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Cca Whiteville Contract Violations 2007
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WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR January 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 10/13/06 Yes 10/16/06 Yes 10/18/06 Yes 10/19/06 Yes Monitoring Instrument ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES While monitoring drug testing procedures Warden’s response dated: 10/16/06 Just prior to the this period, staff could not provide Drug testing audit of this area, the drug testing officer went on FMLA documentation to support testing for July 1 and CM note: Non-compliance issued leave and has not returned to work. Facility staff was Substance through and August 2006. Even though some 1/25/07 for same or similar items, unable to find the required documentation. Another documentation was present for 7 abuse items outstanding. employee has been assigned the responsibility for drug Septembers testing, the 10% of treatment testing. population required weren’t completed. Warden’s response dated: 10/18/06: As noted on the previous finding, the UA officer went on sudden FMLA Staff could not provide requested leave just prior to the audit of this area and the Verified 1/25/07: By review of records/documentation required for supervisor’s position had been vacant with the person Records and 10 drug testing documentation and conducting a complete quarterly audit of hired for the position still in training. Changes in this area Reports TOMIS entries. inmate drug testing procedures. of assignment have been made and steps to correct the deficiencies and preclude their reoccurrence are being taken. A planned non-emergency use of force with chemical agents occurred to extract inmate from his cell. The warden/designee Warden’s response dated: 10/23/06 An investigation was not notified for prior approval of a was conducted by AW and Chief into this incident and large canister of OC chemical agents (MKthe resulting use of force. Facility agrees that the Lt. who IX) to be used during this extraction. CM note: Non-compliance issued was just recently promoted into the position failed to 4g(1,2, Use of Force Medical staff had been notified nor was 11/6/06 for same or similar item, follow applicable policy and that the TOMIS report 3) the inmates medical file reviewed prior”. item outstanding. contained information that was not completely accurate. Staff with first–hand knowledge did enter The Lt. was counseled and will receive disciplinary a TOMIS report, (00675408) Use of Force action. chemical agents. This report does not reflect a true and accurate account of the incident as witnessed by the acting CD. Records and Reports Warden’s response dated: 10/23/06 First issue is a repeat of the other NC finding of same date and incident and as answered on that response, corrective action is Staff with first–hand knowledge did enter being taken. As to the failure to provide incident reports, a TOMIS report, (00675408) Use of Force the facility acknowledges that due to several recent Verified 2/6/07: By review of 2b, 10 chemical agents. This report does not changes in staffing including the Chief of Security, Asst. incident reports UOF chemical reflect a true and accurate account of the Chief of Security and the Chief of Security’s secretary, agents 1/4/07 and 2/6/07. there was some confusion regarding the provision of the incident as witnessed by the acting CD. CCA incident report to the monitor and communications have been made to appropriate staff to provide the 5-1A to the monitor in the future. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 1/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR January 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 10/26/06 Yes 10/26/06 Yes 11/6/06 Yes Monitoring Instrument Special management Inmates ITEM NO. 2b NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Inmate was segregated 10/16/06 pending an investigation for protective custody. Warden’s response date: 11/6/06 Corrective actions Verified 12/26/06: by review of The protective services routing form (CR- have been initiated to ensure that the CR-3241 form is segregation documentation, 3241) was not provided to the completed and given to the Commissioner’s Designee as inmates files and TOMIS entries. Commissioners Designee for approval soon as it is reviewed by the Chief of Security. within the 72-hour policy guideline. 12/11/06 DCCO CM note (summarized): 1. Policy requires the Use of Force report to be submitted Warden's response, dated 11/28/06, makes the following to the CD no later than the conclusion of shift. 2. points: 1. The report cited by the CM is required to be The late submission of these reports was reported completed within 21 days. 2. The CM should have on an NCR 10/19/06. 3. This incident is dealt with On 10/30/06 staff used force (chemical advised the Warden that the report was expected by the in the NCR for item 4g above. The Warden admits agents) incident #00676614. The 5-1a end of the shift. 3. The NCR is not specific enough to in his response that the Use of Force report in incident report packet wasn’t submitted to respond to. 4. The Liaisons do not work to improve question was not accurate. 4. TDOC staff CM note: Non-compliance issued the CD by conclusion of the shift. This facility operation and cooperation. 5. The Liaisons keep Records and constantly communicate with facility staff. 5. Open 10/19/06 and 11/6/06 for same or report was under the TDOC Liaisons door 10 trying to find things that are wrong, resulting in Reports communication does not preclude the use of the similar item, item outstanding. 11/2/06. Furthermore the 5-1a and TOMIS inaccurate reports based on assumptions rather than monitoring process required by the contract and report does not reflect a true and accurate facts. 6. The TDOC is not complying with many policy. 6. WCFA management has indicated such account of the incident told to the CM by requirements of the contract, including weekly meetings meetings would not be helpful or necessary. 7. the shift supervisor. between the Warden and Liaisons. 7. The Liaisons The issues discussed in the NCRs issued by the continue to seek minute details to report on without CM are not “minute”. They are required by discussing them with the Warden in advance. Policies and the contract, and are listed on the monitoring instruments with which the State safeguards its interests. 12/11/06 DCCO CM note (summarized): The Staff used OC from a (MK IV) canister on CD's report is based on what she was told by the Warden's response, dated 11/28/06, makes the following an inmate inside an unlocked cell without Shift Supervisor. 2. WCFA policy requires medical points: 1. The CD's report that the Shift Supervisor had prior notification to medical staff or review review prior to gas use; use of gas to make an not told her about the inmate's alleged aggressive of medical file. When reporting incident to inmate spit something out is questionable, and behavior was based only on her feelings. 2. The issue the CD, shift supervisor failed to mention the cell door could simply have been closed if the raised by the CM that the gas was used in a cell is any details of inmate aggressive behavior. inmate was aggressive. 3. This was not a irrelevant. 3. The use of force was spontaneous and did Use of Force 4g (2,3) There is no documentation in inmates spontaneous use of force. 4. it would have been not require prior approval. 4. Policy does not require that medical file to support that medical staff appropriate for medical staff to have been made medical be made aware that the inmate who was gassed was advised during the pre-segregation aware that the inmate had swallowed something was trying to swallow something (reportedly drugs) at the evaluation that the inmate had and for this to be documented in the inmate's time. 5. TDOC staff fails to communicate with facility chewed/swallowed an alleged substance, medical file, and for a drug screen to have been staff. possibly drugs. performed. 5. TDOC staff regularly communicate with facility staff. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 1/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR January 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 11/15/06 Yes 1/25/07 No Monitoring Instrument ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 3 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Warden’s response dated: 11/20/06 On October 31, 2006, Disciplinary Chairperson SCO Ponds sought and received approval for the above Segregation placements and four additional inmates who are not on the above 10 inmates were segregated 10/31/06 list, by notifying TDOC Bettie Hammond via telephone after being on a segregation waiting list. and discussing the placements. Additionally, per the The segregation packs with movement Disciplinary Chief of Security’s Secretary, on November 1, 2006, the 4a (6) confinement forms were not immediately Procedures segregation packs with movement confinement forms made available for commissioner’s were placed in the TDOC Office. However, the designee review until 11/13/06. employee who retrieved the files from the TDOC Office failed to check all of the files to ensure they were signed and therefore ten out of the fourteen files were not signed. 1c. Staff conducted 16 reasonable suspicion drug screens during December 06. Only 4 were documented as authorized/approved by designated staff. Warden’s response dated: 1/29/07 Warden concurs with Drug testing 2f. Positive test results were not findings. A new Drug Testing Officer was recently and maintained in a confidential file. appointed and while he has made significant progress in 1c,2f,2g Substance 2g. No documentation to support improving this area of operations, was deficient in the ,2i abuse treatment services are recommended for areas noted. Corrections have been made in all areas treatment inmates convicted of a positive drug test. noted to ensure these findings are not repeated. 2i. No documentation to support that inmates who test positive on a drug screen are retested as required. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 1/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR January 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 1/31/07 NO CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Monitoring Instrument ITEM NO. Use of Force Assistant Shift Supervisor used chemical agents (OC) inappropriately to control an inmate inside a segregation cell. When staff opened the food flap to retrieve food trays the inmate threw a substance. Asst. Supervisor immediately reacted by spraying the inmates twice with a MK-IX fogger through the food flap. The Shift Warden’s response dated 2/6/07: Warden concurs that Supervisor approved for a large canister the Assistant Shift Supervisor failed to follow proper 4g(1), (MK-IX) of OC chemical agents to be procedure in this incident and reacted to the inmate 4g(2) issued without question or a complete throwing what was believed to be urine on the staff understanding of the events surrounding involved by utilizing inflammatory agent (OC). the incident. Prior precautions were not taken in advance to minimize OC exposure to inmate Griffin who was not an active participant. Medical staff was not notified prior or present during the use of force nor were the affected inmates medical records reviewed prior to the use of chemical agents NON-COMPLIANCE ISSUE Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 4 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 1/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR February 2007 OUT- CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS DATE OF STANDING REPORT ISSUE Y/N Monitoring Instrument 10/13/06 Yes While monitoring drug testing procedures Warden’s response dated: 10/16/06 Just prior to the this period, staff could not provide Drug testing audit of this area, the drug testing officer went on FMLA documentation to support testing for July 1 and CM note: Non-compliance issued leave and has not returned to work. Facility staff was Substance through and August 2006. Even though some 1/25/07 for same or similar items, unable to find the required documentation. Another documentation was present for 7 abuse items outstanding. employee has been assigned the responsibility for drug Septembers testing, the 10% of treatment testing. population required weren’t completed. Yes A planned non-emergency use of force with chemical agents occurred to extract inmate from his cell. The warden/designee Warden’s response dated: 10/23/06 An investigation was not notified for prior approval of a was conducted by AW and Chief into this incident and large canister of OC chemical agents (MKthe resulting use of force. Facility agrees that the Lt. who IX) to be used during this extraction. CM note: Non-compliance issued 4g(1,2, was just recently promoted into the position failed to Use of Force Medical staff had been notified nor was 11/6/06 and 1/31/07 for same or 3) follow applicable policy and that the TOMIS report the inmates medical file reviewed prior”. similar item, item outstanding. contained information that was not completely accurate. Staff with first–hand knowledge did enter The Lt. was counseled and will receive disciplinary a TOMIS report, (00675408) Use of Force action. chemical agents. This report does not reflect a true and accurate account of the incident as witnessed by the acting CD. 10/18/06 10/26/06 Yes Records and Reports ITEM NO. Page 1 10 NON-COMPLIANCE ISSUE TDOC MANAGEMENT COMMENTS/NOTES 12/11/06 DCCO CM note (summarized): 1. Policy requires the Use of Force report to be submitted Warden's response, dated 11/28/06, makes the following to the CD no later than the conclusion of shift. 2. points: 1. The report cited by the CM is required to be The late submission of these reports was reported completed within 21 days. 2. The CM should have on an NCR 10/19/06. 3. This incident is dealt with On 10/30/06 staff used force (chemical advised the Warden that the report was expected by the in the NCR for item 4g above. The Warden admits agents) incident #00676614. The 5-1a end of the shift. 3. The NCR is not specific enough to in his response that the Use of Force report in incident report packet wasn’t submitted to respond to. 4. The Liaisons do not work to improve question was not accurate. 4. TDOC staff CM note: Non-compliance issued the CD by conclusion of the shift. This facility operation and cooperation. 5. The Liaisons keep constantly communicate with facility staff. 5. Open 10/19/06 and 11/6/06 for same or report was under the TDOC Liaisons door trying to find things that are wrong, resulting in communication does not preclude the use of the similar item, item outstanding. 11/2/06. Furthermore the 5-1a and TOMIS inaccurate reports based on assumptions rather than monitoring process required by the contract and report does not reflect a true and accurate facts. 6. The TDOC is not complying with many policy. 6. WCFA management has indicated such account of the incident told to the CM by requirements of the contract, including weekly meetings meetings would not be helpful or necessary. 7. the shift supervisor. between the Warden and Liaisons. 7. The Liaisons The issues discussed in the NCRs issued by the continue to seek minute details to report on without CM are not “minute”. They are required by discussing them with the Warden in advance. Policies and the contract, and are listed on the monitoring instruments with which the State safeguards its interests. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 2/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR February 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 11/6/06 Yes 11/15/06 Yes 1/25/07 Yes Monitoring Instrument ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS Staff used OC from a (MK IV) canister on Warden's response, dated 11/28/06, makes the following an inmate inside an unlocked cell without points: 1. The CD's report that the Shift Supervisor had prior notification to medical staff or review not told her about the inmate's alleged aggressive of medical file. When reporting incident to behavior was based only on her feelings. 2. The issue the CD, shift supervisor failed to mention raised by the CM that the gas was used in a cell is CM note: Non-compliance issued any details of inmate aggressive behavior. irrelevant. 3. The use of force was spontaneous and did 10/18/06 and 1/31/07 for same or Use of Force 4g (2,3) There is no documentation in inmates not require prior approval. 4. Policy does not require that similar item, item outstanding. medical file to support that medical staff medical be made aware that the inmate who was gassed was advised during the pre-segregation was trying to swallow something (reportedly drugs) at the evaluation that the inmate had time. 5. TDOC staff fails to communicate with facility chewed/swallowed an alleged substance, staff. possibly drugs. Warden’s response dated: 11/20/06 On October 31, 2006, Disciplinary Chairperson SCO Ponds sought and received approval for the above Segregation placements and four additional inmates who are not on the above 10 inmates were segregated 10/31/06 list, by notifying TDOC Bettie Hammond via telephone after being on a segregation waiting list. and discussing the placements. Additionally, per the The segregation packs with movement Disciplinary Chief of Security’s Secretary, on November 1, 2006, the 4a (6) confinement forms were not immediately Procedures segregation packs with movement confinement forms made available for commissioner’s were placed in the TDOC Office. However, the designee review until 11/13/06. employee who retrieved the files from the TDOC Office failed to check all of the files to ensure they were signed and therefore ten out of the fourteen files were not signed. 1c. Staff conducted 16 reasonable suspicion drug screens during December 06. Only 4 were documented as authorized/approved by designated staff. Warden’s response dated: 1/29/07 Warden concurs with Drug testing 2f. Positive test results were not findings. A new Drug Testing Officer was recently and appointed and while he has made significant progress in 1c,2f,2g maintained in a confidential file. 2g. No Substance documentation to support treatment improving this area of operations, was deficient in the ,2i abuse services are recommended for inmates areas noted. Corrections have been made in all areas treatment convicted of a positive drug test. 2i. No noted to ensure these findings are not repeated. documentation to support that inmates who test positive on a drug screen are retested as required. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES 12/11/06 DCCO CM note (summarized): The CD's report is based on what she was told by the Shift Supervisor. 2. WCFA policy requires medical review prior to gas use; use of gas to make an inmate spit something out is questionable, and the cell door could simply have been closed if the inmate was aggressive. 3. This was not a spontaneous use of force. 4. it would have been appropriate for medical staff to have been made aware that the inmate had swallowed something and for this to be documented in the inmate's medical file, and for a drug screen to have been performed. 5. TDOC staff regularly communicate with facility staff. 2/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR February 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 1/31/07 Yes CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 3 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS Monitoring Instrument ITEM NO. Use of Force Assistant Shift Supervisor used chemical agents (OC) inappropriately to control an inmate inside a segregation cell. When staff opened the food flap to retrieve food trays the inmate threw a substance. Asst. Supervisor immediately reacted by spraying the inmates twice with a MK-IX fogger through the food flap. The Shift Warden’s response dated 2/6/07: Warden concurs that Supervisor approved for a large canister the Assistant Shift Supervisor failed to follow proper CM note: Non-compliance issued 4g(1), (MK-IX) of OC chemical agents to be procedure in this incident and reacted to the inmate 10/18/06 and 11/6/06 for same or 4g(2) issued without question or a complete throwing what was believed to be urine on the staff similar item, item outstanding. understanding of the events surrounding involved by utilizing inflammatory agent (OC). the incident. Prior precautions were not taken in advance to minimize OC exposure to inmate Griffin who was not an active participant. Medical staff was not notified prior or present during the use of force nor were the affected inmates medical records reviewed prior to the use of chemical agents Warden’s response dated: 3/2/07: It is my understanding 2/27/07 NO Use of Force 3a 2/27/07 NO Records and Reports 2b NON-COMPLIANCE ISSUE TDOC MANAGEMENT COMMENTS/NOTES that on the date of this incident the Shift Supervisor On January 1, 2007 staff used physical entered an LIBJ incident report on the finding of the force to conduct a strip search of an drugs (TOMIS #00683027) but did fail to enter a inmate. A TOMIS (LIBJ) report was not separate incident report for the Use of Force. Upon entered for this incident within policy discovery of this the necessary report was entered into guidelines. the TOMIS system. (See #689631). The supervisor on this shift is one of the most experienced supervisors and simply forgot to do the additional report. Same as above Same as above Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 2/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR March 2007 OUT- CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS DATE OF STANDING REPORT ISSUE Y/N Monitoring Instrument 10/13/06 Yes While monitoring drug testing procedures Warden’s response dated: 10/16/06 Just prior to the this period, staff could not provide Drug testing Verified 3/29/07: By review of audit of this area, the drug testing officer went on FMLA documentation to support testing for July 1 and documentation and log books. leave and has not returned to work. Facility staff was Substance through and August 2006. Even though some CM note: Non-compliance issued unable to find the required documentation. Another documentation was present for 7 abuse 1/25/07 for same or similar items, employee has been assigned the responsibility for drug Septembers testing, the 10% of treatment items outstanding. testing. population required weren’t completed. Yes A planned non-emergency use of force with chemical agents occurred to extract inmate from his cell. The warden/designee Warden’s response dated: 10/23/06 An investigation Verified 3/31/07: By review of was not notified for prior approval of a was conducted by AW and Chief into this incident and UOF chemical agents incidents large canister of OC chemical agents (MKthe resulting use of force. Facility agrees that the Lt. who 2/6, 2/17, 3/6, 3/11, 3/24 IX) to be used during this extraction. 4g(1,2, was just recently promoted into the position failed to appropriate procedures and Use of Force Medical staff had been notified nor was 3) follow applicable policy and that the TOMIS report documentation. CM note: Nonthe inmates medical file reviewed prior”. contained information that was not completely accurate. compliance issued 11/6/06 and Staff with first–hand knowledge did enter The Lt. was counseled and will receive disciplinary 1/31/07 for same or similar item, a TOMIS report, (00675408) Use of Force action. item outstanding. chemical agents. This report does not reflect a true and accurate account of the incident as witnessed by the acting CD. 10/18/06 10/26/06 Yes Records and Reports ITEM NO. Page 1 10 NON-COMPLIANCE ISSUE TDOC MANAGEMENT COMMENTS/NOTES 12/11/06 DCCO CM note (summarized): 1. Policy requires the Use of Force report to be submitted Warden's response, dated 11/28/06, makes the following to the CD no later than the conclusion of shift. 2. points: 1. The report cited by the CM is required to be The late submission of these reports was reported completed within 21 days. 2. The CM should have on an NCR 10/19/06. 3. This incident is dealt with On 10/30/06 staff used force (chemical advised the Warden that the report was expected by the Verified 3/31/07: By review of in the NCR for item 4g above. The Warden admits agents) incident #00676614. The 5-1a end of the shift. 3. The NCR is not specific enough to UOF chemical agents incidents in his response that the Use of Force report in incident report packet wasn’t submitted to respond to. 4. The Liaisons do not work to improve 2/6, 2/17, 3/6, 3/11, 3/24 question was not accurate. 4. TDOC staff the CD by conclusion of the shift. This facility operation and cooperation. 5. The Liaisons keep appropriate procedures and constantly communicate with facility staff. 5. Open report was under the TDOC Liaisons door trying to find things that are wrong, resulting in documentation. CM note: Non- communication does not preclude the use of the 11/2/06. Furthermore the 5-1a and TOMIS inaccurate reports based on assumptions rather than compliance issued 10/19/06 and monitoring process required by the contract and report does not reflect a true and accurate facts. 6. The TDOC is not complying with many 11/6/06 for same or similar item, policy. 6. WCFA management has indicated such account of the incident told to the CM by requirements of the contract, including weekly meetings item outstanding. meetings would not be helpful or necessary. 7. the shift supervisor. between the Warden and Liaisons. 7. The Liaisons The issues discussed in the NCRs issued by the continue to seek minute details to report on without CM are not “minute”. They are required by discussing them with the Warden in advance. Policies and the contract, and are listed on the monitoring instruments with which the State safeguards its interests. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 3/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR March 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 11/6/06 Yes 11/15/06 Yes 1/25/07 Yes Monitoring Instrument ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS Staff used OC from a (MK IV) canister on Warden's response, dated 11/28/06, makes the following an inmate inside an unlocked cell without points: 1. The CD's report that the Shift Supervisor had Verified 3/31/07: By review of prior notification to medical staff or review not told her about the inmate's alleged aggressive UOF chemical agents incidents of medical file. When reporting incident to behavior was based only on her feelings. 2. The issue 2/6, 2/17, 3/6, 3/11, 3/24 the CD, shift supervisor failed to mention raised by the CM that the gas was used in a cell is appropriate procedures and any details of inmate aggressive behavior. irrelevant. 3. The use of force was spontaneous and did Use of Force 4g (2,3) There is no documentation in inmates documentation. CM note: Nonnot require prior approval. 4. Policy does not require that medical file to support that medical staff compliance issued 11/6/06 and medical be made aware that the inmate who was gassed was advised during the pre-segregation 1/31/07 for same or similar item, was trying to swallow something (reportedly drugs) at the evaluation that the inmate had item outstanding. time. 5. TDOC staff fails to communicate with facility chewed/swallowed an alleged substance, staff. possibly drugs. Warden’s response dated: 11/20/06 On October 31, 2006, Disciplinary Chairperson SCO Ponds sought and received approval for the above Segregation placements and four additional inmates who are not on the above 10 inmates were segregated 10/31/06 list, by notifying TDOC Bettie Hammond via telephone after being on a segregation waiting list. and discussing the placements. Additionally, per the Verified 3/31/07: By review of The segregation packs with movement Disciplinary Chief of Security’s Secretary, on November 1, 2006, the segregation pack, unit logs and 4a (6) confinement forms were not immediately Procedures segregation packs with movement confinement forms TOMIS reports made available for commissioner’s were placed in the TDOC Office. However, the designee review until 11/13/06. employee who retrieved the files from the TDOC Office failed to check all of the files to ensure they were signed and therefore ten out of the fourteen files were not signed. 1c. Staff conducted 16 reasonable suspicion drug screens during December 06. Only 4 were documented as authorized/approved by designated staff. Warden’s response dated: 1/29/07 Warden concurs with Verified 3/29/07: By review of Drug testing 2f. Positive test results were not findings. A new Drug Testing Officer was recently testing procedures, and appointed and while he has made significant progress in documentation and log books. 1c,2f,2g maintained in a confidential file. 2g. No Substance documentation to support treatment improving this area of operations, was deficient in the CM note: Prior non-compliance ,2i abuse services are recommended for inmates areas noted. Corrections have been made in all areas issued 10/13/06 for same or treatment convicted of a positive drug test. 2i. No noted to ensure these findings are not repeated. similar items, items outstanding. documentation to support that inmates who test positive on a drug screen are retested as required. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES 12/11/06 DCCO CM note (summarized): The CD's report is based on what she was told by the Shift Supervisor. 2. WCFA policy requires medical review prior to gas use; use of gas to make an inmate spit something out is questionable, and the cell door could simply have been closed if the inmate was aggressive. 3. This was not a spontaneous use of force. 4. it would have been appropriate for medical staff to have been made aware that the inmate had swallowed something and for this to be documented in the inmate's medical file, and for a drug screen to have been performed. 5. TDOC staff regularly communicate with facility staff. 3/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR March 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 1/31/07 Yes CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Monitoring Instrument ITEM NO. Use of Force Assistant Shift Supervisor used chemical agents (OC) inappropriately to control an inmate inside a segregation cell. When staff opened the food flap to retrieve food trays the inmate threw a substance. Asst. Supervisor immediately reacted by spraying the inmates twice with a MK-IX fogger through the food flap. The Shift Warden’s response dated 2/6/07: Warden concurs that Supervisor approved for a large canister the Assistant Shift Supervisor failed to follow proper 4g(1), (MK-IX) of OC chemical agents to be procedure in this incident and reacted to the inmate 4g(2) issued without question or a complete throwing what was believed to be urine on the staff understanding of the events surrounding involved by utilizing inflammatory agent (OC). the incident. Prior precautions were not taken in advance to minimize OC exposure to inmate Griffin who was not an active participant. Medical staff was not notified prior or present during the use of force nor were the affected inmates medical records reviewed prior to the use of chemical agents Warden’s response dated: 3/2/07: It is my understanding NON-COMPLIANCE ISSUE DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Verified 3/31/07: By review of UOF chemical agents incidents 2/6, 2/17, 3/6, 3/11, 3/24 appropriate procedures and documentation. CM note: Noncompliance issued 10/18/06 and 11/6/06 for same or similar item, item outstanding. that on the date of this incident the Shift Supervisor On January 1, 2007 staff used physical entered an LIBJ incident report on the finding of the force to conduct a strip search of an drugs (TOMIS #00683027) but did fail to enter a inmate. A TOMIS (LIBJ) report was not separate incident report for the Use of Force. Upon entered for this incident within policy discovery of this the necessary report was entered into guidelines. the TOMIS system. (See #689631). The supervisor on this shift is one of the most experienced supervisors and simply forgot to do the additional report. 2/27/07 Yes Use of Force 3a 2/27/07 Yes Records and Reports 2b Same as above NO Security and ControlCounts 5 Warden’s response dated: 3/12/07: Facility concurs that Routine inmate movement is not ceased inmates have not been in cells 15 minutes prior to count. 15 minutes prior to count. Inmates are not The facility schedule has been revised and every effort in their assigned cells 15 minutes before will be made to have inmates in their cell 15 minutes count time. prior to count times. 3/8/07 Page 3 Same as above Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 3/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR March 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 3/9/07 NO 3/23/07 NO Monitoring Instrument Policies and Procedures manual Records and Reports ITEM NO. 1a NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 4 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Warden’s response dated: 3/9/07: Policies have been made accessible. Policy nor contract requires these December 1, 2006, while monitoring the policies to be made available but we concur it is the right inmate library, CM discovered that some thing to do and had agreed to place them there when TDOC policies that WCFA is not required this issue arose several months ago. The clerk tasked to follow but should be accessible to with the directive to place these in the library in the TDOC inmates were not in the library. To library miscommunicated the intention to the librarian this date these policies are not readily and the policies were provided to the librarian but not accessible to the inmate general made available to the inmate population. This was not population. the intention of facility management and has been corrected. Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff Wardens response dated: 4/16/07 The Warden concurs to find. Staff failed to enter TOMIS (LIBJ) that the supervisor on duty failed to enter the appropriate CM note: Non-compliance 6a(3) reports within eights (8) hours of the LIBJ report. The LIBJ has since been entered and the issued 8/8/06 for same or similar incident’s occurrence/discovery supervisor that was responsible for the incident entry item, item outstanding. concerning the attempted suicide and was disciplined transportation to outside hospital and surrounding incidents. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. 3/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR April 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N Monitoring Instrument ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN 2/27/07 Yes Use of Force 3a Warden’s response dated: 3/2/07: It is my understanding that on the date of this incident the Shift Supervisor On January 1, 2007 staff used physical entered an LIBJ incident report on the finding of the force to conduct a strip search of an drugs (TOMIS #00683027) but did fail to enter a inmate. A TOMIS (LIBJ) report was not separate incident report for the Use of Force. Upon entered for this incident within policy discovery of this the necessary report was entered into guidelines. the TOMIS system. (See #689631). The supervisor on this shift is one of the most experienced supervisors and simply forgot to do the additional report. 2/27/07 Yes Records and Reports 2b Same as above 3/8/07 Yes Security and ControlCounts 5 3/9/07 Yes Policies and Procedures manual 1a 3/23/07 Yes Records and Reports Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Same as above Warden’s response dated: 3/12/07: Facility concurs that Routine inmate movement is not ceased inmates have not been in cells 15 minutes prior to count. 15 minutes prior to count. Inmates are not The facility schedule has been revised and every effort in their assigned cells 15 minutes before will be made to have inmates in their cell 15 minutes count time. prior to count times. Warden’s response dated: 3/9/07: Policies have been made accessible. Policy nor contract requires these December 1, 2006, while monitoring the policies to be made available but we concur it is the right inmate library, CM discovered that some thing to do and had agreed to place them there when TDOC policies that WCFA is not required this issue arose several months ago. The clerk tasked to follow but should be accessible to with the directive to place these in the library in the TDOC inmates were not in the library. To library miscommunicated the intention to the librarian this date these policies are not readily and the policies were provided to the librarian but not accessible to the inmate general made available to the inmate population. This was not population. the intention of facility management and has been corrected. Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff Wardens response dated: 4/16/07 The Warden concurs to find. Staff failed to enter TOMIS (LIBJ) that the supervisor on duty failed to enter the appropriate CM note: Non-compliance 6a(3) reports within eights (8) hours of the LIBJ report. The LIBJ has since been entered and the issued 8/8/06 for same or similar incident’s occurrence/discovery supervisor that was responsible for the incident entry item, item outstanding. concerning the attempted suicide and was disciplined transportation to outside hospital and surrounding incidents. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 6/6/07 CMC note: Breach letter issued by Commissioner 5/14/07. 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. 4/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR April 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 4/18/07 5/1/07 NO NO Monitoring Instrument Special Management Inmates Records and Reports ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS 2b Warden’s response date: 4/18/07: Concur that the supervisor failed to obtain signature within proscribed time frame. He had obtained the Designee’s verbal Inmate was segregated 4/14/07 pending approval at the time of the placement but filed the form in an investigation for protective custody. the segregation packet. The error was later discovered CM note: Non-compliance The protective services routing form (CR- and TDOC liaison’s signature obtained but it was outside issued 10/26/06 for same or 3241) was not provided to the the time frame in policy. The Shift Supervisor handling similar item, item outstanding. Commissioners Designee for approval the Protective Custody Investigation routing process had transferred from another facility shortly before this and within the 72-hour policy guideline. followed the procedure used at that facility, as he had become accustomed. He has subsequently had the TDOC required process communicated to him. 10 According to TOMIS incident report Warden’s response dated 5/9/07: I was notified at #00697394, at 6:05am an inmate was approx. 6:15 at home that the inmate had been found found unresponsive by the facility medical unresponsive, medical staff was performing CPR and clinic officer. The inmate was transported EMS was en-route. There was no intention to delay in to outside hospital where he was this instance. At 6:05 I had no information other than an pronounced dead. WCF Warden notified inmate who was unresponsive was being transported to Acting Assistant Commissioner at 7:40am. CM note: Non-compliance the emergency room and made the notification As per Department of Corrections Central issued 10/16/06, 10/19/06 and immediately upon reaching the facility and obtaining the Office memorandum dated July 2004 to all 11/6/06 for same or similar item, information that he had died and the particulars. From facility warden's. “Class (A) incidents, and item outstanding. what I have since discovered the shift supervisor erred in other incidents assessed by the facility prematurely telling the TDOC Liaison that an inmate had official as significant and requiring died long before receiving a death pronouncement from prompt notification, shall be reported to the hospital. TDOC Liaison then called the Asst. the Assistant Commissioner of Operations Commissioner and informed him that we had an inmate immediately by phone on a 24 hour basis death. by the warden”. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES 6/6/07 CMC note: Since this is the second instrument in an 18-month period on which this item has been found in non-compliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach. Breach letter pending. 4/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR May 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N Monitoring Instrument ITEM NO. 2/27/07 Yes Use of Force 3a 2/27/07 Yes Records and Reports 2b 3/8/07 Yes Security and ControlCounts 5 3/9/07 Yes Policies and Procedures manual 1a 3/23/07 Yes Records and Reports NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Warden’s response dated: 3/2/07: It is my understanding that on the date of this incident the Shift Supervisor On January 1, 2007 staff used physical entered an LIBJ incident report on the finding of the force to conduct a strip search of an drugs (TOMIS #00683027) but did fail to enter a Verified 5/22/07: By review of inmate. A TOMIS (LIBJ) report was not separate incident report for the Use of Force. Upon TOMIS incident reports, facility entered for this incident within policy discovery of this the necessary report was entered into reports and segregation logs. guidelines. the TOMIS system. (See #689631). The supervisor on this shift is one of the most experienced supervisors and simply forgot to do the additional report. Verified 5/22/07: By review of Same as above Same as above TOMIS incident reports, facility reports and segregation logs. Warden’s response dated: 3/12/07: Facility concurs that Routine inmate movement is not ceased inmates have not been in cells 15 minutes prior to count. 15 minutes prior to count. Inmates are not The facility schedule has been revised and every effort in their assigned cells 15 minutes before will be made to have inmates in their cell 15 minutes count time. prior to count times. Warden’s response dated: 3/9/07: Policies have been made accessible. Policy nor contract requires these December 1, 2006, while monitoring the policies to be made available but we concur it is the right inmate library, CM discovered that some thing to do and had agreed to place them there when TDOC policies that WCFA is not required this issue arose several months ago. The clerk tasked to follow but should be accessible to with the directive to place these in the library in the TDOC inmates were not in the library. To library miscommunicated the intention to the librarian this date these policies are not readily and the policies were provided to the librarian but not accessible to the inmate general made available to the inmate population. This was not population. the intention of facility management and has been corrected. Verified 5/24/07: By review of inmate movement prior to counts, outcount count sheets, countroom procedures and routine movement. Verified 5/22/07: By review of applicable/accessable TDOC and facility policies in inmate library. Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff Wardens response dated: 4/16/07 The Warden concurs to find. Staff failed to enter TOMIS (LIBJ) that the supervisor on duty failed to enter the appropriate CM note: Non-compliance 6a(3) reports within eights (8) hours of the LIBJ report. The LIBJ has since been entered and the issued 8/8/06 for same or similar incident’s occurrence/discovery supervisor that was responsible for the incident entry item, item outstanding. concerning the attempted suicide and was disciplined transportation to outside hospital and surrounding incidents. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 6/6/07 CMC note: Breach letter issued by Commissioner 5/14/07. 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. 5/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR May 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 4/18/07 5/1/07 No No Monitoring Instrument Special Management Inmates Records and Reports ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS 2b Warden’s response date: 4/18/07: Concur that the supervisor failed to obtain signature within proscribed time frame. He had obtained the Designee’s verbal Inmate was segregated 4/14/07 pending approval at the time of the placement but filed the form in an investigation for protective custody. the segregation packet. The error was later discovered CM note: Non-compliance The protective services routing form (CR- and TDOC liaison’s signature obtained but it was outside issued 10/26/06 for same or 3241) was not provided to the the time frame in policy. The Shift Supervisor handling similar item, item outstanding. Commissioners Designee for approval the Protective Custody Investigation routing process had transferred from another facility shortly before this and within the 72-hour policy guideline. followed the procedure used at that facility, as he had become accustomed. He has subsequently had the TDOC required process communicated to him. 10 According to TOMIS incident report Warden’s response dated 5/9/07: I was notified at #00697394, at 6:05am an inmate was approx. 6:15 at home that the inmate had been found found unresponsive by the facility medical unresponsive, medical staff was performing CPR and clinic officer. The inmate was transported EMS was en-route. There was no intention to delay in to outside hospital where he was this instance. At 6:05 I had no information other than an pronounced dead. WCF Warden notified inmate who was unresponsive was being transported to Acting Assistant Commissioner at 7:40am. CM note: Non-compliance the emergency room and made the notification As per Department of Corrections Central issued 10/16/06, 10/19/06 and immediately upon reaching the facility and obtaining the Office memorandum dated July 2004 to all 11/6/06 for same or similar item, information that he had died and the particulars. From facility warden's. “Class (A) incidents, and item outstanding. what I have since discovered the shift supervisor erred in other incidents assessed by the facility prematurely telling the TDOC Liaison that an inmate had official as significant and requiring died long before receiving a death pronouncement from prompt notification, shall be reported to the hospital. TDOC Liaison then called the Asst. the Assistant Commissioner of Operations Commissioner and informed him that we had an inmate immediately by phone on a 24 hour basis death. by the warden”. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES 7/5/07 CMC note: Notice of Breach letter issued by Commissioner 6/7/07. 6/6/07 CMC note: Since this is the second instrument in an 18month period on which this item has been found in non-compliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach. Breach letter pending. 5/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR June 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 3/23/07 4/18/07 5/1/07 Yes No No Monitoring Instrument Records and Reports Special Management Inmates Records and Reports ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff Wardens response dated: 4/16/07 The Warden concurs to find. Staff failed to enter TOMIS (LIBJ) that the supervisor on duty failed to enter the appropriate 6a(3) reports within eights (8) hours of the LIBJ report. The LIBJ has since been entered and the incident’s occurrence/discovery supervisor that was responsible for the incident entry concerning the attempted suicide and was disciplined transportation to outside hospital and surrounding incidents. 2b Warden’s response date: 4/18/07: Concur that the supervisor failed to obtain signature within proscribed time frame. He had obtained the Designee’s verbal Inmate was segregated 4/14/07 pending approval at the time of the placement but filed the form in Verified 7/19/07 by review of an investigation for protective custody. the segregation packet. The error was later discovered segregation logs, TOMIS entries The protective services routing form (CR- and TDOC liaison’s signature obtained but it was outside and PC routing. CM note: Non3241) was not provided to the the time frame in policy. The Shift Supervisor handling compliance issued 10/26/06 for Commissioners Designee for approval the Protective Custody Investigation routing process had same or similar item, item transferred from another facility shortly before this and outstanding. within the 72-hour policy guideline. followed the procedure used at that facility, as he had become accustomed. He has subsequently had the TDOC required process communicated to him. 10 According to TOMIS incident report Warden’s response dated 5/9/07: I was notified at #00697394, at 6:05am an inmate was approx. 6:15 at home that the inmate had been found found unresponsive by the facility medical unresponsive, medical staff was performing CPR and clinic officer. The inmate was transported EMS was en-route. There was no intention to delay in to outside hospital where he was this instance. At 6:05 I had no information other than an pronounced dead. WCF Warden notified inmate who was unresponsive was being transported to Acting Assistant Commissioner at 7:40am. the emergency room and made the notification As per Department of Corrections Central immediately upon reaching the facility and obtaining the Office memorandum dated July 2004 to all information that he had died and the particulars. From facility warden's. “Class (A) incidents, and what I have since discovered the shift supervisor erred in other incidents assessed by the facility prematurely telling the TDOC Liaison that an inmate had official as significant and requiring died long before receiving a death pronouncement from prompt notification, shall be reported to the hospital. TDOC Liaison then called the Asst. the Assistant Commissioner of Operations Commissioner and informed him that we had an inmate immediately by phone on a 24 hour basis death. by the warden”. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES 6/6/07 CMC note: Breach letter issued by Commissioner 5/14/07. 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. 7/5/07 CMC note: Notice of Breach letter issued by Commissioner 6/7/07. 6/6/07 CMC note: Since this is the second instrument in an 18month period on which this item has been found in non-compliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach. Breach letter pending. 6/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR July 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 3/23/07 4/18/07 5/1/07 Yes Yes Yes Monitoring Instrument Records and Reports Special Management Inmates Records and Reports ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff Wardens response dated: 4/16/07 The Warden concurs to find. Staff failed to enter TOMIS (LIBJ) that the supervisor on duty failed to enter the appropriate 6a(3) reports within eights (8) hours of the LIBJ report. The LIBJ has since been entered and the incident’s occurrence/discovery supervisor that was responsible for the incident entry concerning the attempted suicide and was disciplined transportation to outside hospital and surrounding incidents. 2b Warden’s response date: 4/18/07: Concur that the supervisor failed to obtain signature within proscribed time frame. He had obtained the Designee’s verbal Inmate was segregated 4/14/07 pending approval at the time of the placement but filed the form in Verified 7/19/07 by review of an investigation for protective custody. the segregation packet. The error was later discovered segregation logs, TOMIS entries The protective services routing form (CR- and TDOC liaison’s signature obtained but it was outside and PC routing. CM note: Non3241) was not provided to the the time frame in policy. The Shift Supervisor handling compliance issued 10/26/06 for Commissioners Designee for approval the Protective Custody Investigation routing process had same or similar item, item transferred from another facility shortly before this and outstanding. within the 72-hour policy guideline. followed the procedure used at that facility, as he had become accustomed. He has subsequently had the TDOC required process communicated to him. 10 According to TOMIS incident report Warden’s response dated 5/9/07: I was notified at #00697394, at 6:05am an inmate was approx. 6:15 at home that the inmate had been found found unresponsive by the facility medical unresponsive, medical staff was performing CPR and clinic officer. The inmate was transported EMS was en-route. There was no intention to delay in to outside hospital where he was this instance. At 6:05 I had no information other than an pronounced dead. WCF Warden notified inmate who was unresponsive was being transported to Acting Assistant Commissioner at 7:40am. the emergency room and made the notification As per Department of Corrections Central immediately upon reaching the facility and obtaining the Office memorandum dated July 2004 to all information that he had died and the particulars. From facility warden's. “Class (A) incidents, and what I have since discovered the shift supervisor erred in other incidents assessed by the facility prematurely telling the TDOC Liaison that an inmate had official as significant and requiring died long before receiving a death pronouncement from prompt notification, shall be reported to the hospital. TDOC Liaison then called the Asst. the Assistant Commissioner of Operations Commissioner and informed him that we had an inmate immediately by phone on a 24 hour basis death. by the warden”. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES 6/6/07 CMC note: Breach letter issued by Commissioner 5/14/07. 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. 7/5/07 CMC note: Notice of Breach letter issued by Commissioner 6/7/07. 6/6/07 CMC note: Since this is the second instrument in an 18-month period on which this item has been found in noncompliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach. Breach letter pending. 7/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR July 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 7/18/07 7/18/07 7/18/07 No Monitoring Instrument Secuity Equipment No Use of Force No Records and Reports ITEM NO. NON-COMPLIANCE ISSUE 4 WCFA staff notified TDOC Liaison that a MK IX chemical agent fogger was missing from central control. 7i This security equipment (fogger) was not logged out nor any documentation as to its location. It was later discovered a staff member had removed the fogger from the facility without permission. 10 No CCA 5-1 report packet was submitted to the CD by conclusion of the shift, nor was a finalized report submitted within 21 days of occurrence. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Warden’s response July 24, 2007: The Warden concurs that the item was found to be missing from Central Control and that it was not logged out. He also indicates that an investigation was conducted and remains open, but has not identified the person responsible. He indicates that it appears to have been stolen rather than issued and not returned. He states that this is not a contractual violation but is rather the act of an individual acting outside the scope of their employment and the policies and practices of the facility. Both the Commissioner’s Designee and the Contract Monitor were fully apprised as well as the Acting Assistant Commissioner . An LIBJ entry was made in accordance with TDOC policy. No 5-1 packet was provided to TDOC because one was not prepared. This incident is not categorized as requiring a 5-1 packet. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 9/24/07 CMC note: Determined not to be a noncompliance issue for this item. The CCA 5-1 policy is currently under review and the distribution requirement is in question. 7/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR August 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 3/23/07 5/1/07 Yes Yes 7/18/07 7/18/07 No No Monitoring Instrument ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Records and Reports Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff Wardens response dated: 4/16/07 The Warden concurs to find. Staff failed to enter TOMIS (LIBJ) that the supervisor on duty failed to enter the appropriate 6a(3) reports within eights (8) hours of the LIBJ report. The LIBJ has since been entered and the incident’s occurrence/discovery supervisor that was responsible for the incident entry concerning the attempted suicide and was disciplined transportation to outside hospital and surrounding incidents. Records and Reports According to TOMIS incident report Warden’s response dated 5/9/07: I was notified at #00697394, at 6:05am an inmate was approx. 6:15 at home that the inmate had been found found unresponsive by the facility medical unresponsive, medical staff was performing CPR and clinic officer. The inmate was transported EMS was en-route. There was no intention to delay in to outside hospital where he was this instance. At 6:05 I had no information other than an pronounced dead. WCF Warden notified inmate who was unresponsive was being transported to Acting Assistant Commissioner at 7:40am. the emergency room and made the notification As per Department of Corrections Central immediately upon reaching the facility and obtaining the Office memorandum dated July 2004 to all information that he had died and the particulars. From facility warden's. “Class (A) incidents, and what I have since discovered the shift supervisor erred in other incidents assessed by the facility prematurely telling the TDOC Liaison that an inmate had official as significant and requiring died long before receiving a death pronouncement from prompt notification, shall be reported to the hospital. TDOC Liaison then called the Asst. the Assistant Commissioner of Operations Commissioner and informed him that we had an inmate immediately by phone on a 24 hour basis death. by the warden”. Secuity Equipment Use of Force 10 4 WCFA staff notified TDOC Liaison that a MK IX chemical agent fogger was missing from central control. There is no record in the equipment issuance log in Central Control that the fogger was issued. 7i This security equipment (fogger) was not logged out nor any documentation as to its location. It was later discovered a staff member had removed the fogger from the facility without permission. Warden’s response July 24, 2007: The Warden concurs that the item was found to be missing from Central Control and that it was not logged out. He also indicates that an investigation was conducted and remains open, but has not identified the person responsible. He indicates that it appears to have been stolen rather than issued and not returned. He states that this is not a contractual violation but is rather the act of an individual acting outside the scope of their employment and the policies and practices of the facility. Both the Commissioner’s Designee and the Contract Monitor were fully apprised as well as the Acting Assistant Commissioner . An LIBJ entry was made in accordance with TDOC policy. No 5-1 packet was provided to TDOC because one was not prepared. This incident is not categorized as requiring a 5-1 packet. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 9/24/07 CMC note: Verification of Breach cure pending. 6/6/07 CMC note: Breach letter issued by Commissioner 5/14/07. 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. 9/24/07 CMC note: Verification of Breach cure pending.7/5/07 CMC note: Notice of Breach letter issued by Commissioner 6/7/07. 6/6/07 CMC note: Since this is the second instrument in an 18-month period on which this item has been found in non-compliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach. Breach letter pending. 9/24/07 CMC note: It has been determined that the non-compliance item Security Equipment #4, above, is more appropriately applicable to this incident. Use of Force item 7i will not be found in non-compliance due to this incident. 8/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR September 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 3/23/07 5/1/07 Yes Yes Monitoring Instrument Records and Reports Records and Reports ITEM NON-COMPLIANCE ISSUE NO. Inmate was transported and admitted to outside hospital after attempting suicide. A suicide note was left in the cell for staff to find. Staff failed to enter TOMIS (LIBJ) 6a(3) reports within eights (8) hours of the incident’s occurrence/discovery concerning the attempted suicide and transportation to outside hospital and surrounding incidents. 10 An inmate was found unresponsive by the facility medical clinic officer and transported to outside hospital where he was pronounced dead. WCFA Warden notified Acting Assistant Commissioner at 7:40am. As per Department of Corrections Central Office memorandum dated July 2004 to all facility warden's. “Class (A) incidents, and other incidents assessed by the facility official as significant and requiring prompt notification, shall be reported to the Assistant Commissioner of Operations immediately by phone on a 24 hour basis by the warden”. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Wardens response dated: 4/16/07 The Warden concurs that the supervisor on duty failed to enter the appropriate LIBJ report. The LIBJ has since been entered and the supervisor that was responsible for the incident entry was disciplined. 10/16/07 CMC note: Warden's response dated 10/1/07 indicates there have been no reoccurrrences since initial response to the NCR.This has been verified. The Breach is determined to be cured. 9/24/07 CMC note: Verification of Breach cure pending. 6/6/07 CMC note: Breach letter issued by Commissioner 5/14/07. 5/3/07 CMC note: Determined to be a Breach issue (2nd finding on semi-annual instrument in 18 mo [ref. NCR dated 8/8/06]). Notice of Breach letter pending. Warden’s response dated 5/9/07: I was notified at approx. 6:15 at home that the inmate had been found unresponsive, medical staff was performing CPR and EMS was en-route. There was no intention to delay in this instance. At 6:05 I had no information other than an inmate who was unresponsive was being transported to the emergency room and made the notification immediately upon reaching the facility and obtaining the information that he had died and the particulars. From what I have since discovered the shift supervisor erred in prematurely telling the TDOC Liaison that an inmate had died long before receiving a death pronouncement from the hospital. TDOC Liaison then called the Asst. Commissioner and informed him that we had an inmate death. 10/16/07 CMC note: Warden's response dated 10/1/07 indicates there have been no reoccurrrences since initial response to the NCR.This has been verified. The Breach is determined to be cured. 9/24/07 CMC note: Verification of Breach cure pending.7/5/07 CMC note: Notice of Breach letter issued by Commissioner 6/7/07. 6/6/07 CMC note: Since this is the second instrument in an 18-month period on which this item has been found in noncompliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach. Breach letter pending. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR September 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N Monitoring Instrument ITEM NON-COMPLIANCE ISSUE NO. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN 7/19/07 Yes Security Equipment 4 Warden’s response July 24, 2007: The Warden concurs that the item was found to be missing from Central Control and was not logged out. He also indicates that an investigation was conducted and remains open, but has not identified the person responsible, and that it WCFA staff notified TDOC Liaison that a appears to have been stolen rather than issued and not MK IX chemical agent fogger was missing returned. He states that this is not a contractual violation from central control. There is no record in but is rather the act of an individual acting outside the scope of their employment and the policies and practices the equipment issuance log in Central of the facility. Both the CD and CM were fully apprised Control that the fogger was issued. as well as the Acting Assistant Commissioner . An LIBJ entry was made in accordance with TDOC policy. No 5-1 packet was provided to TDOC because one was not prepared. This incident is not categorized as requiring a 5-1 packet. 9/11/07 No Staffing 1b All three shifts and the administrative shift Warden's response September 24, 2007: Revised are using rosters that are not approved by rosters have been submitted for approval. TDOC. 3 Warden's response September 24, 2007: Verification that the noted posts were covered was provided to the monitor. The shift supervisor had inadvertently failed to Several posts not manned according to the shift rosters provided by the institution. show the staff on the shift rosters but records/logbooks reflect these posts were manned. Monitor was provided Weekend rosters not provided to the monitor. SCO in segregation unit was not the rosters in question. The rosters did not reflect a being reflected on the rosters as a critical supervisor as mandatory in segregation, however the practice since this meeting has been to assign a post. supervisor to segregation. Logbooks and rosters reflect this was done. 9/11/07 9/18/07 No No Staffing Staffing 16 Three of six personnel files of applicable staff did not contain copies of signed security addendum form. Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Warden's response September 24, 2007: Training was conducted in the past year for all applicable staff however the three (3) files that did not have a signed security addendum had been promoted/hired since that time and had not had this completed. The HR Manager will ensure that this is accomplished for all future hires in the applicable positions and the ones currently lacking this will have a signed copy placed in their file. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR September 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 9/19/07 9/19/07 9/19/07 9/19/07 9/27/07 No No No No No Monitoring Instrument Use of Force Use of Force Use of Force Use of Force Security and Controls Counts ITEM NON-COMPLIANCE ISSUE NO. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN 3h Warden's response September 24, 2007: Facility attempted to reach CD within the hour time frame but the time shown on the incident report was the actual time that contact was made. There are times when the On two different incidents, one on 6-2-07 supervisors are unable to reach CD within the specified and one on 8-14-07, notification exceeded time frame. In the future if the CM is not immediately the one (1) hour timeframe. available, call will be made to the CM. Additionally supervisors will log times in report that calls were made with no answer and if neither the CD or CM can be reached then Turney Center will be notified. 4a The requirements of the applicable approved Use of Force policies were not Warden's response: September 24, 2007: See 3h above followed concerning issuance of chemical and 7e below. agents and reporting use, as noted in Items 3h above and 7e below. 7e On 7-1-07, a MK 9 fogger was issued to the Assistant Shift Supervisor. On 8-2107, a MK 9 fogger was issued to a Correctional Officer. Per CCA approved policy neither of these positions are authorized. Warden's response September 24, 2007: Warden does not concur.TDOC approved facility policy specifies that use of OC must be approved by Shift supervisor or higher authority. It does not state that OC cannot be issued to other staff. He notes in both incidents the supervisor sent personnel to pick up the OC. 7i On 7-22-07, at 7:20 p.m. a MK 9 fogger was used in a Use of Force incident. There is no record of a MK9 fogger being issued by Central Control. Warden's response September 24, 2007: The facility concurs that the staff in central control failed to log the issuance of OC in this instance as required. Corrective steps have been taken to address their failure. On 9-3-07, 9-12.07 and 9-21-07, there were count slips filled out incorrectly or not in their entirety. Warden's response October 3, 2007: Facility agrees with the noncompliance issues concerning S/C - Count. After review, it was discovered that each of the three shifts had contributed to the noncompliance issues. Therefore, on Oct. 2, 2007, a meeting was held with all Shift Supervisors and Count Room Officers to conduct training on the proper count procedures and expectations of count. Additionally, the Shift Supervisors will personally observe the count procedure while each count is being conducted and ensure that the policy is being followed. Also, the Chief of Security will monitor the count procedure and the Shift Supervisors to ensure compliance 1b Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 3 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 10/30/07 CMC note: This is the 2nd instrument in 12 months on which this item has been found in non-compliance. A third noncompliance finding will trigger a Breach. 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR September 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 9/27/07 No Monitoring Instrument Security and Controls Counts ITEM NON-COMPLIANCE ISSUE NO. 4d On 9-25-07, at 10:30 am count, all outcount slips were not received prior to count being announced. 10/3/07 No Food Service 2 On 7-29-07, sack lunches were served for the dinner meal, however, no documentation could be found to support this substitution. 10/3/07 No Food Service 20 Eating utensils are sent by the case to segregation unit, however, they are in bulk form and have no covering whatsoever. 10/3/07 No Food Service 34b On two different dates, hot food delivered to segregation unit never reached required temperature of 140 degrees. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 4 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR October 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 5/1/07 7/19/07 9/11/07 9/11/07 Yes Yes Yes Yes Monitoring Instrument Records and Reports Security Equipment Staffing Staffing ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN 10 An inmate was found unresponsive by the facility medical clinic officer and transported to outside hospital where he Warden’s response dated 5/9/07: I was notified at approx. 6:15 at home that the inmate had been found unresponsive, medical staff was performing CPR was pronounced dead. WCFA Warden notified Acting Assistant Commissioner at and EMS was en-route. There was no intention to delay in this instance. At 7:40am. As per Department of Corrections 6:05 I had no information other than an inmate who was unresponsive was being transported to the emergency room and made the notification Central Office memorandum dated July immediately upon reaching the facility and obtaining the information that he 2004 to all facility warden's. “Class (A) had died and the particulars. From what I have since discovered the shift incidents, and other incidents assessed by supervisor erred in prematurely telling the TDOC Liaison that an inmate had the facility official as significant and died long before receiving a death pronouncement from the hospital. TDOC requiring prompt notification, shall be Liaison then called the Asst. Commissioner and informed him that we had an reported to the Assistant Commissioner of inmate death. Operations immediately by phone on a 24 hour basis by the warden”. 4 Warden’s response July 24, 2007: The Warden concurs that the item was found to be missing from Central Control and was not logged out. He also indicates that an investigation was conducted and remains open, but has not identified the person responsible, and that it appears WCFA staff notified TDOC Liaison that a to have been stolen rather than issued and not returned. He states that MK IX chemical agent fogger was missing this is not a contractual violation but is rather the act of an individual from central control. There is no record in acting outside the scope of their employment and the policies and the equipment issuance log in Central practices of the facility. Both the CD and CM were fully apprised as Control that the fogger was issued. well as the Acting Assistant Commissioner . An LIBJ entry was made in accordance with TDOC policy. No 5-1 packet was provided to TDOC because one was not prepared. This incident is not categorized as requiring a 5-1 packet. 1b All three shifts and the administrative shift Warden's response September 24, 2007: Revised rosters have been are using rosters that are not approved by submitted for approval. TDOC. 3 Several posts not manned according to the shift rosters provided by the institution. Weekend rosters not provided to the monitor. SCO in segregation unit was not being reflected on the rosters as a critical post. Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 11/21/07 CMC note: After additional discussion of this incident and NCR between CCA and TDOC management staff, it has been determined that this specific incident was not a non-compliance issue. The NCR and subsequent finding of Breach have, therefore, been withdrawn and removed from the tracking system. NOTE: Previous non-compliance findings are still valid for this item. 10/16/07 CMC note: Warden's response dated 10/1/07 indicates there have been no reoccurrences since initial response to the NCR. This has been verified. The Breach is determined to be cured. 9/24/07 CMC note: Verification of Breach cure pending.7/5/07 CMC note: Notice of Breach letter issued by Commissioner 6/7/07. 6/6/07 CMC note: Since this is the second instrument in an 18-month period on which this item has been found in non-compliance (ref. NCRs dated 10/16/06, 10/19/06 and 10/26/06), this item is now in breach Breach letter pending 11/21/07 CMC note: The theft of the chemical agent was an illegal act by an individual acting outside of Policy, however, the accountability for chemical agents and the secure storage and accessibility to such security devices is an institutional and contractual issue. This is a valid compliance concern. The monitor will check the appropriate storage, issuance, use and accessibility to chemical agents to verify that appropriate corrective action has been taken. CM note: Asst. Commissioner approved rosters on 10-11-07. Approval of the rosters has occurred. The institution is advised that only approved rosters are to be used. PRIOR TDOC approval is required for any changes to rosters, staffing patterns or policies. Warden's response September 24, 2007: Verification that the noted posts were covered was provided to the monitor. The shift supervisor had inadvertently failed to show the staff on the shift rosters but This is a valid monitoring issue. The approved rosters records/logbooks reflect these posts were manned. Monitor was CM note: Log books and records did for documentation of security post assignments must provided the rosters in question. The rosters did not reflect a supervisor show posts were manned as required. be accurately completed. as mandatory in segregation, however the practice since this meeting has been to assign a supervisor to segregation. Logbooks and rosters reflect this was done. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR October 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 9/18/07 9/19/07 Yes Yes Monitoring Instrument Staffing Use of Force ITEM NO. NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Three of six personnel files of applicable staff did not contain copies of signed security addendum form. 3h Warden's response September 24, 2007: Facility attempted to reach CD within the hour time frame but the time shown on the incident report was the actual time that contact was made. There are times when the On two different incidents, one on 6-2-07 supervisors are unable to reach CD within the specified time frame. In and one on 8-14-07, notification exceeded the future if the CM is not immediately available, call will be made to the one (1) hour timeframe. the CM. Additionally supervisors will log times in report that calls were made with no answer and if neither the CD or CM can be reached then Turney Center will be notified. 9/19/07 Yes Use of Force 4a 9/19/07 Yes Use of Force 7e 9/19/07 Yes Use of Force 7i 9/27/07 Yes Security and Controls Counts 1b 9/27/07 Yes Security and Controls Counts 4d 10/3/07 Yes Food Service 2 10/3/07 Yes Food Service 20 On 9-3-07, 9-12.07 and 9-21-07, there were count slips filled out incorrectly or not in their entirety. On 9-25-07, at 10:30 am count, all outcount slips were not received prior to count being announced. On 7-29-07, sack lunches were served for the dinner meal, however, no documentation could be found to support this substitution. DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Warden's response September 24, 2007: Training was conducted in the past year for all applicable staff however the three (3) files that did not have a signed security addendum had been promoted/hired since that time and had not had this completed. The HR Manager will ensure that this is accomplished for all future hires in the applicable positions and the ones currently lacking this will have a signed copy placed in their file. 16 The requirements of the applicable approved Use of Force policies were not followed concerning issuance of chemical agents and reporting use, as noted in Items 3h above and 7e below. Redacted On 7-22-07, at 7:20 p.m. a MK 9 fogger was used in a Use of Force incident. There is no record of a MK9 fogger being issued by Central Control. Page 2 11/21/07 CMC note: The procedures cited in the response to this NCR as corrective action to be taken are already required by Policy. The monitor will check subsequent Use of Force notifications to verify that Policy is now being adhered to. 10/30/07 CMC note: This is the 2nd instrument in 12 months on which this item has been found in non-compliance. A third noncompliance finding will trigger a Breach. Warden's response: September 24, 2007: See 3h above and 7e below. Warden's response September 24, 2007: The facility concurs that the staff in central control failed to log the issuance of OC in this instance as required. Corrective steps have been taken to address their failure. Warden's response October 3, 2007 indicates that the facility agrees with the noncompliance issues. After review, it was discovered that each of the three shifts had contributed to the noncompliance issues. Therefore, on Oct. 2, 2007, a meeting was held with all Shift Supervisors and Count Room Officers to conduct training on the proper count procedures and expectations of count. Additionally, the Shift Supervisors will personally observe the count procedure while each count is being conducted and ensure that the policy is being followed. Also, the Chief of Security will monitor the count procedure and the Shift Supervisors to ensure compliance. Same as above. Warden's response dated 10/18/07: Facility concurs and the following actions have been taken to correct the identified areas: All substitutions will have a hard copy of form sent to AW and will be checked to verify they are being properly completed; Eating utensils are sent by the case to Warden's response dated 10/18/07: Starting 10/2/07 separately presegregation unit, however, they are in bulk wrapped utensils are being used. form and have no covering whatsoever. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Monitored on 11/5/07 and eating utensils were individually wrapped. 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR October 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 10/3/07 Yes 10/24/07 No Monitoring Instrument Food Service Release and Pre-Release ITEM NO. 34b 16 10/29/07 No Security and Control Searches 6 10/31/07 No Inmate Identification 2 NON-COMPLIANCE ISSUE CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 3 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Warden response dated 10/18/07: A warming cart is now being used to On two different dates, hot food delivered transport trays from FS to seg unit and meals will be checked on a Monitored on 11/5/07 and food was to segregation unit never reached required random basis each week by the Chief of Security and the FS Manager still not at the required temperatures. temperature of 140 degrees. for temp compliance. No copies of Health Care Discharge Summary CR-3616 could be located. Wardens response dated 10/30/07: Facility concurs that this document has not been maintained in the medical files. As verified by the facility IPO's WCFA medical staff have been completing the required document and forwarding to the IPO's but have not retained and filed a copy. Warden response dated 11/01/07: WCFA agrees with the Checked twenty (20) cells where noncompliance issue. The Unit Managers and Shift Captains have contraband was found and disciplinary been advised that each time a cell is searched, regardless of the issued. Eleven (11) did not have reason (confidential information or other reason) that a LIBQ and LIBR LIBQ/LIBR, six (6) had LIBQ but LIBR was must be completed. The Chief of Unit Management and Chief of incorrect. It do show items found in cell Security will follow up to ensure this is being completed in every as charged on LIBJ. instance. Inmate Institutional Files, Volumes I & II Wardens response dated 11/2/07: Facility concurs that the files were were checked on twenty-five (25) files. in non-compliance as stated and a process to ensure compliance has Thirteen (13)were noncompliant in regards been initiated. However would note that the TDOC equipment used to to the Face Sheet. Five (5) were missing take and print the photos was not working for several months (Junethe face sheet either in Volume I or II or September 2007) thus created a serious backlog. Additional both. Two (2) had black and white photos; employees were assigned to assist in this process as at the time the policy requires they be in color. six (6) equipment was repaired there was a backlog of 175 inmates needing files exceeded the four (4) year timeframe photos. required by policy. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 11/21/07 CMC note: This issue was not caused by equipment malfunction. The photos had been made, but were not placed in the IIR, as required. 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR NOVEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 7/19/07 Yes Monitoring Instrument Security Equipment ITEM NON-COMPLIANCE ISSUE NO. 4 9/11/07 No Staffing 3 9/18/07 No Staffing 16 9/19/07 No Use of Force 3h 9/19/07 No Use of Force 4a 9/19/07 No Use of Force 7e 9/19/07 No Use of Force 7i CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Warden’s response July 24, 2007: The Warden concurs that the item was found to be missing from Central Control and was not logged out. He also indicates that an investigation was conducted and remains open, but has not identified the person responsible, and that it appears to have been stolen rather than issued and not WCFA staff notified TDOC Liaison that a MK IX returned. He states that this is not a contractual violation but is chemical agent fogger was missing from central rather the act of an individual acting outside the scope of their control. There is no record in the equipment issuance employment and the policies and practices of the facility. Both the log in Central Control that the fogger was issued. CD and CM were fully apprised as well as the Acting Assistant Commissioner . An LIBJ entry was made in accordance with TDOC policy. No 5-1 packet was provided to TDOC because one was not prepared. This incident is not categorized as requiring a 51 packet. Warden's response September 24, 2007: Verification that the noted posts were covered was provided to the monitor. The shift Several posts not manned according to the shift supervisor had inadvertently failed to show the staff on the shift rosters provided by the institution. Weekend rosters rosters but records/logbooks reflect these posts were manned. not provided to the monitor. SCO in segregation unit Monitor was provided the rosters in question. The rosters did not was not being reflected on the rosters as a critical reflect a supervisor as mandatory in segregation, however the post. practice since this meeting has been to assign a supervisor to segregation. Logbooks and rosters reflect this was done. Warden's response September 24, 2007: Training was conducted in the past year for all applicable staff however the three (3) files that did not have a signed security addendum had been Three of six personnel files of applicable staff did not promoted/hired since that time and had not had this completed. contain copies of signed security addendum form. The HR Manager will ensure that this is accomplished for all future hires in the applicable positions and the ones currently lacking this will have a signed copy placed in their file. Warden's response September 24, 2007: Facility attempted to reach CD within the hour time frame but the time shown on the incident report was the actual time that contact was made. There On two different incidents, one on 6-2-07 and one on are times when the supervisors are unable to reach CD within the 8-14-07, notification exceeded the one (1) hour specified time frame. In the future if the CM is not immediately timeframe. available, call will be made to the CM. Additionally supervisors will log times in report that calls were made with no answer and if neither the CD or CM can be reached then Turney Center will be notified. The requirements of the applicable approved Use of Force policies were not followed concerning issuance Warden's response: September 24, 2007: See 3h above and 7e below. of chemical agents and reporting use, as noted in Items 3h above and 7e below. Redacted Warden's response September 24, 2007: The facility concurs that On 7-22-07, at 7:20 p.m. a MK 9 fogger was used in a the staff in central control failed to log the issuance of OC in this Use of Force incident. There is no record of a MK9 instance as required. Corrective steps have been taken to fogger being issued by Central Control. address their failure. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 11/21/07 CMD note: The theft of the chemical agent was an illegal act by an individual acting outside of Policy, however, the accountability for chemical agents and the secure storage and accessibility to such security devices is an institutional and contractual issue. This is a valid compliance concern. The monitor will check the appropriate storage, issuance, use and accessibility to chemical agents to verify that appropriate corrective action has been taken. 12/21/07 CMD note: The monitor will examine the rosters in a subsequent month to ensure that the Log books and records did show corrective action has been effective, 1/21/07 CMD posts were manned as required. note: This is a valid monitoring issue. The approved rosters for documentation of security post assignments must be accurately completed. Security addendum forms have been signed by all applicable staff. 12/21/07 CMD note: The monitor will check files for applicable new hires in a subsequent month to ensure corrective action has been effective. 11/21/07 CMD note: The procedures cited in the response to this NCR as corrective action to be taken are already required by Policy. The monitor will check subsequent Use of Force notifications to verify that Policy is now being adhered to. 10/30/07 CMD note: This is the 2nd instrument in 12 months on which this item has been found in non-compliance. A third noncompliance finding will trigger a Breach. 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR NOVEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N Monitoring Instrument ITEM NON-COMPLIANCE ISSUE NO. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN 9/27/07 No Security and Controls Counts 1b On 9-3-07, 9-12.07 and 9-21-07, there were count slips filled out incorrectly or not in their entirety. Warden's response October 3, 2007: Facility agrees with the noncompliance issues concerning S/C - Count. After review, it was discovered that each of the three shifts had contributed to the noncompliance issues. Therefore, on Oct. 2, 2007, a meeting was held with all Shift Supervisors and Count Room Officers to conduct training on the proper count procedures and expectations of count. Additionally, the Shift Supervisors will personally observe the count procedure while each count is being conducted and ensure that the policy is being followed. Also, the Chief of Security will monitor the count procedure and the Shift Supervisors to ensure compliance. 9/27/07 No Security and Controls Counts 4d On 9-25-07, at 10:30 am count, all out-count slips were not received prior to count being announced. Same as above. 2 Warden's response dated 10/18/07: Facility concurs and the On 7-29-07, sack lunches were served for the dinner following actions have been taken to correct the identified areas: meal, however, no documentation could be found to All substitutions will have a hard copy of form sent to AW and will support this substitution. be checked to verify they are being properly completed; 20 Eating utensils are sent by the case to segregation unit, however, they are in bulk form and have no covering whatsoever. 34b Warden response dated 10/18/07: A warming cart is now being On two different dates, hot food delivered to used to transport trays from FS to seg unit and meals will be segregation unit never reached required temperature checked on a random basis each week by the Chief of Security of 140 degrees. and the FS Manager for temp compliance. 10/3/07 No 10/3/07 No 10/3/07 Food Service Food Service No Food Service No Release and Pre-Release 10/29/07 No Security and Control Searches 6 10/31/07 No Inmate Identification 2 10/24/07 16 Warden's response dated 10/18/07: Starting 10/2/07 separately pre-wrapped utensils are being used. Wardens response dated 10/30/07: Facility concurs that this document has not been maintained in the medical files. As verified by the facility IPO's WCFA medical staff have been completing the required document and forwarding to the IPO's but have not retained and filed a copy. Warden response dated 11/01/07: WCFA agrees with the Checked twenty (20) cells where contraband was noncompliance issue. The Unit Managers and Shift Captains have found and disciplinary issued. Eleven (11) did not been advised that each time a cell is searched, regardless of the have LIBQ/LIBR, six (6) had LIBQ but LIBR was reason (confidential information or other reason) that a LIBQ and incorrect. It do show items found in cell as charged LIBR must be completed. The Chief of Unit Management and on LIBJ. Chief of Security will follow up to ensure this is being completed in every instance. Wardens response dated 11/2/07: Facility concurs that the files Inmate Institutional Files, Volumes I & II were were in non-compliance as stated and a process to ensure checked on twenty-five (25) files. Thirteen (13)were compliance has been initiated. However would note that the noncompliant in regards to the Face Sheet. Five (5) TDOC equipment used to take and print the photos was not were missing the face sheet either in Volume I or II or working for several months (June-September 2007) thus created a both. Two (2) had black and white photos; policy serious backlog. Additional employees were assigned to assist in requires they be in color. six (6) files exceeded the this process as at the time the equipment was repaired there was four (4) year timeframe required by policy. a backlog of 175 inmates needing photos. Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Corrective action verified: Monitored on 11/5/07 and eating utensils were individually wrapped. Monitored on 11/5/07 and food was still not at the required temperatures. AWO Collins and F/Mgr. Logan are working to come up with a solution. At this point, temperatures are not consistently at the required temperature. No copies of Health Care Discharge Summary CR3616 could be located. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Corrective action verified: Monitor checked searches daily and LIBQ/LIBR are now being done for cell searches where contraband is found. 11/21/07 CMD note: This issue was not caused by equipment malfunction. The photos had been made, but were not placed in the IIR, as required. 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR NOVEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 11/8/07 Yes 11/19/07 Yes Monitoring Instrument Security and Control Counts Special Management Inmates ITEM NON-COMPLIANCE ISSUE NO. 4a NIN While monitoring the 4:30 am count in I pod on November 5, 2007, the control room light was showing unsecure for cell IA-110. Both officers said no one was assigned to that cell. However, the count room had 2 inmates assigned to cell IA-110. One inmate had been moved to cell IA-103 and the other had been moved to cell IA-107. The count room was not notified that these inmates had changed cells. This apparently meant that these inmates were not properly accounted for on TOMIS or the count room locator board, and had gone through counts uncorrected. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Wardens response dated 11/15/07: A directive has been given to facility employees that in no circumstance are inmates to be moved without count room approval. The employee who initiated these moves was identified and corrective action has been taken. Unit Managers and other supervisory staff are conducting meetings with line staff to ensure all staff know not to move inmates unless approved by the count room. This has also been added to the Warden's agenda for the upcoming staff recall meetings on November 27th that all employees are expected to attend. Wardens response dated 12/3/07: The facility agrees that staff assigned to supervise and monitor the segregation unit activities had failed to follow applicable policy and post orders resulting in Per TDOC incident #721199, on November 16, 2007 this incident. As a result of this incident a thorough review of at approximately 12:30 p.m., a maximum custody segregation operations was conducted by external CCA inmate and a protective custody inmate were placed management staff and areas were identified that contributed to this in the recreation cage together. The max. inmate incident. A number of immediate actions were taken to ensure a pulled a 10 inch homemade weapon and held to the higher level of supervision and accountability of staff assigned to PC inmate's throat. Verbal attempts by the Mental the recreation unit and to full compliance with TDOC/CCA policies Health Supervisor and Nurse Practitioner were and post orders. In addition, a meeting was held with Managing successful to retrieve the weapon. No use of force or Director Kevin Myers and Wardens of all 3 TDOC contract injury resulted. facilities. This meeting addressed segregation concerns at WCFA, HCCF and SCCF and outlined a plan to establish a focus team to evaluate current operations at each facility. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 3 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 1/7/08 CMD note: This item is identified as an Essential item. It has been determined that a Breach notification will not be issued at this time; however, a letter of concern will be sent addressing this issue. 1/7/08 CMD note: This issue, due to the significance of the incident, is being considered an Essential requirement. As such, a notification of Breach is being drafted for distribution. 9/07 monthly WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR DECEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 7/19/07 9/19/07 Yes Yes Monitoring Instrument Security Equipment Use of Force ITEM NON-COMPLIANCE ISSUE NO. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 1 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS 1/31/08 CMD note: The issue of proper procedures for the issuance and documentation of security equipment, including chemical agents, needs to be effectively addressed. The monitor is requested to verify the effectiveness of the corrective action taken within 30 days. If the problem persists, another NCR should be issued. 11/21/07 CMD note: Verified 12/4/07: Equipment The theft of the chemical agent was an illegal act by an issuance properly documented in individual acting outside of Policy, however, the logs. accountability for chemical agents and the secure storage and accessibility to such security devices is an institutional and contractual issue. This is a valid compliance concern. The monitor will check the appropriate storage, issuance, use and accessibility to chemical agents to verify that appropriate corrective action has been taken. 4 Warden’s response July 24, 2007: The Warden concurs that the item was found to be missing from Central Control and was not logged out. He also indicates that an investigation was conducted and remains open, but has not identified the person responsible, and that it appears to have been stolen rather than issued and not WCFA staff notified TDOC Liaison that a MK IX returned. He states that this is not a contractual violation but is chemical agent fogger was missing from central rather the act of an individual acting outside the scope of their control. There is no record in the equipment issuance employment and the policies and practices of the facility. Both the log in Central Control that the fogger was issued. CD and CM were fully apprised as well as the Acting Assistant Commissioner . An LIBJ entry was made in accordance with TDOC policy. No 5-1 packet was provided to TDOC because one was not prepared. This incident is not categorized as requiring a 51 packet. 3h Warden's response September 24, 2007: Facility attempted to reach CD within the hour time frame but the time shown on the incident report was the actual time that contact was made. There On two different incidents, one on 6-2-07 and one on are times when the supervisors are unable to reach CD within the Verified 12/7/07: All notifications 8-14-07, notification exceeded the one (1) hour specified time frame. In the future if the CM is not immediately have been within required time. timeframe. available, call will be made to the CM. Additionally supervisors will log times in report that calls were made with no answer and if neither the CD or CM can be reached then Turney Center will be notified. 11/21/07 CMD note: The procedures cited in the response to this NCR as corrective action to be taken are already required by Policy. The monitor will check subsequent Use of Force notifications to verify that Policy is now being adhered to. 10/30/07 CMD note: This is the 2nd instrument in 12 months on which this item has been found in non-compliance. A third noncompliance finding will trigger a Breach. 1/31/08 CMD note: The non-compliance finding for this item is being removed. The problem is addressed separately and sufficiently by findings for other monitored items. The issue of proper procedures for the issuance and documentation of security equipment, including chemical agents, needs to be effectively addressed. 9/19/07 Yes Use of Force 4a The requirements of the applicable approved Use of Force policies were not followed concerning issuance Warden's response: September 24, 2007: See 3h above and 7e of chemical agents and reporting use, as noted in below. Items 3h above and 7e below. 9/19/07 Yes Use of Force 7e Redacted 7i Warden's response September 24, 2007: The facility concurs that On 7-22-07, at 7:20 p.m. a MK 9 fogger was used in a the staff in central control failed to log the issuance of OC in this Use of Force incident. There is no record of a MK9 Repeat finding 12/7/07 below. instance as required. Corrective steps have been taken to fogger being issued by Central Control. address their failure. 9/19/07 Yes Use of Force TDOC MANAGEMENT COMMENTS/NOTES Repeat finding 12/7/07 below. 9/27/07 Yes Security and Controls Counts 1b On 9-3-07, 9-12.07 and 9-21-07, there were count slips filled out incorrectly or not in their entirety. Warden's response October 3, 2007: "Facility agrees... a meeting was held with all Shift Supervisors and Count Room Officers to conduct Corrective Action Verified training on the proper count procedures and expectations of count. 11/7/07: Count slips were Additionally, the Shift Supervisors will personally observe the count procedure while each count is being conducted and...the Chief of Security completed accurately. will monitor the count procedure and the Shift Supervisors..." 9/27/07 Yes Security and Controls Counts 4d On 9-25-07, at 10:30 am count, all out-count slips were not received prior to count being announced. Same as above. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Corrective Action Verified 11/5/07: Paperwork received prior to count being announced. WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR DECEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 10/3/07 Yes 10/3/07 Yes 10/24/07 10/31/07 11/8/07 11/19/07 Monitoring Instrument Food Service Food Service Yes Release and Pre-Release Yes Inmate Identification Yes Security and Control Counts Yes Special Management Inmates ITEM NON-COMPLIANCE ISSUE NO. 2 34b 16 2 4a NIN CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 2 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS Warden's response dated 10/18/07: Facility concurs and the On 7-29-07, sack lunches were served for the dinner following actions have been taken to correct the identified areas: meal, however, no documentation could be found to All substitutions will have a hard copy of form sent to AW and will support this substitution. be checked to verify they are being properly completed; Corrective Action Verified December 18, 2007: All substitutions had documentation. Warden response dated 10/18/07: A warming cart is now being On two different dates, hot food delivered to used to transport trays from FS to seg unit and meals will be segregation unit never reached required temperature checked on a random basis each week by the Chief of Security of 140 degrees. and the FS Manager for temp compliance. Outstanding: Monitored on 11/5/07 and food was still not at the required temperatures. AWO F/Mgr. are working to come up with a solution. At this point, temperatures are not consistently at the required temperature. Wardens response dated 10/30/07: Facility concurs that this document has not been maintained in the medical files. As verified No copies of Health Care Discharge Summary CRby the facility IPO's WCFA medical staff have been completing the 3616 could be located. required document and forwarding to the IPO's but have not retained and filed a copy. Wardens response dated 11/2/07: Facility concurs that the files Inmate Institutional Files, Volumes I & II were were in non-compliance as stated and a process to ensure checked on twenty-five (25) files. Thirteen (13)were compliance has been initiated. However would note that the noncompliant in regards to the Face Sheet. Five (5) TDOC equipment used to take and print the photos was not were missing the face sheet either in Volume I or II or working for several months (June-September 2007) thus created a both. Two (2) had black and white photos; policy serious backlog. Additional employees were assigned to assist in requires they be in color. six (6) files exceeded the this process as at the time the equipment was repaired there was four (4) year timeframe required by policy. a backlog of 175 inmates needing photos. Wardens response dated 11/15/07: A directive has been given to facility employees that in no circumstance are inmates to be moved without count room approval. The employee who initiated The count room was not notified that 2 inmates had these moves was identified and corrective action has been taken. changed cells. This apparently meant that these Unit Managers and other supervisory staff are conducting inmates were not properly accounted for on TOMIS or meetings with line staff to ensure all staff know not to move the count room locator board, and had gone through inmates unless approved by the count room. This has also been counts uncorrected. added to the Warden's agenda for the upcoming staff recall meetings on November 27th that all employees are expected to attend. Wardens response dated 12/3/07: "The facility agrees that staff...failed to follow applicable policy and post orders... As a result of this incident a thorough review of segregation operations Per TDOC incident #721199, on November 16, 2007 was conducted by external CCA management staff... A number of at approximately 12:30 p.m., a maximum custody immediate actions were taken to ensure a higher level of inmate and a protective custody inmate were placed supervision and accountability...In addition, a meeting...with in the recreation cage together. Managing Director Kevin Myers and Wardens of all 3 TDOC contract facilities...addressed segregation concerns at WCFA, HCCF and SCCF and outlined a plan to establish a focus team to evaluate current operations at each facility." Instrument name and Item numbers for Liquidated Damages issues are in BOLD print TDOC MANAGEMENT COMMENTS/NOTES Corrective Action Verified December 21, 2007: Checked medical files, a copy of CR-3616 is being kept now. Corrective Action Verified 11/21/07 CMD note: This issue was not caused by December 12, 2007: All files equipment malfunction. The photos had been made, have been checked and face but were not placed in the IIR, as required. sheets are in the files as required. Monitors Note: On 12/19/07 went to the unit to verify that the 1/31/08 CMD note: Letter of Concern issued problem had been fixed. An 1/16/08. 1/7/08 CMD note: This item is identified as an Inmate, according to LIMC/count Essential item. It has been determined that a Breach room was assigned to IA202, but notification will not be issued at this time; however, a he was living in IA103. Therefore I letter of concern will be sent addressing this issue. will continue to monitor compliance on this item. 1/31/08 CMD note: Breach letter issued 1/16/08. 1/7/08 CMD note: This issue, due to the significance of the incident, is being considered an Essential requirement. As such, a notification of Breach is being drafted for distribution. WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR DECEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 12/4/07 12/4/07 12/4/07 12/4/07 12/4/07 12/4/07 12/4/07 Monitoring Instrument No Drug Testing and Substance Abuse Treatment No Drug Testing and Substance Abuse Treatment No Drug Testing and Substance Abuse Treatment No Drug Testing and Substance Abuse Treatment No No No Drug Testing and Substance Abuse Treatment Drug Testing and Substance Abuse Treatment Drug Testing and Substance Abuse Treatment Page 3 DATE/METHOD OF CONFIRMATION BY TDOC MANAGEMENT COMMENTS/NOTES MONITOR/COMMENTS Corrective action verified on Wardens response dated 12/4/07. WCFA concurs with the 1/8/08. Checking LIBJ daily and There were ten (10) positive drug screens. Four (4) noncompliance issues. Staff did not follow already established maintaining tickler file on all inmates never received a disciplinary for this charge. 2e procedures to ensure all DR's were logged, entered printed and positive drug screens to ensure (They were entered into the computer, but never served. This resulted in some DR's being entered but proper procedures are followed. issued.) Essential Item. unprocessed. No finding of non-compliance since this NCR. Corrective action verified on Four (4) inmates never received a disciplinary charge. Wardens response dated 12/4/07. WCFA concurs with the 1/8/08. Checking LIBJ daily and (They were entered into the computer, but never noncompliance issues. As noted above the 4 not charged were the maintaining tickler file on all 2h issued.) Therefore, this resulted in no charge for the result of employee negligence. The 2 that were heard but not positive drug screens to ensure test. In addition, two (2) inmates found guilty were not assessed the test fee were found to have occurred when a new D- proper procedures are followed. charged the lab confirmation test cost. Board clerk assumed that responsibility and made the error. No finding of non-compliance since this NCR Wardens response dated 12/4/07. WCFA concurs with the noncompliance issues. These inmates will be drug tested this Corrective action verified on It was verified that four (4) inmates did not receive an week. Additionally, upon admission into the Drug and Alcohol 1/8/08. ATU Manager is now 8c initial drug screening upon being moved into J Program, the ATU Manager will ensure that the inmates receive an maintaining listing and ensuring housing unit in September and October. initial drug screen. The ATU Manager is currently creating a step drug screens are placed in the by step procedure to ensure that this will be completed once an treatment file. inmate is admitted into the program. Wardens response dated 12/4/07. The ATU Manager will be implementing a detailed process and spreadsheet to ensure that Corrective action verified on Treatment plans are not being completed within the the treatment plans are completed within the thirty (30) day 1/8/08. Treatment plans are now 8d(1) thirty (30) day requirement. requirement. The staff will be conducting a complete audit of the being completed within the program files to ensure all required paperwork has been required time frame. completed. ITEM NON-COMPLIANCE ISSUE NO. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN The Participation Agreements CR-3586 were not 8d(2) completed in eight (8) out of twenty (20) files. Wardens response dated 12/4/07. The ATU Manager will ensure that this form is completed within the intake into the program paperwork. Corrective action verified on 1/8/08. The Participation Agreement CR-3586 is now being completed as required. The program drug test copy was not in the program file. Wardens response dated 12/4/07. In the past, the drug test copies were stored in the ATU Manager's office. That procedure has changed and the copies will be placed in the inmate's program file. Therefore, this part of the admission process will also be placed on a spreadsheet to ensure that it is being completed. Corrective action verified on 1/8/08. ATU Manager is now maintaining listing and ensuring drug screens are placed in the treatment file. The program file did not contain the completed assessment form. Wardens response dated 12/4/07. The ATU Manager will ensure that this form is completed upon admission into the program. After the new process is set up, the staff will be conducting a complete audit of the program files to ensure all required paperwork has been completed. Corrective action verified on 1/8/08. The assessment form has been completed on all inmates in the ATU program. 8d(3) 8e Instrument name and Item numbers for Liquidated Damages issues are in BOLD print WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR DECEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 12/7/07 12/7/07 12/7/07 12/7/07 12/7/07 12/7/07 12/7/07 Monitoring Instrument ITEM NON-COMPLIANCE ISSUE NO. CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN No Security and Control Security Equipment 5 MK 3 Fogger actual count was nine (9). Perpetual inventory showed ten (10). October and November monthly inventories showed twelve (12). Essential. No Security and Control Security Equipment 6 Documented inventories present, however due to Wardens response dated 12/12/07. Weekly inventories will be Item 5 above, inventoried did not match the perpetual conducted and any discrepancies will be immediately reported to records. the Chief of Security and the Duty Officer. No Security and Control Security Equipment 7 Redacted No Security and Control 12a (1) Redacted Security Equipment No Security and Control Security Equipment 12b Quarterly reports are not being done for key inventories. Essential. No Security and Control Security Equipment 12c Redacted No Security and Control Security Equipment NIN Wardens response dated 12/12/07. A complete inventory has been scheduled for the week of 12/17/07. Wardens response dated 12/7/07. Quarterly reports will be documented in regards to keys in the future. On 11-6-07, 11/12/07, and 11/27/07 the concave Wardens response dated 12/7/07. Supervisors have been given shield was used but no record of it being checked out clear directives that they will be held accountable for ensuring the in the armory. items are signed out and back in when used. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print Page 4 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES 2/1/08 CMD note: Per Policy, essential items found in non-compliance may result in a breach determination regardless of the number of times the item has been found in non-compliance. At this time, a breach determination is being held in abeyance in this instance, however, another finding of non-compliance for this item in the next 12 months shall result in a breach finding and immediate assessment of liquidated damages. See 2/1/08 CMD note above. 1/31/08 CMD note: The issue of proper procedures for the issuance and documentation of security equipment, including chemical agents, needs to be effectively addressed. The monitor is requested to verify the effectiveness of the corrective action taken within 30 days. If the problem persists, another NCR should be issued. WCFA SUMMARY OF NON-COMPLIANCE NOTIFICATIONS FOR DECEMBER 2007 OUT- DATE OF STANDING REPORT ISSUE Y/N 12/11/07 12/11/07 No No Monitoring Instrument Use of Force Use of Force ITEM NON-COMPLIANCE ISSUE NO. 4a 7e 12/11/07 No Use of Force 7i 12/11/07 No Use of Force NIN CONTRACTOR RESPONSE/DATE/ CORRECTIVE ACTION TAKEN Page 5 DATE/METHOD OF CONFIRMATION BY MONITOR/COMMENTS TDOC MANAGEMENT COMMENTS/NOTES Wardens response dated 12/11/07, The Warden concurs that central control staff and shift supervisors have failed to maintain The requirements of the applicable approved Use of issuance logs appropriately and in accordance with policy. Force policies were not followed concerning issuance Expectations have been communicated to all staff responsible and of chemical agents and reporting use, as noted in to the managers they report to. Procedures are in place and Items 7e and 7i. Repeat finding - NCR dated management will be ensuring staff comply with the policy(s). A 9/19/07. tracking process has been implemented to provide oversight and ensure employees continue to follow procedures. 1/31/08 CMD note: The non-compliance finding for this item is being removed. The problem is addressed separately and sufficiently by findings for other monitored items. The issue of proper procedures for the issuance and documentation of security equipment, including chemical agents, needs to be effectively addressed. On 11/30/07, six (6) cans of MK9 were issued to a correctional officer with no authorizing supervisor's signature. Repeat finding - NCR dated 9/19/07. 1/31/08 CMD note: The issue of proper procedures for the issuance and documentation of security equipment, including chemical agents, needs to be effectively addressed. The monitor is requested to verify the effectiveness of the corrective action taken within 30 days. If the problem persists, another NCR should be issued. Same as above. On 12/3/07, incident #723026 MK9 was used in a Use of Force incident. On 11/14/07, incident #720934 MK9 was used in a Use Force incident. There was no Same as above. record of MK9 being issued by Central Control in either of these incidents. Repeat finding - NCR dated 9/19/07. On 10/29/07, log shows one MK9 in the cabinet with Chief of Security being notified. Explanation entered on 11/1/07 that canister was empty and removed by Captain. Armory personnel are to remove/add canisters. On 11/8/07, log sheet showed three (3) MK9's exchanged but the count was changed to four Same as above. (4). Also supervisors are not signing the central control chemical agent check out log consistently. Note: There were fourteen (14) occasions during the monitoring period (Oct. 1-Dec.7) that the supervisor did not sign the central control check out log for chemical agents. Instrument name and Item numbers for Liquidated Damages issues are in BOLD print 1/31/08 CMD note: Same as above. 1/31/08 CMD note: Same as above.