Capstone Review of the Federal Bureau of Prisons’ Response to the Coronavirus Disease 2019 Pandemic
- Document type
- PDF source document
- Date
- 2023-03-21
Summary
A capstone review, report 23-054 dated March 2023, by the Evaluation and Inspections Division of the U.S. Department of Justice Office of the Inspector General on the Federal Bureau of Prisons' response to the COVID-19 pandemic. It draws on 16 remote facility inspections, staff and inmate surveys and data dashboards, and reports BOP figures as of June 21, 2022 of over 60,000 inmate cases, 13,000 staff cases, 296 inmate deaths and 7 staff deaths. The review finds areas for BOP action on single-cell placement, use of home confinement authorities, staffing shortages and morale, communication with inmates' families and the public, protective equipment and testing. It makes 10 recommendations. The report closes with the BOP's responses and the OIG's analysis, which asks for updates by June 23, 2023.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
L IM ITE D O F F IC IA L U SE - P RO P RI ETA RY I NF O RMA TI O N
Capstone Review of the Federal Bureau of
Prisons’ Response to the Coronavirus
Disease 2019 Pandemic
E VA L U AT I O N A N D I N S P E C T I O N S D I V I S I O N
23-054
MARCH 2023
EXECUTIVE SUMMARY
Capstone Review of the Federal Bureau of Prisons’
Response to the Coronavirus Disease 2019 Pandemic
Introduction pandemic and in mitigating the effects of future public
health emergencies.
The Federal Bureau of Prisons (BOP) is responsible for
the care, safekeeping, and subsistence of federal
inmates, as well as for reentry programming to help Results of the Review
them return to the community. The BOP houses The COVID-19 pandemic has required the BOP to
inmates in BOP-operated federal prisons and, if certain prevent and manage the spread of COVID-19 and
conditions are met, in contracted Residential Reentry protect inmate and staff health and safety, while
Center (RRC) facilities, commonly known as halfway adhering to changing guidance and communicating
houses, or in home confinement. essential information to stakeholders. As of June 21,
2022, the BOP reported that there had been over
The coronavirus disease 2019 (COVID-19) pandemic 60,000 inmate cases and 13,000 BOP staff cases of
created significant safety and staffing challenges for the COVID-19 since the beginning of the pandemic, as well
BOP due to the high risk of COVID-19 spread among as 296 inmate deaths and 7 BOP staff deaths. We
staff and inmates once it is introduced into a identified several areas in which the BOP should take
correctional facility. Since April 2020, the U.S. action to address ongoing challenges, improve existing
Department of Justice (Department, DOJ) Office of the processes whose weaknesses were highlighted during
Inspector General (OIG) has conducted substantial the pandemic, and better prepare for future public
oversight of the BOP’s response to the COVID-19 health emergencies.
pandemic. The resulting body of work, which the OIG
previously publicly released, includes remote The BOP Should Improve and Retain Effective Practices
inspections of 16 facilities housing BOP inmates for Protecting Staff and Inmate Health and Safety
completed during the early months of the pandemic, During Public Health Emergencies
multiple surveys of BOP staff conducted at different We found that BOP facilities used a variety of strategies
times, and a collection of interactive data dashboards to try to implement social distancing, quarantine, and
containing up-to-date information about COVID-19 medical isolation guidance, but were often limited by
within BOP facilities. The OIG is also completing facility infrastructure and population size. We also
analysis of its first survey of BOP inmates. identified several areas in which the BOP should
improve its processes and identify long-term changes
This capstone review summarizes our overall findings to better protect staff and inmate health and safety
regarding the BOP’s response to the COVID-19 during a public health emergency.
pandemic, the issues we identified through our
pandemic oversight work, the topics that have emerged First, the BOP should review its policies and processes
following that work, the challenges that the BOP will on placing inmates in single cells given the serious
likely continue to face during and after the pandemic, failures we identified in the BOP’s use of single cells
and actions that the BOP should undertake to prepare during COVID-19 modified operations. The BOP
for future potential healthcare emergencies. reported to the OIG that seven inmates died by suicide
from March 2020 through April 2021 while housed in
Recommendations single-cell confinement in quarantine units related to
We make 10 recommendations to assist the BOP in COVID-19. We found that numerous facilities single-
managing challenges during and after the COVID-19 celled inmates during COVID-19 modified operations
despite BOP guidance stating that facilities should
i
–
avoid doing so to the greatest extent possible. requiring facilities to “promptly” notify inmate families of
Additionally, although BOP guidance stated that a serious illness, we found that, in almost one-third of
psychology staff should be consulted for inmates the 49 cases of COVID-19 related inmate deaths we
proposed for single-celling, we found that this did not reviewed, facilities took more than 3 days to try to notify
occur for at least five of the seven single-celled inmates families of the inmates’ serious illness.
who died by suicide. The BOP’s postmortem
documentation indicated that all seven inmates had We also received numerous complaints about the
factors that made them vulnerable to suicide. Second, BOP’s communications with inmates, the public, and
the BOP should explore permanent facility attorneys, despite the BOP’s attempts to communicate
modifications to help it more easily implement future proactively during the pandemic. We identified issues
infection control measures. with the BOP’s notifications to crime victims and
limitations with its website data.
Third, the BOP needs to assess how it can more
effectively use its home confinement authorities. For The BOP Should Provide Clear Guidance on the Use of
example, the BOP did not fully utilize its authorities to Healthcare Protective Equipment and Compliance with
help address inmate population issues at prisons with Healthcare Safety Guidance
COVID-19 outbreaks and social distancing, quarantine, Our remote inspections identified numerous personal
and staffing challenges. While the BOP transferred a protective equipment (PPE)-related issues, perceived
substantial number of inmates from prisons to home PPE shortages, and staff concerns and confusion about
confinement during the first few months of the guidance on PPE and face coverings. While PPE supply
pandemic, the BOP actually transferred fewer inmates stabilized and staff concerns and confusion decreased
during the first year of the pandemic than it had during during the pandemic, in OIG surveys staff and inmates
the year immediately preceding the pandemic. We note identified an issue with the inconsistent use of face
that, due to the decreasing inmate population overall, coverings when social distance could not be
the percentage of inmates transferred to home maintained. Additionally, our remote inspections found
confinement was similar for both years. Additionally, we that the BOP encountered challenges managing COVID-
found that the BOP did not meet its facility population 19 testing delays early during the pandemic. Long
reduction goals at some minimum and low security turnaround times when the market for testing supplies
facilities. Of the inmates who were transferred to home was burdened meant that inmates sometimes had to
confinement during the first year of the pandemic, less wait several days for test results, and some facilities did
than 2 percent failed to comply with program rules. not properly follow quarantine guidance to manage the
risk of COVID-19 transmission between inmates
The BOP Should Take Appropriate Steps to Address awaiting test results.
Staffing Shortages and Staff Morale
We found that the COVID-19 pandemic exacerbated the The BOP Should Respond to Ongoing Pandemic
effects of preexisting BOP medical and nonmedical Challenges and Prepare for Future Public Health
staffing shortages, increased staff workloads, and Emergencies
impeded facilities’ ability to fully respond to the We found that aspects of the BOP’s COVID-19 pandemic
pandemic. The pandemic also strained BOP staff response evolved over time and that the BOP should
morale. Staff reported experiencing stress or anxiety at capture lessons learned from its COVID-19 response.
work due to the pandemic and identified a need to First, the BOP should continue to explore ways to safely
improve communication between BOP leadership and accommodate inmate access to mental healthcare,
staff. Staff expressed concerns about inconsistent or programming, counsel, recreation, commissary, and
changing guidance regarding leave and when to communication options during extended modified
quarantine. The BOP can improve how it pandemic operations. Second, to protect inmates and
communicates the available staff support options. staff, the BOP should continue COVID-19 vaccine
educational campaigns for inmates and ensure that
The BOP Should Improve Its Communication of inmates and staff have access to the vaccine. Finally, to
Essential Information to Stakeholders prepare for future public health emergencies, the BOP
We identified a significant deficiency in the BOP’s should document best practices and lessons learned
communication with inmates’ families regarding from its ongoing COVID-19 challenges related to its
COVID-19 related serious illnesses. Despite BOP policy continued use of modified operations and vaccines.
ii
Table of Contents
Introduction .................................................................................................................................................................. 1
Background ................................................................................................................................................................1
The OIG’s COVID-19 Oversight of the BOP.............................................................................................................6
Scope and Methodology...........................................................................................................................................8
The BOP’s COVID-19 Response................................................................................................................................8
Results of the Review ................................................................................................................................................. 16
The BOP Should Improve and Retain Effective Practices for Protecting Staff and Inmate Health and
Safety During Public Health Emergencies ........................................................................................................... 17
The BOP Should Take Appropriate Steps to Address Staffing Shortages and Staff Morale ........................ 44
The BOP Should Improve Its Communication of Essential Information to Stakeholders ............................ 62
The BOP Should Provide Clear Guidance on the Use of Healthcare Protective Equipment and
Compliance with Healthcare Safety Guidance ................................................................................................... 75
The BOP Should Respond to Ongoing Pandemic Challenges and Prepare for Future Public Health
Emergencies ............................................................................................................................................................ 82
Conclusion and Recommendations ......................................................................................................................... 99
Conclusion ............................................................................................................................................................... 99
Recommendations ............................................................................................................................................... 100
Appendix 1: Purpose, Scope, and Methodology .................................................................................................. 102
Standards .............................................................................................................................................................. 102
Purpose and Scope .............................................................................................................................................. 102
Methodology ......................................................................................................................................................... 102
Appendix 2: Previous, Related OIG Work .............................................................................................................. 106
Appendix 3: The BOP’s COVID-19 Guidance ......................................................................................................... 109
Guidance for Federal and Contract Prisons ..................................................................................................... 109
Guidance for Residential Reentry Centers ........................................................................................................ 109
Appendix 4: The BOP’s Early Use of Medical Isolation and Quarantine ............................................................ 111
Appendix 5: Factors Affecting COVID-19 Testing Practices and Availability ...................................................... 112
Availability of COVID-19 Tests ............................................................................................................................. 112
CDC Guidance on COVID-19 Testing .................................................................................................................. 112
BOP Use of COVID-19 Rapid Tests ..................................................................................................................... 113
Appendix 6: Home Confinement and Compassionate Release: Key Differences ............................................ 114
Appendix 7: BOP COVID-19 Vaccine Guidance: Priority Levels for Inmate Vaccination (Eliminated in
January 2022) ............................................................................................................................................................ 115
iii
Appendix 8: The BOP’s Response to the Draft Report ........................................................................................ 116
Appendix 9: OIG Analysis of the BOP’s Response ................................................................................................ 120
iv
Introduction
Background
Coronavirus disease 2019 (COVID-19) is an infectious respiratory disease caused by the SARS-CoV-2 virus.
COVID-19 was first identified in December 2019 and spread quickly, reaching the level of global pandemic by
March 2020. By June 2022, there had been over 85 million confirmed cases of COVID-19 in the United
States. The COVID-19 pandemic created challenges for the Federal Bureau of Prisons (BOP) as it worked to
prevent and manage the spread of COVID-19 among its staff and the inmates in its custody. The Centers for
Disease Control and Prevention (CDC) has noted that the confined nature of correctional and detention
facilities, combined with their congregate environments, “heighten[s] the potential for COVID-19 to spread
once introduced” into a facility. Federal inmates typically eat, sleep, and participate in activities in close
proximity to one another in these facilities, which can include custody, housing, healthcare, food service,
education, recreation, and workplace components in a single physical setting. As of June 21, 2022, the BOP
reported that there had been over 60,000 inmate cases and 13,000 BOP staff cases of COVID-19 since the
beginning of the pandemic, as well as 296 inmate deaths and 7 BOP staff deaths attributed to COVID-19.
In response to the COVID-19 pandemic, beginning in April 2020, the U.S. Department of Justice (Department,
DOJ) Office of the Inspector General (OIG) began conducting intensive oversight of the BOP, including
16 remote inspections of facilities housing inmates in BOP custody completed within the first several months
of the pandemic, 5 surveys of BOP staff and inmates conducted at various times, and a collection of interactive
data dashboards reflecting staff and inmate COVID-19 cases and deaths in each BOP facility over time. During
the inspections, we examined how the pandemic affected those facilities and assessed the steps BOP officials
took to prepare for, prevent, and manage COVID-19 transmission within the facilities, as well as whether each
facility’s policies and practices complied with BOP directives implementing CDC guidance and DOJ policy and
guidance. In this capstone report, we highlight the BOP’s response to the pandemic, including an overview of
the themes we identified during the remote inspections, other topics that emerged after those inspections,
and challenges that the BOP will likely continue to face during and after the pandemic. This report seeks to
assist the BOP in managing those challenges and mitigating the effects of future public health emergencies.
The Federal Bureau of Prisons
The BOP is responsible for the care, safekeeping, and subsistence of federal inmates as they serve their
sentences of imprisonment, as well as for providing reentry programming to help them return to the
community. When we began this review, the BOP housed inmates in its custody in three main facility types:
BOP-operated federal prisons, privately operated (contract) prisons, and contracted Residential Reentry
Centers (RRC). In this report, we use the phrase “facilities housing BOP inmates” to encompass all three
facility types. In addition, the BOP has inmates in its custody who are serving their sentence of
imprisonment in home confinement. Below, see Figure 1 for the number of inmates in each facility type and
in home confinement in March 2020, 2021, and 2022.
1
• Federal Prisons: The BOP currently operates 121 federal prisons (also called institutions) across the
country.1 The BOP designates its prisons at five security levels (minimum, low, medium, high, or
administrative) based on a variety of infrastructure and security features. Thirty-nine of the prisons
are located within 15 Federal Correctional Complexes, which encompass multiple facilities of
different security levels in proximity. The BOP also assigns each prison a Care Level from 1 (Low) to
4 (High), based on the institution’s level of medical or mental healthcare staffing and resources. BOP
Health Services staff provide medical care for inmates in federal prisons.
• Contract Prisons: In March 2020, the BOP housed inmates at 12 contract prisons operated by
3 vendors. According to the BOP, the vast majority of federal inmates housed in contract prisons
were criminal aliens or non-U.S. citizens subject to possible deportation. Contract prisons provided
medical care to inmates inside the facilities. In January 2021, President Joseph R. Biden, Jr., signed
Executive Order (E.O.) 14006 instructing the Attorney General not to renew DOJ contracts with
private prisons.2 The last contract ended on November 30, 2022. The BOP transferred inmates
previously housed in contract prisons to federal prisons.
• RRCs: Commonly known as halfway houses, RRCs are contracted to supervise inmates who are
generally nearing completion of their sentences and to help prepare them for their transition back
into the community. RRCs supervise and provide reentry services for inmates assigned to both RRC
facilities and home confinement. Inmates in both RRC facilities and home confinement are in BOP
custody and are therefore included in the population totals in Figure 1 below. Between March 2020
and March 2022, the BOP maintained contracts for services at over 150 RRC facilities operated by
over 75 different vendors nationwide. Unlike federal and contract prisons, RRC facilities do not offer
in-house medical care; inmates receive care from community medical providers.
1
This figure does not include Metropolitan Correctional Center (MCC) New York. In August 2021, the Department
announced that it was closing MCC New York, at least temporarily, to assess steps to improve conditions at the facility.
2
E.O. 14006 on Reforming Our Incarceration System to Eliminate the Use of Privately Operated Criminal Detention
Facilities, January 26, 2021, www.federalregister.gov/documents/2021/01/29/2021-02070/reforming-our-incarceration-
system-to-eliminate-the-use-of-privately-operated-criminal-detention (accessed November 10, 2022).
2
Figure 1
Annual Snapshots of the BOP’s Inmate Population
200,000
175,315
175,000
151,658 153,537
150,000
125,000
100,000
75,000
50,000
25,000
0
March 2020 March 2021 March 2022
Federal Prisons 146,367 124,600 134,231
Contract Prisons 17,519 12,584 6,017
RRC Facilities 8,089 6,141 6,966
Home Confinement 2,649 7,514 5,627
Other 691 819 696
Notes: Less than 1 percent of inmates in BOP custody are housed in other types of facilities, including contract
juvenile facilities and jails or short-term detention facilities.
Source: OIG analysis of BOP public website data
As Figure 1 reflects, the overall BOP inmate population decreased substantially between March 2020 and
March 2021. While we did not examine the specific causes, we note that there are likely several factors
contributing to the decrease in BOP population. For example, the BOP’s inmate population had already
been decreasing each year since a peak in 2013 due to, among other things, various statutory and
sentencing guidelines changes. There was also a substantial drop in the number of federal sentencings in
fiscal year (FY) 2020 as the COVID-19 pandemic affected the work of the Department and the courts,
resulting in far fewer arrests and convictions and therefore fewer people entering BOP custody.3
Additionally, there was an increase in compassionate release motions granted by the courts during
FY 2020.4 The population decrease is unrelated to the increase in the number of inmates in home
3
U.S. Sentencing Commission, 2020 Annual Report and Sourcebook of Federal Sentencing Statistics,
www.ussc.gov/sites/default/files/pdf/research-and-publications/annual-reports-and-sourcebooks/2020/2020-Annual-
Report-and-Sourcebook.pdf (accessed November 16, 2022), 7, 48.
Bureau of Justice Statistics, Federal Justice Statistics, 2020, bjs.ojp.gov/content/pub/pdf/fjs20.pdf (accessed
December 12, 2022), 4.
4
U.S. Sentencing Commission, Compassionate Release: The Impact of the FIRST STEP Act and COVID-19 Pandemic
(March 2022), www.ussc.gov/sites/default/files/pdf/research-and-publications/research-publications/2022/20220310_
compassionate-release.pdf (accessed November 16, 2022), 3.
3
confinement during that same period because, as mentioned above, an inmate transferred to home
confinement remains in the BOP’s custody.
The increase in the number of inmates in home confinement between March 2020 and March 2021 shown
in Figure 1, as we discuss in greater detail in the Results of the Review, was not due to an overall increase in
the number of inmates transferred from BOP facilities to home confinement. Rather, our analysis showed
that fewer inmates were transferred from BOP facilities to home confinement from April 2020 through
March 2021 than were transferred during the prior year (April 2019 through March 2020). We found that, as
described below, the increase was most likely attributable to the fact that inmates were spending longer
amounts of time in home confinement as a result of the Coronavirus Aid, Relief, and Economic Security Act
(CARES Act), passed by Congress in March 2020, which allowed the BOP to transfer inmates to home
confinement with more time remaining on their sentences than allowed under its regular home
confinement authorities, which we discuss below. The CARES Act also allowed prerelease inmates who had
been placed in RRCs to be transferred from RRCs to home confinement earlier than under the BOP’s
standard prerelease process. Eligible inmates residing in RRC facilities whom the BOP transferred to home
confinement increased the home confinement population while decreasing the number of inmates residing
in RRC facilities.
COVID-19 at Facilities Housing BOP Inmates
As mentioned above, the COVID-19 pandemic created significant challenges for the BOP in preventing and
managing the spread of COVID-19 among its staff and the inmates in its custody. In its 2023 Congressional
Budget Submission, the BOP reported that there had been over 60,000 inmate cases of COVID-19 since
March of 2020. According to data presented on the BOP website, as of January 26, 2023, 131 federal
inmates and 130 BOP staff at BOP-managed facilities and RRCs had confirmed positive test results (active
cases); 46,559 inmates and 14,990 staff had recovered from the disease; and there had been 312 inmate
and 7 staff deaths attributed to COVID-19.5 Also as of January 26, 2023, the BOP reported that 55,283
inmates in its custody at that time had received a positive COVID-19 test result at some point. Figures 2 and
3 below show the number of inmate and staff active COVID-19 cases at BOP facilities from March 31, 2020,
through September 30, 2021.
5
“Active cases” includes open and lab-confirmed cases of COVID-19 contracted by inmates or staff in BOP custody or
employment. Once someone has recovered or died, that individual is no longer considered an active case. “Recovered”
reflects the number of inmates or staff in BOP custody or employment but does not include inmates who had been
released or staff who had left BOP employment. Because of these definitions, the number of active and recovered
cases is lower than the total cases reported by the BOP in its 2023 Congressional Budget Submission. We discuss
limitations of the data posted on the BOP’s website in the report section The BOP’s Transparency and Communication
with the Public.
4
Figure 2
Number of Inmate Active Cases in BOP Facilities, March 31, 2020–September 30, 2021
Source: OIG Office of Data Analytics visualization of data collected from the BOP’s public website
Figure 3
Number of Staff Active Cases in BOP Facilities, March 31, 2020–September 30, 2021
Source: OIG Office of Data Analytics visualization of data collected from the BOP’s public website
5
The OIG’s COVID-19 Oversight of the BOP
Between April and June 2020, the OIG conducted remote inspections of 16 facilities housing BOP inmates:
11 BOP-managed federal prisons, 3 privately managed contract prisons, and 2 contracted RRCs.6 The
inspections examined how the pandemic affected each facility; the steps that the BOP took to prepare for,
prevent, and manage COVID-19 transmission; and whether each facility’s policies and practices complied
with BOP directives implementing CDC guidance and DOJ policy and guidance.
Between April 2020 and April 2021, the OIG conducted five surveys to gauge staff and inmate experiences
during the pandemic. In April and May 2020, we conducted three surveys (BOP federal staff, contract prison
staff, and RRC staff) to collect information on staff concerns, effects, and immediate needs at the outset of
the pandemic; we included facility-specific survey results in each of the 15 remote inspection reports. In
February 2021, we conducted a follow-up survey of staff working at the BOP’s federal prisons to collect staff
perspectives on how their respective institutions were managing the pandemic; we presented those survey
results in an interactive web-based product.7 In March and April 2021, the OIG conducted a novel survey of
federal inmates to understand their experiences during the pandemic. After receiving responses from
25,504 inmates, we applied statistical weighting techniques to generate results that represent 123,219 (or
97.5 percent) of the inmates held in BOP-operated facilities at the time of the survey launch.8 Table 1 below
presents the number of responses and response rates to the five OIG surveys of BOP staff and inmates.
6
The OIG published 15 reports for the 16 remote inspections; the results of the inspections of two nearby institutions
are in a single report.
7
See DOJ OIG, “Staff Perceptions of the Federal Bureau of Prisons’ Management of the Coronavirus Disease 2019 Pandemic:
A Follow-up Survey of BOP Staff,” February 2021, experience.arcgis.com/experience/582f32f0127c4c86870b2e129c05b9bc.
8
Because we applied statistical weights, we refer to the estimated percentage of inmates rather than the percentage of
respondents when referencing inmate survey analysis in this report. We plan to present additional results from the
inmate survey in an interactive, web-based product.
6
Table 1
OIG Surveys Issued to BOP Staff and Inmates, April 2020–April 2021
Invitations Open Response Total
Sent Period Rate Responses
Surveys Issued to Staff
Federal Prison Staff (All Staff) 38,651 April 21–29, 2020 28% 10,735
Contract Prison Staff 2,689 May 1–11, 2020 29% 774
Contract RRC Staff 1,514 May 5–12, 2020 26% 395
Total Staff Responses to 2020 Surveys 11,904
Federal Prison Staff (institution only) 34,925 February 2–17, 2021 19% 6,578
Survey Issued to Inmates
Federal Inmates in BOP-Operated Facilities 126,379 March 28–April 27, 2021 20% 25,504
Source: OIG surveys
The OIG also used multiple data sources to better understand trends across facilities housing and
monitoring inmates. We collected data on BOP staff and inmate COVID-19 cases and deaths, inmate testing,
vaccination efforts, home confinement, and modified operations that the BOP posted on its public website.
The OIG published and maintains a collection of interactive dashboards of BOP staff and inmate COVID-19
cases and deaths and inmate testing over time, as well as estimated inmate vaccination percentages.9 (The
text box below lists our COVID-19 oversight work for the BOP.)
Lastly, we received complaints sent to the OIG Hotline by individuals with concerns about the BOP’s
handling of the pandemic, including inmates, their attorneys, friends and family, and BOP staff.10 We
analyzed 3,190 complaints received from February through September 2020 to identify trends; we did not
substantiate or assess the validity of each complaint.
9
DOJ OIG, “Interactive Dashboards Relating to COVID-19 within the Federal Bureau of Prisons,”
experience.arcgis.com/experience/ab22fb4c564e4f4b986e257c685190e8/page/page_0/.
10
If you know about waste, fraud, abuse, misconduct, or whistleblower retaliation within DOJ, you may report it to the
OIG Hotline, oig.justice.gov/hotline.
7
Scope and Methodology
In this capstone review, we highlight the BOP’s response to
the COVID-19 pandemic, present an overview of the themes Remote Inspections
we identified across the remote inspections and surveys
Federal Institutions
described above, discuss topics that emerged following that
1. FCC Lompoc
work, and identify challenges that the BOP will likely 2. FCC Tucson
continue to face during and after the COVID-19 pandemic. 3. MDC Brooklyn
This report seeks to assist the BOP in managing those 4. FCC Oakdale
challenges and mitigating future effects of public health 5. FCC Pollock
6. FMC Fort Worth
emergencies within its facilities. In addition to the remote
7. FCC Coleman
inspections and surveys that we began in April 2020, from 8. FCI Terminal Island
June 2020 through May 2022 we conducted additional 9. FCC Butner
fieldwork, which consisted of document reviews, data 10. FCI Milan
analysis, and additional interviews. We analyzed applicable 11. MCC Chicago
policies and guidance in place through November 2021. Contract Prisons
Due to the summary nature of this product, the scope of the 12. CI Dalby
fieldwork for individual topics and sources varies but 13. CI McRae
generally extends no later than the end of FY 2021. See 14. CI Moshannon Valley
Appendix 1 for a more detailed description of the review Residential Reentry Centers
methodology. See Appendix 2 for a summary of previous 15. Brooklyn House
OIG reviews of the BOP that relate to the topics discussed in 16. Toler House
this review.
Staff and Inmate Surveys
Staff Surveys
The BOP’s COVID-19 Response • April 2020 BOP Federal Staff Survey
• May 2020 Contract Prison Staff Survey
In January 2020, the BOP began planning its response to • May 2020 RRC Staff Survey
reduce the transmission of COVID-19 in facilities housing • February 2021 BOP Staff Survey
BOP inmates. The BOP also established an Incident
Command Center to centrally manage its COVID-19 Inmate Survey
• April 2021 BOP Inmate Survey
response; published guidance for BOP facilities and other
facilities housing BOP inmates; modified its inmate
Dashboards of BOP COVID-19 Data
management system, SENTRY, to collect new COVID-19 data
from each prison; and established a centralized process for The OIG maintains a public collection of interactive
dashboards of BOP staff and inmate COVID-19
collecting data to be published on the BOP’s public website.
cases and deaths and inmate testing data over time.
COVID-19 Guidance Key: CI=Correctional Institution; FCC=Federal
Correctional Complex; FCI=Federal Correctional
CDC and BOP guidance on how to prevent and manage Institution; FMC=Federal Medical Center;
MCC=Metropolitan Correctional Center;
COVID-19 evolved over the pandemic in response to
MDC=Metropolitan Detention Center
improved scientific understanding of the disease and the
scale of the outbreak in the United States. BOP physicians
and other officials consulted with the CDC early during the pandemic and continued working closely with
the CDC throughout the pandemic, basing the BOP’s COVID-19 guidance on CDC guidelines. BOP managers
and medical officials emphasized to us that they based their COVID-19 management strategy on the CDC’s
evidence-based recommendations, which evolved quickly as the CDC and medical community learned more
about the novel virus. As the CDC modified its guidelines for the general public, and subsequently for
8
correctional settings, the BOP progressively updated guidance to the facilities housing federal inmates. To
ensure maximum consistency in virus control measures, BOP Central Office officials directed Wardens to
follow CDC and BOP guidance. On March 23, 2020, the CDC issued interim guidance to provide guiding
principles for healthcare and non-healthcare administrators of correctional and detention facilities, noting
that modifications based on a facility’s individual structure and resources may be needed.11 The BOP
worked with the CDC to develop the CDC’s interim guidance, and the BOP’s guidance to its federal and
contract prisons mirrored this guidance.
In late August 2020, the BOP began issuing consolidated guidance in its COVID-19 Pandemic Response Plan,
which includes 11 modules on topics such as infection prevention and control measures; screening and
testing; inmate programming and services; and BOP employee, volunteer, and contract staff management.
The BOP posted the COVID-19 Pandemic Response Plan on its intranet for staff to reference and continued
to update it throughout 2020, 2021, and 2022 based on guidance from stakeholders, including the CDC and
DOJ; the BOP intends to continue updating the plan as the CDC updates its COVID-19 guidance. See
Appendix 3 for more information on the BOP’s guidance to federal prisons, contract prisons, and RRCs.
Modified Operations and Social Distancing
The BOP implemented modified operations intended to help mitigate the spread of COVID-19 and
implement social distancing inside BOP facilities. In its March 13, 2020 Phase Two Action Plan, the BOP
announced that it was suspending inmates’ in-person social and legal visits, stopping nonmedical inmate
transfers, canceling staff travel and training, restricting contractors’ and volunteers’ access to BOP facilities,
and requiring Wardens to modify operations to maximize social distancing by staggering inmates’ meal and
recreation times. In its March 31, 2020 Phase Five Action Plan, the BOP began requiring inmates to remain
in their cells or housing units for extended periods based on health concerns. Some facilities described this
action as a “Shelter in Place” or a similar term to distinguish it from a punitive lockdown. These movement
and gathering restrictions remained in place until the BOP’s August 5, 2020 Phase Nine Action Plan
instructed inmate programming, including residential programs and Evidence-based Recidivism Reduction
Programs and Productive Activities, to resume with social distancing modifications; instructed the
resumption of outdoor recreation time, not including group sports or use of gym equipment; and instructed
Wardens to develop safety plans to restore UNICOR operations to 80 percent capacity by September 1,
2020, and to 100 percent by October 1, 2020.12 The BOP’s August 31, 2020 Modification of Phase Nine
Action Plan provided guidance for the safe resumption of in-person social visits at facilities. The BOP’s
Phase Two Action Plan measures were initially scheduled to last 30 days, and the Phase Five Action Plan
referenced the enactment of a 14-day nationwide action to minimize movement to decrease the spread of
the virus. The BOP extended most of these measures multiple times until November 2020, when they were
extended until further notice.
11
CDC, “Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention
Facilities,” March 23, 2020 (updated May 3, 2022), www.cdc.gov/coronavirus/2019-ncov/community/correction-
detention/guidance-correctional-detention.html (accessed July 11, 2022).
12
Federal Prison Industries, called UNICOR, is a government corporation within the BOP that offers work opportunities
and job training for inmates at federal prisons throughout the United States.
9
In August 2021, the BOP moved to a Modified Operations Matrix Plan that provided guidance on how
facilities should modify their operations based on the individual facilities’ COVID-19 medical isolation rates,
percentages of staff and inmates who had completed a COVID-19 vaccination series, and the local county
transmission rates of COVID-19.13 The BOP’s public website provided updates on facilities’ operational levels
on a scale of Level 1 to Level 3, with guidance for Level 1 facilities to generally follow normal operations and
Level 3 facilities to implement more restrictive COVID-19 related modifications. Under this Modified
Operations Matrix Plan, the BOP also provided guidance for general COVID-19 modifications to all facilities
regardless of their operational levels. In November 2022, the BOP removed from its Modified Operations
Matrix Plan the direction that facilities consider staff and inmate vaccination rates as indicators for modified
operations; the BOP’s Modified Operations Matrix Plan, as reflected in its November 30, 2022 COVID-19
Pandemic Response Plan, directed facilities to consider two primary factors in modifying operations: facility
COVID-19 medical isolation rates and COVID-19 community risk.
Personal Protective Equipment and Cloth Face Coverings
The BOP issued its first consolidated guidance on the use of
personal protective equipment (PPE) in specific COVID-19 CDC Definitions
scenarios on March 18, 2020, and updated it several times as PPE: a variety of barriers used alone or in
the pandemic progressed.14 The BOP issued guidance on the combination to protect mucous membranes,
use of cloth face coverings on April 6, 2020. The BOP skin, and clothing from contact with
disseminated its PPE instructions to staff via email and made infectious agents. Depending on the
them available on its employee intranet. Beginning in August situation, PPE may include gloves, surgical
2020, the BOP also updated its PPE and face covering masks, N95 respirators, goggles, face shields,
guidance in versions of its COVID-19 Pandemic Response Plan and gowns.
posted to its employee intranet. The BOP’s PPE and cloth face Cloth Face Coverings: items fashioned from
covering instructions mirrored CDC recommendations on common materials or household items that
using PPE in correctional facilities and cloth face coverings are intended to keep the wearer from
where social distancing is difficult to maintain (see the text spreading respiratory secretions when
box). These instructions identified three types of protection talking, sneezing, or coughing. The CDC does
not consider cloth face coverings to be PPE.
for an individual’s nose and mouth and described the
situations in which each type of protection should be used: Source: CDC
• N95 Respirators: Tight-fitting masks that filter out at least 95 percent of airborne particles and
provide the wearer with respiratory protection. The BOP’s instructions advised that N95 respirators
were for use by staff working on units with inmates in medical isolation, staff present when inmates
received certain medical procedures, and staff in close contact with an inmate suspected of or
confirmed with COVID-19. The BOP’s March and April 2020 guidance, which followed CDC guidance,
13
Isolation is used to separate people who have a confirmed or suspected case of COVID-19 from people who are not
infected to prevent contact and reduce the risk of transmission. In a correctional setting, the CDC recommends using
the term “medical isolation” to distinguish the isolation from punitive action. See CDC, “Interim Guidance.”
14
Prior to March 18, the BOP’s Action Plans recommended PPE for individuals in close contact with someone diagnosed
with COVID-19 and for people performing temperature screenings. The guidance also recommended educating staff
about how to correctly put on and take off PPE.
10
noted that N95 respirators were in short supply and permitted the use of surgical masks in certain
situations if no N95s were available.
• Surgical Masks: Loose-fitting, fluid-resistant masks that protect the wearer against large droplets,
splashes, or sprays of bodily or other hazardous fluids and protect others from the wearer’s
respiratory emissions but do not provide the wearer with respiratory protection. Surgical masks are
for use by staff working in quarantine units, as well as inmates in medical isolation or quarantine.
The BOP’s October 2020 update to its COVID-19 Pandemic Response Plan states that staff should
also wear surgical masks when providing routine health services to inmates and performing staff
screening and temperature checks.
• Cloth Face Coverings: Reusable nose and mouth coverings made of cloth worn to help reduce the
spread of COVID-19 by asymptomatic persons. Pursuant to CDC guidelines, the BOP does not
consider cloth face coverings to be PPE. Rather, they are for use by staff and inmates in all areas of
the facility other than medical isolation or quarantine units. The BOP’s April 6, 2020 guidance
advised that UNICOR was manufacturing cloth face coverings for all facilities and the BOP would
issue all staff and inmates three cloth face coverings for personal use. In an email to all staff on
April 15, 2020, the BOP mandated that “all BOP staff and inmates will wear face coverings provided
by [the BOP].” On August 24, 2020, the BOP issued a memorandum stating that facility staff are
required to wear facility-approved face coverings at work when social distancing is not possible and
in common areas. When the BOP moved to its Modified Operations Matrix Plan in August 2021,
staff and inmates were instructed to wear cloth face coverings according to the instructions for their
facility’s modified operations level.
Medical Isolation and Quarantine
Medical isolation and quarantine are measures that help
prevent the spread of COVID-19 (see the text box). CDC Definitions
Throughout the pandemic, BOP facilities ideally had a variety Medical Isolation: confinement of an
of physically separate quarantine and medical isolation individual with a confirmed or suspected
spaces: medical isolation for inmates with confirmed COVID- COVID-19 case to prevent contact with others
19, medical isolation for inmates with suspected COVID-19, and to reduce the risk of transmission.
quarantine for close contacts of those with confirmed or Quarantine: confinement of an individual
suspected COVID-19, quarantine for incoming inmates, and who has had close contact with a COVID-19
quarantine for outgoing inmates. For more detailed case to determine whether that individual
information on the BOP’s early use of medical isolation and develops symptoms of the disease.
quarantine as part of its approach to COVID-19, see Source: CDC
Appendix 4.
COVID-19 Testing
Viral COVID-19 testing is used to diagnose or screen individuals for current infection with SARS-CoV-2, the
virus that causes COVID-19. The BOP’s protocols surrounding COVID-19 testing evolved over the pandemic
and with changes in CDC recommendations, availability of tests, and COVID-19 outbreaks in facilities
housing BOP inmates. (See Appendix 5 for more detailed information on factors that affected the BOP’s
testing protocols.) As a result, COVID-19 testing at facilities housing BOP inmates also evolved:
11
• Testing at Federal Prisons: The BOP’s initial guidance on COVID-19 testing mirrored the CDC’s
guidance and limited testing to only symptomatic inmates consistent with local health authority
protocols. In late April 2020, the BOP announced that it had acquired rapid test equipment and that
it would begin to expand testing of asymptomatic inmates to “assist the slowing of transmission [by]
isolating those individuals who test positive and quarantining contacts.” However, due to
equipment availability, it took several weeks for all BOP facilities to receive rapid test machines and
test kits. On May 19, the BOP published guidance identifying high, intermediate, and low testing
priorities for facilities that were limited in the number of tests they could conduct. As access to
testing supplies stabilized over the following months, the BOP again expanded its testing strategies.
On September 28, the BOP identified indications for testing both symptomatic and asymptomatic
inmates and noted that facilities should consult with BOP medical officials to prioritize testing if a
facility’s ability to test was limited.
• Testing at Contract Prisons: Contract prisons received the same BOP guidance on testing as part of
the BOP’s Action Plans issued between March and October 2020. Like the federal prisons, all
contract prisons housing BOP inmates acquired rapid testing equipment for COVID-19.
• Testing at RRCs: The RRC contractual model relies on community providers for inmate healthcare,
including medical tests, so COVID-19 testing was not directly provided at these types of facilities.
Instead, inmates at RRC facilities and in home confinement under RRC supervision relied on testing
resources in the local community.
COVID-19 Vaccination
Both the CDC and the BOP have identified COVID-19 vaccination as an important tool for controlling the
spread of the virus and reducing serious illness and death from COVID-19. According to the CDC, COVID-19
vaccines reduce the risk of COVID-19, including the risks of serious illness and death among people who are
fully vaccinated, and can reduce the spread of disease, which helps protect those who get vaccinated and
the people around them. As of January 2022, there were three COVID-19 vaccines authorized or approved
for adults in the United States.
In November 2020, the BOP began planning for the distribution of COVID-19 vaccines for staff and inmates
in federal prisons. The BOP developed a vaccine task force and worked in partnership with Operation Warp
Speed, a government-led public-private partnership between various entities to facilitate and accelerate the
development, manufacturing, and distribution of the vaccine across the United States. The BOP also
worked with the CDC, developing a memorandum of agreement to receive and administer the vaccines at
no cost to the BOP. The BOP first offered the COVID-19 vaccine to full-time staff due to the risk of possible
introduction of the virus by staff traveling between BOP facilities and the community. The BOP distributed
remaining doses of the vaccine to inmates based on priority levels determined by its COVID-19 Vaccine
Guidance, which outlines four priority levels for vaccinating inmates in federal facilities. These levels
prioritized inmates in certain jobs and housing situations, inmates 65 years and older, and inmates with
underlying medical conditions as eligible to receive the vaccine first.
The BOP offered all staff and federal inmates the vaccine on a voluntary basis. In September 2021, an
Executive Order required COVID-19 vaccination for all federal employees subject to exemptions as required
12
by law.15 Federal inmates are not required to receive the COVID-19 vaccine, and the BOP told us that
historically inmate vaccinations are not required unless court ordered. Inmates and staff located at RRCs
and contract prisons (when they were in operation) are referred to community resources, such as state and
local health departments, to receive COVID-19 vaccinations. Inmates housed at RRCs and contract prisons
were not part of the total CDC allotments of the vaccines distributed to the BOP under the current
memorandum of agreement.
Home Confinement
BOP inmates with less than 12 months remaining on their sentences are typically eligible for transfer to an
RRC, and some of these RRC-eligible inmates are permitted to complete the final portion of their sentences
(10 percent or 6 months, whichever is shorter) in home confinement, under the supervision of an RRC or the
U.S. Probation Office per 18 U.S.C. § 3624(c)(2).16 Additionally, under the FIRST STEP Act of 2018 (FSA),
inmates age 60 or older are eligible for home confinement for the last third of their sentences and
terminally ill inmates are eligible for longer periods of home confinement if they meet certain additional
eligibility criteria.17 Inmates on home confinement are still in federal custody. They may work and
participate in approved activities but must otherwise remain at home. Inmate compliance with these
conditions is monitored through electronic monitoring equipment or regular contact with supervisory staff,
in person or by telephone. An inmate’s failure to remain at approved locations, return at required times, or
otherwise follow the program rules may result in disciplinary action, including return to a BOP facility.
In a March 26, 2020 memorandum, then Attorney General William P. Barr directed the BOP to prioritize the
use of its existing statutory authorities to grant home confinement, described above, and provided a non-
exhaustive list of factors for the BOP to consider when assessing inmates for home confinement placement.
CARES Act Home Confinement
On March 27, 2020, one day after then Attorney General Barr’s memorandum, the CARES Act was signed
into law, authorizing the BOP Director to lengthen the maximum amount of time under 18 U.S.C.
§ 3624(c)(2) that an inmate may be placed in home confinement “if the Attorney General finds that
emergency conditions will materially affect the functioning of the [BOP].”18 Barr made such a finding in an
April 3, 2020 memorandum, in which he directed the BOP to “immediately maximize appropriate transfers
to home confinement of all appropriate inmates” at those facilities “where COVID-19 is materially affecting
15
E.O. 14043 on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, September 9, 2021,
www.federalregister.gov/documents/2021/09/14/2021-19927/requiring-coronavirus-disease-2019-vaccination-for-
federal-employees (accessed November 10, 2022).
16
According to the BOP, the U.S. Probation Office monitors a small percentage of BOP inmates on home confinement
though a program called Federal Location Monitoring. Participation is contingent on whether the U.S. Probation Office
accepts the BOP’s home confinement referral. Most inmates on home confinement are monitored by an RRC.
17
See 34 U.S.C. § 60541(g). The FSA reauthorized and modified a pilot program for eligible elderly and terminally ill
offenders that was conducted under the Second Chance Act of 2007. Eligibility criteria ruled out inmates who had been
convicted of crimes of violence, sex offense, terrorism, or espionage; had a history of escape or attempted escape; or
posed a substantial risk to the public or of criminal conduct if granted home confinement.
18 Coronavirus Aid, Relief, and Economic Security Act, Pub. L. No. 116-136.
13
operations.”19 This finding expanded the pool of inmates who could be considered for home confinement
by allowing the BOP to consider inmates for placement earlier than they would have been eligible
otherwise.20
The CARES Act did not specify what should happen to inmates on CARES Act home confinement after the
pandemic ends. In January 2021, the DOJ Office of Legal Counsel published an initial opinion stating that the
BOP would be required to recall inmates currently on home confinement to BOP facilities after the COVID-
19 emergency period ends unless the inmates are otherwise eligible for home confinement under 18 U.S.C.
§ 3624(c)(2).21 That would have meant that only inmates with less than 6 months or 10 percent of their
sentence remaining would have been allowed to remain in home confinement and the BOP would have had
to return inmates who did not meet those eligibility requirements to BOP facilities at the end of the
pandemic. The Office of Legal Counsel reversed this opinion on December 21, 2021, concluding that the
CARES Act language and the BOP’s preexisting home confinement authorities give the BOP discretion to
permit inmates in extended home confinement to remain there after the COVID-19 emergency period ends.
In June 2022, the Department published a regulatory proposal consistent with the December 21, 2021 Office
of Legal Counsel opinion.
Comparison of Home Confinement to Compassionate Release
Under the federal compassionate release statutes, 18 U.S.C. § 3582(c)(1)(A) or 18 U.S.C. § 4205(g), as
applicable, the BOP or an inmate may request that a federal judge reduce the inmate’s sentence for
“extraordinary and compelling reasons,” such as age, terminal illness, other physical or medical conditions,
or family circumstances.22 Home confinement and compassionate release authorities have different
eligibility criteria, approval processes, and decision makers, all of which we summarize in Appendix 6. A
primary difference is that, while home confinement allows an inmate to serve a portion of his or her
sentence at home while still in BOP custody, compassionate release generally ends an inmate’s sentence
early. Additionally, while home confinement authorities were expanded by the CARES Act and through the
Attorney General’s memoranda, compassionate release authorities were not expanded. When responding
to compassionate release motions filed by inmates with the courts, the Department’s position has been that
the risk of contracting COVID-19 alone is not an “extraordinary and compelling circumstance” warranting
19 William P. Barr, Attorney General, memorandum for Director of Bureau of Prisons, Increasing Use of Home
Confinement at Institutions Most Affected by COVID-19, April 3, 2020, www.justice.gov/file/1266661/download (accessed
July 11, 2022), 1.
20
The OIG is conducting a separate review of the BOP’s use of home confinement as a response to the COVID-19
pandemic. That review is assessing the BOP’s processes for implementing its home confinement authorities under the
CARES Act, considering the eligibility criteria outlined in the Attorney General’s memoranda, and evaluating Wardens’
recommendations for inmates who did not meet the Attorney General’s criteria to be placed in home confinement.
21
The then President declared the COVID-19 pandemic a national emergency on March 13, 2020. Under the CARES Act,
the expanded home confinement authority will end “30 days after the date on which the national emergency declaration
terminates.”
22
18 U.S.C. § 3582(c)(1)(A) is applicable for inmates whose offenses occurred on or after November 1, 1987. 18 U.S.C.
§ 4205(g) was repealed effective November 1, 1987, but remains the controlling law for inmates whose offenses
occurred prior to that date.
14
compassionate release.23 Although 13 of our 15 remote inspection reports briefly discuss the
compassionate release requests the respective facilities received during the first several weeks of the
pandemic, we do not examine compassionate release requests and outcomes in this capstone report.
23
See, for example, Response by the United States in Opposition to Defendant’s Emergency Motion for Immediate
Reduction of Sentence at 13-17, United States of America v. Saad, No. 16-cr-20197 (E.D. Mich. 2020), and Government’s
Response to Defendant’s Motion for Compassionate Release at 9-11, United States of America v. Franco, No. 14-10205-
01-EFM (D. Kan. 2020).
15
Results of the Review
The COVID-19 pandemic required the BOP to adapt to unique challenges in trying to prevent and manage
the spread of COVID-19 and protect inmate and staff health and safety while adhering to changing guidance
and communicating essential public health information to stakeholders. Our remote inspections, staff and
inmate surveys, and review of other BOP information identified several areas in which the BOP should take
action to better prepare for future public health emergencies and improve and address existing processes
whose weaknesses, and in some cases failures, were highlighted during the pandemic. We identified
particularly serious failures by BOP facilities in their compliance with the BOP’s March 2020 guidance on the
single-celling of inmates during modified operations and their handling of inmates vulnerable to suicide while
quarantined due to COVID-19. These findings, coupled with prior OIG findings regarding the mental health
effects of the BOP’s placement of inmates in single cells for extended periods of time, led us to conclude that
the BOP should undertake a comprehensive review of its policies regarding the single-celling of inmates.
We also found that medical and nonmedical staffing shortages at a number of BOP facilities had predictable
and significant ramifications on their ability to respond effectively to the pandemic. We determined that the
BOP should take steps to address its staffing shortages, as well as staff morale issues that arose during the
pandemic, and that it also needs to improve its processes for communicating essential information to
stakeholders and correct a significant deficiency that we identified regarding its notification to families about
inmates’ COVID-19 related serious illnesses.
Further, we found that the BOP should improve certain processes to mitigate the risk of infection transmission
inside facilities and protect the health of staff and inmates while also retaining best practices to prepare for
future pandemics. Among the challenges that we found the BOP faced during the COVID-19 pandemic was
the limitation on its ability to maintain social distancing in many of its prisons and to ensure that there was
sufficient space to appropriately medically isolate inmates who had COVID-19 symptoms, quarantine those
who had been exposed to inmates with symptoms, and quarantine incoming and outgoing inmates. Yet,
despite these challenges, our remote inspections concluded that, at a number of facilities, the BOP did not
fully leverage the home confinement authorities that it was given in the Coronavirus Aid, Relief, and Economic
Security Act (CARES Act) that could have permitted facilities to reduce their inmate population and thereby
assist in mitigating COVID-19 transmission and improve inmate-to-staff ratios. Indeed, we found that, overall,
the number of inmates whom the BOP transferred from facilities to home confinement was lower during the
first year of the pandemic (April 2020 through March 2021) compared to the prior year, though we note that,
due to the decreasing inmate population overall, the percentage of inmates transferred to home confinement
was similar for both years. We determined that the BOP should assess how lessons learned related to the use
of its home confinement authorities during the COVID-19 pandemic could apply to future public health
emergencies and that it should monitor the challenges that can arise related to a significant increase in home
confinement use.
Finally, we identified several other areas that the BOP should address, including inmate access to counsel and
other essential services during emergency or modified operations, as well as taking additional actions to better
prepare for potential future public health emergencies.
16
The BOP Should Improve and Retain Effective Practices for Protecting Staff and Inmate
Health and Safety During Public Health Emergencies
Throughout the COVID-19 pandemic, to protect staff and inmate health and safety, the BOP needed to
adapt to unique challenges in trying to prevent and manage the spread of COVID-19 in its facilities and in
contract facilities housing BOP inmates. We found that some related BOP processes must be reassessed or
require further improvements to better protect the health and safety of inmates and staff. For example, we
identified serious failures by BOP facilities in their compliance with the BOP’s March 2020 guidance regarding
the single-celling of inmates during modified operations and found that the BOP’s existing practices were not
sufficient to protect inmates vulnerable to suicide while quarantined due to COVID-19. The BOP should
comprehensively review existing policies and processes on single-cell confinement, as well as those designed
to protect inmates vulnerable to suicide. Additionally, we found that the BOP should ensure that it captures
lessons learned during the pandemic. Identifying and retaining best practices for inmate social distancing,
quarantine, and medical isolation, especially those that address space and infrastructure limitations, by
incorporating them into standard operations and pandemic contingency plans will help the BOP respond
effectively to future public health emergencies. Assessing how lessons learned in the BOP’s use of home
confinement during the pandemic could apply to other public health emergencies could also help the BOP
respond more effectively in the future.
The BOP Should Ensure that Its Processes Prevent Inappropriate Single-Cell Assignments and
Protect Inmates Vulnerable to Suicide When Quarantined
The BOP reported to the OIG that from March 2020 through April 2021 seven inmates died by suicide while
housed in single-cell confinement in quarantine units related to COVID-19. Our review identified serious
failures by BOP facilities in their compliance with the BOP’s March 2020 guidance regarding the single-celling
of inmates during modified operations. One provision of the BOP guidance stated that facilities should limit
single-celling of inmates (i.e., housing inmates alone in cells) to the greatest extent possible when inmates
were confined to their cells during COVID-19 related modified operations. Contrary to this provision, we
found that inmates in numerous BOP facilities were single-celled during periods when the facilities were in
COVID-related modified operations.
An additional provision of the March 2020 guidance advised facilities that Psychology Services staff should
be consulted regarding any inmates proposed for single-celling to assess whether they were vulnerable
inmates. Yet, we found that psychology staff did not assess the suitability of single-cell assignments for at
least five of the seven inmates who died by suicide prior to their single-cell placement. Further, postmortem
documentation indicated that all seven inmates had factors that made them vulnerable to suicide.
According to internal BOP documentation, a single-cell environment may afford an inmate greater privacy
and increased opportunity to effectuate their death by suicide. We also noted that the BOP has had
ongoing challenges with the use of single-cell confinement. Our 2017 report on the BOP’s use of restrictive
housing for inmates with mental illness noted that single-celling may present risks to inmate mental health,
17
and both of our recommendations from that report regarding the use and oversight of single-celling
remained open as of February 2023.24
Guidance on Single-Celling During the COVID-19 Pandemic
At the outset of the pandemic, BOP directives to limit single-celling of inmates warned about the risks of
single-celling and inmate suicide. On March 13, 2020, the Assistant Director of the Reentry Services Division
(RSD) issued to all Wardens a memorandum that stated, “If inmates are confined to their cells, single celling
should be eliminated to the greatest extent possible to reduce the isolation and privacy that can facilitate
suicide.” The memorandum further stated, “Psychology Services staff should be consulted regarding any
inmates proposed for single celling to ensure they are not particularly vulnerable individuals and/or to make
recommendations.” The BOP incorporated this memorandum language into its October 2020 COVID-19
Pandemic Response Plan and its subsequent versions.25
On March 23, 2020, the CDC published guidance for correctional facilities that identified the housing of
inmates in quarantine separately in single cells as the ideal practice from an infection control perspective.26
However, contemporaneous BOP guidance issued by the RSD, described above, directed Wardens to limit
single-celling to reduce the risk of inmate suicide and did not make exceptions for inmates housed in
quarantine units. On February 1, 2021, almost 1 year later, the RSD issued to Wardens another
memorandum, which stated, “Single celling must stop, particularly in restrictive housing and quarantine,
except when approved by the Warden on a case by case basis.” The RSD memorandum noted that from
October 1, 2020, through February 1, 2021, 15 total inmates had died by suicide, 12 of whom were single-
celled at the time of their deaths. Four of those 12 inmates who died by suicide were in single cells related
to COVID-19 quarantine, while the remaining 8 were in single cells for other reasons.27 One additional
inmate suicide occurred in a COVID-19 quarantine unit after the RSD issued this directive, in addition to two
24
DOJ OIG, Review of the Federal Bureau of Prisons’ Use of Restrictive Housing for Inmates with Mental Illness,
Evaluation and Inspections (E&I) Report 17-05 (July 2017), oig.justice.gov/reports/review-federal-bureau-prisons-use-
restrictive-housing-inmates-mental-illness.
In response to a draft of this report, the BOP stated that since May 2021 it has implemented two successive Restrictive
Housing Work Groups to reduce the number of individuals in restrictive housing and to make restrictive housing safer
for all individuals who are placed there. Because this occurred after the period of our review, we did not assess the
efficacy of the work groups.
25
For example, the BOP’s November 30, 2022 COVID-19 Pandemic Response Plan stated, “If medical isolation in single
cells is necessary (inmates are not cohorted), Psychology Services staff should be consulted to ensure inmates proposed
for single celling are not particularly vulnerable individuals and/or to make recommendations.” The COVID-19 Pandemic
Response Plan also stated, “If quarantining in single cells is necessary (inmates are not cohorted), consult Psychology
Services staff for mental health suitability for placement in single cell.”
26
As described in the Introduction to this report, “quarantine” refers to the confinement of an individual who has had
close contact with a COVID-19 case to determine whether that individual develops symptoms of the disease. The BOP
used quarantine for incoming inmates, inmates who were close contacts of those with confirmed or suspected COVID-
19, and outgoing inmates. During our remote inspections, we learned that some facilities used vacant housing units for
quarantine purposes.
27
We made this determination based on the number of single-celled inmate suicides in quarantine units that the BOP
reported to the OIG in April 2021. The OIG did not review the circumstances of all inmate suicides presented in the RSD
memorandum or the reasons that the BOP single-celled the eight inmates who were not part of our review.
18
inmate suicides that occurred prior to October 1, 2020, for a total of seven inmate suicides in COVID-19
quarantine units between March 2020 and April 2021. In connection with this capstone report, we reviewed
these seven inmate suicides.
The required internal BOP psychological reconstruction reports following the seven inmate suicides that
occurred in COVID-19 quarantine units recommended that those facilities avoid single-celling inmates and
also recommended that they document decisions about single-cell placement.28 Although BOP policy did
not require facilities to use a single-cell approval form, our review found that some BOP facilities had
successfully implemented the use of such a form.29 At facilities that used this form, single-celling inmates
required the Warden’s approval with input from correctional supervisors, the Unit Manager, and the Chief
Psychologist prior to single-celling an inmate. However, we found no evidence that any of the facilities that
housed the seven inmates whose cases we reviewed used such a form at the time of the inmates’ single-cell
assignments. A detention center where one of the inmate suicides occurred utilized such a form prior to
the pandemic but did not use it in the case of the inmate who died by suicide during the pandemic. The
BOP’s psychological reconstruction documentation noted that the detention center did not consistently use
the single-cell request form during the pandemic due to “competing quarantine and isolation needs.”
We found that five of the BOP’s psychological reconstruction reports recommended that facilities implement
enhanced documentation or procedures to ensure that relevant staff receive notifications about who is
single-celled and to minimize the amount of time any inmate is housed in a cell alone. One report
recommended that a facility develop staff notification procedures to decrease the number of single-celled
inmates, including inmates in quarantine.
We have the same concerns about the BOP’s single-celling of inmates that we identified in our 2017
restrictive housing review, which found that single-cell confinement may present added risks to inmate
mental health. Our 2017 review also found that the BOP did not track its housing of inmates in single-cell
restrictive housing unit confinement and that policies addressing single-cell confinement were inadequate.
As of February 2023, the BOP had yet to fully implement six of our 2017 recommendations, including five
recommendations regarding the BOP’s policies and tracking of single-cell confinement and restricted
28
See BOP Program Statement 5324.08, Suicide Prevention Program, April 5, 2007, www.bop.gov/policy/progstat/5324_008.pdf
(accessed July 11, 2022). The policy provides guidance regarding the completion of an after-action review, or
psychological reconstruction report, by a BOP psychologist in the event of an inmate suicide. The report includes
background information about the inmate, the circumstances surrounding the inmate’s death, a conclusion, and
recommendations. The OIG did not conduct investigative analysis of the BOP’s psychological reconstruction
documentation or independently assess the BOP’s psychological reconstruction findings and recommendations.
29
In response to a draft of this report, the BOP stated that in May 2021 it established a Single Cell Task Force to review
single-celling practices and inmate suicide and to provide recommendations to reduce single-celling and provide
increased oversight for those housed alone. The BOP stated that it has since implemented several of the task force’s
recommendations and, based on the task force’s work, has provided guidance to each region concerning regular review
and oversight of those housed alone. The BOP further stated that each region has provided a single-cell review form to
facilities and requires regular oversight and reporting of the use of single cells to the Regional Office. Because
establishment of the task force and these practices occurred after the period of our review, we did not assess their
efficacy. Finally, the BOP stated that vulnerable inmates may at times need to be single-celled due to their level of
disruptive behavior, isolation, or quarantine.
19
housing, two of which specifically address single-celling.30 In response to these recommendations, the BOP
stated that as of September 2022 it had completed final steps for approval of its revised Special
Management Unit (SMU) policy and that it had planned to conduct discussions with the national union
regarding revisions to its Special Housing Unit (SHU) policy.31 The BOP also stated that as of September
2022 it had developed a SHU mental health dashboard extension to its SHU dashboard program that would
generate rosters of inmates housed in a SHU and include inmate mental healthcare level assignments, the
length of time they had spent in a SHU, the number of days they had been single-celled, and other
information. Further, the BOP has struggled to enforce multiple directives to limit single-celling at facilities
during the pandemic.32 The occurrence of inmate suicide in single-celled quarantine units at many facilities
presents a significant risk for the BOP in ensuring inmate safety.
Use and Conditions of Single-Celling in Quarantine Units
All seven single-celled inmate suicides we reviewed occurred by hanging. One of the inmate suicides
occurred after Health Services staff failed to conduct pill line in restrictive housing for 2 days, in violation of
the BOP’s Patient Care policy, resulting in the inmate missing two doses of antidepressant medication.33
Staff failure to conduct pill line was reportedly due to staffing issues, which are more broadly discussed in
The BOP Should Take Appropriate Steps to Address Staffing Shortages and Staff Morale section of this
report, as well as staff error. Separately, initiation of lifesaving measures for one inmate who died by
30
DOJ OIG, Use of Restrictive Housing. Five of the open recommendations regarding the BOP’s policies and tracking of
single-cell confinement and restricted housing are to: (1) establish in policy the circumstances that warrant the
placement of inmates in single-cell confinement while maintaining institutional and inmate safety and security and
ensuring appropriate, meaningful human contact and out-of-cell opportunities to mitigate mental health concerns; (2)
define and establish in policy extended placement in measurable terms; (3) track all inmates in single-cell confinement
and monitor, as appropriate, the cumulative amount of time that inmates with mental illness spend in restrictive
housing, including single-cell confinement; (4) identify all forms of restrictive housing utilized throughout its institutions
and ensure that all local policies are updated to reflect standards for all inmates in restrictive housing consistent with
established nationwide policies; and (5) evaluate and limit as appropriate the consecutive amount of time that inmates
with serious mental illness may spend in restrictive housing. Recommendations 1 and 3 are related to single-cell
confinement. A sixth open recommendation is specific to a restrictive housing unit at one BOP facility.
31
BOP Program Statements 5217.02, Special Management Units, August 9, 2016, www.bop.gov/policy/progstat/5217_02.pdf,
and 5270.11, Special Housing Units, November 23, 2016, www.bop.gov/policy/progstat/5270.11.pdf (both accessed
November 9, 2022). A SMU is a type of restrictive housing that the BOP established to house inmates who require
greater management of their interactions with others to ensure the safety, security, or orderly operation of BOP
institutions and to protect the public. The BOP defines SHUs as “housing units in Bureau institutions where inmates are
securely separated from the general inmate population, and may be housed either alone or with other inmates.”
32
In response to a draft of this report, the BOP stated that the Psychology Services Branch provides quarterly reviews
of common recommendations and concerns detailed in psychological reconstruction reports and disseminates that
information to Wardens for training purposes. Additionally, the BOP stated that facilities with increased rates of suicide
(two suicides in 2 years) receive Risk Reduction Reviews from a multidisciplinary BOP team to examine adherence to
psychological reconstruction recommendations, compliance with relevant policy, issues of facility culture, and training
needs. The BOP stated that as of February 2023 it had completed these reviews at multiple facilities.
33
BOP Program Statement 6031.01, Patient Care, June 31, 2014, www.bop.gov/policy/progstat/6031_004.pdf (accessed
July 11, 2022). “Pill line” refers to BOP medical staff’s administration of prescribed medication to inmates, during which
staff may directly observe inmates consuming their medication.
20
suicide were delayed for several minutes because officers did not have immediate access to keys to the
inmate’s cell door, which was inconsistent with the BOP’s Patient Care policy.34
BOP psychological reconstruction reports found that two inmates who had recently entered BOP custody
and were recent arrivals to their facilities likely experienced opioid withdrawal symptoms prior to their
suicides. The reconstruction teams recommended that both facilities update local procedures to improve
opioid withdrawal monitoring. One report recommended that staff conceptualize opioid withdrawal as an
acute risk for suicide and that the facility’s Psychology Services Division staff complete additional Suicide
Risk Assessment (SRA) training.35
According to the BOP’s psychological reconstruction reports, conditions of confinement in the quarantine
unit may have contributed to inmate hopelessness and depression. In a description of quarantine unit
conditions, one reconstruction report noted that “[staff] rounds and puzzles are not sufficient for occupying
one’s mind for what was likely 112 waking hours per week.” Another report observed that inmates in the
quarantine unit had only three 15-minute periods per week in which they were permitted out of their cells.
According to one reconstruction report, quarantine and isolation conditions limited access to resources that
can prevent suicide, such as peer support, psychology services, and telephones to call family or counsel.
The BOP also found no evidence that one of the inmates was provided any educational or recreational
activities or offered telephone calls, despite Regional Office direction that inmates be afforded
programming and two 15-minute phone calls per month.
Additionally, we found that two of the inmates who died by suicide had both completed the BOP’s required
14-day quarantine period for inmates newly admitted to a BOP facility and tested negative for COVID-19. As
a result, under BOP guidance, they could have been removed from single-cell quarantine at the time of their
deaths.36 However, we found that two of the inmates who died by suicide remained in quarantine for 2 to 3
days after receiving their negative COVID-19 test results. In both cases, the reconstruction reports noted
that the inmates would have been placed with cellmates had the BOP removed them from quarantine.
34
The Patient Care policy says, “ACA standards require a four-minute response to life- or limb-threatening medical
emergencies.”
35
We did not consider the totality of potential suicide risk factors in this review. In response to a draft of this report,
the BOP stated that it already considers opioid withdrawal as an acute risk for suicide, that its SRA allows clinicians to
provide substance use history as part of the clinical information gathered to conceptualize the inmate’s risk of suicide,
and that current intoxication is listed as a dynamic risk factor in the SRA. Further, the BOP issued clinical guidance in
February 2020 that discusses the risk of suicide for inmates with substance abuse disorder and stated that frequent
patient assessments are indicated during the withdrawal period, with particular attention to thoughts of self-harm. The
guidance further stated that patients in active substance withdrawal are at increased risk of suicide and stated that
extra care was warranted, including monitoring inmates for thoughts of self-harm. Additionally, the BOP stated that
national training for BOP psychology staff included content connecting withdrawal and substance use, including opioid
use, to suicide risk.
36
BOP guidance states that inmates in quarantine should be retested for COVID-19 on or after 14 days of quarantine.
Inmates may be discharged from quarantine if those test results are negative.
21
Conclusion
We identified serious failures by BOP facilities in their compliance with the BOP’s March 2020 guidance
regarding the single-celling of inmates during modified operations. We were particularly troubled to find that
the BOP did not address at the time these persistent deficiencies and violations of multiple BOP policies in
single-celled quarantine suicide cases spanning many facilities.37 Inmate suicide in single-cell units, including
in COVID-19 quarantine units, remains a continued serious risk area for the BOP, and the BOP’s internal
oversight mechanisms have not been able to adequately address the scope of the problem. We recognize
the inherent and conflicting challenges posed in a correctional environment during a pandemic, including the
need to balance infection control measures, such as medically isolating or quarantining inmates to prevent
the spread of the virus, with directives to stop single-celling inmates. However, quarantining inmates during
the pandemic did not require them to be placed in single cells given the number of inmates who were being
quarantined at the time. Further, the BOP failed to follow its own guidance that recognized that single-celling
of inmates generally should not occur for quarantine purposes and that inmates should be assessed for
possible vulnerability to suicide before being single-celled. That did not occur in at least five of the seven
inmate suicide cases we reviewed, and in all seven of those cases the inmates had factors that made them
vulnerable to suicide. To address these serious failures and limit the risk of single-celled suicide, including in
quarantine and other pandemic-related housing, the BOP should conduct a thorough assessment of its
policies, processes, and oversight surrounding the single-cell placement of inmates.
Recommendations
To ensure that BOP processes prevent inappropriate single-celling assignments and protect inmates
vulnerable to suicide, including when they are quarantined, we recommend that the BOP:
1. Conduct a thorough assessment of single-celling policies and processes, including those applicable
to inmates housed in quarantine and medical isolation units and to inmates vulnerable to suicide.
2. Ensure that actions, including any policy revisions, the BOP takes to close the two open
recommendations from our 2017 restrictive housing report that reference single-celling also apply
to single-celling during quarantine and medical isolation.
The BOP Should Ensure that Lessons Learned in Attempting to Address Space and
Infrastructure Limitations at Its Facilities Are Captured for Future Public Health Emergencies
CDC guidance for correctional and detention facilities emphasized the importance of social distancing,
quarantine, and medical isolation as tools to manage and help prevent the spread of COVID-19. The CDC
also acknowledged that the guidance “may need to be adapted based on individual facilities’ physical space,
staffing, population, operations, and other resources and conditions.” Over the course of the pandemic,
BOP facilities relied on a variety of guidance and protocols when responding to the public health
emergency, including those from the CDC, BOP Central Office, and individual facility plans.
37
The OIG is currently conducting a review of BOP inmate deaths in custody to assess the circumstances surrounding
nonnatural inmate deaths at BOP facilities.
22
We found that many BOP facilities, due to infrastructure limitations, faced challenges in maintaining social
distancing and in quarantining inmates. While we found that BOP facilities took a variety of actions to
achieve appropriate social distancing and quarantining of inmates, we also found, as discussed in the next
section of this report, that at some facilities the BOP did not fully utilize its home confinement tools,
including those provided for in the CARES Act, that could have allowed it to better manage social distancing,
reduce exposure risks to staff and inmates, and help address staffing challenges at a number of those
facilities. Separately, as described below, we found that, although the BOP developed a plan in the summer
of 2020 to reduce the population in its minimum and low security facilities, as of December 2021 the BOP
had not met its goals at many facilities. It is important for the BOP to capture lessons learned and best
practices, at both individual facility and agency-wide levels, from the COVID-19 pandemic. Doing so will help
the BOP ensure that its public health emergency response plans are as useful as possible for facilities that
may need to implement them in the future.
Social Distancing
The OIG’s remote inspections, as well as the BOP’s internal compliance reviews, found that facilities
implemented a variety of social distancing measures in line with CDC guidance. However, because inmates
live, eat, sleep, and work in communal environments, maintaining the recommended 6 feet of space
between people was a challenge. Interviewees, complainants, and staff and inmate survey respondents all
indicated that social distancing in BOP facilities could be improved. For example, between March and
September 2020, the OIG received over 400 complaints regarding social distancing challenges. Additionally,
the 2021 inmate survey results revealed that an estimated two-thirds (66 percent) of inmates were rarely or
never able to maintain a distance of 6 feet between themselves and other inmates or BOP staff in common
spaces during the pandemic. Thirty-four percent of 2021 BOP Staff Survey respondents also believed that
social distancing of inmates is a Top 5 area in which the BOP most needs to improve.
We found that the physical infrastructure of facilities contributed to social distancing challenges. The
housing units in federal and contract prisons generally fall into two general categories: cell-type housing
and open dormitory housing. The photographs below show examples of these types of housing units. In
cell-type housing units, cells include beds, a toilet, and a sink and are generally occupied by one to four
inmates. Cell doors lock, providing the option for controlled access to communal spaces, including showers,
phones, and recreation areas. High and medium security facilities generally have cell-type housing. In open
dormitory housing, there is generally a large room with rows of bunk beds. The room may be divided using
partial-wall partitions between beds, in a configuration also called cubicle housing. Inmates in open
dormitory housing are generally free to move between sleeping, restroom, and communal areas. Furniture,
such as beds, is generally fixed and cannot be rearranged to increase distance among inmates. Low and
minimum security facilities have mostly open dormitory or cubicle housing. However, housing unit layouts
vary across facilities.38 For example, most housing units at Federal Medical Center (FMC) Fort Worth, an
38
Administrative facilities have specialized missions, such as detaining pretrial offenders; treating inmates with serious
or chronic medical conditions; or containing extremely dangerous, violent, or escape-prone inmates.
23
administrative facility, have cells without doors, meaning that, while there is more separation between
inmates, they can still move freely within the unit.39
Left, Solid-Door Cell-Type Housing Unit with Central Common Area at Federal Correctional Complex (FCC) Tucson,
Right, Barred-Door Cell-Type Housing Unit at FCC Lompoc
Source: BOP, with OIG enhancement
Left, Open Dormitory Housing Unit at Metropolitan Detention Center Brooklyn, Right, Partitioned, Open Dormitory, or
Cubicle Housing Unit at FCC Coleman FCI Coleman Low and the Camp have open, dormitory-style housing, as
shown here. Two inmates occupy each “cubicle,” which contains two
Source: BOP, with OIG enhancement
beds (bunk or side by side) and a dresser for each inmate.
Source: BOP
Interviewees, including the then BOP Medical Director, agreed that the inability to social distance in open
dormitory housing units is likely one of the reasons why some BOP facilities experienced larger COVID-19
outbreaks than others. In contrast, staff at Metropolitan Detention Center (MDC) Brooklyn, an
administrative detention center that has mostly self-contained, tiered housing units with closed cells, told us
that the physical layout of MDC Brooklyn helped the facility to limit contact between inmates and between
39
DOJ OIG, Remote Inspection of Federal Medical Center Fort Worth, E&I Report 21-012 (December 2020),
oig.justice.gov/reports/remote-inspection-federal-medical-center-fort-worth.
24
housing units.40 These observations are in line with a CDC study on mass testing initiatives in correctional
settings suggesting that inmates in dormitory settings were at greater risk of COVID-19 infection.41
Through our remote inspections of BOP facilities, we found that BOP staff in facilities housing inmates
employed a variety of strategies to increase social distancing in housing units and in some cases to
overcome the limitations of the physical layout and infrastructure of the facilities. Below, the text box
describes some examples of social distancing strategies and the photographs show two of the strategies:
40
DOJ OIG, Remote Inspection of Metropolitan Detention Center Brooklyn, E&I Report 21-002 (November 2020),
oig.justice.gov/reports/remote-inspection-metropolitan-detention-center-brooklyn, 1.
MDC Brooklyn is an administrative facility with the mission to detain pretrial offenders. It houses inmates at all security
levels, including unsentenced pretrial detainees and sentenced inmates.
41
See Liesl M. Hagan et al., “Mass Testing for SARS-CoV-2 in 16 Prisons and Jails—Six Jurisdictions, United States, April–
May 2020,” U.S. Department of Health and Human Services/CDC, Morbidity and Mortality Weekly Report, no. 33 (August
2020), www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6933a3-H.pdf (accessed July 11, 2022).
25
Social Distancing Strategies Identified Through OIG
Remote Inspections of BOP Facilities
• Staggering inmates’ access to common areas
(FCC Tucson, CI Moshannon Valley, CI Dalby,
CI McRae, FCC Oakdale, and FCC Pollock)
• Reducing the number of inmates
participating in a program or activity or
offering alternatives to in-person programs
(FCC Tucson, CI Dalby, and CI McRae)
• Increasing space between computer
stations (MDC Brooklyn)
• Instructing inmates in bunk beds to sleep
“head-to-toe” (FCI Milan, FCC Oakdale, Toler
House RRC)
• Moving inmates from open dormitory
housing to cell-type housing (FCC Oakdale)
• Creating temporary housing units in other
areas of the facility to increase space
between inmate bunks (FCC Lompoc, FMC
Fort Worth, FCI Terminal Island)
• Installing plexiglass barriers to create
separations in open dormitory housing
(MCC Chicago)
• Installing plastic sheeting to cover
doorways of cells that do not have a solid Top, Plastic Sheeting Covering Open Cell Doors at FMC
door (FMC Fort Worth) Fort Worth
Key: CI=Correctional Institution; FCI=Federal Correctional Bottom, Wooden Frames Holding Plexiglas Barriers
Institution; FCC=Federal Correctional Complex; Separating the Floors of an Open Dormitory Housing
FMC=Federal Medical Center; MCC=Metropolitan Unit at MCC Chicago
Correctional Complex; MDC=Metropolitan Detention
Center; RRC=Residential Reentry Center Source: BOP, with OIG enhancement
Source: OIG remote inspections of BOP facilities
26
Another strategy that the BOP used to improve social distancing and reduce exposure risk was to reduce
the number of inmates in its facilities. While the BOP developed a plan to reduce the inmate population
levels at low and minimum security facilities during the pandemic and reduced the populations at some
facilities, it did not uniformly meet its intended population targets at all facilities in 2020 and 2021. On June
19, 2020, the BOP issued to facility Wardens a memorandum that outlined a plan to reduce the inmate
population levels at minimum and low security facilities due to COVID-19, setting temporary population
targets intended to help with social distancing and to guide decision making regarding inmate movement.
The plan included population targets for 144 minimum and low security facilities, satellite facilities, and
cohorts at facilities of other security levels.
OIG analysis of population data, as of June 4, 2020, at the 108 minimum and low security facilities and
satellite facilities we examined indicates that the BOP would have needed to reduce its overall minimum
and low security population by over 2,700 inmates in order to meet the population targets set in its June
2020 memorandum.42 While over half of the facilities were already at or below their target populations in
June 2020, 49 of the 108 facilities needed to decrease their populations to meet the targets. By December
2020, the overall population of minimum and low security inmates was below the total target population
but 26 facilities still had populations that exceeded their targets. The number of facilities that did not meet
the BOP’s population targets increased to 38 facilities by December 2021 (see Table 2 below).
Table 2
Minimum and Low Security Facilities and Satellite Facilities Meeting Population Targets,
June 2020–December 2021
June 2020 December 2020 June 2021 December 2021
Facilities Meeting Target Population 59 82 79 70
Facilities Not Meeting Target Population 49 26 29 38
Source: OIG analysis
In its 2022 performance budget, the BOP reported that there was extra space available at its low and
minimum security facilities. Specifically, the BOP reported that, for the first time in many years, the system-
wide population was below rated capacity at its low security facilities and that it had a 52 percent surplus
capacity at its minimum security facilities as of March 25, 2021. Although these lower populations could
help facilitate social distancing at low and minimum security facilities, the BOP’s higher than intended
populations at some facilities could present barriers to improving social distancing.
42
We analyzed population data at 108 facilities, which include 37 minimum and low security facilities as well as
69 minimum and 2 low security satellite facilities that the BOP generally counts as part of its other facilities. For this
analysis, we excluded the minimum and low security cohorts at medium and administrative security facilities because
the population datasets for those facilities did not distinguish between the various security levels. See Appendix 1 for
additional discussion of our methodology.
27
Maintaining facility populations below a prison’s rated capacity could help the BOP respond effectively to
future public health emergencies that require social distancing, as well as address some of its staffing
challenges. However, this could be a challenge given that the BOP’s medium and high security facilities
continue to experience overcrowding, according to the BOP’s 2022 performance budget. A BOP Facilities
Management official explained that BOP facilities were designed to house a specific number of inmates
based on their classification and security requirements. If facilities are at or near capacity, there may not be
enough space to leave beds empty in order to allow inmates to maintain social distance while sleeping.
Quarantine and Medical Isolation
We found that the amount of available space affected the facilities’ abilities to create quarantine and
medical isolation areas. The facilities we inspected that had vacant cell-type housing available had an easier
time designating enough space for their needs, and some facilities created temporary housing units to
increase the number of beds available. However, at some facilities, such as Federal Correctional Complex
(FCC) Butner, a large outbreak of COVID-19 overwhelmed the available space.43 Having sufficient quarantine
and medical isolation space appeared to be a widespread and ongoing concern during the pandemic. Thirty
percent of respondents to the OIG’s 2021 BOP Staff Survey reported that there was “usually not enough
space” or “never enough space” for inmates who needed to be placed in quarantine over the course of the
pandemic. Thirty percent also reported that there was “usually not enough space” or “never enough space”
for inmates who needed to be placed in medical isolation.
As described in the Background of this report, facilities needed to designate as many as five separate areas
for quarantine and medical isolation purposes.44 Interviewees at 7 of the 16 facilities we inspected,
including 5 of the 11 federal facilities, specifically reported using vacant housing areas in their facilities for
quarantine or medical isolation. For example, at FCC Oakdale, staff initially established medical isolation
and quarantine space in a vacant housing unit and used a second unit that had been empty while mold
remediation work was completed to create additional space for inmates typically housed in the open
dormitory camp.45 Several facilities we inspected used temporary housing solutions, such as converted
visitation rooms or tents outfitted with electricity and restrooms (see the photographs below), to
supplement quarantine and medical isolation space.
Finally, several of the facilities we inspected also used SHUs as quarantine or medical isolation areas. In
particular, facilities with open dormitory style housing relied on the cell-type housing of SHUs to quarantine
or medically isolate inmates. The BOP’s COVID-19 Pandemic Response Plan specifies that, when facilities
use restrictive housing for medical isolation, the conditions of confinement should be “operationally distinct”
43 DOJ OIG, Remote Inspection of Federal Correctional Complex Butner, E&I Report 21-031 (January 2021),
oig.justice.gov/reports/remote-inspection-federal-correctional-complex-butner, 5.
44
Per CDC, “Interim Guidance,” medical isolation and quarantine locations should be separate and, if possible, incoming
inmates should be quarantined separately from individuals quarantined due to contact with a COVID-19 case.
45
DOJ OIG, Remote Inspection of Federal Correctional Complexes Oakdale and Pollock, E&I Report 21-003 (November
2020), oig.justice.gov/reports/remote-inspection-federal-correctional-complexes-oakdale-and-pollock, 16.
28
from the use of restrictive housing for disciplinary or administrative reasons.46 For example, facilities should
try to provide similar access to radio, television, reading materials, personal property, and commissary as
would be available in the inmate’s regular housing unit and should consider allowing increased telephone
privileges so inmates can maintain connection with others. In addition, the BOP stated that inmates in the
SHU for medical quarantine or isolation purposes are categorized as being in administrative detention and
are placed on a medical hold until cleared for COVID-19. However, we note that inmates in SHUs may be
housed alone in their cells, and we identified concerns with the BOP’s use of single-celling for quarantine
purposes, as we discussed above. In May 2022, Executive Order (E.O.) 14074 directed the BOP to identify
alternatives to the use of restrictive housing for quarantine and medical isolation.47
Left, Exterior of Medical Tents at FMC Fort Worth; Center, Interior of a Medical Tent Set-up at FMC Fort Worth; Right,
Restroom Facilities for the Medical Tents at FMC Fort Worth
Source: BOP, with OIG enhancement
Capturing Lessons Learned and Considering Facilities Modifications
In August 2020, the BOP issued the first version of its COVID-19 Pandemic Response Plan, which compiled
COVID-19 guidance and “best practices” identified during the first months of the pandemic for limiting the
spread of the disease in its facilities. The COVID-19 Pandemic Response Plan also instructs BOP facilities to
periodically review agency and institution plans to “identify what has worked well (best practices), what has
46
According to the BOP’s SHU policy, inmates in disciplinary detention status have personal property impounded, may
have limited commissary privileges, and may have their participation in programming activities suspended. Inmates in
administrative detention status have access to a reasonable amount of personal property, reasonable access to
commissary, and access to programming activities to the extent that such access does not jeopardize facility operations
or public safety.
47
E.O. 14074 on Advancing Effective, Accountable Policing and Criminal Justice Practices to Enhance Public Trust and
Public Safety, May 25, 2022, www.federalregister.gov/documents/2022/05/31/2022-11810/advancing-effective-
accountable-policing-and-criminal-justice-practices-to-enhance-public-trust-and (accessed September 26, 2022).
29
not, and deviations from established guidance (opportunities for improvement).” However, in a July 2021
report on the BOP’s COVID-19 response, the U.S. Government Accountability Office (GAO) recommended
that the BOP take additional steps to ensure that lessons learned and best practices are captured,
particularly those discussed among BOP officials during their regular information sharing teleconferences.48
The GAO further recommended that the BOP develop and implement an approach for ensuring that its
facilities are applying the best practices, as appropriate.
The BOP has reported that it considered potential permanent changes to facility infrastructure to help
mitigate the risk of infection transmission inside its facilities. For example, Federal Correctional Institution
(FCI) Terminal Island reported that it was considering placement of computers in the housing units instead
of using a shared computer lab, which could help ensure access to the Trust Fund Limited Inmate Computer
System (TRULINCS) inmate email system during extended modified operations while limiting cross-
contamination among housing units.49 The BOP should also look for opportunities to incorporate proactive
infrastructure changes into its planned construction, modernization, and repair projects.50 In its fiscal year
2022 budget submission, the BOP reported having 904 ongoing major and minor modernization and repair
projects at its facilities. The BOP Facilities Management Branch Chief told us that the BOP plans to prioritize
projects targeting the efficiency of heating, ventilation, and air conditioning systems, as these systems may
affect the spread of COVID-19.51
Conclusion
Building on these steps already taken or in progress, we recommend that the BOP specifically look at the
challenges related to the limitations of existing facility infrastructure and the methods that have been
successful in mitigating those challenges. First, as described above, facilities have unique challenges based
on their specific layouts, populations, and other circumstances. In addition to ensuring that best practices
are shared such that similarly situated facilities can benefit from lessons learned during the pandemic,
facility-specific measures and solutions should be captured and updated in individual facility pandemic
plans. Updating these plans will ensure that future facility leadership will have access to information on
what has worked well in their facility’s context if they need to respond to a public health emergency in the
future. The BOP reported that it has already made several updates to its pandemic contingency plans based
48
GAO, BOP Could Further Enhance Its COVID-19 Response by Capturing and Incorporating Lessons Learned, GAO-21-
502 (July 2021), www.gao.gov/products/gao-21-502 (accessed July 11, 2022), 58.
49
TRULINCS enables electronic messaging (email) between inmates and approved contacts in a monitored and secure
manner. DOJ, OIG, Remote Inspection of Federal Correctional Institution Terminal Island, E&I Report 21-025 (January
2021), oig.justice.gov/reports/remote-inspection-federal-correctional-institution-terminal-island.
50
Since 2017, the OIG has identified aging infrastructure at BOP facilities as an area of concern in its Top Management
and Performance Challenges reports. The OIG is currently conducting an audit of the BOP’s efforts to construct and
maintain its institutions. See DOJ OIG, “Audit of the Federal Bureau of Prisons’ Efforts to Maintain and Construct
Institutions,” oig.justice.gov/node/23304.
51
The CDC states that the risk of spreading the virus that causes COVID-19 through ventilation systems is not yet clear.
However, the CDC does recommend improvements to building ventilation as tools to use in conjunction with other
measures, such as social distancing, hand hygiene, and vaccination, to help reduce risk of exposure to the virus. See
CDC, “Ventilation in Buildings,” updated June 2, 2021, www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html
(accessed July 11, 2022).
30
on CDC guidance as detailed information was gathered on vaccinations, testing, and treatment of COVID-19
and that it intended to continue collaborating with the CDC as part of its pandemic response.
Second, the BOP should build on its lessons learned by exploring potential permanent changes to facility
infrastructures that could help the BOP more easily implement infection prevention and control measures
in the future. While these projects require sufficient funding, the BOP should take the opportunity to
consider how it could incorporate modifications that would help with managing public health emergencies
into other planned modernization and repair projects.
Recommendations
To ensure that lessons learned are captured for future public health emergencies, we recommend that the
BOP:
3. Compile and regularly update best practices for addressing space limitations to meet social
distancing, quarantine, and medical isolation needs.
4. Explore options for permanent changes to facility infrastructures that would allow for better
implementation of social distancing and other infection control measures.
The BOP Should Assess How Lessons Learned Implementing CARES Act Home Confinement
Could Apply to Future Public Health Emergencies While Monitoring How RRC Providers Manage
a Larger Home Confinement Population
On April 3, 2020, the Attorney General gave the BOP the authority under the CARES Act to transfer to home
confinement additional eligible inmates who would not have been eligible under the BOP’s other existing
authorities at the time of transfer (see the text box below). We concluded in five of our remote inspections
that the BOP did not fully leverage its home confinement authorities under the CARES Act to transfer
inmates within 6 months of release from the inspected facilities to home confinement. Greater use of these
authorities could have allowed the BOP to better address the social distancing and quarantine challenges
that many facilities faced, as well as assist with the staffing issues that it faced.
During this review, we found that the BOP’s implementation of the Attorney General’s memoranda on home
confinement and related direction from the Department, as well as available resources, affected the extent
to which the BOP transferred inmates to home confinement under the CARES Act. We also found that
several factors led to delays in home confinement transfers, limiting the efficacy of home confinement as a
tool to manage active COVID-19 outbreaks. Additionally, as described below, while the number of inmates
transferred by the BOP to home confinement increased substantially in May and June 2020, shortly after the
CARES Act was passed, the overall number of inmates transferred by the BOP to home confinement during
the first year of the CARES Act—from April 2020 through March 2021—was actually less than the number of
transfers that occurred from April 2019 through March 2020. However, we note that, due to the decreasing
inmate population overall, the percentage of inmates transferred to home confinement was similar for both
years. We also determined that, despite the lower number of facility-to-home-confinement transfers
compared to the prior year, the BOP’s home confinement population more than tripled during the first year
of the CARES Act, generally due to (1) the longer period of time that inmates were remaining in home
confinement because the CARES Act allowed the BOP to transfer inmates to home confinement with more
31
than 6 months remaining on their sentence and (2) the fact that the BOP also transferred inmates from
Residential Reentry Center (RRC) facilities to home confinement in response to the pandemic, including
under CARES Act authorities. Additionally, we determined that the home confinement failure rate for
inmates transferred to home confinement during the first year of the CARES Act was less than 2 percent.
Failure in the home confinement setting occurs when an inmate commits misconduct or fails to comply with
program rules, such as by using illicit drugs, missing check-ins, or committing new criminal activity.
The BOP’s Pre-Pandemic Home Confinement Authorities
Prerelease Inmates: Inmates nearing the end of their sentences are routinely considered for home confinement as
part of their transition back into the community. Eligible inmates can spend up to 10 percent of their total sentence
or 6 months, whichever is shorter, in home confinement under 18 U.S.C. § 3624(c)(2).
Elderly Inmates: Eligible inmates age 60 or older who have served at least two-thirds of their sentence may be
placed in home confinement until the end of their sentence through a pilot program reauthorized under the FIRST
STEP Act (FSA), codified at 34 U.S.C. § 60541(g).
Terminally Ill Inmates: Eligible inmates who are terminally ill may be placed in home confinement through a pilot
program reauthorized under the FSA, codified at 34 U.S.C. § 60541(g).
Additional Home Confinement Authority During the COVID-19 Pandemic
Inmates Eligible Under the CARES Act: The CARES Act, Public Law No. 116-136, removed the 6 months or 10 percent
of the total sentence time limit under 18 U.S.C. § 3624(c)(2) during the pandemic emergency period, allowing inmates
to be considered for home confinement earlier in their sentences than usual. Memoranda from the Attorney
General and the BOP defined additional eligibility criteria for home confinement placement under the CARES Act.
Sources: OIG summary of 18 U.S.C. § 3624(c)(2), 34 U.S.C. § 60541(g), and Public Law No. 116-136
In order to implement the Attorney General’s April 3 memorandum and pre-CARES Act home confinement
memorandum from March 26, the BOP issued its own memoranda to institutions on April 3, April 22, and
May 8, 2020. Generally, under these BOP-issued memoranda, inmates were eligible for home confinement
if they:
• were not serving a sentence for a crime of violence, a sexual offense, or terrorism;
• did not present a substantial risk of engaging in criminal conduct or endangering the community, as
determined by the BOP;52
52 To assess inmates’ recidivism risk, the BOP uses the Prisoner Assessment Tool Targeting Estimated Risk and Needs
(PATTERN) system, which the Department developed in response to the FSA. The FSA directed the Department to
complete its initial risk and needs assessment for each federal inmate by January 15, 2020, which, among other things,
calculated inmates’ recidivism risk using a point system that classifies inmates into either minimum, low, medium, or
high risk categories based on: (1) infraction convictions during current incarceration, (2) number of programs
completed, (3) work programming, (4) drug treatment while incarcerated, (5) noncompliance with financial
responsibility, (6) history of violence, (7) history of escape, (8) education score, (9) age at time of the assessment,
32
• did not have a history of serious misconduct, such as violence or gang activity, while incarcerated;
• did not have a current detainer requesting the inmate’s custody after sentence completion;53
• had a verifiable reentry plan, appropriate residence for home confinement, and ability to get any
medical needs met appropriately in the community;
• had particular COVID-19 risk factors, as described in the CDC guidelines; and
• had served at least 50 percent of their sentence or had 18 months or less remaining on their
sentence and had served at least 25 percent of their sentence (beginning with the April 22
memorandum).
The BOP’s April 22, 2020 memorandum also granted Wardens additional authority to seek home
confinement approval, for inmates who did not meet the criteria outlined in the memoranda, by sending to
BOP Central Office the inmates’ information for further consideration. A committee of Central Office
officials reviewed these referrals and approved or denied the transfers to home confinement. However, a
November 16, 2020 BOP memorandum, while reiterating the criteria for home confinement consideration
and providing additional guidance, eliminated a Warden’s ability to refer to the Central Office inmates who
did not meet the home confinement criteria. This meant that Wardens would make the final decisions on
which inmates to refer for home confinement but could not refer or seek approval for inmates who did not
meet the memoranda criteria for CARES Act home confinement.54 Five months later, in an April 13, 2021
memorandum, the BOP reverted to the practice outlined in the April 2020 memorandum allowing Wardens
to seek approval from the Central Office for inmates with COVID-19 risk factors who did not meet all of the
other eligibility requirements; the memorandum also emphasized the importance of continuing to review
at-risk inmates for home confinement placement in accordance with the CARES Act and Attorney General
guidance.
From the outset of the BOP’s effort to review inmate eligibility for home confinement transfer, BOP Central
Office and Regional Office officials sought to assist facilities in identifying eligible inmates by providing them
with rosters of inmates who might meet the criteria listed in the guidance. According to a Correctional
(10) instant violent offense, (11) sex offense, and (12) criminal history score. For more information, see Office of the
Attorney General, The First Step Act of 2018: Risk and Needs Assessment System–Update (January 2020),
nij.ojp.gov/sites/g/files/xyckuh171/files/media/document/the-first-step-act-of-2018-risk-and-needs-assessment-system-
updated.pdf (accessed July 13, 2022).
53
A detainer may come from a federal, state, or local jurisdiction and may be related to criminal charges or noncriminal
charges (e.g., material witnesses, deportation, probation/parole violator warrants, child support, etc.).
54
BOP Central Office continued to review referrals in cases related to court orders, settlement agreements, or other
legal matters. Documents we reviewed indicated that the Department was aware of this change and considered it to be
an appropriate step.
33
Programs Division official, BOP facility staff were expected to review the inmates on the rosters and any
other inmates they believed might be eligible.
OIG analysis of BOP data showed that the BOP transferred fewer inmates to home confinement during the
first year it was given CARES Act authorities than the year prior. From April 2020 through March 2021, the
BOP transferred 28,353 total inmates to home confinement, including 6,781 inmates who were specifically
transferred under CARES Act authorities. By comparison, from April 2019 through March 2020, the BOP
transferred 29,273 total inmates to home confinement. Although the number of transfers to home
confinement was lower, the percentage of inmates transferred to home confinement was similar for both
years due to the decrease in the inmate population overall. Additionally, the average number of inmates
residing in home confinement during that same time period more than tripled. Two related factors
contributed to the increased home confinement population. First, the CARES Act allowed the BOP to
transfer inmates to home confinement regardless of the amount of time remaining on their sentence, as
opposed to the standard prerelease home confinement statute that generally allowed transfers only for
inmates with no more than 6 months remaining on their sentence; therefore, inmates were spending longer
amounts of time in home confinement before their sentences ended.55
Second, Attorney General directives to maximize the use of home confinement authorities during the
pandemic, including the CARES Act, also applied to inmates at RRC facilities. Inmates could be transferred
from RRC facilities to home confinement, reducing the in-house RRC population and increasing the home
confinement population.56 Additionally, on April 3, 2020, the BOP’s Residential Reentry Management Branch
issued a memorandum to all RRC contract providers to use home confinement “to the fullest extent
practicable, as outlined in the Attorney General’s [March 26] memorandum.” While we did not examine
BOP-wide data on the number of inmates transferred specifically from RRCs to home confinement, our
remote inspections of Brooklyn House RRC and Toler House RRC found that those RRCs heeded this
direction and moved many of their inmates into home custody settings as the pandemic worsened.
Additionally, respondents to our 2020 survey of RRC contract staff generally indicated that their RRC
facilities had increased the number of inmates on home confinement early during the pandemic.
Specifically, 80 percent (247 of 307) of respondents who answered the survey question about measures
their RRC facility was employing at the time of the survey stated that the number of residents placed on
home confinement had increased.
As Figure 4 below shows, the vast majority of home confinement placements before April 2020 were part of
the BOP’s regular prerelease process, through which inmates generally spend a maximum of 6 months in
home confinement prior to their release. The CARES Act resulted in an unprecedented increase in the
number of inmates in home confinement for far more than 6 months. For example, as of December 2021,
55
As discussed in the Introduction to this report, inmates in home confinement are supervised by RRCs or the U.S.
Probation Office but remain in BOP custody and are therefore included in the BOP’s inmate population totals.
56
The BOP’s April 3 memorandum to RRC contract providers further noted that referrals must be made based on
appropriateness for home confinement and that consideration should be given to whether inmates had a demonstrated
verifiable reentry plan that would prevent recidivism and maximize public safety. A subsequent BOP memorandum to
RRC contract providers on April 7, 2020, provided an update following the passage of the CARES Act and the Attorney
General’s April 3 memorandum and stated that the BOP was working to “ensure that all individuals who are appropriate
for home confinement placement within our RRCs are placed on home confinement as soon as practical.”
34
over 2,800 inmates in CARES Act home confinement had more than 1 year remaining on their sentences,
including some inmates who had over a decade remaining. We discuss the effects of an increased home
confinement population later in this section.
Figure 4
Number of Inmates Transferred Under Home Confinement Authorities, April 2019–March 2021
4,000 3,866
3,500
3,000 2,934
2,500 2,420
2,116
2,000
1,605
1,500
1,000
500
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019 2020 2021
Regular Prerelease Process Elder HC CARES Act Pre-CARES Act Average
Notes: Data labels show total inmates transferred each month. “Elder HC” refers to transfers of elderly and terminally
ill inmates to home confinement under 34 U.S.C. § 60541(g). The pre-CARES Act average is the average number of
inmates transferred to home confinement each month from April 2018 through March 2020.
Source: OIG analysis of BOP data
Figure 4 also shows a large increase in the number of transfers to home confinement in May and June 2020,
following the passage of the CARES Act.57 While the majority of inmates whom the BOP transferred to home
confinement during that time were part of the BOP’s regular prerelease process rather than under CARES
Act authorities, a large number of additional inmates were released using the CARES Act authority. In the
second half of 2020, the number of monthly transfers to home confinement dropped and remained below
the pre-CARES Act average, with a small percentage of the releases being made using the CARES Act
authority. According to a GAO report on the BOP’s COVID-19 response, BOP officials told the GAO that the
BOP transferred fewer inmates from July through December 2020 because it had developed a list of inmates
57 Although the CARES Act passed at the end of March 2020, it often took a few weeks for an inmate to be reviewed for
home confinement and complete a mandatory quarantine period before being transferred to home confinement. The
lower number of inmates transferred in April as compared to May and June reflects these delays. We discuss factors
contributing to delays in home confinement transfers later in this section.
35
eligible for home confinement during the early stages of the pandemic.58 The GAO report stated that, as a
result, the transfer process was front loaded during the initial stages of the pandemic, from May through
June 2020, resulting in a decrease in home confinement transfers after July 2020. As we discuss in the next
section, the BOP’s general practice of limiting eligibility for CARES Act consideration to inmates with COVID-
19 risk factors also affected the number of inmates who were transferred to home confinement.
The Effect of the BOP’s Implementation of the Attorney General’s Memoranda and BOP Resource
Limitations on Inmate Transfers Under Expanded Home Confinement Authorities
The OIG has previously reported that the BOP failed to broadly consider home confinement for inmates
with a short amount of time remaining on their sentences during the pandemic, instead focusing its use of
CARES Act and Attorney General authorities primarily on inmates with enhanced vulnerability to COVID-19.59
In five of our remote inspections of BOP facilities during the pandemic, we concluded that the BOP did not
fully leverage the available home confinement authorities because only small proportions of potentially
eligible inmates were transferred from those facilities to home confinement. In particular, these inspections
raised concerns about the number of inmates who were scheduled to be released within 6 months but who
remained at BOP facilities instead of being transferred to home confinement. We noted in those reports
that some inmates who were within 6 months of release could have been eligible for home confinement
under the BOP’s regular authorities and that they would have been releasing into the community shortly.60
The conclusions in our remote inspection reports are in line with a 2016 OIG audit report on the BOP’s
management of inmate placements in RRCs and home confinement. In the 2016 report, we found that the
BOP could more strategically identify inmates suitable for placement directly into home confinement and
that the BOP had underutilized direct home confinement placement as an alternative to RRC placement for
transitioning low risk, low need inmates back into society despite BOP policy and guidance stating that
direct home confinement placement was preferred for such inmates.61
During this review, we found that the BOP’s implementation of the Attorney General’s memoranda on home
confinement—based on the Department’s direction to the BOP following both memoranda—affected the
extent to which the BOP transferred inmates to home confinement under the CARES Act. DOJ officials in the
Offices of the Attorney General and the Deputy Attorney General worked directly with BOP executives to
convey specific direction on how to implement the Attorney General’s March 26 and April 3, 2020
memoranda. For example, one document we reviewed described the Department’s interest in making
inmates with one or more COVID-19 risk factors who had 18 months or less remaining on their sentences
and who had served at least 25 percent of their sentences a priority for home confinement. Other
58
GAO, BOP Could Further Enhance Its COVID-19 Response, 46.
59
See DOJ OIG, Top Management and Performance Challenges Facing the Department of Justice–2021 (October 2021),
oig.justice.gov/reports/top-management-and-performance-challenges-facing-department-justice-2021.
60
BOP policy provides that inmates who fit certain categories, such as those who present certain public safety risks,
should not ordinarily participate in RRC or home confinement. BOP Program Statement 7310.04, Community
Corrections Center Utilization and Transfer Procedures, December 16, 1998, www.bop.gov/policy/progstat/7310_004.pdf
(accessed July 13, 2022).
61
DOJ OIG, Audit of the Federal Bureau of Prisons’ Management of Inmate Placements in Residential Reentry Centers
and Home Confinement, Audit Report 17-01 (November 2016), oig.justice.gov/reports/audit-federal-bureau-prisons-
management-inmate-placements-residential-reentry-centers-and.
36
documents described the Department’s evolving direction to the BOP about which of the home confinement
criteria it considered “hard,” meaning that the BOP should not approve any inmates who did not meet all
such criteria, and other criteria the BOP could use to exercise its discretion when determining whether to
transfer inmates to home confinement.
A Correctional Programs Division official told us that, in practice, at the facility level, inmates had to meet all
of the factors listed in the BOP’s home confinement memoranda to be considered eligible for home
confinement. As discussed above, between April and November 2020, and again starting in April 2021, BOP
memoranda allowed Wardens to refer to the Central Office review committee inmates who did not meet all
the listed factors for case-by-case home confinement consideration. We reviewed documentation
describing discussions between the BOP and the Department that indicate that, as least beginning in May
2020, the Department viewed certain criteria, including the presence of COVID-19 risk factors, as criteria that
could be “waived” at the Central Office level when considering inmates whom Wardens referred to Central
Office for home confinement consideration. However, the same Correctional Programs Division official and
a Health Services Division official told us that they understood the Attorney General’s memoranda to mean
that only inmates with COVID-19 risk factors defined by the CDC could be transferred to home confinement
under the CARES Act. They pointed to language in the Attorney General’s April 3, 2020 memorandum
directing the BOP to “immediately review all inmates who have COVID-19 risk factors, as established by the
CDC.”62 Additionally, the lack of COVID-19 risk factors was a reason that BOP staff gave for denying CARES
Act home confinement at facilities we inspected, including at MDC Brooklyn, where 139 of the 196 inmates
who had been deemed ineligible for home confinement as of June 1, 2020, were denied due to lack of
medical risk.
The OIG is conducting a separate review of the BOP’s use of home confinement as a response to the COVID-
19 pandemic; that review is assessing the BOP’s processes for implementing its home confinement
authorities under the CARES Act, considering the eligibility criteria outlined in the Attorney General’s
memoranda, and evaluating Wardens’ recommendations that inmates who did not meet the Attorney
General’s criteria be placed in home confinement. That review will also select particular cases for
examination to determine whether there were irregularities in the BOP’s processes. Accordingly, while this
report draws some conclusions about the BOP’s use of home confinement, it does not draw specific
conclusions regarding the BOP’s processes related to implementing its home confinement authorities
during the pandemic or make recommendations in this area.
A BOP Reentry Services Division official told us that available resources additionally affected the extent to
which the BOP transferred inmates to home confinement. RRC contractors are retained by the BOP to
monitor inmates in home confinement, and we were told that RRC and home confinement capacities are
limited to what the RRC contractors can reasonably manage.63 According to this official, the BOP wanted to
focus its limited resources on (1) inmates with the greatest risk of contracting COVID-19 and (2) inmates who
would be participating in the program as part of the traditional reentry philosophy in preparation for
release from BOP custody. This same official pointed to the addition of the time-served criteria for home
62
Barr, memorandum for Director of Bureau of Prisons, April 3, 2020, 1.
63
The U.S. Probation Office can also monitor BOP inmates on home confinement. However, according to the BOP, the
Probation Office monitors a small percentage of BOP inmates on home confinement while RRCs monitor most inmates
on home confinement.
37
confinement consideration in the BOP’s April 22, 2020 memorandum, which prioritized for home
confinement inmates who had served a certain portion of their sentences, or who had only a relatively short
amount of time remaining on their sentences, as a way the BOP tried to prioritize its limited resources in the
community.
The Department has recently indicated its support of the BOP’s interpretation of the Attorney General’s
memoranda and the BOP’s implementation of the expanded home confinement authorities. In response to
the OIG’s 2021 Top Management and Performance Challenges report, which discussed the OIG’s findings
from our remote inspection reports, the Department responded that it believes that the BOP properly
executed the Attorney General’s memoranda and that it was appropriate for the BOP to focus its efforts on
medically vulnerable inmates. The Department further responded, “Although transferring healthy offenders
with short sentences to home detention may have temporarily reduced the inmate population in some
facilities, it would have drained available home detention resources from medically vulnerable offenders
who were most at risk for contracting COVID-19 and subsequently developing serious illness or dying.”
While we appreciate the BOP’s home confinement resource challenges, some BOP facilities also faced
significant staffing and resource challenges, particularly those facilities where COVID-19 outbreaks occurred.
Thus, deciding that inmates, particularly those who presented a low safety risk, could not be referred for
transfer to home confinement at the facility level if they did not have any COVID-19 health risk factors, even
if they met all of the other factors that the BOP and Department developed, meant that facility populations
could have remained higher, including at facilities experiencing staffing shortages and space and
infrastructure limitations.
We separately received OIG Hotline complaints about home confinement indicating that there was
confusion among some inmates and other stakeholders about the eligibility criteria and the BOP’s home
confinement decisions. Home confinement was one of the most significant concerns for complainants;
from March through September 2020 we received over 800 complaints related to home confinement, most
of them from inmates. Complainants frequently requested inmate transfers to home confinement, and
many complainants expressed interpretations of the home confinement eligibility criteria that differed from
the BOP’s interpretation.64 According to some complainants, the BOP approved certain inmates for home
confinement but subsequently reversed its decisions as guidance evolved.
We observed that the BOP’s communication with the public regarding home confinement only restated the
criteria in the Attorney General’s memoranda without clarifying them in plainer language or describing how
the BOP was interpreting or implementing the criteria. For example, while the BOP provided a Frequently
Asked Questions section on home confinement on its public website during the pandemic, the section did
not mention the additional time-served criteria the BOP was using to determine eligibility for home
confinement. Clearly stating to the public how and why the BOP was implementing and prioritizing its
64
We analyzed complaints to identify trends but did not substantiate or assess the validity of individual complaints or
examine whether individual inmates were eligible for home confinement.
38
expanded home confinement authorities could have helped the BOP be more transparent with inmates and
other stakeholders at a time of high stress and uncertainty.65
The Home Confinement Review Process, COVID-19 Outbreaks, and Quarantine Protocols Potentially
Contributed to Delays in Home Confinement Transfers
The Attorney General’s April 3, 2020 memorandum instructed the BOP to “immediately maximize
appropriate transfers to home confinement of all appropriate inmates” at those prisons “where COVID-19 is
materially affecting operations.”66 We found, however, that the BOP’s April 22 guidance, which implemented
the April 3 memorandum, did not specifically address the Attorney General’s instruction to “immediately
maximize appropriate transfers to home confinement.” A BOP Correctional Programs Division official stated
that the Central Office sent additional rosters of potentially eligible inmates to facilities that were
experiencing an increase in COVID-19 cases, following an initial roster of eligible inmates sent to all BOP
facilities. This official further stated that the BOP authorized temporary duty (TDY) assignments at certain
facilities to assist with reviewing inmates for potential transfer to home confinement. According to this
official, the BOP expected institution staff to review inmates and complete referrals for home confinement
as quickly as possible.
We found that the time it took to transfer inmates, coupled with the active COVID-19 outbreaks, potentially
limited the effect that transfers to home confinement had on managing the outbreaks. The BOP facilities
we inspected reported that it took at least 2–4 weeks between an inmate’s identification for home
confinement consideration and his or her transfer date. For example, our FCC Lompoc remote inspection
found that the process for reviewing inmates for home confinement, coupled with the 14-day quarantine
period the Attorney General memoranda required to ensure that inmates placed into the community did
not have COVID-19, resulted in 3 or more weeks between the time the Central Office identified an inmate
for transfer consideration to the date the inmate was actually transferred to home confinement. By May 13,
2020, over 900 inmates at FCC Lompoc had contracted COVID-19 and only 8 inmates had been transferred
to home confinement under CARES Act authorities and BOP guidance. These delays are reflected in the
relatively low number of CARES Act transfers BOP-wide in April 2020 as compared to May and June of 2020,
as shown in Figure 4 above.
COVID-19 outbreaks may have also affected the ability of BOP facilities to promptly transfer inmates to
home confinement. For example, at FMC Fort Worth, officials told us that some of the inmates approved for
home confinement had their transfers delayed because those inmates had tested positive for COVID-19. As
we discuss in the Introduction, facilities needed to designate several separate quarantine and medical
isolation spaces for inmates, including separate spaces for isolation of inmates with COVID-19 and for
quarantine for outgoing inmates, including those transferring to an RRC or home confinement. Outbreaks
meant that there were sometimes competing quarantine and medical isolation needs. For example, an FCC
Butner staff member reported that during a large outbreak the designated quarantine space was being
used to quarantine outgoing inmates so it could not be used for exposure-related quarantine. While
transferring inmates to home confinement allowed for improved social distancing, time and competing
65
We discuss other topics related to the BOP’s communication with stakeholders in the section titled The BOP Should
Improve its Communication of Essential Information to Stakeholders.
66
Barr, memorandum for Director of Bureau of Prisons, April 3, 2020, 1.
39
resources may have limited the effect that home confinement transfers had on the virus spread in affected
facilities.
Potential Challenges for RRCs Due to the Increased Number of Inmates in Home Confinement
We found that in the year following the passage of the CARES Act, from April 2020 through March 2021,
there was an average of 12,480 inmates under RRC supervision, either living in an RRC facility or in home
confinement. This was a 41 percent increase in the average population under RRC supervision over a
comparable period before the CARES Act. And, when we specifically examined inmates in home
confinement, we found that the number of inmates in home confinement more than tripled, averaging
7,372 inmates in home confinement during the first year of the CARES Act as compared to 2,271 inmates in
home confinement during the year before the CARES Act. Figure 5 below shows the number of inmates
living in RRC facilities and in home confinement before and during the first year of the CARES Act.
Figure 5
Total Inmate Population in Community-Based Custody, April 2019–March 2021
14,000
CARES Act
12,000 Passed
10,000
8,000
6,000
4,000
2,000
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019 2020 2021
RRC Home Confinement
Source: OIG analysis of BOP data
As we discussed above, one of the reasons for this increase was the CARES Act provision allowing inmates to
be transferred to home confinement with more than 6 months remaining on their sentence; therefore,
inmates were spending longer amounts of time in home confinement than would be permitted under
standard prerelease authorities, resulting in an unprecedented increase in the number of inmates in
extended home confinement. When using its CARES Act authority, the BOP transferred inmates directly
40
from prisons to home confinement.67 The addition of the CARES Act authority also allowed prerelease
inmates who had been placed in RRCs to transfer from RRCs to home confinement earlier than under the
BOP’s standard prerelease process. Eligible inmates residing in RRC facilities whom the BOP transferred to
home confinement increased the home confinement population while decreasing the number of inmates
residing in RRC facilities. Under the RRC contractual model, RRCs may typically place inmates in home
confinement if (1) they met a home confinement eligibility date provided by the BOP and (2) the RRC could
verify a suitable home address with mechanisms, such as a landline telephone, in place to maintain
accountability.
Our remote inspections of Brooklyn House RRC and Toler House RRC found that the RRCs received direction
from BOP officials that they could expand the use of home visit passes, which are traditionally used to allow
for temporary, short-term home visits. Expanded home visit passes offered RRCs the flexibility to
temporarily reduce the in-house RRC populations and increase social distancing at RRC facilities. Our
inspections of Brooklyn House RRC and Toler House RRC found that, by using these flexibilities and home
confinement, the only inmates who continued to reside in those RRCs at the time of our fieldwork were
homeless or lacked a suitable home residence for placement. Between home confinement and the use of
other flexibilities, RRCs needed to supervise a much larger population of inmates located outside of RRC
facilities.
The increased home confinement population may pose challenges for RRCs and in the management of
inmates in community-based custody. Changes in managing home confinement populations, RRC staffing
and cost concerns, and addressing failures in the home confinement setting are all areas that the BOP will
need to continue to monitor as the population in home confinement remains high during the COVID-19
pandemic and beyond. Below, we present the specific challenges in each area.
Monitoring a Larger Home Confinement Population
In response to the COVID-19 pandemic, the BOP allowed RRCs to reduce certain monitoring and
accountability measures that it typically requires. For example, on March 24, 2020, the BOP allowed RRC
staff to suspend routine breathalyzer and drug testing and replace in-person check-ins, employment site
checks, and home site checks with virtual accountability measures such as telephone or video calls. On April
3, 2020, the BOP’s Reentry Services Division (RSD) further modified guidance for interaction with and
monitoring of inmates placed in a home setting. The April 3 guidance required that all inmates in home
confinement be monitored via technology tools but allowed for virtual supervision and confirmation of
electronic monitoring equipment functionality in certain circumstances, with the expectation that RRCs
would physically verify inmate location via visual confirmation at least monthly.
An RSD official told us that the initial increase of inmates in home confinement was manageable due to the
reduced RRC contractual requirements. However, as the pandemic continued, it became difficult to
maintain contract compliance with increasing home confinement and RRC populations. Once all modified
operations end, RRC contractors will need to meet all of the terms and conditions of their contracts, such as
onsite monitoring, employment assistance, and drug and alcohol counseling, that were suspended during
67
Under the BOP’s prerelease process, inmates often spend a period of months in RRC facilities as a part of the
transition back into the community before moving into home confinement.
41
the pandemic. The DOJ Office of Legal Counsel has determined that inmates placed in home confinement
under the CARES Act can remain there after the pandemic ends, and in June 2022 the Department published
a regulatory proposal consistent with the Office of Legal Counsel’s opinion.68 Therefore, the population of
inmates in home confinement will likely continue to be higher than it was pre-pandemic. However, other
factors may also affect the population of inmates in RRC custody, including those in home confinement. For
example, on September 10, 2021, the BOP issued a memorandum to RRCs announcing that inmates on
CARES Act home confinement who have underlying federal convictions for nonviolent drug offenses may be
considered for clemency on an expedited basis by the Biden administration. The memorandum instructed
RRCs to encourage inmates in home confinement and RRC facilities to apply for sentence commutation.
Regardless of the effect that these external factors have on the number of inmates in home confinement,
the BOP will need to ensure that RRCs are appropriately managing inmate populations in compliance with
their contractual requirements during and after the pandemic.
Retaining Sufficient Services as RRCs Adjust to Staffing and Cost Changes
The shift in the RRC-managed population to predominately home confinement inmates required RRCs to
adjust their operations and reallocate their resources. For example, RRCs have needed more field staff to
conduct home visits and more global positioning system (GPS) equipment to monitor their larger home
confinement populations. These changes may result in staffing and costs concerns for RRC providers as
they experience additional costs driven by the pandemic. BOP RSD officials told us that some RRC
contractors had reported reduced staffing and challenges hiring new staff and that some RRCs had needed
to provide hazard pay in order to retain staff. Additionally, RRCs generally are paid based on a negotiated
daily rate for each inmate housed at the RRC facility and are paid half the daily rate to monitor an inmate in
home confinement. The BOP reported that it has already received funding adjustment requests from some
RRC providers and that it expects to receive more. The BOP further observed that new contract solicitations
have included higher prices. While the OIG did not independently conduct RRC cost assessments for this
review, we note that the shift toward supervising more inmates in home confinement and fewer in RRC
facilities may affect whether RRCs can afford their operational costs. The BOP may need to explore options
to retain necessary services in an environment in which traditional RRC providers may be less able or willing
to provide services to meet the demands of the larger home confinement population.
Handling Failure in the Home Confinement Setting
Although failures in the home confinement setting were rare during the first year of the CARES Act, RRCs
and the BOP have fewer options for managing failures in CARES Act home confinement. Failure in the home
confinement setting occurs when an inmate commits misconduct or fails to comply with program rules,
such as by using illicit drugs, missing check-ins, or committing new criminal activity. Typically, if an inmate
fails in home confinement or if the home setting is no longer an appropriate place for that inmate, the BOP
can move the inmate into an RRC. However, RRC placements are generally limited to 12 months and the
CARES Act did not authorize extended placement in RRCs when it authorized extended placement in home
confinement. Therefore, if an inmate in home confinement under the CARES Act with more than 12 months
remaining on his or her sentence breaks the rules, the BOP must decide between returning the inmate to a
BOP facility or letting the inmate remain in home confinement. The BOP reported that this limitation makes
68
See DOJ Office of Legal Counsel, Slip Opinion, “Discretion to Continue the Home-Confinement Placements of Federal
Prisoners After the COVID-19 Emergency,” December 21, 2021, www.justice.gov/olc/file/1457926/download (accessed
July 13, 2022).
42
it more challenging to address lower-level noncompliance because it does not have an intermediate
sanction to impose before returning the inmate to a BOP facility.
RSD officials expressed concerns about long-term placements in home confinement and anticipated an
increase in program failures. In particular, RSD officials anticipated that, when normal inmate monitoring,
such as drug testing, resumed, failures would increase. OIG analysis of home confinement failure data
through March 2021 indicates that the home confinement failure rate for inmates released under CARES Act
authorities was low and only slightly higher than the failure rate for inmates released under preexisting
authorities. Of the 6,781 inmates who were transferred to home confinement under the CARES Act from
April 2020 through March 2021, 116 (1.7 percent) had failed in the home confinement setting as of the end
of March 2021. By comparison, there were 21,572 inmates transferred to home confinement under other
authorities during the same period and 249 (1.2 percent) had failed in the home confinement setting as of
the end of March 2021. As shown in Figure 6 below, the majority of home confinement failures were related
to drug or alcohol use. The most serious infraction, new criminal conduct, was infrequent for both inmates
placed in home confinement under the CARES Act and inmates placed under other home confinement
authorities.
Figure 6
Causes of Home Confinement Failures, April 2020–March 2021
Non-CARES Act
116 18 55 26 52 249
Failures
Total
CARES Act
50 8 20 1 37 116
Failures
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Drug Use Alcohol Use Escape Assault/Threats Bodily Harm New Criminal Conduct Other
Notes: In the home confinement setting, “Escape” refers to failing to remain at approved locations or failing to check
in at required times. “Other” encompasses violations that do not fit into the categories listed. Some examples
include no longer having an appropriate residence for home confinement and repeated noncompliance with the
conditions of home confinement.
Source: OIG analysis of BOP data
Conclusion
During our remote inspections, and in our work on this capstone review, we found that the BOP limited its
use of the CARES Act home confinement authorities by generally requiring that inmates have COVID-19
43
health risk factors in order to be eligible for transfer to home confinement. We also found that the BOP
experienced challenges in timely transferring eligible inmates to home confinement at the outset of the
pandemic. The OIG is taking a deeper look at some of these issues in its ongoing review of the BOP’s use of
home confinement as a response to the COVID-19 pandemic.
Ultimately, the BOP did transfer a substantial number of inmates to home confinement in May and June
2020; but we determined that the number of inmates transferred to home confinement during the first year
of the pandemic was actually lower than the number of inmates transferred during the year immediately
prior to the pandemic. We also found that the overall number of inmates monitored on home confinement
increased and remained high because inmates were being transferred to home confinement with longer
periods of time remaining in their sentences and therefore were spending more time in home confinement.
Additionally, inmates who had been serving their sentences in RRC facilities were transferred to home
confinement. In light of the increase in the number of inmates supervised by RRCs in the home
confinement setting, we believe that the BOP should continue to assess the effects of the larger home
confinement population on RRCs and their ability to monitor, manage, and provide services for inmates in
home confinement. While we do not make specific recommendations on this topic in this report, we
encourage the BOP to continue to assess how it can most effectively use its available authorities to
appropriately place inmates in home confinement during and after the COVID-19 pandemic.
The BOP Should Take Appropriate Steps to Address Staffing Shortages and Staff Morale
During our remote inspections, we identified several facilities that faced COVID-19 challenges due to staffing
shortages and found that the BOP used overtime, augmentation, and TDY assignments in an effort to
alleviate them. The effects of insufficient staffing were also illustrated in our BOP staff surveys, indicating a
need for more custody and medical staff in federal facilities, as well as a range of professional and personal
impacts on staff due to the pandemic. Additionally, we found that staffing shortages at BOP facilities may
have impeded some facilities’ ability to respond to the COVID-19 pandemic in a timely and thorough
manner. Finally, our remote inspections found that the pandemic strained staff morale and that facilities
varied in their abilities to support staff.
COVID-19 Exacerbated the Effects of Staffing Shortages, Increased Staff Workloads, and
Impeded Some Facilities’ Ability to Fully Respond to the Pandemic
During our remote inspections, we found that the BOP has continued to struggle with staffing issues,
including existing vacancies, staff absences, and increased workloads. The OIG has highlighted the BOP’s
staffing shortages as a long-standing issue in Top Management and Performance Challenges reports dating
back to 2015.69 The OIG discussed facilities’ medical staffing shortages in particular in our 2016 Review of
the Federal Bureau of Prisons' Medical Staffing Challenges.70 As shown in Table 3 below, the BOP increased
its total number of onboarded staff from FY 2018 through FY 2021. However, as of September 2022 the
69
Each year, the OIG prepares a report on Top Management and Performance Challenges Facing the Department of
Justice, which is required by statute to be included in the Department's Agency Financial Report. The OIG’s 2021 report
continued to highlight the BOP’s staffing shortages. See DOJ OIG, Top Management and Performance Challenges–2021.
70
DOJ OIG, Review of the Bureau of Prisons’ Medical Staffing Challenges, E&I Report 16-02 (March 2016),
oig.justice.gov/reports/review-federal-bureau-prisons-medical-staffing-challenges.
44
BOP had over 2,500 staff vacancies, including 21 percent of its authorized Correctional Officer positions.
The number of onboarded Correctional Officers declined from 17,114 at the end of September 2021 to
16,153 at the end of September 2022. As of September 2021, the BOP also reported that 14 percent of its
Health Services positions were vacant, as shown in Table 4 below. A December 2020 OIG Management
Advisory Memorandum on the BOP’s FY 2019 overtime hours and costs noted that the BOP uses overtime
as a mechanism to supplement staffing and found that the BOP spent over $300 million in overtime costs
during FY 2019.71 As part of the OIG’s ongoing work with the Pandemic Response Accountability Committee,
we are also assessing the BOP’s healthcare personnel shortages during the COVID-19 pandemic, the impact
of healthcare personnel shortages, and strategies to attract and retain healthcare personnel.
Table 3
BOP Staff Vacancy Rates, September 2017–September 2022
All BOP Employees Correctional Officers
Authorized Onboarded Authorized Onboarded
As-of Date % Vacant % Vacant
Positions Positions Positions Positions
End of September 2017 37,974 36,350 4% 20,921 18,170 13%
End of September 2018 38,557 34,414 11% 19,361 17,142 11%
End of September 2019 38,557 34,666 10% 20,446 17,031 17%
End of September 2020 38,680 35,869 7% 20,446 17,134 16%
End of September 2021 38,884 35,886 8% 20,446 17,114 16%
End of September 2022 38,995 34,094 13% 20,446 16,153 21%
Notes: “Authorized Positions” refers to the total possible staff positions, as reported in the BOP’s Enacted Spend Plans.
This number does not necessarily reflect the number of staff positions for which the BOP received funding in the given
year. In each year except FY 2018, the BOP received funding for fewer than the number of authorized positions. For
this table, the OIG calculated the vacancy rates using onboarded and authorized positions. The BOP’s Administration
Division told us that it calculated vacancy rates using funded positions instead of authorized positions, which is different
from the manner that we present in this table. However, the Administration Division was not able to provide the OIG
the number of funded Correctional Officer positions.
Source: BOP Congressional Budget Submissions and BOP Administration Division data
71
DOJ OIG, Management Advisory: Analysis of the Federal Bureau of Prisons’ Fiscal Year 2019 Overtime Hours and Costs,
Audit Report 21-011 (December 2020), oig.justice.gov/reports/management-advisory-analysis-federal-bureau-prisons-
fiscal-year-2019-overtime-hours-and.
45
Table 4
BOP Health Services Staff Vacancy Rates, September 2019–September 2021
As-of Date Total Positions Onboarded Positions % Vacant
September 2019 3,746 3,052 19%
September 2020 3,878 3,246 16%
September 2021 3,806 3,255 14%
Notes: “Health Services Staff” includes civil service and U.S. Public Health Service (PHS) staff (described below) at the
Central Office, six Regional Offices, and BOP facilities. There were between 95 and 103 onboarded Central and Regional
Office Health Services staff each year. The BOP’s Administration Division does not track Health Services positions and
they are not reported in BOP budget documentation, so the OIG requested this data from the BOP separately from the
data in Table 3 above. Thus, the data is not directly comparable to the data we present in Table 3.
Source: BOP data
In our 2021 BOP Staff Survey, 78 percent of respondents said that their facility’s Correctional Officer staffing
is insufficient and 53 percent said that their facility’s Health Services staffing is insufficient. BOP policy states
that the vacancy rate of staff positions that work directly with inmates shall not exceed 10 percent during
any 18-month period.72 Although our remote inspections did not assess individual facilities’ compliance with
this policy, we identified examples of what we believe are insufficient staffing levels, especially for Health
Services staff positions, at several facilities. For example, our remote inspection reports identified the
following staffing issues:
• During our remote inspection of FCC Lompoc, Lompoc’s Health Services Administrator indicated that
prior to the COVID-19 outbreak the facility’s medical staff had a 38 percent vacancy rate.73
• Our remote inspection of MDC Brooklyn found that the facility’s vacancy rates for Health Services
positions were between 33 percent and 27 percent from March 15 through May 9, 2020.
Additionally, MDC Brooklyn’s Custody Department was approximately 14 percent vacant from mid-
March through mid-May 2020 and the facility received staff on TDY assignment to fill vacancies.74
72
BOP Program Statement 3000.03, Human Resource Management Manual, December 19, 2007,
www.bop.gov/policy/progstat/3000_003.pdf (accessed July 11, 2022).
73
The Lompoc Health Services Administrator told the OIG that prior to the COVID-19 outbreak the facility’s medical
staffing was at only 62 percent. See DOJ OIG, Remote Inspection of Federal Correctional Complex Lompoc, E&I
Report 20-086 (July 2020), oig.justice.gov/reports/remote-inspection-federal-correctional-complex-lompoc.
74
BOP staff on TDY assignments deploy to other BOP institutions or offices on a temporary basis to address staffing
needs. Our remote inspection of MDC Brooklyn found that the facility staffed between 20 and 22 of its 30 authorized
Health Services positions (between 67 and 73 percent) from March 15 to May 9, 2020. MDC Brooklyn’s Custody
Department was approximately 86 percent filled from mid-March through mid-May 2020.
46
• During our remote inspection of FCC Coleman, management and Health Services staff identified
medical staffing shortages as the greatest challenge facing FCC Coleman in its efforts to combat
COVID-19.75 At the time of the remote inspection, Coleman’s Health Services Department had about
a 20 percent vacancy rate.
BOP data, BOP staff survey results, and our remote inspections identified instances of COVID-19 related
staff unavailability or absences:
• Based on our 2021 BOP Staff Survey results, 24 percent of BOP staff respondents reported that they
contracted COVID-19 and believed it was due to work exposure, 23 percent reported taking leave
due to demands at home, and 28 percent reported that they were required to work longer shifts.
The effect that the pandemic had on BOP staff work assignments and schedules, based on our 2021
BOP Staff Survey, is further illustrated below in Figure 7.
• As of October 2021, BOP data indicated that over 7,800 current staff members had contracted and
recovered from COVID-19.76
• At FCI Milan, three-quarters of the facility’s healthcare staff caught COVID-19 at some point, most of
them during the first week of the facility’s outbreak in April 2020.77
• At FCC Oakdale, staff reported numerous absences due to illness, the need to quarantine, and fear
of reporting to work, which forced some remaining staff to work longer shifts.
75
At the time of our remote inspection, Coleman’s Health Services Department had only 66 of its 83 authorized medical
personnel on hand. See DOJ OIG, Remote Inspection of Federal Correctional Complex Coleman, E&I Report 21-026
(January 2021), oig.justice.gov/reports/remote-inspection-federal-correctional-complex-coleman.
76
This data does not account for individuals who may have contracted and recovered from COVID-19 while working at
the BOP but who were no longer employed by the BOP.
77
DOJ OIG, Remote Inspection of Federal Correctional Institution Milan, E&I Report 21-032 (January 2021),
oig.justice.gov/reports/remote-inspection-federal-correctional-institution-milan.
47
Figure 7
2021 BOP Staff Survey Results: Impact on Staff
Source: OIG dashboard of 2021 BOP Staff Survey data
Additionally, BOP staff who continued to work during the COVID-19 pandemic requested a large number of
temporary job modifications that we believe may have affected their ability to conduct their usual work.78
OIG analysis of BOP data showed that, from March 2020 through May 2021, over 1,700 temporary job
modifications related to the ongoing COVID-19 pandemic were approved. About 58 percent of the
temporary job modifications involved duty modifications beyond the BOP’s social distancing and face
covering requirements. These modifications included remaining separate from others or staying away from
the facility, both of which severely limit the work that BOP facility staff can do, especially for staff whose jobs
generally require in-person contact with inmates.
Staffing Shortages and Increased Workloads Due to COVID-19 Protective Measures
We found that modified operations and increased infection prevention and control measures due to the
COVID-19 pandemic increased BOP facility staff workloads. Staff needed to take on additional
responsibilities, including regularly screening inmates and staff for symptoms of COVID-19; managing
quarantine and medical isolation units; and taking on tasks, such as food service, cleaning, and laundry,
normally done by inmate work crews, in an effort to manage and reduce transmission of COVID-19 in
48
federal facilities. At some BOP facilities we inspected, so many inmates were simultaneously hospitalized
for COVID-19 that dozens of Correctional Officers per shift were assigned to accompany and supervise
them. For example, at FMC Fort Worth, teams of two Correctional Officers are required to accompany each
inmate receiving care at a hospital. Our inspection found that at one point in April 2020 as many as 81
Correctional Officers were assigned to the hospital and were not available to fill posts at the FMC due to the
risk of further COVID-19 transmission.79 Additionally, restrictions on inmate movement meant that staff had
to bring services into the housing units rather than allowing inmates to gather in a common area to receive
services. For example, our inspection of FCC Pollock found that Education Department staff performed
rounds and made materials available to inmates for self-study when inmates could not visit classrooms.80
Our inspection of FCC Tucson found that Health Services staff had to provide all medical services, such as
sick calls and medication deliveries, inside housing units, which Tucson management described as “taxing.”81
We also found that facility staff were asked to work overtime to cover staffing shortages during the
pandemic.82 For example, the remote inspection of FCC Oakdale noted an increased use of overtime to
address COVID-19 related staffing issues. Collectively, Oakdale staff worked more than 18,700 overtime
hours between March 29 and April 25, 2020, during the height of Oakdale’s COVID-19 crisis. This was a 487
percent increase from the 3,186 collective overtime hours that Oakdale staff worked between February 2
and 29, 2020. The BOP acknowledged that some Oakdale staff volunteered to work shifts as long as 40
hours straight but asserted that no staff member was mandated to work beyond a 16-hour shift. Nurses
and Correctional Officer Lieutenants were mandated to work up to 12-hour shifts rather than their standard
8-hour shifts. The 2021 BOP Staff Survey results indicated that the use of overtime was widespread during
the pandemic, with 46 percent of staff respondents reporting that they had been asked to work overtime
and 39 percent of staff respondents reporting that they had been required to work overtime. These
numbers were higher for Correctional Officers, with 64 percent of Custody staff (Correctional Officer)
respondents reporting that they had been asked to work overtime and 72 percent reporting that they had
been required to work overtime. In addition to overtime, staff workloads during the pandemic contributed
to delayed family notifications of inmate serious illness. We discuss that issue below in The BOP Should
Improve Its Communication of Essential Information to Stakeholders section of the report.
Finally, we found that BOP staff were often pulled from their normal duties to perform tasks in areas that
were short staffed. In our 2021 BOP Staff Survey, 66 percent of respondents reported that they had been
asked to perform tasks outside their normal duties. Further, at FCC Oakdale, staff from the Recreation,
Education, Religious Services, Facilities Management, and Human Resources Departments were reassigned
78
Temporary job modifications allow the BOP to place staff members at work posts different from their normal job
responsibilities.
79
BOP Program Statement 5538.07, Escorted Trips, December 10, 2015, www.bop.gov/policy/progstat/5538_07.pdf
(accessed July 11, 2022).
80
DOJ OIG, Remote Inspection of Federal Correctional Complexes Oakdale and Pollock.
81
DOJ OIG, Remote Inspection of Federal Correctional Complex Tucson, E&I Report 20-087 (July 2020),
oig.justice.gov/reports/remote-inspection-federal-correctional-complex-tucson.
82
Previous OIG work has examined the BOP’s use of overtime. In FY 2019, BOP employees worked 6.71 million
overtime hours, the equivalent of 3,107 full-time positions. See DOJ OIG, The Federal Bureau of Prisons’ Fiscal Year 2019
Overtime Hours and Costs.
49
to cover general inmate supervision posts. A BOP Central Office official told us that, during the pandemic,
facilities used education staff to augment correctional posts, which often resulted in insufficient staff to run
education or recreation programming for inmates.83 The OIG has previously raised concerns about
augmentation because it often places program staff into critical security positions and interferes with the
BOP’s ability to ensure the safety of its staff and inmates, as well as its ability to provide inmate programs.84
The GAO has also identified concerns in this area, specifically noting that the BOP has not assessed the risks
associated with both overtime and augmentation, despite increased use of both practices between 2015
and 2019.85
Staffing Shortages’ Effect on Some Facilities’ Ability to Fully Respond to the COVID-19 Pandemic
We found that medical staffing shortages affected the BOP’s ability to provide routine medical care at
certain facilities. The remote inspections of FCC Lompoc and MDC Brooklyn found that medical staffing
shortages may have negatively affected the facilities’ ability to screen inmates for COVID-19 symptoms in
addition to providing routine medical care to inmates. MDC Brooklyn Health Services staff indicated that
sick-call wait times increased significantly due to COVID-19, as the facility faced a much higher volume of
sick calls compared to the prior year. Staff also reported that 160 inmate sick call requests, dating to early
July 2020, had not been scheduled or completed as of late September 2020. MDC Brooklyn Health Services
staff told us that, in addition to medical staffing shortages, the requirement for healthcare providers to visit
inmates in housing units also lengthened the time it took for providers to evaluate and treat patients. In
addition, as discussed previously, it was determined that, at another facility where an inmate had died by
suicide, staff had failed to conduct pill line in restrictive housing, a failure that reportedly occurred due to
staffing issues as well as staff error.
Shortages of staff also affected the implementation of COVID-19 control measures at certain facilities. At
FCC Lompoc, an insufficient number of correctional staff members resulted in Lompoc officials delaying
mandates on staff movement restrictions until 15 days after the BOP directed facilities with COVID-19 cases
to maximize social distancing to help control the spread of the infection. Lompoc officials told us that they
could not fully implement staff movement restrictions due to COVID-19 concerns until the arrival of
adequate TDY staff because the facility did not have enough staff to fill all mandatory correctional posts,
both at FCC Lompoc and at the local hospitals where some inmates were receiving care. Additionally,
staffing shortages at FCI Milan due to a COVID-19 outbreak made it difficult for that facility to restrict staff
movement to prevent the spread of the virus.
The BOP’s Efforts to Address Staffing Shortages During the COVID-19 Pandemic
In addition to utilizing overtime and augmentation, as we described above, the BOP used a variety of
methods to address the ongoing staffing shortages at its facilities. To address its immediate needs, the BOP
83 Augmentation is the assignment of non-custody staff members to assume the duties of a Correctional Officer. The
BOP practices augmentation to address custody staffing shortages. In response to augmentation practices described in
a draft of this report, the BOP stated that it assigns necessary work to any staff member as all staff are correctional
workers first and expected to complete work duties as a law enforcement professional first.
84
DOJ OIG, Top Management and Performance Challenges Facing the Department of Justice–2019 (October 2019),
oig.justice.gov/reports/top-management-and-performance-challenges-facing-department-justice-2019, 3.
85
See GAO, BOP Could Further Enhance Its COVID-19 Response, 57–59.
50
used short-term measures such as sending staff on TDY assignments and receiving additional support from
the U.S. Public Health Service (PHS), a branch of deployable medical officers from the U.S. Department of
Health and Human Services who serve in federal agencies. The BOP also continued efforts to increase
employee retention and hire new staff during the pandemic. As shown in Table 3 above, the BOP increased
its total staff from FY 2018 through FY 2021; however, in FY 2022, the number of total staff declined and
21 percent of the BOP’s budgeted Correctional Officer positions remained vacant.
TDY staff are deployed from other BOP facilities or offices on a temporary basis to address a facility’s
immediate need for staff and ultimately return to their official duty post when the assignment is
completed.86 During our inspections, we found that the BOP deployed TDY staff to alleviate medical staffing
shortages, decrease staff overtime hours, and assist staff with inmate supervision duties. Between March
2020 and April 2021, the BOP deployed 1,770 TDY staff for COVID-19 related assignments. As shown in
Figure 8 below, the majority of the TDY assignments occurred during the beginning of the pandemic, in April
and May 2020, though TDY surges occurred at various facilities throughout the first year of the pandemic.
Overall, 59 BOP facilities and offices, including MDC Brooklyn, FCI Terminal Island, FMC Fort Worth, FCC
Lompoc, and FCC Oakdale, received TDY staff to fill vacancies related to the COVID-19 pandemic. We found
that, out of the 11 federal facilities we inspected, FCC Oakdale received the largest number of TDY staff, a
total of 156 TDY staff placements between March 2020 and April 2021. Oakdale staff told the OIG that the
additional help from TDY staff eased the burden on Oakdale’s staff and made them better able to focus
their efforts to contain the spread of COVID-19 at the facility.
86
During our remote inspection of MDC Brooklyn, we conducted independent analysis of healthcare staffing levels and
found that many positions were vacant. These vacancies were caused by extended absences from the institution due to
a variety of reasons, including military leave, TDY assignments to other institutions, and extended sick leave. See DOJ
OIG, Remote Inspection of MDC Brooklyn.
51
Figure 8
Number of BOP Staff Beginning a COVID-19 TDY Assignment, by Month, March 2020–April 2021
700
600
500
400
300
200
100
0
Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr
2020 2021
Source: OIG analysis of BOP data
The BOP employs both civil service employees and PHS officers to provide medical care to inmates in BOP
facilities. A 1991 memorandum of understanding (MOU) between the BOP and PHS established conditions,
responsibilities, and procedures governing the assignment of PHS officers to BOP facilities. As of May 2021,
there were 670 PHS officers working at BOP facilities nationwide, according to a PHS Captain serving as a
liaison on behalf of the BOP. PHS officers serve in various health service roles, including as nurses,
physicians, pharmacists, and dentists. From April 28 through August 1, 2020, 28 additional PHS officers
were deployed on a temporary basis to BOP facilities with the highest need nationwide in response to the
COVID-19 pandemic.
The PHS Captain told us that the BOP and the PHS have been working on an updated MOU that would more
clearly outline the staffing support that the PHS provides to the BOP. Current discussions related to
updating the MOU include enhanced deployment plans, requirements of staff fitness for duty, and
occupational and health safety plans for PHS staff deployed to BOP facilities. We believe that the BOP
should continue its planned updates to the MOU with the PHS to clearly outline the medical staff support
needed at BOP facilities that would help the BOP address medical staffing shortages beyond the pandemic.
To combat staffing shortages, the BOP has implemented programs aimed at hiring and retaining
Correctional Officers and medical professionals. In recent years, the BOP has used recruitment incentives,
relocation incentives, retention incentives, and other such programs in an effort to hire and retain staff.
Beginning in September 2019, in an effort to retain staff, the BOP offered a 5 percent salary increase as part
of a group retention incentive to approximately 3,000 employees who were eligible to retire as of the end of
52
calendar year 2019. This 5 percent group retention incentive was to be in effect until December 31, 2022.
As of September 2019, 2,929 BOP staff had accepted the incentive, and, as of November 2022, 1,461 BOP
staff continued to receive this incentive while remaining employed at the BOP despite their retirement
eligibility.
In addition, according to a February 2021 GAO report, the BOP may repay federally insured student loans to
attract job candidates or retain current staff. The GAO report further noted that, following U.S. Office of
Personnel Management (OPM) approval, the BOP has established higher pay rates for some specialist
positions, such as physicians and psychologists, as well as allowances for certain eligible physicians or
dental professionals who enter into service agreements.87 Additionally, all BOP facilities were instructed to
hold at least one recruitment event per month to recruit more external staff and the BOP offered a $1,000
recruitment incentive for staff who successfully recruited new hires.
For this report, we did not analyze the pay scales of BOP medical staff or potential challenges with staff
recruitment. However, our 2016 report on the BOP’s medical staffing challenges found that the BOP was
required to classify positions according to the General Schedule pay scale, and, for physical therapists and
pharmacists especially, the BOP struggled to offer competitive pay because the assigned grade of the
positions limited the salaries they could offer. 88
To further understand the BOP’s staffing shortages, we analyzed staffing data from 2018 through 2021.
BOP staff retention remained largely the same over this 3-year period, with the BOP reporting total staff
separation rates as 8.3 percent in 2018 and 7.4 percent in 2019. During the pandemic, in 2020, the
separation rate for BOP employees was similar, at 7.6 percent. As shown in Figure 9 below, the number of
separations month by month was fairly consistent throughout the 3-year period, despite the pressures of
the ongoing pandemic.
87
GAO, Bureau of Prisons: Opportunities Exist to Better Analyze Staffing Data and Improve Employee Wellness
Programs, GAO-21-123 (February 2021), www.gao.gov/products/gao-21-123 (accessed December 21, 2021), 27.
In January 2020, to improve healthcare recruiting and retention, the Department and OPM formally granted the BOP
authority to pay physicians and dentists using the laws governing medical professional compensation in the U.S.
Department of Veterans Affairs (Title 38 Pay Plan), which allows the BOP to offer staff in those positions higher pay than
the BOP would otherwise be able to offer.
88
DOJ OIG, Review of the Bureau of Prisons’ Medical Staffing Challenges, 8–9. Our 2016 report also found that there
was a large gap between the salaries the BOP pays its medical employees and those offered for similar positions in the
local areas surrounding facilities.
In response to a draft of this report, the BOP stated that the pay scales of BOP medical staff, compared to those of
medical staff in the general public, remain a major hurdle to the BOP’s recruitment of medical staff. Separately, the OIG,
in collaboration with the Pandemic Response Accountability Committee, is conducting a review of healthcare staffing in
federal healthcare programs, including the BOP, to determine whether these programs experienced shortages in
healthcare personnel during the pandemic, the impact of any shortages, and strategies used by agencies to reduce
shortages of healthcare personnel for future pandemics.
53
Figure 9
Comparing BOP Staff Separations, by Month, April 2019–March 2021
500
400
300
200
100
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
April 2018–March 2019 April 2019–March 2020 April 2020–March 2021
Note: “Staff Separations” include retirements, transfers to other agencies, resignations, terminations,
removals, and deaths.
Source: OIG analysis of BOP data
From April 2020 through January 2021, the BOP ran an advertising and marketing campaign to hire
additional custody and Health Services staff through expanded recruitment efforts that reached an
estimated 6.5 million viewers. This hiring campaign represented an attempt to rebrand and market the BOP
for new recruits and included the use of online recruiting, social media, and web analytics to reach and
engage new applicants. The BOP held live social media events geared toward the recruitment of nurses and
Correctional Officers to reach wider audiences and drive applicants to the BOP application portal. However,
new staff hiring levels appear to have remained largely the same despite the BOP’s increased focus on
recruitment and retention. OIG analysis of BOP hiring data indicates that the number of new staff hired
during the first year of the pandemic was similar to the number of staff hired during the year before the
pandemic. The BOP hired 3,882 new staff from April 2019 through March 2020 and 3,823 new staff from
April 2020 through March 2021. In March 2021, the then BOP Director told the House Appropriations
Committee, Commerce, Justice, Science, and Related Agencies Subcommittee, that the BOP was able to hire
new staff in 2020 but lost the same number of staff due to separations.
Conclusion
Overall, our inspections found that staffing shortages impeded the ability of some BOP facilities to provide
routine medical care to inmates during the COVID-19 pandemic and implement effective infection mitigation
strategies at various federal facilities, as well as straining already heavy staff workloads with additional
responsibilities. In addition, as we discuss in the next section, the pandemic had a serious impact on staff
morale. To alleviate staffing shortages, the BOP used overtime and augmentation and deployed TDY staff to
requesting facilities most often related to COVID-19. The OIG has repeatedly highlighted the BOP’s staffing
shortages issues, including its medical staffing shortages, in our Top Management and Performance
Challenges reports. Additionally, a December 2021 GAO report found that the BOP lacks a plan for
54
identifying and addressing staffing challenges and has not leveraged available data to help identify and
address the causes and potential impacts of staffing challenges.89 Although we are not making any new
recommendations on this topic given the GAO’s open recommendations, we encourage the BOP to continue
implementing additional proactive strategies to address staffing challenges and better prepare for public
health emergencies in the future.
Staff Were Negatively Affected by the COVID-19 Pandemic, and the BOP Should Take
Appropriate Steps to Support Staff Morale
Our remote inspections found that the pandemic strained staff morale and that facilities varied in their
abilities to support staff. In addition to the negative effects of staffing shortages on facility staff that we
described above, 70 percent of facility staff respondents from the 2021 BOP Staff Survey reported having
experienced stress or anxiety at work due to the pandemic. Further, BOP Central Office Psychology Services
Branch officials we interviewed heard concerns from BOP staff related to facilities’ implementation of
COVID-19 related guidance, confusion regarding staff leave and quarantine, and fear of transmitting COVID-
19 to family members. At FCC Oakdale, management’s failure to adequately communicate and engage with
staff at the beginning of the complex’s COVID-19 outbreak confused staff and created an environment in
which staff felt that management did not appreciate them or lacked concern for their overall well-being.
According to medical staff at FCC Milan, persistent staffing shortages took a toll on the health and well-being
of medical staff. We also found that staff throughout the BOP expressed concerns regarding leave,
including inconsistent and changing guidance about leave and quarantine due to COVID-19. Lastly, 2021
BOP Staff Survey respondents indicated that providing mental health resources for staff was one of the top
five areas in which the BOP most needed to improve its pandemic response.
Staff’s Mixed Perceptions of BOP Facility Leadership’s Communication
We found in our remote inspections and staff survey responses that there were mixed reports about the
BOP’s communication with its staff during the pandemic. Respondents to the 2021 BOP Staff Survey
identified facility leaders’ communication with staff as the top area that the BOP most needed to improve in
its handling of the pandemic. Further, our inspection reports found that facility leadership communication
failures contributed to FCC Oakdale’s delay in implementing the BOP’s February 2020 staff screening
guidance and FCC Lompoc staff’s ignorance about a close contact who had tested positive for COVID-19, the
latter of which potentially exposed others to the virus. In contrast, 2020 BOP Staff Survey respondents at
eight BOP-managed facilities we inspected praised facility executive leadership for their proactive
communication with staff members. Additionally, our inspections of the Toler House Residential Reentry
Center (RRC) and three contract prisons found that contract facility leadership generally communicated
information clearly to staff. The GAO’s July 2021 report on the BOP’s COVID-19 response recommended that
the “BOP Director should routinely evaluate how the BOP communicates COVID-19 guidance to facility staff
and that the BOP modify its approach, as needed, based on the results to ensure that BOP protocols are
clearly communicated to staff.”90 The totality of staff perspectives that we received highlighted the
89
GAO, BOP: Opportunities Exist, 41.
90
GAO, BOP Could Further Enhance Its COVID-19 Response, 58.
55
importance of the BOP’s communication with staff in maintaining facility safety and staff well-being during
the pandemic.
Staff’s Concerns About Inconsistent and Changing Guidance Regarding Leave
We found that BOP facility staff reported confusion about guidance on staff use of leave and quarantine due
to COVID-19. To reduce the spread of COVID-19, the CDC advised the general public in 2020 to stay home if
they were sick, had been in close contact with someone who had symptoms consistent with COVID-19, or
had been in close contact with someone who tested positive for the disease.91 OPM and the CDC issued
additional guidance to help federal employees whose ability to report to work may be affected by COVID-19,
and the BOP subsequently issued its own guidance. Despite this guidance, we found that BOP staff were
confused about their eligibility to use various types of leave and about the directions on whether to
quarantine or continue reporting to work if they had been exposed to COVID-19.
BOP staff also expressed confusion about which types of leave they should use and their abilities to use
leave during the pandemic. In March 2020, the BOP’s Human Resources Management Division issued
guidance advising that employees who were symptomatic or diagnosed with COVID-19 should use accrued
or advance sick leave to cover the period of illness. The BOP’s guidance further advised that asymptomatic
employees who were told not to return to work by either a local health authority or the BOP’s Health
Services Division should either telework, if possible, or be placed on Weather and Safety leave. In April 2020
the BOP issued additional guidance explaining how the additional 80 hours of paid sick leave authorized by
the Emergency Paid Sick Leave Act applied to BOP employees.92
During our remote inspection fieldwork, BOP employees from 4 of the 11 federal facilities we inspected told
us that they were unsure about aspects of the leave guidance, such as the types of leave afforded in various
situations or how staff should determine when it was appropriate to return to work. Nationally, 45 percent
(3,695 of 8,153) of 2020 BOP Staff Survey respondents who answered the survey question, “Which of the
following are immediate needs for your institution during the COVID-19 pandemic,” identified needing
greater flexibilities for use of administrative leave due to COVID-19 related absences. Staff concerns about
leave guidance and staff’s ability to use leave were also expressed in complaints submitted to the OIG during
the pandemic. Respondents to the 2021 BOP Staff Survey reported continued confusion about leave
guidance, as less than half stated that guidance on using leave for COVID-19 reasons was easy to understand.
Staff’s Reported Confusion About Whether to Quarantine or Report to Work
Another area of confusion for staff was whether they should quarantine or report to work following COVID-
19 exposure. Early during the pandemic, CDC guidance on this topic applicable to BOP staff changed.
Specifically, the CDC’s March 23, 2020 interim guidance on management of COVID-19 in correctional
facilities recommended that if a staff member was identified as a close contact of a COVID-19 case he or she
should self-quarantine at home for 14 days before returning to work. However, the U.S. Cybersecurity
91
The CDC defines close contact as being within 6 feet for at least 15 minutes over a 24-hour period.
92
The Families First Coronavirus Response Act, enacted on March 18, 2020, made full-time federal employees generally
eligible for expanded leave provisions if they were unable to work because of COVID-19. On April 1, 2020, the Emergency
Paid Sick Leave Act went into effect as part of the Families First Coronavirus Response Act. Emergency Paid Sick Leave Act
paid sick leave was available for use by federal employees from April 1, 2020, through December 31, 2020.
56
Infrastructure and Security Agency identified personnel in corrections as critical infrastructure workers and
the CDC’s April 9, 2020 guidance for critical infrastructure workers stated that asymptomatic workers
exposed to COVID-19 could report to work following additional precautions.93 For BOP correctional staff,
this represented a significant change from the CDC’s correctional facilities guidance that advised
asymptomatic staff to quarantine for 14 days at home following COVID-19 exposure. A BOP Central Office
Health Services official we interviewed described her own frustration about these inconsistencies and the
resulting confusion and told us that representatives from the national union representing BOP Correctional
Officers had expressed similar frustration.
On May 4, 2020, in a Families First Coronavirus Response Act Frequently Asked Questions document, the
BOP’s Human Resources Management Division wrote that asymptomatic employees should continue to
report to work until advised otherwise. We did not find evidence that the BOP issued additional detailed
guidance on this topic for non-TDY staff until September 2020, when the BOP issued the first version of its
COVID-19 Pandemic Response Plan. This plan included an instructional flowchart for symptomatic facility
and non-facility staff who had been potentially exposed to COVID-19, in addition to guidance for
asymptomatic facility and non-facility staff who had been potentially exposed to COVID-19.
Respondents from our 2020 BOP Staff Survey also expressed confusion about whether to report to work if
they had been exposed to COVID-19 and were asymptomatic. Some 2020 respondents reported instances
in which they were advised by their physician to quarantine but told by the BOP to continue reporting to
work. Similarly, a Central Office Health Services official we interviewed cited instances in which BOP staff
had received mixed messages from healthcare providers. A 2020 BOP Staff Survey respondent observed
that, by not offering administrative leave for the purposes of quarantining staff who had been exposed to
COVID-19, the BOP’s practices were inconsistent with those of local law enforcement or fire departments.94
Prior to the BOP’s issuance of its COVID-19 Pandemic Response Plan, facility staff working in different parts
of the BOP reported receiving different instructions on what to do if they had been exposed to COVID-19.
Federal staff working directly in facilities most commonly reported in our 2020 BOP Staff Survey that if they
were exposed to COVID-19 they were expected to continue reporting to work unless they developed
symptoms (45 percent, or 4,141 of 9,163). In contrast, federal staff working in the BOP’s Central and
Regional Offices most commonly reported in our 2020 BOP Staff Survey that if they were exposed to COVID-
19 they were expected to quarantine for 14 days (47 percent, or 328 of 693).95 Additionally, numerous 2020
93
The CDC’s suggested precautions included screening for elevated temperature and other symptoms, wearing a face
mask or cloth face covering, social distancing, and regular cleaning and disinfecting workspaces.
94
For example, news media reported in March 2020 that the New York City Fire Department initially quarantined
Emergency Medical Services workers who had been exposed to COVID-19 before changing its policy to require exposed
staff to continue working unless they developed symptoms. Ali Watkins, “Last Week One Paramedic Was Infected. Now
Over 150 Are in Quarantine,” The New York Times, March 20, 2020, www.nytimes.com/2020/03/20/nyregion/coronavirus-
nyc-emergency-response.html (accessed July 13, 2022).
95
Central and Regional Office respondents were also three times as likely as institution respondents to say that they
were advised that they should use administrative leave or COVID-related leave if they were quarantined due to
exposure to COVID-19. Specifically, 34 percent of Central and Regional Office respondents (235 of 693) said that they
were advised that they should use administrative leave or COVID-related leave, compared to only 10 percent of
institution respondents (955 of 9,163).
57
BOP Staff Survey respondents—nearly one in five facility respondents and one in seven Central and
Regional Office respondents—reported that the guidance they had received on what to do if they had been
exposed to COVID-19 was conflicting.96
Uncertainty about whether to report to work or quarantine was of particular concern for staff returning
from TDY assignments at other BOP facilities to their facilities of record. As we discussed above, the BOP
utilized TDY staff to assist some facilities in their response to COVID-19, including at locations with high
COVID-19 transmission. During our inspections, some staff reported concerns about the risk of COVID-19
transmission from TDY staff returning to their home facilities. Our inspection of FCC Oakdale found that
staff returning from March 2020 TDY assignments in New York City, one of the areas hit hardest by COVID-
19 at the time, were not initially given instructions about quarantine procedures and reported to work
before being told to return home and quarantine for 14 days. Seven 2020 BOP Staff Survey respondents
reported that TDY staff members returning from locations with high COVID-19 transmission were not
required to quarantine. Similarly, in eight complaints submitted to the OIG in April and May 2020,
complainants alleged that TDY staff returned to work without quarantining upon return to their primary
work locations. Staff confusion about appropriate quarantine practices for returning TDY staff continued
through 2021, as only 44 percent of 2021 BOP Staff Survey respondents reported that guidance on
quarantining staff following TDY assignments or official travel was easy to understand and that their facility
followed communication and guidance on this issue.
The BOP’s guidance for staff members returning to work from COVID-19 related TDY assignments evolved
throughout the pandemic and likely contributed to staff’s reported confusion. Between April and
September 2020, the BOP issued three versions of guidance for staff returning from COVID-19 TDY
assignments that included instructions on whether to report to work for both facility and non-facility staff in
various scenarios (for a scenario example, see Table 5 below). For some staff members, the BOP’s guidance
on whether to report to work or take leave and quarantine at home changed each time the BOP updated its
guidance. For example, we identified that an asymptomatic Correctional Officer returning from a TDY
assignment working on a quarantine unit at a facility with active COVID-19 cases to his or her home facility
with no active COVID-19 cases would have received the instructions presented in Table 5.
96
Overall, 19 percent of federal institution respondents (1,750 of 9,163) and 14 percent of Central and Regional Office
respondents (97 of 693) reported that they had received conflicting guidance.
58
Table 5
The BOP’s TDY Guidance, May–September 2020
Scenario Date Applicable BOP TDY Guidance
April 9, 2020 Report to work.a
An asymptomatic Correctional
Officer returns from a TDY
assignment working on a
Stay at home and use 10 days of Weather and Safety
quarantine unit at a facility with May 20, 2020
Leave.
active COVID-19 cases to their
home facility with no active
COVID-19 cases. Stay at home and use 14 days of Weather and Safety
September 11, 2020
Leave.b
a The April 9, 2020 guidance stated that Wardens could decide, contingent on staffing needs, to place an asymptomatic
staff member returning from TDY on home quarantine for 14 days if he or she had been identified as a prolonged close
contact of a COVID-19 positive case and did not have the appropriate PPE or had experienced a breach in PPE. The
guidance further stated that staff who fit this category did not need to wear a face mask if a temporary job modification
for a 14-day period could be provided to permit the staff member separation of greater than 6 feet from other
individuals. On April 15, 2020, the BOP mandated that all staff and inmates would wear BOP-provided face coverings.
b The September 11, 2020 guidance stated that an asymptomatic staff member who had been assigned to a quarantine
unit, isolation unit, hospital duty, or inmate transport while on TDY “shall be placed on Weather & Safety Leave for
14 calendar days, unless otherwise determined by the [Warden] of their home institution (because of staffing needs).”
Source: OIG analysis of the BOP’s 2020 TDY guidance
We found that during the pandemic there was uncertainty throughout the BOP about where to direct
questions regarding leave and reporting to work. Concerns about use of leave and leave guidance were
among the most common issues that staff raised in their calls to the BOP’s COVID-19 staff support line,
which we discuss below. At Central Office, the Human Resources Management Division was primarily
responsible for the dissemination of guidance, which was largely derivative of OPM or DOJ guidance, about
types of leave available to employees while the Health Services Division generally disseminated health
guidance developed by the CDC. According to an official at the Occupational Health and Safety Branch
within the Health Services Division, it was challenging for the branch to monitor updates to CDC guidance
and the branch did not receive alerts when the CDC updated its guidance.
During interviews, BOP Occupational Health and Safety Branch staff told us that there had been constant
challenges and areas of confusion regarding the use of leave for quarantine or isolation purposes and that it
often referred those questions to the Human Resources Management Division. Despite these reported
referrals, Human Resources Management Division staff advised us that they were unaware of staff
members’ confusion about leave during the pandemic and that facility staff concerns about leave were
typically directed to the Regional Offices. Our analysis of call logs documenting calls made to the staff
support line found that Central Office employees working on the staff support line often advised callers to
consult their facilities regarding questions about leave and reporting to work. However, only 50 percent of
2021 BOP Staff Survey respondents reported that their facility followed guidance on the use of leave for
59
COVID-19 reasons. Based on persistent BOP staff confusion about guidance on leave issues and differing
directions about whom staff should consult, the BOP should clarify to staff where to direct leave inquiries.97
The BOP Should Better Communicate Support Options to Staff
We found that the BOP could have better communicated the support options available to staff during the
pandemic. The primary support options available to BOP staff during the pandemic include: (1) the
Employee Assistance Program (EAP), which “provides employees and their family members with access to
resources that help address work-related problems, traumatic incidents, substance abuse, mental illness,
and other personal problems”; (2) a COVID-19 staff support line maintained by the BOP Central Office; and
(3) Crisis Support Teams, which provide peer support to staff in response to critical incidents.98 We found
during our remote inspections that some facilities took actions to mitigate the effects of the pandemic on
staff well-being. For example, management at contract prison Correctional Institution (CI) Moshannon
Valley instituted morale and welfare teams composed of local staff to check on the well-being of staff and
inmates during the pandemic.99 Additionally, staff at three facilities we inspected told us that Crisis Support
Teams were available to provide emotional support to staff. However, the BOP modified the support
options available to staff during the pandemic, including changing EAP providers and creating and
eventually discontinuing the COVID-19 specific 24-hour staff support line. Below, we discuss the support
options available to staff during the pandemic:
• EAP: In December 2020, the BOP switched to a new EAP provider to provide enhanced resources to
staff. BOP staff had expressed concerns about the effectiveness of the previous EAP provider the
BOP utilized during the first 8 months of the pandemic. Although we did not assess the quality of
EAP services as part of this review, a 2021 GAO report recommended that the BOP collect EAP
participation and cost data in a more timely manner and routinely collect and evaluate feedback on
its EAP.100 The BOP Central Office announced the new EAP provider’s services using several
methods, such as a video message from the then BOP Director, a written announcement posted to
the BOP’s intranet, and virtual training. Of the 98 percent of 2021 BOP Staff Survey respondents
who reported that they had heard of the EAP, approximately three-quarters stated that they had not
used it.
97
In response to a draft of this report, the BOP stated that, following the issuance of the GAO’s July 2021 report
regarding the BOP’s COVID-19 response, the BOP adjusted its annual employee feedback survey to include two new
questions related to staff perspectives on its COVID-19 guidance as of December 2021. The BOP stated that it has
analyzed the results of this survey and is continuing its communication strategy for COVID-19 guidance based on those
results. See GAO, BOP Could Further Enhance Its COVID-19 Response.
98
In response to a draft of this report, the BOP stated that it changed the name “Crisis Support Team” to “Correctional
Support Team” (CST). In this report, we refer to Crisis Support Teams to reflect the period of our review. The BOP
stated that it has restructured CSTs to place more emphasis on regional involvement in oversight of and communication
with facility CSTs.
99
DOJ OIG, Remote Inspection of Federal Bureau of Prisons Contract Correctional Institution Moshannon Valley,
Operated by the Geo Group, Inc., E&I Report 20-097 (August 2020), oig.justice.gov/reports/remote-inspection-federal-
bureau-prisons-contract-correctional-institution-moshannon-valley.
100
GAO, BOP: Opportunities Exist, 41.
60
• COVID-19 Staff Support Line: From April through December 2020, the BOP made a 24-hour COVID-
19 staff support line available for facility staff to discuss their concerns with a BOP staff member.
Central Office psychologists and chaplains took turns fielding staff support line calls in 24-hour
shifts. Central Office staff told us that support line staff elevated some of the concerns that callers
raised to BOP leadership, with caller consent. While the BOP updated its announcement about the
activation of the COVID-19 staff support line on its internal employee website on April 3, 2020, 36
percent of facility staff respondents to our 2021 BOP Staff Survey had not heard of the staff support
line.101 Further, our review of staff support line call logs indicated that some staff were unclear
about how the support line worked. Moreover, the BOP’s COVID-19 Pandemic Response Plan as of
September 7, 2021, incorrectly listed the staff support line as an available resource for staff over 9
months after the line had ended. While the then BOP Director’s April 2020 announcement stated
that vocalizing concerns was a better way for staff to cope with pandemic stress than not speaking
about them, his December 2020 message about the support line ending encouraged staff to contact
an email box about their future COVID-19 concerns.
We found that the staff support line generally served as a useful source of support for staff who
used it during the pandemic and that, overall, the number of staff calls to the support line decreased
over time. Specifically, 74 percent of 2021 BOP Staff Survey respondents who called the staff
support line reported that they found it to be helpful. Additionally, call log summaries indicated that
callers expressed appreciation for the staff support line, which helped multiple callers resolve issues
by sharing resources or providing guidance and support. However, the staff support line was
available to staff for only about the first 8 months of the pandemic; a Central Office official told the
OIG that the new EAP provider effectively replaced the support line.
• Crisis Support Teams: BOP data indicated that there were 289 Crisis Support Team activations in
2020, including 58 activations as a result of the pandemic. According to a psychologist at one BOP
facility we inspected, a Crisis Support Team provided facility staff with resources related to mental
health, childcare, and community services. A Central Office official explained that during the
pandemic it was challenging to fully implement the Crisis Support Team peer support model, which
entails peer support staff walking throughout facilities and talking to staff members, due to staff
movement restrictions and limited face-to-face interactions. Lastly, 84 percent of 2021 BOP Staff
Survey respondents reported that they had heard of Crisis Support Teams but had not used them,
while 9 percent reported they had used them and found them helpful.
101
In response to a draft of this report, the BOP stated that its current EAP provider offers in-the-moment crisis support
for staff similar to what was provided through the COVID-19 staff support line. The BOP stated that its recently
negotiated Staff Wellness and CST policies emphasize communication and training with staff regarding available support
services to help staff develop skills to maintain wellness during a public health emergency. Additionally, the BOP stated
that the Psychology Services Branch created materials to be used in person and virtually so that they may be available
for staff during future public health emergencies. Finally, the BOP stated that it has built a page on its employee
intranet site for all staff safety and support services and that it would be rolled out in conjunction with the official
release of three staff safety and support policies. We did not assess the draft policies in this review.
61
Conclusion
Ongoing staffing shortages during the sustained COVID-19 pandemic had a significant and negative effect
on staff morale. Staffing shortages have contributed to staff workload responsibilities and the BOP’s use of
overtime, staffing augmentation, and reliance on TDY staff during the pandemic. While this report does not
make new recommendations for the BOP to address its ongoing staffing shortages, the GAO’s February
2021 report recommendations to the BOP represent important next steps for the BOP to continue its efforts
to address staffing challenges.102 In addition, BOP staff often expressed concerns and confusion regarding
guidance about leave and quarantine procedures, highlighting the need for the BOP to provide clear
guidance. Additionally, 2021 BOP Staff Survey respondents chose mental health resources as one of the top
five areas that the BOP should seek to improve, which, when combined with reports of staff unawareness
about the staff support line and incorrect BOP guidance about its availability, highlights the need for the
BOP to better communicate support options available to facility staff. Clearly communicating staff support
options, namely those the BOP described that it recently expanded, including the current EAP provider’s
crisis support services, the restructured CST, the intranet page for staff safety and support services, and the
staff wellness materials, should help enable staff to take full advantage of all the resources available to
them.
Recommendation
To improve staff support during public health emergencies, we recommend that the BOP:
5. Assess methods to engage with staff during public health emergencies to ensure that the BOP
provides sufficient staff support and clearly communicates support options available to staff.
The BOP Should Improve Its Communication of Essential Information to Stakeholders
We identified a significant deficiency in the BOP’s communication with inmates’ families regarding COVID-19
related serious illness notifications. We also received numerous complaints about the BOP’s
communications with the public, inmates, and other stakeholders, including complaints from inmates’
attorneys, about the BOP’s lack of transparency regarding its management of COVID-19 inside facilities and
the information it shared on its public website. Additionally, our remote inspections of particular facilities
identified communication failures at some facilities that inhibited the ability of those facilities to fully
respond to the COVID-19 pandemic, while other remote inspections found that facility leadership was
proactive and clear in communicating with staff and inmates. The BOP should strengthen its overall
communication as the pandemic continues and for future public health emergencies. In The BOP Should
Take Appropriate Steps to Address Staffing Shortages and Staff Morale section above, we discussed the
BOP’s challenges and issues in communicating with BOP staff. In this section, we discuss the BOP’s
communications with inmates, families of inmates, contract facilities, crime victims, and the public. We
discuss concerns regarding the BOP’s communication with inmates’ attorneys and further discuss inmate
access to counsel in The BOP Should Respond to Ongoing Pandemic Challenges and Prepare for Future
Public Health Emergencies section.
102
GAO, BOP: Opportunities Exist, 41.
62
The BOP Should Improve Its Procedures for Notifying Families About Inmate Serious Illness
During our remote inspections of BOP facilities, we found that facilities did not always comply with the
BOP’s policy to promptly notify families when an inmate develops a serious illness.103 The BOP’s Patient
Care policy requires facilities to “promptly” notify the family of an inmate with any serious illness that it is of
“immediate concern” to the family.104 In the case of an inmate death, the BOP requires facilities to notify
family of the deceased in the same manner as a serious illness notification; the Warden or designee must
call the designated person listed in the deceased inmate’s Acknowledgment of Inmate Form, BP-A0408,
“immediately” to inform him or her of the circumstances surrounding the death and “as soon as practical”
must also mail a condolence letter to the inmate’s family advising them of the circumstances of the death.105
We reviewed 49 cases of inmates who died of COVID-19 between April and July 2020 at 4 of the BOP-
managed facilities we inspected: FCC Butner, FCC Coleman, FMC Fort Worth, and FCI Terminal Island. We
found that, in just under a third of the inmate deaths we reviewed, facilities took more than 3 days to
attempt to notify family of the inmate’s serious illness, including complicating factors related to COVID-19
infection. Although the BOP’s Patient Care policy does not specify a timeframe for prompt notification of
serious illness, we believe that these instances of attempted family notification that took the BOP more than
3 days do not represent prompt notification as intended in the policy. For notifications of inmate deaths, in
almost all of the cases we reviewed the inmates’ family was notified within 1 day of the inmate’s death.
BOP Guidance on Family Notification
The BOP’s Patient Care policy outlines the effective delivery of medically necessary healthcare in order to
preserve and extend the life of inmates in BOP custody.106 Consistent with that goal for seriously ill or dying
inmates, the policy states that an inmate’s serious illness is of immediate concern to the inmate’s family and
requires the facility to notify the inmate’s family “promptly.” However, the policy does not include a
standard definition for what constitutes a serious illness, a standardized procedure for how to determine
whether and when a serious illness is deemed to be of immediate concern to an inmate’s family, or a
timeframe for prompt notification. The procedure for family notification of an inmate’s serious illness
begins with the Health Services Unit, which is responsible for notifying the Warden and Chaplain by phone
or in person of the inmate’s condition. Then the Warden or designee will arrange notification of the
inmate’s family. The Patient Care policy also directs facilities to develop supplemental guidance
incorporating the specific information covered in the policy’s Serious Illness and Death Procedures section.
These supplements can include specific definitions, steps to take, timeframes, and assignment of
responsibilities.
103
In this report section, we use the term “family” to describe the next of kin or the individual listed in the BOP’s
Acknowledgment of Inmate form.
104 BOP Program Statement 6031.04, Patient Care, June 3, 2014, www.bop.gov/policy/progstat/6031_004.pdf (accessed
July 12, 2022).
105
BOP Program Statement 5553.08, Escapes/Deaths Notifications, January 4, 2017, www.bop.gov/policy/progstat/5553.08.pdf
(accessed July 12, 2022).
106
BOP Program Statement 6031.04.
63
The BOP has an additional, more detailed policy on handling notification in the case of an inmate death.
The BOP’s Escapes/Deaths Notifications policy requires timely notifications to a variety of interested parties,
including family members.107 Upon an inmate’s death, the Warden or official designee is responsible for
contacting the deceased inmate’s family, or person named on the inmate’s BP-A0408 form, by telephone
“immediately” to communicate the circumstances surrounding the inmate’s death.108 According to the
Escapes/Deaths Notifications policy, if the inmate’s file does not contain family or a designated person’s
contact information, Unit Management must attempt to locate and notify family members to determine the
disposition of the deceased inmate’s remains and property. The policy further states that the Warden, or
designee, is responsible for mailing a letter of condolence “as soon as practical” to the inmate’s family
advising of the circumstances of the death.
Delays in Notifying Inmates’ Families of Serious Illness Related to COVID-19
Among the cases of inmate deaths related to COVID-19 that we reviewed, we found that the BOP did not
always timely notify the family of an inmate with serious illness before the inmate died. Based on available
documentation provided by the BOP, we analyzed 49 cases of inmate death related to COVID-19 and
determined that 40 of those inmates (82 percent) were determined to be seriously ill prior to their deaths.109
Of the 40 serious illness cases we examined, the BOP attempted to notify 18 families (45 percent) within 0–3
days of the inmate’s serious illness and 12 families (30 percent) more than 3 days after the inmate became
seriously ill, including 8 families whom the BOP notified over 1 week after the inmate became seriously ill.
In six cases, the BOP did not notify the inmate’s family of the inmate’s serious illness prior to his or her
death.110 In contrast, when inmates died, the BOP typically notified their families within 1 day of their
deaths. We found a variety of reasons for delays in the BOP’s serious illness notification, including staff
workload, limited staff access to emergency contact information, inability to contact family, and varying
definitions of serious illness, as we discuss further below.
Staff Workload
FCC Butner, which had some of the longest delays in family notification of inmate serious illness, pointed to
staff workloads during the pandemic as a reason for its delayed notifications. In one case at FCC Butner, an
inmate had been in the hospital with respiratory failure for 18 days and on a ventilator for 5 days before the
inmate’s family was contacted. In a second case, an inmate had been on a ventilator for 16 days before the
inmate’s family was contacted. FCC Butner staff reported that delays in family notification were due to the
unprecedented demands on BOP staff during the ongoing public health crisis. FCC Butner staff reported
that they had to set aside their normal duties, including notifying next of kin in the case of inmate serious
107
BOP Program Statement 5553.08.
108
The BP-A0408 form also allows inmates to list additional emergency contacts whom the BOP may contact in the
event of an inmate’s serious illness or other emergency.
109
For those 40 cases, we determined an inmate to be seriously ill if documentation showed that he or she was
experiencing respiratory failure, moved to the intensive care unit in the hospital, placed on a ventilator, or determined
to be seriously ill by a physician. For the remaining nine cases, we could not determine whether the inmate was
determined to be seriously ill based on the information the BOP provided.
110
In an additional four cases of inmate serious illness, BOP documentation did not reflect the exact timeline of the
serious illness determination and the family notification of serious illness.
64
illness or death, to support the emergency medical mission of providing care and security for a large
population of at-risk and sick inmates during the pandemic.
Limited Access to Emergency Contact Information
We found that another cause of delayed serious illness notification was the availability of Unit Team staff
with access to inmate emergency contact information found in Section 4 of an inmate’s Form BP-A0408. For
example, in one case we reviewed, FCI Coleman staff did not notify an inmate’s emergency contact
immediately after being notified of the inmate’s quickly deteriorating illness. An Associate Warden at the
facility told us that the Unit Team staff, who normally would have reached out to the inmate’s emergency
contact to offer the contact the opportunity to visit the inmate, had already departed on the Friday evening
when the hospital called to report that the inmate’s condition was declining.111 He also told us that only Unit
Team staff have access to the inmate’s emergency contact information and that they handle notifications
the next business day rather than after hours. This means that the family of an inmate who becomes
seriously ill on a Friday night would not be notified until Monday. In the FCC Coleman case, the inmate died
on Sunday, before the BOP could make a serious illness notification. An FCC Coleman official told us that, to
make after-hours notifications possible, a policy change requiring a Unit Team member to report to the
facility after hours would be necessary. An official at FMC Fort Worth also identified the lack of access to
inmate emergency contact information as a problem, noting that delays in staff obtaining the form could
result in delays notifying families.
Challenges Contacting Families
The BOP’s Inmate Classification and Program Review policy specifies that a designated BOP staff member
verify information in the Acknowledgment of Inmate Form, BP-A0408, which includes emergency contact
and next of kin information, at the time of inmate program reviews, which occur at least every 180 days (or
at least every 90 days if an inmate is within 12 months of release).112 However, we found that BOP staff
faced challenges identifying and contacting families, which contributed to delays in their serious illness
notifications of inmates’ families. In cases we reviewed, BOP staff described trying a variety of methods to
identify and reach family members when they could not reach them using the inmate-provided emergency
contact information. These methods included reviewing pre-sentencing materials, conducting internet
searches, and requesting that the local police department attempt to contact the next of kin at the inmate’s
last known address. While the BOP’s policy on inmate death notifications requires the BOP to attempt to
locate next of kin if no one is listed on the inmate’s emergency contact form, the BOP’s policy on inmate
serious illness notification does not require this. However, the case documents we reviewed indicated that
BOP staff members attempted to identify inmates’ next of kin for serious illness notifications as well. For
example, at FCI Terminal Island, for 10 days BOP staff attempted to contact family about one inmate’s
serious illness but were unable to speak to the emergency contact or leave a voicemail at the phone number
on file. Eventually, the FCI was able to contact another family member about the inmate’s serious illness as
a result of multiple attempts by BOP staff to find next-of-kin information.
111
A BOP press release indicates that the inmate was placed on a ventilator that day.
112
BOP Program Statement 5322.13, Inmate Classification and Program Review, May 16, 2014,
www.bop.gov/policy/progstat/5322_013.pdf (accessed February 13, 2023).
65
We also found cases in which challenges making contact with the listed emergency contact or family
member meant that the inmate’s family was unable to be involved in making time-sensitive end-of-life
decisions. For example, in one case at FCC Butner, the hospital made end-of-life decisions for an inmate
after FCC Butner was unable to reach the inmate’s family members. FCC Butner finally reached the inmate’s
next of kin after the inmate’s death. At FMC Fort Worth, one staff member told us that inmate emergency
contact forms are updated only when an inmate enters the facility, which indicated that inmate emergency
contact information could be outdated.
Varying BOP Definitions of Serious Illness
Finally, we found that the four facilities for which we reviewed inmate COVID-19 deaths had varying
definitions for what constitutes a serious illness and at what time BOP staff should notify the family. For
example, FCC Butner specifies that a serious illness is one with such severity that it threatens an inmate’s life
and that the attending physician will make that determination and notify the family. In contrast, FCI
Terminal Island reported that it notifies families only of inmates who are critically ill, specifying that a critical
illness is one in which death is considered imminent, as contrasted with a serious illness, which may persist
for weeks or months. An FMC Fort Worth staff member told us that the acting Clinical Director established
the threshold between seriously ill and critically ill designations to be when an inmate can no longer make
decisions for himself or herself. Finally, FCC Coleman specifies that if an inmate is diagnosed with a terminal
illness family should be notified within 72 hours but does not specify a timeframe for notification in the case
of nonterminal illness. The other three facilities for which we reviewed inmate COVID-19 deaths do not
specify timeframes for serious illness notification.
The lack of clear thresholds for serious illness caused delays in the BOP’s time-sensitive family notifications.
For example, during our remote inspection of FCI Terminal Island, we learned that the facility did not notify
the family of an inmate that he had been hospitalized and intubated due to COVID-19 until after the inmate
had died.113 At the time, Terminal Island staff told us that the facility was not required to notify family
members when an inmate was intubated. However, a Western Regional Office official also told us that, as a
result of FCI Terminal Island’s failure to notify the inmate’s family of his serious illness, the Western Regional
Office issued verbal guidance shortly after the inmate’s death, followed by written guidance on May 4, 2020,
to all facilities in the region stating that they should notify the families of COVID-19 positive inmates who
become hospitalized.
The issuance of E.O. 14074 in May 2022 requires the Attorney General to issue guidance to federal law
enforcement agencies and other entities responsible for death notifications of persons in correctional or law
enforcement agency custody on best practices for timely notification of family members and designated
emergency contacts.114 Additionally, in May 2022, the Family Notification of Death, Injury, or Illness in
Custody Act of 2022 was introduced in the U.S. Senate. If enacted, the legislation would require the
Department to establish policies and procedures to promptly notify family members or emergency contacts
113
“Intubated” refers to endotracheal intubation, a type of medical procedure in which a tube is placed into a patient’s
windpipe to facilitate breathing.
114
E.O. 14074.
66
of the death, serious illness, or serious injury of persons in federal custody, including all inmates in BOP-
managed facilities.
Conclusion
Overall, among the facilities we inspected there were several instances of delayed notification to families
about inmate serious illness and some families did not receive notification of inmates’ serious illnesses prior
to their deaths. Although we recognize that the COVID-19 public health emergency put an unprecedented
strain on BOP custody and medical staff, the stresses of the pandemic revealed weaknesses in the BOP’s
guidance and procedures for family notification that must be addressed. For example, having uniform
guidance on what constitutes a serious illness and when staff should notify families in the case of an
inmate’s serious illness could help ensure that families receive these time-sensitive notifications regardless
of the BOP facility in which the inmate is housed. Additionally, ensuring that family contact information is
updated at least every 180 days, as required by policy, and is made readily available to the BOP staff who
make family notifications could help the BOP contact inmates’ families more quickly and reduce the need
for the BOP to take additional steps to find alternate emergency contact or family contact information.
Recommendations
To improve its procedures for notifying inmates’ families about serious illness related to COVID-19 and other
serious illnesses, we recommend that the BOP:
6. Immediately update guidance regarding (1) when staff should notify the families of inmates who
become seriously ill or die, including a specific timeframe, and (2) uniform criteria for what
constitutes a serious illness.
7. Ensure that inmate family information, or the inmate emergency contact form, is updated according
to policy and readily available for BOP staff who need to notify next of kin in cases of inmate serious
illness or death.
The BOP Should Improve Its Communication with Other Key Stakeholder Groups
The BOP’s Guidance for Contract Facilities
During our remote inspections, we found that COVID-19 related guidance that the BOP developed early
during the pandemic was delayed in distribution to contract facilities despite being largely applicable to
contract prison settings. Services provided by RRCs (and contract prisons, when in operation) are governed
by contractual agreement and carried out by non-BOP personnel, so modified operations require approval
from the BOP and new requirements must be formally implemented into contractual agreements. During
the pandemic, contract operators had to determine how BOP guidance would fit within the existing
arrangements for services and ensure that they consistently communicated the guidance to facility staff at
the over 150 RRCs and 11 contract prisons nationwide. 115
115
At the time of our remote inspections, the BOP had contracts with over 150 RRCs and 11 contract prisons. Following
the January 2021 E.O. 14006, the BOP began transferring inmates out of contract prisons as the contracts expired. The
67
During our three contract prison remote inspections, we found that contract prison staff implemented
strategies outlined in the BOP’s technical directions and CDC guidance. However, between February and
April 2020, the BOP’s Privatization Management Branch, which provides guidance to and oversight of
contract prison vendors, issued guidance, known as technical directions, to contract prisons later than the
BOP issued guidance to BOP-managed facilities.116 Contract prisons received most of these guidance
documents between 1 and 5 days after comparable guidance was issued to BOP-managed facilities, but
some delays were more significant. During our remote inspections, a BOP official asserted that the BOP’s
underlying contracts with contract prison vendors required the vendors to comply with the CDC’s COVID-19
guidance. Our remote inspections of contract prisons CI Giles W. Dalby, CI Moshannon Valley, and CI McRae
found that in early April 2020 the BOP modified its contracts to require contract staff, in the event of an
epidemic or pandemic, “to check with the CDC daily for updates and…implement those changes timely to
prevent further spread of the disease.”117 In two of our three contract prison remote inspections, the
vendors did not wholly agree with the BOP’s interpretation that they should have consulted and
implemented CDC guidance before the BOP modified its contracts in early April 2020. After issuing our
remote inspection reports, we found evidence that the BOP continued to issue technical directions to
contract prisons regarding COVID-19. Our three reports concluded that the prompt issuance of guidance to
contract prison vendors, even that which reiterates CDC guidance, was vital to the BOP’s effective contract
prison oversight and ensuring that inmates receive the same quality of care in contract prisons as in BOP-
managed facilities.
Whereas contract prison staff generally implemented the protocols and modified operations stipulated in
BOP guidance and the COVID-19 Action Plans, the BOP deferred to the RRC contractors in operational
decisions on the handling of certain aspects of the pandemic. The BOP’s March 13, 2020 guidance to
facilities specifically mentioned sharing the guidance with contract prisons and RRCs “so that similar
protocols can be implemented,” and the BOP issued additional guidance specific to RRCs. However, BOP
guidance to RRCs did not cover certain key decisions. For example, there was a lack of specific guidance
from the BOP to RRCs to govern the use of personal protective equipment (PPE) and face coverings in RRC
general population settings. Absent such guidance, Toler House RRC required the use of PPE only in certain
cases and did not widely distribute masks to its resident inmates for 3 weeks after the CDC
BOP’s last contract prison contract ended on November 30, 2022 and as of December 1, 2022 all inmates housed in
contract prisons had been moved to BOP facilities. E.O. 14006 on Reforming Our Incarceration System to Eliminate the
Use of Privately Operated Criminal Detention Facilities, January 26, 2021, www.federalregister.gov/documents/2021/01/
29/2021-02070/reforming-our-incarceration-system-to-eliminate-the-use-of-privately-operated-criminal-detention
(accessed November 10, 2022).
116
The BOP’s contracts with private prisons included a clause defining a technical direction as providing “technical
direction on contract performance.” Technical direction does not include “additional work that is outside the scope of
the contract” or “action that would cause an increase or a decrease in contract pricing.”
117
DOJ OIG, Remote Inspection of Federal Bureau of Prisons Contract Correctional Institution Giles W. Dalby, Operated
by Management & Training Corporation, E&I Report 20-096 (August 2020), oig.justice.gov/reports/remote-inspection-
federal-bureau-prisons-contract-correctional-institution-giles-w-dalby; Remote Inspection of Federal Bureau of Prisons
Contract Correctional Institution Moshannon Valley, Operated by the Geo Group, Inc., E&I Report 20-097 (August 2020),
oig.justice.gov/reports/remote-inspection-federal-bureau-prisons-contract-correctional-institution-moshannon-valley;
and Remote Inspection of Federal Bureau of Prisons Contract Correctional Institution McRae, Operated by CoreCivic, E&I
Report 20-098 (August 2020), oig.justice.gov/reports/remote-inspection-federal-bureau-prisons-contract-correctional-
institution-mcrae-operated.
68
recommendation for individuals to wear cloth face coverings while Brooklyn House RRC did not enforce the
use of PPE such as masks and gloves for staff and inmates until late April 2020.118
Additionally, despite the risk of inmates contracting COVID-19 while using public transportation to travel to
and from an RRC, the BOP did not explicitly require RRCs to quarantine asymptomatic inmates either upon
entry into custody or departure from the RRC for long-term home placement. Although there was no
explicit requirement, the BOP expressed that its intent was to have inmates quarantine before arrival to the
home setting. Absent any such formal requirement, Brooklyn House RRC did not formally quarantine
individuals entering RRC custody or departing to a home placement. Challenges with the interpretation and
implementation of relevant COVID-19 guidance at RRCs and contract prisons underscore the importance of
the BOP’s communication with these entities during the COVID-19 pandemic and other public health
emergencies.
The BOP’s Communication with Inmates
We found that, although the BOP took steps to communicate relevant COVID-19 information to inmates
during the pandemic, the reports we received about the effectiveness of this communication varied. The
BOP employed various mechanisms, such as town halls, inmate bulletins, and guidance posters (see an
example below), to communicate pertinent COVID-19 information to inmates. According to interviewees at
four BOP facilities we inspected, facility staff hosted weekly town halls to inform inmates about proper
hygiene practices, share CDC guidance updates, and explain the status of modified operations. Inmate
bulletins and COVID-19 guidance signs posted throughout BOP facilities and RRCs informed inmates about
the prevalence of COVID-19 at the facilities and recommended best practices regarding sanitation and the
proper use of PPE. Staff also provided these resources to inmates housed at BOP facilities via their
TRULINCS email accounts, and interviewees at some facilities told us that staff responded to inmate
questions sent by TRULINCS email.
118
DOJ OIG, Remote Inspection of the GEO Group, Inc.’s Toler House Residential Reentry Center, Newark, New Jersey,
E&I Report 21-007 (November 2020), oig.justice.gov/reports/remote-inspection-geo-group-incs-toler-house-residential-
reentry-center-newark-new-jersey, and Remote Inspection of the CORE Services Group, Inc.’s Brooklyn House
Residential Reentry Center, Brooklyn, New York, E&I Report 21-006 (November 2020), oig.justice.gov/reports/remote-
inspection-core-services-group-incs-brooklyn-house-residential-reentry-center.
69
During our remote inspection of FCC Tucson, two facility
interviewees told us that they thought that the FCC had
clearly communicated information to inmates.
Respondents to the 2020 BOP Staff Survey from two BOP-
managed facilities reported that facility Wardens were
proactive in sharing information with inmates.
Additionally, our remote inspections of Toler House RRC
and three contract prisons found that in general contract
facility leadership clearly communicated information to
inmates.
However, we received over 185 complaints about
deficiencies in the BOP’s communication with inmates
submitted by inmates, their friends and family, and other
complainants.119 Further, our analysis of 2021 Inmate
Survey results at BOP-managed facilities estimated that 47
percent of the inmates reported that the information they
received from the BOP about how to protect themselves
from COVID-19 infection was poor, and an estimated 7
percent said that they received no information. In
CDC Guidance Poster Displayed at FCC Lompoc
comparison, an estimated 46 percent said that the
in 2020
information was good or fair, 15 and 31 percent,
Source: www.CDC.gov respectively.120 The totality of responses we received from
complainants and inmate survey respondents at BOP-
managed facilities highlights the importance of
communication of information to the inmate population during public health emergencies.
The BOP’s Communication with Crime Victims
We found that the BOP did not always timely notify crime victims during the pandemic. The BOP issues
notifications to victims of crime to provide them with information about specific inmate case events,
including an inmate’s admission to or release from a BOP-managed or contract facility, transfer to an RRC or
home confinement, escape, or death. The Department’s Victim Notification System generates notifications
that BOP staff provide to victims via mail, email, or telephone based on victim contact preferences.121 We
119 As noted in the Introduction, we analyzed complaints to identify trends. Although we did not substantiate or assess
the validity of each complaint, we present the thematic issues that we identified in our complaint review to illustrate
various stakeholder perspectives about the BOP’s response to the pandemic, including concerns about the BOP’s
communication with inmates and other stakeholders.
120
We present inmate survey responses in this report to illustrate the range of views expressed by inmate survey
respondents about their experiences during the pandemic. The number of inmate survey respondents (25,504)
represents a fraction of the number of inmates in BOP custody. Because we applied statistical weights, we refer to the
estimated percentage of inmates rather than the percentage of respondents.
121
The Victim Notification System links the Federal Bureau of Investigation, all Assistant U.S. Attorney’s Offices, and the
BOP through the DOJ intranet. The system maintains victim information and makes notification(s) during the arrest,
arraignment, prosecutorial, and confinement phases to ensure that victims and witnesses are advised of the significant
70
found that during the pandemic the number of the BOP’s missed or incomplete notifications issued to crime
victims increased by 86 percent from April 1, 2020, through March 31, 2021, compared to the same time
period of the previous year. There were also 121 delayed notifications that were not completed until after
the inmate’s release or transfer date from April 1, 2020, through March 31, 2021, a decrease compared to
the same time period of the previous year. However, 40 percent of those delayed notifications occurred in
the cases of inmates who transferred to an RRC or home confinement under the Coronavirus Aid, Relief,
and Economic Security Act (CARES Act).
The BOP reported that limitations to the Victim Notification System data may have contributed to delayed or
missed crime victim notifications. While the system generates notifications automatically, it relies on inmate
data updated from the BOP’s SENTRY system every 24 hours. As a result, the Victim Notification System
may not reflect immediate changes to an inmate’s release or home confinement transfer date or be able to
generate a notification in the event of an inmate’s court-ordered immediate release until after the release
has occurred. Late or unexpected changes to an inmate’s transfer or release date, such as those that
occurred during the pandemic due to accelerated home confinement placements and court-ordered
releases, may have affected the BOP’s ability to timely notify victims.
Additionally, once a victim is notified about the date of an inmate’s forthcoming transfer to an RRC, the
Victim Notification System does not generate another notification if the date changes. Unit Team staff at
BOP facilities must therefore generate manual notifications for victims when there are changes to an
inmate’s RRC transfer date, in addition to when there are court orders for immediate release. BOP Central
Office officials told us that, during accelerated home confinement placements due to the pandemic, mail
notifications might not have reached victims before the inmates were transferred out of BOP facilities. In
August 2021, the BOP reported that it was updating the Victim Notification System to reduce errors and limit
the need for facility staff to generate manual notifications.
The BOP’s Transparency and Communication with the Public
In an April 2021 written statement to Congress, the then BOP Director stated that the BOP had made an
effort to be transparent about its COVID-19 operations, plans, and statistics and had published “one of the
most detailed and thorough COVID pandemic resource areas across government on its public website.” We
found that, while the BOP shared and regularly updated relevant COVID-19 information on its public website
throughout the pandemic, the information did not always provide a complete picture for stakeholders.
Early during the pandemic, the BOP created a COVID-19 resource area on its public website to provide the
public with the BOP’s plans, operations, and COVID-19 related data. When 2021 BOP Staff Survey
respondents were asked to select up to 5 areas in which the BOP most needed to improve its handling of
the COVID-19 pandemic, 906 respondents (16 percent) selected “BOP Central Office’s communication with
the public” as an area for improvement. Additionally, we received OIG Hotline complaints about
information posted to the BOP’s public website and the BOP’s communication with stakeholders.
The BOP first posted COVID-19 related data to its public website at the beginning of the pandemic, and the
types of COVID-19 related information that it shared on its public website evolved over time (see Figure 10
stages in the criminal justice process. For more information, see BOP Program Statement 1490.06, Victim and Witness
Notification Program, May 23, 2002, www.bop.gov/policy/progstat/1490_006.pdf (accessed July 12, 2022).
71
below). Press releases reported expanded inmate COVID-19 testing plans, various phases of the BOP’s
COVID-19 Action Plan, and COVID-19 related inmate deaths at BOP facilities.
Figure 10
Timeline of the BOP’s Posting of COVID-19 Data to Its Public Website
• The BOP began publicly posting daily COVID-19 positive inmate cases by complex
March 13, 2020 and staff cases by duty city.a
March 28, 2020 • The first inmate death due to COVID-19 was reported on the BOP public website.
• The BOP began publicly posting the number of inmates on home confinement:
April 6, 2020 5,472 as of January 31, 2022, and 37,503 total from March 26, 2020, through
January 31, 2022.
• The BOP began reporting inmate and staff active cases and deaths due to COVID-19
April 7, 2020 by facility.b
May 7, 2020 • The BOP began publicly posting staff and inmate recoveries from COVID-19 by
facility.
• The BOP began publicly posting the number of inmates with completed, pending,
June 13, 2020 and positive tests by facility.
• The BOP began publicly posting the total number of vaccine doses distributed to and
February 1, 2021 administered by the BOP, as well as the number of staff and inmates whose vaccine
series was completed at a federal facility.
• The BOP began publicly posting COVID-19 operational levels by facility to display the
August 23, 2021 extent of modified operations.
a “Complex” includes facilities with different security levels that are located in proximity.
b The BOP began reporting BOP-wide recoveries from COVID-19 on April 8, 2022. “Active cases” refers to the number of
individuals with lab-confirmed and open cases at a particular complex or facility on a particular day.
Notes: The BOP posted all of the above statistics for federal facilities. For RRCs, the BOP reported statistics regarding
active and recovered cases, testing, and deaths due to COVID-19 but did not post vaccination statistics. For private
prisons, the BOP reported statistics regarding active and recovered cases and deaths due to COVID-19 but did not post
testing or vaccination statistics.
Source: OIG analysis of BOP data
We observed some limitations in the COVID-19 case, testing, and vaccination data posted on the BOP’s
website. Below, we discuss examples of these limitations.
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Case Data
Although the BOP publishes on its website counts of
active and recovered COVID-19 cases among inmates
currently in BOP custody and current BOP staff (see
the example to the right), it does not publish a
cumulative total of COVID-19 cases reported over the
course of the pandemic. The active case counts do not
include inmates or staff who recovered or died, and
the recovered case counts do not include inmates or
staff who die, inmates who have subsequently been
released from BOP custody, or staff who have left BOP
employment. These omissions mean that the BOP’s Map of Active COVID-19 Cases on the BOP’s Website,
publicly posted data does not represent the full extent as of August 16, 2020
of cumulative COVID-19 cases among inmates and Source: www.bop.gov
staff over the course of the pandemic. Further, the
BOP website does not mention that the staff and
inmate recovery data presented excludes inmates who left BOP custody or staff who left BOP employment,
which could lead stakeholders to draw incorrect conclusions about the BOP’s data.
On October 1, 2020, the OIG released a collection of interactive dashboards relating to COVID-19 in BOP
facilities that allow the public to view active and recovered COVID-19 cases and deaths over time for inmates
and staff at individual federal facilities and aggregated across all federal facilities, among other data trends.
While this presentation of the BOP’s data allows stakeholders to see trends over time, it also highlights the
limitations of the BOP’s public data. For example, the OIG’s presentation of BOP data on recovered cases
shows a decreasing number of recovered inmates over time beginning in late March 2021 because some
inmates who recovered from COVID-19 were subsequently released from BOP-managed facilities. Because
of this, the BOP’s recovered cases data cannot be used as a cumulative measure of the number of inmates
who recovered from COVID-19.
Testing Data
Similar issues exist with the BOP’s publicly posted data on testing, which also includes only inmates
currently in BOP custody. The BOP publicly posts the following statistics for inmates in current BOP
custody: the number of inmates who (1) have completed testing, (2) have pending tests and no previously
completed test, and (3) have ever had a positive test. However, the published pending inmate test data is
not a useful metric for the amount of testing conducted because it counts only the first time an inmate
received a COVID-19 test even though inmates have been tested multiple times over the course of the
pandemic. Additionally, the BOP website states that some inmate COVID-19 tests, such as tests performed
in local hospitals, for example, are not reported to the BOP. Further, the BOP reported that it did not
publicly post testing data for contract prisons when the BOP housed inmates in contract prisons due to the
underlying data not being machine readable. This omission resulted in stakeholders lacking visibility into
testing at BOP contract prisons. Finally, while in April 2022 the BOP added a note to the COVID-19 testing
data section of its public website that it had conducted over 1 million COVID-19 tests for more than 200,000
inmates, the BOP does not publicly share the definitive number of COVID-19 tests that it has administered
to inmates. These limitations result in a lack of complete public data about the BOP’s testing effort over the
course of the pandemic.
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Vaccination Data
The BOP publishes data on the logistics of its vaccination progress at BOP-managed facilities, including the
BOP-wide cumulative number of doses distributed and administered by the BOP and the number of staff
and inmates whose vaccination series was completed by the BOP at each facility. However, the BOP does
not publish data that allows stakeholders to see the proportion of vaccinated individuals at any of the
facilities, as the published data displays only the cumulative number of BOP-administered vaccinations
completed at each facility. Unlike the BOP’s public testing and COVID-19 case data for inmates, which
includes inmates in current BOP custody only, the public vaccination data includes both inmates in current
BOP custody and those who have left BOP custody. Despite this key difference in the BOP’s reporting of
COVID-19 statistics, there is no explanation on the BOP website that the presented vaccination totals include
inmates who have left BOP custody. The absence of this explanation could lead stakeholders to draw
incorrect conclusions about the BOP’s vaccination data.
In addition, the BOP’s facility-specific vaccination data reflects only the number of staff and inmate
vaccinations completed by the BOP at each facility and does not reflect the number of fully vaccinated
inmates and staff currently at that facility. It also does not include vaccinations completed in the
community; namely, the data does not include inmates who received full vaccinations prior to entering BOP
custody or who received the vaccine through community resources at an RRC, contract prison, or while on
home confinement. As new inmates may have received full vaccinations prior to entering BOP custody, the
BOP’s decision to publicly share vaccination data only for those whose vaccination series was completed by
the BOP may make it increasingly difficult for stakeholders to glean useful, complete insights from the BOP’s
public vaccination data about individual facility vaccination levels. On May 25, 2022, President Biden signed
E.O. 14074, which directed the Attorney General to undertake several actions, which include expanding the
sharing and publication of BOP data on vaccination, testing, infections, and fatalities due to COVID-19 “in a
manner that ensures the thoroughness and accuracy of the data; protects privacy; and disaggregates the
data by race, ethnicity, age, sex, disability, and facility.”122 Compliance with this Executive Order offers the
BOP the opportunity to reassess the data that it publishes and to address the limitations we have identified
here.
The OIG’s collection of interactive dashboards includes OIG-estimated percentages of fully vaccinated
inmates across BOP-managed institutions based on inmate vaccination data that the OIG receives from the
BOP weekly. The dashboards also display the distribution of inmate vaccination percentages by BOP-
managed facility.
Attorney and Judicial Concerns Regarding BOP Communication
We learned of reports from defense counsel representing inmates housed at BOP facilities that the BOP did
not always provide them with transparent information during the pandemic. For example, defense counsel
representing inmates at one BOP detention center that we inspected alleged that there was a lack of
transparency about how the facility was managing its response to the COVID-19 crisis and that facility legal
counsel did not answer questions about inmates. In a separate interview with representatives from the
Federal Public and Community Defenders, attorneys alleged that the BOP was not transparent about some
of the terminology used on its public website and that the BOP’s information about its selection of inmates
122
E.O. 14074.
74
for home confinement and compassionate release had not been transparent. To ensure access to current
and accurate information about two facilities’ responses to the pandemic, a judge for the Eastern District of
New York issued an April 2020 order that required the Wardens of MDC Brooklyn and Metropolitan
Correctional Center (MCC) New York to provide biweekly status updates on their facilities’ responses to
COVID-19 to the court, the Executive Director of the Federal Defenders of New York, and the U.S. Marshals
and U.S. Attorneys for the Eastern and Southern Districts of New York.123 We discuss inmate access to
counsel in detail in The BOP Should Respond to Ongoing Pandemic Challenges and Prepare for Future
Public Health Emergencies section of this report.
Conclusion
Although we acknowledge that the BOP has taken steps to proactively and transparently communicate with
stakeholders during the COVID-19 pandemic, we identified weaknesses in the BOP’s communication with
key stakeholders and believe that the BOP needs to continue to find ways to more effectively communicate
with all of its stakeholders. The totality of information about the BOP’s communication during the pandemic
that we received highlights the need for the BOP to improve its communication of information to
stakeholders during current and future public health emergencies. While the BOP should assess its
communication with all stakeholders, we make one specific recommendation to the BOP regarding its
communication with crime victims, in addition to the recommendation regarding family notification above.
Recommendation
To improve its procedures to notify crime victims, we recommend that the BOP:
8. Implement processes to ensure timely crime victim notifications, even under emergency conditions
such as during a pandemic.
The BOP Should Provide Clear Guidance on the Use of Healthcare Protective Equipment
and Compliance with Healthcare Safety Guidance
The BOP reported that, while it was initially affected by the same supply shortages as the rest of the nation,
it has since amassed sufficient quantities of PPE. According to the former BOP Director’s congressional
testimony and Central Office officials we interviewed, the BOP has since made PPE available to its facilities.
Staff concerns and confusion early during the pandemic about the BOP’s PPE and face covering
requirements appear to have decreased over time. However, the BOP faced persistent challenges ensuring
staff and inmate compliance with face covering requirements. We found through our remote inspections
and April 2020 BOP Staff Survey results that BOP staff reported multiple challenges regarding access to PPE
and other PPE-related issues at the beginning of the pandemic. For example, 2020 BOP Staff Survey
respondents at all 16 facilities we inspected identified more PPE for staff as a top five immediate need.
Additionally, during FY 2020 we received over 130 OIG Hotline complaints concerning an inadequate supply
of PPE and face coverings. However, in our 2021 BOP Staff Survey, facility staff respondents generally
reported widespread availability of PPE and face coverings at facilities. Similar to the PPE supply challenges,
the BOP and the nation were affected by limited COVID-19 testing capacity early during the pandemic. This
123
As noted in the Introduction, the Department announced in August 2021 that it was closing MCC New York, at least
temporarily, to assess steps to improve conditions at the facility.
75
resulted in long turnaround times for test results, which meant that COVID-19 positive and negative inmates
were sometimes housed together for several days, increasing the risk of transmission among them.
Further, our remote inspections found that in 2020 some facilities did not properly follow the BOP’s
quarantine guidance to manage the risk of COVID-19 transmission between inmates awaiting test results.
Since then, testing capacity has increased and the BOP added rapid testing options into its protocols,
reducing the risk of long wait times for results.
The BOP Experienced PPE Supply Challenges at the Beginning of the Pandemic
We found numerous PPE-related issues and perceived PPE shortages for staff at the time of our remote
inspections in 2020. For example, our remote inspection of MDC Brooklyn found that some Health Services
staff were unable to obtain the necessary PPE to evaluate inmates with COVID-19 symptoms and treat them
in medical isolation and Health Services staff told us that they believed the facility had sufficient PPE
supplies but did not provide the necessary PPE to healthcare providers. At FCC Oakdale, we found that
some staff lacked the proper PPE when in close contact with COVID-19 infected inmates; according to
interviews we conducted, staff concern about access to PPE was so dire after the first inmate tested positive
in late March 2020 that PPE supplies were being taken from the complex’s medical unit after hours and
without permission. Further, our remote inspections of FCI Milan and FCC Oakdale identified incidents in
which staff transported sick inmates to local hospitals without wearing the appropriate PPE. Additionally,
our FCI Terminal Island remote inspection report found that temporary duty (TDY) staff were not fit tested
for N95 respirators until days after they arrived at the facility. By the time we issued our 2021 BOP Staff
Survey, however, approximately 95 percent of BOP-wide staff respondents reported that they had been fit
tested for an N95 respirator. Results from our 2021 survey also generally found widespread availability of
PPE and face coverings at facilities.
Our remote inspections of BOP contract facilities identified unique PPE-related challenges. Unlike at federal
facilities, PPE supply levels at BOP contract prisons and Residential Reentry Centers (RRC), due to the
privatized and decentralized nature of the BOP’s contract model, depend on the ability of the dozens of
contractors to acquire PPE independently. We found that for at least 2 weeks supply issues made two of the
three contract prisons we inspected unable to comply with an April 3, 2020 CDC recommendation for
individuals to wear cloth face coverings in public settings where social distancing measures are difficult to
maintain. Further, our remote inspection of Toler House RRC found that the facility did not distribute face
masks to all of its residents until nearly 3 weeks after the April 3 CDC recommendation. In addition, our
Brooklyn House RRC remote inspection found that distribution of PPE at the RRC gradually expanded over
the March–May 2020 timeframe and was shaped by both availability of supplies and a lack of PPE
guidance.124
At the beginning of the pandemic, the BOP maintained a central stockpile of PPE supplies for federal
facilities at its Centralized Fill and Distribution Center in Pollock, Louisiana. By late April 2020, the BOP had
created primary and secondary regional logistics sites for all six BOP regions to store PPE and provide PPE
to BOP facilities. The BOP’s Administration Division at its Central Office procured PPE and sent it to the
regional logistics sites. Central Office officials told us that they purchased PPE for the regional logistics sites
124
The BOP did not provide RRCs with specific guidance on PPE and face covering requirements. We discuss this
limited guidance further in The BOP Should Improve Its Communication of Essential Information to Stakeholders section
of this report.
76
in large quantities and never ran out of any PPE supplies. Internal BOP compliance inspection reports from
July 2020 through March 2021 show that 94 percent of the inspected facilities ensured that sufficient PPE
was available to all staff. At the time of our 2020 BOP Staff Survey, most facility respondents (64 percent, or
5,866 of 9,166) reported receiving a limited amount of PPE each week.125
BOP facilities requested PPE through Central Office’s Emergency Operations Center, which routed the
requests to the regional logistics sites; BOP facilities also had the option to purchase their own PPE to
bolster availability. The Central Office monitored PPE levels at the regional logistics sites and facilities daily
via an electronic dashboard. Internal BOP compliance inspection reports found that 96 percent of inspected
facilities uploaded PPE inventories to a Central Office dashboard on a weekly basis. According to Central
Office officials we interviewed, the use of the Centralized Fill and Distribution Center and regional logistics
sites were effective in the BOP’s maintenance and distribution of PPE during the pandemic. Those officials
explained that it would be worthwhile for the BOP to consider replicating in other areas the PPE model that
it used during the COVID-19 pandemic.
Conclusion
PPE supply challenges affected the BOP early during the pandemic, and our remote inspections found
numerous PPE-related issues at BOP facilities, contract prisons, and RRCs. While the BOP subsequently
resolved supply issues to provide adequate PPE to facilities, the BOP should consider how its PPE supply
model could support distribution efficiency beyond the current pandemic.
Recommendation
To mitigate future PPE supply and distribution challenges, we recommend that the BOP:
9. Determine how the Centralized Fill and Distribution Center and regional logistics sites model could
support distribution efficiency beyond the current pandemic.
BOP Staff Expressed Concerns About PPE and Face Covering Guidance Early During the
Pandemic
Though the confusion now appears to have waned, at the beginning of the pandemic BOP staff expressed
concerns and confusion about PPE and face covering guidance. Our remote inspection reports identified
instances of unclear BOP guidance and direction regarding the use of PPE. For instance, staff at FCC
Oakdale who supervised COVID-19 positive inmates were not advised that they would be interacting with
COVID-19 positive inmates and were not furnished proper PPE prior to inmates’ isolation. By early April
2020, staff at FCI Milan had escorted at least one, and possibly more, inmates with COVID-19 symptoms to a
125
On April 3, 2020, the CDC began recommending cloth face coverings for situations in which social distancing was
difficult. CDC, “Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant
Community-Based Transmission,” April 3, 2020.
On April 6, the BOP began issuing two surgical masks per week to all staff and one per week to all inmates as an interim
measure while the BOP’s UNICOR factories manufactured cloth face coverings. Once a facility received its shipment of
UNICOR-manufactured cloth face coverings, distribution of surgical masks was discontinued. At the time of our BOP
Staff Survey in late April 2020, some staff reported that they were still receiving two surgical masks per week.
77
local hospital without wearing appropriate PPE, which potentially contributed to an increased risk of those
staff contracting and spreading COVID-19.126 In our FMC Fort Worth inspection, for example, we found that
the Warden sent a memorandum in March 2020 requiring staff to utilize PPE in the isolation unit but did not
specify what types of PPE were required. During FY 2020 we received over a dozen OIG Hotline complaints
from BOP staff about the BOP’s guidance on the use of PPE.
We found during our 2020 remote inspections that BOP staff were confused about the proper PPE
requirements for specific situations. We received dozens of 2020 BOP Staff Survey responses from staff
who believed that they should have received surgical masks or N95 respirators instead of cloth face
coverings. We were also told that the BOP’s national union had requested that the BOP provide N95
respirators to all staff at all federal facilities. The then BOP Medical Director stated that it would have been
inappropriate for the BOP to distribute N95 respirators for general use, as the BOP followed CDC
recommendations and required N95 respirators for staff only in certain situations, such as when
transporting confirmed or suspected COVID-19 positive inmates. The BOP Occupational Safety and Health
Branch Chief explained that, prior to the pandemic, N95 respirators were in plentiful supply and the BOP did
not place any limits on when staff could wear them; the BOP’s decision to control access to N95 respirators
due to more limited supplies during the pandemic was a factor in staff frustration with the BOP’s guidance.
According to the then BOP Medical Director, another source of confusion about PPE requirements was that
some staff may not have understood the difference between medical isolation and quarantine and why
there were different PPE requirements for those two types of units. Additionally, we believe that a visit to
FCC Oakdale by CDC and Office of the Attorney General staff who wore N95 respirators while FCC Oakdale
was experiencing a COVID-19 outbreak contributed to BOP staff’s perception that the surgical masks
provided by the BOP were insufficient.
Some feedback we received from BOP staff indicates that the BOP’s guidance about whether staff could
wear their own face coverings in lieu of those the BOP provided may have been unclear, particularly during
the early phases of the pandemic. See the photographs below for examples of a BOP staff member wearing
PPE, as well as the cloth face coverings manufactured by UNICOR and provided to BOP staff and inmates by
the BOP. Neither the BOP’s initial face covering guidance on April 6, 2020, nor the Department’s face
covering guidance on April 14, 2020, prohibited BOP staff from wearing their own personal face coverings.
However, our FCC Coleman remote inspection found that the facility prohibited staff from wearing personal
face coverings prior to the BOP’s April 15, 2020 guidance mandating that BOP staff and inmates wear BOP-
provided face coverings.127 This caused confusion among some staff and led to staff concerns that their
safety was not a management priority. Our FCI Milan remote inspection also found that management
discouraged staff from wearing their own masks to avoid causing the inmates stress.
126
The BOP identified inmate transport as a situation in which staff should wear an N95 respirator, eye protection,
gloves, and a gown in its April 2, 2020 Vehicle Transport of Inmates Safety Check for COVID-19 guidance and in several
versions of its Guidance for COVID-19 Personal Protective Equipment issued in late April 2020.
127
As part of our FCC Coleman remote inspection, our review of 2020 BOP Staff Survey responses and OIG Hotline
complaints found that some staff and inmates questioned the quality and effectiveness of the BOP-issued surgical
masks and UNICOR-produced cloth face coverings, which resulted in some staff wearing personal face masks because
they felt that they provided better protection. See DOJ OIG, Remote Inspection of FCC Coleman.
78
In our 2020 BOP Staff Survey,
respondents reported in
34 open-ended comments that
they were prohibited from
wearing their own masks or
face coverings and instead
could wear only those that the
BOP provided while other
respondents reported in
20 comments that they were
permitted to wear their own
masks or face coverings. On
August 24, 2020, the BOP Left, A BOP Staff Member Wearing PPE at FCC Lompoc’s COVID-19 Staff
issued a memorandum to all Screening Location in 2020, Right, BOP-Provided Cloth Face Coverings
staff advising that facility staff Source: BOP, with OIG enhancement
were permitted to wear only
face coverings provided by the
BOP or purchased from a BOP
Employee’s Club with approval from the Warden. Despite this guidance, 66 percent of 2021 BOP Staff
Survey respondents reported that they were permitted to supply their own nose and mouth coverings.
Confusion among BOP staff about PPE and cloth face covering requirements appears to have waned over
the course of the pandemic. For example, over 90 percent of 2021 BOP Staff Survey respondents said that
COVID-19 communication and guidance on wearing cloth face coverings and PPE was easy to understand.
Over the course of the pandemic, the BOP continued to update its PPE guidance to staff for specific
situations. The BOP’s October 8, 2020 update to its COVID-19 Pandemic Response Plan included a table that
described the recommended use of PPE in various situations for both staff and inmates. Further, the
Pandemic Response Plan provided detailed explanations for when staff and inmates should use N95
respirators, surgical masks, or cloth face coverings.
Conclusion
We recognize the inherent challenges that the BOP faced as CDC and DOJ guidance on this topic evolved
during our remote inspections and over the course of the pandemic. Nonetheless, reports of staff
confusion about PPE guidance early during the pandemic led us to conclude that the BOP should continue
to update and clearly communicate guidance regarding PPE and face coverings as circumstances evolve.
Because our 2021 BOP Staff Survey results indicated that staff confusion in this area has declined, we do not
make any recommendations in this report regarding PPE guidance to staff.
BOP Facilities Struggled to Ensure Compliance with Face Covering Requirements
We found that across the BOP there was inconsistent staff and inmate compliance with BOP guidance that
required staff and inmates to wear face coverings inside facilities. As discussed in the Introduction, staff
79
and inmates were first required to wear face coverings in April 2020.128 On August 24, 2020, additional BOP
guidance regarding the mandatory use of face coverings for BOP staff stated that employees who refused to
wear face coverings and failed to follow a direct order to do so could be referred to the BOP’s Office of
Internal Affairs for misconduct. Nearly 95 percent of 2021 BOP Staff Survey respondents reported that they
always or often covered their noses and mouths while working in the facilities, but only 82 percent of
respondents reported that they observed other staff always or often doing so.129 Even fewer respondents
(68 percent) reported that inmates always or often covered their noses and mouths. Similarly, staff and
inmate improper use or non-use of PPE and face coverings was a top concern for individuals who submitted
OIG Hotline complaints: the OIG received over 530 complaints related to this issue between March and
September 2020.
Our 2021 Inmate Survey also revealed face covering compliance issues. Results varied depending on
reference group: inmates referring to themselves, to other inmates, or to staff. An estimated 84 percent of
inmates self-reported always or often wearing cloth face coverings over their nose or mouth in common
areas. In comparison, an estimated 53 percent of inmates indicated that other inmates always or often
wore face coverings and an estimated 44 percent reported that staff did so always or often. BOP internal
compliance inspections conducted between July 2020 and March 2021 found that only 66 of 90 inspected
facilities (73 percent) had appropriate use of face coverings by BOP staff and inmates. Facilities at which
lack of compliance with face covering guidance was observed took corrective actions, including distributing
additional face coverings and making regular announcements to remind staff and inmates that face
coverings were required. However, it is unclear whether those corrective actions were effective in
increasing compliance.
Conclusion
To correct persistent face covering noncompliance at facilities, the BOP should assess ways to improve staff
and inmate face covering compliance and regularly communicate the need to comply with healthcare
protective equipment measures.
Recommendation
To ensure consistent staff and inmate compliance with face covering guidance, we recommend that the
BOP:
10. Assess how to improve staff and inmate compliance with healthcare protective equipment
measures at its facilities and issue clear guidance to facilities about the importance of compliance.
128
On April 6, 2020, the BOP issued initial guidance to Wardens referencing the issuance of face coverings to staff and
inmates and directing facilities to issue surgical masks as an interim measure while advising that UNICOR would
manufacture cloth masks. On April 13, the BOP issued its Phase Six Action Plan, which stated that all staff and inmates
would be issued appropriate face coverings and strongly encouraged to wear them in public areas when social
distancing could not be achieved. The BOP’s April 15 guidance on the Mandatory Use of Face Coverings, sent to all staff
via email, mandated that all staff and inmates wear BOP-provided face coverings.
129
Seventy-five percent of respondents reported that they always covered their noses and mouths while working in
facilities, and 20 percent reported often doing so.
80
Some BOP Facilities Did Not Take Required Preventive
Measures When Waiting for Inmate COVID-19 Test Results Federal COVID-19 Testing Report
Early During the Pandemic In January 2021, the Pandemic
Response Accountability
Our remote inspections generally found that facilities housing BOP Committee, of which the DOJ
inmates complied with COVID-19 testing guidance and that, as testing OIG is a member, published a
capacity increased nationally, the BOP incorporated testing into report on COVID-19 testing
quarantine strategies at its facilities. (See Appendix 5 for more efforts at six federal agencies,
information on the factors affecting COVID-19 testing practices and including the BOP. For more
availability.) While increased access to various rapid testing options has information about types of tests
since decreased the turnaround time for test results, we found that conducted, testing costs, and
demographics of those who
long turnaround times for results early during the pandemic meant that
were tested, see the committee’s
COVID-19 positive inmates were sometimes housed with COVID-19
Federal COVID-19 Testing
negative inmates for several days, especially during the first several Report.
months of the pandemic.
The BOP began to conduct COVID-19 tests through a contracted commercial laboratory, as well as through
partnerships with public health laboratories, in March and April 2020. However, receiving test results from
these laboratories could take several days. BOP medical officials told us that the turnaround time for
commercial laboratory results was usually 2–4 days but that during late July into August 2020 it was as long
as 10–14 days due to increased demand for testing nationwide. In some instances, the turnaround time
limited facilities’ abilities to timely separate inmates who had tested positive for COVID-19 from inmates
who had tested negative. Our remote inspection reports on FMC Fort Worth, FCI Terminal Island, FCC
Oakdale, and FCC Butner all described situations in which inmates were housed together for up to 7 days
before being separated into medical isolation and quarantine units. This resulted in an increased risk of
COVID-19 transmission among inmates, as inmates whose test results were positive could have infected
inmates whose test results were negative in the days before the results were received.
In some cases, this risk was exacerbated by the lack of preventive measures taken while awaiting test
results. For example, at FCC Butner, our remote inspection found that, after COVID-19 positive and negative
inmates in the Low Security Correctional Institution were separated into housing units based on their test
results, the units housing negative inmates were not treated like quarantine units despite those inmates
having had close contact with inmates who tested positive for COVID-19. At FCC Oakdale, inmates waiting
for test results still left their housing units for meals instead of having meals delivered to the unit and staff
working in the unit were not advised of inmates’ positive results or instructed to wear appropriate PPE. The
Regional Medical Director told the OIG that she was “disappointed” with how the situation was handled at
FCC Oakdale and, in hindsight, believed that she and the Regional Medical Team should have more explicitly
communicated to Oakdale officials their expectation about the protocols to follow during the wait period.
Conclusion
Compounding the delays due to test results turnaround time, facilities also took additional time to process
the test results and develop a plan to appropriately place inmates into medical isolation or quarantine.
Given the logistics involved in ensuring sufficient medical isolation and quarantine spaces, moving groups of
inmates safely, and cleaning and sanitizing housing areas between occupants, we recognize that some
delays may occur. However, given the risks associated with further spread of the virus in a communal living
environment where staff move between units, ensuring that facilities are following quarantine guidance is
81
essential for minimizing transmission risk if there are delays. In response to a draft of this report, the BOP
provided updated guidance from its December 2022 COVID-19 Pandemic Response Plan indicating that,
because the virus has become endemic, broad-based testing in housing units was no longer required.130
Additionally, in November 2022, the CDC updated its guidance for management of COVID-19 in correctional
and detention facilities to state that facilities should base their quarantine policies on their risk tolerance
instead of routinely recommending quarantine for people exposed to someone with COVID-19. Due to
these guidance changes, we do not make any recommendations regarding testing and quarantine guidance
in this report.
The BOP Should Respond to Ongoing Pandemic Challenges and Prepare for Future Public
Health Emergencies
Aspects of the BOP’s response to the COVID-19 pandemic—vaccination and modified operations at BOP
facilities—have evolved over time along with various factors, including COVID-19 case counts and changes to
federal guidance and legislation. For example, the BOP implemented programmatic and operational
changes for inmates’ daily activities and responded to evolving circumstances surrounding distribution of
the COVID-19 vaccine to inmates and staff.
As circumstances evolve, the BOP should continue to ensure inmate access to essential services during
modified operations, protect staff and inmate health and safety, and capture lessons learned to prepare for
future public health emergencies. First, the BOP should continue to explore ways to safely accommodate
inmate access to mental healthcare, programming, counsel, recreation, commissary, and communication
options during extended COVID-19 related modified operations and restrictions at facilities. Second, to
protect inmates and staff, the BOP should continue COVID-19 vaccine educational campaigns for inmates
and ensure that inmates and staff have access to the vaccine. Finally, to prepare for future public health
emergencies, the BOP should document best practices and lessons learned from ongoing COVID-19
challenges related to its continued use of modified operations and vaccines. Capturing lessons learned
from these aspects of the BOP’s COVID-19 response, which have evolved significantly during the pandemic,
should assist the BOP in preparing for future public health emergencies and improve its ability to adapt to
changing circumstances, prioritize the health of staff and inmates, and ensure continued inmate access to
essential services.
The BOP Should Safely Accommodate Inmate Access to Services During COVID-19 Modified
Operations and Future Public Health Emergencies
BOP facilities, contract prisons, and RRCs around the country modified their operations, tailoring them to
the unique circumstances of the facility and the presence of COVID-19 in the surrounding area. As the
period of modified operations continues, the BOP must continue to explore ways to balance COVID-19
prevention with inmate mental health and access to essential services. Our remote inspections and review
of BOP documentation found that the BOP’s modified operations resulted in reductions in, or suspension of,
programming, recreation, social visitation, and commissary. In particular, we also identified significant
130
The BOP also provided a January 2022 memorandum issued to Clinical Directors and Health Services Administrators
at all BOP facilities stating that whenever mass testing was being considered at a facility it was important to
communicate with the Regional Office to develop a plan based on the facility’s specific epidemiological situation.
Additionally, the BOP maintains an archive of previous COVID-19 guidance it has issued.
82
challenges related to inmate access to legal counsel during the pandemic. Following our remote
inspections, modified operations continued to significantly affect most BOP facilities through 2022.
Additionally, as we discuss throughout the following sections, the BOP should document best practices and
lessons learned to ensure that it is prepared to accommodate inmate access to these services during future
public health emergencies.
As described in the Introduction to this report, in August 2021 the BOP implemented a Modified Operations
Matrix Plan that provides guidance on how individual BOP facilities should make modifications to their
operations. The plan allowed for BOP facilities to intensify or relax current infection control mitigation
strategies based on local COVID-19 risk factors. The plan also provided guidance on level-specific infection
prevention procedural modifications and generally called for increased modifications at facilities with higher
COVID-19 indicators such as medical isolation rates and facility vaccination rates. According to the BOP’s
public website, over 90 percent of listed BOP facilities remained under intense modifications, or “Level 3
Operations,” as of June 2022. The BOP directed these facilities to follow its COVID-19 Pandemic Response
Plan, which instructed facilities under Level 3 operations to modify congregate activities and advised that
virtual methods for such activities were preferred to in-person meetings.
Inmate Mental Health
As discussed above, inmate suicide in single-cell confinement in quarantine units has been a significant
issue during the pandemic and we found that psychology staff had not assessed the suitability of single-cell
placement for at least five of the seven inmates who died by suicide in quarantine units. (Following these
suicides, BOP psychological reconstruction reports recommended that psychology staff at one facility
complete additional suicide risk assessment training and that two facilities improve opioid withdrawal
monitoring.) The prevalence of inmate suicide in quarantine units underscores the importance of providing
inmates with mental healthcare during modified operations when inmates are confined to their cells. In a
March 13, 2020 memorandum issued to facility Wardens, the Reentry Services Division (RSD) Assistant
Director stated that facilities must ensure that they prevent mental health emergencies and provide
appropriate care to vulnerable inmates. The memorandum stated that facility psychologists must conduct
daily rounds to inmate housing units to observe and communicate with inmates.
Our remote inspections and staff and inmate survey results found varied perceptions of inmate mental
healthcare during the pandemic. Staff at several facilities we inspected told us that, under the Shelter in
Place (or lockdown) early during the pandemic, when modified operations were most restrictive, Psychology
Services staff generally visited housing units daily to evaluate inmates. Further, psychologists at several of
the facilities we inspected told us that they maintained the provision of mental healthcare to inmates during
modified operations. When we asked 2021 BOP Staff Survey respondents to identify the areas that the BOP
most needs to improve in its handling of the COVID-19 pandemic, providing mental healthcare to inmates
was the second least selected response out of 15 possible responses, indicating that it was not among the
top areas that institution staff felt needed improvement. However, inmate survey results show that, of the
roughly three-quarters of inmates who responded that they had received mental healthcare, a higher
proportion of inmates rated the quality of care during the pandemic as poor (an estimated 63 percent)
compared to before the pandemic (an estimated 49 percent) and that during COVID-19 lockdowns an
estimated 74 percent of respondents rated their mental healthcare as poor.
83
Although psychologists at two facilities we inspected reported that daily rounds to housing units enabled
Psychology Services to have more opportunities to interact with inmates than normal, during our inspection
fieldwork we received reports expressing concerns about inmate mental health and access to psychological
care. Specifically, we found that approximately 40 complaints submitted to the OIG detailed concerns about
inmate mental health during the pandemic. In addition, during our remote inspection of FCI Terminal
Island, staff told the OIG that the facility managed inmate mental health well, although a 2020 BOP Staff
Survey respondent from FCI Terminal Island reported that inmates needed better and more frequent access
to mental health services. As discussed above, BOP psychological reconstruction documentation noted that,
at least one facility, quarantine and medical isolation conditions limited access to resources that can prevent
suicide, such as peer support, psychology services, and telephones to call family or counsel.
According to Psychology Services staff at some facilities, lockdowns have been very stressful for inmates and
could exacerbate some inmates’ mental health issues. The Chief Psychologist at FCC Tucson told us in 2020
that mental health issues could increase among inmates due to the monotony of being in their cells for
22 hours a day. Moreover, previous OIG work has raised concerns about mental health for inmates housed
in such conditions. Our 2017 report on the BOP’s use of restrictive housing for inmates with mental illness
noted that the Department defined restrictive housing as “placement in a locked room or cell and the
inability to leave the room or cell for the vast majority of the day, typically 22 hours or more.”131 Further, the
report cited BOP policy as recognizing that “an inmate’s mental health may deteriorate during restrictive
housing placement.”132 As of February 2023, 6 of the 15 recommendations from our 2017 restrictive
housing report remained open, including a recommendation that the BOP evaluate and limit as appropriate
the consecutive amount of time that inmates with serious mental illness may spend in restrictive housing.
In May 2022, E.O. 14074 directed the BOP to identify alternatives to the “use of facility-wide lockdowns to
prevent the transmission of SARS-CoV-2, or to the use of restrictive housing for detainees and prisoners
who have tested positive for SARS-CoV-2 or have known, suspected, or reported exposure.”133
In the absence of regular programming and group therapy sessions, some facilities provided inmates with
mental health handouts, treatment journals, and therapeutic resources. For example, at FCC Tucson,
inmates dealing with mental health challenges were provided with secure audio devices programmed with
cognitive behavioral therapy techniques to help inmates cope with anxiety. We learned following our
remote inspections that the use of these devices was widespread at some facilities and that the BOP had
awarded a contract to supply these devices at all facilities to complement the FIRST STEP Act (FSA)
programming curriculum.
Since RRCs lack medical and psychology staff at their facilities, inmates at RRCs could be at even greater risk
of mental health challenges. At the time of our remote inspections, Brooklyn House RRC and Toler House
RRC had switched to remote interactions for mental healthcare.
131
DOJ OIG, Use of Restrictive Housing.
132
BOP Program Statement 5310.16, Treatment and Care of Inmates with Mental Illness, May 1, 2014,
www.bop.gov/policy/progstat/5310_16.pdf (accessed July 13, 2022), 16.
133
E.O. 14074.
84
Inmate Programming
We found that COVID-19 has significantly affected the ability of BOP facilities to provide programming for
inmates. In the BOP’s March 13, 2020 Phase Two Action Plan, the Central Office directed facilities to
implement modified operations and stated that programs should continue to be operated “when feasible.”
During our remote inspections, we learned that certain group programs and community meetings ceased
during modified operations in order to maintain social distancing. Specifically, we were told that the
Residential Drug Abuse Program (RDAP) and Mental Health Step Down Unit Program had been discontinued
at FCC Butner and our remote inspection of FCI Milan found that Milan had suspended group
programming.134 Our remote inspections at contract facilities CI Moshannon Valley and CI McRae also
identified reductions in programming during the pandemic. As of April 2021, the BOP reported that it was
exploring the purchase of tablets for inmates as an alternative program delivery method and that it would
issue a request for proposal for tablets once Congress approved the BOP’s FSA spending plan.
We found that disruptions to inmate programming continued at BOP facilities beyond the period of our
remote inspection fieldwork. In August 2020, the BOP issued its Phase Nine Action Plan and its
modification, which directed facilities to resume programming, outdoor recreation, and in-person social
visits. The Action Plan stated that “inmate programming is an essential function in our facilities, and delivery
of [FSA] approved Evidence-Based Recidivism Reduction (EBRR) Programs and Productive Activities is
required by law.”135 The FSA provides that an inmate who “successfully completes evidence based
recidivism reduction programming or productive activities, shall earn time credits” toward prerelease
custody (i.e., transfer to an RRC or home confinement) or supervised release (i.e., post-imprisonment
supervision). The BOP’s Phase Nine Action Plan stipulated that residential programs, such as the RDAP,
would immediately resume full-time treatment, with social distancing modifications, and that delivery of
non-residential EBRR Programs and Productive Activities would resume. However, the guidance also stated
that facilities with active COVID-19 cases could make exceptions to programming requirements for the
safety of staff and inmates and submit modification requests to the Regional Director. BOP data indicated
that as of November 2020 at least 20 facilities had submitted waiver requests to suspend programming and
inmate programming remained suspended at some facilities without waiver requests.136 In response to
some facilities’ waiver requests, Central Office staff provided feedback or discussed the initial waiver
134
The RDAP provides intensive drug treatment programming to inmates. The Mental Health Step Down Unit Program
provides evidence-based treatment to seriously mentally ill inmates to maximize their ability to function and minimize
relapse and the need for inpatient hospitalization. Inmates enrolled in either program are housed in a secured unit
separate from general population housing units.
135
The FSA defines an EBRR Program as a group or individual activity that: (1) has been shown by empirical evidence to
reduce recidivism or is based on research indicating that it is likely to be effective in reducing recidivism; (2) is designed
to help inmates succeed in their communities upon release from prison; and may include (3) social learning and
communication, interpersonal, anti-bullying, rejection response, and other life skills. In addition, the FSA defines a
Productive Activity as a group or individual activity that is designed to allow inmates determined to have a minimum or
low risk of recidivating to remain productive and thereby maintain a minimum or low risk of recidivating.
Pursuant to 18 U.S.C. § 3621(h), “The Director of the Bureau of Prisons shall provide all prisoners with the opportunity to
actively participate in evidence-based recidivism reduction programs or productive activities, according to their specific
criminogenic needs, throughout their entire term of incarceration.”
136
The BOP indicated that there were potential errors in the dataset that it provided; the errors may have affected the
accuracy of the figure presented in this sentence.
85
requests with facilities rather than approving them in an effort to encourage programming to continue.
Central Office officials told us that, in practice, Wardens have some discretion during the pandemic
regarding whether to deliver programming.
Due to the Phase Nine Action Plan’s emphasis on the importance of FSA programming, we specifically
reviewed available BOP FSA programming data during the pandemic. We found that FSA EBRR Programs
and Productive Activities remained suspended at many facilities as of November 2020. In December 2020, a
Central Office staff member sent a reminder email to facility program staff to prioritize EBRR Programs and
Productive Activities led by BOP staff, contractors, or volunteers and to consider the use of alternative
spaces for programming. Among the possible COVID-19 related factors that the BOP reported as
contributing to programming disruptions were staff and inmate illness, precautions taken to prevent staff
and inmate illness, and limited inmate transfers and movement within facilities. We also learned that
staffing challenges affected program offerings; staff unavailability due to temporary job modifications and
augmentation contributed to the BOP’s inability to run programming at some facilities (we discuss
temporary job modifications and staff augmentation in The BOP Should Take Appropriate Steps to Address
Staffing Shortages and Staff Morale report section).
The BOP conducted an internal assessment of the COVID-19 pandemic’s effect on FSA programming and
determined that the pandemic had a high impact on “most programs” because they were “interrupted for a
month or more or did not occur with any consistency across sites.” The BOP reported that during the
pandemic all FSA programming either fit this description or was moderately affected by COVID-19, meaning
that it “may have stopped for a period of days or weeks but then quickly resumed.” According to the BOP’s
internal assessment and our interview with a BOP official, while residential programming such as the RDAP
was affected by the pandemic, it was generally less affected than nonresidential programs because services
were provided in housing units and did not require inmates to interact across housing units. Historical data
provided by the BOP showed an overall decline in inmate program participation through March 2021,
compared to pre-pandemic participation. The data also showed marginal increases in program enrollment
several times during the pandemic beginning in August 2020, when the BOP issued Phase Nine Action Plan
directives to resume the program. Figure 11 below shows inmate program enrollment in the RDAP before
and during the pandemic.
The significant disruption of FSA programming is concerning given the potential effects on the ability of
inmates to earn time credits. According to a November 2021 OIG Management Advisory Memorandum,
BOP data as of March 30, 2021, indicated that nearly half (60,146 out of 123,186) of all inmates in BOP
custody were eligible to earn time credits if they had completed EBRR Programs or Productive Activities.137
We found that the BOP has experienced challenges in systematically tracking inmate enrollment in other
FSA programming, which has made it difficult to fully assess the effect of the pandemic on BOP-wide inmate
program participation. According to the BOP, there is no mechanism to compare pre- and post-pandemic
FSA program participation rates because the BOP changed how it tracks program participation following
137
See DOJ OIG, Management Advisory Memorandum: Impact of the Failure to Conduct Formal Policy Negotiations on
the Federal Bureau of Prisons’ Implementation of the FIRST STEP Act and Closure of Office of the Inspector General
Recommendations, E&I Report 22-007 (November 2021), oig.justice.gov/reports/management-advisory-memorandum-
impact-failure-conduct-formal-policy-negotiations-federal.
86
passage of the FSA.138 Further, the BOP reported that, when it began to develop reports to track inmate
program participation in and completion of EBRR Programs and Productive Activities during the pandemic, it
took months to create and test the reports for data accuracy. The BOP was able to provide us with FSA
programming participation totals beginning in November 2020, 8 months after the start of the pandemic.
As shown in Figure 12 below, FSA program enrollment in FSA EBRR Programs and Productive Activities
increased between November 2020 and October 2021.
Figure 11 Figure 12
BOP Inmate Participants in RDAP Programming, BOP Inmate Participants in FSA EBRR Programs and
January 2020–March 2021 Productive Activities, November 2020–October 2021
7,000
Start of the COVID-19 Pandemic
6,000
5,000
4,000
3,000
2,000
1,000
0 Jan Note: This figure presents the total number of participating
Feb
Mar
Apr
inmates as of the last day of each month.
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2020 2021 Source: OIG analysis of BOP data
Source: OIG analysis of BOP data
In addition, we found that some facilities housing female inmates did not have any inmates complete
gender-specific programming for significant periods of time during the pandemic, based on our review of
available EBRR Programs and Productive Activities programming completion data. We reviewed completion
data from 10 Productive Activities that were intended to occur at all-female facilities from January 15
through September 30, 2020, and found that there were 0 inmate program completions for half (5 of 10) of
those Productive Activities. During the subsequent 6-month period, program completion totals remained at
0 for 3 of the 10 Productive Activities for which the listed locations were all-female facilities. Although the
data did not cite COVID-19 as the reason for the lack of completions, we are concerned that the BOP’s
female inmate population has not received essential programming in several areas during the pandemic.
The programs with zero completions for female inmates included curricula to address cognition, trauma,
138
The FSA, which was passed in December 2018, requires that, after 2 years of the FSA’s enactment, the Department
submit to Congress information on the types and effectiveness of recidivism reduction programs and productive
activities provided by the BOP, including the capacity of each program and activity at each prison and any gaps or
shortages in the capacity of such programs and activities.
87
mental health, and anger issues. We identify this lapse in programming completions for female inmates
during the pandemic in light of concerns described in our 2017 review of the BOP’s management of its
female inmate population, which found that the BOP’s programming and policy may not fully consider the
needs of female inmates.139 It is important for the BOP to ensure continued access to programming for
female inmates during the pandemic.
Legal Visiting
Our remote inspections generally found that the BOP facilitated inmate access to legal calls with counsel at
facilities we inspected but that it experienced some challenges providing inmate access to counsel visits
during the pandemic. When the BOP directed facilities to suspend all in-person legal and social visits on
March 13, 2020, facilities’ Unit Teams arranged legal calls for inmates.140 During our remote inspection of
FCI Terminal Island, facility staff reported that they facilitated inmates’ legal communications to the extent
possible but legal communication was limited during the pandemic; an attorney representing inmates
alleged that the facility was unable to grant inmate legal call requests for a 3-week period. In August 2020,
the BOP’s Phase Nine Action Plan provided guidance for in-person legal visits at facilities able to safely
conduct such visits, though inmates continued to have the option of visits by telephone or video
teleconference (VTC).
According to our 2020 BOP Staff Survey results, 35 percent of BOP staff respondents (BOP-wide, as opposed
to from a single institution) and 62 percent of RRC staff respondents (RRC-wide) reported that inmates had
access to their counsel when requested, through facility phones, while 54 percent of BOP staff respondents
did not know what strategies their facilities employed to facilitate inmate communication with legal counsel.
Our analysis of complaints submitted to the OIG Hotline found over 100 complaints from April through
September 2020 concerning inmate access to counsel or access to legal materials, including challenges
reported by inmates’ attorneys attempting to contact their clients. In addition, our analysis of the 2021
Inmate Survey shows that an estimated 84 percent of inmates who needed to contact their attorney during
COVID-19 lockdowns reported that they were rarely or never allowed to do so. In comparison, an estimated
47 percent of inmate respondents said they were rarely or never allowed to contact their attorney before
the pandemic and an estimated 59 percent of inmate respondents said that they were rarely or never
allowed to contact their attorney during non-lockdown periods of the pandemic. These percentages
represent approximately 60 percent of all inmates who responded to the survey question regarding access
to attorneys; the other 40 percent either did not need to contact an attorney during the three reference
periods or declined to answer the question.
Inmates’ continued access to legal counsel is especially important at Federal Detention Centers (FDC), where
pretrial inmates facing federal charges are typically housed. When we examined April 2020 BOP Staff
Survey responses from the BOP’s staff assigned to its detention centers, we found that only 59 percent of
respondents (349 of 595) reported that inmates were able to communicate with their attorneys upon
139
DOJ OIG, Review of the Federal Bureau of Prisons’ Management of Its Female Inmate Population, E&I Report 18-05
(September 2018), oig.justice.gov/reports/review-federal-bureau-prisons-management-its-female-inmate-population.
140
On March 13, 2020, the BOP issued its COVID-19 Phase Two Action Plan, which permitted facilities to accommodate
case-by-case requests for in-person legal visits.
88
request using facility telephones.141 Both FDCs that we inspected, MDC Brooklyn and MCC Chicago, received
a large volume of legal call requests, and in response to the pandemic the BOP provided tablets or VTC units
to facilitate inmate access to counsel and to the courts.142 At MDC Brooklyn, a Unit Manager described the
accommodation of inmate legal calls as Unit Teams’ greatest challenge during COVID-19, as Unit Team staff
had to monitor emails multiple times per day to ensure that inmates had access to counsel. Following the
BOP’s issuance of its Phase Nine Action Plan, which provided guidance regarding in-person legal visits, our
remote inspection of MDC Brooklyn found that the facility resumed in-person legal visits by appointment in
September 2020 while continuing to conduct most visits by telephone or VTC. As mentioned above in the
Attorney and Judicial Concerns Regarding BOP Communication section, an Eastern District of New York
judge issued an April 2020 order that required the Wardens of MDC Brooklyn and MCC New York to provide
biweekly status updates to the court and other organizations on their facilities’ responses to COVID-19.
During a 2019 inspection and review, the OIG found that MDC Brooklyn failed to provide timely and
complete information to inmates’ attorneys and the courts about its decision to cancel legal visits during a
power outage and conditions inside the facility during the outage.143
Although some BOP facilities effectively utilized VTC for virtual attorney-client visits, we found that the BOP
did not provide VTC access for attorney-client video visits at all facilities during the pandemic. While the two
detention centers we inspected had tablets or VTC units available for inmate legal calls and access to virtual
court proceedings, not all BOP facilities utilized VTC capabilities for these purposes. Prior to the pandemic,
all BOP facilities were equipped with VTC capabilities, though requests to use VTC for these purposes were
reportedly rare because inmate-attorney visits generally occurred in person or over the phone while court
appearances were generally held in person.144 According to a Central Office official, there was a significant
increase in requests for attorney-client video visits as a result of the pandemic. Although the BOP reported
purchasing 175 VTC units during the pandemic, the BOP reportedly did not have enough units to support
demand. In addition, the Central Office official told us that there was a need for more staff to help support
the increased demand for VTC calls at facilities.
According to the Central Office official we interviewed, facility physical infrastructure challenges limited the
BOP’s ability to conduct attorney-client video visits at some facilities. For example, some older facilities
needed to add internet ports in rooms intended for VTC use. Technological limitations at some facilities
included insufficient bandwidth that led to poor audio and video quality. During the pandemic, the BOP
initiated a pilot project that sent tablets or laptops for attorney-client video visits to six facilities, including
four detention centers. However, the devices were reportedly unable to hold sufficiently strong mobile data
connections at some of the facilities. Given these reported challenges and the importance of inmate access
141
For this analysis, we evaluated responses from MDC Brooklyn, MCC Chicago, MDC Guaynabo, FDC Honolulu, FDC
Houston, MDC Los Angeles, FDC Miami, MCC New York, FDC Philadelphia, MCC San Diego, and FDC SeaTac.
142
DOJ OIG, Remote Inspection of Metropolitan Correctional Center Chicago, E&I Report 21-053 (March 2021),
oig.justice.gov/reports/remote-inspection-metropolitan-correctional-center-chicago.
143
DOJ OIG, Review and Inspection of Metropolitan Detention Center Brooklyn Facilities Issues and Related Impacts on
Inmates, E&I Report 19-04 (September 2019), oig.justice.gov/reports/review-and-inspection-metropolitan-detention-
center-brooklyn-facilities-issues-and-related.
144
The BOP uses VTC also for telemedicine, Psychology Services programming, and religious services.
89
to counsel, the BOP should continue to explore ways to facilitate inmate access to counsel during modified
operations at BOP facilities.
Recreation
Our remote inspections generally found that the facilities we inspected staggered inmate recreation times,
following the BOP’s March 13, 2020 Phase Two Action Plan, which required Wardens to implement modified
operations at facilities to maximize social distancing. Inmate access to recreation varied at facilities we
inspected and was especially limited during periods of high COVID-19 transmission at the facilities. For
example, inmate access to recreation was suspended during COVID-19 outbreaks at FCC Oakdale and FCC
Coleman.
Our 2017 review of the BOP’s use of restrictive housing for inmates with mental illness underscored the
importance of inmate access to recreation, particularly when inmates are confined to their cells. As part of
that review, the Chief Psychologist at FMC Carswell told us that it is “important for the mental and physical
well-being of a person to get sun and fresh air and you cannot do that indoors.”145 During our COVID-19
remote inspections, Chief Psychologists at two facilities recommended beginning to allow inmates access to
the outdoor recreation yard and one of the Chief Psychologists stated that such increased access could
mitigate potential mental health issues. Additionally, 23 respondents to our 2020 BOP Staff Survey
identified the ability to grant inmates access to recreation, especially outdoor recreation, as an immediate
need. In June 2020, the then BOP Correctional Programs Division Assistant Director told us that he spoke to
Regional Directors about allowing small groups of inmates at facilities with COVID-19 cases to rotate to the
recreation yard. In August 2020, the BOP issued its Phase Nine Action Plan, which stated that recreation
yard access would resume for inmates in the general population and for inmates in Special Housing Units
consistent with standards outlined in policy.146 However, as of November 2020, available BOP data
indicated that at least 20 facilities were not holding outdoor recreation.147 According to the BOP, outdoor
recreation was available to inmates at all BOP facilities as of May 2022.
Commissary
Our remote inspections found that at federal facilities and contract prisons commissaries generally
remained available to inmates who wished to make purchases during modified operations. Staff at several
facilities we inspected delivered commissary items that inmates had purchased to housing units in order to
limit the risk of COVID-19 transmission. While several of our remote inspections found that there were no
disruptions to commissary, temporary commissary suspensions occurred at some facilities, including MDC
Brooklyn, FCC Butner, MCC Chicago, and FCC Oakdale, for reasons such as staffing challenges or lockdown
considerations. According to BOP staff we interviewed, some facilities reduced the inmate spending limit on
145
DOJ OIG, Use of Restrictive Housing, 23.
146
According to the BOP’s Phase Nine Action Plan, general population inmates should have access to the recreation
yard at least 3 times per week and inmates in groups of no more than 100 should be able to access the recreation yard
for at least 1 hour at a time, provided they remain socially distant from one another. Phase Nine further stated that
facilities with active COVID-19 cases could make exceptions to these programming requirements for the safety of staff
and inmates.
147
BOP-provided data contained inconsistencies in the number of facilities not holding outdoor recreation. We state
“at least 20” because the BOP could not report the definitive number.
90
commissary purchases. We were told that spending restrictions at one facility were intended to reduce the
burden on staff working in the commissary, many of whom had other duties. In addition, during FY 2020
there were over 65 complaints submitted to the OIG Hotline about inmate access to commissary during the
pandemic. Inmates residing at RRCs, who normally would have had the opportunity to make purchases in
the community, also had reduced opportunities to do so as these facilities restricted inmate movement
because of the pandemic. For example, during our remote inspection fieldwork we noted that inmates at
Toler House RRC were permitted to leave their facility only once per month to pick up medication and
hygiene supplies.
Inmate Contact with Friends and Family
Inmates typically have contact with friends and family through in-person social visits, telephone calls,
TRULINCS email, and regular mail. When the BOP suspended social visits on March 13, 2020, it took certain
measures to accommodate inmates’ ability to communicate with friends and family. The CARES Act
required the BOP Director to “promulgate rules regarding the ability of inmates to conduct visitation
through [VTC] and telephonically, free of charge to inmates, during the covered emergency period,” if the
Attorney General found that “emergency conditions [would] materially affect the functioning of the
[BOP].”148 In response to an inquiry from Senator Cory Booker regarding the cost of inmate telephone calls
and video visits, the BOP reported that, as of March 13, 2020, it had increased each inmate’s monthly
telephone time from 300 minutes to 500 minutes to help compensate for the lack of visits.149 The BOP
further reported to Senator Booker that, as of April 9, 2020, telephone calls and video visits were made free
of charge to inmates, although, as we explain below, social video visits were available only to certain
facilities housing female inmates. According to a June 2021 BOP Operations Memorandum scheduled to
expire in June 2022, the BOP may, on a case-by-case basis, continue to authorize inmates to have visitation
through VTC and telephonically, free of charge to inmates.
Our remote inspections found that the availability of communication tools was limited for inmates under
modified operations and the amount of time inmates had access to phones and TRULINCS email varied
across facilities, from 10 minutes to 3 hours at a time and from 3 days per week to every day. We also
found that temporary suspensions of inmate access to phones or TRULINCS email occurred during our
inspections of FCC Butner, FCC Oakdale, and FCI Terminal Island. Specifically, staff at FCC Butner and FCI
Terminal Island told us that there were certain times when they temporarily suspended inmate access to
TRULINCS computer terminals and phones in order to limit COVID-19 transmission. Additionally, a staff
survey respondent at FCI Milan reported that having such limited time outside their cells meant that
inmates had to choose between calling their loved ones and showering or cleaning the housing unit.
Although only 9 percent of 2020 BOP Staff Survey respondents overall said that their facilities had
decreased inmates’ ability to communicate with loved ones by restricting access to telephones and
148
On April 3, 2020, Attorney General Barr found that emergency conditions were materially affecting the functioning of
the BOP. The “covered emergency period” refers to the period beginning on the date the President declares a national
emergency under the National Emergencies Act (50 U.S.C. § 1601 et seq.) and ending 30 days after the date on which the
national emergency declaration terminates. The emergency period was subsequently extended and remained in effect
as of August 2022.
149
Michael D. Carvajal, Director, BOP, letter to the Honorable Cory A. Booker, U.S. Senator, April 10, 2020.
91
computers, we found that this response was selected by nearly half of respondents at one facility that
implemented a 14-day lockdown, which was in effect during our entire survey window.
Although the BOP made video visits free of charge
to inmates during the pandemic beginning in April
Tablet Pilot Program for Hospitalized Inmates
2020, the use of VTC for social visits was available
only to certain subsets of the inmate population During the pandemic, the BOP initiated a pilot program
that provided tablets for social video visits to inmates
throughout the pandemic. Pre-dating the
hospitalized with COVID-19. These tablet video calls were
pandemic, the use of TRULINCS video services for
conducted via a secure connection and allowed
social visits at BOP facilities had been available hospitalized inmates to virtually meet with family
only to the BOP’s female inmate population. BOP members and loved ones who would otherwise have
officials told the OIG that, as of August 2021, video been unable to visit them in the hospital during the
social visits were not available for all female pandemic. In November 2020, the BOP issued a technical
inmates. According to BOP data as of May 2022, bulletin to facilities providing instructions on how to
video social visits were available at 25 of the 27 request the purchase of approved tablets for hospitalized
BOP facilities that house female inmates. inmates. According to a Central Office official, the pilot
program was successful and expanded over time. The
Additionally, we learned that in 2018 the BOP
BOP initially provided tablets to 5 BOP facilities, and
decided not to expand TRULINCS video services to
17 facilities had received tablets as of June 2021.
other facilities. However, according to a Central
Office official, the BOP has issued a request for Source: BOP
information to explore the expansion of social
video visiting at facilities. The BOP also initiated a
pilot program to provide tablets for social video
visits to inmates hospitalized with COVID-19 (see the text box).
The BOP’s August 31, 2020 Modification of the Phase Nine Action Plan stated that non-contact social visits
would restart at BOP facilities no later than October 3, 2020, and outlined COVID-19 mitigation measures
such as scheduled visits, social distancing, and sanitation of visiting spaces. According to the BOP’s August
31, 2020 COVID-19 Pandemic Response Plan, an agency-level decision to suspend or resume inmate social
visits can be made based on agency- and pandemic-specific circumstances. The response plan further
states that “visitation should not occur at [facilities] with a COVID-19 movement moratorium or when active
facility transmission is occurring.”
Conclusion
We identified disruptions to inmate access to programming, legal counsel, recreation, commissary, and
communication options during the period of modified operations because of the pandemic. The pandemic
also heightened the importance of continued inmate access to mental healthcare. While we do not make
specific recommendations in this section, as the period of modified operations continues, we encourage the
BOP to explore ways to accommodate inmate access to these essential services and prepare for a transition
to normal operations. In addition, we encourage the BOP to document best practices and lessons learned
to ensure that it is prepared to accommodate inmate access to these essential services in the event of
future public health emergencies.
92
The BOP Should Continue to Ensure that All Inmates and Staff Have Access to the COVID-19
Vaccine
On December 16, 2020, the BOP began administering the COVID-19 vaccine to staff and inmates. The BOP
received, distributed, and administered the vaccine to full-time BOP staff and inmates housed at BOP-
managed facilities in collaboration with the CDC and the federal government’s COVID-19
Vaccine/Therapeutics Operation, formerly known as Operation Warp Speed. The BOP received allotments
of the COVID-19 vaccine directly from the CDC, at no cost to the BOP, as part of a memorandum of
agreement between the BOP and the CDC. To distribute vaccines both fairly and efficiently, the BOP
developed COVID-19 Vaccine Guidance, which provides direction on vaccine eligibility for inmates and staff.
This guidance was intended to promote vaccine use as a means for controlling the spread of COVID-19
within federal facilities and to protect the health of inmates and staff, as well as outside community
members at risk of exposure. The BOP’s COVID-19 Vaccine Guidance identified vaccines as an important
tool to stop the pandemic and followed criteria established by the Advisory Committee on Immunization
Practices and the CDC.150
The BOP offered the vaccine to full-time staff first
due to the risk of staff contracting the virus BOP Director Congressional Testimony on
because they travel between BOP facilities and the Vaccine Status
community. The BOP then distributed the As of January 26, 2022, approximately
remaining vaccine doses to inmates based on the 80 percent of Bureau staff are fully
priority levels determined by the BOP’s COVID-19 vaccinated, and 70 percent of inmates
Vaccine Guidance.151 To guide its decisions are fully vaccinated against COVID-19.
surrounding vaccine allocation orders sent to the The Bureau continues to offer and
CDC, the BOP established a vaccine allocation encourage both booster and primary
vaccine doses to all inmates upon arrival
subcommittee that developed sub-allocation
at a Bureau facility and to all staff. We
plans for facilities and relied on its COVID-19
achieved a milestone in the distribution
Vaccine Guidance document. Ultimately, the CDC and administration of COVID-19
determined the quantity of vaccines allocated to vaccines, exceeding 288,000 total doses
the BOP in coordination with Operation Warp administered, as of January 26, 2022, to
Speed. A Central Office Health Services Division staff and inmates.
official told us that starting in early December
Source: Michael Carvajal, Director, BOP, before the U.S.
2020 BOP facilities received the vaccine through House of Representatives Committee on the Judiciary,
the sub-allocation process based on priority. The “Oversight of the Bureau of Prisons,” February 3, 2022
vaccine supply was very limited at that time, and
some facilities had to wait several weeks to
receive second doses after initial distributions were received at the facility, according to the Health Services
Division official. The BOP told us that some vaccine shipments initially went to primary BOP facility locations
150
The Advisory Committee on Immunization Practices includes 15 voting members who make vaccine
recommendations. The Secretary of the U.S. Department of Health and Human Services selects members of the
committee following an application and nomination process.
151
The BOP makes its COVID-19 Vaccine Guidance available to the public for information only, and the guidance may be
adapted for the unique situations within federal facilities, according to the BOP’s public website. See, for example, BOP,
COVID-19 Vaccine Guidance: Federal Bureau of Prisons Clinical Guidance, Version 16, January 6, 2022,
www.bop.gov/resources/pdfs/covid19_vaccine_guidance_20210311.pdf (accessed July 28, 2022).
93
in proximity to other BOP facilities and were subsequently transported to the other facilities. On January 28,
2021, the then BOP Director received a certificate of achievement recognizing the BOP for leading all
jurisdictions and federal entities in the rate of vaccination utilization, having the highest percentage of
vaccines administered per doses allocated nationally at that time. On February 3, 2022, the then BOP
Director testified at a congressional hearing that, as of January 26, 2022, approximately 80 percent of BOP
staff and 70 percent of inmates were fully vaccinated against COVID-19 (see the text box above). According
to the OIG’s collection of interactive dashboards, an estimated 71 percent of inmates BOP-wide were fully
vaccinated against COVID-19 as of August 2022.152
Inmate Vaccination
The BOP’s COVID-19 Vaccine Guidance initially outlined priority levels for inmate vaccination. These levels
prioritized inmates based on factors such as job assignments, certain housing situations, age, and risk
factors. Appendix 7 contains the BOP’s March 11, 2021 COVID-19 Vaccine Guidance priority levels for
inmates at BOP facilities. Vaccine priority levels within the BOP’s COVID-19 Vaccine Guidance have changed
over time in response to the evolving pandemic and the availability of vaccines. For example, once vaccines
became more readily available across the country, the BOP introduced into its guidance booster shots for
both immunocompromised and non-immunocompromised inmates after their prospective vaccine series
were completed. By January 6, 2022, the BOP had published Version 16 of its COVID-19 Vaccine Guidance,
which eliminated priority levels for inmate vaccination and provided guidance for facilities to offer primary
vaccination and a single booster shot to all inmates. We expect the BOP’s COVID-19 Vaccine Guidance to
continue to evolve in response to CDC guidance and the ongoing pandemic.
According to the BOP’s Patient Care policy, medical treatment, including medication, is generally given only
when an inmate consents.153 However, certain diagnostic procedures for specific communicable diseases
may be required for the protection of all inmates and staff. In addition, medical treatment, including
prescribed medication, may also be required for an inmate if there is a court order in place for a specific
treatment plan, if a physician determines that the inmate’s life is in danger, or if it is determined that the
inmate may pose a risk to others by refusing medical treatment. Accordingly, the BOP does not require
inmates to receive the COVID-19 vaccine. A Health Services Division official told us that the BOP generally
does not require vaccines or medical care for inmates unless court ordered. The BOP’s COVID-19 Vaccine
Guidance, Version 11.0, stated that the BOP must obtain documentation of vaccine consent or declination
for all staff and inmates.
In the 2021 Inmate Survey, when asked what they would do when COVID-19 vaccinations were available, an
estimated 62 percent of BOP inmates were either already vaccinated or planned to receive a COVID-19
vaccine. An estimated 24 percent of inmates had already declined or would decline to be vaccinated against
COVID-19, and an estimated 14 percent were undecided.
152
This OIG-estimated percentage represents fully vaccinated inmates currently in custody at any BOP-managed facility,
regardless of the location of vaccine administration.
153
BOP Program Statement 6031.01.
94
The BOP told us that it encouraged multiple strategies to educate inmates
about the COVID-19 vaccine and to increase vaccine use among inmate
populations. These strategies included conducting town halls with inmates
to answer frequently asked questions, sending inmates vaccine information
through TRULINCS, and ensuring that educational posters were prominently
displayed throughout BOP-managed facilities. To the right is an example of
an educational poster that the BOP displayed in BOP-managed facilities.
As of September 30, 2021, the BOP reported that it had administered full
vaccinations to 101,806 inmates in BOP-managed facilities.154 As discussed
in The BOP’s Transparency and Communication with the Public section of
this report, although the BOP updates the number of total BOP-
administered doses and full staff and inmate vaccinations completed, by
federal facility, on its public website each weekday, the BOP website lacks
information about the proportion of vaccinated individuals at individual BOP Educational Poster
facilities. Displayed in BOP Facilities
Source: BOP
As discussed in the Introduction, federal inmates and staff located at RRCs
and contract prisons (when they were in operation) are referred to
community resources, such as state and local health departments, to receive COVID-19 vaccinations. As of
November 16, 2021, the BOP reported that all inmates in contract prisons had been offered the vaccine and
that 5,554 inmates housed in those facilities were fully vaccinated. Figure 13 below shows the total number
of inmates whose COVID-19 vaccination series was completed at a BOP facility between February and
September 2021.
154
This metric reflects inmates who either received both doses, or at least the final dose, of the complete vaccine series
at a BOP-managed facility.
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Figure 13
Total Number of Inmates whose Vaccination Series Was Completed by the BOP,
February 2021–September 2021
Notes: An inmate is counted as having received a full vaccination series completed by the BOP when
he or she has received a complete vaccine series and both doses, or at least the final dose, of the
vaccine series were administered at a BOP facility. Inmates who received all rounds of their
vaccination series in the community rather than a BOP-managed facility are not reflected in the data.
Source: OIG Office of Data Analytics visualization of data collected from the BOP’s public website
Staff Vaccination
Prior to initiating inmate vaccinations, the BOP first offered COVID-19 vaccines to BOP staff and U.S. Public
Health Service officers assigned to the BOP to decrease the possible introduction of COVID-19 into federal
facilities and protect the health of inmates, staff, and local communities. The BOP’s COVID-19 Vaccine
Guidance Version 11.0 stated that if vaccine supplies were low the BOP should prioritize staff to receive the
vaccine based on job functions that pose a higher risk of transmission of infection. Table 6 below displays
the BOP’s employee sub-priorities for staff vaccination, based on the BOP’s COVID-19 Vaccine Guidance
Version 11.0.
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Table 6
BOP COVID-19 Vaccine Guidance: Sub-Priorities for Employee Vaccination
Staff with potential for close contact with sick persons (e.g., healthcare workers, workers in
First Sub-Priority isolation or quarantine units, and those performing COVID-19 symptom screens and
temperature checks)
Second Sub-Priority Staff who are currently on COVID-19 related temporary job modifications
Third Sub-Priority Staff in nursing care units and other residential healthcare units
Staff involved in receiving and discharge of inmates at facilities or performing inmate
Fourth Sub-Priority
transfer or escort functions
Staff with other potential close contact with inmates (e.g., performing pat searches,
Fifth Sub-Priority
supervising inmate work details)
Sixth Sub-Priority All other staff
Source: BOP COVID-19 Vaccine Guidance Version 11.0, March 11, 2021
Beginning in December 2020, the BOP offered staff and federal inmates the COVID-19 vaccine on a
voluntary basis. As of September 2021, E.O. 14043 required full COVID-19 vaccination for all federal
employees, subject to exemptions as required by law, by November 22, 2021.155 Additionally, all federal
employees were required to upload proof of their vaccination status via an online application. The BOP had
a similar online application for all BOP staff to upload proof of their vaccination status. The BOP continued
to offer and encourage both booster and primary vaccine doses to all inmates upon arrival at a BOP facility
and to all staff. In January 2022, a federal court in Texas issued an injunction against President Biden’s
COVID-19 vaccine mandate for the federal workforce, pausing implementation of E.O. 14043. Additionally, a
federal employee union filed a lawsuit challenging the vaccine mandate. The case aims to invalidate the
Executive Order and subsequent guidance from the Safer Federal Workforce Task Force and OPM.
As of September 30, 2021, the BOP reported that it had administered full vaccinations to 20,226 BOP staff.156
According to our 2021 BOP Staff Survey, 55 percent of staff respondents said that they had been vaccinated
prior to the survey, 8 percent said that they would get vaccinated as soon possible, 10 percent said that they
might vaccinate at a later date, 9 percent were undecided on their vaccination plans, and 18 percent said
that they did not plan to get vaccinated. Custody staff respondents were more likely to say that they did not
plan to get vaccinated (26 percent) compared to 11 percent of Health Services staff respondents who stated
that they had no plans to get vaccinated. In addition to encouraging the display of educational posters in
BOP facilities, the BOP reported that it has encouraged staff to ask questions about the vaccine. Figure 14
155
E.O. 14043 on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, September 9, 2021,
www.federalregister.gov/documents/2021/09/14/2021-19927/requiring-coronavirus-disease-2019-vaccination-for-
federal-employees (accessed November 10, 2022).
156
This metric reflects staff who received both doses, or at least the final dose, of the complete vaccine series at a BOP-
managed facility.
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below displays the total number of BOP staff whose COVID-19 vaccination series was completed at a BOP
facility between February 2021 and September 2021.
Figure 14
Total Number of BOP Staff Whose Vaccination Series Was Completed by the BOP,
February 2021–September 2021
Note: A staff member is counted as having a full vaccination series completed by the BOP when he or
she has received a complete vaccine series and both doses, or at least the final dose, of the vaccine
series were administered at a BOP facility. Staff who received all rounds of their vaccination series in
the community rather than at a BOP facility are not reflected in the data.
Source: OIG Office of Data Analytics visualization of data collected from the BOP’s public website
Conclusion
The BOP has promoted the COVID-19 vaccine among inmates and staff and collaborated with the CDC
regarding vaccine allotment and distribution. The BOP has reported that significant percentages of inmates
and staff were fully vaccinated as of January 2022. Additionally, the BOP has updated its COVID-19 Vaccine
Guidance based on contemporaneous public health advisements and the BOP began offering primary
vaccination and booster shots to all inmates at federal facilities on January 6, 2022. Given the BOP’s efforts
to fully vaccinate inmates and staff and promote vaccination, and considering the status of E.O. 14043, we
do not make recommendations in this report regarding vaccination. The BOP should continue to encourage
COVID-19 vaccination and assess the effectiveness of its educational campaigns to encourage vaccination in
federal facilities. To prepare for future public health emergencies, the BOP should document best practices
and lessons learned from its COVID-19 vaccination campaign.
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Conclusion and Recommendations
Conclusion
The COVID-19 pandemic tested the BOP’s ability to respond to a widespread public health emergency and
required the BOP to implement a variety of strategies to increase social distancing inside its facilities and to
create spaces for quarantine and medical isolation. We concluded that the BOP should compile and
regularly update best practices it has identified from its COVID-19 response to assist preparations for future
public health emergencies. We also identified serious failures by BOP facilities in their compliance with the
BOP’s March 2020 guidance on the single-celling of inmates during modified operations and found that the
BOP should review existing practices regarding single-celling of inmates, including inmates vulnerable to
suicide. Additionally, we identified several areas for improvement in the BOP’s pandemic response
regarding processes to protect the health and safety of inmates and staff. The BOP should address these
issues by exploring permanent changes to facility infrastructures to help it more easily implement infection
mitigation strategies.
Further, the number of inmates on home confinement increased during the pandemic and the BOP should
continue to monitor the effects of this increase on Residential Reentry Center (RRC) providers. Our remote
inspections concluded that, at a number of facilities, the BOP did not fully leverage the home confinement
authorities that the BOP was given in the Coronavirus Aid, Relief, and Economic Security Act that could have
permitted facilities experiencing COVID-19 outbreaks to reduce their inmate population and thereby assist in
mitigating COVID-19 transmission and help with staffing issues. While we found that, overall, the BOP
significantly increased the number of inmates in home confinement during the pandemic, we determined that
the BOP should assess how it can most effectively use its home confinement authorities during and after the
COVID-19 pandemic, as well as monitor the challenges that can arise related to a significant increase in home
confinement use.
Staffing shortages during the pandemic impeded the BOP’s ability to provide routine medical care at some
facilities and to implement COVID-19 control measures at various facilities. Staffing shortages also
contributed to increased staff workloads and negatively affected staff morale. We concluded that the BOP
needs to better communicate support options to staff working at facilities, which we based on reports of
staff confusion regarding the BOP’s leave and quarantine guidance, reports of staff unawareness about a
COVID-19 staff support line, and responses to our 2021 BOP Staff Survey regarding the BOP’s need to
improve its provision of mental health resources to staff.
We found also that the BOP should improve its communication of essential information to stakeholders.
First, the BOP must update its family notification processes and guidance to ensure that inmates’ families
can be appropriately involved in time-sensitive decisions if an inmate becomes seriously ill. Second,
although the BOP took steps during the pandemic to communicate proactively with stakeholders, we
received numerous complaints about the BOP’s communications with inmates, the public, and other
stakeholders, including complaints from inmates’ attorneys. We also identified issues with the BOP’s
notifications to crime victims and limitations with its website data.
Personal protective equipment (PPE) supply challenges and COVID-19 testing challenges affected the BOP
early during the pandemic, and our remote inspections found numerous PPE-related issues at BOP facilities,
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contract prisons, and RRCs. While the BOP subsequently resolved supply issues to provide adequate PPE to
facilities, the BOP should determine how its PPE supply model could support distribution efficiency beyond
the current pandemic. We found that BOP staff were confused about PPE and face covering guidance,
particularly early during the pandemic, though our 2021 BOP Staff Survey results indicated that staff
confusion in this area has declined. To correct persistent face covering noncompliance at facilities, the BOP
should assess how to improve staff and inmate compliance with healthcare protective equipment measures
at its facilities and issue clear guidance to facilities about the importance of compliance. Additionally, we
found that long turnaround times for test results when the market for testing supplies was burdened meant
that inmates sometimes had to wait several days for test results and some facilities that we inspected did
not properly follow quarantine guidance to manage the risk of COVID-19 transmission between inmates
awaiting test results.
The BOP should also continue to monitor several ongoing challenges related to its COVID-19 response as
circumstances evolve, as well as take additional actions to better prepare for potential future public health
emergencies. We identified disruptions to inmate access to essential services, such as programming, legal
counsel, recreation, commissary, and communication options during the period of modified operations. The
BOP should explore ways to accommodate inmate access to these essential services and prepare for a
transition to normal operations. In addition to continuing to ensure staff and inmate access to the COVID-
19 vaccine, the BOP should continue to educate inmates about the vaccine and assess the effectiveness of
ongoing vaccine educational campaigns. Finally, to prepare for future public health emergencies, the BOP
should document best practices and lessons learned from ongoing COVID-19 challenges related to its
continued use of modified operations and vaccines.
Recommendations
To assist the BOP in managing challenges during and after the COVID-19 pandemic and in mitigating the
effects of public health emergencies in the future, we recommend that the BOP:
1. Conduct a thorough assessment of single-celling policies and processes, including those applicable
to inmates housed in quarantine and medical isolation units and to inmates vulnerable to suicide.
2. Ensure that actions, including any policy revisions, the BOP takes to close the two open
recommendations from our 2017 restrictive housing report that reference single-celling also apply
to single-celling during quarantine and medical isolation.
3. Compile and regularly update best practices for addressing space limitations to meet social
distancing, quarantine, and medical isolation needs.
4. Explore options for permanent changes to facility infrastructures that would allow for better
implementation of social distancing and other infection control measures.
5. Assess methods to engage with staff during public health emergencies to ensure that the BOP
provides sufficient staff support and clearly communicates support options available to staff.
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6. Immediately update guidance regarding (1) when staff should notify the families of inmates who
become seriously ill or die, including a specific timeframe, and (2) uniform criteria for what
constitutes a serious illness.
7. Ensure that inmate family information, or the inmate emergency contact form, is updated according
to policy and readily available for BOP staff who need to notify next of kin in cases of inmate serious
illness or death.
8. Implement processes to ensure timely crime victim notifications, even under emergency conditions
such as during a pandemic.
9. Determine how the Centralized Fill and Distribution Center and regional logistics sites model could
support distribution efficiency beyond the current pandemic.
10. Assess how to improve staff and inmate compliance with healthcare protective equipment
measures at its facilities and issue clear guidance to facilities about the importance of compliance.
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Appendix 1: Purpose, Scope, and Methodology
Standards
The OIG conducted this review in accordance with the Council of the Inspectors General on Integrity and
Efficiency’s Quality Standards for Inspection and Evaluation (January 2012).
Purpose and Scope
The OIG conducted this capstone review to assess the BOP’s response to the COVID-19 pandemic and
highlight themes we identified through our COVID-19 oversight work, including remote inspections of
16 facilities housing BOP inmates, 5 surveys of BOP staff and inmates, and a collection of interactive
dashboards. This capstone review also examines COVID-19 topics that have emerged following that work.
Finally, this review identifies challenges that the BOP will likely continue to face during and after the
pandemic and actions that the BOP should undertake to prepare for potential public health emergencies in
the future.
The COVID-19 oversight work we summarize in this report covers a variety of time periods. The remote
inspections covered the period from April through June 2020. The first set of BOP staff surveys we
conducted covered April and May 2020, and the follow-up survey of staff at the BOP’s federal prisons
covered February 2021. The survey of federal inmates covered March and April 2021. The interactive data
dashboards reflecting staff and inmate COVID-19 cases and deaths in each BOP facility over time were
launched on October 1, 2020, and present data starting from March 31, 2020. The OIG added data on
inmate vaccination trends at BOP-managed facilities to the collection of the interactive dashboards in
August 16, 2022, with data beginning August 4, 2021. Our additional fieldwork, conducted from June 2020
through May 2022, included data collection and analysis, interviews, and document reviews. To provide the
most recent information on evolving BOP operations and practices, we reviewed supporting documentation
provided by the BOP in January and February 2023 to a draft of this report and included applicable updates.
Methodology
Review and Summary of Previous COVID-19 Oversight Work
We reviewed our 15 remote inspection reports on 16 facilities and 5 surveys of staff and inmates to collect
common themes and challenges identified in that body of work. We also reviewed the underlying support
for the reports, including documents received during the remote inspections and records of interviews
conducted for those projects. Additionally, we relied on data collected in support of the OIG’s interactive
dashboards to report on inmate and staff COVID-19 cases and vaccinations to inform our assessment of the
BOP’s public data reporting.
Data Collection and Analysis
The OIG used a variety of data provided by the BOP to assess and evaluate the BOP’s response to the
COVID-19 pandemic and the effects that the pandemic had on BOP operations, staff, and inmates. The
scopes of individual data sets vary but generally extend no later than the end of FY 2021.
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To examine changes in the BOP population over time, we analyzed snapshots of BOP population data that
are regularly updated on the BOP’s public website. To determine whether the BOP met its population
targets for minimum and low security facilities during the pandemic, we compared population snapshots
from the BOP’s public website to the target populations set in the BOP’s June 19, 2020 memorandum to
facility Wardens. The memorandum lists population targets for minimum and low security facilities,
including minimum and low security satellite facilities that are typically counted as part of other BOP
facilities and minimum and low security cohorts at medium and administrative security facilities, by security
level and gender, for a total of 141 individual minimum and low security groups. The population data we
used did not have breakouts by gender, so we combined the population targets at facilities that housed
both genders at the same security level. We excluded minimum and low security groups at medium and
administrative security facilities because the population data we used did not break out population totals by
security level at these facilities. Due to these limitations, we ultimately compared population snapshots to
the set target populations at 108 minimum and low security locations: 7 minimum security facilities, 30 low
security facilities, 69 minimum security satellite facilities, and 2 low security satellite facilities.
To assess the effects of the pandemic on BOP staffing, we compiled data on overall staffing between
September 2017 and September 2021 from BOP budget documents and data received from the BOP, as
well as data on Correctional Officer and Health Services staffing specifically. We also requested and
analyzed data on temporary job modifications requested and offered between March 2020 and May 2021,
temporary duty assignments made specifically to address needs related to COVID-19 between March 2020
and September 2021, and hiring and separations data before and during the pandemic.
To assess the use of staff support resources, we analyzed the call logs for the COVID-19 staff support line to
examine call frequency and topic areas for questions and concerns. The call logs covered the period that
the staff support line was active, April 3, 2020–December 1, 2020. We also reviewed data on Crisis Support
Team activations in 2020, including those specifically related to the COVID-19 pandemic.
To assess the BOP’s communication with various stakeholders, we analyzed data on family notification and
victim notification. For family notification, we compiled a dataset of dates of inmate serious illnesses and
deaths related to COVID-19 and dates that families were notified to assess the timeliness of those
notifications. The scope of this data set encompassed inmate deaths related to COVID-19 that occurred at
FCC Butner, FCC Coleman, FMC Fort Worth, and FCI Terminal Island between April and July 2020. We
selected these locations because they had reported inmate COVID-19 deaths at the time of the OIG’s remote
inspections. For our analysis of the BOP’s crime victim notification process, we requested data from the
Victim Notification System to understand the frequency of delayed and missed notifications about inmate
transfers to a Residential Reentry Center (RRC) or home confinement before and during the pandemic, as
well as for notifications regarding inmates transferred to home confinement under the Coronavirus Aid,
Relief, and Economic Security Act (CARES Act). We chose to use April 1, 2019–March 31, 2020, as the pre-
pandemic period and April 1, 2020–March 31, 2021, as the during-pandemic period to roughly align the two
periods before and after passage of the CARES Act on March 27, 2020.
We created a dataset of results from the BOP’s internal COVID Compliance Review Checklists, which the BOP
used to conduct oversight of its facilities’ implementation of COVID-19 guidance, to understand the
frequency of pandemic-response compliance issues across facilities reviewed by the BOP. The dataset
comprised results from internal compliance reviews of 90 BOP institutions completed between August 2020
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and April 2021. Because the BOP used several versions of the checklist over the course of its compliance
reviews, we analyzed only topics that were consistent across the checklist versions.
We requested and analyzed a variety of BOP data related to home confinement and the population under
RRC supervision. To examine the effect of expanded home confinement authorities under the CARES Act,
we reviewed the number of transfers that occurred under each of the BOP’s home confinement authorities.
We also examined the population under RRC supervision, comprising both inmates in home confinement
and inmates housed at RRC facilities. For both datasets, we chose to use April 2019–March 2020 as the pre-
pandemic period and April 2020–March 2021 as the during-pandemic period to roughly align the two
periods before and after passage of the CARES Act. To compare the percentage of inmates transferred to
home confinement during these two periods, we used total population snapshots from within 6 weeks of
April 1 each year and subtracted the home confinement population at that time from the total inmate
population to better estimate the pool of inmates not already in home confinement that year.157 We divided
the total number of transfers for each yearlong period by the total number of inmates not already in home
confinement to estimate the percentage of the inmate population transferred to home confinement each
year. Finally, we analyzed failures in the home confinement setting to understand the types and frequency
of failures between April 2020 and March 2021. We also used the failure data to compare the types and
frequency of failures between inmates in home confinement under the CARES Act and under the BOP’s
other home confinement authorities.
To assess the effect that the COVID-19 pandemic had on inmate programming, we requested and analyzed
available data from the BOP. The BOP provided data on Residential Drug Abuse Program participation from
January 2020 through March 2021 and for Evidence Based Recidivism Reduction Program and Productive
Activities participation between November 2020 and October 2021.
Interviews
In addition to reviewing the OIG interviews conducted to support the remote inspections, we conducted
over 35 new interviews with BOP staff working in the Health Services Division; Reentry Services Division;
Office of General Counsel; Program Review Division; Administration Division; Correctional Programs
Division; Information, Policy, and Public Affairs Division; and Human Resource Management Division,
including group interviews with other BOP Central Office and Regional Office staff. We also interviewed
representatives of the Federal Public and Community Defenders Office and staff from the DOJ Office of the
Deputy Attorney General.
The primary issues we assessed through our interviews were the BOP’s response to the COVID-19
pandemic; preventive health measures put in place to minimize the spread of COVID-19; development and
implementation of policy and directives for disease management; access to healthcare services, supplies,
and treatment options; and communication practices with staff and outside stakeholders. We also assessed
the BOP’s implementation of the CARES Act and other relevant authorities. Through our interview with non-
157
Although there are multiple potential methods to estimate the total BOP inmate population not already in home
confinement, including using a different population snapshot or an average population over the year, we chose to use a
snapshot from prior to each year as defined above because we believe it to be the best estimate of total inmates not
already in home confinement given the data available.
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BOP staff, we assessed the reported challenges encountered by inmate counsel during the pandemic. Our
interview with Office of the Deputy Attorney General staff sought to understand the Department’s
involvement in the creation of, and the BOP’s implementation of, the Attorney General’s home confinement
guidance.
Policy and Document Review
In addition to the documentation that we collected to support the remote inspections, we reviewed BOP
program statements, BOP educational materials for disease prevention, and information on the BOP’s
public website relevant to the scope of our review. We also reviewed BOP guidance sent to BOP facilities,
contract facilities, and RRCs during the COVID-19 pandemic. We reviewed various versions of the BOP’s
COVID-19 Pandemic Response Plan, COVID-19 Vaccine Guidance, and COVID-19 Action Plans. We also
reviewed a memorandum of understanding between the BOP and the U.S. Public Health Service, a
memorandum of agreement between the BOP and the CDC, Attorney General memoranda related to home
confinement, and BOP memoranda related to suicide prevention. In addition, we reviewed the CARES Act
and presidential Executive Orders, federal statutes, and CDC guidance. Lastly, we reviewed BOP budget
documentation, BOP psychological reconstruction documentation, BOP communications with inmates’
family members, FIRST STEP Act programming documentation, BOP Technical Directions, and BOP staff exit
survey data.
Complaints Analysis
We reviewed over 3,300 complaints submitted to the OIG Hotline and directly to the OIG to assess COVID-19
related trends. The scope of complaints received by the OIG for the purposes of this analysis was February
27–September 30, 2020. Complaints came from several sources, including but not limited to BOP inmates,
their attorneys, friends and family, and BOP staff. During our review, we determined that 3,190 complaints
were COVID-19 related and directly relevant to our review scope. We then analyzed and categorized the
complaints by primary topic categories to assess trends, but we did not substantiate or assess the validity of
each complaint. The complaints sometimes detailed multiple issues or potential topic categories, and our
analysis of complaints by topic category may not have captured each discrete issue detailed in each
complaint. Examples of topic categories that we identified in the complaints include home confinement,
improper or nonuse of personal protective equipment, and challenges of social distancing.
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Appendix 2: Previous, Related OIG Work
As described in the Introduction to this report, the OIG conducted a variety of COVID-19 pandemic oversight
work, including remote inspections, surveys, and interactive dashboards. (See the text box in the
Background section for links to the published results of that work.) Over the past several years, the OIG has
also conducted reviews and audits of topics that are relevant to the BOP’s response to the COVID-19
pandemic. From contingency planning and staffing to inmate medical and mental healthcare, the COVID-19
pandemic has reemphasized the importance of these issues:
Review of the Impact of an Aging Inmate Population on the Federal Bureau of Prisons, May 2015. As
of FY 2013, inmates age 50 and older were the fastest growing segment of the inmate population in
BOP-managed institutions. The review found that the increasing population of aging inmates
resulted in a need for increased trips outside of institutions for medical care but that institutions did
not have enough Correctional Officers to staff such trips and had limited medical staff to meet older
inmates’ health needs within institutions, resulting in delays receiving medical care. The review also
found that the physical infrastructure at BOP institutions could not adequately house aging inmates
and that overcrowding throughout the BOP system limits access to lower bunks or handicapped-
accessible cells that aging inmates often require. Additionally, the review found that insufficient
support and access to medical care may limit the placement of aging inmates on home confinement.
The OIG made eight recommendations to the BOP as a result of this review. As of September 2022,
the OIG had closed seven of the recommendations and one remained open.
Review of the Federal Bureau of Prisons’ Medical Staffing Challenges, March 2016. In September
2014, the BOP’s institutions had 83 percent of its 3,871 Health Services positions filled and 12 of 97
institutions were medically staffed at or below 71 percent. The review found that multiple factors,
including institution locations, pay, and the correctional setting, negatively affect the BOP’s ability to
recruit and retain medical staff. The review also found that the BOP did not identify or address
these challenges in a strategic manner. In response to the OIG’s two recommendations that the
BOP use data to assess and prioritize medical vacancies and develop ways to address the vacancies,
the BOP exempted 429 medical vacancies from a 2017–2018 hiring freeze and as of October 2018
had filled 303 of those positions. Considering the difficulty of filling these high-demand positions,
the BOP continued to offer employment incentives and enacted several strategies, including
expanding and examining its recruiting practices and identifying hiring obstacles. The BOP also
implemented a pilot program allowing U.S. Department of Health and Human Services Public Health
Service officers, who already make up a significant percentage of the BOP’s medical staff, to fill
temporary clinical assignments to satisfy professional licensing requirements. Both
recommendations are closed.
Audit of the Federal Bureau of Prisons' Management of Inmate Placements in Residential Reentry
Centers and Home Confinement, November 2016. Among other things, this audit found that the
BOP underutilized direct home confinement placement as an alternative to Residential Reentry
Center (RRC) placement for transitioning low-risk, low-need inmates back into society. Between
October 2013 and March 2016, the home confinement population averaged nearly 159 percent of
contracted monitoring capacity, despite the apparent underutilization. The OIG made five
recommendations to the BOP as a result of this audit. In particular, the OIG recommended that the
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BOP reevaluate the availability of alternatives to RRC placement, including consideration of
increasing direct home confinement placement and home confinement monitoring capacity. All five
recommendations are closed.
Review of the Federal Bureau of Prisons' Use of Restrictive Housing for Inmates with Mental Illness,
July 2017. This review identified significant issues with the adequacy of the BOP’s policies and its
implementation efforts surrounding the use of restrictive housing units for inmates with mental
illness. In particular, the review found that inmates, including those with mental illness, were
housed in single-cell confinement for long periods of time. The review also found that the BOP did
not sufficiently track or monitor inmates with mental illness, including those in restrictive housing.
The OIG made 15 recommendations to the BOP as a result of this review. As of February 2023, 6 of
the 15 recommendations from this report remained open, including recommendations regarding
the use and oversight of single-celling.
Review of the Federal Bureau of Prisons’ Management of Its Female Inmate Population, September
2018. This review concluded that the BOP had not been strategic in its management of female
inmates and that the BOP needed to take addition steps to ensure that the needs of female inmates
are met at the institution level. In particular, the review identified instances in which the BOP’s
programming and policy had not fully considered the needs of female inmates, which made it
difficult for inmates to access key programs and supplies. As a result of this review, the OIG made
10 recommendations, all of which are closed.
Review and Inspection of Metropolitan Detention Center Brooklyn Facilities Issues and Related
Impacts on Inmates, September 2019. This review examined the BOP’s response to an electrical fire
in January 2019 that caused a 7-day power outage at MDC Brooklyn. The review found that MDC
Brooklyn did not effectively communicate with stakeholders its decision to suspend legal and social
visiting during the power outage and did not provide sufficient information to the public about the
fire and the conditions of confinement during the power outage. The review also found that MDC
Brooklyn’s contingency plans did not address how and when staff should alert external stakeholders
about significant disruptions that affect legal and social visits and conditions of confinement. The
OIG made nine recommendations to the BOP as a result of this review. As of September 2022,
seven of the recommendations remained open.
Review of the Federal Bureau of Prisons’ Pharmaceutical Drug Costs and Procurement, February
2020. Among other things, the report recommended that the BOP assess the costs and benefits of a
Central Fill and Distribution program for institutions that do not have in-house pharmacies to
determine whether the program would be helpful to control long-term costs. As a result of this
review, the OIG made nine recommendations, all of which are closed.
Analysis of the Federal Bureau of Prisons’ Fiscal Year 2019 Overtime Hours and Costs, December
2020. This analysis found that 31,126 BOP employees worked 6.71 million overtime hours—the
equivalent of 3,107 full-time positions, at a cost of $300,874,769—during FY 2019. The vast majority
of the overtime hours were worked by Correctional Officers. Health Services staff accounted for 4
percent of overtime hours, working almost 238,000 hours of overtime. The OIG did not make
recommendations as part of this analysis.
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Management Advisory Memorandum: Impact of the Failure to Conduct Formal Policy Negotiations
on the Federal Bureau of Prisons’ Implementation of the FIRST STEP Act and Closure of Office of the
Inspector General Recommendations, November 2021. This Management Advisory Memorandum
reported that there had been a 20-month period during the COVID-19 pandemic during which
formal policy negotiations had not occurred between the BOP and its national union. The lack of
formal negotiations disrupted aspects of the BOP’s implementation of the FIRST STEP Act of 2018, as
well as policy changes to address OIG recommendations on systemic correctional and safety issues.
The OIG made two recommendations, both of which are closed.
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Appendix 3: The BOP’s COVID-19 Guidance
Guidance for Federal and Contract Prisons
On January 31, 2020, the BOP issued its first COVID-19 related memorandum to BOP medical staff,
identifying the potential risk of exposure within BOP facilities, and informed recipients about risk factors,
symptoms, and preventive measures. The memorandum also recommended screening new inmates for
COVID-19 risk factors and symptoms and recommended the use of PPE for those in close contact with
persons who may have COVID-19. Between January and October 2020, the BOP issued a series of
memoranda to federal and contract prisons outlining phases of its overarching COVID-19 Action Plan and
additional guidance addressing specific topics. The OIG published timelines of BOP guidance in its remote
inspection reports, including the inspection of Metropolitan Correctional Center (MCC) Chicago.
In late August 2020, the BOP began issuing consolidated guidance in its COVID-19 Pandemic Response Plan,
which included modules on topics such as infection prevention and control measures; screening and
testing; inmate programming and services; and BOP employee, volunteer, and contract staff management.
The BOP posted the COVID-19 Pandemic Response Plan on its intranet for staff to reference and continued
to update it throughout the period of our review, in 2020, 2021, and 2022, based on guidance from
stakeholders, including the CDC and DOJ; the BOP intends to continue updating the plan as the CDC
updates its COVID-19 guidance. As an additional step for contract prisons (which were in operation during
our review period), on April 1, 2020, the BOP modified its underlying contracts with private prison vendors,
emphasizing that in the event of an epidemic or pandemic the “contractor shall check with the CDC daily for
updates and shall implement those changes timely to prevent further spread of the disease.”
Guidance for Residential Reentry Centers
There is no specialized CDC guidance for community correctional settings like Residential Reentry Centers
(RRC), but the CDC stated that its correctional setting guidance can be adapted to the specific circumstances
of other custodial settings as needed. The CDC stated that guidance topics “related to healthcare evaluation
and clinical care of persons with confirmed and suspected COVID-19 infection and their close contacts may
not apply directly to facilities with limited or no onsite healthcare services.” The CDC cautioned staff
working in these types of facilities—which include RRCs—to coordinate closely with their state, local, tribal,
and/or territorial health department when they identify inmates or staff with confirmed or suspected
COVID-19.
In March 2020, the BOP called for modified operations at RRCs, including (1) discontinuing social
movements, (2) restricting residents on home confinement and limiting trips beyond their approved
residence locations, (3) discontinuing groups and nonessential facility services by external providers and
vendors, (4) discontinuing access to outside religious services (with in-house alternative accommodations),
and (5) removing the requirement of in-person visits for certain inmates deemed to be at high risk for
illness. In May 2020, the BOP’s Residential Reentry Management Branch provided guidance to RRCs
regarding the gradual resumption of normal RRC operations, advising contract providers to follow local
guidance where applicable and to tailor the application of local guidance based on local circumstances,
staffing concerns, and individual population concerns. This phased-in approach to returning to regular
operations called for vulnerable inmates to continue to shelter in place before eventually resuming public
interactions while practicing social distancing, minimizing exposure to social settings where social distancing
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is not practicable, observing all precautionary measures, and wearing appropriate personal protective
equipment. In September 2021, the Residential Reentry Management Branch provided guidance to all RRCs,
instructing case managers to help inmates apply for commutation of their sentences under a Biden-Harris
administration clemency initiative. Inmates who had been convicted of nonviolent drug offenses or were on
home confinement under Coronavirus Aid, Relief, and Economic Security Act authorities were potentially
eligible.
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Appendix 4: The BOP’s Early Use of Medical Isolation and
Quarantine
The use of medical isolation and quarantine was part of the BOP’s approach to managing COVID-19 as early
as its Phase One Action Plan issued on January 31, 2020. Below, we provide a timeline of the BOP’s
recommendations to facilities:
• January 2020: The BOP recommended that institutions screen incoming inmates for risk factors and
COVID-19 symptoms, placing symptomatic inmates in medical isolation and asymptomatic inmates
with risk factors in quarantine for 14 days. The BOP screened inmates for two risk factors:
o recent travel from, or through, locations that the CDC identified as having increased
epidemiological risk and
o close contact with anyone diagnosed with COVID-19.
The BOP’s choice to screen for these risk factors was in line with the CDC’s guidance to healthcare
providers in January and February 2020.
• February–March 2020: As the number of COVID-19 cases in the United States grew in February and
March 2020, the BOP directed facilities to establish quarantine areas in case they were needed.
• Mid-March 2020: Following the first cases of COVID-19 in BOP facilities in mid-March 2020, the
BOP’s Phase Four Action Plan mandated that all facilities screen incoming inmates for COVID-19
symptoms, placing those who were asymptomatic in quarantine for at least 14 days and those who
were symptomatic in medical isolation until they met CDC criteria for release from medical isolation.
At the same time, the BOP mandated that facilities screen inmates for COVID-19 symptoms prior to
leaving the facility for routine reasons and medically isolate inmates who were symptomatic.
• Late March 2020: In its Phase Five Action Plan on March 31, 2020, the BOP emphasized that
institutions should quarantine close contacts of any suspected or confirmed COVID-19 cases.
• April 2020: In its April 13, 2020 Phase Six Action Plan, the BOP added a quarantine requirement for
all inmates being released, including those releasing to Residential Reentry Centers or to home
confinement. The BOP also emphasized specific medical isolation instructions, including a
requirement that inmates in medical isolation be placed in a single cell if possible and the possible
strategies for determining when an inmate could be safely released from medical isolation.
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Appendix 5: Factors Affecting COVID-19 Testing Practices and
Availability
Availability of COVID-19 Tests
During January and February 2020, diagnostic testing for COVID-19 in the United States was almost
exclusively handled by CDC laboratories. In early February, the CDC received the first “emergency use
authorization” from the U.S. Food and Drug Administration (FDA) to produce and distribute its laboratory-
based COVID-19 test kit.158 By February 6, the CDC had begun shipping the test kits to public health
laboratories; but within days, laboratories began reporting that the test kits did not work properly. Over the
next few weeks, the CDC identified a contaminated test component, determined that the test could be run
without that component, and worked with the FDA to allow the tests to be run without it. It wasn’t until late
February 2020 that healthcare providers began to have access to COVID-19 testing through public health
laboratories in their areas. In March 2020, commercial laboratories began offering their own FDA-approved
testing for COVID-19 and healthcare providers were able to obtain test kits from these vendors as well.
CDC Guidance on COVID-19 Testing
The CDC’s COVID-19 testing recommendations evolved over the course of the pandemic and as new
information about the virus became available. When the CDC test kits first became available in February
2020, criteria for testing was limited to individuals who had both symptoms of lower respiratory infection
and possible exposure to COVID-19 due to recent travel to China or recent close contact with someone
diagnosed with COVID-19. As the virus spread in the United States, the CDC updated its recommendations
for populations to be tested. On March 4, 2020, the CDC expanded its criteria, stating that clinicians should
use their judgment about whether a patient should be tested based on the patient’s symptoms and how
COVID-19 was affecting the local area.
From late March through mid-June 2020, the CDC’s testing guidance included priority categories, recognizing
the potential for testing resources to be limited. Priority categories generally focused on symptomatic
individuals and those at higher risk of severe illness if infected with COVID-19. For example, on April 27 the
CDC identified symptomatic staff and residents in congregate living settings, including correctional facilities,
as high priority for COVID-19 testing. In June 2020, the CDC broadened its testing guidance by removing
prioritization categories, and, in September 2020, the CDC again updated its testing guidance to further
emphasize testing asymptomatic individuals due to the potential for asymptomatic and pre-symptomatic
transmission of COVID-19.
158
Under § 564 of the Federal Food, Drug, and Cosmetic Act of 1938, the FDA may grant emergency use authorization
for unapproved medical products or unapproved uses of approved medical products to be used in an emergency to
diagnose, treat, or prevent serious or life-threatening diseases when certain criteria are met, including that there are no
adequate, approved, and available alternatives. See FDA, “Emergency Use Authorization,” content current as of
September 26, 2022, www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-
framework/emergency-use-authorization (accessed September 27, 2022).
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BOP Use of COVID-19 Rapid Tests
Testing capacity increased again through April and May 2020 with the introduction of COVID-19 rapid tests,
which allowed tests to be analyzed quickly where the sample was collected rather than requiring it to be
sent to a laboratory for analysis. The BOP began receiving rapid molecular RNA test machines (rapid test
machines) and test kits from the Strategic National Stockpile in April 2020.159 The BOP reported that all
institutions had received at least one rapid test machine by mid-June 2020, and, as of September 2020,
every BOP facility had at least two rapid test machines. In late 2020, the FDA began approving at-home
COVID-19 test kits, and, in January 2021, the BOP added the use of these rapid antigen self-tests to its
testing guidance as well.
159
The Strategic National Stockpile, run by the U.S. Department of Health and Human Services, helps supplement state
and local medical supplies and equipment during public health emergencies. U.S. Department of Health and Human
Services, “Strategic National Stockpile,” last reviewed August 9, 2021, www.phe.gov/about/sns/Pages/default.aspx
(accessed July 13, 2022).
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Appendix 6: Home Confinement and Compassionate Release:
Key Differences
Home Confinement Compassionate Release
Statutory
18 U.S.C. § 3624(c)(2) and 34 U.S.C. § 60541(g)a 18 U.S.C. § 3582(c)(1)(A) or 18 U.S.C. § 4205(g)b
Authority
Allows an inmate to serve the final portion of his
or her sentence (generally, 10 percent or Generally ends an inmate’s sentence early.
6 months, whichever is shorter) at home rather Upon compassionate release, individuals are
What It Does than in a prison or a Residential Reentry Center typically no longer in BOP custody. However,
(RRC). An inmate on home confinement is still they may still be subject to probation or
in BOP custody and is subject to monitoring supervised release.
requirements.
Inmates nearing the end of their sentences who
are referred for RRC placement. Candidates for Inmates with “extraordinary and compelling
home confinement under RRC supervision circumstances,” which may include advanced
Who Is Eligible
typically have an appropriate residence, low age, terminal illness, other physical or medical
reentry support needs, and a low risk of conditions, or family circumstances
reoffending.
An inmate, or another person on behalf of the
inmate, may submit a compassionate release
request to the Warden at the inmate’s
BOP staff routinely consider inmates for home institution. If the BOP approves the request, it is
How It Is
confinement near the end of their sentences as submitted to the U.S. Attorney’s Office for
Requested
part of their transition back into the community. consideration by the court. An inmate may
petition the court directly if the BOP denies the
inmate’s request or if 30 days elapse after
petitioning the Warden, whichever occurs first.
Who Makes The BOP approves or denies home confinement Federal judges in the U.S. court system approve
the Decision placement. or deny compassionate release.
The Coronavirus Aid, Relief, and Economic
Changes Security Act removed the time limit (6 months or No change. The Department took the position
During the 10 percent of the total sentence time) under that the risk of COVID-19 alone is not an
COVID-19 18 U.S.C. §§ 3624(c)(2), allowing inmates to be “extraordinary and compelling circumstance”
Pandemic considered for home confinement earlier in their warranting compassionate release.
sentences than usual.
a 18 U.S.C. § 3624(c)(2) is applicable for inmates who are approaching the end of their sentences. 34 U.S.C. § 60541(g) is
applicable for elderly or terminally ill inmates.
b 18 U.S.C. § 3582(c)(1)(A) is applicable for inmates whose offenses occurred on or after November 1, 1987. 18 U.S.C.
§ 4205(g) was repealed effective November 1, 1987, but remains the controlling law for inmates whose offense occurred
prior to that date.
Source: OIG summary of federal statutes and BOP policy
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Appendix 7: BOP COVID-19 Vaccine Guidance: Priority Levels for
Inmate Vaccination (Eliminated in January 2022)
• Inmates assigned to health service jobs
• Inmates in certain housing situations (e.g., nursing care centers or other residential
Priority Level 1
healthcare units)
• Inmates in other job assignments considered high priority by the BOP
• Inmates age 65 years and older
• Inmates of any age that meet one or more CDC criteria for being “at increased risk” for
Priority Level 2 severe illness from COVID-19 (e.g., those with medical conditions such as cancer or
chronic kidney disease)
• Inmates in job assignments considered a priority by the BOP
• Inmates age 50 to 64 or inmates of any age with certain underlying medical conditions
Priority Level 3
who might be at increased risk for severe illness from COVID-19
• All other inmates upon completion of all preceding priority levels and following current
Priority Level 4
CDC guidance
Source: BOP COVID-19 Vaccine Guidance, Version 11.0, March 11, 2021
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Appendix 8: The BOP’s Response to the Draft Report
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117
118
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Appendix 9: OIG Analysis of the BOP’s Response
The OIG provided a draft of this report to the BOP for its comment. The BOP’s response is included in
Appendix 8 to this report. The OIG’s analysis of the BOP’s response and the actions necessary to close the
recommendations are discussed below.
Recommendation 1
Conduct a thorough assessment of single-celling policies and processes, including those applicable to
inmates housed in quarantine and medical isolation units and to inmates vulnerable to suicide.
Status: Resolved.
BOP Response: The BOP stated that single-celling in the context of medical isolation and quarantine is not
restrictive housing and that guidance concerning this topic is separately addressed through relevant Health
Services Division materials previously provided to the OIG, including the BOP’s COVID-19 Pandemic
Response Plan Module Four. The BOP stated that, as acknowledged in the OIG’s formal draft report, in May
2021 the BOP established a Single Cell Task Force that reviewed single-celling practices and provided
recommendations. In response to the OIG’s recommendation, the BOP stated that it will assess the task
force’s work to ensure that single-celling policies and processes, including those applicable to adults in
custody housed in quarantine and medical isolation units and to adults in custody vulnerable to suicide, are
addressed.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. The OIG recognizes that
the BOP does not consider single-celling in the context of medical isolation and quarantine to be restrictive
housing. However, the guidance that the BOP referenced in its COVID-19 Pandemic Response Plan Module
Four includes direction to consult Psychology Services staff for inmates proposed for single-celling, which is
similar to guidance in the BOP’s March 13, 2020 Reentry Services Division memorandum described in this
OIG report. As explained in this report, we identified serious failures by BOP facilities in their compliance
with the BOP’s March 2020 guidance and in their handling of inmates vulnerable to suicide while
quarantined due to COVID-19. Further, this report notes that the BOP failed to follow its own guidance that
recognized that single-celling of inmates generally should not occur for quarantine purposes. By June 23,
2023, please provide documentation evincing that the BOP, either through the work of the Single Cell Task
Force or other mechanisms, has thoroughly assessed its single-cell policies and processes, including those
applicable to inmates housed in quarantine and medical isolation units and to inmates vulnerable to
suicide.
Recommendation 2
Ensure that actions, including any policy revisions, the BOP takes to close the two open recommendations
from our 2017 restrictive housing report that reference single-celling also apply to single-celling during
quarantine and medical isolation.
Status: Resolved.
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BOP Response: The BOP stated that, to the extent medical isolation or quarantine occurs in a restrictive
housing environment, it will ensure that the protections applicable to those settings are utilized. The BOP
reiterated that single-celling in the context of medical isolation and quarantine is not restrictive housing and
referenced its COVID-19 Pandemic Response Plan Module Four guidance, which states, “If medical isolation
in single cells is necessary…Psychology Services staff should be consulted to ensure inmates proposed for
single celling are not particularly vulnerable individuals and/or to make recommendations.” The BOP added
that it currently reviews all single-cell placements in restrictive housing, stating that, when a BOP facility
needs to place an adult in custody in a single cell, employees seek concurrence from Psychology, Medical,
Unit Team, and the Captain prior to requesting the Warden's approval for placement.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. The OIG recognizes that
the BOP does not consider single-celling in the context of medical isolation and quarantine to be restrictive
housing and that the BOP’s COVID-19 Pandemic Response Plan Module Four states that “medical isolation
for COVID-19 should be distinct in name and practice from the use of restrictive housing for disciplinary or
administrative reasons—even though limited housing availability may require the use of cells normally used
for restrictive housing.” However, the guidance that the BOP referenced in its COVID-19 Pandemic
Response Plan Module Four includes direction to consult Psychology Services staff for inmates proposed for
single-celling, which is similar to guidance in the BOP’s March 13, 2020 Reentry Services Division
memorandum described in the OIG’s report. As explained in this report, we identified serious failures by
BOP facilities in their compliance with the BOP’s March 2020 guidance and in their handling of inmates
vulnerable to suicide while quarantined due to COVID-19. Further, this report notes that the BOP failed to
follow its own guidance that recognized that single-celling of inmates generally should not occur for
quarantine purposes and that inmates should be assessed for possible vulnerability to suicide before being
single-celled. By June 23, 2023, please provide documentation evincing that any actions the BOP takes in
response to the two open recommendations that reference single-celling from the OIG’s 2017 restrictive
housing report, including any policy revisions, would also apply to single-celling during quarantine and
medical isolation that may occur in a restrictive housing environment.
Recommendation 3
Compile and regularly update best practices for addressing space limitations to meet social distancing,
quarantine, and medical isolation needs.
Status: Resolved.
BOP Response: The BOP concurred with this recommendation and stated that it will continue to compile
and regularly update best practices for addressing space limitations to meet social distancing, quarantine,
and medical isolation needs. The BOP stated that current best practices include but are not limited to the
following: (1) separating those in medical isolation should always take priority; (2) when identifying spaces
for isolation, quarantine, or movement observation, it is preferable to have these areas in separate units;
(3) if it becomes necessary to house these types of adults in custody in different ranges or floors within the
same unit, providing at least a 6-foot distance between the different groups is optimal (e.g., empty cell
between cohorts with clear signage); (4) consider spaces not being utilized such as those used for education,
religious services, visiting, recreation, or facilities; and (5) tents, shower stations, and mobile hand hygiene
stations may need to be obtained to create separate spaces at some facilities.
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OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
describe the BOP’s efforts to compile and regularly update best practices for addressing space limitations to
meet social distancing, quarantine, and medical isolation needs. Please include supporting documentation
that details any updates to these best practices.
Recommendation 4
Explore options for permanent changes to facility infrastructures that would allow for better
implementation of social distancing and other infection control measures.
Status: Resolved.
BOP Response: The BOP concurred with this recommendation and stated that it will continue to explore
whether feasible options exist for permanent changes to facility infrastructure that would allow for better
implementation of social distancing and other infection control measures within the confines of correctional
safety and security requirements.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
describe how the BOP has explored options for permanent changes to facility infrastructures that would
allow for better implementation of social distancing and other infection control measures. Please include
supporting documentation or plans that describe the BOP’s consideration of such options.
Recommendation 5
Assess methods to engage with staff during public health emergencies to ensure that the BOP provides
sufficient staff support and clearly communicates support options available to staff.
Status: Resolved.
BOP Response: The BOP concurred with this recommendation and stated that it will assess methods to
engage with employees during public health emergencies to ensure that it provides sufficient employee
support and clearly communicates support options available to employees.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
provide the OIG with information and documentation evincing that the BOP has assessed methods to
engage with employees during public health emergencies to ensure that it provides sufficient employee
support and clearly communicates support options available to employees.
Recommendation 6
Immediately update guidance regarding (1) when staff should notify the families of inmates who become
seriously ill or die, including a specific timeframe, and (2) uniform criteria for what constitutes a serious
illness.
Status: Resolved.
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BOP Response: The BOP concurred with this recommendation and stated that, to the extent the OIG
recommends that policy be changed, the BOP must abide by the terms of its policy development process.
The BOP stated that it will need to assess whether and how to capture what constitutes a serious illness due
to the variety of situations that can unfold. The BOP stated that it already provides clear expectations to
employees regarding next-of-kin notifications following a death.
OIG Analysis: The BOP’s planned actions are sufficiently responsive to the recommendation. While the OIG
recognizes that any policy changes must abide by the terms of the BOP’s policy development process and
that the BOP will need to assess how to capture what constitutes a serious illness, given the nature of the
issue and the failures we identified, we believe the BOP must move expeditiously to address this issue.
Similarly, in light of the examples in the OIG report of inconsistent staff notification to inmates’ families
regarding inmates’ serious illnesses prior to their deaths, it is not apparent to us that BOP staff have clear
expectations and understandings regarding next-of-kin notifications following an inmate death. To address
the issues described in this report, the BOP should update its guidance in this area, either through policy
changes or other guidance it provides to staff. By June 23, 2023, please provide copies of updated guidance
regarding when staff should notify the families of inmates who become seriously ill or die, including a
specific timeframe, and uniform criteria for what constitutes a serious illness. Also, please provide copies of
guidance that the BOP has already provided to its staff that detail clear expectations regarding next-of-kin
notifications following an inmate death.
Recommendation 7
Ensure that inmate family information, or the inmate emergency contact form, is updated according to
policy and readily available for BOP staff who need to notify next of kin in cases of inmate serious illness or
death.
Status: Resolved.
BOP Response: The BOP concurred with this recommendation and stated that it will address the need to
ensure that adult-in-custody emergency contact forms are updated according to policy. The BOP stated
that, as part of its training, it will also address the need to ensure that such forms are readily available.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
describe actions the BOP has taken to ensure that inmate family information, or the inmate emergency
contact form, is updated according to policy and readily available for BOP staff who need to notify next of
kin in cases of serious illness or death and provide supporting documentation evincing these efforts.
Recommendation 8
Implement processes to ensure timely crime victim notifications, even under emergency conditions such as
during a pandemic.
Status: Resolved.
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BOP Response: The BOP concurred with this recommendation and stated that, as part of its training
program, it will address the need to ensure timely crime victim notifications even under emergency
conditions such as a pandemic.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
describe how the BOP has implemented processes to ensure timely crime victim notifications, even under
emergency conditions such as during a pandemic. Also, please provide supporting documentation evincing
the implementation of processes to ensure timely crime victim notifications.
Recommendation 9
Determine how the Centralized Fill and Distribution Center and regional logistics sites model could support
distribution efficiency beyond the current pandemic.
Status: Resolved.
BOP Response: The BOP concurred with this recommendation and stated that it will determine how the
Centralized Fill and Distribution Center and regional logistics sites model could support distribution
efficiency beyond the current pandemic. The BOP stated that the original Centralized Fill and Distribution
Center model was developed and proved by BOP leadership in 2009. The BOP stated that, as a result of this
approval, Centralized Fill and Distribution Center 1 was implemented on the grounds of Federal Correctional
Complex Pollock and remains in operation today, pending funding approval for additional Centralized Fill
and Distribution Center operations in the future. The BOP stated that, with the implementation of
additional Centralized Fill and Distribution Center operations across the BOP, this would model the current
Centralized Fill and Distribution Center operations along with the regional logistics sites. The BOP stated
that funding for Centralized Fill and Distribution Center 2 operations was requested in the fiscal year 2023
budget call and remains pending approval.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
describe the BOP’s efforts to determine how the Centralized Fill and Distribution Center and regional
logistics sites model could support distribution efficiency beyond the current pandemic. Please include
supporting documentation evincing these efforts.
Recommendation 10
Assess how to improve staff and inmate compliance with healthcare protective equipment measures at its
facilities and issue clear guidance to facilities about the importance of compliance.
Status: Resolved.
BOP Response: The BOP concurred with this recommendation and stated that it will conduct an
assessment regarding how to improve employee and adult in custody compliance with healthcare
protective equipment measures at its facilities and issue guidance to facilities regarding the importance of
compliance. The BOP noted that its Health Services team has already issued guidance regarding
appropriate healthcare protective equipment measures through multiple channels including memoranda,
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email correspondence, and COVID-19 Pandemic Response Plan modules that have been widely
disseminated to all employees and made available on its intranet.
OIG Analysis: The BOP’s planned actions are responsive to the recommendation. By June 23, 2023, please
describe and provide supporting documentation evincing the BOP’s assessment of how to improve staff and
inmate compliance with healthcare protective equipment measures at its facilities. Also, please provide
copies of guidance available to facilities about the importance of compliance with these measures.
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