF staff, in collaboration with the United States and the monitoring team, developed curricula for training health care and custody staff (as required) on these policies and procedures. A training plan for these policies and procedures was approved by the United States and this Monitor and file as D.E. 923-1 on June 16, 2015. This plan divides training into four groups with specified timelines for demonstrating completion of training for each group. Combined, the four groups comprise some 37 training topics. Training for groups 1-3 (26 topics) was completed as of September 14, 2015. The final 11 topics (group 4) is scheduled for completion by July 31, 2016.

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On April 22, 2016, the Territory issued written notice the this Monitor and the United States that the weekly training schedule for completing grouping 4 training was not underway due to holidays that were not contemplated when developing the training schedule. Nonetheless, the Territory stated that it remains on track to complete all training by July 31, 2016. The Territory advised this Monitor they will file this information in their next status report.

The Territory has selected a contract-provider to develop and implement the training requirements of this Agreement; we had the opportunity to meet representatives from this company and review proposal documents while onsite. These interviews and review of documents seem to indicate that the contract-provider is well qualified and competent, and voiced a serious determination to ensure that their product complied with the conditions of the Agreement and produced required outcomes.

Briefly, the Territory and contract-training provider are developing training curricula for 1) policies and procedures and 2) other training topics contained in the training policy. This contractor stated that all components of the curricula will meet industry standards and include all lesson plans, learning materials, and pre and post-training assessments. Additionally, instructor development curriculum will be developed for preparing qualified GGACF staff to facilitate and instruct the new curricula, and onsite instructor monitoring and coaching by the contractor during the first 80 hours of staff training to ensure instructor fidelity to the prescribed training protocols. Training GGACF staff to train their own will be a major step toward the Territory demonstrating sustainable compliance during and beyond the term of this Agreement. Section F.2 of the Territory’s approved training policy below specifies pre and in-service training requirements for unformed and civilian staff, and GGACF leadership. This robust list of basic and advanced topics on contemporary correctional science meets industry standards and is adequately comprehensive to meet compliance requirements and GGACF staff professional needs.

General Assignment

Pre-Service Training Requirement (Subject Areas)

Civilian Staff (noninmate/detainee contact,

1. Orientation to Corrections / BOC / GGACF 2. Facility Orientation 3. Emergency Procedures 4. Communication Systems / Uses

determined by job description)

5. Sexual Abuse Prevention and Response (PREA), BOC-PREA-4000
6. Facility Access & General Security 7. Professionalism 8. Incident Reporting Policy, BOC-SEC-1003 9. Administrative Investigations/Staff Discipline Policy, BOC-SEC-1006 10. Searches Policy, BOC-SEC-1011 11. Fire and Life Safety Policy, BOC-EHS-3003 12. Training Policy, BOC-TRAIN-1000

13. OJT

Civilian (Qualified Medical/Mental Health Staff)

1. Same training as Civilian Staff (non Inmate/Detainee Contact) 2. Inmate/Detainee Complaints/Grievance Process, BOC-SEC-1007 3. Communicable Diseases 4. The following approved medical and mental health policies and procedures:
a. Infection Control, P-B-01 b. Suicide Prevention and Observation, P-G-05 c. Informed Consent and Refusal of Care, P-I-05 d. Medical Records, P-H-01,3,4

e. Emergency Psychotropic Medications, P-I-02

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Minimum Duration of
Training 20 Hrs. Total
1. 20 Hrs. 2-4- 20
Hrs.
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f. Terminally Ill Inmates/Detainees, P-G-11 g. Pregnant Care, P-G-09 h. Alcohol and Drugs Detoxification and Intoxication, P-G-06&07 i. Basic Mental Health Services, P-G-04 j. Infirmary Care, P-G-03 k. Medical Diets, P-F-02 l. Chronic Disease Management, P-G-01 m. Discharge Planning, P-E-13 n. Contraception, P-G-09 o. Restraints and Seclusion, P-I-01 p. Continuity of Care, P-E-12 q. Nursing Assessment Protocols, P-E-11 r. Emergency Services, P-E-08 s. Hospital and Specialty Care, P-D-05 t. Oral Care, P-E-06 u. Basic Health Assessment v. Receiving Screening, P-E-02 w. Nonemergency Health Services/Sick Call, P-E-07 x. Aids to Impairment, P-G-10 y. Psychotropic Medication, P-D-02B z. Medication Services, P-D-02 aa. Pharmaceutical Operations, P-D-01 bb. Patient Safety, P-B-02 cc. Grievance Mechanism for Health Complaints, P-A-11 dd. Notification of Serious Illness or Injury and Procedure in the Event of Death, P-
A-10 ee. Privacy of Care, P-A-09 ff. Continuous Quality Improvement, P-A-06 gg. Access to Care, P-A-02 hh. Transfer Screening, P-E-03 ii. Segregated Inmates/Detainees, P-E-09 jj. Patient Escort, P-E-10

Civilian Staff 1. Same as civilian staff with no inmate/detainee contact, and:

2-6. 40 Hrs.

(inmate/detainee 2. Radio Communications

Total

contact,

3. Personal Safety/Security

determined by 4. Effectively Communicating with Inmates/Detainees

job description) 5. Detection and Reporting of Prisoner Medical, Mental Health, and Suicide Risk Detection

& Reporting

6. Training on the following policies based on job responsibilities:

a. Classification and Housing Review, BOC-CLAS-2000

b. Special Housing Management, BOC-CLAS-2001

c. Inmate/Detainee Complaints/Grievance Process, BOC-SEC-1007

d. Inmate/Detainee Discipline, BOC-SEC-1005

e. Environmental Health and Safety, BOC-EHS-3000

f. Environmental Health and Safety-Food Service, Sanitation and Hygiene, BOC-

EHS-3006

g. Environmental Health and Safety -Control of Chemicals, Flammables, Toxic and

Caustic Materials, BOC-EHS-3004

h. Environmental Health and Safety-Inmate/Detainee Clothing, Bedding, and Linen

Supplies, BOC-SEC-3002

Custody Staff

1. Same as Civilian staff with inmate/detainee contact 2. Legal & Constitutional Aspects of Pre-Trial Confinement and Convicted Imprisonment 3. Security Methods and Practices 4. Inmate/Detainee Supervision

1. 40 hrs. 2.-26. 120 Hrs. Classroom

5. Contraband Prevention, Identification, Detection, Removal, Processing & Reporting 6. Use of Force, BOC-SEC-1004

27. 480 Hrs. OJT

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Mid-Level Custody Supervisor (Sergeants and Lieutenants)
UpperManagement Custody Supervisor (Chiefs of

7. Verbal Escalation Methods & Techniques 8. Weapon Retention 9. Interpersonal Communications 10. Crisis Intervention & Resolution 11. Inmate/Detainee Rules, Regulations, Rights, Privileges 12. Detection, Identification, Response, and Referral of medical and mental health
emergencies 13. Basic First Aid/CPR/AED 14. Communicable Disease Awareness & Prevention 15. Emergency Response & Management 16. Key Control 17. Social / Cultural Aspects of Prisoner Populations and Correctional Operations 18. Counseling Techniques 19. Inmate/Detainee and Workplace Cultural Diversity 20. Self-Defense 21. All approved security policies, procedures, post orders, and protocols 22. The following medical and mental health policies and procedures:
a. Discharge Planning, P-E-13 b. Suicide Prevention and Observation, P-G-05 c. Intoxication and Detoxication of Alcohol & Drugs, P-G-06 &07 d. Emergency Psychotropic Medications, P-I-02 e. Medication Services, P-D-02 f. Restraints and Seclusion, P-I-01 g. Hospital and Specialty Care, P-D-05 h. Segregated Inmates/Detainees, P-E-09 i. Patient Escort, P-E-10 j. Receiving Screening, P-E-02 23. OJT 1. Pre-service training for custody officer 2. Effective Supervision of Line Staff (Custody/Civilian) 3. Resource Management & Control 4. Leading Supervisors 5. Counseling & Discipline of Supervisors 6. Techniques of Instruction and Training 7. Staff / Resource Allocation & Management 8. Program Supervision, Management & Evaluation 9. Legal Aspects of Employee Discipline 10. Administrative Investigations and Documentation 11. Leadership in Supervision 12. Professionalism and Human Relations 13. Problem Solving & Decision Making 14. On-Scene Event Control & Management 15. Incident & Administrative Investigation 16. Shift Management 17. Staff Counseling & Discipline 18. Staff Performance Assessment & Evaluation 19. Collaboration 20. Conflict Intervention & Resolution 21. Monitoring & Enforcing Policy Compliance 22. Effective Documentation 23. OJT / Probationary Period: Student First-Line Supervisor consistently demonstrates proficiency and application of 80 hr. classroom topic areas under the mentorship of a qualified supervisor(s). Has completed all training for Mid-Level Custody Supervisor, and: 1. Executive Leadership, Command & Control 2. Leading and Supervising Mid-Level Managers 3. OJT

Probationary Training
1. same as above 2.-22. 80 Hrs. 23. 480 Hrs. OJT Probationary
1.-2. 80 Hrs. 3. 120 Hrs. OJT Probationary

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Security, Assistant Warden, Warden)

This contractor’s presentation of this training program development plan was very positive and promising. The selection of this vendor and the training plan seems to indicate deliberate intentions by the Territory to comply with the Agreement while improving the overall quality of GGACF staff performance. Draft curricula remains under development and will be forwarded to this Monitor and the United States for review and approval once completed, according to the BOC Director.
Train the trainer instruction on the approved PREA policy is tentatively scheduled with the National PREA Resource Center for June 28-29.
RECOMMENDATIONS: Previous recommendations remain appropriate.
1. Implement training policies and curricula once approved.
2. Provide this Monitor and United States all requested training documents.

b. Pre-service training for all new employees;
ASSESSMENT: NONCOMPLIANCE
FINDINGS: Unformed staff continue to receive basic preservice training as discussed in previous reports. The BOC Director understands the limitations of this training and has including an overhaul of all preservice training with the assistance of the new training program contractor. Topics for pre and in-service training are clearly delineated in the approved training policy and the training contractor will develop the requisite curricula needed to meet the requirements of this provisions, according to the BOC Director. Draft training materials will be forwarded to this Monitor and the United States as they are completed.
RECOMMENDATIONS:
1. Implement training policies and curricula once approved.
2. Provide this Monitor and United States all requested training documents.

c. Periodic in-service training and retraining for all employees following their completion of pre-service training;
ASSESSMENT: NONCOMPLIANCE

FINDINGS: As discussed previously in this section of the Agreement.


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RECOMMENDATIONS: Same as above.
d. Documentation and accountability measures to ensure that staff complete all required training as a condition of commencing/continuing employment. ASSESSMENT: NONCOMPLIANCE FINDINGS: As discussed previously in this section of the Agreement. RECOMMENDATIONS: As stated in previous provisions of this section.

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IX. IMPLEMENTATION

1. Defendants will begin implementing the requirements of this Agreement immediately upon the effective date of the Agreement. Within 30 days after the effective date, Defendants will propose, after consultation with the Technical Compliance Consultants (“TCCs”), a schedule for policy development, training, and implementation of the substantive terms of this agreement. The schedule shall be presumptive and enforceable until the Monitor is appointed.

FINDINGS: Implementation of this agreement remains somewhat slow but steady. New BOC and GGACF leadership seem positive and determined to ensure ongoing implementation of the agreement.

2. Upon appointment, the Monitor will adopt the schedule as proposed or as amended by the Monitor after consultation with the parties and the TCCs. Either party may seek a modification to the schedule by making a request to the Monitor, or the Monitor may modify the schedule as necessary. If the parties disagree with each other or with the Monitor and cannot resolve it with the Monitor, either party may submit the dispute to the district court.

FINDINGS: This Monitor has adopted and will continue to adopt all implementation schedules agreed to by the Parities or ordered by the court. This Monitor has and will continue to make all reasonable efforts to resolve disagreements between the parties about implementation schedules and support either parties’ right to seek dispute resolution from the court.

3. Defendants will implement every policy, procedure, plan, training, system, and other items required by this Agreement. Each policy required by this Agreement will become effective and Defendants will promulgate the policy to all staff involved in its implementation within 45 days after it is submitted to the United States, unless the United States or the Monitor provides written objections. The Monitor will assist the parties to resolve any disputes regarding any policy, procedure, or plan referred to in this document. If the parties still cannot resolve a dispute, either party submit the dispute to the district court.

FINDINGS: The development of final policies, procedures, and training curriculum has become a positive and collaborative process involving this Monitor and monitoring team members, and the parties. There are no outstanding standing disputes currently.

4. Defendants will conduct a semiannual impact evaluation to determine whether the policies, procedures, protocols, and training plan are achieving the objectives of this Agreement and to plan and implement any necessary corrective action. The Monitor will assist Defendants in identifying and analyzing appropriate data for this evaluation. The evaluation and all recommendations for changes to policies, procedures, or training will be provided to the United States and the Monitor.

FINDINGS: As previously reported, the semiannual impact evaluation documents submitted by the Territory only describe, but do not evaluate, compliance progress. This Monitor has provided the Territory consultation and documents to assist it in the development of methods for completing qualitative and quantitative evaluations. However, it is important to note that only medical and

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mental health policies and training have been fully implement and ready for empirical evaluation. Such evaluation of non-health care policies, procedures, and training will come once those requirements are fully implemented. This Monitor will provide additional and ongoing assistance to the Territory.
5. Defendants may propose modifying any policy, procedure, or plan, provided that the United States is provided with the 14 days’ notice in advance of the action. If the United States or the Monitor provides written objections, the Monitor will assist the parties to resolve any disputes regarding these items. If the parties still cannot resolve a dispute, the parties agree to submit the dispute to the district court.
FINDINGS: The Territory has become much more timely and proactive in involving this Monitor and the United States in proposed changes to policies, procedures, and/or compliance plans. This improvement has helped to improve the pace of programs and reduce unresolvable disputes.
6. Defendants shall provide status reports every four months reporting actions taken to achieve compliance with this Agreement. Each compliance report shall describe the actions Defendants have taken during the reporting period to implement each provision of the Agreement.
FINDINGS: The Territory continues to timely file required status reports. Descriptions of actions taken to comply with the agreement are improving.
7. Defendants shall promptly notify the Monitor and the United States upon any prisoner death, serious suicide attempt, or injury requiring emergency medical attention. With this notification, Defendants shall forward to the Monitor and the United States any related incident reports and medical and/or mental health reports and investigations as they become available.
FINDINGS: The Territory has become more proactive in notifying this Monitor and the United States of such incidents. The Territory monthly provides documents listing all prisoners who were provided emergency medical attention for the prior month. Also, the Territory provides notification and documentation of such incidents before submitting that monthly report where required by this agreement.
9. USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove, prisoners, and documents to fulfill its duties in monitoring compliance and reviewing and commenting on documents pursuant to this Agreement. Except to the extent that contact would violate the Rules of Professional Conduct as they apply in the Territory of the Virgin Islands, USDOJ and its attorneys, consultants, and agents shall have sufficient access to Golden Grove’s staff.
FINDINGS: This Monitor is not aware of any recent deviations from this requirement by the Territory.

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10. Excluding onsite tours, within 30 days of receipt of written questions from USDOJ concerning Defendants’ compliance with the requirements of this Agreement, Defendants shall provide USDOJ with written answers and any requested documents unless the Defendants obtain relief.
FINDINGS: Responses have been generally received within this 30-day requirement.

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X. MONITORING
D.1 Monitoring Access: Within 30 days of appointment by the Court, the monitor will conduct the first site visit and submit to the parties for their review and comment a description of how the Monitor will assess compliance with each of the Compliance Measures, how the monitor intends to gather information necessary for the assessment, and what information the Monitor will require the defendants to routinely report and with what frequency.
FINDINGS: This requirement has and continues to be met by this Monitor. Both parties have demonstrated positive support to this Monitor in carry-out these responsibilities.
D.2. Monitoring Access: With reasonable advance notice, the Monitor will have full and complete reasonable access to the Golden Grove Correctional Facility and Detention Center, all facility non-privileged records, prisoners’ medical and mental health records, staff members, and prisoners, Defendants will direct all employees to cooperate fully with the Monitor. Reasonable advance notice must be provided in this Agreement, this Agreement shall not be deemed a waiver of any privilege or right the Territory or Defendants may assert against a third party, including those recognized at common law or created by statute, rule, or regulation against any other person or entity with respect to the disclosure of any document. All nonpublic information obtained by the Monitor will be maintained in a confidential manner.
FINDINGS: Generally speaking, there has been improvement in the Territory’s efforts to facility compliance with this requirement. However, this Monitor continues to experience delays in receiving complete monthly monitoring documents, and responses to requests for information where reasonable advance requests are provided. That said, then Territory seems to be making better efforts to ensure timely and complete responses to this Monitor’s request for information and records.

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APPENDIX A – ASSESSMENT METHODOLOGY
This compliance assessment involved activities before, during, and following the onsite visit by the monitoring team and the Parties.
Pre-visit activities ensured involvement and input from officials and legal counsel representing the Territory (defendant) and the United States (plaintiff) in the planning of the site visit. Pre-visit activities included conference calls and exchange of relevant documents intended to maximize clarity and mutual understanding for assessment visit purposes and scheduling, and monitoring compliance expectations in general.
Pursuant to Section X.D.1 of the 2013 Settlement Agreement, the Monitor provided the following information to the Territory and U.S. Department of Justice officials for review and comment. This information intended to provide to the Parties: 1) the description of how compliance with the Agreement will be assessed; 2) how information necessary for on and offsite work will be gathered; and 3) what information the Monitor will require the defendants to routinely report and with what frequency.
1. Description of how the Monitor will assess compliance with each of the Compliance Measures.
In general, compliance assessment will include the following activities:
A. Discussions and meetings with facility officials, staff, providers, and inmates.
B. Discussions and meetings with community agency officials providing inspection or other regulatory oversight of GGACF.
C. Discussion and meetings with officials and staff of contract providers and community agencies who provide services within and/or for GGACF and inmates held in its custody.
D. Discussions and meetings with other pertinent staff, personnel, and community members, either as requested by the parties or who, in the determination of the Monitor, can provide relevant information for the purposes of monitoring.
E. Onsite tours of grounds, perimeter security barriers, perimeter access control and entrance points, all external security technology and methods, building and structural exteriors, roofs, and utility systems.
F. Onsite tours of all buildings, housing units, special environments, health care facilities, receiving and discharge areas, segregation units, all cell areas, food service and storage areas, utility closets and chases, utility technology and systems, fire prevention and suppression systems, life safety locations and equipment, other interior areas and location relevant to determine compliance.
G. Examination of all security equipment and systems used for perimeter, external, structural, internal, and special security operations purposes.

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H. Examination of health care equipment, supplies, materials, technology, and other material methods and processes used for inmate health care assessment, diagnosis, treatment planning, treatment (long and short-term), follow-up, and discharge planning.
I. Examination of agency motor fleet including all cars, busses, trucks, vans, and any other motorized vehicle used for correctional operations purposes.
J. Examination of any and all available records, data and/or information relevant to compliance and compliance monitoring not limited to the following:

 Administration  Budget  Personnel  Operations  Training  Facility construction, renovation, repairs, and maintenance  Equipment, supplies, and materials  Inmate case files  Medical and mental health screenings, assessments, evaluations, diagnoses,
treatment plans, progress charts, notes, medication logs and records, drug formularies, appointment calendars, invoices, etc.  Labor contracts  Incident reports and logs  Evidence/contraband reports and logs  Use of force incidents and logs  Inmate grievances and disciplinary records and actions  Policies, procedures, protocols, guidelines, post-orders, logs, memos, and other documents and information that support accurate compliance assessment and progress determinations  Employee complaints, grievances, claims, etc. directly or indirectly related to the compliance provisions  Other information required to determine compliance and compliance progress
The information described above is intended to assist the Monitor to determine compliance and the degree to which each of the compliance ratings (Noncompliance, Partial Compliance, and Substantial Compliance) apply to each provision assessed. Additionally, the Monitor will collaborate with the parties to develop metrics and core measures for qualitative and quantitative measurement of progress and compliance. Core measures and metrics should specifically pertain to the conditions set forth in the Settlement Agreement, and generally consider accepted standards and recommendations promulgated by the National Correctional Association, American Jail Association, National Commission of Correctional Health Care, American Psychiatric Association, American Nursing Association, ASIS International, National Fire Protection Association, Centers for Disease Control (CDC), OSHA, Territory regulations, and other nationally accepted standards for compliance and assessment and management. Additionally, specific measures articulated in the Order of the Court dated May 14, 2014 [Dkt 742] (the “Order”) shall be followed. The following compliance management terms are suggested for assessment and compliance monitoring:

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 Compliance Control: Implies activities designed and intended to inspect and reject
 defective or deficient performance, processes, services, equipment, etc. when applied.

 Compliance Assurance: Implies activities designed and intended to identify performance
 and services that assure compliance when applied.
 Compliance Improvement: Implies activities designed and intended to correct and/or improve compliance in performance and services.
 Compliance Management: Implies activities designed and intended to ensure targeted compliance outcomes.
 Domain: A core aspect of the organization’s performance, such as access to care, costs of care, or quality of care (e.g., consumer level of functioning, relapse and recidivism rates, or consumer satisfaction).
 Performance Indicator: A defined, objectively measurable variable that can be used to assess an organization’s performance within a given domain. For example, within the domain of consumer satisfaction, a performance indicator might be: “the percentage of consumers who state that they received the types and amounts of services that they felt they needed.”

2. How information necessary for on and offsite assessment work will be gathered.

Monitoring will involve gathering various forms of information both on and offsite and not limited to:

 Communications with Territory and U.S. Department of Justice Officials as authorized in the Order
 Onsite visits, tours, meetings, individual and group meetings, and interviews  Collection and examination of electronic, paper, and photographic records, information and
data  Photographs taken during inspections (not to be used in any report without expressed
written agreement of both parties)
  Online media information
  Online public records
  Electronic and standard mailing of information
  Email communication and phone consultations


3. What information the Monitor will require the Defendants to routinely report and with what frequency.

It is understood that the Territory will use existing records systems and processes to provide routine reports. However, new records and information systems and methods may become necessary to accurately report progress compliance and related performance. It is this Monitor’s desire to assist the Territory in developing records and information methods and processes that yield accurate, complete, and efficient reporting of compliance efforts and progress. Therefore, it is assumed that the compliance reporting process will evolve throughout the life of the Order.

Compliance reporting should include statistical reports, narrative descriptions of compliance activities and progress, improvement plans, case reviews, incident reports, and other information and data that helps the parties and the Monitor understand compliance progress as well as to identify issues and concerns that challenge compliance efforts. As recommended in previous

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reports, a monthly compliance report is proposed until the reporting system and compliance progress evolves to justify less frequent routine reporting.

Non-exclusive information required for assessments and monitoring include the following:

A) Corrections Information:

1. The most recent census report. 2. Last five (years) admission, release, average daily inmate population. 3. The housing unit floor plans for all facilities and housing units. 4. A copy of the facility’s policies and procedures manual(s), including the facility’s Use of
Force policy. [If you have the policies and procedures in electronic form, we would request all of them prior to our visit. Otherwise, we request only the Use of Force policy prior to our arrival]. 5. The Use of Force Log for the past twelve (12) months and a few sample Use of Force packages [we request only the Use of Force Log prior to our arrival]. Please indicate any use of force on an inmate on the mental health case list. 6. The Serious Incident Report Log for the past twelve (12) months. 7. The Inmate disciplinary Log for the past twelve (12) months. 8. The Contraband Log for the past twelve (12) months. 9. The Administrative Investigations Log for the past twelve (12) months. 10. A copy of the Inmate Grievance Policy. 11. A copy of the Inmate Grievance Log for the past twelve (12) months. 12. All forms and documents used by staff for inmate intake, assessment, classification, release, housing, supervision, disciplining, etc. Generally speaking, any form, report, log book, etc. used in the course of a corrections officers workday. 13. Documentation reflecting the current classification system, including policies and procedures related to such classification system. 14. Documentation reflecting any training facility staff has received, including any corrections officer training manuals, pre-service and in-service training completed by all staff over the past 36 months. 15. Current staffing schedules for security positions and shifts. 16. Job descriptions for all non-health care staff. 17. Copies of any self-evaluation reports, grand jury reports, American Correctional Association surveys, National Institute of Corrections reports/evaluations, National Commission on Correctional Health Care reports/evaluations, or any other outside consultant reports regarding the facility. 18. Any questionnaires, intake forms, or inmate handbooks provided to inmates upon their entry to the facility or during their stay in the facility. 19. The most recent Staff Manpower Report/Matrix that shows all authorized positions and which ones are vacant. 20. Reports and data showing turnover information and statistics for security, medical, mental health, and other staff positions budgeted and authorized for the previous 36 months. 21. Any staffing improvement plan, applications for technical assistance, and Territory budget proposals/authorizations to address staffing shortfalls. 22. Facility maintenance requests and work orders for the past 12 months. 23. Records and/or lists of physical improvements, repairs, and renovation completed to correct security problems and deficiencies over the past 36 months. 24. Past 26 months of agency budgets.

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25. List and contact information for any and all community vendors who provide services of any kind to GGACF and contracts or professional services agreement authorizing those services.
26. List and contact information for community regulatory agencies who inspect, review, approve, and/or provide consultation to the GGACF, i.e., health inspections, fire inspections, etc., and any inter-local agreements involved in these services.
B) Medical and Mental Health Information:
27. A mock or blank chart containing all forms used, filed in appropriate order. 28. The infection control policies. 29. The names of inmates who have died in the past year, and access to/or copy of both their
records and mortality review. 30. The names of any inmates diagnosed with active TB in the past year and access to/or a
copy of their records. 31. To the extent not provided above, the policies and procedures governing medical and
mental health care. 32. A staffing roster with titles and status, part time or full time, and if part time, how many
hours worked per week. 33. The staffing schedule for the past two (2) months for nursing and providers, including on-
call schedules for the same time period. 34. Job descriptions for medical staff and copies of current contracts with all medical care
providers, including hospitals, referral physicians, and mental health staff. 35. Inter-local professional services agreements with health care providers, companies, to
include health care policies under which those persons and/or entities provide inmate health care. 36. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or offsite for hospitalization listing where applicable name, date of service, diagnosis and services provided. 37. A list of all persons with chronic illness listing name, location, and name of chronic illness. 38. A schedule of all mental health groups offered. 39. Minutes of any meeting that has taken place between security and medical for the past year. 40. Quality assurance and Medical Administration Committee minutes and documents for the past year. 41. A list of all emergency equipment at the facility. 42. A list of current medical diets. 43. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 44. A copy of nursing protocols. 45. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment. 46. A list of all the inmates housed at the facility by birthdate, entry date, and cell location. 47. To the extent not provided above, external and internal reviews or studies of medical or mental health services including needs assessments and any American Correctional Association and National Commission on Correctional Healthcare reports.

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48. List of all inmates placed in restraints, and all inmates receiving mental health treatments, under suicide watch, or taking psychotropic drugs.
49. Current mental health case list including inmate name, number, diagnosis, date of intake, last psychiatric appointment, and any case lists of inmates followed only by counseling staff with last appointment date and follow-up appointment.
50. Documentation reflecting any training that facility staff have received on suicide prevention, including certificates and training materials.
51. All documents related to any suicide occurring within the past year. 52. List of all persons on warfarin, Plavix, digoxin.
C) Suicide Prevention Information:
53. All policies and directives relevant to suicide prevention. 54. All intake screening, health evaluation, mental health assessment, and any other forms
utilized for the identification of suicide risk and mental illness. 55. Any suicide prevention training curriculum regarding pre-service and in-service staff
training, as well as any handouts. 56. Listing of all staff (officers, medical staff, and mental health personnel) trained in the
following areas within the past year: first aid, CPR/AED, and suicide prevention. 57. The entire case files (institutional, medical and mental health), autopsy reports, and
investigative reports of all inmate suicide victims within the past three years. 58. List of all serious suicide attempts (incidents resulting in medical treatment and/or
hospitalization) within the past year. 59. List of names of all inmates on suicide precautions (watch) within the past year. 60. The suicide watch logs for the past year. 61. Clinical Seclusion logs for the past year. 62. Use of clinical restraint logs for the past three years. 63. Any descriptions of special mental health programs offered. 64. A list of all uses of emergency and forced psychotropic medications in the past year. 65. A list of any use of force associated with administration of psychiatric medications for the
past year. 66. A description of medical and mental health’s involvement/input into the disciplinary
process and clearance for placement in segregation. 67. List of all inmates referred for off-site psychiatric hospitalization in the past three years.
It is also understood that the above lists are not all inclusive and the Monitor retains the discretion to request additional information and documents deemed necessary for legitimate monitoring purposes and within the scope of conditions provided within the Agreement.

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 U.S. v. Virgin Islands

PC-VI-002-002 IN THE UNITED STATES DISTRICT COURT FOR THE

DISTRICT OF THE VIRGIN ISLANDS-

'+

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE VIRGIN ISLANDS: JUAN LUIS,

)

GOVERNOR, U.S. Virgin Islands;

)

EDWIN POTTER, Director, Bureau

)

of Corrections; ISIDORE BELL,,

)

Warden, Golden Grove Adult

)

Correctional Facility;

)

)

Defendants.

)

)

CONSENT DECREE

Civil Action-Jygjo
~Z O So

1. This case was filed by the plaintiff on November 21

1986, pursuant to the Civil Rights of Institutionalized Persons

Act, 42 U.S.C. 1997.

2. This Court has jurisdiction over this action pursuant

to 28 U.S.C. 1345.

3. Venue is appropriate pursuant to 28 U.S.C. 1391(b).

4. The United States is authorized to institute this

action pursuant to 42 U.S.C. 1997a and has met all prefiling

requirements stated in that statute.

5. The Defendants are the Virgin Islands of the United

States; the Honorable Juan Luis, Governor of the Virgin

Islands; Edwin Potter, Director, Bureau of Corrections, and

Isidore Bell, Warden of the Golden Grove Adult Correctional

Facility.

-26. The Defendants have authority and responsibility for the operation of the Golden Grove Adult Correctional Facility and are officers of the Executive Branch of the Virgin Islands 7. On May 28, 1985, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, Wm. Bradford Reynolds, notified the Governor of the Virgin Islands of his intention to investigate alleged unconstitutional conditions of confinement at the Golden Grove Adult Correctional Facility, St. Croix, Virgin Islands, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. 1997. 8. Following a thorough investigation of conditions at Golden Grove, on January 23, 1986, the Assistant Attorney General for Civil Rights informed Governor Juan Luis of the findings of the United States that the Attorney General had reasonable cause to believe that inmates confined to the Golden Grove Adult Correctional Facility were being subjected to egregious or flagrant conditions that deprive them of their rights, privileges or immunities secured by the Constitution. 9. The parties agree that the confinement of inmates at Golden Grove implicate rights, privileges or immunities of these inmates which are secured and protected by the Constitution of the United States. The parties entering into this Decree recognize these constitutional interests and for

— 3 — the purpose of avoiding protracted and adversarial litigation, agree to the provisions set forth herein.
10. In entering into this Consent Decree, Defendants do not admit any violation of law and this Consent Decree may not be used as evidence of liability in any other proceeding.
11. The provisions of this Consent Decree are a fair, appropriate and adequate resolution of this case.
12. This Consent Decree shall be applicable to and binding upon all of the parties, their officers, agents, employees, assigns and their successors.
I. Purposes and Objectives The Virgin Islands and the United States stipulate and agree that the purposes and objectives of this Consent Decree are to establish as promptly as practicable the following conditions at Golden Grove Adult Correctional Facility in order to ensure that both pretrial detainees and convicted inmates at the facility are not being deprived of rights, privileges or immunities secured to them by the Constitution of the United States. 1. Defendants shall protect inmates from unreasonable fire safety risks to their lives and safety. 2. Defendants shall provide such security and staff supervision to protect inmates from wanton and reckless physical violence by other inmates or staff.

-43. Defendants shall provide minimally adequate sanitation to protect inmates from unreasonable risks to their physical health. 4. Defendants shall provide minimally adequate medical care for the serious medical.needs of inmates. These purposes and objectives shall be achieved at the Golden Grove Adult Correctional Facility by implementing the requirements set forth,in Part II and by developing and implementing the plans described in Part III of this Consent Decree. II. Conditions Requiring Immediate Correction In order to eliminate conditions which pose an immediate threat to life, health and safety of inmates at Golden Grove, the Virgin Islands agrees to meet the following requirements within 30 days after entry of this Consent Decree: 1. All fire hazards will be removed from inmate cells; 2. At all times, at least one guard will be on duty and
present in each inmate living unit; and 3. All living units will have adequate means to safely
evacuate inmates in case of emergency. III. Plans In order to ensure compliance with this Consent Decree, the Virgin Islands shall file with the Court no later than November 1, 1986, its plan(s) for implementing this Consent Decree. Such plan(s) shall set forth:

-5-
1. The procedures to be used (a) to provide for the emergency evacuation of each building at Golden Grove that houses inmates or detainees, (b) to ensure that all emergency equipment is functional, (c) to ensure that all emergency exits are functional, and (d) to identify and correct conditions which are fire hazards.
2. The procedures and equipment to be used to provide adequate security within Golden Grove, including policies and equipment that will ensure adequate communication among all units, and policies relating to the deployment of staff.
3. The procedures to be utilized to provide minimally adequate sanitary conditions in the food service area and in inmate living areas.
4. The steps to be taken (a) to provide for adequate medical care in medical emergencies and (b) to provide medical care for the serious medical needs of inmates, including procedures to provide for appropriate storage and administration of medicat ions.
5. The strategies to be utilized to provide that sufficient numbers of qualified staff are employed to implement the conditions set forth in paragraphs 1-4 above.

d k
-6Al1 plans shall state in specific terms and reasonable detail the actions to be taken by the Defendants, the dates of such actions, the text of procedures, regulations, or orders to be promulgated and issued by the Defendants. All plans shall als state the specific date or dates by which each item abo /e shall be implemented Jjl toto, but in no event shall the fin 1 implementation date of a plan be later than June 1, 1988. IV. Construct on and Implementation In construing nd implementing the terms of this Decree, the following are a reed to by the parties: 1. A. The Uni ed States shall have sixty (60) days from receipt of any plan in which to file a response to the plan with the Court. If the United States objects to any plan or portion thereof fil d by the Defendants, Defendants and Federal officials s all meet in a good faith effort to resolve their differences. If the Defendants and Federal officials are unable to resol e their differences through negotiation the adequacy of the contested portions of the proposed plan to achieve the purpose and objectives set forth in Part I of this Consent Decree shall be determined by the Court. Defendants shall have the burd n to persuade the Court that the plan is adequate under this standard. B. If, after plan is approved, Defendants decide to modify that plan or any portion thereof, Defendants shall notify the Court an the United States of the proposed

-7modification. The United States shall have sixty (60) days from the receipt of any proposed modification in which to file a response to the proposed modification with the Court. If the United States objects to the modification sought, Defendants and Federal officials shall meet in a good faith effort to resolve their differences concerning the proposed modification. If Defendants and Federal officials are unable to resolve their differences through negotiation, the adequacy of the proposed modification to achieve the purposes and objectives set forth in Part I of this Consent Decree shall be determined by the Court. The Defendants shall have the burden to persuade the Court that the modified plan is adequate under this standard.
C. Plans, including modification of plans, to which the United States do not timely object, shall be deemed approved by the Court.
2. A. Defendants shall submit periodic compliance reports to the United States and the Court. The first report shall be filed on December 15, 1986. Thereafter, the reports shall be filed quarterly, fifteen (15) days after the end of each quarter continuing until such time as this Consent Decree is terminated.
B. The compliance reports shall describe the Defendant's progress towards implementation and compliance with the provisions of this Consent Decree and the plan(s) submitted pursuant thereto.

d k
3. The United States and its attorneys, consultants, and agents shall have reasonable access to the facilities, records, residents, and employees of the Golden Grove Adult Correctional Facility upon reasonable notice to the State for the purpose of ascertaining compliance with the Decree. Such access shall continue until this Consent Decree is terminated.
4. All parties shall bear their own costs, including attorney fees.
V. Termination of Decree 1. The parties contemplate that the defendants shall have fully and faithfully implemented all provisions of this Consent Decree, and plans herein required to be submitted and approved by the Court, on or before June 1, 1988. 2. The Court shall retain jurisdiction of this action for all purposes under this Consent Decree until the Defendants shall have fully and faithfully implemented all provisions of the Consent Decree and plans submitted pursuant thereto and until the judgment be discharged. 3. All plans required under this Decree shall be submitted for approval by the Court and, if approved, shall be issued as orders of the Court and enforceable as such. 4. On or after the date on which the Defendants shall have fully and faithfully implemented all provisions of this Consent Decree and plans submitted thereto, the Defendants may move that the injunctions entered herein be dissolved, the judgment discharged, jurisdiction terminated, and the

-9case closed and dismissed with prejudice on ground that the defendants have fully and faithfully implemented and maintained all provisions of this Consent Decree and plans submitted pursuant thereto.
5. Dismissal shall be granted unless, within sixty (60) days after receipt of the Defendants' motion, the United States objects to the motion. If such an objection is made with particularity, the Court shall hold a hearing on the motion and the burden shall be on the United States to demonstrate that the Defendants have not fully and faithfully implemented all provisions of this Consent Decree or any approved plan(s) or any part thereof and, if objection is based upon failure to implement any plan or part thereof, that such plan or part thereof is essential to the achievement of one or more of the purposes and objectives set forth in Part I of this Consent Decree. If the United States fails to meet this burden, the injunctions shall be dissolved, this judgment shall be discharged jurisdiction shall be terminated forthwith, and the case shall be closed and dismissed with prejudice.

-10Consented to by the undersiqned:

FOR THE VIRGIN ISLANDS

FOR THE UNITED STATES OF AMERICA

JUAN LUIS Governor

Ass*fsTantAttorney General Civil .JCights Division

LEROY Attorney General

. DIEHM United States Attorney ^mstrict of the Virgin Islands

EDWIN POTTER Director Bureau of Corrections

ARTHUR E. Chief Special Litigation Section

ISIDORE BELL Warden Golden Grove Adult Correctional
Facility

V.^COLLEEN MILLER
At torney U.S. Department of Justice Civil Rights Division Washington, D.C. 20530

WHEREFORE, the parties to this action having agreed to

the provisions in the Consent Decree set forth above, gnd t h e ^

Court being advised in the premises, this Consent Decree/is —

hereby entered as the JUDGMENT of this Court
' O

SO ORDERED this /

day of

1986,

St. SHraTtrers, Virgin Islands.

CO

CJ)

UNITED STATES DISTRICT JUDGE

 
 U.S. v. Virgin Islands
- 1111111111 PC VI-002-009

IN THE UNITED STATES DISTRICT COUKX

FOR THE DISTRICT OF THE VIRGIN ISLANDS

"

DIVISION OF ST. CROIX

"' :

UNITED STATES OF AMERICA,
Plaintiff, v.
THE VIRGIN ISLANDS, et al., Defendants.

)

c v . '•••-

)

?

)
) ) Civil Action No. 86-265 ) ) ) )

ORDER

Pending before the Court in this action are motions by the United States seeking findings of contempt for the Defendants1

alleged failure to comply with several Orders of this Court

directing the Defendants to take certain actions to provide

adequate conditions of confinement at Golden Grove Adult

Correctional Center. The parties have conferred and agree that the

Plan of Correction proposed by the experts for the United States

on March 22, 1989, should be adopted by the Court and that the

Consent Decree should be extended for two and one half years beyond

the date of the adoption of the Plan. Because the Plan was

originally proposed over one year ago, the parties further agree

that changes in the due dates set forth in the Plan are

appropriate. Compliance by the Defendants with this Order will

purge any alleged contempt currently before the Court.

Accordingly, it is hereby ORDERED THAT:

1. The Plan of Correction is hereby amended to reflect the

timeline attached to this Order;

2. The Plan, as amended, is hereby adopted as an Order of this Court;
3. The Consent Decree is; hereby extended to a contemplated termination date two and one-half years from the date of this Order (October 11, 1992); and
4. Termination of the Consent Decree will be in accordance with {{V.2, V.4, and V.5 of the Consent Decree.
SO ORDERED, This 11th day of April, 1990.
UNITED STATES DISTRICT JUDGE

PLAN OF CORRECTION TIMELINE

The following is a revised timeline for compliance with the provisions of the Plan of Correction and amends the deadlines provided therein:

Designation of responsible staff for all sections of the Plan will be made and names will be provided to the Court and the United States within thirty (30) days of the entry of this plan.

Requirement

Completion Date

Plan Provision

outdated medications discarded

6/1/90

physician two hours/day

6/1/90

emergency keys

6/1/90

transfer to hospital for medication

6/1/90

kitchen exhaust hood

6/1/90

hot water delivery system to kitchen 6/1/90

prescription medication not re-used

6/1/90

housekeeping plan

6/1/90

prescriptions obtained within six hours 6/1/90

kitchen/dining area screens

6/1/90

lab studies

6/1/90

health screening questions

6/1/90

kitchen freezers and coolers

6/1/90

exterminator

6/15/90

fire extinguishers

6/15/90

nursing personnel hours

6/15/90

communication system

6/15/90

all primary and secondary exits

6/15/90

nurse supervisor on duty

7/1/90

preventive maintenance

7/1/90

medical intake evaluation

7/1/90

emergency equipment available

7/1/90

sick call

7/1/90

locked narcotic cabinet

7/1/90

physician on call 24 hours/day

7/1/90

emergency generator

8/1/90

list of medical diets

8/1/90

medical diet request system

8/1/90

electrical wiring and equipment

8/1/90

emergency plan

8/1/90

maximum emergency exit

8/1/90

emergency hospital referrals

9/15/90

mental health referrals

9/15/90

follow-up care

9/15/90

hospital referral log

9/15/90

vehicle available for emergencies

9/15/90

medical staff CPR

9/15/90

VII.E.
V.D. I.H. VILA. I.B. III.C. VII.C. II.G. VII.B.
II.A. VIII.C. VIII.A. IV. B. II.F. I.L. V.C. I.E. I.K. V.B. III.B. VIII.B. VI.A. IX.A. VII.D. V.E. I.D. XII.C. XII.A. i.e. I.G. I.J. VI.D. XI.A. X.A. XIII.A. VI. C. VI.B.l.

r

correctional staff CPR

9/15/90

mental health worker on duty

9/15/90

tool control system

9/15/90

diet guidelines in kitchen

10/1/90

mental health housing area

10/1/90

drinking water system

10/1/90

medical reference materials

10/15/90

review of mental health recommendations 10/15/90

toilets

11/1/90

smoke detection and fire alarm system l l / l / 9 0

water heaters

12/1/90

kitchen appliances

1/1/91

staffing

1/1/91

showers

2/1/91

roof repair

3/21/91

VLB.2 V.F.
I.F.
XII.B. XI. C
II.B.
XIV.B.
XI. B.
II.E.
I.A.
II.D.
IV.A.
I.I. II.C. III.A.

 
 U.S. v. Virgin Islands
- •Illlllllll

PC-VI-002-010 DISTRICT COURT OF THE VIRGIN ISLANDS
DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

Plaintiff, )

v.

)

THE TERRITORY OF THE V.I.

)

et. al.

) Defendants; )

j

Tl ._O
CIVIL NO. 1986/265 "". -^ -^
- -. 2 f^ ">- co PJ
-y •£• '- U4
co O

ORDER

' •

on

: ~

A conference was held at the Magistrate Judge's Office

on May 23, 1991. The U.S. Government was represented by Attorney

Gayle Fidler of the U.S. Department of Justice. The Territory of

the V.I. was represented by Attorneys Ford Adiyia and Elliott

Davis of the V.I. Department of Justice. Also participating were

General Moorhead, Co-ordinator of Prison Repairs for the V.I.

Department of Justice and Isadore Bell and Samuel Garnett of the

Bureau of Corrections, V.I. Department of Justice.

A point by point review of compliance with particular

aspects of the Consent Decree was conducted. In furtherance of

such discussion it is ORDERED AS FOLLOWS:

1. Quarterly reports shall be co-ordinated and

submitted by the V.I. Department of Justice, commencing with the

quarter terminating June 30, 1991. The reports shall track

compliance with all aspects of the Consent Decree and shall be on

standardized forms. The reports shall be mailed to plaintiff by

express mail or equivalent service no later than the 15th day of

the month following the completed quarter.

f •

Order Page 2

2. Plaintiff shall monitor compliance and shall

schedule further conferences or seek orders of contempt or other

proceedings as they shall deem appropriate.

ENTI

Dated: U hM ^ ^
ATTEST: ORINN ARNOLD Clerk of Court

JEFF: U.S.

RESNICK TRATE JUDGE

eputy Clerk

 
 - u8•

1/ :

6;

U.S. v. Virgin Islands

PC-VI-002-011 UNITED STATES DISTRICT COURT FOR THE DISTRICT OF THE VIRGIN ISLANDS; DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,
Plaintiff,
v.
VIRGIN ISLANDS: ALEXANDER FARREL1Y, GOVERNOR, U.S. Virgin Islands; JAMES E. AIKEN, Director, Bureau of Corrections; KURT WALCOTT, Warden, Golden Grove Adult Correctional Facility;
Defendants.

Civil Action No. 8 6-2 55 Honorable Thomas K. Moore

UNITED STATES' MOTION TO LIFT LOCK-DOWN Pursuant to Rule 7(b), Federal Rules of civil Procedure, Rule 6 of the Federal Local Court Rules, Virgin Islands, and the equitable powers of this Court, the United States of America, plaintiff herein, hereby moves this Court for an order lifting the existing lock-down of prisoners at Golden Grove Adult Correctional Facility (hereinafter "Golden Grove") and restoring meaningful inmate visitation, access to legal materials, and opportunity for religious observance. This motion is based upon the attached memorandum and all other papers on file in this action.

L*i L

. •**.

\&i.\ u u o

Respectfully submitted,

Hugh P. Mabe I I I United States Attorney District of the Virgin Islands

James P. Turner, Acting Assistant Attorney General Civil Rights Division

Timothy Rx7 Payne Senior Trial Attorney Spec. Litigation Section Civil Rights Division P.O. BOX 66400
Washington D.C. 20035 (202)514-6441

 
 U.S. v. Virgin Islands

^004

PC-VI-002-012 UNITED STATES DISTRICT COURT FOR THE DISTRICT OF THE VIRGIN ISIANDS, DIVISION OF ST. CP.OIX

UNITED STATES OF AMERICA,
Plaintiff,
v.
VIRGIN ISIANDS: ALEXANDER FARRELLY, GOVERNOR, U.S. Virgin Islands; JAMES E. AIKEN, Director, Bureau of Corrections; KURT WALCOTT, Warden, Golden Srove Adult Correctional Facility;
Defendants.

civil Action No. 86-265 Honorable Thomas K. Moore

MEMORANDUM IN SUPPORT OF UNITED STATES/ MOTION TO LIFT LOCK-DOWN INTRODUCTION
on December 1, 1986, this Court entered a Consent Decree designed to remedy unconstitutional conditions at the Golden Grove Adult Correctional Facility (hereinafter "Golden Grove") and to ensure that conditions and practices at the facility comply with constitutional standards. Exhibit A. By virtue of a protracted, unlawful lock-down initially imposed on Golden Grove inmates on September 18, 1992, and maintained to date, Defendants are violating the constitutional rights of all inmates incarcerated there. Specifically, Defendants' lock-down subjects inmates to cruel and unusual punishment, violates the Consent Decree because the lock-down is an illegal means of ensuring reasonable security, and violates constitutionally protected rights of inmates to reasonable visitation, meaningful access to

the courts, and exercise of religion. To remedy these constitutional violations, the United States seeks an immediate Order lifting the Golden Grove lock-down.
FACTS • On September 18, 1992, Defendants imposed a lock-down at the Golden Grove prison. This lock-down applies to all prisoners regardless of security risk, and some lock-down restrictions have been in effect for more than one year. While prison officials finally granted inmates one hour of out-of-cell tine per day last May, inmates continue to be confined to their cells 23 hours a day. As a result, a blanket denial of inmate visitation rights continues into its second year. Additionally, under the lockdown, prisoners can only get legal materials by requesting that specific titles be sent to their cells. The prison administration has imposed a limit of one book per inmate, and often fails to provide even that in any reasonably timely manner. Finally, there are no religious programs allowed under the lockdown other than occasional visits by a single Pentecostal nun.1 Despite repeated requests by the United States, the Defendants have failed to provide a specific"timetable for lifting these
1 The United States' most recent information is based in part on a telephone conversation of October 20, 1993 with attorneys of the ACLU National Prison Project. Attorneys visited Golden Grove on October 13 and 14, 1993, and although denied access to the prison (i.e. the inmate housing areas) by Territorial officials, they did conduct private interviews of 28 inmates in a prison administration office. See also, Tyler Treadway and Kay Johnson, v.I. bars ACLU from Golden Grove, The Virgin Islands Daily News, October 14, 1993, p.l.
- 2-

i-li

»k

restrictions. This failure denies inmates their constitutional rights and warrants immediate judicial relief.
ARGUMENT Generally, the decision to lock down a facility falls within the prison administrators' discretion, but it is equally true that such a decision must bear some rational relationship to a legitimate objective. 0/Lone v. Estate of Shabazz, 482 U.S. 342 (1987); Satmders v. Packel. 436 F.Supp. 618 (E.D.Pa. 1977). The United States contends that the continued prisoner lock-down at Golden Grove is illegal and undermines and frustrates the purpose of the consent decree without rationally serving any legitimate goal. I. The consent decree protects inmates' constitutional rights. A consent decree should be read in light of its overall purpose. United States v. Reader's Digest Ass'n, Inc.. 662 ?.2d 955 (3rd Cir. 1981), cert, denied. 455 U.S. 908 (1982). The consent decree at hand is intended to "... ensure that both pretrial detainees and convicted inmates at the [Golden Grove] facility are not being deprived of rights, privileges or immunities secured to them by the Constitution of the United States." See. Exhibit A, p. 3. When Defendants signed the consent decree, they agreed "... that the confinement of inmates at Golden Grove implicate[s] rights, privileges, or immunities of these inmates which are secured and protected by the Constitution of the United States''. Id. at 2.
- 3-

The consent decree also states: "Defendants shall provide such security and staff supervision to protect initiates from wanton and reckless physical violence by other inmates or staff." Id. at 3. Given the overall objective of the consent decree, this provision implicitly must mean that Defendants have to improve security conditions by constitutional means. Yet, Defendants have instead imposed a draconian lock-down in violation of several constitutional standards. II. Defendants are violating the consent decree and inmates' constitutional rights.
Under the Constitution, inmates have a right to be free from cruel and unusual punishment, to reasonable visitation, to access to legal materials, and the right to practice their religion. The Defendants have maintained the Golden Grove facility in the highly restricted status of "lock-down" for more than one year, and in the process, have violated all of these constitutional guarantees and have engaged in unlawful conduct in an effort to achieve security and safety at Golden Grove in violation of the Consent Decree.
A. The confinement of inmates^ to their cells for nearly 2 4 hours per day in grossly inadequate conditions of confinement in violation of their fundamental rights constitutes cruel and unusual punishment. Housing inmates in their cells nearly continuously in inadequate conditions of confinement such as exist at Golden Grove violates the constitutional rights of prisoners and subjects them to cruel and unusual punishment. The "sound discretion" of prison administrators does not justify the
- 4-

imposition of restrictive measures disproportionate to the legitimate objective of ensuring safety and security, Rhodes v. chapman. 452 U.S. 337 (1981), or justify their imposition longer than necessary to ensure security. Saunders v. Packel. 4 36 F.Supp. 618 (E.D. Pa. 1977) (noting that a lock-down can extend beyond the time of crisis as a precautionary measure, but only for a reasonable period); see also. Jefferson v. Southworth. 447 F.Supp. 179 (D.R.I. 1978).
The facts in Jefferson v. Southworth bear an uncanny resemblance to the situation at hand, and that Court's decision presents guidelines applicable here. Jefferson v. Southworth. 447 F.Supp. 179 (D.R.I. 1978). In Jefferson, prison officials imposed a lock-down at a maximum security facility within sixteen days after a federal court issued an order addressing longstanding problems with conditions at the prison. Id., at 181. This lock-down resulted in the denial of inmate visitation and recreation for mor« than six months. Id. As is the case at Golden Grove, the prison administration alleged that the lockdown was required to maintain security. Id. at 181-182. The court saw through the administration's obfuscation, and noted that there was no imminent emergency, and the lock-down was "...a classic example of 'overkill'" if it was being used merely to ensure general security. Id. To placate the court, the Jefferson officials also claimed they would end the lock-down as soon as it was possible to do so in an orderly way. Ifl, However the court found this promise to be meaningless, since the
- 5-

administration, when pressed, admitted they had no definite plans or deadlines by which they could be counted on to end the lcckdown. Id. at 186-187. The Golden Grove prison has been in lockdown for twice the length of time as the lock-down in Jefferson. Moreover, the restrictions at Golden Grove are even broader than the ones in Jefferson, since in Jefferson, at least some inmates were allowed up to eight hours out of their cells. An overextended lock-down devastates the inmates' psychological health, and creates a volatile environment as it leads to "growing 'feelings of anger and hostility on the side of the inmates as well as the guards'". Id^_ at 185. The expert penologist of the United States who inspected the Golden Grove facility in February, 1993, asserts that the lock-down should have been completely lifted by May 1, 1993. See Declaration of Mr. John Dahm, attached. Defendants have been aware since April 1993 that this has been the United States' position. Yet, six months later Golden Grove officials continue to impose the lockdown on an indefinite basis. This Court should not tolerate such blatant disregard of the Constitution.2 More than a decade ago,.

2 The restrictions at Golden Grove are also more severe than the ones in g^uscino v. Carlson, 854 F.2d 162 (7th Cir. 1938), certt denied. 491 U.S. 907 (19S9). As discussed in Bruscino. The United States Penitentiary in Marion, Illinois is a modern "Alcatraz", and remains in permanent lock-down. Id. at 162-164. Vet even Marion prisoners get seven to eleven hours a week of recreation and time to visit a law library. Id. There is also no suggestion in gruscino that inmates are generally denied visitation privileges. Even though the Bruscino inmates are the most incorrigible and most dangerous criminals in America, the Marion prison officials recognized that there are differences even among such hardened inmates and gave some more

- 6-

(continued...)

ifCv. i_xx

-.

the Jefferson court spoke to the present when it ordered the
lifting of lock-down restrictions and ruled:
The Court cannot permit the defendants to inflict unconstitutional hardships on the great majority of inmates, because they, the defendants, are incapable of remedying the conditions they rely upon to justify their^actions. The prisoners cannot be made to suffer unconstitutional deprivations because of the lack of management capability found in the Department of Corrections.
Id. at 187.
In sum, the duration of the lock-down at Golden Grove,
together with the continuous denial of fundamental,
constitutional rights as argued below, subjects inmates to cruel
and unusual punishment.
B. The long, protracted unlawful lock-down is an illegal means of complying with the consent decree requirement to provide reasonable safety.
The Defendants claim the lock-down helps protect
constitutional rights by protecting inmate safety and ensuring
institutional security. However, when the Defendants agreed to
"...provide such security and staff supervision to protect
inmates from wanton and reckless physical violence..." and
"...eliminate conditions which pose an immediate threat to life, health and safety of inmates at Golden Grove...",3 no license was
granted to permit the Defendants to achieve compliance with its
2(...continued) privileges than others. Id. at 16 6-167. Golden Grove on the other hand locks down everyone from pretrial detainees to misdemeanants to murderers, as though they are all of equal security risk and of equal culpability.
3 December 1, 1986 Consent Decree, 1.2. & II.
- 7-

terms by unlawful methods or by simply obliterating the inmates' other constitutional rights with a year-long lock-dcwn.
Ironically, denying inmate rights for such a long period of time may actually jeopardize prison security. For example, federal courts have recognized that visitation plays a critical role in ensuring a humane psychological atmosphere within a prison. See. e,_pi. , Barnes. 415 F.Supp. at 1228-1229 (noting that the difference between a smoothly run institution and one bordering on the edge of riot may depend on small details) . By denying visitation and other fundamental rights, the defendants may actually increase emotional tension within the facility and increase the possibility of violence. Id.; see also, young, 960 F.2d at 363-364 (prolonged, inhumane conditions may jeopardize inmates' physical and mental health); Jefferson v. Southworth. 447 F.Supp. 179 (D.R.I. 1978) (extended lock-down creates psychological problems including dangerous levels of anger and hostility). Visitation from family and loved ones helps inmates adjust to life within a prison and also lets the inmates retain a link to the outside world which will make their transition back to the community easier. Barnes. 415 F.Supp. at 1228-1229. The Defendants have severed such links, depriving inmates of an important pressure valve, their family's emotional support, exercise of religious beliefs — and violated their constitutional rights.
In sum, the lock-down appears to be Defendants' easy solution to difficult constitutional deficiencies which require a
- 8-

J\
more serious effort to permanently solve. Yet, rather than being a temporary measure/ the lock-down enters its second year. Other Third Circuit courts have admonished defendants who tried to evade their obligations under a consent decree with unconstitutional stop-gap measures, and so should the present court. Inmates of Allegheny County Jajlf 612 F.Supp. at 884 (use of city lockup to house female inmates for significant periods of time violated court order that county officials find adequate alternate jail facilities).
c. Defendants are violating the inmates' constitutional right to visitation. The United States asserts that when Defendants agreed to respect inmates' constitutional rights, they implicitly agreed to retain preexisting inmate visitation. Instead, while still bound by their obligations under the consent decree, tha Defendants imposed a lock-down upon the entire Golden Grove facility. As part of this lock-down, Defendants have prohibited visitation for Golden Grove inmates for over a year. The Constitution guarantees an inmate's right to visitation subject only to reasonable limitations. Thomas v. Brierley. 481 F.2d 660 (3rd Cir. 1973) (denial of visitation may be cru»l and unusual punishment); Ali v. Gibson. 483 F.Supp. 1102 (D.V.I. 1979) (asserts in dicta that prisoners have a right to visitation) rev'd. on grounds unrelated to visitation, 631 F.2d 1126 (3rd Cir- 1980), cert, denied, 449 U.S. 1129 (1981); Valentine v. Knalehardt. 474 F.Supp. 294 (D.N.J. 1979) (total ban on visitation by children is unconstitutional); Owens-El v.
- 9-

Robinson, 442 F.Supp. 1368 (W.D.Pa. 1978) (as long as reasonable
visitation allowed, form is within province of jail
administrators) ; Tunnell v. Robinson. 486 F.Supp. 1265 (W.D.Pa.
980) (arbitrary denial of visitation is unconstitutional).4
Defendants' blanket ban on visitation is arbitrary, and
bears no reasonable or rational relationship to legitimate
institutional concerns. The courts recognize that denials of
innate rights which are permissible in limited circumstances
often become impermissible if imposed for extended periods of
time, gee e.g.. Young v. Ouinlan. 960 F.2d 351 (3rd Cir. 1992);
Inmates of Allegheny County Jail v. Wecht;. 612 F.Supp. 874
(W.D.Pa. 1985); sejg also. Bell v. Wolfish. 441 U.S. 520, 542
(19 79) (overcrowding for extended periods of time may raise Due
process problem). Whatever emergency may have justified the
initial lock-down, it cannot possibly justify maintaining the
lock-down for more than one year, long after the initial crisis
4 Two Supreme court cases indirectly address the issue as well. In yell v. Procunier. the Supreme Court upheld limits on visitation by the press. Pell v. Procunier. 417 U.S. 817 (1974); In the process, the Court reasoned..that some limitations on visitation are acceptable provided the inmates have adequate alternative channels for communicating with outsiders, jd. at 823-827. The Court specifically pointed to the ameliorating fact that the prison allowed inmates to have personal contact with family, clergy, and attorneys. Id. The Court also noted that the need for security "... would not permit prison officials to prohibit all expression or communication by prison inmates ...", although it might "... justify the imposition of some restrictions on the entry of outsiders for face-to-face contact with inmates". Id. at 827. See also. Kentucky Dept. of
tio v. Thompson. 490 U.S. 454 (1989) (Kenned(y, J., concurring) (noting that a regulation which permanently forecloses visits to some or all prisoners may implicate the Due Process Clause).
-10-

should have been solved. Promptly lifting the ban on visitation after addressing the initial crisis and gaining reasonable control of the facility should not have been difficult. As this court once noted, "Prison officials should take advantage of reforms such as increased visitation which constitute good therapy but do not require an undue amount of effort on their part." Barnes v. Government of Virgin Islands. 415 F.Supp. 1213 (D.V.I. 1976). Yet amazingly, Golden Grove claims to be incapable of providing such a basic right. It is probably impossible to find any other example where a facility's entire inmate population has been denied all visitation (excepting with attorneys), whether contact or non-contact, for no specific reason, and for such a long period of time. Such a blanket ban is patently unconstitutional.
Moreover, visitation by itself surely cannot pose such a grave security threat so as to warrant a one-year prohibition, or there would be such prohibitions constantly imposed by virtually every prison in the United States.
D. Defendants are violating the inmates7 constitutional right of access to legal materials. The Supreme Court has held that prison inmates have a right to adequate law libraries or assistance from persons trained in the law. Bounds v. smith. 430 U.S. 817 (1977). Since initiation of the locK-down, Golden Grove inmates have had virtually no access to legal materials, and consequently, have been denied meaningful access to the courts. The prison's current lock-down policy does apparently allow for provision of one law book at a
-11-

^2 08.93 17:48 © 2 0 2 M L 6273

CRT SPEC LIT

rm

^013

time to any inmate who requests a specific title. Evidence indicates that even this policy — however inadequate — is not being consistently implemented. In addition, those books actually produced by Defendants are not provided until several weeks after they were requested.
E. Defendants are violating the inmates' constitutional right to practice religion. Religious programs at Golden Grove are constitutionally inadequate. The prison's only religious program apparently is an occasional visit by a Pentecostal nun. The rest of the time, the lock-down and ban on visitation means prisoners must stay within their cells, where there is no opportunity to practice their religion with other members of their faith, including clergy. The Constitution protects inmates' right to the free exercise of religion, subject only to the prison's legitimate penological interests. O'Lone v. Estate of Shabazz. 482 U.S. 342 (1986); gee also. Pell, 417 U.S. at 824-825 (visitation from clergy constitutes significant channel of communication). The Defendants cannot offer a legitimate reason for depriving Golden Grove inmates of all religious programs for more than one year. As already discussed, the need to ensure institutional security cannot justify arbitrary and prolonged violation of constitutional rights. See, Young. 960 F.2d 351. The Pentecostal nun has apparently tended to some of the inmates' religious needs without creating any significant problems, and there is no reason to believe other clergy cannot do the same.
-12-

CONCLUSION Therefore, the United States Government, plaintiff in this case, requests that the court enforce the December 1, 1986 consent decree by - (l) lifting the lock-down at the Golden Grove Adult Correctional Facility, (2) order the Defendants to provide meaningful visitation, access to legal materials, and religious programs, and (3) grant any necessary additional relief.

Hugh P. Mabe III United States Attorney District of the Virgin Islands

James P. Turner, Acting Assistant Attorney General Civil Rights Division
. / Payne Senior tfrial Attorney Special Litigation Section Civil Rights Division P.O. BOX 66400 Washington, D.C. 20532 202/514- 6441

-13-

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF THE VIRGIN ISLANDS; DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

VIRGIN ISLANDS: ALEXANDER

)

FARRELLY, GOVERNOR, U.S. Virgin )

Islands; JAMES E. AIKEN,

)

Director, Bureau of Corrections; )

KURT W A L C O T T , warden, Golden

)

Grove Adult Correctional Facility; )

Defendants.

)

Civil Action No. 86-265 Honorable Thomas K. Moore

ORDER This Court has reviewed the United States' Motion to Lift Lock-down, and the materials filed in support thereof, namely the Memorandum in Support of United States' Motion to Lift Lockdown, and the affidavit of John J. Dahm, exhibits, and being fully advised of the premises, including oral argument presented by both parties, and the Defendants' response to the motion. Accordingly, Defendants are ORDERED to lift the lock-down at Golden Grove Adult Correctional Facility and: 1) Provide inmates with meaningful opportunities for visitation. 2) Provide inmates with meaningful access to legal materials. 3) Provide inmates with meaningful opportunity to practice their religion.

f\

4) Provide reasonable safety and security to all instates.

Defendants shall fully comply with this order within 10

days.

Done and Ordered this

day of December, 1993, at St.

Croix, Virgin Islands.

United States District Judge

Presented by:
Timothy y Attorn»y^for Plaintiff U.S. Dept. of Justice Civil Rights Division Special Litigation Section

r\

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF THE VIRGIN ISLANDS, DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

)

J

Plaintiff,

)

)

v.

)

VIRGIN ISLANDS: ALEXANDER

FARRELLY, GOVERNOR, U.S. Virgin

islands; JAMES E. AIKEN,

Director, Bureau of Corrections;

KURT WALCOTT, Warden, Golden

Grove Adult Correctional Facility;

Defendants.

Civil Action No. 86-265 Honorable Thomas K. Moore

CERTIFICATE OF SERVICE
I hereby certify that the foregoing United States' Motion to
Lift Lock-down, Memorandum in Support of United States' Motion to
Lift Lock-down, Order, and supporting documents were mailed by
regular mail, postage prepaid, this 7th day of
December, 1993 to the following counsel of record.
Darlene Grant, Esquire Department of Justice U.S. Virgin Islands 488-50C Krondprindsens Gade GERS Comoplex, 2nd Floor Charlotte Amalie St. Thomas,Virgin Islands 00802
Timothy Payne Attorney Tor Plaintiff U.S. Dept. of Justice Civil Rights Division Spec. Litigation Section P.O. Box 66400 Washington D.C. 20035

 
 0 14 01 I

U.S. v. Virgin Islands

PC-VI-002-013 UNITED STATES DISTRICT COURT FOK THE DISTRICT OF THE VIRGIN ISLANDS, DIVISION OP ST. CROIX

UNITED STATES OF AMERICA, Plaintiff,

v.

VIRGIN ISLANDS: ALEXANDER

FARRELLY, GOVERNOR, U.S. Virgin

islands; JAMES E. AIKEN,

Director, Bureau of Corrections;

KURT WALCOTT, Warden, Golden

Grove Adult Correctional Facility; )

)

Defendants

)

)

____

_^__^_ )

Civil Action No. 86-265

I, John J. Dahra, The United States' expert in penology in the abovecaptioned action, pursuant to 28 U.S.C. section 1746, do hereby declare:
1, I currently serve as the Warden of the Omaha Correctional Center of the Nebraska Department of Correctional Services, a position undertaken in June of this year. Previously, I served as the Warden of the Lincoln (Nebraska) Correctional Center, a position I held since 1986. I have nineteen years work experience in the area of corrections, dating back to 1974 when I was appointed Director of Coiraaunity Services for the Missouri Department of Corrections. I have acted as a corrections consultant on numerous occasions, serving as an auditor since 1980 for the national Commission on Accreditation for Corrections, serving as a consultant to the American Correctional Association Sta.-.dards Coir.ir.ittee, ar-d serving as an expert consultant for the City of Albuquerque, New Mexico's Department of Corrections, and for the United States Department of Justice, Civil Rights Division, regarding correctional facilities in a number of jurisdictions. I also possess a
1

l_ft

4UUJ

Doctorate degree in History/ Social Science, awarded at Case Western Reserve University in 1969, and have taught courses in penology at Nebraska Wesleyan University. See, attached hereto, a true and correct copy of my professional resume.
2. Since February 1988, I have been employed by the United States Department cf Justice as an expert consultant in its legal action against the Virgin Islands regarding conditions of confinement at the Golden Grove Adult Detention facility in St. Croix. In that capacity I have had the occasion to conduct evaluative tours of Golden Grove on six seperate occasions.
3-. Most recently I conducted an evaluative tour of the Golden Grove facility or. February 11 and 12, 1993. As I was already aware, the facility at that tine was in a state of "lockdown." This lockdown entailed inmates being confined to their cells lor essentially twenty-four hours a day, excepting for a few minutes tioe allotted for showering. The purpose of my tour, in accordance with instructions froa Mr, Timothy R. Payne, attorney for the Deparcnent of Justice, was to evaluate the facility's state of compliance with requirements under the consent decree and the court-ordered Plan of Compliance, and to evaluate issues surrounding the innate lockdown. As a result of this inspection I wrote a report in March 1993, which sets forth ny findings and opinions ss to the issues evaluated. See copy of March 16, 1993 expert report attached.
4. Based on my evaluative and investigative tour of the Golden Grove facility in February 1993, and other tours conducted of this facility in the pasc, and based upon my years cf experience in the field of corrections, it is my opinion that any imminent emergency at the facility has Ions passed, and that the imposed lockdown of the inmates could reasonably have been lifted in its entirety by May 1, 1993, us I recommended in my March 1993 attached report. Since the lockdovn

orcw ill

was initiated on September 18, 1992, a deadline for lifting the iockdown on y.ay 1,1993, allowed the jurisdiction more than adequate cime, i• e. more than saveii months time, to gain sufficient control of the environment so as to permit lifting of the Iockdown under reasonably secure conditions. It is also -y opinion based on my experience that imposition of a Iockdown for a longer period than necessary usually leads to increased tension, anger and hostility anong the innate population. The level of such tension and anger is likely to become increasingly dangerous the longer such a Iockdown remains in effect.
I certify under penalty of perjury that the foregoing is correct.

*

Joh/rf J. Bahra, Affiant

SUBSCRIBED AND SWORN TO before me this //.>&(. day of November, 1993.

SEAL

-ft

PROFESSIONAL RESUXE OP
JOHN J. DAHM

HOME ADDRESS: BUSINESS ADDRESS: EDUCATION:

3316 South l?th Street Lincoln, Nebraska 68502 Phone: (402) 423-7531
Omaha Correctional Center 2323 East Avenue J Omaha, Nebraska 68110 Phone. (402) 595-3964
Massachusetts Institute of Technology, 1957-58 Calvin College, 1958-61, B.S. June 1961
(Chemistry) University of Michigan, 1961-63, M.A. June 1963
(History/Social Science) Case Western Reserve University, 1964-69, Ph.D.
January 1969 (History/Scciel Seienc«)
***************

PRESENT POSITION
Warden, Omaha Correctional Center, Nebraska Department of Correctional Services, June 1993 to present.
The Omaha Correctional Center is a medium/minimum security facility which has about 550 male inmates. An additional 100 male and 15 female inmates are housed in a Work Release Center adjacent to the main institution. As Chief Executive Officer of both the prison and vork release facility, I am responsible to the Director of Correctional Services for all aspects of the complex's operations and programs. Total staff at both facilities numbers 210.
PREVIOUS EXPERIENCE

Warden, Lincoln Correctional Center, Nebraska Department of Correctional Services. July 1986 to June 1993.
The Lincoln Correctional Center is a maximum/medium security facility housing about 850 sale inmates. Part of the facility serves as a reception/diagnostic center for all adult males sentenced to the state prison system. Other special programs include the protective custody and the mental health units for the adult male inmates in th« Nebraska system. As chief executive officer of the facility, I was responsible to the Director of Correctional Services for all aspects of the institution's operations and programs. The L.C.C. staff numbers 350.

Vftl OfLV - 1 i . Pfc

ifci UUO

Assistant Director for Adult Services, Nebraska Department of Correctional Services, July 1979 to June 1986.
Reporting to the Director of Correctional Services, my duties involved assisting the Director with the supervision of the state's adult correctional institutions. The system had five institutions with a total of 800 employees and 1,700 inmates. As Assistant Director, I helped handle all adult institutional activities including personnel and budget, monitored and developed institutional programs, and promulgated and standardized institutional policies and procedures. Along with the other three assistant directors (Administrative Services, Community Services and Juvenile Services), I advised the Director on overall Department operations and policy.
Assistant Superintendent, Missouri Intermediate Reformatory, Missouri Department of Corrections, July 1978 to June 1979.
The Reformatory is a medium security, adult institution which housed approximately 600 male felony offenders between the ages of 18 and 25. My duties centered on supervision of custody and programs. The specific areas included security, inmate special activities, recreation, medical services, religion, classification, and unit management.
Director of Community Services, Missouri Department of Corrections, January 1974 to June 1978.
Using substantial Law Enforcement Assistance Administration funding, I developed and supervised the first community corrections program for the state of Missouri, This included responsibility for the supervision of field offices of the Department which provided aftercare services for released inmates. The other major responsibility involved operating the Department's halfway house program using private community-based treatment facilities under contract.
Project Director for Corrections Projects through the University of Missouri-Rolla Extension Division for the following LEAA funded projects:
1. Stu,dv Release Program. This involved the first such effort in Missouri under which eight to ten inmates were released from the Missouri State Penitentiary to attend UMR as full-time resident students. Project planning, budget control, staff hiring, reporting, selection of new inmate students,^and general coordination with the Department of Corrections were included in my responsibilities. My tenure as project director ran from May 1971 to January 1974 with the University releasing me 25Z time from academic duties to operate the program.
2. Pre-release Treatment Program. The first stages of this program focused on the renovation of part of the Renz Prison Farm in Jefferson City as the Corrections Department's first pre-release facility. Development of the treatment program, hiring and supervision of staff, budget control and coordination with the Department of Corrections were included in my responsibilities. I served as project director from October 1971 to January 1974 with the University releasing me 25Z time from academic duties to operate the program.

r\
Professor of History, University of Missouri-Rolla, 1973-74.
A s s i s t a n t Professor of History, University of Missouri-Rolla, 1968-73.
Assistant Instructor of History, Calvin College, 1963-64.
CONSULTANT ACTIVITIES
Since September 1980, I have servad *s an auditor for the national Commission on Accreditation for C o r r e c t i o n s , I have audited forty-two long-term adult correct i o n a l i n s t i t u t i o n s t o determine compliance with national standards. The i n s t i t u t i o n audit* include ten for the Federal Bureau of Prisons, two for the Correct i o n a l Service of Canada, twenty-eight s t a t e correctional f a c i l i t i e s , and tvo U.S. military p r i s o n s . In addition, I have audited the central administrations of the Oklahoma ( t w i c e ) , Oregon, Minnesota, and Massachusetts Corrections Departments, a p r i v a t e c o r r e c t i o n a l corporation, and the U.S. Bureau of Prisons. The audits at the i n s t i t u t i o n s are b a s i c a l l y program audits which measure compliance or noncompliance with some 460 standards covering a l l aspects of i n s t i t u t i o n a l o p e r a t i o n s . A t y p i c a l audit i s conducted by a three person team and t a k e * about 2 1/2 days t o complete. Of the forty-nine audit teams on which I have served, I functioned as chairperson for thirty-two of those teams.
I have a l s o served twice as a consultant to the Corrections Department of the City of Albuquerque, Navf Mexico, concerning correctional standards. I helped t o develop a f a c i l i t y performance inventory for the American Correctional Associat i o n Standards Committee. The Civil Rights Division of the U.S. Department of J u s t i c e has used ay s e r v i c e s seventeen times on projects concerning conditions of confinement. My work for the Justice Department started in June 1986 and i n cluded inspections and reviews at the Kansas Stace Penitentiary (three v i s i t s ) , the Golden Grove Correctional F a c i l i t y on the U.S. Virgin Islands ( s i x v i s i t s ) , the Jefferson County (Ohio) J a i l (two v i s i t s ) , the Adult Correctional F a c i l i t y on the U.S. Island of Guam (one v i s i t ) , the Texas Department of Corrections ( t h r e e v i s i t s ) , and the San Diego County Correctional System (two v i s i t s ) .
I taught an advanced s o c i o l o g y course, "Corrections and Penology," at Nebraska Wesleyan University in Lincoln, Nebraska, (Fall 1985 and Pall 1991).
TRAINING
In addition to management training offered by. our departmental training academy, I have attended thirteen short courses and seminars offered by the National Institute of Corrections, the American Arbitration Association, and Harper and Row since June 1979.
PROFESSIONAL MEMBERSHIPS
American Correctional Association Nebraska Correctional Association
REFERENCES
Available on Request
6/93

I. Introduction
This report is filed in connection with my February 1112. 1993 visit to the Golden Grove Correctional Facility on St. Croix, U.S. Virgin Islands. I toured the facility at the request of the U.S. Justice Department. Civil Rights Division, Special Litigation Section in connection with U.S. v. Vircin Islands CA No. 86-265 (D.V.I.). The main purpose of my visit was to monitor and check the process of the Government of the Virgin Islands in implementing and following the Plan of Correction ordered by the Court. The Virgin Islands Government is required to follow the plan to comply with the terms of the Consent Decree entered in this case on December 1. 1986.
As one of the authors of the Plan of Correction. I had responsibility for issues involving safety, sanitation, shelter and food service. A secondary purpose of the tour was to examine the reasons for the lockdown of the Golden Grove facility which has been in effect since September 18. 1992.
II. Visit to the Golden Grove Correctional Facility 11-12. 1993.
This tour included Department of Justice Attorney Timothy R. Payne ar.d consultants Charles Braslow, M.D. and James Balsair.o. Our first activity on February 11
1

•fit

J\

consisted of a meeting with Corrections Director James Aiken. Acting Warden Kurt Walcott and other correctional staff, attorney Darlene C. Grant representing the Virgin Islands Attorney General and various contractors. At that meeting Mr. Aiken briefed us on the situation at Golden Grove with respect to the lockdown which he ordered shortly after becoming Director of the V.I. Bureau of Corrections. The involvement of the U.S. Department of the Interior in assisting with funding of changes at the institution was explained. Representatives of contractors who were working on or bidding on the fire alarm system, repairing electrical systems, repairing security doors, renovating the kitchen, and enhancing perimeter security gave presentations and answered questions. Director Aiken also detailed his approach to upgrading the staff and management of the facility. Note was made of the assistance already received from the U.S. Bureau of Prisons and the National Institute of Corrections. A representative of the Virgin Islands Fire Protection Service was also present and commented on areas where his expertise was or would be utilized.
Following the meeting, I toured the inmate laving units of the facility, the kitchen/dining area (under renovation) . the warehouse, the laundry, the maintenance shop. the carpenter shop, the automotive shop and the
2

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medical are-?., The balance of the day was spent in aoc: review and iinterviews with staff and contractor?.
On February 12 I concluded my tour of the institution by inspecting both towers, the institution's perimeter, the generator room and the central control station. I went through two of the housing units again and talked with a number of staff. Some documents I requested earlier were made available and I reviewed them. An exit interview with acting Warden Kurt Walcott and attorney Tim Payne concluded the day's activity. At this interview I outlined some of ray preliminary observations and conclusions.
III. Findings and Conclusions - Consent Decree Issues
This account of my findings and conclusions will follow the outline and format of the court-ordered Plan of Correction.
A. Safety Issues
i. Centrally Monitored Smoke Detection and Fire Alarm System (I.A.)
This part of the plan is noi much further along than it was a yeer ago. At that time (March 1992) . the Department said they could net proceed until the leaking roofs had been repaired. These repairs were completed and
3

seem to have held. Bids are now being sought for the system and a contract seems likely to be awarded soon. An appropriation has been made to pay for the system. One contractor who is bidding on the project said, he was ready to start immediately to install the system which will include smoke detectors in the inmate cells. Completion within 90 days was anticipated. It was very encouraging to note the detailed input bein$r received from the Virgin Island Fire Protection Service on the specifications for the system. It was also noted that the system can be modified to include a body alarm system which will enhance staff security throughout the facility.
2. Kitchen Exhaust Hood (I.B.)
This hood and a fire extinguishing system have been in place' for some time. Since the entire kitchen/dining room was shut down for extensive renovation, it was not feasible to check on the operation and maintenance of the system. This will need to be assessed during the next tour/inspect ion.
4

J\
3. Electrical Wiring and Equipment (I.C.)
The contract for the project has been awarded and the contractor estimates that he is 70% completed with the required work. There was considerable evidence of the electrical work which I viewed during ny tours of the facility. All of the work should be completed in the next few months. A final evaluation of the scope and quality of the repairs should be done during the next tour/inspection.
4. Emergency Generator (I.D.)
I inspected the generator and it appeared to be functional. Reports of the periodic testing of the generator were reviewed and appeared to be in order. There was evidence of an inspection of the generator by the Virgin Islands Fire Protection Service. In response to that inspection. the facility extended the~diesel exhaust pipe well above the roof line and did a thorough cleanup of the area around the generator building. Staff indicated that the entire island is subject to frequent power outages and that the generator always performed as it should during those periods.

f\

5. Communication System (I.E.)

The radio communication system is still in plevce

and functioning.

There continues to be an

adequate supply of radios. The telephone system

was in better shape than one year ago. All of the

housing units have telephone service now. New

phones are being installed in other areas of the

facility. The telephone company representative

told me that water leaks into the underground

cable still cause problems from time to time.

There was no evidence of a monthly test of the

communication systems by institutional staff nor

was there evidence that an annual simulated

emergency drill had been conducted at the

institutions by the Virgin Islands Fire Protection

Service. I was told that the Service preferred to

wait to conduct the drill until the emergency

plans were complete and staff had been trained in

the plan.

6. Tool Control System (I-F.)
Additional progress has been made in this area since my March 1992 visit. There was evidence that more "shadow boards" for tools are in use. Al1 of the tools I found laying around during my previous visits have been secured. Staff have
6

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been assigned to do tool inventories and to keep

records of the inventories. Locked cages and

cabinets for tools are in the kitchen and in the

shops. Security is greatly improved in this area.

A. tool control policy has been issued (February 1,

1993) which details how tools are to be issued,'

maintained, and controlled.

Inventories and

regular reports are required. It should be

possible, during our next tour, to find the

necessary documentation to monitor the

effectiveness of the tool control system- The

only problem I discovered during my inspection was

security for kitchen utensils in the institution

warehouse. Some large forks were lying in plain

sight on a shelf toward the rear of the warehouse.

The practice of securing this material needs to be

implemented as soon as it is brought inside the

secure perimeter.

7. Emergency Plan (I.G.")
Director Aiken informed us that he has received and accepted an offer of assistance from the California Department of Corrections to help develop an emergency plan and to train staff in this area. Hence compliance with this part of the Plan of Correction has not been achieved. The

f\
representative of the Virgin Islands Fire Protection Service told me that they will have input and review responsibility for those sections of the plan dealing with fire situations.
I reviewed documentation indicating that some fire drills were held between March and September of 1992. Since the lockdown there does not appear to have been any drills held at the facility.
This entire area will need extensive scrutiny and review during our next tour.
8. Emergency Keys (I.H.)
Emergency keys for all areas are maintained in the control center. There is a conscientious effort to maintain, test, and repair all of the locks on doors which function. The continuing difficulty with all of this is that many doors are still jammed shut, particularly in the housing units.
9. Staffing (I.I.)
The additional custody and maintenance staff called for in the Plan of Correction are still in place. The institution is still experiencing difficulty in hiring skilled tradespersons in the maintenance area. There are some plans to hire a
8

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certified engineer. At the present time there are only three maintenance persons on staff. The number of custody staff exceeds the 70 FTE requirement and seems to be adequate.
At the tine of our tour, the number of inmates was 252 (235 men and 17 women). In a lockdown situation, the number of security staff was adequate. At the time of our next tour, custody staffing must be closely examined to see if the numbers are adequate to handle the inmate population and maintain good security.
10. Maximum Security Exit (I.J.)
The construction of a second exit from the maximum security section in the administration building has not been accomplished. However, at the time of our tour there were no inmates housed in this section. It was undergoing renovation and prison officials told us they were not certain they would be using the area for inmate housing.
The construction of a second exit remains a requirement if the area is to be used for inmate housing. Prison officials acknowledged this and indicated they would construct the e*it if it was

decided to house inmates there. At the tine of our next tour, this will be checked again.
11. Functioning of All Primary and Secondary Exits (I.K.)
Problems here have continued since my March 1992 visit. There continue to be no more than one or two exits from each of the housing units. Doors are jammed and, in some cases, have been welded shut.
However funds have been allocated and a contractor's bid has been accepted to rectify the situation. The contractor is expected to begin work soon.
In addition to new doors and door jams, those doors which have direct exposure to rainwater must have some sort flashing installed above them to prevent water from settling on top of the doors and re-creating the "problems caused by rust and premature deterioration.
12. Fire Extinguishers (I.L.)
There were fully charged fire extinguishers in all the living areas I inspected. The institution is evidently maintaining them and is meeting this aspect of the Plan of Correction.
10

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B. Sanitation Issues
1. Kitchen/Dining Area Screens (II.A.)
Most of the missing screens in the kitchen/dining area have been replaced and the louvers damaged by Hurricane Hugo have been repaired. I reviewed inspection reports of the kitchen which had been prepared by the Virgin Islands Health Department and noted that the institution had been cited for numerous sanitation problems in the kitchen, including insect control. The last report, dated January 7. 1993, undoubtedly precipitated the closing of the kitchen for major renovation and cleaning. This area will need close scrutiny during our next inspection tour.
2. Drinking Water System (II.B.)
The institution is still struggling to supply clean drinking water, in the housing units. During our March 199"2 visit they were overhauling and cleaning the cistern system which supplies drinking water to the housing units. During th» current tour we were shown a new chlorinating system for purifying the water. However a review of violation reports from the Virgin Islands Department of Planning and Natural Resources
11

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Division of Environmental Protection shows that as recently as January 8, 1993 there wer* unacceptable levels of coliform bacteria in the drinking water.
The institution appeared to be hard at work to solve this problem and the D.P.N.R. seems committed to an ongoing testing program until the problem is solved.
3. Showers (II.C.)
The retiling of the showers and the replacement of the shower heads have still not been totally completed. Outside contractors were busy trying to complete the tiling work during our tour. Considerable progress in this area since our March 1992 tour was noted.
4. Water Heaters (II.D.)
The water heaters for the housing units have been installed and appeared to be in good working order.
5. Toilets (II.E.) New toilets have been installed in the inmate cells. There was some evidence of spot plumbing
12

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problems which the institution needs to address with its maintenance staff.
6. Exterminator Services (II.F.)
I did not recheck this area specifically, but did note the comments of the Health Department Inspector during the January 7, 1993 inspection that flies, roaches and mice continue to be a problem — particularly in the kitchen. More frequent visits by the exterminator may be necessary.
7. Housekeeping Plan (II.G.)
There was no evidence presented that a written housekeeping plan had. been developed by the facility. During our last visit we were told that parts of it would be incorporated in the post orders for correctional staff. It is appropriate to note that, overall, the institution appeared much neater and cleaner than in March 1992. A written plan is still required and should be reviewed during our next inspection.
C. Shelter Issues 1. Roof Repair (III.A.)
13

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This item was completed at the time of our last tour (March 1992). Indications are that leaky
are no longer the problem they once were,
2. Preventative Maintenance Plan (III.B.)
There is no written preventative maintenance plan at the institution. Officials told us they would not develop one until all the equipment on order or about to be installed is in place. They intend then to use manufacturer's specifications in the written preventative maintenance plan.
This requirement must be checked during the next tour.
D. Food Service Issues
1. Kitchen Appliances (IV.A.)
During my March 1992 visit there was evidence that a number of new kitchen appliances had been installed. The new dishwasher, however, was not working.
Shortly before our arrival on this tour, all equipment was removed from the kitchen in order to install new floor tile and undertake other renovations. Appliances were moved outside the kitchen and were being cleaned. Food for the
14

inmates was being prepared at the National Guard Armory kitchen and transported to the institution at mealtime.
Obviously a determination of compliance with this part of the plan will need to wait until our next tour.
2. Kitchen Freezers and Coolers (IV.B.)
As with the kitchen appliances, the walk-in freezer and walk-in cooler were undergoing renovation and replacement during our tour. Compliance will be monitored during our next inspection.
3. Hot Water Delivery System to Kitchen (IV.C.)
We could not determine whether or not this system was working due to renovation and plumbing repairs in the kitchen. This too will be an it«m for our attention on the next visit. IV. Summary Comments on Compliance"With the Plan of Correction.
I anticipated much progress after my March 1992 visit to Golden Grove. There has not been the improvement I had expected. However during this inspection, I sensed that fundamental change was taking place in the organization. There is now a management structure in place and a degree of organization which did not exist earlier. An overall plan
15

X.:.. » „ « . „ „

tK1^Lii

^

of faction with specific action steps for each of the

element* of the Plan of Correction lias been developed and is

being followed. There is a spirit of professionalism among

most of the staff with whom I talked. There is support for

the new Director in the organization and from other

governmental organizations. Particularly gratifying is the

degree to which the Bureau of Corrections is working with

the Virgin Islands Fire Protection Service, the Health

Department and the various contractors who are working on

physical plant improvements.

Outside agencies are

inspecting the facility more frequently than in the past.

The new Director has professional credentials in prison work

and is well connected with the national correctional

establishment.

This will enhance obtaining grants and

assistance to re-build the Bureau of Corrections.

I believe there are grounds for optimism that fundamental change is taking place at the Golden Grove facility. I also think that the continued monitoring of the Plan of Correction by the U.S. Department of Justice is important in helping the new administration achieve its goals.

V. Lockdowri Issues end Comments

Shortly after his arrival as Director of the V.I. Bureau of Corrections. James Aiken determined that the situation at the Golden Grove prison was out-of-control . He found that:

16

<*T SPEC LIT ^

^0,4

1. Physical security was inadequate because gun towers, (fence alarms) electronic door systems. lighting, and cemmunication systems were inoperable.
2. Correctional staff were not adequately trained nor armed to supervise the potentially dangerous inmate population.
3. Very little informention was known about the inmate population's criminal history (no classification).
4. Contraband drugs and weapons were present.
5. High-risk inmates were not segregated from other inmates.
6. There were no adequate maintenance and repair programs. 7. Inmate living conditions were unsafe and unsanitary. 8. Criminal gangs were in control of the facility. 9. Correctional staff were allowed to sleep in gun towers. 10... No equipment. training nor useful plans existed to
manage a prison emergency. 11. Inmates had access to the existing computer system and
sabotaged it. 12. Inmates had access to employee records.
13. Inmates had exercised control over some administrators.
14. Tool control was substandard. 15. Correctional officers and other staff morale wes low. 16. Policy and procedures were basically nonexistent. 17. Inmates had tunnels to move from cell to cell. 18. Cells had wire mesh instead of bars. 19. Security doors were rusted in many places. 20. Security keys were worn and inoperable.
21. Emergency generators were not properly maintained.
22. Food service was substandard.
17

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23. The Bureau of Corrections had not complied with the Court ordered Consent Decree.
24. There was a lack of procedures to properly account for offender population.
25. Poor documentation and record keeping were existent. 26. Visits between inmates and family were not properly
supervised. 27. Visitors were not properly screened prior to enterinq
the facility.
28. "Blind spots" existed which prohibit proper security along the fence.
29. Inmate population had civilian clothing which was not regulated.
30. Some inmates were allowed "free" run of the community without proper supervision.
31. Work Release regulations were not constant with community expectations and sound correctional practice.
32. Some inmates were supervising other inmates without employees present.
33. Electrical wiring was exposed and energized. 34. Inmates with mental problems were mixed with general
population. 35. The Front Gate. Control Room, and Back Gate were not
secured. 36. The Grounds had tall "grass and were not properly
maintained. 37. Medical health system was substandard.
Eased on these perceived security risks, he ordered all
prisoners confined to their cells unless they were working
under close staff supervision. The lockdown was imposed on
September 18. 1992 and was still in effect at the time of
our tour. 18

While I cannot certify from personal knowledge that all of the thirty-seven identified problems are real. I can say that I have observed the majority of them to be true at the time of my visits to the facility during the past five years. Many of the problem areas are also mentioned and addressed by the Plan of Correction which is far from being completed.
During my visit at the facility I reviewed a confidential evaluation of the prison made by the Intelligence Chief of the U.S. Bureau of Prisons - Craig H. Trout. Mr. Trout gave a rather grim assessment of the situation, concluding that the Golden Grove Correctional Institution was nonfunctional in a number of critical areas.
Clearly Mr. Aiken was shocked at whet he found and at what the experts (including those of us who have been examining conditions at the prison during the past five years) were telling him.
The lockdown was a drastic, yet necessary reaction to evidence that the Golden Grove facility was a dysfunctional prison.
However, after a five month lockdown. it. is clearly time for the Director to set a schedule for modifying and ultimately lifting it. Progress has been made in e number of the thirty-seven identified problem areas. I agree with the
19

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Director's view that the keys to totally lifting: the lockdown arc:
1. Solving the perimeter security problems. 2. Creating the capability to respond to emergency
situations. 3. Developing & classification system for inmates.
Of particular concern is the situation with respect to the female inmates. Under "normal" circumstances. they have very little freedom of movement and few program and recreational opportunities. With only 17 inmates. lifting the lockdown in that part of the prison is a step that should be taken immediately.
As for the rest of the prison, male inmates should be allowed, under escort, to go to the dining hall as soon as the renovations are finished. Access to the yard areas can be allowed, by housing unit, for limited periods. This process of affording outside recreation should begin immediately. If the numbers of inmates are limited and they are under the supervision of correctional officers on the yard, there should be minimal security problems in affording recreational and exercise opportunities. If needed, a roving, motorized perimeter patrol can augment tower supervision in the area where the inmates are exercising. Assicnments of inmates to work in food service, maintenance. the chops and routine sanitation projects should occur at
20

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the same tine. I would recommend that lifting of the lockdown for the male inmates be completed by May 1, 1993.

Date

John J. Dahm. Consultant

21

 
 U.S. v. Virgin Islands

I • • ••• •• •• m v
PC-VI-002-014 DISTRICT COURT OF THE VIRGIN ISLANDS

DIVISION OF ST. CROIX

UNITED STATES OF AMERICA,

Plaintiff,

CIVIL NO. 1986/265

V.

TERRITORY OF THE VIRGIN ISLANDS

Defendant

TO: Honorable Rosalie S. Ballentine, Attorney General Darlene L. Grant, Assistant Attorney General Timothy Payne, Esq. Special Litigation Section Civil Rights Division U.S. Dept. of Justice P.O. BOX 37076 Washington, DC 20066 Hugh P. Mabe III, Esq., U.S. Attorney
ORDER

THIS MATTER is set for status conference with Chief Judge

Thomas K. Moore and Magistrate Judge Jeffrey L. Resnick on

Wednesday, December 15, 1993 at 9:00 A.M. at the Magistrate's

Conference Room, District Court, 3013 Golden Rock, Christiansted,

St. Croix 00820. The Attorney General is requested to notify and

invite all appropriate representatives of the Bureau of

Corrections.

ENTER:

DATED: September 23, 1993
ATTES O&ENN

JEFFREY VL. RESNICK U.S. MAGISTRATE JUDGE
Clerk

 
 *
U.S. v. Virgin Islands PC-VI-002-015

10 '2S 93 17:0-'

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US. Depai mt of Justice Civil Rights Division

FO. vgton. D.C 2!Y;3
FAX TRANSMXTTAI, SHEET

DATE:

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XO; NatT;*?.

TIME:

FAX P h o n e N o . O f f i c e Phon-5 N o .

SUB-TKCT/ INS

KG.

202/514-6273

202/514-

Krur.bcr o r p a c e s x;;rfr.smit.t.eti (iricxudln-g t h i s (wax - t r a n s . 3 0

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CRT SPEC L I T

1 • r'fiys ic-ji s s c u r i zy was insd^cust.* because cur. r.-v^rs. ^fence ii&ras) e l e c t r o n i c door s y s t e m s . l i g h t i n g , end C'..^;jiTiJn i Cd 11 on $ys ~^/us Tn*$r c i n c c ^ r s b 1^ .
2. Correc tior.di s t a f f were not a d e q u a t e l y t r a i n e d ,-ior annee -o supervise the p o t e n t i a l ly dangerous lnn:ate population.
3^ Very l i t t l e information was known abou: the i n n a t e p o p u l a t i o n ' s criminal h i s t o r y (no c l a s s i f i c a t i o n ) .
4. Contraband drugs and weapons were present.
5. Kigh-rf.sk inmates were not segregated frctfi ether inmates.
6- There were no adequate maintenance and repair programs. 7. Ira^.te living conditions were unsafe a.nd unsanitary. 3. Criminal gangs were in control of the facility-
9. Correctionsi staff were allowed to sleep in can towers.
10. No equipment, training nor useful plans existed to manage a prison emergency.
II - Inmates had access to the existing computer system and sabotaged it.
1 2 . Inmates had.cicc&ss tc empl cyee records .
13 Iiiiu-^tes had exercised control over some c.aministrators .
14. Tool control was substandard.
15. Correct ional officers and other staff morale was low.
16. Poj icy and procedures were basically nonexistent.
1? . Innict.es had tunnels to move from eel 1 ro eel 1 -
18. Cells had wire mesh instead of bars.
19. Security doors were rusted in ~3ny places.
2G. Security keys were worn ar.d inoperable.
21. Emergency generators were not properly maintained.
22. Focd service was substandard.

10.-2S.-03 1 7 : 0 5 ©202 314 8273

CRT SPEC LIT

©003

Cou;'; orj^re-i Concent D-scro*:

not comp-3 led with the

lack of proc-?dur^s to rrop^rly account for

2i> - F-cor do curneriv.-stion a n d r e c o r c k e e p inq were exist ant

26. Visits between irmates a n d fami ly were not prop sup«rrvisea .

27. Visitors were not properly screened prior to e n U the f cci 1i t.y .

25. "Blind spot?" existed which prohibit proper sec-ority d.! oi\g the fence,

population hod civiiidii clothi ng v?hich

not

ed

20 Some inmates were a.licwed "free" run of the. cooiun:ty vithout proper supervision.

Work Release regulations \rere ncn constant with community expectations s.nd sound correct ignc.1 practice.

Some lmfia-te? w e r e s u p e r v i s i n g or,her iiini^tei

1OU1

employees present-

53. Electrical wiring was exposed and energised. Inmat-^s vit;h nient-al p r o b l e m s w e r e mix-sci with qen^rai

The Front Gate. Control Room, andLack Gate ver* not secured
36 The Grounds h a d tall g r a s s a n d w e r e r;c: properly maintained.
3 7 , M-adicel health system w a s s u b s t a n d a r d .

 
 U.S. v. Virgin Islands

—

—

~~

~™ ^ ™ ™ •

• • ••

•• • •

•• •• •

PC-VI-002-017

IN THE DISTRICT COURT OF THE VIRGIN ISLANDS

DIVISION OF SAINT CROIX

UNITED STATES OF AMERICA,

)

Plaintiff, )

CIVIL NO. 1986/265

vs.

)

GOVERNMENT OF THE VIRGIN ISLANDS, )

ET AL.,

)

Defendants. )

m

o

ORDER

o

This matter having come for a hearing before* ChePC6%rt<

on March 2, 1988 on an Order to Show Cause, and fga

having been heard on the matter, it now hereby ORDERED

That the hearing on the Order to Show Cause is recessed.

It is further hereby ORDERED

That the defendants will submit detailed plans in accor-

dance with the consent decree on or before March 16, 1988.

Failure by the defendants to comply with this Order will

result in reinstitution of these proceedings at the request

of the United States. DATED this 2L d a y o f March, 1988.

ATTEST: ORINNrARNOLD, CLERK BY>

•MS-
V. O'BRIEN JUDGE

 
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STAYED,CLOSED

District Court of the Virgin Islands District of the Virgin Islands (St. Croix Division) CIVIL DOCKET FOR CASE #: 1:86­cv­00265­WAL­GWC

United States of America v. Territory of The Virgin Islands Assigned to: Chief Judge Wilma A. Lewis Referred to: US Magistrate Judge George W. Cannon Demand: $0 Case in other court: Third Circuit, 12­04305

Date Filed: 11/21/1986 Date Terminated: 05/14/2013 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

Special Master Kenneth Ray

Plaintiff United States of America

represented by Angela Tyson­Floyd Department of Justice 1108 King Street Suite 201 St Croix, VI 00820 340­773­3920 Fax: 340­773­1407 Email: Angela.P.Tyson­Floyd@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Kristin Hucek US Department of Justice 950 Pennsylvania Avenue N.W. Washington, DC 20530 202­305­3454 Fax: 202­514­4883 Email: kristin.hucek@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Marlysha Myrthil U.S. Department of Justice Civil Rights Division, Special Litigation Section 950 Pennsylvania Avenue NW Washington, DC 20530 202­305­3454 Fax: 202­514­4883 Email: marlysha.myrthil@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

https://ecf.vid.uscourts.gov/cgi­bin/DktRpt.pl?104856160684568­L_1_1­1

Rita Katherine Lomio U.S DEPARTMENT OF JUSTICE CIVIL RIGHTS DIVISIONS , SPECIAL
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LITIGATION SECTION 950 PENNSYLVANIA AVE NW WASHINGTON, DC 20530 202­353­1279 Fax: 202­514­0212 Email: rita.lomio@usdoj.gov TERMINATED: 08/19/2016 LEAD ATTORNEY

Sharon Brett United States Department of Justice Civil Rights Division 950 Pennsylvania Avenue, NW; SPL 601 D Street Washington, DC 20530 202­353­1091 Fax: 202­514­4883 Email: sharon.brett@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Alyssa Lareau U.S. Department of Justice Civil Rights Division, Special Letigatio Section 601 D. Street, NW Washington, DC 20530 Email: Alyssa.Lareau@usdoj.gov TERMINATED: 05/21/2014

Andrew John Barrick U.S. Department of Justice 950 Pennsylvania Ave.N.W. Room 5632 PHB Washington, DC 20530 202­514­6249 Fax: 202­514­6273 Email: andrew.barrick@usdoj.gov TERMINATED: 11/02/2011

Emily Anna Gunston United States Department of Justice Civil Rights Division, Special Litigation Section 601 D. Street, NW Washington, DC 20530 202­305­3203 Email: emily.gunston@usdoj.gov TERMINATED: 05/21/2014

https://ecf.vid.uscourts.gov/cgi­bin/DktRpt.pl?104856160684568­L_1_1­1

Joycelyn Hewlett U.S. Attorney's Office Ron De Lugo Federal Bldg 5500 Veterans Drive, Suite 260
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St Thomas, VI 00802 340­774­5757 Fax: 340­776­3474 Email: joycelyn.hewlett@usdoj.gov TERMINATED: 02/01/2010
Lashanda Branch Chirunga U.S. Department of Justice 601 D. Street, N.W. Room 5517 202­514­4883 Washington, DC 20530 202­353­2234 Fax: 202­514­4883 Email: lashanda.branch@usdoj.gov TERMINATED: 05/06/2011
Laura Lee Coon U.S. Department of Justice 950 Pennsylvania Avenue, NW Washington, DC 20530 202­514­6255 Fax: 202­514­0212 Email: laura.coon@usdoj.gov ATTORNEY TO BE NOTICED

V. Defendant Territory of The Virgin Islands

represented by Raymond T. James Department of Justice 6040 Castle Coakley Christiansted, VI 00820 340­773­0295 Fax: 340­773­1425 Email: rjames@doj.vi.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Shari N D'Andrade Virgin Islands Department of Justice Design Centre Building 6040 Castle Coakley Christiansted, VI 00820 340­773­0295 Fax: 340­773­1425 Email: shari.d'andrade@doj.vi.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

https://ecf.vid.uscourts.gov/cgi­bin/DktRpt.pl?104856160684568­L_1_1­1

Aquannette Y. Chinnery V.I. Department of Justice 8000 Nisky Shopping Center Suite 500
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Intervenor Ronald Edward Gillette

District Court CM/ECF ­ LIVE
St Thomas, VI 00802 340­775­3070 Fax: 340­775­3248 Email: achinnery@doj.vi.gov TERMINATED: 08/28/2015
Carol Thomas­Jacobs 18 Kongens Gade St Thomas, VI 00802­0000 340­774­5666 ext 155 Fax: 340­776­3494 Email: carol.jacobs@doj.vi.gov ATTORNEY TO BE NOTICED
Kenrick E. Robertson Office of the Attorney General 6040 Estate Castle Coakley C'sted, VI 00820 340­773­6309 Fax: 340­773­9762 Email: kenrickr@gmail.com
Nathan T Oswald Davies, Ruck & Speweik, Ltd. 427 W. Collage Ave., Box 412 Pemberville, OH 43450 419­287­3233 Fax: 419­931­6934 Email: nathan.oswald@utoledo.edu TERMINATED: 09/04/2014 PRO HAC VICE
Richard S Walinski 900 Adams Street Toledo, OH 43604 419­349­2333 Fax: 419­720­34452 Email: walinski@tmlpa.com TERMINATED: 07/08/2013
represented by Joseph A DiRuzzo , III Fuerst Ittleman David & Joseph, PL 1001 Brickell Bay Drive Suite 3112 Miami, FL 33131 305.350.5690 Fax: 305­371­8989 Email: jd@diruzzolaw.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Date Filed

# Docket Text

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11/21/1986

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Jams Calendar Events (Entered: 11/21/1986)

02/06/1996 113 SEE DOCKET CARD FOR PREVIOUS ENTRIES (Entered: 02/06/1996)

02/06/1996

113 ORDER ASSIGNS HEARING to 04/17/96 at 10:00AM Room 295 (JLR) c/m eod 02/23/96 (Entered: 02/06/1996)

08/12/1996

257 NOTICE of motion (Document was filed in St. Thomas Division and received to St. Croix division on 10/5/06) (Entered: 08/12/1996)

04/04/1997

114 ORDER ASSIGNS CONF to 05/22/97 at 09:00AM Room 295 (JLR) c/m eod 04/07/97 [MWR] (Entered: 04/04/1997)

07/24/1997 115 STIPULATION of the parties eod 07/25/97 [MWR] (Entered: 07/24/1997)

09/05/1997

116 NOTICE of filing six­week compliance report eod 09/09/97 [MWR] (Entered: 09/05/1997)

10/01/1997

117 NOTICE OF FILING monthly compliance report eod 10/02/97 [MWR] (Entered: 10/01/1997)

11/03/1997

118 NOTICE OF FILING monthlly cmpliance report October 1997 eod 11/04/97 [MWR] (Entered: 11/03/1997)

11/10/1997

118 VOLUME (7) SEVEN began with pleading #118 eod 11/10/97 [MWR] (Entered: 11/10/1997)

12/02/1997

119 NOTICE OF FILING monthly compliance report 11/1997 eod 12/03/97 [MWR] (Entered: 12/02/1997)

01/14/1998

120 NOTICE OF FILING monthly compliance report 12/97 eod 01/15/98 [MWR] (Entered: 01/14/1998)

03/09/1998

121 NOTICE OF FILING monthly compliance report 1/98 ­2/98 eod 03/10/98 [MWR] (Entered: 03/09/1998)

03/09/1998

121 VOLUME (8) EIGHT began with pleading #121 eod 03/10/98 [MWR] (Entered: 03/09/1998)

03/10/1998 121 VOLUME (9) NINE eod 03/10/98 [MWR] (Entered: 03/10/1998)

03/10/1998

122 ORDER ASSIGNS CONF to 05/21/98 at 02:00PM Room 295 (JLR) c/m eod 03/11/98 [MWR] (Entered: 03/10/1998)

05/21/1998

123 MEMORANDUM of status / GRANTED (JLR) cc attys eod 05/22/98 [MWR] (Entered: 05/21/1998)

12/14/1998

124 ORDER ASSIGNS CONF to 02/04/99 at 02:30PM Room 295 (JLR) c/m eod 12/15/98 [MWR] (Entered: 12/14/1998)

02/05/1999

125 PTC ORDER FROM P/T ON Feb. 4, 1999 scheduling order entered, cc atty eod 02/08/99 [THT] (Entered: 02/05/1999)

09/09/1999

126 ORDER ASSIGNS CONF to 11/04/99 at 02:30PM Room 295 (JLR) c/m eod 09/09/99 [MWR] (Entered: 09/09/1999)

11/05/1999

127 ORDER (JLR) post conference entered cc attys eod 11/05/99 [MWR] (Entered: 11/05/1999)

11/30/1999

128 ORDER (JLR) amending post conference order effectuation of a joint compliance coordinator is extended to 12/15/99 cc attys eod 12/02/99 [MWR] (Entered: 11/30/1999)

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01/11/2000 06/12/2000 08/04/2000 08/18/2000 08/18/2000 09/13/2000 09/14/2000 09/18/2000 11/28/2000 03/16/2001 03/16/2001 03/21/2001 06/11/2001 11/28/2001 11/28/2001 01/10/2003 01/13/2003 02/27/2003 09/25/2003 10/10/2003 10/14/2003 03/18/2004 11/08/2004

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129 NOTICE of compliance report eod 01/14/00 [MWR] (Entered: 01/11/2000)
130 STIPULATION for appointment of a joint compliance coordinator for health services GRANTED (JLR) cc attys eod 06/19/00 [MWR] (Entered: 06/12/2000)
131 ORDER ASSIGNS CONF (TELEPHONIC) to 08/17/00 at 03:00PM Room 295 (JLR) c/m eod 08/07/00 [MWR] (Entered: 08/04/2000)
132 ORDER ASSIGNS HEARING to 11/09/00 at 10:00AM Room 295 (JLR) c/m eod 08/18/00 [MWR] (Entered: 08/18/2000)
133 ORDER (JLR) Post Conference Order, cc counsel eod 08/24/00 [NAH] (Entered: 08/18/2000)
134 ORDER (JLR) on pltf motion to order Immediate Payment of the Joint Compliance Ccoordinator cc attys eod 09/15/00 [MWR] (Entered: 09/13/2000)
135 MOTION to order immmediate payment of joint compliance coordinator (see document #134) eod 09/15/00 [MWR] (Entered: 09/14/2000)
136 ORDER (JLR) that the Order to show cause for deft to appear and show cause on on Sept. 18, 2000 at 9:00 a.. is moot cc atty eod 09/21/00 [THT] (Entered: 09/18/2000)
137 ORDER (JLR) post conference entered eod 11/29/00 [MWR] (Entered: 11/28/2000)
138 MOTION to order immediate payment of joint compliance coordinator eod 03/19/01 [MWR] (Entered: 03/16/2001)
139 ORDER (JLR) on pltf motion to order immediate payment of the joint compliance coordinator cc attys eod 03/19/01 [MWR] (Entered: 03/16/2001)
140 ORDER (JLR) cnacelling show cause hearing cc attys eod 03/22/01 [MWR] (Entered: 03/21/2001)
141 ORDER (JLR) granting motion for withdrawal of Kelli Evans, Esq. cc attys eod 06/12/01 [MWR] (Entered: 06/11/2001)
142 ORDER (JLR) for responses and for hearing cc attys eod 11/30/01 [MWR] (Entered: 11/28/2001)
142 ORDER ASSIGNS HEARING to 12/18/01 at 02:30PM Room 295 (JLR) c/m eod 11/30/01 [MWR] (Entered: 11/28/2001)
143 APPEARANCE of LaShqanda D. Branch Esq. for pltf eod 01/13/03 [MWR] (Entered: 01/10/2003)
144 ORDER ASSIGNS CONF to 02/27/03 at 02:00PM Room 295 (JLR) c/m eod 01/14/03 [MWR] (Entered: 01/13/2003)
145 APPEARANCE of Andrew J. Barrick, Esq. for pltf eod 02/28/03 [THT] (Entered: 02/27/2003)
146 STIPULATED agreement filed eod 10/08/03 [MWR] (Entered: 09/25/2003)
147 STIPULATED agreement filed eod 10/14/03 [MWR] (Entered: 10/10/2003)
148 ORDER (JLR) regarding stipulated agreement cc attys eod 10/15/03 [TS] (Entered: 10/14/2003)
149 PROGRESS REPORT by deft (Entered: 03/18/2004)
154 MOTION for an order to show cause why defts should not be held in contempt

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(Entered: 11/08/2004)

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11/08/2004

155 MEMORANDUM of law in support of its motion for an order to show cause why deft should not be held in contempt (Entered: 11/08/2004)

11/08/2004

156 MOTION of the US for leave to file exhibits under seal and for protective order (Entered: 11/08/2004)

11/08/2004

157 MEMORANDUM in support of motion for leave to file exhibits under seal and for protective order (Entered: 11/08/2004)

04/12/2005 150 REQUEST FOR Emergency Hearing (Entered: 04/12/2005)

07/28/2005 151 ORDER (GWC) for response cc attys (Entered: 07/28/2005)

08/12/2005 153 RESPONSE of the U.S. to inmate request for hearing (Entered: 08/12/2005)

08/15/2005 152 MOTION TO DISMISS by defts (Entered: 08/15/2005)

11/21/2005 158 NOTICE of substitution of counsel by pltf (Entered: 11/21/2005)

11/22/2005

159 NOTICE of appearance of Co­Counsel for the United States by pltf (Entered: 11/22/2005)

11/23/2005

160 ORDER (GWC) to withdraw,and that the United States Assistant James S. Carroll III shall appear on behalf of federal government in the instant case cc attys (Entered: 11/23/2005)

11/23/2005

161 NOTICE of withdrawal by co­counsel for the United States by pltf (Entered: 11/23/2005)

11/23/2005 162 NOTICE of unavailablity by DEFT. (Entered: 11/23/2005)

11/29/2005 163 ORDER (GWC) for an order to show cause cc attys (Entered: 11/29/2005)

11/30/2005 165 MOTION for enlargement of time by deft (Entered: 11/30/2005)

12/01/2005

164 ORDER (GWC) for status conference and hearing for an order to show cause cc attys (Entered: 12/01/2005)

12/16/2005 166 OPPOSITION response to United States Contempt motion (Entered: 12/16/2005)

12/19/2005 167 ORDER (RLF) that the joint motion is Granted, cc attys (Entered: 12/19/2005)

12/20/2005

168 OPPOSITION response to the United States' contempt motion by defts (Entered: 12/20/2005)

12/20/2005 169 NOTICE to the court by pltf (Entered: 12/20/2005)

01/13/2006 170 MOTION for enlargement of time (Entered: 01/13/2006)

01/13/2006

171 NOTICE of service of interrogatories and requests for the production of documents (Entered: 01/13/2006)

01/17/2006

172 REPLY memorandum of law in support of its motion for an order to show cause Why defts should not be held in contempt (Entered: 01/17/2006)

01/18/2006

173 ORDER (GWC) continuing status conference on 2/8/06 @ 9:00 a.m. and February 9, 2006 @ 9:30 a.m. cc attys (Entered: 01/18/2006)

01/20/2006 174 ORDER (GWC) that the pltf's motion is GRANTED, cc attys (Entered: 01/20/2006)

01/30/2006

175 NOTICE of service of defts objections and responses and supplemental responses to pltfs interrogatories and document request by deft (Entered: 01/30/2006)

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02/03/2006 02/06/2006
02/06/2006
02/06/2006
02/06/2006
02/06/2006
02/07/2006
02/07/2006
02/07/2006
02/07/2006
02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/07/2006 02/08/2006 02/08/2006 02/08/2006 02/08/2006

District Court CM/ECF ­ LIVE
176 MOTION for mediationby defts (Entered: 02/03/2006)
177 ORDER ((GWC) on defts motion for mediation is DENIED cc attys (Entered: 02/06/2006)
178 ORDER (GWC) that defts motion in limine to exclude prisojners'declarations, stipulated agreement and corrective action plan is DENIED, cc attys (Entered: 02/06/2006)
183 OPPOSITION to the territory of the virgin islands motion for mediation by pltf (Entered: 02/06/2006)
184 OPPOSITION to the territory of the Virgin Islands motion in limine to exclude prisoners declaration, stipulated agreement and corrective action plan by pltf (Entered: 02/06/2006)
185 MOTION in limine to exclude prisoners declarations, stipulated agreement and corrective action plan by defts (Entered: 02/06/2006)
179 ORDER (GWC) regarding filing exhibits under seal and protective order cc attys (Entered: 02/07/2006)
180 EXHIBIT List (FIRST SUPPLEMENTAL)for show cause hearing commencing on 2/8/06 by pltf (Entered: 02/07/2006)
181 EXHIBIT List for show cause hearing commencing on 2/8/06 by pltf (Entered: 02/07/2006)
182 WITNESS LIST for show cause hearing commencing on 2/8/06 by pltf (Entered: 02/07/2006)
186 WITNESS LIST by defts (Entered: 02/07/2006)
187 EXHIBIT List by defts (Entered: 02/07/2006)
188 SUBPOENA issued to Rosaldo Horsford ,Acting Warden (Entered: 02/07/2006)
189 SUBPOENA issued to Jennifer Charles (Entered: 02/07/2006)
190 SUBPOENA issued to Orsel Edney, Chief of security (Entered: 02/07/2006)
191 SUBPOENA issued to Dr. Yousef mustafa Ali (Entered: 02/07/2006)
192 SUBPOENA issued to Stephen McIntosh­Luis (Entered: 02/07/2006)
193 SUBPOENA issued to Stephen Mcintosh­Luis (Entered: 02/07/2006)
194 SUBPOENA issued to Dr. Yousef Mustafa Ali (Entered: 02/07/2006)
195 SUBPOENA issued to Orsel Edney,Cheif of Security (Entered: 02/07/2006)
196 SUBPOENA issued to Jennifer Charles (Entered: 02/07/2006)
197 SUBPOENA issued to Rosaldo Horsford, Acting Warden (Entered: 02/07/2006)
198 MOTION requesting taking of judicial notice by defts (Entered: 02/08/2006)
199 SUBPOENA issued to Stephanie McIntosh­Luis (Entered: 02/08/2006)
200 SUBPOENA issued to Nurse Qualey (Entered: 02/08/2006)
201 SUBPOENA issued to Officer Belardo (Entered: 02/08/2006)

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02/08/2006

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202 SUBPOENA issued to Orsel Edney, Chief of security (Entered: 02/08/2006)

02/08/2006 203 SUBPOENA issued to Orsel Edney, Cheif of security (Entered: 02/08/2006)

02/08/2006 204 SUBPOENA issued to Rosaldo Horsford, Acting Warden (Entered: 02/08/2006)

02/08/2006 205 SUBPOENA issued to Dr. Yousef Mustafa Ali (Entered: 02/08/2006)

02/08/2006 206 SUBPOENA issued to Dr. Yousef Mustafa Ali (Entered: 02/08/2006)

02/08/2006 207 SUBPOENA issued to Rosaldo Horsford, Acting Warden (Entered: 02/08/2006)

02/13/2006

208 CTRM. MIN. show cause hearing held (GWC) (Ct.REPORTER C. Hasse on 2/8/06 (Entered: 02/13/2006)

02/13/2006

209 CTRM. MIN. CONTINUATION of Show Cause Hearing held (CT.Reporter C. Haase) dated 2/9/06 (Entered: 02/13/2006)

02/13/2006

210 CTRM. MIN. CONTINUANCE of Show Cause hearing held (CT. Reporter V. Lawrense Present) Dated 2/10/06 (Entered: 02/13/2006)

02/13/2006

211 CTRM. MIN. CONTINUANCE of Show Cause hearing held (Ct. Reporter C. Haase) dated 2/13/06 (Entered: 02/13/2006)

02/16/2006

212 TRANSCRIPT Reporter's of proceedings order to show cause dated 2/9/06 (Entered: 02/16/2006)

02/17/2006

213 TRANSCRIPT of continuation of order to show cause dated 2/10/06 (Entered: 02/17/2006)

02/17/2006 214 EXHIBIT and witness list by deft (Entered: 02/17/2006)

02/17/2006 215 EXHIBIT and witness list by pltf (Entered: 02/17/2006)

02/21/2006 216 TRANSCRIPT (REPORTER'S) of proceedings (Entered: 02/21/2006)

03/03/2006 216 VOLUME (10) TEN BEGINS WITH # 154­216 (Entered: 03/03/2006)

03/03/2006 216 VOLUME (11) ELEVEN (Entered: 03/03/2006)

03/03/2006

217 CERTIFICATE of Compliance Re Food Service: Kitchen Freezers and Coolers by defts (Entered: 03/03/2006)

03/13/2006

218 NOTICE OF FILING and service of proposed findings of fact, conclusions of law,and order granting United States' motion to find defts in contempt and for appointment of a special master by pltf (Entered: 03/13/2006)

03/13/2006 219 PROPOSED FINDINGS/CONCL. BY of law by pltf (Entered: 03/13/2006)

03/13/2006 220 CERTIFICATE OF SERVICE by pltf (Entered: 03/13/2006)

03/13/2006

222 NOTICE that deft's finding of fact and conclusions of law contains reference to information under seal by defts (Entered: 03/13/2006)

03/13/2006

223 PROPOSED FINDINGS/CONCL. BY law and order granting United States motion to find defts in contempt and for appointment of a special master by pltf (Entered: 03/13/2006)

03/14/2006

221 NOTICE OF FILING of draft order denying pltf's motion by defts (Entered: 03/14/2006)

03/15/2006 223 VOLUME (11) ELEVEN BEGINS with Docket # 218 (Entered: 03/15/2006)

03/23/2006 224 ORDER (GWC) GRANTING United States' motion to find defts in contempt and for

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appointment of a special master cc attys (Entered: 03/23/2006)

03/28/2006 225 RULE 60(A) motion by defts (Entered: 03/28/2006)

04/12/2006 226 NOTICE OF FILING by defts (Entered: 04/12/2006)

04/12/2006 227 STATEMENT OF ADMITTANCE (CHECK # 4619544) (Entered: 04/12/2006)

04/12/2006 228 NOTICE of unavailability by deft (Entered: 04/12/2006)

04/12/2006 229 JOINT Recommendation for appointment of special master (Entered: 04/12/2006)

04/13/2006 230 ORDER (GWC) appointing Special Master cc attys (Entered: 04/13/2006)

04/18/2006

231 ORDER (GWC) Granting defts Rule 60(a) motion; 2. The Order Granting U.S.A. motion to Find Deft in contempt and for appointment of a Special Master (Docket No. 224), entered 03/23/06, is hereby AMENDED by substituting an apostrophe and the letters for the comma immediately following the words Special Master in Section H, subparagraph 5, page 27. Said paragraph shall read, as amended: 5. Within twenty (20) days of the date of this Order, Defendants shall deposit with the Clerk of Court, U.S. District Court of the Virgin Islands, Division of St. Croix, to the Clerk's Registry Account, a sum in the amount of $100,000.00 (one Hundred­thousand dollars), and defts hall, as order by the Court, deposit such additional monies as required for payment of the statements in the Special Master's consultants, expert, and staff., cc attys cc attys (Entered: 04/18/2006)

05/01/2006 232 NOTICE of designation of compliance coordinator by defts (Entered: 05/01/2006)

05/01/2006 233 NOTICE of unavailable by defts (Entered: 05/01/2006)

05/01/2006

234 NOTICE of designation of compliance coordinator (repeated docket AS TO entry 232& 233) (Entered: 05/01/2006)

05/01/2006

235 NOTICE of unavailablity (REPEATED DOCKET AS TO ENTRY 232 &233) (Entered: 05/01/2006)

05/15/2006

236 ORDER (GWC) that the deft motion for enlargement of time to file report is GRANTED; and ORDERED that defts shall file their report on or before 05/18/06. cc attys (Entered: 05/15/2006)

05/15/2006

237 RESPONSE and opposition to defts motion for enlargement of time by U.S.A. (Entered: 05/15/2006)

05/15/2006 238 MOTION FOR EXTENSION OF TIME TO by deft (Entered: 05/15/2006)

05/18/2006 239 STATUS REPORT by defts (Entered: 05/18/2006)

06/23/2006

240 LETTER to Attorney Drue from Shanetta. Y. Cutlar, Chief Special Litigation Section dated 6/16/06 (Entered: 06/23/2006)

06/30/2006 241 STATUS REPORT re attachment B by defts (Entered: 06/30/2006)

06/30/2006 242 STATUS REPORT 2nd by defts (Entered: 06/30/2006)

06/30/2006 243 Status Report re Attachment B (Entered: 06/30/2006)

06/30/2006 244 2ND STATUS REPORT BY defts (Entered: 06/30/2006)

07/05/2006 245 LETTER to Atty. Drue from Joseph Sperber IV dated 6/26/06 (Entered: 07/05/2006)

07/24/2006 246 STATUS Report of July 2006 by defts (Entered: 07/24/2006)

07/31/2006 247 NOTICE OF FILING of amended certificate of service by defts (Entered: 07/31/2006)

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08/18/2006
08/18/2006
08/18/2006
08/21/2006
08/21/2006 09/07/2006 09/11/2006
09/14/2006 09/18/2006 09/18/2006 10/11/2006 10/12/2006 10/13/2006 10/16/2006 10/17/2006 10/24/2006 10/24/2006 10/26/2006 11/03/2006 11/21/2006

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248 ORDER (GWC) that the Clerk of the Court process and pay from funds deposited by the defts into the Clerk's registry Account, the sum of 8,515.79. and that the Clerk reinmberce to Susan Mc Cambe; $1,576.69 to cover hotel costs 750.00 air fare 826.69. cc attys (Entered: 08/18/2006)
249 ORDER (GWC) that the clerk of Court process and pay from funds deposited by the defts into the Clerk's registry account of 7,892.03) to Harry E. Grenawitzke (Entered: 08/18/2006)
250 ORDER (AMENDED) that the clerk of Court process and pay from funds deposited by the defts into Clerk's Registry Account, the sum of (7,757.03) to Harry E. Grenawitzke (Entered: 08/18/2006)
251 ORDER (GWC) that the Clerk of Court process and pay from funds appropriated to the Judiciary, invoices submiteed Special Master Susan McCambell, ($18,984.93) (Entered: 08/21/2006)
252 STATUS REPORT Defts' August 2006 (Entered: 08/21/2006)
253 ORDER (GWC) that the clerk of Court procss and pay from funds appropriated to the Judiciary, 4,768.14 cc attys (Entered: 09/07/2006)
254 ORDER (GWC) that te Clerk of Vourt orocess and psy from funds deposited by the deft in the the Cler's Registry Account, the sum of $2,000.00 to Harry E Grenawitke to cover consulting services, technical report and record review completed on Aug. 31, 2006, cc attys (Entered: 09/11/2006)
255 LETTER of memorandum to Honorable Kerry Drue, Esq. from Susan Mccambel, Special Master dated September 12, 2006 (Entered: 09/14/2006)
256 status Report by defts (Entered: 09/18/2006)
256 VOLUME 12 START AT DOCKET NO. 257 (Entered: 09/18/2006)
258 ORDER (GWC) that the Clerk of the court pay from funds appropriates to the Judiciary invoices submitted by Special Master Susan W.Mc Campbell (Entered: 10/11/2006)
259 STATUS REPORT and request for adoption and filing of the full report (Entered: 10/12/2006)
260 OBJECTION to Special Master's report and its attachments Status Report (Entered: 10/13/2006)
261 MOTION for an order to seal the Special Master's Status Report and its attachments by defts (Entered: 10/16/2006)
262 MEMORANDUM of law in support of motion for an order to seal the special Master's status Report and its attachments (Entered: 10/17/2006)
263 STATUS REPORT by defts (Entered: 10/24/2006)
264 NOTICE OF FILING of staffing reports by deft (Entered: 10/24/2006)
265 OPPOSITION to the deft's motion for an order to seal the Special Master's Report and its attachments (Entered: 10/26/2006)
266 ORDER (GWC) that the Clerk of Court process and pay from funds appropriated to the judiciary, cc attys (Entered: 11/03/2006)
267 STATUS REPORT of November 2006 by defts (Entered: 11/21/2006)

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11/30/2006 12/27/2006 12/28/2006
12/29/2006 12/29/2006 01/22/2007 01/26/2007 02/21/2007 02/21/2007 02/22/2007 02/22/2007 02/26/2007 02/26/2007
03/08/2007 03/15/2007 03/20/2007 03/23/2007 03/23/2007 03/23/2007 03/29/2007
03/29/2007
03/30/2007

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268 NOTICE OF FILING of defts November staffing report by defts (Entered: 11/30/2006)
270 NOTICE OF FILING of December Status Report (Entered: 12/27/2006)
269 ORDER (GWC) that the Clerk of the Court process and pay from funds appropriated to the judiciary, invoices submitted by Special Master Susan McCampbell cc attys (Entered: 12/28/2006)
271 STATUS REPORT by deft (Entered: 12/29/2006)
272 STATUS REPORT by defts (Entered: 12/29/2006)
273 STATUS REPORT by defts (Entered: 01/22/2007)
274 NOTICE of apperance of Joycelyn Hewitt (Entered: 01/26/2007)
275 ORDER (GWC) scheduling review hearing for Apr. 3, 2007 at 9:00 a.m. (Entered: 02/21/2007)
276 REPORT (status) of Feb. 2007 by defts (Entered: 02/21/2007)
277 NOTICE OF FILING of February activity report by deft (Entered: 02/22/2007)
278 NOTICE OF FILING of February staffing report by deft (Entered: 02/22/2007)
279 ORDER (GWC) that the Clerk of Court process and pay $1,750.00 to Darnley R, Hodge for expert services rendered 9/16/06 through 9/28/2006, cc attys (Entered: 02/26/2007)
280 ORDER (GWC) that the Clerk of Court process and pay Special Master Susan W. McCampbell $6,942.87 to cover cost and expenses from 12/9/2006 through 2/9/2007, cc attys (Entered: 02/26/2007)
281 NOTICE of designation of compliance coorporator by defts (Entered: 03/08/2007)
282 ORDER (GWC) that the Clerk of Court process and pay from funds appropriated to the judiciary cc attys (Entered: 03/15/2007)
283 NOTICE OF FILING of defts March Status report with report with report and attachment (Entered: 03/20/2007)
284 ORDER (GWC) that the Clerk of Court process and pay from funds appropriated to the judicary cc attys (Entered: 03/23/2007)
285 ORDER (GWC) that the clerk of Court process and pay from funds deposited by the defts cc attys (Entered: 03/23/2007)
286 NOTICE OF FILING of March Activity Report by defts (Entered: 03/23/2007)
287 MOTION for an order to seal the special master's status report and its attachments and Emergency motion to seal the special Master's supplemental status report and to close the April 3, 2007 review hearing (Entered: 03/29/2007)
288 MEMORANDUM in law in support of Emergency renewed motion for an order to seal the special master's status report and its attachments and emergency motion to seal supplemental status report and close the April 3, 2007 Review Hearing (Entered: 03/29/2007)
289 ORDER (GWC) that deft's Emergency renewed motion for an Order to seal the Special Master's status report and its attachments and emergency motion to Seal the Special Master's supplemental Status Report and to Close the April 3, 2007 review hearing (filed March 29, 2007) is DENIED cc attys (Entered: 03/30/2007)

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04/02/2007 04/02/2007
04/03/2007 04/13/2007 04/13/2007 04/23/2007 04/23/2007 04/23/2007 04/24/2007
04/24/2007 04/25/2007 05/01/2007 05/02/2007 05/07/2007 05/07/2007 05/15/2007
05/21/2007 05/21/2007 06/01/2007 06/01/2007 06/04/2007
06/04/2007

District Court CM/ECF ­ LIVE
290 ORDER (GWC) that the clerk of the Court process and pay from funds (Entered: 04/02/2007)
292 ORDER (GWC) that the Order entered March 23, 2007, and docketed on 3/27,2007 as item No. 284 is vacated and the Clerk of Court is instructed not to process payment dicted in this order cc attys (Entered: 04/02/2007)
291 CTRM. MIN. hearing held (GWC) on Review Recommendation (FTR RECORDING) (Entered: 04/03/2007)
293 MOTION for enlargement of time (Entered: 04/13/2007)
294 ORDER (GWC) that defts motion is GRANTED, cc attys (Entered: 04/13/2007)
295 Status Report with attached activity report and staffing report by defts (Entered: 04/23/2007)
296 NOTICE OF FILING of defts April 2007 Status Report (Entered: 04/23/2007)
299 DEFENDANTS April 2007 Status Report (Entered: 04/23/2007)
298 ORDER (GWC) that the clerk of the Court process and pay from funds to special Master Susan W. McCampbell one thousand nine hundred twenty four dollars and ninety­five cents cc attys (Entered: 04/24/2007)
298 VOLUME 13 (Entered: 04/24/2007)
297 RESPONSE to recommended orders by defts (Entered: 04/25/2007)
300 REPLY to deft's response to recommended orders by pltf's (Entered: 05/01/2007)
303 NOTICE OF FILING of supplement to defts April 2007 Status Report and defts response to recommended Orders by defts (Entered: 05/02/2007)
301 ORDER (GWC) that the Clerk of Court process and pay from funds the amount of 9,957.63 to Darnley Hodge cc attys (Entered: 05/07/2007)
302 ORDER (GWC) that the Clerk of the Court shall pay Special Master Susan McCampbell 8,483.82 cc attys (Entered: 05/07/2007)
304 ORDER (GWC) this court found defts in contempt of this Court's order regarding defts duty to provide and Maintain Constitutionally adequate conditions of confinement at Golden Grove Adult, cc attys (Entered: 05/15/2007)
305 NOTICE OF FILING of defts May 2007 Status Report by defts (Entered: 05/21/2007)
306 STATUS REPORT OF May 2007 by defts (Entered: 05/21/2007)
307 ORDER (GWC) that the Clerk of Court process and Pay from funds deposited by defts into the clerk's registry of 9, 228.80 (Entered: 06/01/2007)
310 MOTION for enlargment of time to comply with portion of order of the court requiring action by May 31, 2007 and June 1, 2007 by defts (Entered: 06/01/2007)
308 ORDER (GWC) defts motion for enlargment of time to comply with portions of order of the Court requiring action by May 31, 2007 and June 1, 2007 is GRANTED, cc attys (Entered: 06/04/2007)
309 ORDER (GWC) defts motion for enlargement of time to Comply with Portions of Order of the Court requiring Action by May 31, 2007 and June 1, 2007 is GRANTED, cc attys (Entered: 06/04/2007)

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311 NOTICE OF FILING of compliance report regarding the May 15, 2007 order of the Court, by defts (Entered: 06/06/2007)

06/06/2007

312 COMPLIANCE report regarding the May 15, 2007 order of the Court by defts (Entered: 06/06/2007)

06/08/2007

313 NOTICE OF FILING Supplemental compliance report regarding the May 25, 2007 order of the Court by defts (Entered: 06/08/2007)

06/08/2007

314 supplemental compliance report regarding the May 15, 2007 order of the Court by defts (Entered: 06/08/2007)

06/12/2007

315 ORDER (GWC) that the Vlerk of Court process and pay from funds appropriated to the Judiciary, invoices submitted by Special Master Susan W. McCampbell THE SUM OF $2,834.84, cc attys (Entered: 06/12/2007)

06/14/2007

316 ORDER (GWC) AMENDED that the Clerk of Court process and pay from funds appriated to the Judiciary, invoices submitted by Special Master Susan McCampbell cc attys (Entered: 06/14/2007)

06/14/2007 316 VOLUME THIRTEEN (13) (Entered: 06/14/2007)

06/21/2007

317 NOTICE of Filing of Defendants' June 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit Exhibit 1 (Defendants' June 2007 Status Report and its attached Activity Report and Staffing Report)) (Chinnery­Montell, Acquannette) Modified on 7/19/2007 (Serrano, Thamala). (Entered: 06/21/2007)

06/27/2007

318 NOTICE of Filing of Omitted Page 7 of Defendants' June 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit Exhibits 1 and 2) (Chinnery­ Montell, Aquannette) Modified on 7/19/2007 (Serrano, Thamala). (Entered: 06/27/2007)

07/02/2007

319 ORDER (GWC) dated 7/2/2007 Scheduling Status Conference for Tuesday, August 28, 2007, at 10:00 a.m. in Magistrate's Chambers. (KD) (Entered: 07/02/2007)

07/02/2007

Minute Order, 15 minutes.Proceedings held in chambers before Judge George W Cannon : Telephone Conference held on 7/2/2007. (CB) (Entered: 08/14/2007)

07/09/2007

320 ORDER the clerk process and pay funds appropriated to the Judiciary, invoices submitted by Special Master Susan McCampbell(GWC) dated 7/9/2007(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (MB) (Entered: 07/18/2007)

07/20/2007

321 NOTICE of Filing of Defendants' July 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 (Defendants' July 2007 Status Report and its attached Activity Report and Staffing Report)) (Chinnery­Montell, Aquannette) (Entered: 07/20/2007)

08/13/2007

322 ORDER (GWC) that the clerk of the court process and pay from funds deposited by the defendants into the Clerk's Registry Account, the sum of Two Thousand one Hundred Eighty Seven Dollars nd Fifty cents to Daryl R. Hodge Sr. dated 8/13/07 (TNS) (Entered: 08/21/2007)

08/13/2007

323 ORDER (GWC) that the Clerk of Court process and pay from funds deposited by the defendants into the Clerk's Registry Account, the sum of Two Thousand Five Hundred Dollar and zero cents to Darnley R. Hodge,Sr. dated 8/13/07 (TNS) (Entered: 08/21/2007)

08/13/2007

324 ORDER (GWC) that the Clerk of the Court process and pay from funds deposited by the defendants into the Clerk's registry Account, the sum of Six Thousand Nine

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09/11/2007 09/20/2007
09/21/2007 10/03/2007 10/22/2007 10/22/2007

District Court CM/ECF ­ LIVE
Hundred Twenty One Dollars and sixty cents to Madelene La Marre, PC dated 8/13/07 (TNS) (Entered: 08/21/2007)
325 ORDER (GWC) that the Clerk of Court process and pay from funds appropriated to judiciary invoices submitted by Special Master Susan McCampbell totaling Three Thousand Five Hundred Seventy­Two Dollars and Zero cents. dated 8/13/07 (TNS) (Entered: 08/21/2007)
326 NOTICE of Filing of Defendants' August 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1) (Chinnery­Montell, Aquannette) (Entered: 08/21/2007)
327 NOTICE of Substitution of Counsel by Territory of The Virgin Islands (Chinnery­ Montell, Aquannette) (Entered: 08/22/2007)
328 NOTICE of Filing of Defendants' August 2007 Staffing Report by Territory of The Virgin Islands re 326 Notice (Other) (Attachments: # 1 Exhibit 1) (Chinnery­Montell, Aquannette) (Entered: 08/22/2007)
329 SCHEDULING ORDER: (GWC) dated 8/29/2007 Status Conference set for 1/11/2008 at 9:00 AM in Chambers before US Magistrate Judge George W Cannon. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KMD) (Entered: 08/29/2007)
Minute Order. 2 hours. 15 minutes.Proceedings held in chambers before Judge George W Cannon : Status Conference held on 8/29/2007. (CB) (Entered: 08/29/2007)
Minute Order. One hour. Status conference with Special Master Susan McCampbell.Proceedings held in chambers before Judge George W Cannon : Status Conference held on 8/30/2007. (CB) (Entered: 08/30/2007)
331 ORDER (GWC)that the Clerk of Court process and pay from funds deposited by the defendants into the Clerk's Registry Account, the sum of Seven Thousand Two Hundred Fifty Two Dollars and Ninety One Cents ($7,252.91) to Madeleine La Marre, PC.dated 9/10/07 (MAIN DOCUMENT WAS EDITED) (TNS) (Entered: 09/12/2007)
330 ORDER (GWC)AUTHORIZING PAYMENT to Susan McCampell Special Master in the Amount of : $ $2,846.86. for expenses 8/26 thru 9/1/2007 dated 9/11/2007 (MB) (Entered: 09/11/2007)
332 ORDER (GWC) that the Clerk of court process and pay from funds appropriated to the Judiciary, invoices submitted by Special Master Susan W. McCampbell six thousand six hundred eighty dollars ($6,680.08) and eight cents dated 9/19/2007 (TNS) (Entered: 09/20/2007)
333 NOTICE of Filing of Defendants' September 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' September 2007 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 09/21/2007)
334 ORDER (GWC) that the clerk of Court process and pay from funds three thousand nine hundred seventy dollars ($3,970.73)dated 10/3/07 (TNS) (Entered: 10/04/2007)
335 STATUS REPORT for October 2007 by Territory of The Virgin Islands. (Chinnery­ Montell, Aquannette) (Entered: 10/22/2007)
341 ORDER (GWC)that the clerk of court process and pay from funds deposited by the defts into the Clerk's Registry Account, the sum of Two Thousand Three Hundred Seven Dollars and twenty cents to MADELEINE LA MARRE, PC dated 10/22/07 (TNS) (Entered: 10/31/2007)

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342 ORDER (GWC) that the clerks of court process and pay from funds deposited by defts into the Clerk's Registry Account the sum of One Thousand Eight Hundred Dollars and Zero Cents (1,800.00) dated 10/22/07 (TNS) (Entered: 11/01/2007)

10/23/2007

336 NOTICE of Filing of Defendants' October 2007 Status Report by Territory of The Virgin Islands re 335 Status Report (Chinnery­Montell, Aquannette) (Entered: 10/23/2007)

10/23/2007

337 ORDER (GWC) dated 10/23/2007granting 138 ; see Order 139 and Motion to pay compliance coordinator and granting 135 ; see Order 134 , Motion to pay compliance coordinator. This Order is to clear these motions off the pending motions list. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 10/23/2007)

10/23/2007

338 ORDER (GWC) dated 10/23/2007granting 310 Motion enlargement of time by Orders 308 and 309 . This order is to clear this motion off the pending motion list. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 10/23/2007)

10/29/2007

339 SCHEDULING ORDER: (GWC) dated 10/29/2007 Status Conference set for 11/27/2007 at 2:00 PM in Chambers before US Magistrate Judge George W Cannon, Jr. (KMD) (Entered: 10/29/2007)

10/30/2007

340 NOTICE of Filing of October Status Report by Territory of The Virgin Islands (Thomas­Jacobs, Carol) (Entered: 10/30/2007)

11/14/2007

346 ORDER (GWC) dated 11/14/07 that the clerk of Court process and pay from funds appropriated to the Judiciary, to Susan Campbell, four thousand seven hundred nine dollars and eighty cents (4,709.80) (TNS) (Entered: 11/30/2007)

11/21/2007

343 NOTICE of Filing of Defendants' November 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' November 2007 Status Report) (Chinnery­Montell, Aquannette) (Entered: 11/21/2007)

11/28/2007

344 SCHEDULING ORDER: (GWC) dated 11/28/2007 Status Conference set for 1/11/2008 at 9:00 AM in Chambers before US Magistrate Judge George W Cannon, Jr. (KMD) (Entered: 11/28/2007)

11/28/2007

345 Minute Order. 3 hours. Proceedings held in chambers before Judge George W Cannon : Status Conference held on 11/28/2007. (CB) (Entered: 11/28/2007)

12/11/2007 347 ORDER approving payment(GWC) dated 12/4/2007 (MB) (Entered: 12/11/2007)

12/11/2007

348 AMENDED ORDER granting payment (GWC) dated 12/6/2007 (MB) (Entered: 12/11/2007)

12/21/2007

349 NOTICE of Filing of Defendants' December 2007 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' December 2007 Status Report) (Chinnery­Montell, Aquannette) (Entered: 12/21/2007)

01/11/2008

350 SCHEDULING ORDER:(GWC) dated 1/11/2008 Status Conference set for 4/9/2008 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 01/11/2008)

01/11/2008

351 Minute Order. Proceedings held in chambers before Judge George W Cannon : Status Conference held on 1/11/2008. (CB) (Entered: 01/11/2008)

01/22/2008

352 NOTICE of Filing of Defendants' January 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1) (Chinnery­Montell, Aquannette) (Entered:

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03/28/2008 03/31/2008 04/08/2008 04/08/2008 04/09/2008
04/09/2008 04/21/2008
05/06/2008 05/15/2008 05/21/2008
06/09/2008 06/23/2008
06/24/2008
06/24/2008

01/22/2008)

District Court CM/ECF ­ LIVE

353 ORDER (GWC) dated 1/22/08 (TNS) (Entered: 01/29/2008)

354 NOTICE of Filing of Defendant's February 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendant's Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 02/21/2008)

Motions terminated: 152 MOTION TO DISMISS by defts.(GWC) dated 3/7/2008(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 03/07/2008)

355 ORDER (GWC) dated 3/10/2008 (TNS) (Entered: 03/10/2008)

357 NOTICE of Filing of Defendants' March 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' March 2008 Status Report) (Chinnery­ Montell, Aquannette) (Entered: 03/19/2008)

358 ORDER (GWC) dated 3/28/2000 (TNS) (Entered: 03/31/2008)

359 NOTICE of Appearance by Laura Lee Coon on behalf of Plaintiff United States of America (Coon, Laura) (Entered: 03/31/2008)

362 ORDER (GWC) dated 4/8/2008 (TNS) (Entered: 04/15/2008)

363 ORDER (GWC) dated 4/8/2008 (TNS) (Entered: 04/15/2008)

360 SCHEDULING ORDER:(GWC) dated 4/9/2008 Status Conference set for 10/10/2008 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 04/09/2008)

361 Minute Order. Proceedings held in chambers before Judge George W Cannon : Status Conference held on 4/9/2008. (CB) (Entered: 04/09/2008)

364 NOTICE of Filing of Defendants' April 2008 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' April 2008 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 04/21/2008)

365 ORDER (GWC) dated 5/6/2008 (MB) (Entered: 05/15/2008)

366 ORDER (GWC) dated 5/13/2008 (MB) (Entered: 05/15/2008)

367 NOTICE of Filing of Defendants' May 2008 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' May 2008 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 05/21/2008)

369 ORDER (GWC) dated 06/09/08 (Hess, Nydia) (Entered: 06/24/2008)

368 MOTION for Extension of Time to File Defendants' June 2008 Monthly Status Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion for enlargement of time) (Chinnery­Montell, Aquannette) (Entered: 06/23/2008)

370 ORDER (GWC) dated 6/24/2008 granting 368 Defendants' Motion for Enlargement of Time File [sic] Defendants' June 2008 Monthly Status Report (KMD) (Entered: 06/24/2008)

371 NOTICE of Filing of Defendants' June 2008 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' June 2008 Monthly Status

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08/26/2008 09/17/2008
09/18/2008
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District Court CM/ECF ­ LIVE
Report, # 2 Exhibit 1­A June 2008 Activity Report, # 3 Exhibit 1­B June 2008 Staffing Report) (Chinnery­Montell, Aquannette) (Entered: 06/24/2008)
372 MOTION for Extension of Time to File Defendants' July 2008 Monthly Status Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order Granting Motion for Enlargement of Time) (Chinnery­Montell, Aquannette) (Entered: 07/21/2008)
373 ORDER (GWC) dated 7/22/2008granting 372 Motion for Extension of Time to File July 2008 Monthly Status Report. (CB) (Entered: 07/22/2008)
374 NOTICE of Filing of Defendants' July 2008 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' July 2008 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 07/23/2008)
375 ORDER (GWC) dated 7/25/2008 regarding 10/10/2008 hearing (KMD) (Entered: 07/25/2008)
376 MOTION for Extension of Time to File Formal Notice in Response to July 25, 2008 Order by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting Motion for Enlargement of Time) (Chinnery­Montell, Aquannette) (Entered: 08/11/2008)
377 NOTICE of Filing in Response to Court's July 25, 2008 Order by Territory of The Virgin Islands (Chinnery­Montell, Aquannette) (Entered: 08/11/2008)
378 ORDER (GWC) dated 8/12/2008 granting 376 Defendants' Motion for Enlargement of Time to File (KMD) (Entered: 08/12/2008)
379 ORDER (GWC) dated 8/12/08 (TNS) (Entered: 08/14/2008)
380 ORDER (GWC) dated 8/11/2008 (TNS) (Entered: 08/14/2008)
381 ORDER (GWC) dated 8/12/2008 (TNS) (Entered: 08/14/2008)
382 ORDER AMENDED (GWC) dated 8/19/2008 (TNS) (Entered: 08/19/2008)
383 NOTICE of Filing of Defendants' August 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' August 2008 Status Report) (Chinnery­ Montell, Aquannette) (Entered: 08/21/2008)
384 Letter from Susan Campbell dated 7/28/2008 (TNS) (Entered: 08/26/2008)
385 MOTION for Extension of Time to File by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion for enlargement of time) (Chinnery­Montell, Aquannette) (Entered: 09/17/2008)
386 ORDER (GWC) dated 9/18/2008 granting 385 Defendants' Motion for Enlargement of Time File [sic] Defendants' September 2008 Monthly Status Report. Defendants' shall file their September 2008 monthly status report on or before 9/23/2008. (KMD) (Entered: 09/18/2008)
387 ORDER (GWC) dated 9/17/2008 (TNS) (Entered: 09/19/2008)
388 NOTICE OF CORRECTED DOCKET ENTRY Document was removed Filed erroneously. ( previous entry Summons) Docket # 388 (TNS) (Entered: 09/23/2008)
389 NOTICE of Filing of Defendants' September 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit 1 Defendants' September 2008 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 09/23/2008)

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10/08/2008 10/08/2008 10/10/2008 10/10/2008 10/10/2008
10/21/2008
10/22/2008 10/31/2008
11/10/2008
11/10/2008 11/21/2008 12/22/2008
01/22/2009 01/22/2009 01/23/2009 01/27/2009 02/04/2009

District Court CM/ECF ­ LIVE
390 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Telephone Conference held on 9/10/2008. (CB) (Entered: 10/08/2008)
396 ORDER (GWC) dated 10/6/08 That the Clerk of the court process and pay Special Master Susan McCambell. (TNS) (Entered: 10/24/2008)
392 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 10/10/2008. (CB) (Entered: 10/10/2008)
391 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 10/10/2008. (Court Reporter FTR.) (AM) Modified on 10/10/2008 (AM). (Entered: 10/10/2008)
393 SCHEDULING ORDER:(GWC) dated 10/10/2008 Status Conference set for 11/10/2008 09:00 AM in Chambers before US Magistrate Judge George W Cannon. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 10/10/2008)
394 MOTION for Extension of Time to File Defendants' October 2008 Monthly Status Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting Motion for Enlargement of Time) (Chinnery­Montell, Aquannette) (Entered: 10/21/2008)
395 ORDER (GWC) dated 10/22/2008 granting 394 Motion for Extension of Time to File. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 10/22/2008)
397 NOTICE of Filing of Defendants' October 2008 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' October 2008 Monthly Status Report, # 2 Exhibit B October Monthly Staffing Report) (Chinnery­Montell, Aquannette) (Entered: 10/31/2008)
398 SCHEDULING ORDER: Status Conference set for 3/10/2009 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(GWC) dated 11/10/2008(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 11/10/2008)
399 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 11/10/2008. (CB) (Entered: 11/10/2008)
400 NOTICE of Filing Defendants' November 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' November 2008 Status Report and attachments) (Chinnery­Montell, Aquannette) (Entered: 11/21/2008)
401 NOTICE of Filing of Defendants' December 2008 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' December 2008 Monthly Status Report, December Activity Report, December Staffing Report, & Amended November Staffing Report) (Chinnery­Montell, Aquannette) (Entered: 12/22/2008)
402 ORDER (GWC) dated 11/14/09 (TNS) (Entered: 01/22/2009)
403 ORDER (GWC) dated 1/22/09 (TNS) (Entered: 01/22/2009)
404 ORDER (GWC) dated 1/12/09 (TNS) (Entered: 01/23/2009)
405 NOTICE of Filing of Defendants' January 2009 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' January 2009 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 01/27/2009)
406 ORDER (GWC) dated 2/4/2009 (TNS) (Entered: 02/05/2009)

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02/23/2009
03/10/2009
03/10/2009 03/11/2009 03/23/2009
03/23/2009
03/24/2009 03/25/2009 03/26/2009
03/30/2009 04/21/2009
05/19/2009 05/20/2009
06/12/2009 06/22/2009
07/13/2009
07/20/2009

District Court CM/ECF ­ LIVE
407 NOTICE of Filing of Defendants' February 2009 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' February 2009 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 02/23/2009)
408 SCHEDULING ORDER:(GWC) dated 3/10/2009 Status Conference set for 9/14/2009 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 03/10/2009)
409 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 3/10/2009. (CB) (Entered: 03/10/2009)
410 ORDER RE PAYMENT(GWC) dated 3/11/2009 (MB) (Entered: 03/11/2009)
411 MOTION for Extension of Time to File Defendants' March 2009 Monthly Status Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion for enlargement of time) (Chinnery­Montell, Aquannette) (Entered: 03/23/2009)
412 ORDER (GWC) dated 3/23/2009 granting 411 Motion for Extension of Time to File. Defendants shall file their March 2009 status report by 3/26/2009. (KMD) (Entered: 03/23/2009)
413 ORDER RE­PAYMENT REQUEST (GWC) dated 3/24/2009 (MB) (Entered: 03/24/2009)
414 AMENDED ORDER RE PAYMENT REQUEST(GWC) dated 3/25/2009 (MB) (Entered: 03/25/2009)
415 NOTICE of Filing of Defendants' March Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' March Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 03/26/2009)
416 ORDER (GWC) dated 3/30/2009 granting request for payment (MB) (Entered: 03/30/2009)
417 NOTICE of Filing of Defendants' April 2009 Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' April 2009 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 04/21/2009)
418 ORDER (GWC) dated 5/19/09 (TNS) (Entered: 05/20/2009)
419 NOTICE of Filing of Defendants' May 2009 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' May 2009 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 05/20/2009)
420 ORDER (GWC) dated 6/12/09 (TNS) (Entered: 06/12/2009)
421 NOTICE of Filing of Defendants' June 2009 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' June 2009 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 06/22/2009)
422 ORDER that the Clerk of the Court process ad pay from funds appropriated to the judiaciary invoices submitted(GWC) dated 07/13/09(GWC) dated 07/13/09 (Attachments: # 1 Exhibit Invoice, # 2 Exhibit) (AM) (Entered: 07/13/2009)
423 MOTION for Extension of Time to File Response/Reply June 2009 Status Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Thomas­Jacobs, Carol) (Entered: 07/20/2009)

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07/21/2009

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424 ORDER (GWC) dated 7/21/2009 granting 423 Motion for Enlargement of Time to File Defendants' June 2009 Monthly Status Report; Defendants' shall file their June 2009 Monthly Status Report by 7/27/2009 (KMD) (Entered: 07/21/2009)

07/27/2009

425 NOTICE Of Filing July 2009 Monthly Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (Thomas­Jacobs, Carol) (Entered: 07/27/2009)

09/14/2009

426 SCHEDULING ORDER:(GWC) dated 9/14/2009 Status Conference set for 11/3/2009 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 09/14/2009)

09/14/2009

427 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 9/14/2009. (CB) (Entered: 09/14/2009)

09/14/2009 428 ORDER (GWC) dated 9/14/09 (TNS) (Entered: 09/14/2009)

09/14/2009

429 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 9/14/2009. (Court Reporter FTR.) (Hess, Nydia) (Entered: 09/15/2009)

10/14/2009

430 ORDER (GWC) dated 10/14/2009 (TNS) Modified on 10/15/2009 (TNS).That the Clerk of Court process and pay from funds appropriated to the Judiciary invoices submitted (Entered: 10/15/2009)

10/14/2009

431 ORDER (GWC) dated 10/9/2009 that the Clerk of Court process and pay from funds appropriated to judiciary, invoices submitted (TNS) (Entered: 10/15/2009)

10/21/2009

432 MOTION for Extension of Time to File Defendants October 2009 Monthly Status Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion for enlargement of time) (Chinnery­Montell, Aquannette) (Entered: 10/21/2009)

10/21/2009

433 ORDER (GWC) dated 10/21/2009 granting 432 Motion for Extension of Time to File (KMD) (Entered: 10/21/2009)

10/22/2009

434 SCHEDULING ORDER:(GWC) dated 10/22/2009 Status Conference set for 11/3/2009 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 10/22/2009)

10/23/2009

435 NOTICE of Filing of Defendants' October 2009 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Defendants' October 2009 Monthly Status Report) (Chinnery­Montell, Aquannette) (Entered: 10/23/2009)

10/29/2009

436 NOTICE of Filing of October 2009 Staffing Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A October 2009 Staffing Report) (Chinnery­Montell, Aquannette) (Entered: 10/29/2009)

11/03/2009

437 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 11/3/2009. (CB) (Entered: 11/03/2009)

11/03/2009

438 SCHEDULING ORDER:(GWC) dated 11/3/2009 Status Conference set for 1/20/2010 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 11/03/2009)

11/23/2009

439 NOTICE of Filing of Report for November 2009 Submitted by Dwayne A. Benjamin, Prison Compliance Coordinator with Attached Monthly Staffing Update by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Report for November 2009 Submitted

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11/25/2009 11/25/2009 12/08/2009 12/09/2009 12/09/2009 12/10/2009 12/21/2009
01/14/2010 01/20/2010 01/20/2010
01/20/2010
01/22/2010 01/27/2010 01/29/2010 01/30/2010 02/01/2010
02/02/2010 02/08/2010 02/22/2010 02/22/2010
02/23/2010

District Court CM/ECF ­ LIVE
by Dwayne A. Benjamin, Prison Compliance Coordinator, with Attached Monthly Starffing Update, # 2 Exhibit B Monthly Staffing Update for November 2009 from BOC) (Chinnery­Montell, Aquannette) (Entered: 11/23/2009)
440 ORDER (GWC) dated 11/25/2009 (TNS) (Entered: 11/30/2009)
441 ORDER (GWC) dated 11/25/2009 (TNS) (Entered: 11/30/2009)
443 Summons Issued as to Maria Aran (TNS) (Entered: 12/09/2009)
442 ORDER (GWC) dated 12/9/09 (TNS) (Entered: 12/09/2009)
444 NOTICE OF CORRECTED DOCKET ENTRYRe: 443 Summons Issued. Document # 443 was erronously filed. (TNS) (Entered: 12/09/2009)
445 ORDER (GWC) dated 12/10/2009 (KMD) (Entered: 12/10/2009)
446 NOTICE of Filing of December 2009 Monthly Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A December Monthly Status Report) (Chinnery­ Montell, Aquannette) (Entered: 12/21/2009)
447 ORDER (GWC) dated 1/14/2010 (TNS) (Entered: 01/14/2010)
448 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 1/20/2010. (CB) (Entered: 01/20/2010)
449 SCHEDULING ORDER:(GWC) dated 1/20/2010 Status Conference set for 3/18/2010 09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 01/20/2010)
450 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 1/20/2010. (Court Reporter FTR Recorder.) (Hess, Nydia) (Entered: 01/20/2010)
451 Sealed Document. (MB) (Entered: 01/22/2010)
453 ORDER (GWC) dated 1/27/2010 (MB) (Entered: 01/29/2010)
452 ORDER (GWC) dated 1/27/2010 (MB) (Entered: 01/29/2010)
454 First MOTION to Substitute Attorney by Plaintiff United States of America. (Tyson­ Floyd, Angela) (Entered: 01/30/2010)
Attorney Joycelyn Hewlett terminated and Angela Tyson­Floyd is substituted.(GWC) dated 2/1/2010(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 02/01/2010)
455 ORDER (GWC) dated 2/1/2010 (TNS) (Entered: 02/02/2010)
456 ORDER (GWC) dated 2/8/2010 (TNS) (Entered: 02/08/2010)
457 ORDER (GWC) dated 2/22/2010 re: agreed deadlines (KMD) (Entered: 02/22/2010)
458 NOTICE of filing of Monthly Report for February 2010 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A) (Chinnery­Montell, Aquannette) (Entered: 02/22/2010)
Motions terminated: 454 First MOTION to Substitute Attorney filed by United States of America.(GWC) dated 2/23/2010(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 02/23/2010)

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03/11/2010
03/11/2010
03/15/2010 03/16/2010 03/16/2010 03/16/2010 03/18/2010 03/18/2010
03/18/2010 03/29/2010 04/05/2010 04/21/2010 04/22/2010 04/28/2010 04/29/2010 05/12/2010

District Court CM/ECF ­ LIVE
459 SCHEDULING ORDER:(GWC) dated 3/11/2010 Status Conference set for 3/18/2010 09:00 AM in Chambers before US Magistrate Judge George W Cannon. Due to clerical error, this conference is re­set.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 03/11/2010)
460 SCHEDULING ORDER:(GWC) dated 3/11/2010 Status Conference set for 3/18/2010 09:00 AM in Magistrate Judge Courtroom 3 in St. Croix before US Magistrate Judge George W Cannon. The status conference will begin on the record in the courtroom and continue in the conference room off the record. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 03/11/2010)
461 ORDER (GWC) dated 3/15/2010 (MB) (Entered: 03/15/2010)
462 ORDER (GWC) dated 8/12/2009 that the Clerk of Court process and pay from funds to Susan Campbell (Attachments: # 1 Invoice) (TNS) (Entered: 03/16/2010)
463 ORDER (GWC) dated 8/12/209 that the Clerk of Court process and pay from funds appropriated to the Judiciary to Susan McCambell. (Attachments: # 1 Invoice) (TNS) (Entered: 03/16/2010)
464 ORDER (GWC) dated 8/12/2009 that the Clerk of Court and pay from funds appropriated to the judiciary. (TNS) (Additional attachment(s) added on 3/17/2010: # 1 INVOICES) (TNS). (Entered: 03/16/2010)
465 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 3/18/2010. (CB) (Entered: 03/18/2010)
466 SCHEDULING ORDER:(GWC) dated 3/18/2010 Status Conference set for 8/5/2010 10:00 AM in Mag Judge Ctrm 3 STX before US Magistrate Judge George W Cannon. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 03/18/2010)
467 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 3/18/2010. (Court Reporter FTR Recorder.) (Hess, Nydia) (Entered: 03/20/2010)
468 ORDER (GWC) dated 3/29/10 that the Clerk of Court process and pay from funds to Susan Campbell (TNS) (Entered: 03/29/2010)
469 ORDER (GWC) dated 4/5/10 that the Clerk of Court process and pay from funds to Susan McCampbell (TNS) (Entered: 04/06/2010)
470 NOTICE of Filing of Report for April 2010 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Report for April 2010) (Chinnery­Montell, Aquannette) (Entered: 04/21/2010)
471 NOTICE of Filing of Amended Report for April 2010 by Territory of The Virgin Islands re 470 Notice (Other) (Attachments: # 1 Exhibit A Notice of Filing of Amended Report for April 2010) (Chinnery­Montell, Aquannette) (Entered: 04/22/2010)
472 NOTICE of Filing of Letter from BOC Director by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Letter from BOC Director to Court) (Chinnery­Montell, Aquannette) (Entered: 04/28/2010)
473 ORDER (GWC) dated 4/29/10 that the Clerk's of Court process and pay from funds Robert B. Greifinger, M.D. (TNS) (Entered: 04/29/2010)
474 ORDER (GWC) dated 5/12/10 that the clerk of the court pay from funds to Susan Campbell (TNS) (Entered: 05/12/2010)

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05/20/2010 06/07/2010 06/21/2010 07/08/2010
07/08/2010 07/13/2010 07/19/2010 07/19/2010 07/20/2010 07/20/2010 07/20/2010 07/27/2010 07/30/2010
08/05/2010
08/05/2010 08/05/2010
08/06/2010 08/10/2010 08/12/2010

District Court CM/ECF ­ LIVE
475 ORDER (GWC) dated 5/20/10 that clerk of the court pay from clerk's registery to Robert Greifinger (TNS) (Entered: 05/20/2010)
476 ORDER (GWC) dated 6/7/10 that the Clerk of the Court pay from funds to Susan McCampbell (TNS) (Entered: 06/07/2010)
477 NOTICE of Filing of Report for June 2010 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A) (Chinnery, Aquannette) (Entered: 06/21/2010)
478 STIPULATION (Joint Stipulation for Extension of Time for Defendants to Comply) by Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Chinnery, Aquannette) (Entered: 07/08/2010)
479 ORDER (GWC) dated 7/8/2010 approving and granting 478 Joint Stipulation For Extension of Time (KMD) (Entered: 07/08/2010)
481 Letter from Fanklin Xavier dated 7/14/10 (Attachments: # 1 envelope) (TNS) (Entered: 07/19/2010)
480 ORDER (GWC) dated 7/19/2010 that the Clerk of Court process and pay from funds to Susan Campbell. (TNS) (Entered: 07/19/2010)
Docket # 481 was erounously filed in the wrong case. Document was removed. (TNS) (Entered: 07/19/2010)
482 ORDER (GWC) dated 7/20/10 (AMENDED) (TNS) (Entered: 07/21/2010)
483 ORDER (GWC) dated 7/20/2010that the Clerk of the Court pay Susan McCampbell from funds (TNS) (Entered: 07/21/2010)
484 ORDER (GWC) dated 7/20/2010 that the clerk of the court shall process and pay Susan McCampbell (TNS) Modified on 7/21/2010 (TNS). (Entered: 07/21/2010)
485 NOTICE of Designation of Compliance Coordinator by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 07/27/2010)
486 NOTICE of Amendment of Certificate of Service Regarding Designation of Compliance Coordinator by Territory of The Virgin Islands re 485 Notice (Other) (Chinnery, Aquannette) (Entered: 07/30/2010)
487 SCHEDULING ORDER:(GWC) dated 8/5/2010 Status Conference set for 11/9/2010 09:00 AM in Mag Judge Ctrm 3 STX before US Magistrate Judge George W Cannon. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 08/05/2010)
488 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 8/5/2010. (CB) (Entered: 08/05/2010)
489 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 8/5/2010. (Court Reporter FTR Recorder.) (Hess, Nydia) (Entered: 08/05/2010)
490 ORDER (GWC) dated 8/6/2010, that the clerk of court process and pay from funds to Ms. susan McCampbell (TNS) (Entered: 08/10/2010)
491 ORDER (GWC) dated 8/6/2010 that the Clerk of Court process and pay from funds to Susan Campbell (TNS) (Entered: 08/10/2010)
492 ORDER (GWC) dated 8/12/2010 that the Clerk of Court pay ms. McCampbell (TNS) (Entered: 08/12/2010)

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09/21/2010
10/07/2010 10/08/2010 10/26/2010
10/28/2010 10/28/2010 11/09/2010
11/09/2010
11/10/2010 11/10/2010
11/15/2010 11/16/2010 11/16/2010
11/16/2010 11/16/2010 11/16/2010 12/01/2010 12/06/2010

District Court CM/ECF ­ LIVE
493 NOTICE of Filing of Report for September 2010 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A (Compliance Matrix/Report)) (Chinnery, Aquannette) (Entered: 09/21/2010)
494 ORDER (GWC) dated 10/7/2010 that the clerk of Court process and pay from funds to Ms. Campbell (TNS) (Entered: 10/07/2010)
495 ORDER (GWC) dated 10/7/2010 that the Clerk of Court process and pay from funds to Ms Susan Campbell. (TNS) (Entered: 10/08/2010)
(GWC) dated 10/26/2010 Status Conference set for 11/9/2010 09:00 AM in Mag Judge Ctrm 3 STX before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 10/26/2010)
496 ORDER (GWC) dated 10/28/2010 that the Clerk of Court process and pay from funds to Susan Mccampbell. (TNS) (Entered: 10/28/2010)
497 ORDER (GWC) dated 10/28/2010 that the Clerk of Court process and pay from funds to susan Campbell. (TNS) (Entered: 10/28/2010)
498 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 11/9/2010. (Court Reporter FTR Recorder.) (NH) (Entered: 11/09/2010)
499 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 11/9/2010. Next Status Conference set for 3/8/2011 09:00 AM in Chambers before US Magistrate Judge George W Cannon. (CB) (Entered: 11/09/2010)
500 ORDER (GWC) dated 11/10/2010 that the Clerk of Court process and pay from funds appropriated to Ms. Susan McCampbell. (TNS) (Entered: 11/10/2010)
501 NOTICE of filing of November 2010 Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A November Report) (Chinnery, Aquannette) (Entered: 11/10/2010)
502 ORDER (GWC) dated 11/15/2010that the Clerk of Court process and pay from funds to Wynnie Testamark­Samuels. (TNS) (Entered: 11/15/2010)
503 ORDER (GWC) dated 11/16/2010 that the Clerk of Court process and pay from funds to Susan McCampbell (TNS) (Entered: 11/17/2010)
504 ORDER (GWC) dated 11/16/10 that the Clerk of the Court pay from funds to Ms Susan McCambell. (TNS) (Main Document 504 replaced on 2/2/2011) (TNS). (Entered: 11/17/2010)
505 ORDER (GWC) dated 11/16/10 of reinbursement book Purchases by Ms. Mccambell. (TNS) (Entered: 11/17/2010)
506 ORDER (GWC) dated 11/16/2010 Reimburse Book Purchase by McCampbell and Associates (TNS) (Entered: 11/17/2010)
524 Docket #505 and Docket #506 was erroneously filed.See docket # 504. (TNS) (Entered: 02/01/2011)
507 ORDER (GWC) dated 12/1/10 that the Clerk of the court pay from funds to Ms. susan McCampbell. (TNS) (Entered: 12/02/2010)
508 SCHEDULING ORDER:(GWC) dated 12/6/2010 Status Conference set for 3/8/2011

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09:00 AM in Chambers before US Magistrate Judge George W Cannon.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 12/06/2010)

12/06/2010

509 ORDER re: 11/9/2010 hearing (GWC) dated 12/6/2010 (Status Hearing set for 3/8/2011 at 9:00 AM in Mag Judge Ctrm 3 STX before US Magistrate Judge George W Cannon, Jr.) (KMD) (Entered: 12/06/2010)

12/10/2010

510 NOTICE of Filing of Report for December 2010 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A. GGACF Compliance Report December 10, 2010) (Chinnery, Aquannette) (Entered: 12/10/2010)

12/27/2010

511 ORDER (GWC) dated 12/27/2010 that the Clerk of Court process and pay to Susan W. McCampbell (TNS) (Entered: 12/27/2010)

12/30/2010

512 ORDER (GWC) dated 12/29/2010 that Clerk of the Court pay from funds to Wynnie Testamark­Samuels (TNS) (Entered: 12/30/2010)

01/10/2011

513 NOTICE of Filing of Report for January 2011 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Monthly Report) (Chinnery, Aquannette) (Entered: 01/10/2011)

01/12/2011

514 ORDER (GWC) dated 1/12/2011 directing Defendants to deposit funds (KMD) (Entered: 01/12/2011)

01/14/2011

515 NOTICE of Filing of Response to Order of the Court dated December 6, 2010 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A GGACF Compliance Implementation Dates ­ January 14, 2011) (Chinnery, Aquannette) (Entered: 01/14/2011)

01/14/2011

516 NOTICE of Filing Supplemental Response to Order of the Court Dated December 6, 2010 by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 01/14/2011)

01/19/2011

517 MOTION for Extension of Time to File (Produce) to Special Master by January 15, 2011, pursuant to Order dated December 6, 2010 by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit A­­Transmittal Letter from BOC Director to Special Master dated January 19, 2011, # 2 Text of Proposed Order) (Chinnery, Aquannette) (Entered: 01/19/2011)

01/20/2011

518 ORDER (GWC) dated 1/20/2011 granting 517 Motion for Extension of Time (KMD) (Entered: 01/20/2011)

01/21/2011

519 ORDER clerk process and pay Special Master (GWC) dated 1/19/2011 (MB) (Entered: 01/21/2011)

01/21/2011

522 Receipt number 100001091 in the amount of Fifty Thousand Dollars received from the Government of The Virgin Islands. on 1/21/2011 Check # 04909071 (TNS) (Entered: 01/25/2011)

01/24/2011

520 ORDER TO SHOW CAUSE (GWC) dated 1/24/2011 Show Cause Hearing set for 1/28/2011 at 10:00 AM in Mag Judge Ctrm 3 STX before US Magistrate Judge George W Cannon, Jr. (KMD) (Entered: 01/24/2011)

01/25/2011

521 NOTICE of Filing of Proof of Deposit by Territory of The Virgin Islands (Attachments: # 1 Exhibit A: Proof of Deposit) (Chinnery, Aquannette) (Main Document 521 replaced on 1/25/2011) (Thomas, Theresa). (Attachment 1 replaced on 1/25/2011) (Thomas, Theresa). (Entered: 01/25/2011)

01/25/2011

523 ORDER (GWC) dated 1/25/2011 vacating 520 Order to Show Cause (KMD) (Entered: 01/25/2011)

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02/01/2011 02/07/2011 02/22/2011 03/02/2011 03/08/2011 03/08/2011
03/10/2011 03/22/2011 04/01/2011 04/18/2011 04/22/2011
05/06/2011 05/10/2011 05/10/2011 05/17/2011
05/17/2011

District Court CM/ECF ­ LIVE
525 NOTICE of Filing of Amended Report for January 2011 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A­GGACF Amended January 2011 Report) (Chinnery, Aquannette) (Entered: 02/01/2011)
526 ORDER (GWC) dated 2/7/11 that the Clerk of the Court process and pay from funds to Susan McCampbell. (TNS) (Entered: 02/07/2011)
527 ORDER (GWC) dated 2/22/2011 that the Clerk of the court process and pay from funds. (TNS) (Entered: 02/22/2011)
528 ORDER (GWC) dated 3/2/11 that the Clerk of the Court pay Ms. Campbell from funds. (TNS) (Entered: 03/02/2011)
529 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 3/8/2011. (Court Reporter FTR Recorder.) (NH) (Entered: 03/08/2011)
530 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 3/8/2011. Next Status Conference set for 7/28/2011 09:00 AM in Magistrate Judge Courtroom 3 St. Croix before US Magistrate Judge George W Cannon. (CB) (Entered: 03/08/2011)
531 NOTICE of Filing of March 2011 Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A. Defendants' March 2011 Report) (Chinnery, Aquannette) (Entered: 03/10/2011)
532 ORDER (GWC) dated 3/22/11 that the Clerk of the Court pay from funds to Ms. Susan Campbell. (TNS) (Entered: 03/29/2011)
544 Letter from Andrew J. Barrick, US Department of Justice. (TNS) (Entered: 06/13/2011)
533 ORDER (GWC) dated 4/18/11 that the Clerk of the court pay from funds to Ms. Susan McCampbell. (TNS) (Entered: 04/18/2011)
545 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 3/8/11, before Judge George W. Cannon. Court Reporter/Transcriber Terry Gribbon's Transcription Service. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 5/16/2011. Redacted Transcript Deadline set for 5/26/2011. Release of Transcript Restriction set for 7/25/2011. (TNS) (Entered: 06/13/2011)
534 NOTICE of Appearance by Emily Anna Gunston on behalf of Plaintiff United States of America (Gunston, Emily) (Entered: 05/06/2011)
535 NOTICE of Filing of May 2011 Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A) (Chinnery, Aquannette) (Entered: 05/10/2011)
536 ORDER (GWC) dated 5/10/2011that the clerk of the court shall pay from funds to Ms. Susan Mccampbell (TNS) (Entered: 05/10/2011)
537 MOTION for enlargement of time regarding certain compliance mandate deadlines set for June 1, 2011 by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion for enlargment of time regarding certain compliance mandates) (Chinnery, Aquannette) (Entered: 05/17/2011)
538 MEMORANDUM in Support re 537 MOTION for enlargement of time regarding certain compliance mandate deadlines set for June 1, 2011 filed by Defendant Territory of The Virgin Islands. (Chinnery, Aquannette) (Entered: 05/17/2011)

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05/31/2011 06/09/2011 06/09/2011 06/10/2011 06/10/2011 06/15/2011 06/15/2011 06/27/2011 06/27/2011 06/27/2011 06/27/2011
06/27/2011 06/27/2011
07/05/2011 07/05/2011 07/06/2011 07/08/2011

District Court CM/ECF ­ LIVE
539 Opposition to Motion re 537 MOTION for enlargement of time regarding certain compliance mandate deadlines set for June 1, 2011 filed by Plaintiff United States of America. (Gunston, Emily) (Entered: 05/31/2011)
540 MOTION for Leave to File Excess Pages for Motion for Appointment of a Receiver by Plaintiff United States of America. (Barrick, Andrew) (Entered: 06/09/2011)
541 MOTION to Appoint Receiver by Plaintiff United States of America. (Attachments: # 1 Memorandum of Points & Authorities) (Barrick, Andrew) (Entered: 06/09/2011)
542 ORDER (GWC) dated 6/10/2011 denying 537 Motion For Enlargement of Time (KMD) (Entered: 06/10/2011)
543 ORDER (GWC) dated 6/10/2011 granting 540 Motion for Leave to File Excess Pages (KMD) (Entered: 06/10/2011)
546 Letter from Aquannette Chinnery,Esq (TNS) (Entered: 06/15/2011)
547 ORDER (GWC) dated 6/13/2011 that the Clerk of the Court pay from funds to Susan Campbell. (TNS) (Entered: 06/15/2011)
548 MOTION for Leave to File Excess Pages by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion to exceed page limit) (Chinnery, Aquannette) (Entered: 06/27/2011)
549 Opposition to Motion re 541 MOTION to Appoint Receiver filed by Defendant Territory of The Virgin Islands. (Chinnery, Aquannette) (Entered: 06/27/2011)
550 MEMORANDUM in Support of Opposition re 541 MOTION to Appoint Receiver filed by Defendant Territory of The Virgin Islands. (Chinnery, Aquannette) (Entered: 06/27/2011)
551 NOTICE of filing of omitted exhibit to memorandum of law in support of opposition to motion for appointment of a receiver by Territory of The Virgin Islands re 550 Memorandum in Support of Opposition (Attachments: # 1 Exhibit A) (Chinnery, Aquannette) (Entered: 06/27/2011)
552 ORDER (GWC) dated 06/27/11granting 548 Motion for Leave to File Excess Pages ( Nunc Pro Tunc) (AM) (Entered: 06/27/2011)
553 MEMORANDUM in Support of Opposition re 541 MOTION to Appoint Receiver AMENDED MEMORANDUM OF LAW IN SUPPORT OF OPPOSITION TO MOTION TO APPOINT A RECEIVER filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit A Director's Notes, # 2 Exhibit B Plata v. Schwarzenneger Order Appointing Receiver) (Chinnery, Aquannette) (Entered: 06/27/2011)
554 MOTION for Extension of Time to File Response/Reply as to 549 Opposition to Motion requesting appointment of receiver by Plaintiff United States of America. (Gunston, Emily) (Entered: 07/05/2011)
555 ORDER (GWC) dated 7/5/2011 granting 554 Motion for Extension of Time to File Reply regarding 541 Motion to Appoint Receiver Reply due by 7/22/2011. (CB) (Entered: 07/05/2011)
557 ORDER OF DISTRIBUTION of Funds(GWC) dated 7/6/2011 (MB) (Main Document 557 replaced on 7/12/2011) (MB). (Entered: 07/11/2011)
556 NOTICE of Filing of July 2011 report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A July 2011 report) (Chinnery, Aquannette) (Entered: 07/08/2011)

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07/11/2011 07/21/2011 07/21/2011
07/22/2011 07/22/2011 07/26/2011 07/27/2011
07/27/2011
07/28/2011 07/28/2011 07/28/2011 07/29/2011 07/29/2011 07/29/2011 08/01/2011

District Court CM/ECF ­ LIVE
558 ORDER OF DISTRIBUTION of Funds(GWC) dated 7/6/2011 (MB) (Main Document 558 replaced on 7/12/2011) (MB). (Entered: 07/11/2011)
559 STIPULATION Regarding Change of Date of Status Conference by Territory of The Virgin Islands. (Attachments: # 1 Exhibit A) (Chinnery, Aquannette) (Entered: 07/21/2011)
Status Conference set for 7/29/2011 09:00 AM (moved from 7/28/2011 at 9:00 A.M.) in Chambers before US Magistrate Judge George W Cannon.(GWC) dated 7/21/2011(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 07/21/2011)
560 MOTION for leave to File Document Under Seal by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 07/22/2011)
561 REPLY to Opposition to Motion re 553 Memorandum in Support of Opposition, filed by Plaintiff United States of America. (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit) (Gunston, Emily) (Entered: 07/22/2011)
562 ORDER (GWC) dated 7/26/2011 granting 560 Motion to Seal Exhibits 1­10 to 561 Reply to Opposition to Motion (KMD) (Entered: 07/26/2011)
563 MOTION for Leave to Appear Pro Hac Vice of Attorney: Richard S. Walinski by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Certificate of Good Standing Richard S. Walinski, # 2 Exhibit Pro Hac Vice Application Richard S. Walinski, # 3 Text of Proposed Order granting motion) (Chinnery, Aquannette) (Entered: 07/27/2011)
564 MOTION for Leave to Appear Pro Hac Vice of Attorney: Nathan T. Oswald by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Certificate of Good Standing Nathan T. Oswald, # 2 Exhibit Pro Hac Vice Application Nathan T. Oswald, # 3 Text of Proposed Order granting motion) (Chinnery, Aquannette) (Entered: 07/27/2011)
565 MOTION to Vacate (Motion to Terminate Prospective Relief) by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Proposed Order granting Motion to Terminate Prospective Relief) (Chinnery, Aquannette) (Entered: 07/28/2011)
566 MEMORANDUM in Support re 565 MOTION to Vacate (Motion to Terminate Prospective Relief) filed by Defendant Territory of The Virgin Islands. (Chinnery, Aquannette) (Entered: 07/28/2011)
567 NOTICE OF INTENTION TO FILE OBJECTIONS TO SPECIAL MASTER'S REPORT ON AUGUST 1, 2011 by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 07/28/2011)
568 ORDER (GWC) dated 7/29/2011 scheduling briefing related to 565 Motion to Terminate Prospective Relief (KMD) (Entered: 07/29/2011)
569 ORDER (GWC) dated 7/29/2011 granting 563 [ 564 Motions for Leave to Appear Pro Hac Vice for Richard S. Walinksi, Esquire nd Nathan T. Oswald, Esquire. (CB) (Entered: 07/29/2011)
570 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 7/29/2011. (Court Reporter FTR Recorder.) (NH) (Entered: 07/29/2011)
571 NOTICE of Filing of Defendants' Objections by Territory of The Virgin Islands to the Special Master's Ninth Report to the Court, July 21, 2011 (Attachments: # 1 Exhibit A

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(Defendants' Objections)) (Chinnery, Aquannette) (Entered: 08/01/2011)

08/03/2011 572 Sealed Document (TNS) (Entered: 08/03/2011)

08/03/2011

573 NOTICE of United States' Intent to Respond to Objections by United States of America re 571 Notice (Other) (Gunston, Emily) (Entered: 08/03/2011)

08/11/2011

574 Opposition to Motion re 565 MOTION to Vacate (Motion to Terminate Prospective Relief) filed by Plaintiff United States of America. (Attachments: # 1 Exhibit, # 2 Exhibit) (Gunston, Emily) (Entered: 08/11/2011)

08/15/2011

575 ORDER that the Clerk of the court process and pay from funds.(RLF) dated 8/16/2011 (TNS) (Entered: 08/16/2011)

08/19/2011

576 REPLY to Opposition to Motion re 571 Notice (Other) Response to Defendants' objections to Special Master's Ninth Report filed by Plaintiff United States of America. (Gunston, Emily) (Entered: 08/19/2011)

08/22/2011

577 NOTICE of intention to file objections to Special Master's Supplemental Report by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 08/22/2011)

08/22/2011

578 NOTICE of Appearance by Nathan T Oswald on behalf of Defendant Territory of The Virgin Islands (Oswald, Nathan) (Entered: 08/22/2011)

08/24/2011

579 NOTICE of Appearance by Richard S Walinski on behalf of Defendant Territory of The Virgin Islands (Walinski, Richard) (Entered: 08/24/2011)

08/24/2011

580 MOTION for Leave to File Excess Pages by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 08/24/2011)

08/25/2011

581 ORDER (GWC) dated 8/25/2011 granting 580 Motion for Leave to File Excess Pages (KMD) (Entered: 08/25/2011)

08/25/2011

582 MOTION postponement of automatic stay by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 08/25/2011)

08/25/2011

583 REPLY to re 574 Opposition to Motion filed by Plaintiff United States of America filed by Defendant Territory of The Virgin Islands. Responses due by 9/8/2011 (Oswald, Nathan) (Entered: 08/25/2011)

08/26/2011

584 ORDER (GWC) dated 8/26/2011 granting 582 Motion to Postpone Automatic Stay (KMD) (Entered: 08/26/2011)

08/26/2011

585 NOTICE of Filing of Defendants' Objections to the Special Master's Supplemental Report to the Ninth Report to the Court by Territory of The Virgin Islands (Attachments: # 1 Exhibit (Defendants' Objections)) (Oswald, Nathan) (Entered: 08/26/2011)

08/30/2011

586 MOTION for Leave to File Surreply to Defendants' Motion to Terminate Prospective Relief by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 08/30/2011)

08/30/2011

587 ORDER (GWC) dated 8/30/2011 granting 586 Motion for Leave to File Surreply (KMD) (Entered: 08/30/2011)

09/07/2011

588 REPLY to Opposition to Motion re 585 Notice (Other) US' Response to Defendants' Objections to Special Master's Supplemental Report filed by Plaintiff United States of America. (Gunston, Emily) (Entered: 09/07/2011)

09/07/2011

589 MOTION to Amend/Correct Order Granting Unites States' Motion to Find Defendants in Contempt and for Appointment of a Special Master by Defendant Territory of The

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09/08/2011 09/09/2011 09/09/2011 09/12/2011 09/13/2011 09/13/2011 09/13/2011 09/14/2011 09/20/2011 09/21/2011
09/26/2011 09/26/2011 09/30/2011 10/04/2011

District Court CM/ECF ­ LIVE
Virgin Islands. (Attachments: # 1 Exhibit Memorandum of Points and Authorities in Support) (Oswald, Nathan) (Entered: 09/07/2011)
590 REPLY to re 583 Reply to filed by Defendant Territory of The Virgin Islands Surreply to Motion to Terminate Prospective Relief filed by Plaintiff United States of America. Responses due by 9/22/2011 (Gunston, Emily) (Entered: 09/08/2011)
591 MOTION for Leave to File Instanter by Defendant Territory of The Virgin Islands. (Attachments: # 1 Errata Defendants' Reply in Support of Defendants' Objections to the Special Master's Supplemental Report to the Ninth Report to the Court) (Oswald, Nathan) (Entered: 09/09/2011)
592 MOTION for Leave to File Surreply in Support of Defendants Motion to Terminate Prospective Relief by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 09/09/2011)
Case Reassigned to Wilma A Lewis District Judge Raymond L. Finch no longer assigned to the case. (MB) (Entered: 09/12/2011)
593 ORDER (GWC) dated 9/13/2011 that the Clerk of Court process and pay from funds to Ms Susan McCampbell. (TNS) (Entered: 09/13/2011)
594 ORDER (GWC) dated 9/13/2011 granting 591 Motion for Leave to File Reply in Support of Defendants' Objections to the Sepcial Master's Supplemental Report (KMD) (Entered: 09/13/2011)
595 ORDER (GWC) dated 9/13/2011 granting 592 Motion for Leave to File Surreply in Support of Defendants' Motion to Terminate Prospective Relief (KMD) (Entered: 09/13/2011)
596 NOTICE by Territory of The Virgin Islands of Filing September 2011 Report (Attachments: # 1 Exhibit September 2011 report by Territory of The Virgin Islands) (Oswald, Nathan) (Entered: 09/14/2011)
597 REPLY to re 590 Reply to filed by Plaintiff United States of America Surreply in Support of Motion to Terminate Prospective Relief filed by Defendant Territory of The Virgin Islands. Responses due by 10/3/2011 (Oswald, Nathan) (Entered: 09/20/2011)
598 Opposition to Motion re 589 MOTION to Amend/Correct Order Granting Unites States' Motion to Find Defendants in Contempt and for Appointment of a Special Master filed by Plaintiff United States of America. (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit, # 5 Exhibit, # 6 Exhibit, # 7 Exhibit) (Gunston, Emily) (Entered: 09/21/2011)
599 SCHEDULING ORDER: (GWC) dated 9/26/2011 Telephone Conference set for 9/30/2011 at 10:00 AM in Chambers before US Magistrate Judge George W Cannon, Jr. (KMD) (Entered: 09/26/2011)
600 REPLY to Opposition to Motion re 598 Opposition to Motion, to Modify Order Granting United States Motion to Find Defendants in Contempt and for Appointment of a Special Master filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 09/26/2011)
601 Minute Order. Proceedings held in chambers before US Magistrate Judge George W Cannon: Status Conference held on 9/30/2011. Next Status Conference set for 10/4/2011 10:00 AM in Chambers before US Magistrate Judge George W Cannon. (CB) (Entered: 09/30/2011)
602 Minute Order. Proceedings held in chambers before US Magistrate Judge George W

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10/24/2011 10/26/2011 10/26/2011
11/01/2011 11/02/2011 11/04/2011
11/07/2011 11/07/2011 11/18/2011 11/22/2011
12/05/2011 12/05/2011 12/06/2011 12/12/2011

District Court CM/ECF ­ LIVE
Cannon: Status Conference held on 10/4/2011. (CB) (Entered: 10/04/2011)
603 ORDER (GWC) dated 10/24/11 that the Clerk of the court process and pay Susan McCampbell. (TNS) (Entered: 10/24/2011)
604 Notification of Automatic Stay of all Prospective Relief Effective October 27, 2011 (WAL) dated 10/26/2011 (GS) (Entered: 10/26/2011)
605 ORDER (WAL) dated 10/26/2011. It is Ordered that a status conference will be held telephonically on November 7, 2011, at 2:00 p.m. AST (1:00 p.m. EST) to discuss further proceedings in this matter. Counsel are responsible for arranging the conference call and shall provide the Court with the necessary information so the Court may join the conference at the designated time. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (GS) (Entered: 10/26/2011)
606 MOTION to Substitute Attorney by Plaintiff United States of America. (Gunston, Emily) (Entered: 11/01/2011)
607 ORDER (GWC) dated 11/2/2011 granting 606 Motion to Substitute Attorney. Attorney Andrew John Barrick terminated (KMD) (Entered: 11/02/2011)
NOTICE of Hearing: (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.)It is Ordered that a status conference will be held telephonically on November 7, 2011, at 2:00 p.m. AST (1:00 p.m. EST) to discuss further proceedings in this matter. Counsel are responsible for arranging the conference call and shall provide the Court with the necessary information so the Court may join the conference at the designated time before District Judge Wilma A Lewis. (MB) (Entered: 11/04/2011)
Document entered on 11/4/2011 is ONLY a status conference and NOT a hearing as previously docketed. (MB) (Entered: 11/07/2011)
608 NOTICE of Hearing on Motion 565 MOTION to Vacate (Motion to Terminate Prospective Relief) : Motion Hearing set for 12/6/2011 01:30 PM in District Judge Ctrm 1­STX before District Judge Wilma A Lewis. (MB) (Entered: 11/07/2011)
609 STIPULATION Protective Order Regarding Inadvertent Disclosures by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 11/18/2011)
610 MOTION to Vacate 224 Pretrial Order Motion to Vacate Order Finding Defendants in Contempt by Defendant Territory of The Virgin Islands. (Attachments: # 1 Supplement Memorandum in Support of Motion to Vacate Order Finding Defendants in Contempt, # 2 Exhibit Exhibit 1: Order of July 22, 1987, # 3 Text of Proposed Order) (Oswald, Nathan) (Entered: 11/22/2011)
611 Opposition to Motion re 610 MOTION to Vacate 224 Pretrial Order Motion to Vacate Order Finding Defendants in Contempt MOTION to Vacate 224 Pretrial Order Motion to Vacate Order Finding Defendants in Contempt filed by Plaintiff United States of America. (Lareau, Alyssa) (Entered: 12/05/2011)
615 ORDER (GWC) that the Clerk of the court pay from funds to Susan McCampbell.dated 12/5/2011 (TNS) (Entered: 12/16/2011)
612 Minute Entry for proceedings held before District Judge Wilma A Lewis: Motion Hearing held on 12/6/2011 re 565 MOTION to Vacate (Motion to Terminate Prospective Relief) filed by Territory of The Virgin Islands. (Court Reporter V. Lawrence.) (MB) (Entered: 12/07/2011)
613 MOTION for Extension of Time to File Response/Reply in support of Motion to Vacate

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12/15/2011
01/02/2012
01/02/2012 01/04/2012 01/05/2012 01/09/2012 01/11/2012 01/13/2012
01/19/2012 01/20/2012 01/20/2012 01/20/2012 01/27/2012
01/27/2012

District Court CM/ECF ­ LIVE
Order Finding Defendants in Contempt by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 12/12/2011)
614 ORDER (WAL) dated 12/15/2011 granting 613 Defendants' Motion for Enlargement of Time and ordering that Defendants shall have up to and including January 2, 2012, within which to file a Reply to Plaintiff's Opposition to the Motion to Vacate. (GS) (Entered: 12/15/2011)
616 MOTION for Leave to File Excess Pages for Defendants' Reply in Support of Motion to Vacate Order Finding Defendants in Contempt Instanter by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 01/02/2012)
617 REPLY to Opposition to Motion re 611 Opposition to Motion, Motion to Vacate Order Finding Defendants in Contempt filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 01/02/2012)
618 MOTION for Leave to File Surreply to Defendants' Motion to Vacate Order Finding Defendants in Contempt by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 01/04/2012)
619 NOTICE of Change of Address by Nathan T Oswald (Oswald, Nathan) (Entered: 01/05/2012)
620 ORDER (WAL) dated 1/9/12 Granting 618 Plaintiff's Motion for Leave of Court to File Surreply and Ordering that Plaintiff shall have up to and including January 19, 2012, within which to file its Surreply. (GS) (Entered: 01/09/2012)
621 ORDER (GWC) dated 1/11/2011that the Clerk of Court process and pay from funds. (TNS) (Entered: 01/12/2012)
622 NOTICE of Supplemental Authority in Support of Motion by Territory of The Virgin Islands re 610 MOTION to Vacate 224 Pretrial Order Motion to Vacate Order Finding Defendants in Contempt MOTION to Vacate 224 Pretrial Order Motion to Vacate Order Finding Defendants in Contempt (Oswald, Nathan) (Entered: 01/13/2012)
623 REPLY to re 617 Reply to Opposition to Motion filed by Defendant Territory of The Virgin Islands filed by Plaintiff United States of America. Responses due by 2/2/2012 (Gunston, Emily) (Entered: 01/19/2012)
624 MOTION for Leave to File Surreply in Support of Defendants' Motion to Vacate Order Finding Defendants in Contempt by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 01/20/2012)
625 STIPULATION Protective Order Regarding Protected Health Information by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 01/20/2012)
626 ORDER (WAL) dated 1/20/12 granting 624 Motion for Leave to File and ordering that Defendants shall have up to and including January 27, 2012, within which to file their Surreply. (GS) (Entered: 01/20/2012)
627 REPLY to re 623 Reply to filed by Plaintiff United States of America Surreply in Support of Motion to Vacate Order Finding Defendants in Contempt filed by Defendant Territory of The Virgin Islands. Responses due by 2/9/2012 (Oswald, Nathan) (Entered: 01/27/2012)
628 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 12/6/11, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number (340) 718­1130. Transcript may be viewed at the court public

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02/08/2012 02/09/2012 02/10/2012 02/16/2012 02/16/2012
02/16/2012
02/17/2012 02/21/2012 02/22/2012 02/23/2012 02/23/2012 02/23/2012 02/23/2012

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terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 2/21/2012. Redacted Transcript Deadline set for 3/1/2012. Release of Transcript Restriction set for 4/30/2012. (Lawrence, Valerie) (Entered: 01/27/2012)
629 ORDER that an evidentiary hearing will be conducted to determine whether there is a current and ongoing violation of a federal right at Golden Grove Adult Correctional Facility; that a telephonic status conference to discuss further proceedings in this matter is scheduled for February 23, 2012, at 3:00 p.m. AST (2:00 p.m. EST); and that parties shall submit a joint plan outlining issues to the Court by noon on February 21, 2012. (WAL) dated 2/8/12 (GS) (Entered: 02/08/2012)
630 MEMORANDUM OPINION (WAL) dated 2/8/12. (GS) (Entered: 02/08/2012)
631 STIPULATION Protective Order Regarding Defendants' Supplemental Document Production by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 02/09/2012)
632 ORDER(GWC) that the Clerk of the Court process and pay from funds to Ms. Susan Campbell. dated 2/10/2012 (TNS) (Entered: 02/13/2012)
633 ORDER (WAL) dated 2/16/12 staying the services of the Special Master until further Order of the Court. (GS) (Entered: 02/16/2012)
634 MOTION to Compel Response to Ninth Interrogatory of Defendants' First Set of Interrogatories by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Stipulation regarding unresolved discovery disputes, # 2 Exhibit Correspondence requesting discovery meet and confer, # 3 Text of Proposed Order) (Oswald, Nathan) (Entered: 02/16/2012)
635 MEMORANDUM in Support re 634 MOTION to Compel Response to Ninth Interrogatory of Defendants' First Set of Interrogatories filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Plaintiff's Revised Interrogatory Responses) (Oswald, Nathan) (Entered: 02/16/2012)
HARD COPY NOTICE of filing sent via email to Susan McCampbell Related Document: 633 (MB) (Entered: 02/17/2012)
636 DISCOVERY MEMORANDUM­Rule 16 by Plaintiff United States of America. (Lareau, Alyssa) (Entered: 02/21/2012)
637 Joint MOTION to Amend/Correct 629 Order, Scheduling Order,, Joint Motion to Amend Order of February 8, 2012 by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 02/22/2012)
638 MOTION to Compel Entry Upon Land by Plaintiff United States of America. (Attachments: # 1 Stipulation Regarding Unresolved Discovery Disputes, # 2 Exhibit Ex 1 to Stipulation, # 3 Text of Proposed Order) (Lareau, Alyssa) (Entered: 02/23/2012)
639 MEMORANDUM in Support re 638 MOTION to Compel Entry Upon Land filed by Plaintiff United States of America. (Attachments: # 1 Exhibit 1, # 2 Exhibit 2) (Lareau, Alyssa) (Entered: 02/23/2012)
640 MOTION to Expedite Review of Motion to Compel Entry Upon Land by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Lareau, Alyssa) (Entered: 02/23/2012)
645 Minute Entry for proceedings held before District Judge Wilma A Lewis: Status Conference held on 2/23/2012. (Court Reporter V. Lawrence.) (TNS) (Entered:

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02/24/2012

641 ORDER (WAL) dated 2/24/12. It is ORDERED that the Joint Motion to Amend/Correct Order is GRANTED. The evidentiary cutoff date is extended until March 9, 2012, for purposes of determining whether there is a current and ongoing violation of a federal right. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (GS) (Entered: 02/24/2012)

02/24/2012

642 ORDER (WAL) dated 2/24/12. It is ORDERED that the Motion for Expedited Briefing is GRANTED. Per the agreement reached at the February 23, 2012, status conference, Defendants shall have up to and including March 1, 2012, within which to file their Response to Plaintiffs Motion to Compel Entry. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (GS) (Entered: 02/24/2012)

02/28/2012

643 SCHEDULING ORDER for the § 3626(b)(3) evidentiary hearing. (WAL) dated 2/28/12 (GS) (Entered: 02/28/2012)

02/29/2012

644 ORDER (GWC) dated 2/29/12 that the clerk of the court pay from the funds to Susan Campbell. (TNS) (Entered: 02/29/2012)

03/01/2012

646 Opposition to Motion re 638 MOTION to Compel Entry Upon Land filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 03/01/2012)

03/02/2012

647 Opposition to Motion re 634 MOTION to Compel Response to Ninth Interrogatory of Defendants' First Set of Interrogatories filed by Plaintiff United States of America. (Lareau, Alyssa) (Entered: 03/02/2012)

03/05/2012

648 ORDER (WAL) dated 3/5/12 denying 638 Motion to Compel Entry Upon Land. (GS) (Entered: 03/05/2012)

03/16/2012

649 MOTION to Withdraw 634 MOTION to Compel Response to Ninth Interrogatory of Defendants' First Set of Interrogatories by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 03/16/2012)

03/20/2012

650 ORDER (WAL) dated 3/20/12. ORDERED that Defendants' Motion to Withdraw is GRANTED; ORDERED that Defendants' Motion to Compel Response to the Ninth Interrogatory of Defendants' First Set of Interrogatories is WITHDRAWN WITHOUT PREJUDICE. (GS) (Entered: 03/20/2012)

04/16/2012

651 Joint MOTION for Extension of Time to Complete Discovery Mot to Amend Mediation Deadline by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 04/16/2012)

04/18/2012

652 ORDER (WAL) dated 4/18/2012 granting 651 Motion for Extension of Time to Complete Discovery and Joint Motion to Amend Mediation Deadline. Parties shall have up to and including May 7, 2012 within which to commence mediation. (RDB) (Entered: 04/18/2012)

04/19/2012

653 Joint MOTION for Extension of Time to Complete Discovery by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 04/19/2012)

04/19/2012

658 Process Receipt and Return Executed by United States Marshall Service (TNS) (Additional attachment(s) added on 5/3/2012: # 1 return of service) (TNS). (Entered: 05/03/2012)

04/19/2012

659 Process Receipt and Returned Executed by United States Marshall Services (Attachments: # 1 return of service) (TNS) (Entered: 05/04/2012)

04/27/2012 654 ORDER (WAL) dated 4/27/2012 granting 653 Motion for Extension of Time to

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Complete Discovery. (GS) (Entered: 04/27/2012)
655 MOTION to Continue Dates in Scheduling Order by Plaintiff United States of America. (Attachments: # 1 Memorandum of Law, # 2 Text of Proposed Order) (Gunston, Emily) (Entered: 04/27/2012)
656 NOTICE of communication with the Special Master (WAL) dated 4/29/2012. (GS) (Entered: 04/29/2012)
657 ORDER (WAL) dated 5/1/2012: Defendants shall have up to and including May 4, 2012, within which to file a response to Plaintiff's Motion to Amend the Scheduling Order. A telephonic status conference to discuss further proceedings in this matter is scheduled for May 8, 2012, at 10:00 a.m. (GS) (Entered: 05/01/2012)
660 Process Receipt and Returned Executed by United States Marshall Service (Attachments: # 1 Proof Of Service) (TNS) (Entered: 05/04/2012)
661 Processed Receipt and Returned Executed by United States Marshall Service (Attachments: # 1 Proof Of Service) (TNS) (Entered: 05/04/2012)
662 REPLY to re 655 MOTION to Continue Dates in Scheduling Order filed by Plaintiff United States of America filed by Defendant Territory of The Virgin Islands. Responses due by 5/17/2012 (Oswald, Nathan) (Entered: 05/04/2012)
664 Minute Entry for proceedings held before District Judge Wilma A Lewis: Status Conference held on 5/8/2012. (Court Reporter Y. Setorie.) (MB) (Entered: 05/10/2012)
663 REPLY to re 655 MOTION to Continue Dates in Scheduling Order filed by Plaintiff United States of America Memorandum filed pursuant to Court Order filed by Plaintiff United States of America. Responses due by 5/24/2012 (Attachments: # 1 Exhibit US Request for Production of Documents, # 2 Exhibit US Second Request for Production of Documents) (Gunston, Emily) (Main Document 663 replaced on 5/10/2012) (MB). (Attachment 1 replaced on 5/10/2012) (MB). (Attachment 2 replaced on 5/10/2012) (MB). (Main Document 663 replaced on 5/10/2012) (MB). (Entered: 05/09/2012)
Documents # 663 were replace because when they were not being allowed to print on regular size paper only legal size. (MB) (Entered: 05/10/2012)
665 NOTICE OF FILING EXCERPT OF OFFICIAL TRANSCRIPT of Proceedings held on 5/8/2012, before Judge Wilma A. Lewis. Court Reporter/Transcriber Yvonne Setorie, Telephone number 340­718­1318. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 6/4/2012. Redacted Transcript Deadline set for 6/14/2012. Release of Transcript Restriction set for 8/13/2012. (MB) (Entered: 05/11/2012)
666 Process Receipt and Return ­ Subpoena Returned Executed addressed to Emily A. Gunston, Esq. (Attachments: # 1 subpoena Returned) (NH) (Entered: 05/21/2012)
667 ORDER (WAL) dated 5/21/2012 granting 655 Plaintiff's Unopposed Motion to Amend the Court's February 28, 2012 Scheduling Order. The Court will issue an Amended Scheduling Order forthwith. The Court ORDERS that in preparation for and during the course of Plaintiffs May 22­24, 2012 inspection, Defendants shall, through their most diligent efforts, help to facilitate the retrieval, inspection, and copying of documents responsive to Plaintiff's discovery requests. Defendants shall, inter alia, ensure that they are familiar with the documents sought by Plaintiff in its May 9, 2012 Memorandum Regarding Outstanding Documents Responsive to its Document Requests and where those documents are likely to be located. Defendants shall also make available to assist

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05/31/2012 06/04/2012 06/05/2012 06/05/2012 06/19/2012 06/19/2012
06/20/2012 07/02/2012
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Plaintiff during its May 22­24, 2012 inspection individuals who are familiar with the documents, their location, and their manner of storage; and shall utilize and make available to Plaintiff all non­privileged logs, indices, or other tools that would assist in the location and retrieval of responsive documents. (NS) (Entered: 05/21/2012)
668 MOTION status conference regarding scheduling order re 667 Order on Motion to Continue,,,, by Plaintiff United States of America. (Gunston, Emily) (Entered: 05/29/2012)
669 It is hereby ORDERED that Plaintiff's Motion for Status Conference Regarding Scheduling Order is GRANTED. A telephonic status conference to discuss further proceedings in this matter is scheduled for June 4, 2012 at 10:30 a.m. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (GS) (Entered: 05/30/2012)
Telephonic Status Conference set for 6/4/2012 10:30 AM in STX Courtroom 1 before District Judge Wilma A Lewis. counsels will be notified as to the AT & T calling in information via email. (MB) (Entered: 05/31/2012)
672 Minute Entry for proceedings held before District Judge Wilma A Lewis: Status Conference held on 6/4/2012. (Court Reporter V. Lawrence.) (MB) (Entered: 06/06/2012)
670 Supplemental MOTION for Extension of Time to Complete Discovery memorandum regarding proposed scheduling order by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 06/05/2012)
671 MOTION to Adopt Proposed Pre­Hearing Scheduling Order by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 06/05/2012)
673 AMENDED SCHEDULING ORDER (WAL) dated 06/19/2012. (GS) (Entered: 06/19/2012)
Pre­Hearing set for 1/3/2013 03:00 PM in STX Courtroom 1 before District Judge Wilma A Lewis. Hearing will commence on 1/7/2013 09:30 AM, by 8:30 A.M. 1/7/2013 Parties shall provide court with Three (3) sets of exhibits, Courtroom 1 before District Judge Wilma A Lewis. (MB) (Entered: 06/19/2012)
674 NOTICE of Appearance by Kenrick E. Robertson on behalf of Defendant Territory of The Virgin Islands (Robertson, Kenrick) (Entered: 06/20/2012)
675 Joint MOTION to Amend/Correct 673 Order on Motion for Extension of Time to Complete Discovery, Order on Motion for Miscellaneous Relief and Joint PROPOSAL for Evidentiary Cutoff Date by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Lareau, Alyssa) (Entered: 07/02/2012)
676 NOTICE of Appearance by Joseph A DiRuzzo, III on behalf of Intervenor Ronald Edward Gillette (DiRuzzo, Joseph) (Entered: 07/21/2012)
677 MOTION to Intervene by Intervenor Ronald Edward Gillette. (Attachments: # 1 Text of Proposed Order) (DiRuzzo, Joseph) (Entered: 07/21/2012)
678 MEMORANDUM in Support re 677 MOTION to Intervene filed by Intervenor Ronald Edward Gillette. (Attachments: # 1 Exhibit A, # 2 Exhibit B) (DiRuzzo, Joseph) (Entered: 07/21/2012)
679 Opposition to Motion re 677 MOTION to Intervene filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 08/06/2012)

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08/10/2012 08/10/2012 08/13/2012 08/13/2012 08/13/2012 08/22/2012
08/22/2012
08/22/2012 08/31/2012 10/30/2012 11/07/2012 11/07/2012 11/14/2012 11/29/2012

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680 Opposition to Motion re 677 MOTION to Intervene filed by Plaintiff United States of America. (Lareau, Alyssa) (Entered: 08/06/2012)
681 SCHEDULING ORDER (WAL)(GS) (Entered: 08/07/2012)
NOTICE of Hearing: (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.)Hearing set for 2/25/2013 09:30 AM in STX Courtroom 1 before District Judge Wilma A Lewis. Pretrial Conference set for 2/20/2013 03:00 PM in STX Courtroom 1 before District Judge Wilma A Lewis. (MB) (Entered: 08/08/2012)
682 REPLY to Opposition to Motion re 680 Opposition to Motion filed by Intervenor Ronald Edward Gillette. (Attachments: # 1 Exhibit A) (DiRuzzo, Joseph) (Entered: 08/10/2012)
683 REPLY to Opposition to Motion re 679 Opposition to Motion filed by Intervenor Ronald Edward Gillette. (Attachments: # 1 Exhibit A, # 2 petition in intervention) (DiRuzzo, Joseph) (Entered: 08/10/2012)
684 NOTICE service of initial Rule 26 disclosures by Ronald Edward Gillette (DiRuzzo, Joseph) (Entered: 08/13/2012)
685 NOTICE service of 1st request for production to the US by Ronald Edward Gillette (DiRuzzo, Joseph) (Entered: 08/13/2012)
686 NOTICE service of 1st request for production to the USVI by Ronald Edward Gillette (DiRuzzo, Joseph) (Entered: 08/13/2012)
687 ORDER (WAL): UPON CONSIDERATION of the parties joint request for a telephonic status conference, it is hereby ORDERED that a telephonic status conference will be held on August 22, 2012 at 3:00 p.m.(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (GS) (Entered: 08/22/2012)
688 ORDER (WAL) dated 08/22/2012: UPON CONSIDERATION of the colloquy with the Court at the status conference on August 22, 2012, it is hereby ORDERED that the parties shall submit their joint Motion for Settlement on or before August 31, 2012. (GS) (Entered: 08/22/2012)
690 Minute Entry for proceedings held before District Judge Wilma A Lewis: Telephone Conference held on 8/22/2012. (Court Reporter V. Lawrence.) (MB) (Entered: 09/06/2012)
689 Joint MOTION for Settlement by Plaintiff United States of America. (Attachments: # 1 Proposed Settlement Agreement) (Lareau, Alyssa) (Entered: 08/31/2012)
691 ORDER (WAL) dated 10­30­12 permitting briefing regarding the parties' "Joint Motion to Enter Consent Judgment" (Dkt. No. 689) on or before December 14, 2012. (DGP) (Entered: 10/30/2012)
692 ORDER (WAL) dated 11­7­12 denying Motion to Intervene (Dkt. No. 677) in accordance with accompanying Memorandum Opinion. (DGP) (Entered: 11/07/2012)
693 MEMORANDUM OPINION (WAL) dated 11­7­12 denying Motion to Intervene (Dkt. No. 677). (DGP) (Entered: 11/07/2012)
694 NOTICE OF APPEAL as to 692 Order on Motion to Intervene by Ronald Edward Gillette. Appeal Record due by 11/14/2012. (DiRuzzo, Joseph) (Entered: 11/14/2012)
695 ACK SHORT RECORD received & assigned USCA Case Number 12­4305 re 694 Notice of Appeal filed by Ronald Edward Gillette. (NH) (Entered: 11/29/2012)

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696 MOTION for Extension of Time to File Documents Required by the Court's Order of October 30, 2012 by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 12/11/2012)

12/12/2012

697 MOTION for leave to File Document Under Seal by Plaintiff United States of America. (Lareau, Alyssa) (Additional attachment(s) added on 12/13/2012: # 1 Text of Proposed Order) (MB). (Entered: 12/12/2012)

12/12/2012

698 ORDER (WAL) dated 12­12­12. UPON CONSIDERATION of "Defendants' Motion for Extension of Time" (Dkt. No. 695), it is hereby ORDERED that the Motion is GRANTED. The parties shall submit to the Court on or before January 14, 2013 the filings identified in this Court's October 30, 2013 Order­­that is: (1) a joint memorandum of law in support of the parties' "Joint Motion to Enter Consent Judgment" (Dkt. No. 689), and proposed findings of fact and conclusions of law; and (2) a separate memorandum identifying pending motions for resolution. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 12/12/2012)

12/14/2012

699 MOTION to Withdraw 689 Joint MOTION for Settlement and Reopen Discovery by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Lareau, Alyssa) (Entered: 12/14/2012)

12/21/2012

700 ORDER (WAL) dated 12­21­12 referring dispute to mediation before Magistrate Judge George W. Cannon, Jr. (DGP) (Entered: 12/21/2012)

12/24/2012

701 Opposition to Motion re 699 MOTION to Withdraw 689 Joint MOTION for Settlement and Reopen Discovery filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 12/24/2012)

12/28/2012

Mediation set for January 11, 2013 at 10:00 AM in Chambers of US Magistrate Judge George W Cannon. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 12/28/2012)

01/07/2013 702 ORDER FOR POSITION PAPERS. (GWC) dated 1/7/2013 (CB) (Entered: 01/07/2013)

01/07/2013

703 REPLY to Opposition to Motion re 699 MOTION to Withdraw 689 Joint MOTION for Settlement and Reopen Discovery filed by Plaintiff United States of America. (Gunston, Emily) (Entered: 01/07/2013)

01/11/2013

704 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Settlement Conference held on 1/11/2013. (CB) (Entered: 01/11/2013)

01/11/2013 705 ORDER on Mediation. (GWC) dated 1/11/2013 (CB) (Entered: 01/11/2013)

01/11/2013

706 SCHEDULING ORDER:(GWC) dated 1/11/2013 Status Conference set for 1/28/2013 11:00 AM in Chambers before US Magistrate Judge George W Cannon. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 01/11/2013)

01/24/2013

707 NOTICE of Change of Address by Nathan T Oswald (Oswald, Nathan) (Entered: 01/24/2013)

01/28/2013

708 ORDER (GWC) dated 01/28/2013granting 697 Motion to Seal Document (NH) (Entered: 01/28/2013)

01/28/2013

709 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 1/28/2013. (CB) (Entered: 01/28/2013)

01/28/2013

710 ORDER granting extension of time. (GWC) dated 1/28/2013 (CB) (Entered: 01/28/2013)

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711 MOTION to Withdraw 699 MOTION to Withdraw 689 Joint MOTION for Settlement and Reopen Discovery by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Gunston, Emily) (Entered: 01/30/2013)
712 NOTICE Joint Proposal for Schedule of Further Proceedings by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 01/31/2013)
713 ORDER (WAL) dated 1­31­13. UPON CONSIDERATION of the United States' Motion to Withdraw (Dkt. No. 711), in which it seeks to withdraw a previously filed Motion to Withdraw Joint Motion to Enter Consent Judgment and to Reopen Discovery (Dkt. No. 699), it is hereby ORDERED that the instant Motion to Withdraw (Dkt. No. 711) is GRANTED and the previously filed Motion to Withdraw Joint Motion (Dkt. No. 699) is WITHDRAWN. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 01/31/2013)
714 ORDER (WAL) dated 2­4­13. UPON CONSIDERATION of the parties' "Joint Proposal for Schedule of Further Proceedings" (Dkt. No. 712), it is hereby ORDERED that the proposed scheduled is ACCEPTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 02/04/2013)
715 HARD COPY NOTICE of filing Related Document: 708 was hand delivered by USA Angela Tyson­Floyd and filed in the clerks office under seal. (TNS) (Entered: 02/08/2013)
716 Proposed Findings of Fact by United States of America. (Attachments: # 1 Appendix A, # 2 Appendix B, # 3 Appendix C, # 4 Appendix D, # 5 Appendix E) (Lareau, Alyssa) (Entered: 02/08/2013)
717 SUPPLEMENT re 689 Joint MOTION for Settlement Memorandum Establishing that the Appointment of a Monitor Constitutes a Public Exigency by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 02/08/2013)
718 SUPPLEMENT re 689 Joint MOTION for Settlement Joint Memorandum Regarding Pending Motions by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 02/08/2013)
719 ORDER (WAL) dated 2­12­13. UPON CONSIDERATION of the "United States' Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement" (Dkt. No. 716), and in view of the United States' prior representation that "Defendants have agreed not to contest the findings of fact and conclusions of law proposed by the United States, and have agreed to consent to the Court's adoption of them for purposes of determining whether the prospective relief in the Agreement complies with the Prison Litigation Reform Act, 18 U.S.C. § 3626" (Dkt. No. 711 at 1), and it appearing that Defendants have not affirmatively stated on the record their position with respect to the United States proposed findings of fact and conclusion of law and the Courts adoption of them, it is hereby ORDERED that Defendants shall have up to and including February 14, 2013 within which to file a document indicating their position with respect to the "United States' Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement" (Dkt. No. 716) and the Court's adoption thereof. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 02/12/2013)
720 NOTICE of Non­Opposition to United States' Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement and Consent to Court's Adoption by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 02/14/2013)
721 SUPPLEMENT re 720 Notice (Other) Memorandum in Support of Notice of Non­

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Opposition to United States' Proposed Findings of Fact and Conclusions of Law and Consent to Court's Adoption by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 02/14/2013)
(WAL) dated 2­19­13. UPON CONSIDERATION of the parties' "Joint Proposal for Schedule of Further Proceedings" (Dkt. No. 712), which the Court accepted on February 4, 2013 (Dkt. No. 714), it is hereby ORDERED that the pretrial conference scheduled for February 20, 2013 at 3:00 p.m. and the hearing scheduled for February 25, 2013 at 9:30 a.m. are CONTINUED pending further Order of the Court; and it is further ORDERED that a telephonic status conference will be held on February 20, 2013 at 3:00 p.m. to discuss Defendants' Notice of Non­Opposition to United States' Proposed Findings of Fact and Conclusions of Law (Dkt. No. 720) and the Memorandum filed in support thereof (Dkt. No. 721). (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 02/19/2013)
722 ORDER (WAL) dated 2­20­13 requiring Defendants to file a Notice pursuant to the colloquy conducted at the February 20, 2013 telephonic status conference. (DGP) (Entered: 02/20/2013)
725 Minute Entry for proceedings held before District Judge Wilma A Lewis: Status Conference held on 2/20/2013. (Court Reporter V. Lawrence.) (MB) (Entered: 02/28/2013)
723 NOTICE of Non­Opposition to United States' Proposed Findings of Fact and Conclusions of Law in Support of Settlement Agreement and Consent to Court's Adoption by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 02/27/2013)
724 MOTION to Withdraw Documents by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 02/27/2013)
726 ORDER (WAL) dated 3­1­13 GRANTING Defendant's Motion to Withdraw Documents (Dkt. No. 724) and ACCEPTING Defendant's Non­Opposition (Dkt. No. 723), filed on February 27, 2013. (DGP) (Entered: 03/01/2013)
727 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 2/20/13, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number (340) 718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 4/1/2013. Redacted Transcript Deadline set for 4/11/2013. Release of Transcript Restriction set for 6/9/2013. (Lawrence, Valerie) (Entered: 03/08/2013)
728 MOTION for Extension of Time to File Recommended Monitor Nominees to the Court by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Lareau, Alyssa) (Main Document 728 replaced on 3/18/2013) (MB). (Entered: 03/11/2013)
729 ORDER (WAL) dated 3­11­13 requiring the parties to file a supplemental memorandum regarding their "Memorandum Establishing that Appointment of a Monitor Constitutes a Public Exigency" (Dkt. No. 717) on or before March 25, 2013. (DGP) (Entered: 03/11/2013) (Entered: 03/11/2013)
730 ORDER (WAL) dated 3­12­13. UPON CONSIDERATION of the United States' Unopposed Motion for Extension of Time to Recommend Monitor Nominees to the Court (Dkt. No. 728), it is hereby ORDERED that the Motion is GRANTED and the parties shall recommend their remaining nominees to the Court on or before March 21,

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2013. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 03/12/2013)

03/18/2013

***Staff notes document #728 was replaced, on the original document counsel did not have signature on the certificate of service page counsel was notify via email, document was sent and replaced, no notice of corrected docket entry was sent due to the court entering an order on the motion (MB) (Entered: 03/18/2013)

03/21/2013

731 NOTICE Defendants' Recommendations for the Appointment of a Monitor by Territory of The Virgin Islands (Attachments: # 1 Resume of Attorney Henry C. Smock, # 2 Resume of Attorney Matthew Phelan) (Oswald, Nathan) (Entered: 03/21/2013)

03/21/2013

732 NOTICE UNITED STATES MEMORANDUM RECOMMENDING MONITOR NOMINEES by United States of America re 730 Order on Motion for Extension of Time to File, (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D) (Lareau, Alyssa) (Entered: 03/21/2013)

03/22/2013

733 NOTICE Defendants' Memorandum Establishing that the Parties' Request for a Finding of Public Exigency is Moot by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 03/22/2013)

03/25/2013

734 NOTICE Defendants Objection to the United States Memorandum Recommending Monitor Nominees by Territory of The Virgin Islands re 732 Notice (Other), (Oswald, Nathan) (Entered: 03/25/2013)

03/25/2013

735 NOTICE re Parties' Request for Finding of Public Exigency by United States of America re 733 Notice (Other) (Gunston, Emily) (Entered: 03/25/2013)

03/26/2013

736 ORDER (WAL) dated 3­26­13 deeming withdrawn the parties' request that the Court make a finding of public exigency in light of Defendants' "Memorandum Establishing that the Parties' Request for a Finding of Public Exigency is Moot" (Dkt. No. 733) and the United States' "Memorandum Regarding Parties' Request for a Finding of Public Exigency" (Dkt. No. 735). (DGP) (Entered: 03/26/2013)

04/12/2013

737 ORDER (WAL) dated 4­12­13 referring the parties to Magistrate Judge George W. Cannon, Jr. for a conference to discuss the issues underlying the parties' disagreement which precipitated the filing of "Defendants' Recommendation for the Appointment of a Monitor" (Dkt. No. 731) and "United States' Memorandum Recommending Monitor Nominees" (Dkt. No. 732). (DGP) (Entered: 04/12/2013)

04/12/2013

738 SCHEDULING ORDER:(GWC) dated 4/12/2013 Telephone Conference set for 4/17/2013 11:00 AM in Chambers before US Magistrate Judge George W Cannon. A status conference date and time will be discussed. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (CB) (Entered: 04/12/2013)

04/17/2013

739 SCHEDULING ORDER: (GWC) dated 4/17/2013 Status Conference set for 5/7/2013 at 9:00 AM in Chambers before US Magistrate Judge George W Cannon, Jr. (KMD) (Entered: 04/17/2013)

04/29/2013

740 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 4/17/2013. (CB) (Entered: 04/29/2013)

05/07/2013

741 Minute Entry for proceedings held before US Magistrate Judge George W Cannon: Status Conference held on 5/7/2013. (CB) (Entered: 05/07/2013)

05/14/2013

742 ORDER (WAL) dated 5­14­13 GRANTING the parties' "Joint Motion to Enter Consent Judgment" (Dkt. No. 689), ACCEPTING the parties' Settlement Agreement (Dkt. No. 689­1), and ENTERING the Settlement Agreement as an Order of the Court. (DGP) (Entered: 05/14/2013)

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05/14/2013 05/14/2013
05/16/2013
05/17/2013
05/17/2013 06/13/2013 06/13/2013 06/14/2013 06/14/2013 06/19/2013 07/01/2013 07/08/2013 07/26/2013 11/04/2013 12/03/2013

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743 ORDER (WAL) dated 5­14­13 DENYING Defendants' "Motion to Terminate Prospective Relief" (Dkt. No. 565) and deeming WITHDRAWN Dkt. Nos. 541, 589, 610, 616, 670, and 671. (DGP) (Entered: 05/14/2013)
744 ORDER (WAL) dated 5­14­13. UPON CONSIDERATION of "Defendants' Recommendation for the Appointment of a Monitor" (Dkt. No. 731) and "United States' Memorandum Recommending Monitor Nominees" (Dkt. No. 732), it is hereby ORDERED that an oral argument will be held on June 6, 2013 at 1:30 p.m. at which the parties should be prepared to address their respective positions regarding the appointment of a Monitor. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 05/14/2013)
ORDER (WAL) dated 5­16­13. At the request of the parties, a telephonic status conference will be held on May 17, 2013 at 2:00 p.m. to reschedule the oral argument on the selection of a Monitor that is currently scheduled for June 6, 2013. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 05/16/2013)
745 ORDER (WAL) dated 5­17­13. UPON CONSIDERATION of the colloquy conducted during the May 17, 2013 telephonic status conference regarding counsel's availability for oral argument, it is hereby ORDERED that the oral argument on the selection of a Monitor that is currently scheduled for June 6, 2013 is RESCHEDULED to June 19, 2013 at 1:00 p.m. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 05/17/2013)
746 Minute Entry Telephonic Status Conference held on 5/17/2013 before District Judge Wilma A Lewis. (Court Reporter V. Lawrence.) (MB) (Entered: 05/28/2013)
747 NOTICE of Joint Recommendation for the Appointment of a Monitor by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 06/13/2013)
748 Joint MOTION to Vacate Oral Argument by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 06/13/2013)
749 ORDER (WAL) dated 6­14­13 GRANTING the parties' "Joint Motion to Vacate Oral Argument" (Dkt. No. 748) and CANCELLING the Oral Argument previously scheduled for June 19, 2013. (DGP) (Entered: 06/14/2013)
The Oral Argument previously scheduled for June 19, 2013 at 1:00 p.m. is cancelled. (WAL) dated 6­14­13 (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (DGP) (Entered: 06/14/2013)
750 ORDER (WAL) dated 6­19­13 APPROVING the parties' joint selection of Kenneth A. Ray to serve as Monitor. (DGP) (Entered: 06/19/2013)
751 MOTION to Withdraw as Attorney by Richard S. Walinski by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 07/01/2013)
752 ORDER (GWC) dated 07/08/2013granting 751 Motion to Withdraw as Attorney. Attorney Richard S Walinski terminated (NH) (Entered: 07/08/2013)
753 NOTICE of Change of Address by Nathan T Oswald (Oswald, Nathan) (Entered: 07/26/2013)
754 ORDER (WAL) dated 11/4/2013 regarding the Monitor's reporting responsibilities. (KBD) (Entered: 11/04/2013)
755 STATUS REPORT MONITORS BASELINE COMPLIANCE ASSESSMENT REPORT by

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12/04/2013 12/06/2013 12/09/2013 01/07/2014 01/08/2014 01/08/2014 01/09/2014 01/14/2014
01/15/2014 01/17/2014 02/04/2014 02/18/2014 02/19/2014
02/19/2014 02/20/2014 02/24/2014

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United States of America. (Lareau, Alyssa) (Entered: 12/03/2013)
756 AMENDED DOCUMENT by United States of America. Amendment to 755 Status Report . (Attachments: # 1 Appendix Revised Monitors Baseline Compliance Assessment Report) (Lareau, Alyssa) (Entered: 12/04/2013)
757 ORDER (WAL) dated 12/6/2013 regarding the Monitor's next report. (KBD) (Entered: 12/06/2013)
758 THIRD CIRCUIT HEARING scheduled for December 9, 2013 before Judges Fisher, Cowen and Nygaard. (NH) (Entered: 12/09/2013)
759 STRIKEN BY ORDER DATED 01/09/2014,DOCUMENT NO. 762 Modified on 1/10/2014 (Thomas, Theresa). (Entered: 01/07/2014)
760 MOTION to Withdraw 759 Notice (Other) by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 01/08/2014)
761 Opposition to Motion re 760 MOTION to Withdraw 759 Notice (Other) filed by Plaintiff United States of America. (Attachments: # 1 Exhibit A) (Lareau, Alyssa) (Entered: 01/08/2014)
762 ORDER (WAL) dated 1/9/2014 granting 760 Defendants' Motion to Withdraw and ordering the Clerk of Court to strike documents number 759 and 759­1 from the record. (KBD) (Entered: 01/09/2014)
763 ORDER (WAL) dated 1/14/2014 vacating 757 December 6, 2013 Order; setting new deadlines for Monitor's next report; and scheduling a status conference in this matter for 3/19/2014 10:00 a.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (KBD) (Entered: 01/14/2014)
764 NOTICE of Filing Defendants' Status Report of January 15, 2014 by Territory of The Virgin Islands (Attachments: # 1 Exhibit Defendants' status report of Jan. 15, 2014) (Oswald, Nathan) (Entered: 01/15/2014)
Set/Reset Hearings: Status Conference set for 3/19/2014 10:00 AM in STX Courtroom 1 before Chief Judge Wilma A Lewis. (TNS) (Entered: 01/17/2014)
765 NOTICE of Appearance for Sharon Brett by United States of America (Lareau, Alyssa) (Entered: 02/04/2014)
766 NOTICE and Request for Emergency Telephonic Status Conference by United States of America (Lareau, Alyssa) (Entered: 02/18/2014)
767 ORDER (WAL) dated 2/19/2014 granting the United States' request for an emergency telephonic status conference; setting a telephonic status conference for 2:00 p.m. (Atlantic Standard Time) on February 20, 2014; and requiring Defendants to file a response to the issue regarding the Monitor's compensation no later than 5:00 p.m., today, February 19, 2014. (KBD) (Entered: 02/19/2014)
768 NOTICE of Response to Request for Emergency Telephonic Conference by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 02/19/2014)
769 Minute Entry for proceedings held before Chief Judge Wilma A Lewis: Status Conference held on 2/20/2014. (Court Reporter V. Lawrence.) (MB) (Entered: 02/21/2014)
770 ORDER (WAL) dated 2/24/2014 pertaining to the status conference in this matter scheduled for March 19, 2014. (KBD) (Entered: 02/24/2014)

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02/25/2014 02/25/2014 02/28/2014 03/03/2014 03/03/2014 03/03/2014
03/03/2014
03/03/2014 03/05/2014 03/05/2014 03/07/2014 03/07/2014 03/07/2014 03/07/2014

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771 Consent MOTION to File Exhibits Conventionally and Under Seal by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Lareau, Alyssa) (Entered: 02/25/2014)
772 Consent MOTION for Leave to File Excess Pages by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Lareau, Alyssa) (Entered: 02/25/2014)
773 MOTION for Release of Funds by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 02/28/2014)
774 ORDER (GWC) dated 3/3/2014 granting 773 Motion for Release of Funds. (CB) (Entered: 03/03/2014)
775 ORDER (WAL) dated 3/3/2014 granting the United States' 771 "Consent Motion to File Exhibits Conventionally and Under Seal." (KBD) (Entered: 03/03/2014)
776 ORDER (WAL) dated 3/3/2014. UPON CONSIDERATION of the United States' 772 "Consent Motion to Exceed Page Limitations," which requests leave pursuant to Local Rule 7.1(d) to file its forthcoming "Motion for Enforcement of this Court's May 14, 2014 Order Adopting the Parties' Settlement Agreement and for More Specific Orders Implementing That Agreement" in excess of twenty pages, specifically forty­six pages, and further advises the Court that Defendants consent to the United States' request, it is hereby ORDERED that the United States' Motion is GRANTED; and it is further ORDERED that the United States is allotted forty­six pages for its "Motion for Enforcement of this Courts May 14, 2014 Order Adopting the Parties' Settlement Agreement and for More Specific Orders Implementing That Agreement." (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 03/03/2014)
777 MOTION for Enforcement of this Court's May 14, 2013 Order Adopting the Parties' Settlement Agreement and for More Specific Orders Implementing that Agreement by Plaintiff United States of America. (Attachments: # 1 Exhibit A­N (filed under seal)) (Lareau, Alyssa) (Entered: 03/03/2014)
778 ORDER (WAL) dated 3/3/2014 setting a telephonic status conference for 2:00 p.m. (Atlantic Standard Time) on March 7, 2014. (KBD) (Entered: 03/03/2014)
779 ORDER (WAL) dated 3/5/2014 re: March 7, 2014 status conference. (RDB) (Entered: 03/05/2014)
810 Sealed Document by United States of America, received in clerks Office re docket #777 pursuant to order entered on 3/3/2014 exhibit A­N received. (MB) (Entered: 05/01/2014)
780 MOTION for Extension of Time to File Response/Reply to Plaintiff's motion for enforcement by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 03/07/2014)
781 ORDER (WAL) dated 3/7/2014 granting Defendants' 780 "Motion for Enlargement of Time," setting deadlines, scheduling a hearing and status conference, and further advising parties. (KBD) (Entered: 03/07/2014)
782 ORDER (WAL) dated 3/7/2014 cancelling 3/19/2014 status conference. (KBD) (Entered: 03/07/2014)
783 ORDER (WAL) dated 3/7/2014 setting pre­hearing telephonic status conference for 2:00 p.m. on April 24, 2014. (See Dkt. No. 781) (KBD) (Entered: 03/07/2014)

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03/07/2014 03/07/2014 03/17/2014 03/21/2014 03/24/2014
03/24/2014
03/27/2014 03/31/2014 03/31/2014
04/01/2014 04/17/2014 04/17/2014 04/21/2014

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784 ORDER (WAL) dated 3/7/2014 setting hearing and status conference for 9:30 a.m. on April 28, 2014, to proceed from day to day until completed. (See Dkt. No. 781) (KBD) (Entered: 03/07/2014)
785 Minute Entry for proceedings held before Chief Judge Wilma A Lewis: Status Conference held on 3/7/2014. (Court Reporter V. Lawrence.) (MB) (Entered: 03/12/2014)
786 STATUS REPORT Second Compliance Monitoring Report by Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 03/17/2014)
787 MOTION for Leave to File Excess Pages for its response to Plaintiff's Motion for Enforcement [Dkt. No. 777] by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 03/21/2014)
788 ORDER (WAL) dated 3/24/2014. UPON CONSIDERATION of Defendants' unopposed 787 Motion for Leave to File Excess Pages, which requests leave pursuant to Local Rule 7.1(d) for five extra pages for their response to Plaintiff's 777 Motion for Enforcement, it is hereby ORDERED that Defendants' Motion is GRANTED; and it is further ORDERED that Defendants may file a response that is twenty­five pages long. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 03/24/2014)
789 Opposition to Motion re 777 MOTION for Enforcement of this Court's May 14, 2013 Order Adopting the Parties' Settlement Agreement and for More Specific Orders Implementing that Agreement filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Exhibits A­G) (Oswald, Nathan) (Entered: 03/24/2014)
790 MOTION for Leave to File Exhibit to Reply Brief Conventionally and Under Seal (Unopposed) by Plaintiff United States of America. (Attachments: # 1 Text of Proposed Order) (Brett, Sharon) (Entered: 03/27/2014)
791 ORDER (WAL) dated 3/31/2014 granting the United States' 790 "Unopposed Motion to File Exhibit Conventionally and Under Seal." (KBD) (Entered: 03/31/2014)
792 REPLY to Opposition to Motion re 789 Opposition to Motion, 777 MOTION for Enforcement of this Court's May 14, 2013 Order Adopting the Parties' Settlement Agreement and for More Specific Orders Implementing that Agreement filed by Plaintiff United States of America. (Attachments: # 1 Exhibit Cover Page, # 2 Exhibit A, # 3 Exhibit B, # 4 Exhibit C, # 5 Exhibit D (filed under seal), # 6 Exhibit E) (Lareau, Alyssa) (Entered: 03/31/2014)
809 Sealed Document by United States of America, received in clerks Office re exhibit D, order entered on 3/31/2014 docket #791 by the court. (MB) (Entered: 05/01/2014)
793 MOTION for Extension of Time to File Monitor's Third Compliance Report by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 04/17/2014)
794 Response re 793 MOTION for Extension of Time to File Monitor's Third Compliance Report filed by Plaintiff United States of America. (Brett, Sharon) (Entered: 04/17/2014)
795 ORDER (WAL) dated 4/21/2014. UPON CONSIDERATION of Defendants' 793 "Motion for Enlargement of Time for Filing Monitor's Third Compliance Report," filed on behalf of the Monitor, Kenneth A. Ray, and requesting a two­day extension until April 23, 2014 for the Monitor to file his Third Compliance Report, and the United States' 794 "Response to Defendants' Motion for Enlargement of Time," it is hereby

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ORDERED that Defendants' Motion is GRANTED; and it is further ORDERED that in light of the pre­hearing telephonic conference set for April 24, 2014, the Monitor shall file his Third Compliance Report no later than 12:00 p.m. Eastern Standard Time (noon) on April 23, 2014. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 04/21/2014)

04/21/2014

796 NOTICE PROPOSED WITNESS LIST AND SUPPLEMENTAL DOCUMENT LIST FOR APRIL 28, 2014 HEARING by United States of America (Brett, Sharon) (Entered: 04/21/2014)

04/21/2014

797 NOTICE Defendants List of Documents Not Previously Provided and Witness List for April 28, 2014 Hearing by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 04/21/2014)

04/23/2014

798 STATUS REPORT Third Compliance Monitoring Report by United States of America. (Brett, Sharon) (Entered: 04/23/2014)

04/24/2014

799 ORDER (WAL) dated 4/24/2014 memorializing the deadlines set at the April 24, 2014 pre­hearing conference. (KBD) (Entered: 04/24/2014)

04/24/2014

805 Minute Entry for proceedings held before Chief Judge Wilma A Lewis: Status Conference held on 4/24/2014. (Court Reporter V. Lawrence.) (MB) (Entered: 04/29/2014)

04/25/2014

800 NOTICE Monitor's Adopted Implementation Schedule by United States of America (filed on behalf of the Monitor) (Brett, Sharon) (Entered: 04/25/2014)

04/26/2014

801 NOTICE Response to Monitor's Adopted Implementation Schedule by United States of America re 800 Notice (Other) (Brett, Sharon) (Entered: 04/26/2014)

04/26/2014

802 MOTION in Limine by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 04/26/2014)

04/26/2014

803 NOTICE Notice of Acceptance of Monitors Adopted Implementation Schedule by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 04/26/2014)

04/27/2014

804 REPLY to re 802 MOTION in Limine filed by Defendant Territory of The Virgin Islands filed by Plaintiff United States of America. Responses due by 5/12/2014 (Lareau, Alyssa) (Entered: 04/27/2014)

04/28/2014

806 Minute Entry for proceedings held before Chief Judge Wilma A Lewis: Status Conference held on 4/28/2014. (Court Reporter V. Lawrence.) (MB) (MB). (Entered: 04/29/2014)

04/30/2014

807 ORDER (WAL) dated 4/30/2014. UPON CONSIDERATION of the United States' 777 "Motion for Enforcement of this Courts May 14, 2014 Order Adopting the Parties' Settlement Agreement and for More Specific Orders Implementing That Agreement," and the United States' 801 "Response to Monitor's Adopted Implementation Schedule," in which the United States noted that "because the Monitor's Adopted Implementation Schedule sufficiently addresses the relief requested in the United States' [Motion for Enforcement], the United States will withdraw its Motion without prejudice," it is hereby ORDERED that the United States' withdrawal of its Motion for Enforcement is ACCEPTED; and it is further ORDERED that the United States' 777 Motion for Enforcement is WITHDRAWN WITHOUT PREJUDICE. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 04/30/2014)

04/30/2014

808 ORDER (WAL) dated 4/30/2014 setting various deadlines pertaining to Defendants' status reports and the Monitor's next report, and setting a status conference for 9:30 a.m.

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05/09/2014
05/09/2014 05/12/2014
05/12/2014
05/16/2014 05/16/2014 05/20/2014
05/20/2014

District Court CM/ECF ­ LIVE
on September 25, 2014 in STX Courtroom 1 before Chief Judge Wilma A Lewis. (KBD) (Entered: 04/30/2014)
811 MOTION to Intervene by Intervenor Ronald Edward Gillette. (DiRuzzo, Joseph) (Entered: 05/04/2014)
812 MEMORANDUM in Support re 811 MOTION to Intervene filed by Intervenor Ronald Edward Gillette. (DiRuzzo, Joseph) (Entered: 05/04/2014)
813 NOTICE and Request for Emergency Status Conference by United States of America (Brett, Sharon) (Entered: 05/08/2014)
814 ORDER (WAL) dated 5/8/2014 requiring Defendants to file a Response to the United States' 813 "Notice and Request for Emergency Telephonic Status Conference" no later than 5:00 p.m. on May 9, 2014. (KBD) (Entered: 05/08/2014)
815 Response re 802 MOTION in Limine filed by Defendant Territory of The Virgin Islands. (Chinnery, Aquannette) (Entered: 05/09/2014)
816 NOTICE of Filing by Territory of The Virgin Islands in Response to Notice and Request for Emergency Telephonic Status Conference (Amended Response) (Attachments: # 1 Exhibit Monitor's Contract, # 2 Exhibit Approved Budget, # 3 Exhibit Check for April and May invoices, # 4 Exhibit Express Mail receipt) (Chinnery, Aquannette) (Entered: 05/09/2014)
817 NOTICE of Filing by Territory of The Virgin Islands Amended Notice of Filing and Second Amended Response to Notice and Request for Emergency Telephonic Status Conference (Attachments: # 1 Exhibit Monitor's Contract, # 2 Exhibit Approved Budget, # 3 Exhibit Check for April and May invoices, # 4 Exhibit Express Mail receipt) (Chinnery, Aquannette) (Entered: 05/09/2014)
818 NOTICE Monitor's Revised Adopted Implementation Schedule and Work Plan by Territory of The Virgin Islands (Oswald, Nathan) (Entered: 05/09/2014)
Documents #819 thru 822 were removed from the docket they were duplicated documents that were filed by counsel because they were instucted to refile which were not necessary. Document # 817 is the corrected document to docket #816 and the certificate of service is correct in docket 817. (MB) (Entered: 05/12/2014)
819 ORDER (WAL) dated 5/12/2014 granting the Monitor's request for a telephonic status conference and setting a telephonic status conference set for 1:00 p.m. Eastern Standard Time on May 27, 2014. Local counsel are ordered to appear in person. The Courtroom Deputy will contact outside counsel and Mr. Ray with the call­in information for the conference call. (KBD) (Entered: 05/12/2014)
820 NOTICE of Filing Defendants' Status Report Dated May 15, 2014 by Territory of The Virgin Islands (Attachments: # 1 Exhibit A Status Report dated May 15, 2014) (Chinnery, Aquannette) (Entered: 05/16/2014)
Status Conference set for 9/25/2014 09:30 AM in STX Courtroom 1 before Chief Judge Wilma A Lewis. (MB) (Entered: 05/16/2014)
Telephone Status Conference set for 5/27/2014 01:00 PM in STX Courtroom 1. Local counsels are ordered to appear in person. The Courtroom Deputy will contact outside counsels and Mr. Ray with the call­in information for the conference call before Chief Judge Wilma A Lewis. (MB) (Entered: 05/20/2014)
821 Opposition to Motion re 811 MOTION to Intervene filed by Defendant Territory of The Virgin Islands. (Robertson, Kenrick) (Entered: 05/20/2014)

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05/21/2014 05/21/2014
05/27/2014 05/27/2014
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06/06/2014 06/06/2014 06/13/2014 07/10/2014 08/13/2014

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822 NOTICE of Appearance and Substitution of Counsel by United States of America (Brett, Sharon) (Entered: 05/21/2014)
823 ORDER (WAL) dated 5/21/2014. UPON CONSIDERATION of Defendants' 821 "Motion for Extension of Time to File Response for Intervention," in which Defendants request an extension until May 30, 2014 to file their Response to Ronald Gillette's 811 Motion to Intervene, it is hereby ORDERED that Defendants' Motion is GRANTED; and it is further ORDERED that Defendants shall file their Response to Ronald Gillette's 811 Motion to Intervene no later than May 30, 2014. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 05/21/2014)
824 MOTION for Leave to Appear Telephonically by Defendant Territory of The Virgin Islands. (Robertson, Kenrick) (Entered: 05/27/2014)
825 ORDER (WAL) dated 5/27/2014. UPON CONSIDERATION of Defendants' 824 "Motion to Attend Tuesday May 27, 2014 Status Conference Telephonically," it is hereby ORDERED that Defendants' Motion is GRANTED; and it is further ORDERED that Bureau of Corrections Director, Julius Wilson, may attend the May 27, 2014 status conference telephonically. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 05/27/2014)
826 Minute Entry for proceedings held before Chief Judge Wilma A Lewis: Status Conference held on 5/27/2014. (Court Reporter V. Lawrence.) (MB) (Entered: 05/28/2014)
827 Opposition to Motion re 811 MOTION to Intervene filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 05/30/2014)
828 MANDATE as to 694 Notice of Appeal filed by Ronald Edward Gillette (Attachments: # 1 CA Opinion, # 2 CA Judgment) Ordered that the order of the District Court entered November 7, 2012 is AFFIRMED. (NH) (Entered: 06/02/2014)
829 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 4/28/14, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­712­7112. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 6/30/2014. Redacted Transcript Deadline set for 7/10/2014. Release of Transcript Restriction set for 9/8/2014. (Lawrence, Valerie) (Entered: 06/05/2014)
830 ORDER (WAL) dated 6/6/2014 denying the Monitor's request for the establishment of an escrow account and ordering Defendants to pay the Monitor's monthly invoices within thirty days of receipt or be subject to sanctions. (KBD) (Entered: 06/06/2014)
831 MEMORANDUM OPINION (WAL) dated 6/6/2014 denying the Monitor's request for the establishment of an escrow account and ordering Defendants to pay the Monitor's monthly invoices within thirty days of receipt or be subject to sanctions. (KBD) (Entered: 06/06/2014)
832 REPLY to Opposition to Motion re 827 Opposition to Motion filed by Intervenor Ronald Edward Gillette. (DiRuzzo, Joseph) (Entered: 06/13/2014)
Set Hearings: Scheduling Conference set for 9/25/2014 09:30 AM in STX Courtroom 1 before Chief Judge Wilma A Lewis. (CBF) (Entered: 07/10/2014)
833 MOTION for Order to Show Cause and for Expedited Briefing by Plaintiff United States of America. (Attachments: # 1 Exhibit, # 2 Exhibit) (Brett, Sharon) (Entered:

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08/15/2014 08/18/2014 08/18/2014 08/19/2014
08/19/2014
08/27/2014 08/28/2014 08/28/2014
09/01/2014 09/02/2014 09/04/2014 09/09/2014 09/12/2014

08/13/2014)

District Court CM/ECF ­ LIVE

834 Response re 833 MOTION for Order to Show Cause and for Expedited Briefing ­ Response to request for expedited briefing filed by Defendant Territory of The Virgin Islands. (Oswald, Nathan) (Entered: 08/15/2014)

835 Consent MOTION for Leave to File Excess Pages by Plaintiff United States of America. (Brett, Sharon) (Entered: 08/18/2014)

836 NOTICE ERRATA by United States of America re 833 MOTION for Order to Show Cause and for Expedited Briefing (Attachments: # 1 Exhibit 2 to ECF No. 833) (Brett, Sharon) (Entered: 08/18/2014)

837 ORDER (WAL) dated 8/19/2014 granting in part, denying in part, and deferring in part the United States' 833 "Motion for an Order to Show Cause Why Defendants Should Not be Held in Civil Contempt of Court and Request for Expedited Briefing," and setting a hearing for September 25, 2014 at 9:30 a.m. (KBD) (Entered: 08/19/2014)

838 ORDER (WAL) dated 8/19/2014. UPON CONSIDERATION of the United States' 835 "Consent Motion to Exceed Page Limitations," which requested an additional five pages for its "Motion for an Order to Show Cause Why Defendants Should Not Be Held in Civil Contempt of Court and Request for Expedited Briefing," it is hereby ORDERED that the United States' Motion for excess pages is GRANTED nunc pro tunc. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 08/19/2014)

839 Response re 833 MOTION for Order to Show Cause and for Expedited Briefing filed by Defendant Territory of The Virgin Islands. (James, Raymond) (Entered: 08/27/2014)

840 Response re 833 MOTION for Order to Show Cause and for Expedited Briefing filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit A) (Chinnery, Aquannette) (Entered: 08/28/2014)

841 MOTION for Leave to File /MOTION FOR LEAVE TO REFILE DEFENDANTS RESPONSE TO MOTION FOR AN ORDER TO SHOW CAUSE WHY DEFENDANTS SHOULD NOT BE HELD IN CIVIL CONTEMPT OF COURT by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting Motion to Refile) (Chinnery, Aquannette) (Entered: 08/28/2014)

842 MOTION to Withdraw as Attorney by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (Oswald, Nathan) (Entered: 09/01/2014)

843 NOTICE Fourth Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) (Brett, Sharon) (Entered: 09/02/2014)

844 ORDER (GWC) dated 9/4/2014 granting 842 Motion to Withdraw as Attorney. Attorney Nathan T Oswald terminated. (CB) (Entered: 09/04/2014)

845 REPLY to Opposition to Motion re 833 MOTION for Order to Show Cause and for Expedited Briefing filed by Plaintiff United States of America. (Attachments: # 1 Exhibit) (Brett, Sharon) (Entered: 09/09/2014)

846 ORDER (WAL) dated 9/12/2014. UPON CONSIDERATION of Defendants' 841 "Motion to Refile Defendants' Response to Motion for an Order to Show Cause Why Defendants Should Not be Held in Civil Contempt of Court," it here hereby ORDERED that Defendants' Motion is GRANTED nunc pro tunc; and it is further ORDERED that Defendants' Motion is ACCEPTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 09/12/2014)

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09/17/2014
09/17/2014 09/17/2014 09/24/2014 09/25/2014 09/25/2014 09/25/2014 09/30/2014

District Court CM/ECF ­ LIVE
847 MOTION to Withdraw Defendants' Response to Motion for an Order to Show Cause why Defendants' should not be held in Civil Contempt of Court by Defendant Territory of The Virgin Islands. (James, Raymond) (Entered: 09/12/2014)
848 MOTION for Extension of Time to File semi­annual impact statement out of time by Defendant Territory of The Virgin Islands. (Robertson, Kenrick) (Entered: 09/16/2014)
849 STATUS REPORT semi­annual impact evaluation by Territory of The Virgin Islands. (Robertson, Kenrick) (Entered: 09/16/2014)
850 ORDER (WAL) dated 9/17/2014. UPON CONSIDERATION of Defendants' 847 "Motion to Withdraw," which seeks to withdraw their initial filing of their 839 "Response to Motion for an Order to Show Cause Why Defendants Should Not be Held in Contempt of Court," because it was erroneously filed under the wrong attorney's CM/ECF account, it is hereby ORDERED that Defendants' Motion is GRANTED; and it is further ORDERED that Defendants' 839 "Response to Motion for an Order to Show Cause Why Defendants Should Not be Held in Contempt of Court" is WITHDRAWN. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 09/17/2014)
851 ORDER (WAL) dated 9/17/2014. ORDER (WAL) dated 9/17/2014. UPON CONSIDERATION of Defendants' 848 "Motion to File Semi­Annual Impact Statement Out of Time," which requests that the Court accept Defendants' 849 Semi­Annual Impact Statement one day late because of Defendants' difficulty accessing the CM/ECF system, it is hereby ORDERED that Defendants' Motion is GRANTED nunc pro tunc; and it is further ORDERED that Defendants' 849 Semi­Annual Impact Evaluation is ACCEPTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 09/17/2014)
852 SCHEDULING ORDER:( Status Conference set for 9/25/2014 09:30 AM in STX Courtroom 1 before Chief Judge Wilma A Lewis.)(WAL) dated 09/17/2014(This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (NH) (Entered: 09/17/2014)
NOTICE of Hearing: (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) Show Cause Hearing set for 9/25/2014 09:30 AM in STX Courtroom 1 before Chief Judge Wilma A Lewis. (NH) (Entered: 09/17/2014)
853 STIPULATION Joint Motion for Entry of Stipulated Order by Territory of The Virgin Islands, United States of America. (Attachments: # 1 Text of Proposed Order Stipulated Order) (Brett, Sharon) (Entered: 09/24/2014)
854 ORDER (WAL) dated 9/25/2014 granting the parties' 853 "Joint Motion for Entry of Stipulated Order"; ordering additional remedial relief; and ordering the United States' 833 "Motion for an Order to Show Cause Why Defendants Should Not be Held in Civil Contempt of Court" withdrawn without prejudice. (KBD) (Entered: 09/25/2014)
855 ORDER (WAL) dated 9/25/2014 setting telephonic status conference for 1:00 p.m. on September 30, 2014. (KBD) (Entered: 09/25/2014)
856 Minute Entry for proceedings held before Chief Judge Wilma A Lewis: Status Conference held on 9/25/2014. (Court Reporter V. Lawrence.) (TNS) (Entered: 09/25/2014)
857 ORDER (WAL) dated 9/30/2014 continuing the September 30, 2014 telephonic status conference from 1:00 p.m. to 4:00 p.m. in STX Courtroom 1 before Chief Judge Wilma A Lewis. Counsel for both parties and the Monitor shall participate in thetelephonic status conference. The Courtroom Deputy will contact counsel and Mr. Ray with the

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District Court CM/ECF ­ LIVE
call­in information for the conference call. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KBD) (Entered: 09/30/2014)
858 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Telephone Conference held on 10/1/2014. (Court Reporter V. Lawrence.) (TNS) (Entered: 10/01/2014)
859 ORDER (WAL) dated 10/6/2014. Setting deadlines for Monitor's fifth report; Defendants' fourth status report; and setting status conference for December 10, 2014 at 1:30 P.M. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RDB) (Entered: 10/06/2014)
860 STATUS REPORT by Territory of The Virgin Islands. (Robertson, Kenrick) (Entered: 10/15/2014)
861 STATUS REPORT /MONITOR'S SCHEDULE by Territory of The Virgin Islands. (Robertson, Kenrick) (Entered: 10/17/2014)
862 NOTICE of Appearance by Shari N D'Andrade on behalf of Defendant Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 10/28/2014)
863 MOTION to Amend/Correct Monitoring Schedule by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit Revised Monitoring Schedule effective 10/17/14, # 2 Text of Proposed Order) (D'Andrade, Shari) (Entered: 10/29/2014)
864 NOTICE of Appearance by Sharon Brett on behalf of Plaintiff United States of America (Brett, Sharon) (Entered: 11/12/2014)
865 NOTICE Request for Emergency Status Conference by Kenneth Ray (filed on behalf of the Monitor) (Brett, Sharon) (Entered: 11/13/2014)
866 ORDER TO SHOW CAUSE (WAL) dated 11/13/2014 regarding the United States' 865 "Notice and Request for Emergency Telephonic Status Conference." (RET) (Entered: 11/13/2014)
867 Response re 865 Notice (Other) and Request for Emergency Telephonic Status Conference filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit A, # 2 Exhibit B) (D'Andrade, Shari) (Entered: 11/17/2014)
868 ORDER (WAL) dated 11/24/2014 setting Show Cause Hearing for December 10, 2014 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 11/24/2014)
869 NOTICE Monitor's 5th Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) (Brett, Sharon) (Entered: 11/29/2014)
870 NOTICE of Filing Defendants' Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C) (D'Andrade, Shari) (Entered: 12/05/2014)
871 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Show Cause Hearing and Status Conference on 12/10/2014. (Court Reporter V. Lawrence.) (MB) (Entered: 12/11/2014)
872 NOTICE of Monitor's Next Scheduled Onsite Compliance Assessment by United States of America (Myrthil, Marlysha) (Entered: 12/16/2014)
873 ORDER (WAL) dated 12/17/2014 granting Defendants' 863 Motion to File Revised Monitoring Schedule. (RET) (Entered: 12/17/2014)

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01/22/2015 02/10/2015 02/11/2015
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04/10/2015

District Court CM/ECF ­ LIVE
874 MEMORANDUM OPINION (WAL) dated 12/30/2014 finding Defendants in contempt of the Court's 830 June 6, 2014 Order. (RET) (Entered: 12/30/2014)
875 ORDER (WAL) dated 12/30/2014 finding Defendants in contempt of the Court's 830 June 6, 2014 Order. (RET) (Entered: 12/30/2014)
876 ORDER (WAL) dated 1/6/2015. Setting deadlines for Monitor's sixth report; Defendants' fifth status report; and setting status conference for March 5, 2015 at 1:30 P.M. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 01/06/2015)
877 Court Sanction paid Receipt # 100005286 as per order 875 (TNS) (Entered: 01/22/2015)
878 ORDER (WAL) dated 2/10/2015 sealing sidebar discussion at the December 10, 2014 Status Conference. (RET) (Entered: 02/10/2015)
879 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 12/10/14, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 3/9/2015. Redacted Transcript Deadline set for 3/19/2015. Release of Transcript Restriction set for 5/15/2015. (Lawrence, Valerie) (Entered: 02/11/2015)
880 NOTICE Monitor's 6th Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) (Myrthil, Marlysha) (Entered: 02/18/2015)
881 NOTICE of Filing Defendants' Fifth Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C) (D'Andrade, Shari) (Entered: 02/26/2015)
882 ORDER (WAL) dated 3/10/2015 setting deadlines for Defendants' Notice to the Court; the Monitor's seventh report; Defendants' sixth status report; and setting status conference for June 11, 2015 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 03/10/2015)
883 NOTICE of Filing of Response to Order of the Court Dated March 10, 2015 by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 03/17/2015)
884 ORDER (WAL) dated 3/25/2015 requiring Defendants to file a Notice with the Court no later than April 21, 2015. (RET) (Entered: 03/25/2015)
885 ORDER (WAL) dated 3/27/2015 denying as moot Defendants' 802 "Motion in Limine to Exclude Evidence at the Hearing of April 28, 2014." (RET) (Entered: 03/27/2015)
886 NOTICE supplmental authority by Ronald Edward Gillette re 811 MOTION to Intervene , 812 Memorandum in Support to Motion (DiRuzzo, Joseph) (Entered: 04/07/2015)
887 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 3/5/2015, before Chief Judge Wilma A. Lewis. Court Reporter/Transcriber SANDRA HALL, RMR, Telephone number (340) 778­9750 Ext. 6609. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Redaction Request due 5/4/2015. Redacted Transcript Deadline set for 5/14/2015. Release of Transcript Restriction set for 7/13/2015. (MB) (Main Document 887 replaced on 4/10/2015) (MB). Modified on 4/10/2015 (MB). (Entered: 04/09/2015)
888 NOTICE of Objections and Request for Emergency Status Conference by United States

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04/10/2015 04/13/2015 04/13/2015 04/13/2015
04/13/2015
04/13/2015
04/15/2015 04/15/2015 04/15/2015 04/15/2015
04/17/2015 04/20/2015

District Court CM/ECF ­ LIVE
of America (Attachments: # 1 Exhibit S, # 2 Exhibit T, # 3 Exhibit U, # 4 Exhibit V) (Myrthil, Marlysha) (Entered: 04/10/2015)
889 MOTION for leave to File Document Under Seal by Plaintiff United States of America. (Myrthil, Marlysha) (Entered: 04/10/2015)
890 NOTICE of Filing Proposed Order by United States of America re 889 MOTION for leave to File Document Under Seal (Attachments: # 1 Proposed Order) (Lomio, Rita) (Entered: 04/13/2015)
891 NOTICE of Filing Proposed Order by United States of America re 888 Notice (Other) of Objections and Request for Emergency Status Conference (Attachments: # 1 Proposed Order) (Lomio, Rita) (Entered: 04/13/2015)
892 ORDER (WAL) dated 4/13/2015. UPON CONSIDERATION of the United States' 889 "Motion for Leave to File Under Seal Selected Exhibits to its Notice of Objections and Request for Emergency Status Conference," it is hereby ORDERED that the Motion is GRANTED; and it is further ORDERED that the United States shall file Exhibits A­R under seal. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 04/13/2015)
893 Sealed Document Exhibit A by United States of America. (Attachments: # 1 Exhibit B, # 2 Exhibit Exhibit C, # 3 Exhibit Exhibit D, # 4 Exhibit Exhibit E, # 5 Exhibit F, # 6 Exhibit G, # 7 Exhibit H, # 8 Exhibit I, # 9 Exhibit J, # 10 Exhibit K, # 11 Exhibit L, # 12 Exhibit M, # 13 Exhibit N, # 14 Exhibit O, # 15 Exhibit P, # 16 Exhibit Q, # 17 Exhibit R) (MB) (Entered: 04/13/2015)
894 ORDER (WAL) dated 4/13/2015 requiring Defendants to file a Response to the United States' 888 "Notice of Objections and Request for Emergency Status Conference" by 10:00 a.m. on April 15, 2015 and setting Status Conference for April 16, 2015 at 10:00 a.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 04/13/2015)
895 Response re 888 Notice (Other) filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3) (D'Andrade, Shari) (Entered: 04/15/2015)
896 MOTION for Extension of Time to File Response/Reply Nunc Pro Tunc by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 04/15/2015)
897 ORDER (WAL) dated 4/15/2015 continuing hearing on the United States' 888 "Notice of Objections and Request for Emergency Status Conference" from April 16, 2015 at 10:00 a.m. to April 17, 2015 at 2:00 p.m. (RET) (Entered: 04/15/2015)
898 ORDER (WAL) dated 4/15/2015. UPON CONSIDERATION of Defendants' 896 "Motion for Brief Extension of Time to Comply with Court's Order Nunc Pro Tunc," it is hereby ORDERED that the Motion is GRANTED; and it is further ORDERED that Defendants' 895 Response to the United States' 888 Notice is ACCEPTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 04/15/2015)
904 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 4/17/2015. (Court Reporter V.Lawrence.) (MB) (MB). (Entered: 05/05/2015)
899 ORDER (WAL) dated 4/20/2015 memorializing the deadlines set at the April 17, 2015 hearing. (RET) (Entered: 04/20/2015)

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05/08/2015 05/26/2015 05/30/2015 06/01/2015
06/01/2015 06/03/2015
06/03/2015

District Court CM/ECF ­ LIVE
900 AMENDED ORDER (WAL) dated 4/20/2015 setting status conference for June 11, 2015 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 04/20/2015)
901 NOTICE of Filing of Response to Order of the Court dated March 25, 2015 by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 04/21/2015)
902 ORDER (WAL) dated 4/22/2015 requiring Defendants to file a Notice with the Court. (RET) (Entered: 04/22/2015)
903 NOTICE of Filing by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 05/01/2015)
905 MOTION Brief Extension of Time To Submit Monitor's Seventh Report to the Parties by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 05/05/2015)
906 ORDER (WAL) dated 5/5/2015. UPON CONSIDERATION of Defendants' 905 "Motion for Brief Extension of Time to Submit Monitor's Seventh Report to the Parties," and the representation that the United States and Defendants have no objection to the relief sought, it is hereby ORDERED that the Motion is GRANTED; and it is further ORDERED that the Monitor shall have up to and including May 11, 2015 to submit his seventh report to the parties for comment. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 05/05/2015)
907 ORDER (WAL) dated 5/8/2015 requiring Defendants to file a Notice with the Court. (RET) (Entered: 05/08/2015)
908 NOTICE to the Court by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 05/26/2015)
909 MOTION for Extension of Time to File by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order granting motion for enlargement of time for monitor to file report) (Chinnery, Aquannette) (Entered: 05/30/2015)
910 ORDER (WAL) dated 6/1/2015. UPON CONSIDERATION of Defendants' 909 "Motion for Enlargement of Time," and the representation that the United States and Defendants have no objection to the relief sought, it is hereby ORDERED that the Motion is GRANTED; and it is further ORDERED that the Monitor shall have up to and including June 1, 2015 to file his seventh report with the Court. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 06/01/2015)
911 NOTICE of Filing Monitor's 7th Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 06/01/2015)
912 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 4/17/15, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 6/29/2015. Redacted Transcript Deadline set for 7/9/2015. Release of Transcript Restriction set for 9/4/2015. (Lawrence, Valerie) (Entered: 06/03/2015)
913 MOTION for Extension of Time to File by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order Order granting motion for enlargement of time) (Chinnery, Aquannette) (Entered: 06/03/2015)

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914 NOTICE of Filing of Response to Order dated April 22, 2015 by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 06/04/2015)

06/04/2015

915 ORDER (WAL) dated 6/4/2015. UPON CONSIDERATION of Defendants' 913 "Motion for Enlargement of Time," to May 30, 2015, to submit one medical/mental health form and one medical/mental health policy to the United States, it is hereby ORDERED that the Motion is GRANTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 06/04/2015)

06/04/2015

916 NOTICE of Filing Defendants' Sixth Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A) (D'Andrade, Shari) (Entered: 06/04/2015)

06/08/2015

917 NOTICE Regarding Attendance at Status Conferences by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 06/08/2015)

06/10/2015

918 ORDER (WAL) dated 6/10/2015 requiring Acting Deputy Attorney General Joseph Ponteen to appear in person at the June 11, 2015 status conference. (RET) (Entered: 06/10/2015)

06/10/2015

919 MOTION to Appoint Receiver (Fourth Successor Receiver) by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order appointing Fourth Successor Receiver) (Chinnery, Aquannette) Modified on 6/10/2015 (TNS). (Entered: 06/10/2015)

06/10/2015

920 NOTICE OF CORRECTED DOCKET ENTRYRe: 919 was erroneously filed in wrong case counsel was notified as to refiling this document (TNS) (Entered: 06/10/2015)

06/11/2015

921 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 6/11/2015. (Court Reporter V.Lawrence.) (TNS) (Entered: 06/12/2015)

06/15/2015

922 ORDER (WAL) dated 6/15/2015 setting deadline for Monitor's eighth status report; setting deadline for Defendants' seventh status report; setting status conference for September 24, 2015 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis; and setting other deadlines. (RET) (Entered: 06/15/2015)

06/16/2015

923 STIPULATION re 922 Order,, Set Hearings, Joint Motion to Enter Agreed Schedule for Training on Medical and Mental Health Policies as Court Order by United States of America. (Attachments: # 1 Exhibit 1 Agreed Schedule for Training on Medical and Mental Health Policies, # 2 Text of Proposed Order Entering Agreed Schedule for Training on Medical and Mental Health Policies as an Order of the Court) (Myrthil, Marlysha) (Entered: 06/16/2015)

06/16/2015

924 ORDER (WAL) dated 6/16/2015 granting the parties' 923 "Joint Motion for Entry of Stipulated Order." (RET) (Entered: 06/16/2015)

06/22/2015

925 NOTICE of Filing (Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit A) (D'Andrade, Shari) (Entered: 06/22/2015)

07/08/2015

926 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 6/11/15, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 8/3/2015. Redacted Transcript Deadline set for 8/13/2015. Release of Transcript Restriction set for 10/9/2015. (Lawrence, Valerie) (Entered: 07/08/2015)

07/31/2015 927 NOTICE to the Court Regarding Waiver Request by Territory of The Virgin Islands

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(D'Andrade, Shari) (Entered: 07/31/2015)
928 NOTICE of Substitution of Counsel by Territory of The Virgin Islands (Chinnery, Aquannette) (Entered: 08/28/2015)
929 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 9/25/14, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 9/24/2015. Redacted Transcript Deadline set for 10/5/2015. Release of Transcript Restriction set for 12/3/2015. (Lawrence, Valerie) (Entered: 08/31/2015)
930 MOTION for Brief Extension of Time to Submit Post­Tests for Group 3 Medical and Mental Health Policies (Unopposed) by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 09/01/2015)
931 ORDER (WAL) dated 9/2/2015. UPON CONSIDERATION of Defendants' 930 "Unopposed Motion for Brief Extension of Time to Submit Post­Tests for Group 3 Medical and Mental Health Policies," it is hereby ORDERED that the Motion is GRANTED; and it is further ORDERED that Defendants shall have up to and including September 8, 2015 to submit post­tests for the Group 3 medical and mental health policies. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 09/02/2015)
932 NOTICE of Filing Monitor's 8th Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) by United States of America (Lomio, Rita) (Entered: 09/11/2015)
933 NOTICE of Filing Defendants' Seventh Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit A) (D'Andrade, Shari) (Entered: 09/17/2015)
934 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 9/24/2015. (Court Reporter V. Lawrence.) (MB) (Entered: 09/25/2015)
935 ORDER (WAL) dated 9/29/2015 setting deadline for Monitor's ninth status report; setting deadline for Defendants' eighth status report; setting status conference for December 17, 2015 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis; and setting other deadlines. (RET) (Entered: 09/29/2015)
936 ORDER (WAL) dated 10/26/2015 granting 811 Motion to Intervene. (RET) (Entered: 10/26/2015)
937 NOTICE Joint Notice of Filing Related to Security Policy Development Schedule by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 10/30/2015)
938 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 9/24/15, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 11/27/2015. Redacted Transcript Deadline set for 12/7/2015. Release of Transcript Restriction set for 2/4/2016. (Lawrence, Valerie) (Entered: 11/03/2015)
939 MOTION to Unseal Document 791 Order on Motion for Leave to File, 708 Order on Motion to Seal Document, 562 Order on Motion to Seal Document, 775 Order on

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Motion for Miscellaneous Relief by Intervenor Ronald Edward Gillette. (DiRuzzo, Joseph) (Entered: 11/04/2015)

11/10/2015

940 ORDER (WAL) dated 11/10/2015 rescheduling Status Conference set for Thursday, December 17, 2015 at 1:30 p.m. to Wednesday, December 16, 2015 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 11/10/2015)

11/18/2015

941 Response re 939 MOTION to Unseal Document 791 Order on Motion for Leave to File, 708 Order on Motion to Seal Document, 562 Order on Motion to Seal Document, 775 Order on Motion for Miscellaneous Relief filed by Plaintiff United States of America. (Attachments: # 1 Exhibit A) (Lomio, Rita) (Entered: 11/18/2015)

11/18/2015

942 MOTION for Joinder in Plaintiff United States of America's Response to Intervenor Ronald E. Gillette's Motion to Unseal by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 11/18/2015)

11/23/2015

943 REPLY to Opposition to Motion re 942 MOTION for Joinder in Plaintiff United States of America's Response to Intervenor Ronald E. Gillette's Motion to Unseal, 941 Response, filed by Intervenor Ronald Edward Gillette. (Attachments: # 1 Exhibit A) (DiRuzzo, Joseph) (Entered: 11/23/2015)

11/30/2015

944 NOTICE of Filing Monitor's 9th Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) (Lomio, Rita) (Entered: 11/30/2015)

12/10/2015

945 NOTICE of Filing Eighth Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 12/10/2015)

12/16/2015

946 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 12/16/2015. (Court Reporter V. Lawrence.) (MB) (Entered: 12/17/2015)

12/22/2015

947 NOTICE of Monitor's Next Scheduled Onsite Assessment by United States of America (Myrthil, Marlysha) (Entered: 12/22/2015)

12/23/2015

948 ORDER (WAL) dated 12/23/2015 setting deadline for Monitor's tenth status report; setting deadline for Defendants' ninth status report; setting status conference for March 17, 2016 at 1:30 p.m.; and setting other deadlines. (RDB) (Entered: 12/23/2015)

12/28/2015

Status Conference set for 3/17/2016 01:30 PM in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (MB) (Entered: 12/28/2015)

12/31/2015

949 NOTICE of Objections to Staffing Plan and Request for a Status Conference by United States of America (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D) (Lomio, Rita) (Entered: 12/31/2015)

01/07/2016

950 NOTICE of Filing Defendants' Security Staffing and Recruitment Plan by Territory of The Virgin Islands (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C) (D'Andrade, Shari) (Entered: 01/07/2016)

01/13/2016

951 Response re 949 Notice (Other) filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit 1) (D'Andrade, Shari) (Entered: 01/13/2016)

01/25/2016

952 REPLY to re 951 Response filed by Defendant Territory of The Virgin Islands United States' Reply in Support of Objections to Staffing Plan and Request for Status Conference filed by Plaintiff United States of America. Responses due by 2/8/2016 (Myrthil, Marlysha) (Entered: 01/25/2016)

01/26/2016

953 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 12/16/15, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR,

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Telephone number 340­718­1130. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 2/19/2016. Redacted Transcript Deadline set for 2/29/2016. Release of Transcript Restriction set for 4/28/2016. (Lawrence, Valerie) (Entered: 01/26/2016)

02/02/2016

954 ORDER (WAL) dated 2/2/2016 scheduling hearing on the United States' 949 "Notice of Objections to Staffing Plan and Request for a Status Conference." (RET) (Entered: 02/02/2016)

02/08/2016

955 MOTION for Extension of Time Nunc Pro Tunc to Comply With the Court's June 16, 2015 Order by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 02/08/2016)

02/09/2016

956 ORDER (WAL) dated 2/9/2016 granting Defendants' 955 "Motion for Extension of Time Nunc Pro Tunc to Comply with the Court's Order dated June 16, 2015." (RET) (Entered: 02/09/2016)

02/22/2016

957 NOTICE of Filing Monitor's 10th Compliance Monitoring Report by Kenneth Ray (filed on behalf of the Monitor) (Lomio, Rita) (Entered: 02/22/2016)

02/23/2016

958 MOTION to Excuse Emile Henderson, III by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order Proposed Order) (D'Andrade, Shari) (Entered: 02/23/2016)

02/26/2016

959 ORDER (WAL) dated 2/26/2016 granting Defendants' 958 "Motion to Excuse Emile Henderson, Esq." (RET) (Entered: 02/26/2016)

03/08/2016

960 NOTICE of Filing Monitor's Amended 10th Compliance Monitoring Report by United States of America (filed on behalf of the Monitor) (Attachments: # 1 Amended 10th Compliance Monitoring Report) (Lomio, Rita) (Entered: 03/08/2016)

03/08/2016

961 NOTICE Request for Status Conference Regarding Prisoner Transfer by United States of America (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C) (Myrthil, Marlysha) (Entered: 03/08/2016)

03/09/2016

962 ORDER (WAL) dated 3/9/2016 granting the United States' 961 "Request for a Status Conference Regarding Proposed Prisoner Transfer" and requiring Defendants to file a response to the issues raised by the United States by 5:00 p.m. on March 14, 2016. (RET) (Entered: 03/09/2016)

03/10/2016

963 NOTICE of Filing Defendants' Ninth Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 03/10/2016)

03/14/2016

964 MOTION to Compel Production of Documents by Plaintiff United States of America. (Attachments: # 1 Supplement Memorandum of Law in Support of Motion to Compel, # 2 Exhibit A, # 3 Exhibit B, # 4 Exhibit C, # 5 Exhibit D, # 6 Exhibit E, # 7 Exhibit F, # 8 Exhibit G, # 9 Text of Proposed Order) (Myrthil, Marlysha) (Entered: 03/14/2016)

03/14/2016

965 Response re 961 Notice (Other) Request for Status Conference Regarding Prisoner Transfer filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit A, # 2 Exhibit B) (D'Andrade, Shari) (Entered: 03/14/2016)

03/14/2016

966 ORDER (WAL) dated 3/14/2016. UPON CONSIDERATION of the United States' 964 "Motion to Compel Production of Documents and Enforce Settlement Agreement," which was filed on March 14, 2016, it is hereby ORDERED that Defendants shall have up to and including 12:00 noon on March 16, 2016 within which to file a Response. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 03/14/2016)

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03/16/2016

967 REPLY to re 965 Response filed by Defendant Territory of The Virgin Islands to United States' Request for Status Conference Regarding Prisoner Transfer filed by Plaintiff United States of America. Responses due by 3/31/2016 (Attachments: # 1 Exhibit A (Part 1), # 2 Exhibit A (Part 2), # 3 Exhibit A (Part 3)) (Myrthil, Marlysha) (Entered: 03/16/2016)

03/16/2016

968 Opposition to Motion re 964 MOTION to Compel Production of Documents and Motion for Protective Order and Incorporated Memorandum of Law filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order, # 2 Exhibit 1) (D'Andrade, Shari) (Entered: 03/16/2016)

03/17/2016

969 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 3/17/2016. (Court Reporter V. Lawrence.) (AM) (Entered: 03/18/2016)

03/18/2016

970 ORDER (WAL) dated 3/18/2016 denying without prejudice the United States' 964 "Motion to Compel Production of Documents and Enforce Settlement Agreement" and memorializing the deadlines set at the March 17, 2016 hearing. (RET) (Entered: 03/18/2016)

03/18/2016

971 ORDER (WAL) dated 3/18/2016 setting deadline for Monitor's eleventh status report; setting deadline for Defendants' tenth status report; setting status conference for June 15, 2016 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis; and setting other deadlines. (RET) (Entered: 03/18/2016)

03/21/2016

972 MOTION for Extension of Time to File by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 03/21/2016)

03/21/2016

973 ORDER (WAL) dated 3/21/2016. UPON CONSIDERATION of Defendants' 972 "Motion for Brief Extension of Time to Comply with Court Order," it is hereby ORDERED that the Motion is GRANTED; and it is further ORDERED that Defendants shall have up to and including March 22, 2016 within which to finalize the letter described in the Court's 970 March 18, 2016 Order, send it to Mr. Eugene Irish, Vice President of the Seafarers International Union, and file it with the Court. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 03/21/2016)

03/22/2016

974 NOTICE of Filing by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 03/22/2016)

03/31/2016

975 NOTICE REGARDING ITS REQUEST FOR DOCUMENTS AND INFORMATION RELATED TO PRISONER TRANSFER by United States of America re 970 Order, Terminate Motions (Myrthil, Marlysha) (Entered: 03/31/2016)

04/07/2016

976 NOTICE of Filing Defendants' Amended Security Staffing & Recruitment Plan by Territory of The Virgin Islands (Attachments: # 1 Exhibit Amended Security Staffing & Recruitment Plan Part 1, # 2 Exhibit Amended Security Staffing & Recruitment Plan Part 2) (D'Andrade, Shari) (Entered: 04/07/2016)

05/03/2016

977 NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 3/17/16, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1103. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 5/27/2016. Redacted Transcript Deadline set for 6/6/2016. Release of Transcript Restriction set for 8/4/2016. (Lawrence, Valerie) (Entered: 05/03/2016)

05/20/2016 978 ORDER (WAL) dated 5/20/2016 scheduling hearing on Intervenor's 939 "Motion to

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Unseal" for June 15, 2016 at 12:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 05/20/2016)

06/01/2016

979 NOTICE of Filing Monitor's 11th Compliance Monitoring Report by United States of America (filed on behalf of the Monitor) (Lomio, Rita) (Entered: 06/01/2016)

06/08/2016

980 NOTICE of Filing Defendants' Tenth Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 06/08/2016)

06/09/2016

981 NOTICE OF FILING OF CORRECTED OFFICIAL TRANSCRIPT of Proceedings held on 3/17/16, before Judge Wilma A. Lewis. RE: Doc # 977 Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1103. (Lawrence, Valerie) Text Modified on 6/9/2016 (CBF). (Entered: 06/09/2016)

06/10/2016

982 MOTION to Excuse Chief Deputy Attorney General Joseph Ponteen by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 06/10/2016)

06/10/2016

983 ORDER (WAL) dated 6/10/2016. UPON CONSIDERATION of Defendants' 982 "Motion to Excuse Chief Deputy Attorney General Joseph Ponteen," it is hereby ORDERED that the Motion is DENIED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (RET) (Entered: 06/10/2016)

06/15/2016

984 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 6/15/2016. (Court Reporter V. Lawrence.) (AM) (Entered: 06/16/2016)

06/17/2016

985 ORDER (WAL) dated 6/17/2016 memorializing deadlines set at the June 15, 2016 status conference. (RET) (Entered: 06/17/2016)

06/17/2016

986 NOTICE to the Court by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 06/17/2016)

06/24/2016

987 NOTICE to the Court (Supplemental) by Territory of The Virgin Islands re 986 Notice (Other) (D'Andrade, Shari) (Entered: 06/24/2016)

06/30/2016

988 ORDER (WAL) dated 6/30/2016 granting Defendants' 942 Motion for Joinder, to the extent that Defendants join the arguments contained in the United States' Response to the Intervenor's Motion to Unseal; granting Intervenor's 939 Motion to Unseal with respect to the documents that the United States and Defendants agree can now be unsealed, and setting a deadline for the filing of such documents; granting Intervenor's request for a protective order; and setting a deadline to apprise the Court of a reasonable timeframe for review of the documents that the parties believe contain confidential information. (RET) (Entered: 06/30/2016)

06/30/2016

989 NOTICE to the Court Regarding Vendor's Contract by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 06/30/2016)

07/05/2016

990 ORDER (WAL) dated 7/5/2016 requiring additional status report regarding the status of the vendor's contract. (RET) (Entered: 07/05/2016)

07/14/2016

991 NOTICE of Filing Proposed Protective Order by United States of America re 988 Order on Motion to Unseal Document,,, Order on Motion for Joinder,, (Attachments: # 1 Text of Proposed Order) (Myrthil, Marlysha) (Entered: 07/14/2016)

07/14/2016

992 NOTICE of Onsite Compliance Assessment Tour Dates and Reporting Schedule by United States of America (Myrthil, Marlysha) (Entered: 07/14/2016)

07/14/2016

993 NOTICE to the Court by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 07/14/2016)

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994 ORDER (WAL) dated 7/20/2016 requiring Defendants to file a Notice with the Court regarding the status of the vendor's contract. (RET) (Entered: 07/20/2016)

995 NOTICE to the Court Regarding Vendor's Contract by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 08/04/2016)

996 ORDER (WAL) dated 8/10/2016 setting deadline for Monitor's twelfth status report; setting deadline for Defendants' eleventh status report; setting status conference for September 20, 2016 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis; and setting other deadlines. (RET) (Entered: 08/10/2016)

997 ORDER (WAL) dated 8/10/2016 requiring additional status report regarding the status of the vendor's contract and scheduling status conference for September 2, 2016 at 1:00 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (RET) (Entered: 08/10/2016)

998 NOTICE of Appearance and Substitution of Counsel by United States of America (Myrthil, Marlysha) (Entered: 08/17/2016)

999 NOTICE of Filing Regarding Vendor's Contract by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 08/18/2016)

1000 PROTECTIVE ORDER (WAL) dated 8/19/2016. (RET) (Entered: 08/19/2016)

1001 MOTION to Cancel September 2, 2016 Hearing by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 08/23/2016)

1002

ORDER (WAL) dated 8/24/2016. UPON CONSIDERATION of Defendants' 1001 "Motion to Cancel September 6, 2016 Hearing," it is hereby ORDERED that Defendants' motion is GRANTED; and it is further ORDERED that the Status Conference scheduled for Friday, September 2, 2016 at 1:00 p.m. is CANCELLED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 08/24/2016)

1003

NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 6/15/16, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1103. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 9/26/2016. Redacted Transcript Deadline set for 10/6/2016. Release of Transcript Restriction set for 12/2/2016. (Lawrence, Valerie) (Entered: 08/31/2016)

1004 NOTICE of Filing Monitor's 12th Compliance Monitoring Report (filed on behalf of the Monitor) by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 09/06/2016)

1005 MOTION to Excuse Chief Deputy Attorney General Joseph Ponteen by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 09/06/2016)

ORDER (WAL) dated 9/6/2016 rescheduling Status Conference set for Tuesday, September 20, 2016 at 1:30 p.m. to Wednesday, September 21, 2016 at 1:00 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 09/06/2016)

1006 Letter from Ronald Gillette to Judge Raymond Finch dated 9/30/16 (Attachments: # 1 Exhibit, # 2 Exhibit Envelope) (AM) (Entered: 09/07/2016)

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1007

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ORDER (GWC) dated 9/9/2016 to seal 1006 letter due to confidential information contained therein (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (KMD) (Entered: 09/09/2016)

1008

ORDER (WAL) dated 9/12/2016. UPON CONSIDERATION of the United States' 1005 "Motion to Excuse Chief Deputy Attorney General Joseph Ponteen," from the Status Conference scheduled for Wednesday, September 21, 2016 at 1:00 p.m. it is hereby ORDERED that, for the reasons advanced therein, the Motion is GRANTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 09/12/2016)

1010 NOTICE of Filing Defendants' Eleventh Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/14/2016)

1011 NOTICE of Filing Defendants' Amended Eleventh Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/15/2016)

1012 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit) (D'Andrade, Shari) (Entered: 09/19/2016)

1013 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Second Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/19/2016)

1014 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Third Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/19/2016)

1015 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Fourth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/19/2016)

1016 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Fifth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/19/2016)

1017 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Sixth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/20/2016)

1018 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Seventh Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/20/2016)

1019 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Eighth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/20/2016)

1020 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining

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Documents Containing Sensitive or Confidential Information (Ninth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/20/2016)

09/20/2016

1021 NOTICE of Filing of Documents and Proposed Timeframe for Review of Remaining Documents Containing Sensitive or Confidential Information (Tenth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 09/20/2016)

09/21/2016

1022 MOTION for Extension of Time Nunc Pro Tunc by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order) (D'Andrade, Shari) (Entered: 09/21/2016)

09/21/2016

1023

ORDER (WAL) dated 9/21/2016. UPON CONSIDERATION of the Territory's 1022 "Motion for Extension of Time Nunc Pro Tunc," seeking a one­day extension due to technical difficulties in filing documents, it hereby ORDERED that, for the reasons advanced therein, the Motion is GRANTED; and it is further ORDERED that Notices numbered 1017 , 1018 , 1019 , 1020 , and 1021 are ACCEPTED. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 09/21/2016)

09/21/2016

1024 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 9/21/2016. (Court Reporter Valerie Lawrence.) (TJ) (Entered: 09/21/2016)

09/23/2016

1025 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Telephone Conference held on 9/23/2016. (Court Reporter Valerie Lawrence.) (TJ) (Entered: 09/23/2016)

09/23/2016

Set/Reset Hearings: Telephonic Status Conference set for 9/23/2016 11:15 AM in Chambers before Chief Judge Wilma A. Lewis. (TJ) (Entered: 09/23/2016)

09/23/2016

1026 ORDER (WAL) dated 9/23/2016 memorializing deadlines set at the September 21, 2016 status conference. (ARJ) (Entered: 09/23/2016)

10/04/2016

1027 NOTICE (Joint) by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 10/04/2016)

10/07/2016

1028 NOTICE of Filing Regarding Schedule for Review of Remaining Documents Sought by Intervenor (Joint) by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 10/07/2016)

11/04/2016

1029

ORDER (WAL) dated 11/4/2016. UPON CONSIDERATION of the Court's unavailability during the week of February 6, 2017, it is hereby ORDERED that the parties have up to and including November 14, 2016 within which to jointly file a proposed date for the February, 2017 site visit. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 11/04/2016)

11/11/2016

1030 NOTICE Joint Notice of Monitor's Next Compliance Assessment by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 11/11/2016)

11/21/2016

1031 ORDER (WAL) dated 11/21/2016 setting deadline for Monitor's thirteenth status report; setting deadline for Defendants' twelfth status report; setting status conference for February 2, 2017 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis; and setting other deadlines. (ARJ) (Entered: 11/21/2016)

12/07/2016

1032 NOTICE of Filing Monitor's 13th Compliance Assessment Report by Kenneth Ray (filed on behalf of the Monitor) by United States of America (Myrthil, Marlysha) (Entered: 12/07/2016)

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12/20/2016 12/22/2016 12/29/2016
01/19/2017
01/26/2017
01/26/2017 02/02/2017 02/09/2017 02/10/2017 02/13/2017 02/15/2017 02/17/2017 03/13/2017

District Court CM/ECF ­ LIVE

1033 NOTICE of Failure to Timely Pay Monitor by United States of America (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E) (Myrthil, Marlysha) (Entered: 12/20/2016)

1034 Response re 1033 Notice (Other) filed by Defendant Territory of The Virgin Islands. (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit, # 5 Exhibit, # 6 Exhibit, # 7 Exhibit, # 8 Exhibit, # 9 Exhibit, # 10 Exhibit, # 11 Exhibit, # 12 Exhibit, # 13 Exhibit, # 14 Exhibit) (D'Andrade, Shari) (Entered: 12/22/2016)

1035

ORDER (WAL) dated 12/29/2016. UPON CONSIDERATION of the United States' 1033 "Notice of Failure to Timely Pay Monitor," the Territory of the Virgin Islands' 1034 "Response to Notice to the Court," and the Court's 830 , 874 prior Orders, the Court has determined that no action by the Court is necessary under the circumstances presented. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 12/29/2016)

1036

NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 9/21/16, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1103. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 2/13/2017. Redacted Transcript Deadline set for 2/24/2017. Release of Transcript Restriction set for 4/24/2017. (Lawrence, Valerie) (Entered: 01/19/2017)

1037

ORDER (WAL) dated 1/26/2017. UPON CONSIDERATION of the Court's 1031 Order, which required Defendants to file their twelfth status report no later than January 25, 2017, and in light of the fact that the deadline has passed without any such filing, it is hereby ORDERED that Defendants shall file their twelfth status report no later than 6:00 p.m. on January 26, 2017. (This is a TEXT ENTRY ONLY. There is no.pdf document associated with this entry.) (ARJ) (Entered: 01/26/2017)

1038 NOTICE of Filing of Defendants' Twelfth Status Report by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 01/26/2017)

1039 Minute Entry for proceedings held before Chief Judge Wilma A. Lewis: Status Conference held on 2/2/2017. (Court Reporter Valerie Lawrence.) (AM) (Entered: 02/03/2017)

1040 NOTICE of Filing of Documents by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit) (D'Andrade, Shari) (Entered: 02/09/2017)

1041 NOTICE of Filing Documents (Second Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit, # 5 Exhibit) (D'Andrade, Shari) (Entered: 02/10/2017)

1042 NOTICE of Filing of Documents (Third Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit, # 5 Exhibit, # 6 Exhibit) (D'Andrade, Shari) (Entered: 02/13/2017)

1043 NOTICE of Filing of Documents (Fourth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit) (D'Andrade, Shari) (Entered: 02/15/2017)

1044 NOTICE of Training Curricula Development Schedule (Joint Notice) by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 02/17/2017)

1045 NOTICE of Filing Documents (Fifth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit) (D'Andrade, Shari) (Entered: 03/13/2017)

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03/13/2017 03/16/2017 04/04/2017 04/05/2017 04/25/2017
04/25/2017 05/01/2017

District Court CM/ECF ­ LIVE
1046 NOTICE of Filing Documents (Sixth Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit) (D'Andrade, Shari) (Entered: 03/13/2017)

1047 NOTICE of Filing Documents (Seventh Joint Notice) by Territory of The Virgin Islands (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit, # 5 Exhibit, # 6 Exhibit, # 7 Exhibit) (D'Andrade, Shari) (Entered: 03/16/2017)

1048 MOTION for Brief Extension of Time to Pay Monitor by Defendant Territory of The Virgin Islands. (Attachments: # 1 Text of Proposed Order, # 2 Exhibit, # 3 Exhibit) (D'Andrade, Shari) (Entered: 04/04/2017)

1049 ORDER (WAL) dated 4/5/2017 granting Defendants' 1048 "Motion for Brief Extension of Time to Pay Monitor." (ARJ) (Entered: 04/05/2017)

1050

NOTICE OF FILING OF OFFICIAL TRANSCRIPT of Proceedings held on 02/02/2017, before Judge Wilma A. Lewis. Court Reporter/Transcriber Valerie Lawrence, RPR, Telephone number 340­718­1103. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER.. Redaction Request due 5/19/2017. Redacted Transcript Deadline set for 5/30/2017. Release of Transcript Restriction set for 7/27/2017. (Lawrence, Valerie) (Entered: 04/25/2017)

1051 ORDER (WAL) dated 4/28/2017 setting deadline for Monitor's fourteenth status report; setting deadline for Defendants' thirteenth status report; setting status conference for June 29, 2017 at 1:30 p.m. in STX Courtroom 1 before Chief Judge Wilma A. Lewis; and setting other deadlines. (ARJ) (Entered: 04/25/2017)

1052 NOTICE of Filing Monitor's 14th Compliance Assessment Report by Territory of The Virgin Islands (D'Andrade, Shari) (Entered: 05/01/2017)

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 DATE

NR.

PROCEEDIN'

~ JI/i/A

1986 Nov. 2

COMPLAINT MOTION,FOR ADOPTION OF DECREE

yfDec M

CONSENT ^degree ^ ) 4 — 'ORDER (DVO) granting consent degree

1987

Feb. 2 4 JOINT stupulation

Feb. 2 Feb. 3 Apr. 2 Apr. 2 Apr. 15 Apr. 27
Apr 27
Apr. 28

5 NOTICE of filing of implementation plan
ORDER (DVO) granting joint stipulation 6 MEMORANDUM in support of mot. for extension of time 7 MOTION for extension of time 8 OBJECTION to implementation plan 9 AFFIDAVIT of Michael C. Dunston
10 RESPONSE to mot. for extension of time 11 ORDER (DVO) pltf. request for extension of time until April 17, 1987 for filing

comments on implementation is granted

Jul 22 12 ORDER (DVO) magistrate conduct a hearing formal or informal as he decides, to

determine what further steps are necessary to implement the consent judgment

herein and make such recommendations as pertinent thereto

ug

13 ORDER(DVO) that counsel for both p a r t i e s c o m m u n i c a t e the status of

the case by 9/8/87, at that time the c o u r t w i l l set a d a t e for he

Jul_J31_ 14 NOTICE of filing of compliance report

Sep. 10 Sep. 25

ORDER (JEL) Givernment of V.I_ will submit a detailed revised plan no later than Sep. 18, 1987 as to how they propose to specifically implement the improvemen of the condition at the Golden Grove facility, Pltf. counsel will respond to this no later that Sept. 30, 1987, on Oct. 5, 87 counsel for both pltf. and d will communicate with Magistrate by conference as to status of cas at that pc a determination will then be made as to the necessity for conducting a furthe hearing
AMENDED inplementation plan

Sep. 30 )ct. 7 )ct. 7 Nov. 9
12 )ec, 29 Dec. 29
1988 Jan. 20 Feb. 12 Feb 29 Mar 2
Mar 15 Mar 18

MOTION to permit late filing and acceptance nunc pro tune with points and authoi RESPONSES to amended implementation plan ORDER (JEL) NOTICE of appearance of counsel of Gayle D. Fidler, Esq. MEMORANDUM of compliance confere rce & Order (JEL) MEMORANDUM in support of motion for order to show cause MOTION for order to show cause
MEMORANDUM (JEL) of pretrial conference and order ORDER (DVO) to show cause RESPONSE by defts to pltf's motion for an order to show cause
|ORDER (DVO) show cause is recessed, further ordered that deft will submit detai in accordance with consent decree on or before 3/16/88, failure by def to comply with order will result in reinstitution of these proceedings at the request of the Unites States cc to (6) attys of record
REPLY to deft response MOTION for an enlargement of time to permit late filing and acceptance nunc pro
with points and authorities SECOND amended implementation plan with points and authorities by deft MOTION for contempt by pltf OPPOSITION to pltf. mot. for contempt MOTION for extension of tiem to file response to deft second amended implementai

May 25

plan

ORDER (DVO) dated and EDO 5/25/88 mot. of the U.S.A. for extension of time to

"

" " response to deft second amended implementation plan is GRANTED, and

in which the U.S. has to file its response to deft second amended in

ementation plan be extended until the close of business Friday, May

DC 111A (Rev. 1/75)
PLAINTIFF
United States of America

DATE

NR.

CIVIL DOCKET C t , . . NUATION SHEET
DEFENDANT Government of the Virgin Islands
PROCEEDINGS

DOCKET NO. 86/265 1 2 .PAGES
PAGE OF

1988
May 26 35 Jun 2 36 JJuly 12 37 Aug 11 38 Aug. 16 39 Oct 7 40
Oct 21

RESPONSE to defendants' second amended implementation plan with points and

authority NOTICE of withdrawal of counsel MOTION for hearing

mwi mw

ORDER (DVO) matter for hearing before the court on 9/28/88 cc to (7) attys mw

RESPONSE to plaintiff's motion for hearing by deft.

ep

ORDER (DVO) pltf designate experts to draw up the plan the consent decree

contemplated, also provide the court with the names and curriculum vitae

of the experts who will fraft the plan; Gov't shall paythe experts feef

and expenses incurred in drafting the plan (including resonable travel

expenses) andshall provide promptly to the UN.S. experts such records

and data as the experts request; Upon completion of the plan the U.S.

Shall provide it to the court for approval; the Y.S. request for $5,000

per day fins is reserved until submission of the plan cc to (7) tr

ORDER (DVO) section V para '. of the consent decree entered on 12/1/86 is amende

to extend the implementation date of decree from 7/1/88 to two years

following the date this court approves the final plan to implement the

provisions of the consent decree

1989
Mar 28 42 MOTION for payment of experts Mar 28 43 MOTION to adopt the plan of compliance andto extend consent decree Mar 31 44 ORDER (DVO) pltf shall file its response to the U.S. of America for payment o
expert andadoption of the plan by 4/21/89 at 5 p.m. cc to attys (7)

Apr 21 45 MOTION for extension

''

Apr. 28 46 ORDER (DVO) dated 4-27-89 grantong extension 10 additional days

May 19 47 MOTION forimmediate payment of experts andfortelephone status conference May 22 48 ORDER (DVO) experts who drafted the plan of Compliance shall be paid by the

deft's in accordance with the bills submitted on 3/28/89 within ten

days of the date of this order in amount of #3,247 to Charles Brasha

$4,733,76 to John J. Dawtn, 2. a telephone status conference will be

held in this matter on 6/7/89 at noon cc to (5) attys

June 9

ORDER (JLR) cc to (5) attys

June 16

RESPONSE to pltf plan deft mot forcontinuance to find source of paymentmot

for substitution of counsel with points and authorities

Aug 21

MOTION for an order to show cause

Aug 21

REPLY to deft response to plan an memorandum in support of the U.S. mot for

order to show cause

Nov 9

ORDER (JLR) US shall paythe experts who prepared the plan of compliance wi

bills submitted on 3/28/89, 3,247. to Dr. C. Braslow and $4,733.76

John Dahm, Order is amended to state that the V.I. Govt shall pron

reimburse the U.S. for payment of the experts upon submission of i

statement of the experts to counsel of V.I., Order does not const:

a decision on the U.S. motfor contempt forfailure to pay these•

not does it constitute a finding that the U.S. is liable for the

of the experts cc to (5) attys

1990 Feb. 28 54 ORDER (.JLR) setting hearing on April 10, 1990 at 2:00 p.m. Mar 26 55 UNITED STATES pretrial statement

PLAINTIFF

CIVIL DOCKET CONTINUAT. - . . 3HEET DEFENDANT

•United States of America

Govermnent of t h e V i r g i n

DOCKET NO. 86/265
=AGES

DATE

NR.

PROCEEDINGS

1992-
J u l y 17 83 1993
Feb. Feb.
Apr. 15 J u l . 15 Sept. 23

VOLUME 3

SUPPLEMANTAL c o m p l a i n c e r e p o r t f o r J u l y 1 5 , 1992 by d e f t .

NOTICE of f i l i n g of compliance r e p o r t NOTICE of f i l i n g of compliance r e p o r t
NOTICE of filing compliance report NOTICE Of f i l i n g complaince r e p o r t ORDER (JLR) setting status conference before Chief
on Wed., December 15, 1993 at 9:00 a. m.

Judge Thomas K. Moore

ab)m
mwr mwr ep mwr
ep

U.S. v. Virgin Islands
I • • • • • mm • • • • • •
PC-VI-002-020