Department of Justice (DOJ) Inspector General Michael E. Horowitz announced today the release of an inspection of the Federal Bureau of Prisons’ (BOP) Federal Correctional Institution (FCI) Lewisburg, a medium-security male prison in Pennsylvania with an adjacent male minimum-security prison camp. The on-site inspection, which occurred February 5–9, 2024, was the fourth unannounced inspection under the DOJ Office of the Inspector General’s (OIG) on-site BOP inspections program.
The DOJ OIG identified several serious operational deficiencies at FCI Lewisburg. Among the most concerning were the misalignment of staffing-level estimations from different stakeholders, the abrupt discontinuation of some inmates’ antidepressant medications, and violations of BOP guidance that directly compromise the institution’s ability to effectively and timely respond to suicide attempts.
Our findings include:
- Current Staffing Levels and FCI Lewisburg Executive Leadership’s Assessment of the Institution’s Staffing Needs Differ Significantly with Preliminary Staffing Projection Tool Estimates. Specifically, we found that a BOP-hired contractor’s staffing projections for Correctional Services, Correctional Systems, and Health Services yielded significantly lower totals for the facility’s appropriate staffing than FCI Lewisburg’s current staffing levels and its estimates of staffing needs. This misalignment was particularly pronounced in Correctional Services. This misalignment limits the BOP’s ability to ensure that it can reliably and effectively accomplish its missions, and the safety and efficacy of FCI Lewisburg’s recently expanded operations could be impaired.
- Abrupt Discontinuation of Antidepressant Medications for Some Holdover Inmates Does Not Align with BOP Clinical Guidance. We found that 15 of the 121 holdover inmates that arrived at FCI Lewisburg during the week of our inspection had mental health medication prescriptions abruptly discontinued. These medications included antidepressants, which are prescribed to address a variety of mental health conditions including anxiety disorder, obsessive-compulsive disorder, and major depressive disorder. We found that many antidepressant drugs were discontinued abruptly instead of being tapered over 4 weeks as recommended by BOP clinical guidance for management of major depressive disorders. Such abrupt discontinuation can cause an inmate to experience antidepressant withdrawal and increase the risk of major depression relapse and suicide.
- Prevalent Single-Celling of Inmates in Restrictive Housing, as Well as Employees Not Carrying Cut-Down Tools as Required, Increases Opportunities for Inmate Deaths by Suicide. BOP policy strongly discourages single-celling to the greatest extent possible, particularly in restrictive housing. Single-celled inmates have an increased opportunity to attempt suicide given the privacy they are afforded. We found that, at the time of our inspection, 18 percent (13 of 71) of FCI Lewisburg’s inmates in restrictive housing were in single-cell confinement. Additionally, not all employees who were required to carry a cut-down tool to respond to inmate hanging attempts did so. BOP policy requires certain Correctional Officers to carry a cut-down tool because it improves response time on suicide attempts by enabling ligatures to be cut more quickly and lifesaving measures to begin more promptly.
- Employee Professional Concerns Potentially Affect FCI Lewisburg’s Work Environment. We identified several concerns that could create a hostile work environment for BOP employees. For example, we observed multiple examples of obscene and sexually abusive graffiti degrading certain FCI Lewisburg employees and significant allegations of verbal abuse by a subset of institution employees toward inmates and other employees. We also observed in employee-only-access areas that inmate-drawn prison gang artwork was displayed, including Nazi iconography associated with white-supremacist gangs. The BOP asserted that the artwork contained gang-related symbolism that was important for BOP employees to know about and be able to recognize.
The OIG made three recommendations to assist the BOP in addressing risks identified at FCI Lewisburg. These recommendations are consistent with requirements outlined in the recently passed Federal Prison Oversight Act. The BOP agreed with all of the recommendations.