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DOJ OIG Releases Reports of Remote Inspections of BOP FCI Terminal Island and FCC Coleman Examining the Institutions’ Responses to the COVID-19 Pandemic

Department of Justice (DOJ) Inspector General Michael E. Horowitz announced today the release of the eleventh and twelfth reports in a series of remote inspections the Office of the Inspector General (OIG) has been conducting of Federal Bureau of Prisons (BOP) facilities.  Today’s reports concern Federal Correctional Institution (FCI) Terminal Island, located in San Pedro, California (Terminal Island), and Federal Correctional Complex (FCC) Coleman, located in Sumterville, Florida.

The OIG’s findings for Terminal Island included the following:

    • FCI Terminal Island Cases.  FCI Terminal Island’s first staff member tested positive for COVID-19 on April 5, 2020, and its first inmate tested positive on April 10.  On April 13, the institution reported its first inmate death related to COVID-19.  From April 20 through June 21, another 9 inmates died after contracting COVID-19, for a total of 10 inmate deaths.  As of January 6, 2021, no inmates were positive, 11 staff members were positive, and 543 inmates and 26 staff members had recovered from COVID-19. 
    • Testing.  In April 2020, the institution tested its entire inmate population for COVID‑19; but, by the time testing was completed, nearly half of the inmate population was already infected.  Terminal Island officials told us that this universal testing was crucial to being able to move COVID-19 negative and positive inmates into distinct housing units, some newly erected or converted, to manage the COVID-19 outbreak.  However, our analysis showed that 107 negative inmates in 2 housing units remained housed with 129 positive inmates in those units for between 4 and 5 days after the institution received their test results.  While FCI Terminal Island complied with BOP guidance on inmate testing, 5 of the 10 Terminal Island inmates who died after contracting COVID-19 did not receive a COVID‑19 test until after staff sent them to the hospital.  Terminal Island staff told us that three of these five inmates did not initially show COVID-19 symptoms at the institution and that staff sent the other two inmates to the hospital the same day that staff identified their symptoms.
    • Family Notifications.  Terminal Island staff did not comply with BOP policy to notify the families of inmates with serious illness.  In one instance, the inmate was on a ventilator in the hospital for 6 days due to COVID-19 and ultimately died.  Officials from the BOP’s Central Office and Western Regional Office told us that the institution’s lack of notification to the family was an oversight. 
    • Social Distancing.  Beginning in May, FCI Terminal Island complied with BOP guidance to maximize social distancing in the institution but experienced challenges in enforcing social distancing among inmates in open dormitory housing areas.
    • Quarantining.  The OIG’s April survey of FCI Terminal Island staff indicated that institution staff may not have been quarantining inmates according to BOP guidance prior to the movement of inmates to alternative housing.  Our analysis of institution documentation showed that one of the alternative housing areas the institution added to accommodate the need for quarantining did not meet BOP standards for housing on several occasions.
    • Personal Protective Equipment.  FCI Terminal Island complied with BOP guidance regarding the use of personal protective equipment (PPE) in correctional settings.  While Terminal Island officials we interviewed told us that staff had consistent access to adequate PPE, staff survey responses and one staff interview indicated that having adequate PPE was a challenge for staff and inmates. 





The OIG’s findings for FCC Coleman included the following:

    • FCC Coleman Cases.  As of January 3, over 833 FCC Coleman inmates and 175 staff had tested positive for COVID‑19; 5 inmates and 1 staff member died as a result of the disease.  As of January 3, FCC Coleman reported 15 active cases among its approximately 5,288 inmates and 118 active staff cases among its approximately 1,322 federal staff.
    • Medical Staffing.  At a time when an adequate number of medical staff was crucial for controlling the transmission of COVID-19 in correctional settings, FCC Coleman operated with only 80 percent of its authorized medical staff at the onset of the COVID-19 pandemic.
    • Quarantine and Medical Isolation Facilities.  FCC Coleman had adequate space to quarantine and medically isolate inmates affected by COVID-19; however, the physical layout of the FCI Low and the Satellite Prison Camp (Camp) required Coleman staff to quarantine nearly 1,000 inmates when an FCI Low inmate tested positive for COVID-19.  The 14-day quarantine period significantly added to the workload of the medical staff, who were required to conduct twice daily temperature checks.  It also increased the inmates’ concerns of contracting COVID-19 due to FCI Low’s open, dormitory-style layout.
  • Access to Face Coverings and Sanitation Items.  Prior to the issuance of the BOP and DOJ policy on face coverings, the leadership at FCC Coleman denied staff the option to wear personally acquired face masks.  We concluded that this led to staff concerns that their safety was not a priority for management.  Although FCC Coleman management and some staff told us that the inmates had adequate access to hand soap, alcohol-free hand sanitizer, and other handwashing items provided by the BOP or available in the commissary, the results of the OIG’s survey of FCC Coleman staff and Hotline complaints from inmates received by the OIG indicated that staff and inmates perceived deficiencies in this area.





Today’s reports do not include recommendations.  Rather, our inspection reports are intended to assist the BOP and DOJ in identifying strategies to most effectively contain current and future COVID‑19 outbreaks.  Additional reports of the OIG’s remote inspections will be released as they are completed.  The DOJ OIG also plans to prepare a capstone report providing BOP-wide conclusions and recommendations resulting from our inspections.  

Dashboards:  The DOJ OIG maintains a collection of interactive dashboards with data on COVID-19 case trends, testing trends, and deaths due to COVID-19 in BOP-managed correctional facilities.  View the dashboards here: https://experience.arcgis.com/experience/ab22fb4c564e4f4b986e257c685190e8/.  

Background: In April 2020, the OIG initiated a total of 16 remote inspections of selected BOP-managed institutions; contract prisons; and Residential Reentry Centers (RRC), sometimes referred to as halfway houses, to examine whether their response to the COVID-19 pandemic was in compliance with DOJ and BOP policy and pandemic-related guidance issued by the Centers for Disease Control and Prevention (CDC).

Our inspections have been conducted through telephonic interviews; review of BOP documents and complaints we have received; our analysis of data from the respective institutions; and the results of a survey we issued to employees of the BOP, contract prisons, and RRCs.  The OIG conducted these inspections remotely because of CDC guidelines and DOJ policy on social distancing.


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