Department of Justice (DOJ) Inspector General Michael E. Horowitz announced today the release of an inspection of the Federal Bureau of Prisons’ (BOP) Federal Medical Center (FMC) Devens in Ayer, Massachusetts. FMC Devens is composed of two facilities, an administrative-security medical center, housing inmates with serious medical or mental health conditions, and an adjacent minimum-security prison camp. The on-site inspection, which occurred April 22–April 26, 2024, was the fifth unannounced inspection under the DOJ Office of the Inspector General’s (OIG) on-site BOP inspections program.
The DOJ OIG identified several serious issues at FMC Devens. Notably, substantial shortages of healthcare employees and Correctional Officers—which is an issue at many BOP institutions but particularly problematic for a medical institution—have created widespread and troubling operational challenges at FMC Devens that substantially affect the health, welfare, and safety of employees and inmates.
Our findings include:
- Significant Staffing Shortages. Twenty percent of positions in Correctional Services were vacant, as well as 24 percent in Health Services and 39 percent in Psychology Services. After the Clinical Director retired in June 2024, FMC Devens had only 1 physician at the institution to provide daily patient care for over 900 inmates. Other vacancies within the Health Services Department included nearly half of the institution’s pharmacy positions, approximately a quarter of its nursing positions, and its Chief Dental Officer and Deputy Chief Psychologist.
- Serious Issues with FMC Devens’s Provision of Healthcare to Its Inmates. Significant and widespread staffing shortages in the Health Services Department compromise FMC Devens’s ability to provide adequate healthcare to inmates. Concerning healthcare practices include potentially dangerous practices related to the distribution of buprenorphine and naloxone; a backlog of outside medical visits that had yet to be scheduled and a discrepancy in the number of pending inmate medical records; inconsistent access to medical care for routine conditions; inconsistent routine screening of inmates over age 50 for preventive healthcare or cognitive impairment; not all inmates with a diabetes diagnosis being tested within required timeframes; not all healthcare provider credential files being verified according to BOP policy; improper placement of some inmates in the Memory Disorder Unit; and some medical inmate companions not meeting the BOP’s eligibility criteria and some performing duties outside the scope of a medical inmate companion.
- Two Safety and Security Issues Affecting the Safety of Institution Operations. Correctional Officers did not complete all inmate-monitoring rounds as required by policy, leaving vulnerable inmates unobserved for multiple hours each night. In addition, employee radios did not receive a signal in some parts of the institution, namely the hospital and areas below ground, and radios were beyond their serviceable dates, rendering many radios unrepairable.
- Staffing Shortages Limiting Opportunities for Inmates to Participate in Programs Designed to Prepare Them for Successful Reentry. FIRST STEP Act (FSA) programs offered by the Psychology Services Department had the longest waitlist across the institution, which employees attributed to staffing challenges in the Psychology Services Department. Additionally, programming for inmates with higher mental health care levels was prioritized, leaving inmates with lower mental health care levels with a lack of programming and resources. Moreover, shortages of Education Department employees limited FMC Devens from offering General Education Diploma courses, the Commercial Driver’s License program at the Camp, and the Certified Nursing Assistant program at the FMC. Lastly, although FMC Devens received $150,000 in FSA funds in FY 2021 to pilot the initial implementation of the FSA LifeSkills Laboratory program, the institution had yet to enroll inmates in this program as of fiscal year 2025.
- Several Unfunded Major Infrastructure and Equipment Repair Projects Presenting Safety and Security Issues. Many of the institution’s systems are approaching the end of their projected lifespan, and the roofs need repair. Officials estimated the cost of addressing these and other infrastructure issues to be approximately $15 million.
The OIG made 11 recommendations to ensure effective operations at FMC Devens and safe conditions of confinement for the inmates housed there. The majority of the recommendations relate to the quality of healthcare provided to FMC Devens inmates and the medical care issues we identified. These recommendations are consistent with requirements outlined in the recently passed Federal Prison Oversight Act. The BOP agreed with all of the recommendations.