Part A: Major Findings

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

A. Activation and Early Period of Operations at Youngstown

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

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

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

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

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

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

B. Continuing Issues and Concerns

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Major Recommendations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Additional Recommendations

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

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

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

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

Executive Summary

Part C: Narrative Description

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

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

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

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

A. Background Developments

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

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

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

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

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

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

B. Rapid Procurement Process

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

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

• certain key performance requirements are weak;
• the final cost to the District was considerably higher than the early CCA proposal, with no corresponding increase in services;
• there is no sufficient provision to penalize the contractor with liquidated damages or to resolve issues of noncompliance or unacceptable performance; and
• there were no provisions for a staffing pattern which included seasoned supervisors or an adequate start-up period to deliberately phase in the inmate population.

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

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

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

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

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

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

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

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

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

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

D. Selection and Classification of Cases for NEOCC

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

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

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

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

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

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

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

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

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

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

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

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

E. Security Issues

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

• Six inmates escaped from the facility;
• Two homicides occurred, including one between known enemies in the high security unit, involving breakdowns in a number of critical procedures;
• Approximately 17 inmates were stabbed and numerous other serious assaults against staff and inmates transpired;
• Since the onset, numerous homemade weapons were discovered;
• For lengthy periods, the facility was forced to operate under full or partial lock-down to prevent further incidents.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Failure of proper supervision by the shift commanders. This is the most glaring breakdown and is a direct reflection on the management of the facility;
• Inattention to duty by staff assigned to the yard;
• Inadequate plan for external supervision of the yard by staff in the perimeter vehicles;
• Vulnerable physical security of the perimeter fence area;
• Poor policy and procedures;

• Inmate access to a cutting tool, combined with a malfunctioning metal detector; and

• Inadequate fence alarm testing.

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

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

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

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

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

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

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

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

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

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

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

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

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

• Procedures at the front entrance and the vehicle entrance were significantly flawed, leaving the facility vulnerable to potential failure and escape through those exit points. A course of immediate, corrective action was recommended and was being considered by the warden.
• NEOCC or CCA corporate management lacked evident built-in capacity to perform necessary in-depth security audits.

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

F. Management of Inmate Population

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

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

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

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

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

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

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

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

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

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

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

G. Operational Management and Controls, A Reactive Mode

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

H. External Relations and Public Accountability

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

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

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

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

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

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

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

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

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

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

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

I. Staffing/Human Resource Management

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

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

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

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

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

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

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

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

J. Health Services Management

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

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

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

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

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

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

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

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

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

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

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

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

K. Contract Oversight and Management by DOC

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

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

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

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

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

L. Summary of Current Status of NEOCC

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

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

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

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

Chapter I

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

A. The City of Youngstown, Ohio

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

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

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

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

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

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

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

Other standard provisions provided that CCA:

• abide by all federal, state and local statutes and rules,
• seek and obtain ACA accreditation,
• maintain an in-house inmate grievance system,
• not release non-local prisoners into the Youngstown community,
• provide security at its expense for the local transportation of all inmates, and
• establish and maintain a mutually agreed upon emergency plan approved by the City Police Chief in case of a labor or inmate dispute, riot, fire, civil disaster or power failure which plan defined the relationships of CCA to the local, state and federal law enforcement agencies.

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

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

C. District of Columbia Department of Corrections

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

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

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

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

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

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

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

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

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

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

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

Because of various pressures or deficiencies in the system, placement of prisoners among the institutions often was haphazard and inconsistent with the traditional methods used to determine the appropriate classification. Large groups of the inmates housed in these "medium" facilities at Lorton would have been considered of a higher custody in oth