Develop procedures to ensure that all required death-related records are completed and collected consistently and in accordance with established deadlines.

Assess the benefit and feasibility of expanding its policy requiring After Action Reviews to include reviews of all inmate homicides and deaths by accidental and unknown factors, not just for inmate suicides.

Clarify responsibility for tracking at an enterprise level the reports and recommendations required in the wake of an inmate death by suicide, homicide, accident, or unknown factors, and assess the information contained therein for broader trends, applicability, and implementation.

Evaluate existing electronic devices used for inmate screening to identify whether they are functioning as intended, and, if necessary, implement any needed adjustments or upgrades.

[Description omitted; DOJ has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; DOJ has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; DOJ has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; DOJ has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; DOJ has determined that this recommendation contains information that is limited official use or classified.]

Re-evaluate aged seized digital assets to consider whether risks of misstatement related to accurate valuation, existence, and ownership of assets have been adequately addressed considering the evolving nature of digital asset seizures. Based on the results of the evaluation, design and implement processes, procedures, and controls to appropriately account for aged digital assets. (New)

Determine whether a secure enclosure in which an inmate's movement is significantly restricted due to its size is considered a restraint and, if so, update its policies to make this clear.

Amend its policies to address secure enclosures, including the appropriate use(s) of a secure enclosure, the physical dimensions of an appropriate secure enclosure, the approvals required for using secure enclosures as temporary holding cells, how inmates should be monitored and treated while confined in secure enclosures, and how long an inmate may be kept in a secure enclosure.

Remedy the $301,222 in unsupported questioned costs for Grant Number 2019-VM-BX-00014.

Remedy the remaining balance of Grant Number 2019-VM-BX-0014 totaling $191,690 in funds to be put to better use.

In coordination with the BOP and USMS: (a) evaluate what use-of-force requirements and restrictions should apply to custodial situations, and (b) ensure these requirements are incorporated into DOJ, BOP, and USMS policies.

Evaluate components' determination on the applicability of DOJ's 2021 Restraint and "No Knock" Guidance and 2022 Use-of-Force Policy to task force officers and contractors acting in a law enforcement capacity to ensure that legal and operational risks are adequately mitigated.

Remedy $76,929 in unsupported costs charged to the subawards.

1. The BOP should implement a process for assigning a cellmate following suicide watch or psychological observation, with criteria for exceptions based on the particular individual or security considerations.

2. The BOP should establish procedures to ensure inmates at high risk for suicide and for whom a cellmate is recommended will continue to have a cellmate until the recommendation is changed or rescinded, including establishing a contingency plan for cellmate re-assignment, with criteria for exceptions based on the particular individual or security considerations.

3. The BOP should evaluate its current process for obtaining and documenting approval for social or legal visits while an inmate is on suicide watch or psychological observation, which allows for institution-specific variations in the process, and provide guidance on standard components that each institution should include in its process to mitigate security issues that can arise when an inmate is on suicide watch or psychological observation.

4. The BOP should evaluate its methods of accounting for inmate whereabouts and wellbeing and make changes as may be appropriate to improve those methods through policy, training, or other measures.

5. BOP policy should clarify what is required of a Lieutenant when conducting a round.

6. The BOP should continue to develop and implement plans to address staffing shortages at its prisons.

8. The BOP should enhance existing policies regarding institutional security camera systems to ensure they specifically state that such systems must have the capacity to record video and that BOP institutions must conduct regular security camera system functionality checks.

The BOP should amend the language contained in Correctional Services Manual, 103, Section 1, so as to clarify whether the requirement to consult with medical staff prior to the use of OC spray on an inmate with a known history of respiratory or cardiovascular disease, chronic dermatitis, or psychosis applies to only calculated uses of force or both calculated and immediate uses of force.a. If, in response to recommendation 1, above, the BOP clarifies that the requirement to consult with medical staff prior to the use of OC spray on an inmate with a known history of respiratory or cardiovascular disease, chronic dermatitis, or psychosis applies in the context of an immediate use of force, then the BOP should also clarify within the Correctional Services Manual, 103, what constitutes an acceptable consultation with medical staff in such a situation. (If, based on the response to recommendation 1, there is no requirement to consult with medical staff prior to using OC spray in the context of an immediate use of force, then this recommendation (recommendation 1.a.) becomes moot and there is no need for the BOP to respond to it.)

The BOP should amend the language contained in Correctional Services Manual, 103, Section 1, so as to clarify whether the requirement to consult with medical staff prior to the use of OC spray on an inmate with a known history of respiratory or cardiovascular disease, chronic dermatitis, or psychosis applies to only calculated uses of force or both calculated and immediate uses of force.b. If, in response to recommendation 1, above, the BOP clarifies that the requirement to consult with medical staff prior to the use of OC spray on an inmate with a known history of respiratory or cardiovascular disease, chronic dermatitis, or psychosis applies in the context of an immediate use of force, then the BOP should also clarify within the Correctional Services Manual, 103, whether BOP staff must both consult with medical staff prior to the use of OC spray on an inmate with a known history of respiratory or cardiovascular disease, chronic dermatitis, or psychosis and avoid the use of OC spray on such an inmate unless other means of control have been attempted or deemed likely to be ineffective. (If, based on the response to recommendation 1, there is no requirement to consult with medical staff prior to using OC spray in the context of an immediate use of force, then this recommendation (recommendation 1.b.) becomes moot and there is no need for the BOP to respond to it.)

Evaluate its various tracking efforts for DVE-related case data to ensure that it has a holistic view of the threat and a consistent process for capturing, interpreting, and reporting DVE-related case data.

Develop a specific, multiyear plan for how the BOP will evaluate its ongoing and proposed changes to the employee discipline process, as well as key performance indicators, by year, to decrease the backlog of its employee misconduct cases and adjudications.

Develop and implement a reliable method to calculate appropriate staffing levels at the enterprise and institution levels. Such a method should seek to baseline appropriate staffing levels for the current inmate population and be flexible to account for future population changes overall and among institutions, as well as other factors (e.g., institution security level and layout) that determine appropriate staffing levels. Once such a method is developed, communicate the need to align funding levels with appropriate staffing levels to executive and legislative branch stakeholders.

Develop an infrastructure strategy to increase the overall effectiveness of facilities management. The strategy should align infrastructure decisions with the BOP's mission; include one or more methodologies for allocating resources; and include short, medium, and long-range planning goals. As part of this strategy, the BOP should consider incorporating a portfolio-based repair model; a retention or disposal decision model; and business case analyses for new construction, as appropriate.