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

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

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

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

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

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

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

[Description omitted; CSOSA 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.]

BOP should reassess its policies to ensure that SHU round documentation is preserved for the possible use of such documentation as original evidence in criminal and administrative investigations and proceedings. As part of this reassessment, the BOP should, among other things, consider (1) adjusting its records retention schedule for SHU round forms; and (2) amending its policies to ensure that staff responding to crime scenes associated with inmate misconduct also collect evidence of potentially related staff misconduct, such as SHU round documentation, and account for the possible use of such evidence as original evidence in criminal and administrative investigations and proceedings.

BOP should modify its policies regarding SHU round forms, including BOP Program Statement 5500.14, Section 310, to refer employees to the document retention schedule for SHU round forms, or otherwise ensure that its employees across all institutions are aware of the retention schedule.

BOP should ensure that all Special Investigative Services Staff, Executive Management Staff, staff involved with evidence collection and preservation, and other relevant staff are trained/advised on how to preserve SHU logs and to recognize when they may be needed as original evidence in criminal or administrative investigations and proceedings, e.g., when there is an escape or death in custody and the original log may reflect who purportedly conducted round counts during the pertinent time period.

[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.]

Develop strategies to ensure that staff assign accurate, consistent, and timely Mental Health Care Level designations to inmates.

Ensure that all institutions conduct required mock suicide drills, and develop strategies to increase staff participation in those drills.

Ensure that all appropriate staff are trained in automated external defibrillator use and that automated external defibrillators are strategically placed, readily available, and regularly checked to ensure that they are in working order at each BOP institution.

Ensure that cut-down tools in working order are accessible to staff in each housing unit at each institution, that staff are trained on proper use of the tool, and that the BOP determines whether staff should be issued and required to keep their own cut-down tool on their duty belt during their entire shift.

Ensure that each institution has a sufficient number of maneuverable gurneys in strategic locations to provide proper medical response during inmate transport.

Issue standard, enterprise-wide guidance and training to staff on using the radio to communicate clear, descriptive information during inmate medical emergencies.

Ensure that staff receive both the initial and refresher naloxone training and are fully prepared to administer naloxone to an unresponsive inmate suspected of having experienced a drug overdose.

Ensure that all Evidence Recovery Teams are properly trained on post-incident evidence recovery protocols.

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.