United States Government Accountability Office

Report to Congressional Requesters

February 2024

BUREAU OF
PRISONS
Additional Actions
Needed to Improve
Restrictive Housing
Practices

GAO-24-105737

February 2024

GAO

Highlights

BUREAU OF PRISONS
Additional Actions Needed to Improve Restrictive
Housing Practices

Highlights of GAO-24-105737, a report to
congressional requesters.

Why GAO Did This Study

What GAO Found

DOJ’s BOP is responsible for
confining individuals in safe, humane,
and appropriately secure conditions.
In certain circumstances, such as
alleged or substantiated violence,
BOP can move individuals to
restrictive housing, and generally
isolate them in cells for up to 23
hours per day. As of October 2023,
BOP continued to house about 8
percent of its population (about
12,000 individuals) in these settings.
Strengthening management of federal
prisons was added to GAO’s high-risk
list earlier this year.

The Bureau of Prisons (BOP) has not fully implemented 54 of the 87
recommendations from two prior studies on improving restrictive housing
practices. The first study, completed by a BOP contractor in 2014, had 34
recommendations (16 of which are fully implemented.) The other evaluation,
completed in 2016 by the Department of Justice (DOJ), had 53 recommendations
(17 of those are fully implemented). A May 2022 Executive Order on criminal
justice practices directed the Attorney General to ensure full implementation of
the January 2016 recommendations. BOP has made slow progress due in part to
not assigning responsibility for recommendation implementation to appropriate
officials and not establishing associated time frames for completion.
Examples of Two Bureau of Prisons’ Restrictive Housing Unit Types

Among its objectives, GAO was
asked to examine the extent to which
BOP (1) addressed recommendations
from two prior restrictive housing
studies; and (2) leveraged facility
information to ensure restrictive
housing policy compliance and
enhance operations.
GAO analyzed BOP policies and
data; interviewed BOP officials; and
conducted non-generalizable
interviews with staff and incarcerated
individuals at five BOP facilities—
selected to cover a range of
restrictive housing unit types.

Source: BOP.

View GAO-24-105737. For more information,
contact Gretta L. Goodwin at (202) 512-8777
or GoodwinG@gao.gov.

GAO-24-105737

BOP has two key mechanisms—its program review process and its
administrative remedy program—to gather information from facilities about
restrictive housing operations. However, it is not fully leveraging either, resulting
in missed opportunities to ensure compliance and enhance operations:
•

BOP is not ensuring facilities’ timely resolution of deficiencies after
routine program reviews because it does not have a process to verify
that corrective actions were implemented.

•

The administrative remedy program allows incarcerated individuals to file
grievances about issues such as living conditions. However, BOP does
not analyze grievance data to identify trends and improve operations.

What GAO Recommends
GAO is making eight
recommendations to BOP, including
that it assign responsibility and
establish time frames for
recommendation implementation and
identify the cause of racial disparity in
SMU placements. BOP concurred
with the eight recommendations but
raised related concerns; GAO
discusses these in the report.

I

During the 2014 contracted assessment, reviewers found inconsistencies in the
application of subjective criteria used to place individuals in the special
management unit (SMU)—one that is designed for individuals with heightened
security concerns. GAO’s analysis of 2022 data appears to confirm that
inconsistencies continued, resulting in equity concerns. Black individuals were 38
percent of the total BOP population but 59 percent of the SMU placements. In
comparison, White individuals were 58 percent of the total BOP population and
35 percent of the SMU placements. In response to management challenges,
earlier this year BOP closed its remaining SMU and has not yet decided on the
future of such units. Analyzing the cause of the substantial racial disparity could
inform BOP and DOJ decisions on the future of restricted housing and help
ensure consistent and equitable treatment of incarcerated individuals.
United States Government Accountability Office

Contents

Letter

1
Background
BOP Has Not Fully Implemented Prior Recommendations to
Improve Oversight of Restrictive Housing
BOP is Not Fully Leveraging Facility Information to Ensure
Restrictive Housing Policy Compliance and Enhance
Operations
BOP Used Restrictive Housing for Medical Isolation During the
COVID-19 Pandemic Due to Space Constraints
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

6

35
37
38
39

Appendix I

Objectives, Scope, and Methodology

42

Appendix II

Restricted Housing Unit Types

48

Appendix III

Bureau of Prisons’ (BOP) Actions to Implement Prior Restrictive Housing
Reports’ Recommendations
53

Appendix IV

Illustrative Examples from Interviews with Incarcerated Individuals

67

Appendix V

Comments from the Department of Justice

69

Appendix VI

GAO Contact and Staff Acknowledgments

73

Table 1: Number and Percent of Recommendations, by
Implementation Status, as of September 2023

12

12
23

Tables

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GAO-24-105737 BOP Restrictive Housing

Table 2: Bureau of Prisons’ (BOP) Total Incarcerated Population
and the Rate of Restrictive Housing Placements Relative
to the Total BOP Population by Unit Type, Fiscal Years
2018–2022
Table 3: Number and Types of Deficiencies the Bureau of Prisons
Identified in Quarterly Summary Reports for all Facilities,
Fiscal Years 2018–2022
Table 4: Bureau of Prisons’ (BOP) Special Management Unit
(SMU) Population by SMU Program Enrollment Status,
Fiscal Years 2018–2022
Table 5: Illustrative Examples from GAO Interviews with
Incarcerated individuals in Special Housing Units (SHU)
that May Indicate Possible Patterns of Noncompliance
with Policy, July–November 2022

21
24
31

67

Figures
Figure 1: Bureau of Prisons (BOP) Regions, Facilities, and
Restrictive Housing Locations, as of September 2023
Figure 2: Restrictive Housing Placements for Bureau of Prisons’
Incarcerated individuals, by Mental Health Care Level,
Fiscal Years 2018–2022
Figure 3: Bureau of Prisons’ (BOP) Total Population and
Restrictive Housing Placements, by Race, Fiscal Years
2018–2022

Page ii

9
18
29

GAO-24-105737 BOP Restrictive Housing

Abbreviations
ADX
BOP
DOJ
SHU
SMU

Administrative Maximum Unit
Bureau of Prisons
U.S. Department of Justice
Special Housing Units
Special Management Unit

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GAO-24-105737 BOP Restrictive Housing

Letter

GAO

441 G St. N.W.
Washington, DC 20548

U.S. GOVERNMENT ACCOUNTABILITY OFFICE

February 6, 2024
The Honorable Richard J. Durbin
Chairman
Committee on the Judiciary
United States Senate
The Honorable Christopher A. Coons
United States Senate
The Honorable Brian Schatz
United States Senate
The Honorable David Scott
House of Representatives
The Bureau of Prisons (BOP)—a component of the U.S. Department of
Justice (DOJ)—is responsible for confining individuals in its custody in
safe, humane, and appropriately secure conditions. 1 To maintain safety,
BOP may remove individuals from the general housing population under
certain circumstances and place them in more restrictive settings where
they generally may not leave their cells for more than 1–2 hours each
day. 2 Given this isolation, there have been concerns about the impact of
restrictive housing on an individual’s mental and physical health. Further,
concerns arose about BOP’s use of restrictive housing for quarantine
during the COVID-19 pandemic under a modified operational plan. 3 As of
October 2023, BOP housed about 8 percent of incarcerated individuals in
restrictive housing (approximately 11,600 of 144,000).
In May 2013, we reported on BOP’s monitoring and evaluation of
restrictive housing and found that it had not assessed the impacts of long-

1See

18 U.S.C. § 4042.

2BOP

considers restrictive housing to be any type of detention that involves all three of the
following factors: (1) removal from the general population, whether voluntary or
involuntary; (2) placement in a locked cell, whether alone or with another inmate; and (3)
inability to leave the cell for typically 22 hours or more each day.

3We

reported on BOP’s COVID plans in 2021. See GAO, BUREAU OF PRISONS: BOP
Could Further Enhance its COVID-19 Response by Capturing and Incorporating Lessons
Learned, GAO-21-502 (Washington, D.C.: July 29, 2021).

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GAO-24-105737 BOP Restrictive Housing

term segregation on incarcerated individuals. 4 We recommended that
BOP assess such impacts on individuals in restrictive housing units. BOP
agreed and, in response, it developed a mental health screening tool and
issued a policy on the treatment and care of individuals with mental
illness.
We also recommended that BOP ensure that the contractor study
underway at the time of our review examine how restrictive housing
contributes to facility safety. BOP agreed with this recommendation. In
December 2014, this contractor reported its findings, along with 34
recommendations to BOP. 5 In February 2015, BOP published its
response, noting that it concurred with most of the key findings and
recommendations but had some concerns with particular
recommendations.
DOJ also has acknowledged challenges associated with restrictive
housing. In 2016, a DOJ report on restrictive housing included 53
recommendations to BOP with an overarching goal of reducing its use. 6
Further, in May 2022, Executive Order 14074 called for the Attorney
General to submit a report to the President on the steps DOJ has taken to
(1) ensure that restrictive housing in federal detention facilities is used
rarely, applied fairly, and subject to reasonable constraints; (2) ensure
that individuals in DOJ custody are housed in the least restrictive setting
necessary for overall safety; and (3) implement the 2016 DOJ report
recommendations. 7 In response, the Attorney General completed a report
in November 2022 that addresses these three areas, including the steps

4GAO,

BUREAU OF PRISONS: Improvements Needed in Bureau of Prisons’ Monitoring
and Evaluation of Impact of Segregated Housing, GAO-13-429 (Washington, D.C.: May 1,
2013).

5CNA

Analysis and Solutions, Federal Bureau of Prisons: Special Housing Unit Review
and Assessment, a report prepared at the request of the U.S. Department of Justice,
Bureau of Prisons, December 2014. We discuss the status of BOP’s actions to address
these recommendations later in our report.

6U.S.

Department of Justice, Report and Recommendations Concerning the Use of
Restrictive Housing, Final Report (Washington, D.C.: January 2016). In 2015, the
President directed the Attorney General to conduct a review of “the overuse of solitary
confinement across American prisons.” The President directed that the purpose of the
review be not simply to understand how, when, and why correctional systems isolate
certain incarcerated individuals from the general population, but also to develop strategies
for reducing the use of this practice across our nation’s criminal justice system.
7Exec.

Order No. 14,074, Advancing Effective, Accountable Policing and Criminal Justice
Practices to Enhance Public Trust and Public Safety, 87 Fed. Reg. 32,945 (May 25,
2022).

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GAO-24-105737 BOP Restrictive Housing

DOJ has taken toward implementing the 2016 DOJ report
recommendations. 8
In addition, in April 2023, we added the area of Strengthening
Management of the Federal Prison System to GAO’s biennial high-risk
list. 9 This biennial update describes the status of high-risk areas, outlines
actions that are needed to assure further progress, and identifies new
high-risk areas needing attention by the executive branch and Congress.
This area is being added, in part, due to BOP’s longstanding challenges
in managing staff and resources and in planning and evaluating programs
that help incarcerated people successfully return to the community.
You asked us to review issues related to BOP’s use of restrictive housing.
Specifically, we examine (1) the extent to which BOP addressed
recommendations in the 2014 contracted assessment and the 2016 DOJ
report on restrictive housing, (2) the extent to which BOP leverages the
information it collects from facilities to ensure restrictive housing policy
compliance and enhance restrictive housing operations, and (3) how BOP
used restrictive housing units during the COVID-19 pandemic.
To address in part all three of our objectives, we selected a
nongeneralizable sample of five facilities out of BOP’s 121 facilities. 10 We
selected these facilities to reflect a range in the types of restrictive
housing units—Special Housing Units (SHU), the Special Management
Unit (SMU), and the Administrative Maximum Unit (ADX). 11 Our sample
also includes a range of security levels (low, medium, and high security
facilities). Across these five facilities, we interviewed key staff, including
restrictive housing unit managers and correctional officers.

8U.S.

Department of Justice, The Report of the Attorney General Pursuant to Section
16(b)(i) of Executive Order 14074: Department of Justice Efforts to Ensure that Restrictive
Housing in Federal Detention Facilities is Used Rarely, Applied Fairly, and Subject to
Reasonable Constraints, and to Implement Other Legal Requirements and Policy
Recommendations, (Washington, D.C.: February 1, 2023). According to BOP, the report
was completed pursuant to the Executive Order in November 2022 but was not publicly
available until February 1, 2023.

9GAO,

High-Risk Series: Efforts Made to Achieve Progress Need to Be Maintained and
Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20, 2023).

10Although

BOP has 122 facilities, one of its New York facilities was no longer operational
at the time of our review.
11We

discuss each of these units in more detail later in this report.

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GAO-24-105737 BOP Restrictive Housing

We also interviewed 37 incarcerated individuals in restrictive housing
units at these five facilities at the time of our review. 12 Though not
generalizable, these interviews provided insight into these individuals’
respective experiences managing, periodically reviewing, or living in
restrictive housing units.
To address our first objective, we reviewed relevant DOJ and BOP
reports, policies, and training materials on BOP’s actions to implement
recommendations from the 2014 contracted assessment and the 2016
DOJ report. We analyzed summary BOP data on all individuals housed in
each type of restrictive housing unit from fiscal year 2018 through fiscal
year 2022. We selected this period to conduct a 5-year trend analysis of
the data most recently available at the time of our review. To assess the
reliability of these data, we interviewed knowledgeable officials about
BOP’s data systems, reviewed the query code language BOP used to
retrieve requested data, and examined the data for obvious errors. We
determined these data to be sufficiently reliable for the purpose of
reporting the number and type of restrictive housing placements.
To determine how certain subsets of the restrictive housing population
changed during this same time period, we analyzed two daily “snapshots”
of data posted to BOP’s website. These snapshots showed the number of
individuals BOP placed in SHUs for protective custody—a type of
administrative detention status for individuals who require protection from
real or perceived threats to their safety. 13 We accessed and retained
these daily snapshots early in our review in April 2022 and again in
October 2023. 14 Using the same data reliability steps as above, we
determined these snapshot data to be sufficiently reliable for reporting
housing population changes over time. We assessed BOP’s efforts to
12At

each facility, BOP provided a list of individuals who had been recently placed in a
restrictive housing unit. We selected 6–11 individuals from each list who had different
placement reasons, which included administrative detention, disciplinary segregation, and
medical isolation. We then provided written information about this review to each
individual we selected and verbally obtained their consent to participate in the interview.
13These

threats may be due to gang affiliations, certain types of criminal convictions,
gender identify, or sexual orientation. Individuals may request to be placed in protective
custody if they feel threatened or they may be placed in protective custody involuntarily if
BOP staff determine they need protection from verified threats.
14BOP collects data on this population to support the daily operational needs of BOP
facilities. However, BOP does not maintain these records in a format that allows for it to
analyze changes in this population over time. Therefore, we relied on the operational
information reported on BOP’s website to determine the number of individuals who were
placed in protective custody (either voluntarily or involuntarily). See BOP, Restricted
Housing, Inmate Statistics, accessed on April 6, 2022, and October 3, 2023,
https://www.bop.gov/about/statistics/statistics_inmate_shu.jsp.

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GAO-24-105737 BOP Restrictive Housing

address the 2014 and 2016 recommendations against criteria in
Standards for Internal Control in the Federal Government. 15
To address our second objective, we analyzed BOP’s restrictive housing
policies and program review guidance and reports. These included 13
quarterly review summaries for all the program reviews that BOP
conducted from fiscal year 2018 through fiscal year 2022. We assessed
BOP’s efforts to address the deficiencies identified in these reviews
against federal internal control standards. 16 To assess BOP’s compliance
with its SMU policy, we analyzed BOP data on individuals placed in the
SMU at least 1 day during each year from fiscal year 2018 through fiscal
year 2022 by SMU program level and race. 17 To assess the reliability of
these data, we interviewed knowledgeable officials about BOP’s data
systems and reviewed the query code language. We determined the data
to be sufficiently reliable for the purpose of reporting the total number of
SMU placements by program level and race. We assessed BOP’s
compliance with its policies on SMU placements and progression against
federal internal control standards. 18
Lastly, to understand whether BOP leverages available information to
identify possible areas of noncompliance with its policies, we interviewed
BOP officials responsible for oversight and reviewed over 1,500
administrative remedy grievance summaries that individuals housed in
restrictive housing units at the five facilities in our sample submitted to
BOP from fiscal year 2018 through fiscal year 2022. 19 Of these,
individuals housed in SHUs at the five facilities submitted over 500
administrative remedy grievance summaries, individuals housed in the
15GAO,

Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: Sept. 10, 2014). These standards state that management should
oversee the prompt remediation of deficiencies by communicating the corrective actions to
the appropriate level of the organizational structure and delegating authority for
completing corrective actions to appropriate personnel.

16GAO-14-704G. These standards state that agency management should complete and
document corrective actions to remediate internal control deficiencies on a timely basis
and that such corrective actions include resolution of findings from internal program
reviews.
17BOP

generally expects individuals placed in a SMU to complete three program levels
within 9–24 months.
18GAO-14-704G.

These standards state that management should identify, analyze, and
respond to risks related to achieving the defined objectives, particularly when there is a
degree of subjectivity involved with the risk.

19Under the administrative remedy program, incarcerated individuals, including those in
restrictive housing, can seek formal review of any grievances relating to their own
confinement. See 28 C.F.R. pt. 542.

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GAO-24-105737 BOP Restrictive Housing

Thomson facility SMU submitted nearly 600, and individuals housed in
ADX units submitted over 400 during the same period. 20 We assessed the
reliability of these data by reviewing agency policies related to
administrative remedy submissions and interviewing BOP officials about
their methods for uploading and tracking these submissions. We found
these data to be sufficiently reliable for the purpose of summarizing
examples of grievances that individuals in restrictive housing submitted.
To address our third objective, we reviewed BOP policies and guidance
for pandemic response, including BOP’s COVID-19 pandemic plan. We
also reviewed Executive Order 14074 and the DOJ Office of the Inspector
General COVID-19 capstone report to understand directives and
recommendations related to this objective. 21 We interviewed BOP
headquarters officials about their efforts in response. We also interviewed
officials and incarcerated individuals at our five selected facilities to
understand how these facilities used restrictive housing during the
pandemic and the related conditions of confinement. During our
interviews with incarcerated individuals at these five facilities, we asked
which, if any, had experience in restrictive housing during the pandemic
for various reasons. We then asked questions about the conditions of
their confinement during that time. See appendix I for more details on our
overall scope and methodology.
We conducted this performance audit from January 2022 to February
2024 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.

Background
20Individuals

housed in ADX units submitted about 400 administrative remedy grievances.

21Exec.

Order No. 14,074, Advancing Effective, Accountable Policing and Criminal Justice
Practices to Enhance Public Trust and Public Safety, 87 Fed. Reg. 32,945 (May 25,
2022). Department of Justice, Office of the Inspector General, Capstone Review of the
Federal Bureau of Prisons’ Response to the Coronavirus Disease 2019 Pandemic, 23-054
(Washington, D.C.: March 2023).

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GAO-24-105737 BOP Restrictive Housing

BOP Organization

BOP’s Central Office serves as its headquarters and provides oversight of
operations and program areas through several divisions. For example,
the Program Review Division oversees program performance and
compliance, in part through routine facility-level program reviews. As part
of its responsibilities, the Program Review Division conducts internal
audits and makes findings and recommendations to address risk areas
and correct deficiencies based on the results of these audits. The
Correctional Programs Division provides policy direction and manages
case records and inmate discipline. In addition, the Health Services
Division is responsible for medical, dental, and mental health services,
and the Reentry Service Division oversees programs and resources
designed to facilitate the successful reintegration of individuals into their
communities upon release.
BOP also has six regional offices, each with a regional director, to
oversee the operations of the 121 federal facilities within their respective
geographic areas. As part of their oversight duties, regional directors are
to ensure that facility wardens are fully responsive to program review
findings in a timely manner, determine the need for special reviews or
studies in specific program areas, and ensure the completion of such
reviews. BOP’s Central Office and regional directors also review and
approve certain types of restrictive housing unit referrals.
Wardens and associate wardens manage operations at the facility level.
Unit management staff and correctional officers are responsible for
monitoring individuals placed in restrictive housing units and ensuring that
their respective facilities follow procedures. In addition to the unit
management team, other facility staff are responsible for education,
recreation, health, and psychology services.

Types of BOP Restrictive
Housing

BOP generally uses three types of restrictive housing units across its 121
facilities: (1) SHUs, (2) SMUs, and (3) the ADX facility in Florence,
Colorado. The main purpose of all three types of units is to separate
inmates from the general incarcerated individual population to protect the
safety, security, and orderly operation of BOP facilities. BOP operates
other types of housing units where it removes individuals from the general
population, but conditions are less restrictive. For example, BOP has a
Special Confinement Unit for males with a court-imposed death sentence.
It also has a Female Administrative Unit for females with a court-imposed
death sentence, escape attempt, or history of repeated/chronic behavior
incidents. However, individuals placed in this unit experience conditions
similar to conditions in the general population units. This is because they
are permitted to leave their cells to attend programming and recreation

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GAO-24-105737 BOP Restrictive Housing

and to intermingle with other individuals in the unit, rather than being
confined in a locked cell for 22 hours or more each day.
Special Housing Unit. BOP uses these units to house individuals for a
variety of administrative purposes and for disciplinary purposes related to
prohibited acts. 22 Most SHU cells are double-bunked, but some may be
single-bunked. There are a total of 92 facilities with SHUs. 23
Special Management Unit. BOP has used these units to house
individuals whose interactions require greater management to ensure the
safe and orderly operations. 24 BOP generally expects individuals placed
in a SMU to complete three program levels within 9–24 months. 25 In
February 2023, BOP leadership closed the Thomson unit—which was the
only operational SMU at the time of our audit—and temporarily relocated
all the unit’s incarcerated individuals to a SHU at the Federal Correctional
Complex in Terre Haute, Indiana. As of September 2023, BOP had not
made a final decision regarding whether to reopen or relocate the SMU.
Administrative Maximum Facility. The ADX houses individuals who
require the tightest controls and supervision because of the nature of their
offense or their behavior while incarcerated in a BOP facility. This unit has
four distinct programs including the Control Unit, which houses the most
dangerous, violent, and disruptive individuals who would pose a threat to
others in a less restrictive setting. This unit typically houses incarcerated
individuals who have assaulted or killed staff or other incarcerated
22Administrative

purposes include a pending transfer from/to a facility; required protection
from real or perceived threats; and an ongoing investigation or pending hearing for
violating a BOP rule.
23BOP

Federal Correctional Complexes include several facilities with different missions
and security levels located in proximity to one another. Some Federal Correctional
Complexes have more than one SHU.
24BOP

policy states that SMU placement may be because the incarcerated individual has
(1) had a leadership role or participated in disruptive gang-related activity; (2) a history of
serious or disruptive disciplinary infractions; (3) committed a serious prohibited act; (4)
participated in, organized, or facilitated any group misconduct that adversely affected the
orderly operation of a correctional facility; or (5) otherwise participated in or was
associated with activity such that greater management of the incarcerated individual’s
interaction with other persons is necessary to ensure the safety, security, or orderly
operation of BOP facilities.
25Department of Justice, Bureau of Prisons, Special Management Units, 5217.02
(Washington, D.C.: August 9, 2016). While operational, individuals placed in the Thomson
unit earned additional privileges as they progressed through each of the three program
levels. They were expected to demonstrate an ability to function in a general population
setting, refrain from misconduct, and participate in program activities to progress through
each level. Individuals who do not progress through the three program levels within 24
months fail the SMU program, consistent with BOP policy.

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GAO-24-105737 BOP Restrictive Housing

individuals, or who have escaped or attempted to escape from another
facility. All ADX cells are single cells due to these security needs. The
Federal Correctional Complex in Florence, Colorado, is the only ADX
facility.
Each type of restrictive housing unit has specific placement criteria and
conditions of confinement. See appendix II for more details on BOP’s
restricted housing policies and illustrations of restrictive housing. Figure 1
shows the locations of BOP facilities with each type of restrictive housing
unit.
Figure 1: Bureau of Prisons (BOP) Regions, Facilities, and Restrictive Housing Locations, as of September 2023

( Northeast Region )

,6.
♦

( Mid-Atlantic Region )

,6.

,6.
,6.

Western Region

( South Central Region )

D

Special housing unit only

Source : GAO anal ysis of BOP data.

I

♦ Special housing unit and administrative maximum

D

BOP faci lity with no restrictive housing unit

GAO-24- 105737

Note: In February 2023, BOP closed the only operating Special Management Unit (located at the U.S.
Penitentiary in Thomson, Illinois) and temporarily relocated the individuals from that unit to the
Federal Correctional Complex in Terre Haute, Indiana.

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GAO-24-105737 BOP Restrictive Housing

BOP’s Mental Health
Policy

BOP Program Review
Process

BOP’s policy on the treatment and care of individuals with mental illness
also applies to those in restrictive housing. 26 BOP psychologists must
establish and document a mental health care level for each individual, as
well as any changes in mental health care levels. 27 BOP policies
generally prohibit the prolonged placement of individuals in levels three or
four in the SHU, SMU, or ADX. BOP uses the following mental health
care levels to classify mental health needs:
•

Mental Health Care Level One: Individuals with no “significant level
of impairment associated with a mental illness,” who do not require
regular mental health services.

•

Mental Health Care Level Two: Individuals who require regular
outpatient mental health care and/or brief mental health care
interventions of significant intensity. 28

•

Mental Health Care Level Three: Individuals who require weekly
outpatient mental health care interventions or placement in a
residential psychology treatment program.

•

Mental Health Care Level Four: Individuals who require acute care
in a psychiatric hospital if they are gravely disabled and cannot
function in a general population in a level three environment.

BOP’s Program Review Division, which operates out of the Central Office,
oversees program performance and compliance by conducting program
reviews of facilities. It also verifies the completion of facility-led reviews. 29

26Department

of Justice, Bureau of Prisons, Treatment and Care of Inmates with Mental
Illness, 5310.16 (Washington, D.C.: May 1, 2014).
27BOP’s policies dictate that all incarcerated individuals receive a preliminary mental
health screening (which consists of psychological interviews, social history reviews, and
behavioral observation) upon admission to a BOP facility. The purpose of the screening is
to identify incarcerated individuals who need referral for mental health, sex offender, or
substance abuse treatment services; collect information that can be used in future crisis
counseling situations; identify strengths as well as potential adjustment problems to
incarceration; and discuss possible programmatic needs with incarcerated individuals. For
additional information on incarcerated individuals with serious mental illness, see GAO,
Federal Prisons: Information on Inmates with Serious Mental Illness and Strategies to
Reduce Recidivism, GAO-18-182 (Washington, D.C.: Feb. 15, 2018).
28BOP

defines these as “crisis-oriented” services, such as placement on suicide watch or
behavioral observation status.
29The

Program Review Division conducts reviews of all BOP programs, including
correctional services.

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GAO-24-105737 BOP Restrictive Housing

Central Office-led program
reviews

BOP’s Program Review Division, within the Central Office, is to perform
program reviews at each facility at least once every 3 years, according to
policy. 30 The objective is to determine facilities’ compliance with
applicable regulations and policies—including those related to restrictive
housing; the adequacy of internal controls; and the effectiveness,
efficiency, and quality of programs and operations. To conduct reviews,
program reviewers collect and assess evidence at the facility. Then they
develop findings and produce a report with a performance rating for each
facility. 31 Within 30 days of receiving the report and rating, facilities are to
provide a report to the Program Review Division containing planned
corrective actions.

Facility-led reviews

There are two types of facility-led reviews related to the overall program
review process—operational reviews and quarterly perpetual audits. BOP
policy requires that all facilities conduct operational reviews that are
intended in part to provide a status update on every deficiency that the
previous Central Office-led program review found. In addition, all facilities
are to conduct facility-led Quarterly Perpetual Audits of the Correctional
Services program. 32 Facilities must implement corrective actions to
address any deficiencies identified during each audit. As part of the
Central Office-led program reviews, reviewers are to verify that facilities
have completed the operational reviews and quarterly perpetual audits
that BOP policy requires.

Administrative Remedy
Program

Under this program, incarcerated individuals, including those in restrictive
housing, can seek formal review of any grievances relating to their own
confinement. This can include grievances about restrictive housing
placement, status, or living conditions. Incarcerated individuals must first
present their grievances informally to facility staff, and staff are to attempt
to informally resolve them. If individuals do not feel satisfied with the
30Department

of Justice, Bureau of Prisons, Management Control and Program Review
Manual, 1210.23 (Washington, D.C.: Aug. 21, 2002).
31Program reviewers assign one of five ratings: ‘Superior,’ ‘Good,’ ‘Acceptable,’ ‘Deficient,’
and ‘At Risk’. Per policy, reviewers are to assess programs that receive a superior or good
rating every 3 years, acceptable ratings every 2 years, and deficient ratings every 18
months. Reviewers assign a rating of deficient when one or more vital functions are not at
acceptable levels and internal controls are weak, thus allowing for serious deficiencies.
Reviewers assign a rating of ‘at risk’ when the program is unable to accomplish its overall
mission. This rating is also applicable when internal controls are not sufficient for
acceptable performance. The reports we analyzed during this review included
performance ratings. However, according to BOP officials, as of October 2023, the
Program Review Division no longer issues performance ratings for these audits.
32As

part of the correctional services review, BOP focuses on restrictive housing units
(SHU, SMU, and ADX), where applicable.

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action, then they can elevate by formally submitting a Request for
Administrative Remedy to the facility warden. Beyond this stage,
grievances, if not satisfied, can progress to the Regional Director and
then on to BOP General Counsel through an appeals process.

BOP Has Not Fully
Implemented Prior
Recommendations to
Improve Oversight of
Restrictive Housing

BOP has not fully implemented a majority of the recommendations (54 of
87) from the 2014 contracted assessment and 2016 DOJ report to reduce
BOP’s use of restrictive housing and improve its oversight. Specifically,
BOP fully implemented 33 recommendations, partially addressed 42, and
had not taken any steps to address the remaining 12 recommendations
as of September 2023. 33
In Table 1, we show the number and percent of recommendations by
implementation status, and in the sections below, we provide illustrative
examples for each category. See appendix III for our assessment of the
status for each of the 87 recommendations.
Table 1: Number and Percent of Recommendations, by Implementation Status, as of
September 2023
Implementation Status
Category

Number

Percent

Fully Implemented

33

38%

Partially Implemented

42

48%

Not Implemented

12

14%

Total

87

100%

Source: GAO analysis of Bureau of Prisons information. | GAO-24-105737

BOP Fully Addressed 33
of the 87
Recommendations

BOP took actions to fully address 33 of the 87 recommendations, which
generally entailed developing or revising policy documents or developing
new systems or programs. For example, the 2016 DOJ report
recommended that correctional systems develop clear, specific policies
for determining the conditions under which an incarcerated individual can
be placed in restrictive housing in response to an alleged disciplinary
violation—both during the investigative stage and after an adjudication of
guilt. In response, BOP revised its SHU policy in November 2016 to state
33We used three categories to describe the status of BOP’s implementation efforts: (1)
fully implemented, (2) partially implemented, and (3) not implemented. We determined that
recommendations were fully implemented when BOP provided information that showed it
addressed all aspects of the recommendation. We determined that these
recommendations do not require any further action. We determined that recommendations
were partially implemented when BOP had completed some, but not all recommended
steps, or BOP provided information about ongoing work or plans to address
recommended steps. For not implemented, we determined that BOP did not take any of
the recommended steps or did not agree with the recommendation.

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that officials must consider the seriousness of the alleged offense, such
as whether it involved violence, escape, or posed a threat to facility
safety. The policy also states that an individual is placed in disciplinary
segregation after an adjudication of guilt.
In addition, the 2014 contracted assessment found that some
incarcerated individuals’ records were missing a rationale for placement
in the SHU. The assessment recommended that BOP develop an
electronic record system to document SHU placement decisions. In
response, BOP modified its electronic record system to collect this
information.

BOP Partially Addressed
42 of the 87
Recommendations

We determined that BOP partially addressed 42 of the 87
recommendations as of September 2023. These recommendations
covered a range of topics such as (1) protective custody, (2) data and
monitoring, (3) reentry programming, and (4) serious mental illness.
Protective custody. Protective custody is a type of administrative
detention status individuals typically remain in until a real or perceived
threat to their safety no longer exists or the individual is transferred to
another BOP facility. Both the 2014 contracted assessment and 2016
DOJ report stated that, generally, individuals who require protective
custody should not be placed in restrictive housing and recommended
that BOP expand housing alternatives for this population. BOP took
some, but not all, steps necessary to fully address this recommendation.
Since the 2014 contracted assessment, BOP has been expanding the
capacity of two types of alternative housing units it uses to divert
incarcerated individuals in protective custody from SHUs. 34 These units
both have fewer restrictions than SHUs, protect individuals from threats to
their safety, and provide programming opportunities, according to the
2016 DOJ report.
In the 2022 Attorney General report, BOP reported that due to the
expansion of these units, it reduced the number of individuals in
protective custody by half—from 921 in 2015 to 465 in 2022. 35 However,
our analysis of BOP’s data showed the number of individuals in protective
custody has increased since that time—from 481 in April 2022 to 700 in

34These

are Reintegration Units, which BOP uses for any incarcerated individuals in
protective custody status who have had verified or unverified threats to their safety, and
Security Threat Group Drop-Out Units, which BOP uses for individuals who want to
“disassociate from” or “quit” a gang.

35U.S.

Department of Justice, The Report of the Attorney General Pursuant to Section
16(b)(i) of Executive Order 14074.

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October 2023. 36 According to BOP, the number of individuals who require
protective custody may fluctuate for various reasons, such as an increase
in the number of threats related to gang affiliations. However, the 2016
DOJ report states the goal of this recommendation was to eventually
house all individuals who require protective custody in alternative housing
units, rather than placing them in restrictive housing. Therefore, while
BOP has expanded the capacity of alternative housing units, it has not
taken actions to fully address this recommendation because it continues
to house this population in restrictive housing units. According to BOP
officials, as of September 2023, they were focused on moving individuals
into the existing units rather than assessing the need for additional
capacity.
Data and monitoring. BOP uses multiple record systems to collect and
store data on incarcerated individuals, including those placed in restrictive
housing. BOP took some, but not all, steps necessary to address
recommendations related to data and monitoring. Specifically, the 2016
DOJ report found that BOP was not using its data systems to identify
trends and monitor the restrictive housing population. As a result, it
recommended that BOP collect and make publicly available data on
restrictive housing, including the number of individuals in each type of
housing, the number of SHU placements for each individual, and average
length of stay. It also recommended that these data include demographic
information, such as age, race, gender identity, and sexual orientation. In
response, in May 2016, BOP began posting certain restrictive housing
statistics on its public website, including the total number of individuals in
each type of restrictive housing unit and length of stay for SHU
placements. Although it collects information on age, race, ethnicity, and
gender, it does not publish these statistics on its website. Furthermore, it
does not collect certain statistics, such as gender identity and sexual
orientation because doing so is not necessary for its mission, according to
BOP officials.
The 2016 DOJ report also recommended that BOP collect comprehensive
data on individuals in SHUs that would be available to correctional
36BOP collects data on this population to support the daily operational needs of BOP
facilities. However, BOP does not maintain these records in a format that allows for it to
analyze changes in this population over time. Therefore, we relied on the operational
information reported on BOP’s website to determine the number of individuals who were
placed in protective custody (either voluntarily or involuntarily). This statistic included
individuals who requested to be placed in protective custody as well as those who were
involuntarily placed in protective custody. See BOP, “Restricted Housing Statistics,”
Inmate Statistics, accessed on April 6, 2022, and October 3, 2023,
https://www.bop.gov/about/statistics/statistics_inmate_shu.jsp.

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officers. According to the report, the data should allow BOP to track
individuals throughout their incarceration to determine when, how often,
and how long an individual has been placed in restrictive housing and any
changes in status. In response, BOP made incremental improvements
over time to its internal SHU record keeping system. These improvements
include tracking the medical care level and mental health care level for
each incarcerated individual in the SHU.
However, as of September 2023, this system does not have the capability
to specifically track how often individuals were placed in restrictive
housing throughout their incarceration period, as recommended. BOP
officials explained that its SHU record system collects data on SHU
placements that support the daily operational needs of BOP facilities.
However, the system does not maintain these records in a readily
available format that would allow BOP to monitor SHU placement rates
and analyze changes over time. According to the 2016 DOJ report,
having this capacity would allow BOP to track how often individuals were
placed in restrictive housing throughout their incarceration period and
identify potential problems as quickly as possible.
Reentry programming. Reentry programming generally involves life
skills courses, academic classes, and vocational training and is designed
to help individuals prepare for their release from incarceration. BOP took
some, but not all, steps necessary to address recommendations related
to reentry programming. The 2014 contracted assessment found that
BOP was not providing any substantive instructor-led reentry
programming for individuals in restrictive housing; rather, BOP referred to
self-help reading activities as a ‘program’ or ‘therapy.’ In contrast, the
assessment found that individuals in the general population had access to
reentry resources, such as residential reentry centers and BOP release
preparation programs. The report recommended that BOP develop and
provide specialized reentry programming for incarcerated individuals in
restricted housing similar to what is being provided in the general
population. The 2016 DOJ report also noted the lack of programming. It
recommended that BOP provide targeted reentry programming if
incarcerated individuals are in restrictive housing during the last 180 days
of their incarceration and cannot be released to a less restrictive setting.
In response to these recommendations, BOP updated its SHU policy in
2016 to state that incarcerated individuals who remain in the SHU within
180 days of release are to receive targeted reentry programming to
prepare for return to the community. To help implement this policy, BOP
developed “Turning Point” handouts, which provide incarcerated
individuals with some written information about cognitive behavioral

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treatments and resource materials targeting motivation to change, coping
skills, and criminogenic needs. According to BOP officials, it designed
Turning Point handouts to be interactive, with a psychologist or other
treatment provider working with the individual or providing feedback when
appropriate.
However, in most SHUs, Turning Point is the only available reentry
resource, according to BOP documentation and staff and incarcerated
individuals we interviewed. Therefore, many individuals in restrictive
housing do not receive life skills courses, academic classes, or other
types of reentry programming similar to what individuals in the general
population receive. Also, the extent to which these handouts are
interactive is unclear. For example, a few individuals we interviewed who
told us they received the self-guided reading activity handouts said they
did not receive any feedback upon completing them. Further, one
individual who was in a SHU before being released noted not receiving
any reentry programming or services to help with reentering society upon
release. While Turning Point handouts are an available resource, BOP
has not fully addressed this recommendation because it is not providing
specialized reentry programming similar to what it provides in the general
population (e.g., life skills courses, academic classes, and vocational
training).
Serious mental illness. BOP classifies serious mental illness as an
individual’s condition that requires weekly outpatient mental health
interventions, placement in a residential psychology treatment program,
or acute care in a psychiatric hospital. In BOP’s record system, these
individuals are classified as mental health care levels three or four. BOP
took some steps necessary to address recommendations related to
individuals with serious mental illness in restrictive housing. For example,
BOP’s 2014 policy on the treatment and care of individuals with mental
illness generally only allows the placement of individuals with serious
mental illness in SMU or ADX if “extraordinary security needs” are
identified that cannot be managed elsewhere. 37 It also states that BOP
strives to avoid prolonged placement of individuals with serious mental
illness in SHUs.
However, the 2016 DOJ report found continuing challenges related to
individuals with serious mental illness whom BOP had placed in restrictive
housing. Specifically, DOJ found that the long-term placement in
restrictive housing adversely impacted the mental health of incarcerated
37Department

of Justice, Bureau of Prisons, Treatment and Care of Inmates with Mental
Illness, 5310.16 (Washington, D.C.: May 1, 2014).

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individuals diagnosed with serious mental illness. 38 It made multiple
recommendations to address this issue, including that BOP avoid placing
incarcerated individuals with serious mental illness in restrictive housing,
with few exceptions. It also recommended that BOP divert these
individuals to a clinically appropriate alternative housing unit.
To address these recommendations, BOP revised its SHU policy in 2016
to better align with its 2014 policy on the treatment and care of individuals
with mental illness. BOP’s revised policy states that individuals diagnosed
with serious mental illness are generally not to be placed in a SHU unless
they present an immediate or serious danger to self, staff, or the orderly
running of a facility. 39 Should placement be necessary, the revised policy
states psychology services are to conduct a mental health evaluation
within 24 hours of placement.
According to BOP officials, while the number of individuals with a serious
mental illness who BOP places in restrictive housing may fluctuate due to
individual behavior and treatment needs, these steps have resulted in
significantly diverting this population from restrictive housing. However,
our analysis of data from fiscal years 2018 through 2022 shows that BOP
continues to place individuals with serious mental illness in restrictive
housing settings (see figure 2).

38The

2014 policy also requires BOP mental health staff to mitigate negative impacts or
identify appropriate alternative placements for any individuals in restrictive housing units
who appear to be experiencing negative mental health impacts.
39Department

of Justice, Bureau of Prisons, Special Housing Units, 5270.11 (Washington,
D.C.: Nov. 23, 2016).

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Figure 2: Restrictive Housing Placements for Bureau of Prisons’ Incarcerated individuals, by Mental Health Care Level, Fiscal
Years 2018–2022

Mental health
care level
Special Housing Unit•

Special Management Unitb

Administrative Maximum
Facilityc

CJ

FY2018

FY2019

FY2020

FY2021

FY2022

Level one

60,214

59 ,539

52,496

56 ,347

62 ,979

Level two

2,197

2,241

2,070

2,167

2,356

373

406

368

419

405

Level four

33

61

32

30

19

Level one

1,441

1,575

1,436

1,416

1,071

Level two

12

11

15

24

26

Level three

6

3

4

5

10

Level four

0

1

2

Level one

422

417

372

355

357

Level two

34

25

27

30

26

Level three

15

19

21

18

17

Level four

0

0

1

0

Individuals with seri ous mental illness (mental health ca re levels 3 and 4)

Source: GAO analysis of BOP data.

I

GAO-23- 105737

Notes: Total population includes the number of incarcerated individuals who spent at least 1 day of
the year in the unit. We only included incarcerated individuals with a mental health care level
designation. We excluded those individuals who did not have an official mental health care level
designation because they were pending an official mental health evaluation or they have not been
designated to a facility due to being a pre-trial admission or for security reasons, for example.
Individuals may be counted more than once if they have more than one restrictive housing placement
in a given fiscal year. Mental health care level one refers to individuals with no significant mental
health care needs. Mental health care level two refers to individuals requiring routine outpatient
mental health care or brief crisis-oriented mental health care. Mental health care level three refers to
individuals requiring enhanced outpatient mental health care on a weekly basis or residential mental
health care (i.e., placement in a residential Psychology Treatment Program). Mental health care level
four refers to individuals requiring acute care in a psychiatric hospital if they cannot function in a
mental health care level three environment.
aSpecial Housing Units are a type of restrictive housing BOP uses for punitive (disciplinary
segregation) or non-punitive purposes (administrative detention). The length of stay for individuals
placed in Special Housing Units may vary depending on their placement reason.

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bSpecial Management Units are a type of restrictive housing BOP uses for incarcerated individuals

that require greater management.

cThe Administrative Maximum Facility is a type of restrictive housing BOP uses to confine violent,

disruptive, and escape-prone incarcerated individuals.

According to BOP officials, to divert individuals with serious mental illness
from restrictive housing, BOP operates three secure mental health
treatment programs as of September 2023. 40 BOP officials said they plan
to activate three additional secure mental health units in fiscal year 2024
to further expand its capacity to divert this population from restrictive
housing. Therefore, as of September 2023, BOP has partially addressed
these 2016 DOJ report recommendations.

BOP Has Not Addressed
12 of the 87
Recommendations

BOP has not taken any steps as of September 2023 to address 12
recommendations, although it agreed with or had not documented any
concerns with these recommendations. For example, the 2016 DOJ
report recommended that incarcerated individuals who violate disciplinary
rules should be placed in restrictive housing only as necessary and after
correctional officials determine that other available disciplinary sanctions
are not sufficient. 41 However, BOP has not updated its discipline program
policy consistent with this recommendation. Additionally, the 2014
contracted assessment recommended that BOP establish a system for
monitoring patterns and trends in the use of disciplinary sanctions among
BOP facilities. According to officials, BOP’s system has this capability, but
BOP does not use the system for this recommended purpose.

BOP Has Not Developed
an Approach to Fully
Address Remaining
Recommendations

Although BOP has fully addressed 33 of the recommendations in the
2014 and 2016 restrictive housing assessments, 54 remain partially or not
addressed 7 to 9 years since the recommendations were first made.
BOP officials told us that to implement both reports’ recommendations,
they primarily revised policies that were relevant to each recommendation
and relied on individual facilities to implement those policy changes. In
addition, BOP had documented some concerns with six
recommendations from the 2014 contracted assessment, which we
40Secure mental health units are dedicated to the treatment of incarcerated individuals
with mental illness that offer mental health programming in the context of removal from the
general population, whether voluntary or involuntary. Department of Justice, Bureau of
Prisons, Secure Mental Health Units, 5335.01 (Washington, D.C.: Jan. 23, 2023).
41Incarcerated

individuals who commit prohibited acts may receive disciplinary sanctions.
BOP categorizes prohibited acts based on severity ranging from low to greatest severity.
For example, a low-level offense, such as using abusive or obscene language, may result
in a loss of telephone privileges as a disciplinary sanction. Conversely, a greatest severity
level offense, such as killing or assaulting any person, may result in a sanction of up to 12
months in a SHU for disciplinary segregation for the first prohibited act and up to 18
months for repeated prohibited acts within a 24-month period.

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discuss in appendix III. Further, officials also told us that while BOP
concurred with most of the 2014 contracted assessment’s key findings
and took actions to address its recommendations, there was no
requirement that BOP implement all the recommendations as written
since it was a contracted review. 42
Importantly, Executive Order 14074, published in May 2022, calls for the
Attorney General to ensure the Department fully implements the 2016
DOJ report’s recommendations. 43 In the November 2022 Attorney
General report responding to this executive order, BOP reported on the
status of its efforts to implement these recommendations. For example,
the report stated that BOP successfully reduced its use of the SMU and
ADX, but SHU placements increased since 2016.
However, our analysis of BOP population data indicates that while BOP’s
total population decreased by 13 percent from fiscal year 2018 to fiscal
year 2022, the rate of SMU population placements as a percent of the
total BOP population slightly increased between fiscal years 2018 through
2021 and slightly decreased in fiscal year 2022. BOP data indicate the
ADX population rate generally remained steady relative to BOP’s total
population. 44 Further, the data indicate that SHU placements increased
from 29 to 35 percent of the total BOP population from fiscal years 2018
to 2022, and the total number of restrictive housing placements generally
increased over this period (see table 2).

42Department

of Justice, Bureau of Prisons, Special Housing Unit Review and
Assessment Report Response, (Washington, D.C.: Feb. 2015).
4387

Fed. Reg. 32,945.

44In

the 2022 Attorney General report, BOP reported that the SMU population rate
decreased by 56 percent, from 1,260 on December 5, 2015, to 558 on September 14,
2022. BOP also reported that the ADX population rate decreased by 17 percent, from 403
on December 5, 2015, to 336 on September 14, 2022. BOP compared a 2015 daily
snapshot with a 2022 daily snapshot. In contrast, our analysis includes the total number of
incarcerated individuals who spent at least 1 day of each fiscal year in the SMU or ADX
over a 5-year period from fiscal year 2018 to fiscal year 2022.

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Table 2: Bureau of Prisons’ (BOP) Total Incarcerated Population and the Rate of Restrictive Housing Placements Relative to
the Total BOP Population by Unit Type, Fiscal Years 2018–2022
FY2018

FY2019

FY2020

FY2021

FY2022

226,507

225,158

196,343

181,172

196,463

66,646
(29%)

65,845
(29%)

58,281
(30%)

61,656
(34%)

68,577
(35%)

Special Management Unit placementsb

1,462
(0.65%)

1,596
(0.71%)

1,456
(0.74%)

1,449
(0.80%)

1,109
(0.56%)

Administrative Maximum Facility
placementsc

471
(0.21%)

465
(0.21%)

422
(0.21%)

405
(0.22%)

400
(0.20%)

68,579

67,906

60,159

63,510

70,086

Total BOP population
Special Housing Unit

placementsa

Total restrictive housing placements
Source: GAO analysis of BOP data. | GAO-24-105737

Note: The population in each unit includes the number of incarcerated individuals who spent at least 1 day of the year in the unit. Individuals may be
counted more than once if they have more than one restrictive housing placement in a given fiscal year.
aSpecial Housing Units are a type of restrictive housing BOP uses for punitive or non-punitive purposes.
bSpecial Management Units are a type of restrictive housing BOP uses for incarcerated individuals that require greater management.
cThe Administrative Maximum facility is a type of restrictive housing BOP uses for violent, disruptive, and escape-prone incarcerated individuals.

The November 2022 Attorney General report also stated that BOP and
DOJ are committed to further addressing and reducing the use of
restrictive housing and described two recent efforts to achieve this. First,
in November 2022, BOP convened an Executive Working Group
comprised of BOP’s six regional directors as well as leadership from the
National Institute of Corrections and Correctional Programs Division,
among others. 45 The BOP Director tasked this group with conducting an
assessment and providing recommendations related to overhauling its
restrictive housing practices. According to BOP officials, this will include
reviewing and updating the prior restrictive housing recommendations. As
of September 2023, officials told us the group had submitted what they
called a decision paper to BOP’s Executive Staff for consideration.
However, officials also told us they had not implemented any specific
actions and did not provide a timeline for when they expect Executive
Staff to complete their review. BOP officials also did not describe the
45The National Institute of Corrections is an agency within BOP that provides training,
technical assistance, information services, and policy/program development assistance to
federal, state, and local corrections agencies.

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decision paper’s scope or contents or whether it addressed some or all
prior recommendations.
Second, in February 2023, DOJ’s National Institute of Justice issued a
solicitation for another independent study to review and provide
recommendations regarding BOP’s use of restrictive housing. 46 As of
September 2023, the National Institute of Justice had awarded an
approximately $7.8 million contract, and officials told us the contractor’s
study was in the early developmental stages. The statement of work for
this solicitation requires the contractor to provide a comprehensive
assessment of restrictive housing practices within BOP. This work is to be
conducted from July 2023 to November 2026 and could yield additional
recommendations. Officials did not describe how or whether the
Executive Working Group’s efforts are informing the contractor’s work.
According to federal internal control standards, management should
oversee the prompt remediation of deficiencies by communicating the
corrective actions to the appropriate level of the organizational structure
and delegating authority for completing corrective actions to appropriate
personnel. 47 The process is completed only after action has been taken
that (1) corrects identified deficiencies, (2) produces improvements, or (3)
demonstrates that the findings and recommendations do not warrant
management action. Management then, with oversight from the oversight
body, should monitor the status of remediation efforts so that they are
completed on a timely basis. 48
Despite these recent efforts, BOP has not developed an approach to
ensure the full implementation of the 2014 and 2016 recommendations.
Not fully implementing the recommendations from these reports has
impacted BOP’s ability to reduce its use of restrictive housing and
effectively manage its restrictive housing operations. By developing and
implementing an approach to fully address the remaining
recommendations—which would include assigning implementation
responsibility to appropriate officials, establishing a time frame for
completion, and monitoring progress—BOP would be better positioned to
achieve its goal of reducing its use of restrictive housing. Where BOP
does not concur with a recommendation or deems it impractical,
documenting its rationale and the alternative steps, if any, it plans to take
46DOJ’s National Institute of Justice is part of the Office of Justice Programs and provides
objective and independent knowledge and tools to inform efforts to promote safety and
advance justice.
47GAO-14-704G.
48GAO-14-704G.

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would also help BOP track its efforts to address the remaining
recommendations. Further, developing and implementing an approach
will help position BOP to implement any recommendations that may result
from the 2023 contractor assessment once it is complete.

BOP is Not Fully
Leveraging Facility
Information to Ensure
Restrictive Housing
Policy Compliance
and Enhance
Operations
BOP’s Program Review
Process Does Not Ensure
Timely Resolution of
Deficiencies

BOP has two key mechanisms that allow it to collect information from
facilities about restrictive housing operations—its program review process
and its administrative remedy process. However, it is not fully leveraging
information obtained from either, resulting in four key missed
opportunities to ensure compliance and enhance operations:
•

BOP is not ensuring resolution of deficiencies after program reviews.

•

BOP is not examining the causes behind common deficiencies.

•

BOP is not monitoring key aspects of SMU operations, including
individuals’ placement into and progression through the program.

•

BOP is not routinely analyzing administrative remedy program data to
identify potential patterns of restrictive housing policy noncompliance.

BOP’s program review process identifies deficiencies, repeat deficiencies,
and “repeat repeat” deficiencies at facilities but does not ensure that
facilities implement the planned corrective actions before the next
review. 49 We analyzed 13 quarterly review summary reports from 2018
through 2022 (one for each quarter in which BOP conducted a review).
These summary reports show that program reviews found multiple
instances of repeated deficiencies across BOP facilities from one review
to the next. During the COVID-19 pandemic, BOP temporarily suspended
the ratings-based program reviews while reviewers focused on
conducting COVID-19 compliance inspections. 50 The Program Review
Division resumed conducting the regular ratings-based program reviews
in early March 2022. Upon resuming the process, the division did not
identify any repeat deficiencies because they did not have fiscal years
2021 or half of 2020 to compare against. As shown in table 3, between

49Deficiencies

generally reflect a deviation from policy or a weakness in internal controls.
A repeat deficiency is the result of the failure of internal controls that were developed to
correct a previously identified deficiency. A ‘repeat repeat’ deficiency indicates a problem
has occurred in the program area at least three times.
50During the COVID-19 pandemic, BOP’s Program Review Division did not conduct
program reviews during the third and fourth quarters of 2020, in any quarter of 2021, and
the first quarter of 2022. Instead, the Program Review Division conducted unannounced
inspections of 87 BOP facilities to ensure compliance with COVID-19 policies and to
develop further mitigation strategies to address the pandemic.

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fiscal year 2018 and fiscal year 2022, there were 32 repeat deficiencies
and 8 “repeat repeat” deficiencies from the prior year.
Table 3: Number and Types of Deficiencies the Bureau of Prisons Identified in Quarterly Summary Reports for all Facilities,
Fiscal Years 2018–2022
Fiscal
year

Number of
quarterly
reviews
conducted

Number of
program
reviews
conducted

Number of new
deficiencies

Number of
Number of Examples of most frequent
repeat “repeat repeat” restrictive-housing related
deficiencies
deficiencies deficiencies

2018

4

41

142

21

2 Special Housing Unit (SHU)
record forms were not properly
completed to document all
required information.
Operational reviews were not
always conducted or completed
as required.

2019

4

31

144

5

2 SHU procedures and protocols
were not in compliance with
policy, such as irregular rounds
were not conducted as required.
SHU record forms were not
completed to document all
required information.

2020

2

22

95

6

4 SHU procedures and protocols
were not in compliance with
policy, such as irregular rounds
were not conducted as required.
Operational reviews were not
properly completed.

2022

3

16

170

0

0 SHU procedures and protocols
were not in compliance with
policy, such as irregular rounds
were not conducted as required.
Operational reviews were not
always conducted in a timely
manner or completed as required.

Total

13

110

551

32

8

Source: GAO analysis of BOP information. | GAO-24-105737

Note: During the COVID-19 pandemic, BOP temporarily suspended the ratings-based program reviews while reviewers focused on conducting COVID19 compliance inspections. When the Program Review Division resumed conducting the regular ratings-based program reviews in early March 2020,
they restarted the program review process anew and did not identify any repeat deficiencies because they did not have fiscal years 2021 or half of 2020
to compare against. Deficiencies generally reflect a deviation from policy or a weakness in internal controls. A repeat deficiency is the result of the failure
of internal controls that were developed to correct a previously identified deficiency. A ‘repeat repeat’ deficiency indicates a problem has occurred in the
program area at least three times.

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Additionally, we reviewed (1) Central Office-led program review reports,
(2) facility-led operational review reports, and (3) facility-led quarterly
perpetual audit reports that reviewers conducted between fiscal years
2018 and 2022 for the five facilities in our sample. Four of the five
facilities we reviewed had repeat deficiencies in the Central Office-led
program reviews or the facility-led operational review, three of which were
specifically related to restrictive housing policies. For example, the
Thomson facility conducted an operational review in October 2021 and
identified 11 repeat deficiencies from the prior operational review it
conducted earlier that year. 51 One of these repeat deficiencies related to
facility staff not always conducting or documenting their assessments of
incarcerated individuals’ progression through each of the three SMU
program levels. 52 Another facility in our sample had a repeat deficiency of
not conducting the operational review as required by BOP’s Program
Review Manual. 53 Specifically, program reviewers found that the facility
had not properly conducted or completed an operational review in 2015,
which they found again in 2017.
According to BOP’s Program Review Manual, a repeat deficiency is the
result of the failure of internal controls that were developed to correct a
noted deficiency. Federal internal control standards also state that agency
management should complete and document corrective actions to
remediate internal control deficiencies on a timely basis. 54 These
corrective actions include resolution of findings from internal program
reviews. The resolution process is completed only after action has been
taken that (1) corrects identified deficiencies, (2) produces improvements,
or (3) demonstrates that the findings and recommendations do not
warrant management action. The standards state that management, with
oversight from the oversight body, should monitor the status of
remediation efforts so that they are completed on a timely basis.

51A facility that has identified deficiencies or major concerns during its operational review
is to conduct a follow-up review 120–150 calendar days after the last operational review.
52According

to the SMU policy, facility staff are to review incarcerated individuals’
adjustment to the facility, program participation, personal hygiene, and cell sanitation
when considering their progression through the three SMU program levels. Department of
Justice, Bureau of Prisons, Special Management Units, 5217.02 (Washington, D.C.: Aug.
9, 2016).
53Department

of Justice, Bureau of Prisons, Management Control and Program Review
Manual, 1210.23 (Washington, D.C.: Aug. 21, 2002).
54GAO-14-704G.

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According to BOP’s Program Review Division officials, the program
review guidance places the responsibility on wardens to ensure
implementation of corrective action plans. Specifically, this guidance
states that wardens are to establish action plans to address operational
and program review findings.
However, BOP does not have an oversight process to verify that the
wardens implement the plans or document that they corrected the
deficiencies before subsequent program reviews. By enhancing its
oversight to verify and document that facilities have implemented
corrective actions that fully address all deficiencies, BOP would be in a
better position to ensure that identified deficiencies are not repeated in
multiple years during subsequent program reviews.

BOP Does Not Identify or
Address Common Causes
of Recurring Deficiencies

Although BOP’s Program Review Division provides quarterly reports to
facility leadership on the most frequent deficiencies identified in its
program reviews, it does not analyze these reports across all facilities to
identify common causes for deficiencies that frequently recur. Evidence of
recurring deficiencies across multiple facilities could indicate that a BOPwide policy or process may need to be updated.
BOP’s Program Review Manual acknowledges that deficiencies may be
the result of unclear or outdated policies and notes that reviewers should
state when they believe that to be the cause of the problem. 55 As table 3
above shows, BOP has found that the same deficiencies have recurred
across multiple facilities. Identifying the causes of common deficiencies—
such as policies being silent on particular matters or resources being
unavailable—would provide useful information. BOP officials did not
provide a reason why they have not taken steps to identify causes of
common deficiencies but agreed that improvements are needed.
According to federal internal control standards, the resolution of findings
from internal program reviews is completed only after action has been
taken that (1) corrects identified deficiencies, (2) produces improvements,
or (3) demonstrates that the findings and recommendations do not
warrant management action. Because the steps facilities have taken to
resolve their deficiencies have not produced improvements, certain
recurring deficiencies may warrant action by BOP management. By
developing and implementing a mechanism to identify causes of common
deficiencies that recur across multiple facilities and taking steps to

55Department

of Justice, Bureau of Prisons, Management Control and Program Review
Manual, 1210.23 (Washington, D.C.: Aug. 21, 2002).

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GAO-24-105737 BOP Restrictive Housing

address them, BOP would be in a better position to understand and
address problem areas.

BOP Does Not Monitor
Key Aspects of SMU
Operations

BOP has not evaluated SMU placements to understand the cause of
disproportionate representation of individuals in certain racial groups in
the SMU. It also does not have a mechanism to monitor two key areas of
SMU operations: (1) the process for determining SMU placement and (2)
SMU program level progression. Instead, the SMU program review
guidelines focus on confinement conditions, including assessments
related to meals, personal hygiene, and opportunities for recreation.

SMU Placements

BOP policy provides facilities discretion and flexibility in determining
whether to place incarcerated individuals in the SMU program. 56
However, BOP does not have an oversight mechanism to ensure that all
BOP facilities consistently and equitably apply the SMU policy placement
criteria.
During the 2014 contracted assessment, reviewers found inconsistencies
related to the subjective SMU placement criteria. For example, they
observed instances of incarcerated individuals being referred to the SMU
after a single serious disciplinary violation, while recommendations for
other incarcerated individuals with repeated instances of the same
violation were rejected or not initiated by the local facility. Reviewers
noted that the layered review process and the fact that regional
management made the final placement decisions helped balance these
inconsistencies. Therefore, they did not make a recommendation to
address this issue. 57 However, they noted that demonstrable
inconsistencies in placement decisions create equity issues in the
56BOP policy states that SMU placement may be considered for any incarcerated
individual whose interaction requires greater management to ensure the safety, security,
or orderly operation of facilities because the individual has met any of the following criteria
(1) had a leadership role or participated in disruptive gang-related activity; (2) a history of
serious or disruptive disciplinary infractions; (3) committed a serious prohibited act; (4)
participated in, organized, or facilitated any group misconduct that adversely affected the
orderly operation of a correctional facility; or (5) otherwise participated in or was
associated with activity such that greater management of the incarcerated individual’s
interaction with other persons is necessary to ensure the safety, security, or orderly
operation of BOP facilities. Department of Justice, Bureau of Prisons, Special
Management Units, 5217.02 (Washington, D.C.: Aug. 9, 2016).
57The

facilities in Lewisburg and Allenwood, Pennsylvania, had operational SMU
programs—and the facility in Florence, Colorado, closed its SMU program—at the time of
the 2014 contracted assessment. Reviewers made an overarching recommendation that
BOP reexamine the SMU levels as they currently operated, their corresponding conditions
of confinement, the length of time in each level, and their compliance with the SMU
program statement.

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application of the SMU placement criteria. They also acknowledged the
challenge of maintaining the balance between discretion of placement
versus creating a consistent and reliable placement process.
In our analysis of SMU data, we found disproportionate representation of
individuals in certain racial groups in the SMU. This appears to confirm
that inconsistencies in the application of the SMU criteria continued,
resulting in equity concerns. In particular, our findings indicate
disproportionate representation of Black individuals in the SMU for each
year from fiscal years 2018 through 2022, as shown in figure 3. For
example, in fiscal year 2022, Black individuals constituted 38 percent of
the total BOP population and 59 percent of the SMU placements. In
comparison, White individuals constituted 58 percent of the total BOP
population and 35 percent of the SMU placements. In contrast, the SHU
and ADX placement rates were relatively proportionate to the total BOP
population rates.

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GAO-24-105737 BOP Restrictive Housing

Figure 3: Bureau of Prisons’ (BOP) Total Population and Restrictive Housing Placements, by Race, Fiscal Years 2018–2022
Percent

100
90
80
70
60
50
40
30

20
10
0

BOP

SMU

SHU

ADX

BOP

SMU

2018

SHU

ADX

BOP

2019

SMU

SHU

ADX

BOP

SMU

2020

SHU

2021

ADX

BOP

SMU

SHU

ADX

2022

Fiscal year

~

1111
1111
1111

American Indian

BOP

Bureau of Prisons total population'

Asian American and Pacifi c Islander

SMU

Special Management Unit placements'

W hite

SHU

Special Housing Unit placements'

Black

ADX

Administrative Maximum Unit placements'

Source: GAO analysis of BOP data.

I

GAO-24-105737

Note: Total BOP population includes the number of incarcerated individuals who spent at least 1 day
of the year in BOP custody, and total placements include the number who spent at least 1 day of the
year in the respective units. Individuals may be counted more than once if they have more than one
restrictive housing placement in a given fiscal year. Totals do not equal 100 due to rounding. The
race identification categories were provided by BOP. A small number of incarcerated individuals were
not placed into a race category because they had not been designated to a facility due to being a pretrial admission or for security reasons. These individuals are included in the overall population totals
but not in individual race identification categories. Total BOP population varied across the years from
about 181,000 to 226,000 and from about 58,000 to 69,000 for SHU placements; from about 1,100 to
1,600 for SMU placements; and from about 400 to 470 for ADX placements.
aTotal population includes everyone in general population housing units as well as restrictive housing

units.

bSpecial Management Units are a type of restrictive housing BOP uses for incarcerated individuals

that require greater management.

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GAO-24-105737 BOP Restrictive Housing

cSpecial Housing Units are a type of restrictive housing BOP uses for punitive or non-punitive
purposes.
dThe Administrative Maximum Facility is a type of restrictive housing BOP uses to confine violent,

disruptive, and escape-prone incarcerated individuals.

Additionally, an August 2022 BOP Regional Management comprehensive
site review report showed a disproportionate representation of Black
individuals versus White individuals in the SMU population. 58 BOP
officials told us they did not know what was causing the disproportionality
because they had not evaluated SMU placements to determine or
address the cause of disproportionate representation of individuals in
certain racial groups in the SMU. Six of the seven individuals we
interviewed who had been housed in the SMU discussed incidents of
discrimination or poor treatment that they perceived were based on race.
One of these individuals specifically expressed the view that the SMU
placement process was discriminatory. This individual explained that
placement in the SMU was due to a single violation and noted that White
individuals with seemingly repeated instances of the same violation had
never been referred to the SMU.

SMU Program Level
Progression

BOP’s program review process also lacks a mechanism to ensure that
incarcerated individuals progress through each of the three SMU program
levels in accordance with policy. 59 During BOP’s regional management
site review of the Thomson facility in August 2022, the review team
determined that facility staff had not complied with certain aspects of
BOP’s SMU policy. Specifically, the team determined that more than 200
individuals who were in the SMU unit as of August 2022 had remained
longer than required by policy. In particular, the review team noted that
staff prohibited individuals from progressing through the three program
levels based on minor infractions, such as not cleaning their cells.

58Between

August and November 2022, BOP’s North Central Regional Director conducted
multiple visits and a comprehensive site review of the United States Penitentiary in
Thomson, IL—BOP’s only SMU. According to a report that documented the results of the
site review, BOP initiated the review due to recent media reports about management
challenges, staff and incarcerated individuals’ reports of misconduct, and information
indicating a breakdown in programs and procedures throughout the facility. Due in part to
the issues identified during this review, BOP leadership closed the Thomson SMU in
February 2023.
59According to the SMU policy, BOP generally expects all incarcerated individuals in the
SMU to complete the three program levels within 9 to 13 months, and the maximum time
an incarcerated individual may spend in SMU is 24 consecutive months. Department of
Justice, Bureau of Prisons, Special Management Units, 5217.02 (Washington, D.C.: Aug.
9, 2016).

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Our analysis of BOP data indicates that at least 25 individuals failed to
complete the program within 24 months each year from fiscal years 2018
through 2022, as shown in table 4.
Table 4: Bureau of Prisons’ (BOP) Special Management Unit (SMU) Population by SMU Program Enrollment Status, Fiscal
Years 2018–2022
FY2018

FY2019

FY2020

FY2021

FY2022

1,462

1,596

1,456

1,449

1,109

622

904

723

769

554

SMU Level 1

546

458

444

398

373

SMU Level 2

145

114

147

98

69

SMU Level 3

52

11

76

88

45

Other SMU
populationc

72

54

29

59

35

SMU program faild

25

55

37

37

33

Total SMU population
SMU program

completesa

Active SMU program

enrolleesb

Source: GAO analysis of BOP information. | GAO-24-105737

Notes: The SMU program was relocated from the Lewisburg, PA, facility to the Thomson, IL, facility in 2019. In February 2023, BOP closed the Thomson
SMU and relocated the SMU inmates to the Terre Haute, IN, facility.
aIncludes those who demonstrated successful progression through all levels of SMU programming and who have abstained from misconduct for a

minimum of 9 months.

bAt level 1 in the SMU program, interaction between incarcerated individuals is minimal and they are restricted to their cells. At level 2, interaction

expands, and out-of-cell activities and programming may increase. At level 3, interaction in an open, but supervised, setting may occur, and individuals
must demonstrate an ability to effectively coexist or interact with others.
cIncludes those who were in the process of transferring to another facility or who were awaiting a final placement decision.
dIncludes those who failed to complete the SMU program within 24 consecutive months.

BOP Program Review Division officials acknowledged that they did not
identify these issues during routine program reviews because the review
process does not include mechanisms for monitoring SMU placements or
program level progression. BOP officials also stated that there are
opportunities to improve the program review process and to monitor
additional aspects of restrictive housing. They said they began developing
and testing new methods in January 2020 to improve the program review
process. BOP Program Review Division officials told us they temporarily
suspended this work during the COVID-19 pandemic, after which
leadership availability and staff turnover caused additional delays. As of
January 2024, BOP began conducting formal trainings to educate audit
staff on proper auditing procedures and is still evaluating new methods to
improve its ability to monitor and oversee facility operations.

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BOP officials told us the closure of the Thomson facility SMU was
intended to address significant concerns, including the lack of compliance
with SMU policy related to program level progression. However, BOP
officials did not provide perspectives or rationale about instances of
disproportionate representations in SMU placements.
The issues identified in the 2014 contracted assessment related to the
subjective application of the SMU placement criteria and the deficiencies
that contributed to the closure of the Thomson facility’s SMU program
have introduced risks to the SMU program. Federal internal control
standards state that management should identify, analyze, and respond
to risks related to achieving the defined objectives, particularly when there
is a degree of subjectivity involved with the risk. 60 According to these
standards, not responding to risk could cause deficiencies in the internal
control system. To better address risks, management may conduct
ongoing monitoring and separate evaluations. In addition, BOP’s Program
Review Manual states that “monitoring on a continuous or periodic basis
allows staff to correct problems before they get out of hand.” 61 Such
routine monitoring may be performed on a weekly or quarterly basis.
As of September 2023, officials told us they are still considering the
operating status of the SMU program. According to BOP, the SMU
program is a tool that enables facility staff to manage unique security
concerns to ensure a safe and orderly environment.
However, BOP has closed and relocated the SMU program to different
facilities six times over the past 10 years. 62 Should BOP reinstate the
SMU program again, it will be important to evaluate previous SMU
placements to determine and address the cause of disproportionate
representation of individuals in certain racial groups in the SMU
population. Analyzing the cause of the substantial racial disparity could
inform BOP and DOJ decisions on the future of restricted housing and
help ensure consistent and equitable treatment of incarcerated
individuals.

60GAO-14-704G.
61Department

of Justice, Bureau of Prisons, Management Control and Program Review
Manual, 1210.23 (Washington, D.C.: Aug. 21, 2002).
62In 2013, we reported that BOP had closed SMUs in two of the five facilities with SMUs.
GAO-13-429. BOP subsequently closed its three remaining SMUs in Lewisburg and
Allenwood, Pennsylvania, and in Florence, Colorado, between 2014 and 2019. In 2019,
BOP had relocated the Lewisburg SMU to the facility in Thomson, Illinois, which it closed
in February 2023.

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GAO-24-105737 BOP Restrictive Housing

Further, should BOP reinstate the SMU program, developing and
implementing a mechanism for routinely monitoring how BOP facilities are
applying SMU placement criteria would enhance BOP’s oversight and
reduce subjectivity. Likewise, developing and implementing a mechanism
for routinely evaluating SMU review documentation would help BOP
ensure that individuals in SMUs are progressing through the three
program levels, in accordance with SMU policy.

BOP Does Not Routinely
Analyze Administrative
Remedy Program Data to
Identify Potential Patterns
of Policy Noncompliance

BOP does not have a process to routinely analyze administrative remedy
program data to identify broad trends or potential patterns of
noncompliance related to BOP’s grievance policy for incarcerated
individuals. 63 Such analysis could inform BOP about possible areas of
program weaknesses and areas for improvement. Our analysis of a
selection of administrative remedy program data, as well as our
interviews with more than two dozen incarcerated individuals who
experienced restrictive housing, indicate areas of program weaknesses in
both the SHU and SMU.

SHU-related Grievances and
Concerns

We analyzed summary information for over 500 formal grievances that
individuals who were housed in SHUs at our five sample facilities
submitted from fiscal years 2018 through 2022. 64 These grievances
related to a wide range of issues, including complaints about BOP staff
and SHU conditions of confinement, such as lack of access to programs
or services or having inadequate amounts of basic necessities. For
example, grievances about BOP staff included complaints about
discrimination, misconduct, policy violations, and excessive use of force.
Conditions of confinement grievances included complaints about being
denied access to recreation time, lack of access to psychological
services, and being denied or provided inadequate amounts of food and
hygiene products, such as toilet paper and soap.
Our interviews with 28 incarcerated individuals whom BOP had placed in
SHUs at these five facilities provided additional insights into similar issues
raised in these grievances, which may indicate possible patterns of
noncompliance with the SHU policy. For example, many of the 28
individuals we interviewed told us they were denied access to recreation
or psychological services or were provided inadequate amounts of basic
necessities such as food, toilet paper, and hygiene products, which is
63Under

BOP’s administrative remedy program, incarcerated individuals can seek formal
review of any grievances relating to their own confinement.
64We selected these submissions based on 14 BOP subject codes related to restrictive
housing settings and conditions that BOP uses to categorize administrative remedy
grievance submissions.

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GAO-24-105737 BOP Restrictive Housing

inconsistent with BOP policy. Specifically, 18 individuals across all five
facilities described not having enough toilet paper or other hygiene
products. Further, 23 individuals across all five facilities described
unsanitary conditions of SHU clothing and bedding or conditions that
were worse than general population. See appendix IV for additional
illustrative examples in each of these categories.

SMU Related Grievances and
Concerns

We analyzed summary information for nearly 600 formal grievances that
individuals whom BOP housed in the Thomson facility SMU submitted
from fiscal years 2019 through 2022. About 150 of these submissions
were specific complaints related to delays in SMU level progression. As
previously discussed, BOP closed the Thomson facility SMU in February
2023, in part because facility staff had not complied with the SMU policy
on SMU level progression. In addition, over 100 of these submissions
related to Thomson facility staff, including complaints of staff misconduct,
denial of rights, and excessive use of force.
Furthermore, seven individuals we interviewed who were housed in the
SMU described concerns that indicated possible patterns of
noncompliance with the SMU policy. For example, most incarcerated
individuals we interviewed with SMU experience said they were not
provided opportunities to regularly receive recreation time, as required by
policy. 65 Most of these incarcerated individuals also shared experiences
with us about alleged misconduct, abuse, or negligence by facility staff.
Some said they raised informal grievances to facility staff, which were not
resolved. Others said they filed formal grievances through the
administrative remedy process but told us that BOP did not resolve their
grievances.
BOP’s Administrative Remedy Program staff ensure grievance data
submitted by individuals across all facilities are accurate, including the
type of grievance and whether the grievance was addressed or rejected.
Then they use this information to compile statistics which are updated
monthly on BOP’s internal website.

65According to BOP's program statement, "[individuals] have the opportunity to exercise
outside their individual quarters for at least five hours per week, ordinarily in one-hour
periods on different days." Department of Justice, Bureau of Prisons, Special
Management Units, 5217.02 (Washington, D.C.: Aug. 9, 2016). Because we interviewed a
smaller number of individuals who were housed in the sole SMU than those who were
housed in SHUs across multiple facilities, we are not including the specific number of
individuals who responded in a particular way or any information that might be used to
identify them to protect their identity.

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GAO-24-105737 BOP Restrictive Housing

However, they said they did not know who, if anyone, reviews this
information or for what purpose. Neither BOP’s Program Review Division
staff, its Administrative Remedy Program staff, nor its Office of Research
and Evaluation staff have analyzed administrative remedy submissions
for broad trends or patterns of noncompliance with BOP policies or the
causes underlying them. Officials from BOP’s Administrative Remedy
Program said they haven’t done so because they focus on addressing
these grievances. These officials noted that staff could alert management
from the relevant BOP regional office or facility leadership if they
identified a need for corrective actions based on their reviews of these
data. However, they could not provide a specific example that this has
ever occurred. Further, a representative from the administrative remedy
team told us the team does not discuss cross-cutting issues or trends that
could be apparent in the data during its routine meetings.
BOP’s Program Review Manual states that BOP central and regional
office administrators are to ensure information from sources such as
program reviews, management assessments, and other studies are
analyzed to determine whether there is a pattern of noncompliance or
lack of controls in the programs. As BOP is developing improvements to
its program review process, incorporating a mechanism to routinely
leverage available administrative remedy data would provide benefits.
Specifically, developing and implementing a process to routinely analyze
the administrative remedy program data would better position BOP to
identify and address, as needed, any potential patterns of noncompliance
with restrictive housing policies and other areas of program weaknesses.

BOP Used Restrictive
Housing for Medical
Isolation During the
COVID-19 Pandemic
Due to Space
Constraints

During the COVID-19 pandemic, some BOP facilities used SHUs to
quarantine or medically isolate individuals who were exposed to or tested
positive for the virus. 66 For example, officials from four of the five facilities
told us they used SHUs for this purpose because these facilities lacked
space or staff to maintain the recommended distance between
incarcerated individuals. Nationwide, the number of COVID-19 cases had
peaked in December 2020 and January 2021. By May 2021, 45,660
incarcerated individuals across BOP facilities had tested positive for
COVID-19, according to BOP data.
66BOP’s

COVID-19 pandemic plan states that quarantine refers to separating (in an
individual room or cohorting in a unit) asymptomatic not fully vaccinated persons to (1)
observe them for symptoms and signs of illness during the incubation period and (2) keep
them apart from other incarcerated individuals. BOP uses three categories of quarantine:
exposure, intake, and release/transfer. The plan further refers to medical isolation as
confining individuals with suspected (displaying symptoms) or confirmed (based on a
positive test) COVID-19 infection, either to single rooms or by cohorting them with others
with suspected or confirmed infections.

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GAO-24-105737 BOP Restrictive Housing

We previously reported that BOP’s efforts to safeguard incarcerated
individuals during the COVID-19 pandemic generally changed
incarcerated individuals’ living conditions. 67 Specifically, we reported that
BOP limited access to programs, services, visitors, and facility spaces.
However, BOP’s policy dictates that the living conditions for individuals
placed in SHUs for quarantine or medical isolation should be comparable
to their regular housing unit, since these individuals did not have
disciplinary infractions. BOP’s COVID-19 Pandemic Response Plan
requires medical isolation to be distinct from the conditions experienced
by individuals placed in the SHU for administrative detention or
disciplinary segregation. 68 These conditions may include similar access to
radio, television, personal property, and commissary as would be
available in regular housing units.
However, BOP officials at three of the four facilities that used SHUs for
quarantine purposes told us that the living conditions were the same for
all incarcerated individuals placed in the SHU for administrative detention,
disciplinary segregation, and medical isolation. For example, officials in
one facility said that none of the SHU incarcerated individuals were
permitted to have the personal property items that they were permitted in
their general population housing units regardless of whether they were in
the SHU for medical isolation or discipline. Practices in the fourth facility
more consistently aligned with BOP policy. BOP officials there said that
incarcerated individuals placed in the SHU for any type of administrative
detention, which includes quarantine or medical isolation, were generally
allowed more privileges than those in SHUs for disciplinary purposes. 69
We interviewed nine incarcerated individuals at three facilities who had
been placed in a SHU for quarantine or medical isolation during the
COVID-19 pandemic. Of these, eight said they were not able to keep any
personal property while they were in the SHU for quarantine or medical
isolation and/or that the conditions they experienced were the same as
individuals who were placed in the SHU for discipline. For example, one
incarcerated individual who had been placed in the SHU one time for
discipline and one time for COVID-19 quarantine said that the living
67GAO-21-502.
68BOP,

COVID-19 Pandemic Response Plan, Feb. 7, 2022, version 4.

69BOP’s

SHU policy states that individuals in administrative detention status are ordinarily
allowed a reasonable amount of personal property while personal property is to be
impounded for individuals in disciplinary segregation status. The policy also states that
personal property may be limited for individuals in either status for sanitation reasons.
Department of Justice, Bureau of Prisons, Special Housing Units, 5270.11 (Washington,
D.C.: Nov. 23, 2016).

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GAO-24-105737 BOP Restrictive Housing

conditions were the same both times. One individual we interviewed was
able to keep personal property while in the SHU for medical isolation,
including photographs and a radio.
Executive Order 14074 directed the Attorney General to update BOP
procedures and protocols to identify alternatives to the use of restrictive
housing for quarantine and medical isolation of individuals who were
exposed to or tested positive for COVID-19. 70 In response, BOP revised
its COVID-19 pandemic plan to minimize its use of quarantine for this
purpose and to use isolation when necessary. In addition, to mitigate the
risk of mental health strain on individuals who must be isolated, the plan
states that psychology services staff should be consulted if isolation in
single cells is necessary to ensure that those individuals are not
particularly vulnerable.
Furthermore, in its March 2023 COVID-19 capstone report, the DOJ
Office of the Inspector General recommended that BOP compile and
regularly update best practices for addressing space limitations to meet
social distancing, quarantine, and medical isolation needs. 71
Implementing such best practices would help BOP address space
limitations and seek alternatives to using restrictive housing for
quarantine and medical isolation, as such housing is often punitive.

Conclusions

BOP has not fully implemented most of the recommendations from a
2016 DOJ report and a 2014 contractor assessment to reduce its use of
restrictive housing and improve its oversight. By developing and
implementing an approach to fully address the remaining
recommendations, including assigning implementation responsibility to
appropriate officials and setting and monitoring time frames for
completion, BOP could reduce its use of restrictive housing. Where BOP
does not concur with a recommendation or deems it impractical,
documenting its rationale and the alternative steps, if any, it plans to take
would also help BOP track its efforts to address the remaining
recommendations. Further, developing and implementing an approach
will help position BOP to implement any recommendations that may result
from the 2023 contractor assessment once it is complete.
BOP can also ensure restrictive housing policy compliance and improve
operations by using available information it collects from its program
review and administrative remedy processes. However, it is not ensuring
resolution of identified deficiencies, not addressing the causes behind
7087

Fed. Reg. 32,945.

71Department

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GAO-24-105737 BOP Restrictive Housing

common deficiencies, and not analyzing administrative remedy program
data to identify potential patterns of non-compliance. Accordingly, it is
missing opportunities to enhance restricted housing operations.
BOP also has not monitored key aspects of SMU operations, including
individuals’ placements in the unit and their progress in the program. After
closing its only SMU program to address significant concerns related to
the facility’s lack of compliance with SMU policy, BOP has not decided on
the future of this program. As it considers options, it will be important that
BOP address the factors associated with noncompliance with SMU policy.
Further, substantial racial disparities in SMU program participation raise
questions about the consistency and equity of placement decisions.

Recommendations for
Executive Action

We are making the following eight recommendations to BOP:
The Director of BOP should develop and execute an approach to fully
implement all the 2014 and 2016 restrictive housing reports
recommendations. For each recommendation that has not yet been
implemented, the approach should include assigning implementation
responsibility to appropriate officials, establishing a time frame for
completion, and monitoring progress. In instances where BOP does not
concur with a 2014 recommendation or deems it impractical, it should
document its rationale and the alternative steps, if any, it plans to take.
(Recommendation 1)
The Director of BOP should enhance oversight by developing and
implementing a process to verify and document that facilities have
implemented corrective actions that fully address all deficiencies.
(Recommendation 2)
The Director of BOP should develop and implement a mechanism to
identify causes of common deficiencies that recur across multiple facilities
and take steps to address those causes. (Recommendation 3)
The Director of BOP should conduct an evaluation of previous SMU
placements to determine and address the cause of disproportionate
representation of individuals in certain racial groups in the SMU
population. (Recommendation 4)
The Director of BOP should develop and implement a mechanism for
routinely monitoring the extent to which facilities are applying the SMU
placement criteria consistently and equitably across all BOP facilities
should BOP reinstate the SMU program. (Recommendation 5)

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The Director of BOP should develop and implement a mechanism for
routinely evaluating SMU review documentation to ensure that
incarcerated individuals progress through the SMU program levels in
accordance with SMU policy should BOP reinstate the SMU program.
(Recommendation 6)
The Director of BOP should develop and implement a process to routinely
analyze administrative remedy program data. (Recommendation 7)
The Director of BOP should develop and implement a process to address
any identified patterns of noncompliance related to restrictive housing
policies and other areas of program weaknesses. (Recommendation 8)

Agency Comments
and Our Evaluation

We provided a draft of this report to DOJ for review and comment. BOP
concurred with all eight recommendations and described actions planned
or underway to address them. BOP also provided technical comments,
which we have incorporated as appropriate. BOP's comments are
reproduced in appendix V.

BOP stated that it recognizes that restrictive housing is not an effective
deterrent and can increase future recidivism. As such, it is developing
both short term and long-term plans to improve its restrictive housing
practices. Further, BOP stated that it has started implementing a new
strategic framework that devotes a goal specifically to reducing its use
of restrictive housing.
In response to recommendation 1, BOP stated that it does not agree with
our conclusion that there are 55 recommendations that it only partially
implemented or did not implement at all. In BOP’s technical comments, it
asked us to reconsider evidence for one of the 55 recommendations. We
did, and as we note in our final report, we concluded that it had been
implemented, which reduced the total to 54 recommendations not yet fully
implemented.
BOP also stated that to the extent that there are outstanding
recommendations from the 2014 and 2016 reports that BOP can
implement, it will develop and execute a plan to do so. It also stated that
for those recommendations that BOP believes have already been
implemented or disagrees with, it will continue to document the rationale
for its position and any alternative steps. Finally, for each
recommendation that has not yet been implemented, BOP stated that its
approach will include assigning implementation and responsibility to
appropriate officials, establishing a time frame for completion, and
monitoring progress. The planned actions BOP described for each of the

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recommendations not yet implemented, if done effectively, would address
our recommendation.
In response to recommendations 2 and 3, BOP stated that it will
implement an internal audit process to verify and document that
facilities have implemented corrective actions to address deficiencies
identified during internal audits conducted by its Program Review
Division. It further stated that this process will identify causes of
common deficiencies that recur across multiple facilities. Finally, it
stated that this will include an internal audit follow-up process involving
all levels (local, regional, and divisional leadership) of the agency to
establish internal controls that mitigate the recurrence of deficiencies.
The actions BOP described, if implemented effectively, would address our
recommendations.
Regarding recommendation 4, BOP stated that an evaluation of past
SMU placements to determine the cause of disproportionate
representation is included in the scope of an ongoing contracted study.
The actions BOP described, if implemented effectively, would address our
recommendation.
While BOP stated that it concurred with recommendations 5 and 6, BOP
noted that it has already suspended the SMU program and is working
to identify an appropriate replacement in conjunction with the
contracted study referenced above. Further, BOP stated that its
closure of the SMU at USP Thomson, as discussed in our report,
adequately addresses these recommendations and it requests that we
consider them implemented already.

As noted in our report, BOP has closed and relocated the SMU program
to different facilities six times over the past 10 years. Additionally, BOP
considers the SMU program to be a tool that enables facility staff to
manage unique security concerns to ensure a safe and orderly
environment. As BOP works toward an appropriate replacement for the
SMU program, should it decide to reinstate the program at a different
facility or replace it with a similar program in function, routinely monitoring
the application of SMU criteria and reviewing documentation on
individuals’ progress will continue to be essential. Accordingly, we believe
that implementing these recommendations at that time will better position
BOP to ensure the consistency and equity of its placement decisions and
policy compliance.
In response to recommendation 7, BOP stated that it will work towards
developing and implementing a process to routinely analyze
administrative remedy program data. BOP also noted that

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administrative remedy program data should not solely be relied upon
to identify patterns of noncompliance, and other areas of program
weaknesses. This is because the program is designed to individually
assess and respond to grievances specific to individuals challenging
the conditions of their confinement. Therefore, BOP stated that it will
incorporate a review of Administrative Remedy data into broader
analyses of policy concerns and issues. The actions BOP described, if
implemented effectively, would address our recommendation.
In response to recommendation 8, BOP stated that it will develop and
implement a process to address any identified patterns of
noncompliance related to restrictive housing policies, and other
potential areas of program weaknesses. The actions BOP described, if
implemented effectively, would address our recommendation.
We are sending copies of this report to the appropriate congressional
committees, DOJ, BOP, and other interested parties. In addition, the
report is available at no charge on the GAO website
at https://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-8777 or GoodwinG@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix VI.

Gretta L. Goodwin
Director
Homeland Security and Justice

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Appendix I: Objectives, Scope, and
Methodology
Appendix I: Objectives, Scope, and
Methodology

This report examines the following objectives:
1. To what extent has the Bureau of Prisons (BOP) addressed
recommendations in the 2014 contracted assessment and the
2016 DOJ report on restrictive housing?
2. To what extent does BOP leverage the information it collects from
facilities to ensure restrictive housing policy compliance and
enhance restrictive housing operations?
3. How did BOP use restrictive housing units during the COVID-19
pandemic?
To address in part all three of our objectives we selected a
nongeneralizable sample of five of BOP’s 121 facilities. We selected
these facilities to reflect a range in the types of restrictive housing units—
Special Housing Units (SHU); the Special Management Unit (SMU); and
the Administrative Maximum Unit (ADX). Our sample also includes a
range of security levels (low, medium, and high security facilities). We
selected the U.S. Penitentiary in Thomson, Illinois, because at the time of
our review, it was the only facility with a SMU. We selected the Federal
Correctional Complex in Florence, Colorado, because it is the only ADX
facility. We also selected the Federal Correctional Complexes in Butner,
North Carolina, and Terre Haute, Indiana, as well as the Federal
Correctional Institution in Dublin, California. All five facilities have a SHU.
The Dublin, California, facility houses females and the other four facilities
house males.
For each of these five selected facilities, we interviewed facility
management staff, including the facility warden and associate wardens,
as well as restrictive housing unit managers and correctional officers who
work in restrictive housing units. We also interviewed officials responsible
for providing health services and mental health services, including clinical
directors, psychologists, and treatment staff. Lastly, we conducted
interviews with 6–10 incarcerated individuals in restrictive housing units at
these five facilities at the time of our review for a total of 37 individuals. 1
While the anecdotal information we learned during these interviews
provided valuable insights about the experiences of individuals who were
1At

each facility, BOP provided a list of individuals who had been recently placed in a
restrictive housing unit. We selected 6–11 individuals from each list who had different
placement reasons, which included administrative detention, disciplinary segregation, and
medical isolation. We then provided written information about this review to each
individual we selected and verbally obtained their consent to participate in the interview.

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Appendix I: Objectives, Scope, and
Methodology

placed in restrictive housing units, these interviews are not representative
of the entire restrictive housing population or the total BOP population.
We also analyzed facility-specific documents, such as handbooks
provided to incarcerated individuals, supplemental policy guidance,
commissary lists, program review reports, and photographs representing
various types of restrictive housing units, settings, and recreational areas.
While the results from our sample of facilities cannot be generalized to all
BOP facilities with restrictive housing, they provided insights into how
BOP facilities implement restrictive housing policies as well as how BOP’s
Central Office monitors facilities for compliance with these policies.
In addition to the interviews with BOP staff, we interviewed BOP officials
from several Central Office (headquarters) divisions to learn about
bureau-wide policies and administration, including the Correctional
Programs and Program Review Divisions. We also interviewed Regional
Managers from two of BOP’s six regional offices. All regions have
facilities with special housing units, but we selected the North Central
region because it has a facility with an ADX and SMU. We selected the
South Central region because it has a Female Administrative Unit.
To address our first objective, we reviewed relevant DOJ and BOP
reports, policies, and training materials on BOP’s actions to implement
recommendations from the 2014 contracted assessment and the 2016
DOJ report. This included reviews of BOP program statements, forms,
and program review guidance related to various restrictive housing
programs and units. We analyzed BOP data on all individuals housed in
each type of restrictive housing unit and setting from fiscal year 2018
through fiscal year 2022, including the total number of individuals who
were housed in each type of unit at least 1 day during each fiscal year by
mental health care level. We selected this period to conduct a 5-year
trend analysis of the data most recently available at the time of our
review. To assess the reliability of these data, we interviewed
knowledgeable officials about BOP’s data systems, reviewed the query
code language BOP used to retrieve requested data, and examined the
data for obvious errors. We determined these data to be sufficiently
reliable for the purpose of reporting the number and type of restrictive
housing placements.
To determine how certain subsets of the restrictive housing population
changed during this same time period, we analyzed two daily “snapshots”
of data posted to BOP’s website. These “snapshots” showed the number
of individuals BOP placed in SHUs for protective custody—a type of
administrative detention status for individuals who require protection from

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Appendix I: Objectives, Scope, and
Methodology

real or perceived threats to their safety—at a specific point in time. 2 We
used this approach because BOP does not maintain subsets of SHU
placement categories, such as protective custody status, in an accessible
format to analyze trends over time. We accessed and retained these daily
snapshots early in our review in April 2022 and again in October 2023. 3
Using the same data reliability steps as above, we determined these
snapshot data to be sufficiently reliable for reporting changes in protective
custody placements over time since BOP used the same approach to
report these changes.
We assessed BOP’s efforts to address the 2014 and 2016
recommendations against criteria in Standards for Internal Control in the
Federal Government, which state that management should oversee the
prompt remediation of deficiencies by communicating the corrective
actions to the appropriate level of the organizational structure and
delegating authority for completing corrective actions to appropriate
personnel. 4 According to these standards, the process is completed only
after action has been taken that (1) corrects identified deficiencies, (2)
produces improvements, or (3) demonstrates that the findings and
recommendations do not warrant management action. Furthermore,
these standards state that management, with oversight from the oversight
body, should monitor the status of remediation efforts so that they are
completed on a timely basis. 5
To address our second objective, we analyzed BOP’s restrictive housing
policies and program review guidance and reports. These included 13
quarterly review summaries for all the program reviews that BOP
conducted from fiscal year 2018 through fiscal year 2022. These also
included Central Office and facility-level reports for reviews of the five
facilities in our sample that BOP conducted during this same period. We
2These

threats may be due to gang affiliations, certain types of criminal convictions,
gender identify, or sexual orientation. Individuals may request to be placed in protective
custody if they feel threatened or they may be placed in protective custody involuntarily if
BOP staff determine they need protection from verified threats.

3BOP

collects data on this population to support the daily operational needs of BOP
facilities. However, BOP does not maintain these records in a format that allows for it to
analyze changes in this population over time. Therefore, we relied on the operational
information reported on BOP’s website to determine the number of individuals who were
placed in protective custody (either voluntarily or involuntarily). See BOP, “Restricted
Housing Statistics,” Inmate Statistics (Washington, D.C.), accessed on April 6, 2022, and
October 3, 2023, https://www.bop.gov/about/statistics/statistics_inmate_shu.jsp.

4GAO,

Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: Sept. 10, 2014).

5GAO-14-704G.

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Appendix I: Objectives, Scope, and
Methodology

assessed BOP’s efforts to address the deficiencies its program reviews
contained against federal internal control standards. 6 According to these
standards, the resolution process is completed only after action has been
taken that (1) corrects identified deficiencies, (2) produces improvements,
or (3) demonstrates that the findings and recommendations do not
warrant management action.
To assess BOP’s compliance with its SMU policy, we analyzed BOP data
on individuals placed in the SMU at least 1 day during each year from
fiscal year 2018 through fiscal year 2022 by SMU program level and race.
Our analysis of SMU program levels included the total number of
individuals placed in each of the three SMU program levels, those who
had completed the SMU program, and those who failed to complete the
SMU program for each fiscal year from 2018 through 2022.
To assess the reliability of these data, we interviewed knowledgeable
officials about BOP’s data systems and reviewed the query code
language BOP used to retrieve requested data for missing data and
obvious errors. We determined the data to be sufficiently reliable for the
purpose of reporting the total number of SMU placements by program
level and race. We reviewed the comprehensive site review of the
Thomson facility that BOP conducted in August 2022. Of the 37
interviews we conducted with incarcerated individuals, seven of them had
experience in the SMU. We assessed BOP’s compliance with its policies
on SMU placements and progression against federal internal control
standards. 7
Lastly, to understand whether BOP leverages available information to
identify possible areas of noncompliance with its policies, we analyzed
over 1,500 administrative remedy grievance summaries that individuals
housed in restrictive housing units at the five facilities in our sample

6GAO-14-704G.

These standards state that agency management should complete and
document corrective actions to remediate internal control deficiencies on a timely basis
and that such corrective actions include resolution of findings from internal program
reviews. These standards further states that management, with oversight from the
oversight body, monitors the status of remediation efforts so that they are completed on a
timely basis.

7GAO-14-704G.

According to these standards, management should identify, analyze, and
respond to risks related to achieving the defined objectives, particularly when there is a
degree of subjectivity involved with the risk. These standards also state that not
responding to risk could cause deficiencies in the internal control system and
management may conduct ongoing monitoring and separate evaluations to better address
risks.

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Appendix I: Objectives, Scope, and
Methodology

submitted to BOP from fiscal year 2018 through 2022. 8 Of these,
individuals housed in SHUs at the five facilities submitted over 500
administrative remedy grievance summaries, individuals housed in the
Thomson facility SMU submitted nearly 600, and individuals housed in
ADX units submitted over 400 administrative remedy grievances during
the same period.
We selected these submissions based on 14 BOP subject codes related
to restrictive housing settings and conditions that BOP uses to categorize
administrative remedy grievance submissions. We assessed the reliability
of these data by reviewing agency policies related to administrative
remedy submissions and interviewing BOP officials about their methods
for uploading and tracking these submissions. We found these data to be
sufficiently reliable for the purpose of summarizing examples of
grievances that individuals in restrictive housing submitted. We also
asked the 35 incarcerated individuals who had experience in SHU or
SMU about the types of formal and informal grievances they submitted to
BOP officials and the outcomes of those submissions. Though not
generalizable, these interviews provided us with illustrative examples of
their experiences.
To address our third objective, we reviewed BOP policies and guidance
for pandemic response, including BOP’s COVID-19 pandemic plan. We
interviewed officials at our five selected facilities to understand how these
facilities used restrictive housing during the pandemic. We also reviewed
the May 2022 Executive Order 14074 and the DOJ Office of the Inspector
General COVID-19 capstone report to understand directives and
recommendations related to this objective. 9 In addition, we interviewed
BOP officials about their efforts in response. During our interviews with
incarcerated individuals at the five selected facilities, we asked which, if
any, individuals had experience in restrictive housing during the pandemic
for various reasons. We then asked questions about the conditions of
their confinement during that time. Although these interviews are not

8Under

the administrative remedy program, incarcerated individuals, including those in
restrictive housing, can seek formal review of any grievances relating to their own
confinement. See 28 C.F.R. pt. 542.

9Exec.

Order No. 14,074, Advancing Effective, Accountable Policing and Criminal Justice
Practices to Enhance Public Trust and Public Safety, 87 Fed. Reg. 32,945 (May 25,
2022). Department of Justice, Office of the Inspector General, Capstone Review of the
Federal Bureau of Prisons’ Response to the Coronavirus Disease 2019 Pandemic, 23-054
(Washington, D.C.: Mar. 2023).

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Appendix I: Objectives, Scope, and
Methodology

representative of all individuals placed in restrictive housing during the
pandemic, they provided useful insights.
We conducted this performance audit from January 2022 to February
2024 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.

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Appendix II: Restricted Housing Unit Types
Appendix II: Restricted Housing Unit Types

This appendix provides an overview of the three types of restrictive
housing unit types, including the conditions of confinement and placement
criteria for each unit type. The Bureau of Prisons (BOP) generally uses
three types of restrictive housing units across its 121 facilities: 1
1. Special Housing Units (SHUs);
2. The Special Management Unit (SMU); and
3. The Administrative Maximum Facility.
The purpose of all three types of units is to separate incarcerated
individuals from the general population to protect the safety, security, and
orderly operation of BOP facilities. BOP has policies that govern each
type of restrictive housing unit. These policies establish baseline
conditions of confinement, regardless of unit type, or placement reason.
For example, the policies dictate that all restrictive housing settings must
provide
•

well-ventilated, adequately lighted, appropriately heated, and sanitary
living quarters;

•

appropriate medical care;

•

a mattress, blankets, a pillow, and linens for sleeping, as well as
opportunities to exchange linens for clean replacements;

•

nutritionally adequate meals and access to a sink, toilet, and personal
items necessary to maintain an acceptable level of personal hygiene;

•

an opportunity to exercise outside of the cell at least 5 hours per
week, ordinarily on different days in 1-hour periods;

•

reasonable amount of non-legal reading material and permission to
possess religious scriptures of their faith;

•

conduct legal research, file lawsuits, and participate in legal visits and
telephone calls under the same provisions as individuals in the
general population; and

•

access to a variety of programming activities, including behavioral
interventions, literacy programs, adult continuing education, college
correspondence classes, and parenting classes.

1BOP

has 122 facilities, but as of September 2023, one of its New York facilities was no
longer operational.

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Appendix II: Restricted Housing Unit Types

In addition to these baseline conditions of confinement, each type of
restrictive housing unit has specific placement criteria and conditions of
confinement, as follows.

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Appendix II: Restricted Housing Unit Types

SPECIAL HOUSING UNIT (SHU)
LOCATION
92 of Bureau of Prisons' (BOP) 121 facilities have SHUs.

PURPOSE
To house incarcerated individuals for a variety of punitive and nonpunitive purposes.

REFERRAL
BOP places individuals in administrative detention (non-punitive) or
disciplinary segregation (punitive) status, as described below.

Source: BOP
ADMINISTRATIVE DETENTION

I

DISCIPLINARY SEGREGATION

Temporary

Offense determines length of stay

Non-punitive

Punitive

Reason

Pending security classification or reclassification ;
pending transfer to a facility; protection cases; under
investigation for or awaiting a hearing for a violation of
a BOP regulation or criminal law; following confinement
in disciplinary segregation when return to the general
population poses a threat to other inmates, staff, or
orderly operations of BOP facilities .

Fulfilling a sanctioned sentence after violating a BOP
regulation .

Procedures/
policies

Typically receive a notice of reason (s) for placement 24
hours prior.a

Following a disciplinary hearing , the disciplinary hearing
officer is to inform the individual about any sanctions received
for violating a BOP regulation , including a sentence of
disciplinary segregation in a SHU ."

Duration
Status

Conditions of
confinement

Conditions are generally the same for individuals in both administrative detention status and disciplinary segregation
status, except as follows:
Exceptions: Individuals in administrative detention status may have certain personal property items, such as books and
photos, access to programming activities, and access to the comm issary.
Individuals in disciplinary segregation status do not have access to personal property, their participation in programming
activities may be suspended , and their commissary privileges may be limited .c

Release

Released when the placement reasons no longer ex ist.

Released after completing the imposed sanction or when
a supervisory official determines the individual no longer
requires disciplinary segregation status.

Source: GAO analysis of Bureau of Prisons information. I GA0-24-105737

•Individuals are to receive a copy of the administrative detention order, within 24 hours, detailing the reason(s) for placement, unless they are in holdover
status pending classification .
"A disciplinary hearing officer is an independent, impartial decision maker and not a victim, witness, investigator, or otherwise significantly involved in the
incident.
crhe warden may limit the quantity and type of personal property allowed for individuals in either status for security, fire safety, or sanitation/
housekeeping reasons.

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Appendix II: Restricted Housing Unit Types

SPECIAL MANAGEMENT UNIT (SMU)
LOCATION
U.S. Penitentiary Thomson in Illinois from January 2019 to February

2023.•

PURPOSE
To house incarcerated individuals who require greater management. Bureau
of Prisons (BOP) generally expects individuals in a SMU to complete three
program levels within 9-12 months, not to exceed 24 months.

REFERRAL
BOP places individuals in a SMU for having a history of disciplinary
infractions or after committing a single, serious prohibited act.b

SMU
PROGRAM
LEVELS

Level1

I

SMU
PROGRAM

Source: BOP

I

LEVEL
DURATION

SMU

6-8 months

SMU facility staff set behavioral expectations that individuals must meet to progress through this level.

PROGRAM LEVEL CHARACTERISTICS

Privileges/conditions: Individuals are restricted to their cells and interaction with others is minimal. Conditions
are more restrictive than general population. For example, access to recreation areas, personal property, and
programming is limited.
Level2

2-3 months

Individuals must demonstrate positive community interactions , such as participating in programs and being able
to function in a general population setting . Those who fail to do so may return to previous level.
Privileges/conditions: While individuals are still restricted to their cells, there are more opportunities to interact
with other individuals and participate in out-of-cell recreational and educational activities on a case-by-case
basis. Individuals may begin to earn access to more personal property items.

Level3

1-2 months

Individuals must continue to demonstrate positive community interactions, such as being able to function in a
general population setting . Those who fail to do so may return to previous level.
Privileges/conditions: Individuals may interact in an open , but supervised setting with others, openly move
throughout the unit, and participate in group counseling. Individuals who progress to level 3 and maintain good
conduct earn access to more commissary and personal property items.

Criteria for
release

SMU fail

9-24 months

Individuals must (1) progress through all three levels; (2) abstain from disciplinary activity for a minimum of 9
months; and (3) demonstrate an ability to coexist with others in a general population setting .

24 months

Failure to progress through all three levels within 24 months results in a "SMU fail ."

Source: GAO analysis of Bureau of Prisons information.

I

GAO-24-105737

•In February 2023, BOP closed the Thomson SMU and temporarily relocated the individuals who were in the Thomson SMU to Federal Correctional
Complex Terre Haute.
bA SMU serious prohibited act may include having a leadership role in disruptive geographical group/gang-related activity, killing or assaulting another
person , group misconduct that adversely affected the orderly operation of a correctional facility.

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Appendix II: Restricted Housing Unit Types

ADMINISTRATIVE MAXIMUM
FACILITY (ADX)
LOCATION
Federal Correctional Complex in Florence, Colorado.•

PURPOSE
To house the Bureau of Prisons' (BOP) disruptive, escape-prone, and
violent incarcerated individuals.

REFERRAL
BOP places individuals in the ADX who are generally unable to be safely
housed in less restrictive environments. The ADX operates four distinct
types of units, and all units have single cells due to security reasons.
The referral criteria and conditions of confinement vary by unit type, as
described below.

REFERRAL CRITERIA FOR
INDIVIDUALS' PLACEMENT

Control Unit

Harms or make threats towards others;

Special Administrative Measures the
Attorney General imposes.b
Individuals complete a three-phase
program and conditions are less
restrictive with progression. BOP
determines whether individuals can
function with more privileges without
posing security risks.

High Security
Adult
Alternative
Housing Unit

Most restrictive ADX unit.

Two 15-minute phone calls per month .

Possesses contraband , such as deadly
weapons or drugs .

General
Population
& Step-down
Units

CONDITIONS OF CONFINEMENT

Minimum of 7 hours of individual out-of-cell exercise per week.

Escapes or attempts to escape from
BOP facilities ;

Special
Security Unit

I

Source: BOP

Meet general ADX referral criteria listed
above .
Individuals are expected to complete
a four-phase program beginning in the
general population and ending in the
Phase 4 step-down unit. Progression into
each phase leads to more privileges and
less restrictive conditions.c

Restraints required for any out-of-cell activity.
Non-legal phone calls and visits are monitored and recorded.
Minimum of 10 hours of out-of-cell exercise per week, unless in disciplinary
segregation .
Minimum of three showers per week.
Generally, eat meals in cells.

Two escorts always required . Hand restraints required during early phases.
Minimum of 1O hours of out-of-cell exercise per week.
May shower any time they are out of cell unless shower is located in cell.
Phase in program determines if individuals eat meals in cells or outside of cells.

Minimum age of 50 years.

No restraints required while out-of-cell.

Ability to function in less-secure unit, but
safety needs, such as gang affiliation ,
prevent placement in a step-down unit.

20 hours of out-of-cell group exercise per week.

Source: GAO analysis of Bureau of Prisons information.

I

Can eat meals outside of cells.

GAO-24-105737

•Federal Correctional Complex Florence is comprised of three facilities: (1) United States Penitentiary Florence, (2) Federal Correctional Institute
Florence, and (3) ADX Florence.
bThe Attorney General may authorize Special Administrative Measures pursuant to 28 C.F.R. §§ 501 .2, 501 .3 and may limit privileges, such as phone
calls and visits, to prevent the disclosure of classified information and to protect persons against the risk of acts of violence and terrorism .
clndividuals begin in the general population unit before moving to the step-down units.

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Appendix
III: Bureau of Prisons’ (BOP)
Appendix Ill: Bureau of Prisons' (BOP) Actions to Implement Prior Restrictive Housing
Reports' Recommendations
Actions
to Implement Prior Restrictive
Housing Reports’ Recommendations
Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’ Recommendations

Source: GAO analysis of Bureau of Prisons' data and information .

Number of
recommendations

Percent of
implementation

Fully Implemented

33

38%

Partially Implemented

42

48%

Not Implemented

12

14%

I

GAO-24-105737

In 2014, BOP selected an independent contractor to review BOP's restricted housing operations. The
contractor issued its findings, including 34 recommendations to BOP, in a December 2014 report (2014
contracted assessment). a In 2016, the Department of Justice (DOJ) released a report (2016 DOJ report) with
53 recommendations to BOP with an overarching goal to reduce its use of restrictive housing.b
We reviewed the 87 recommendations from these two restrictive housing reports . Specifically, for each
recommendation, we provide our determination of BOP's progress in implementing them . We used three
categories to describe the status of BOP's implementation efforts. These included (1) fully implemented , (2)
partially implemented , and (3) not implemented .
Fully implemented We determined that recommendations were fully implemented when BOP
provided information that showed it addressed all aspects of the recommendation . We determined
that these recommendations do not require any further action. In the tables below, we indicate
the recommendations for which BOP officials reported to us about the steps they took when
documentation was not readily available. We also indicate the recommendations for which BOP had
documented some concerns and took a different approach to implement the recommendation .
Partially implemented We determined that recommendations were partially implemented when
BOP had completed some, but not all , recommended steps, or BOP provided information about
ongoing work or plans to address recommended steps. In the tables below, we indicate the
recommendations for which BOP had documented some concerns and took a different approach to
address certain aspects of the recommendation .
Not implemented We determined that BOP did not take any of the recommended steps.

•CNAAnalysis and Solutions, Federal Bureau of Prisons: Special Housing Unit Revie w and Assessment, a report prepared at the request of the U.S.
Department of Justice, Bureau of Prisons , Dec. 2014 .
bLJ .S. Department of Justice, Report and Recommendations Concerning the Use of Restrictive Housing, Final Report (Washington , D.C.: January
2016). In 2015 , the President directed the Attorney General to conduct a review of "the overuse of solitary confinement across American prisons." The
President directed that the purpose of the review be not simply to understand how, when , and why correctional systems isolate certain incarcerated
individuals from the general population , but also to develop strategies for reducing the use of this practice across our nation 's criminal justice system .

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Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’ Recommendations

BOP has fully implemented the following 33 recommendations. Of these 33
recommendations, BOP implemented 16 of the 34 recommendations from the
2014 contracted assessment and 17 of the 53 recommendations from the
2016 DOJ report.

Source: GAO analysis of Bureau of Prisons' information.

Report
1. 2014 Contracted
Assessment

I

GAO-24-105737

I Recommendation

IdGAtO
. t·
e ermma 10n

Review the practice of keeping [incarcerated individuals] at the Administrative Maximum Facility
(ADX) until halfway house release or release directly to the community.

2.

2014 Contracted
Assessment

Use of existing facility space (to provide programming activities in group settings), should be
considered for [incarcerated individuals] who have been properly screened (e.g. , when proper
security precautions are applied).

3.

2014 Contracted
Assessment

Establish reasonable time frames in which the [disciplinary] hearing must be scheduled , while
permitting reasonable continuances when waiting for investigation reports , drug tests, etc.

4.

2014 Contracted
Assessment

Establish a policy standard requiring the Segregation Review Official [supervisor at BOP facilities
that reviews SHU placements] to conduct private, face-to-face interviews with the [incarcerated
individual] for the ongoing reviews regarding continued Special Housing Unit (SHU) placement.

5.

2014 Contracted
Assessment

Develop and deploy an electronic [incarcerated individual] record system to document SHU
placement decisions.

6.

2014 Contracted
Assessment

A protocol needs to be established that identifies [incarcerated individuals] with serious mental
illness who should be excluded from [a] SHU , Special Management Unit (SMU) , or ADX housing .

7.

2014 Contracted
Assessment

A further review of the frequency and duration of (approved external social) visits should be
conducted at United States Penitentiary Allenwood for Level 3 [incarcerated individuals]. Serious
consideration should be given to allowing additional time for [incarcerated individuals] in Level 3.

8.

2014 Contracted
Assessment

Guidelines that identify specific conditions of confinement and protection policies consistent with
applicable federal regulations and national standards should be developed and included as part of
its program performance review process.

9.

2014 Contracted
Assessment

Establish a [program performance] review for the ADX that is separate from the rest of the Florence
Complex.

BOP took all recommended
steps to implement this
recommendation .

BOP did not agree with all the recommended steps, but
it updated relevant policies and reported to us about the
steps it took to satisfy the intent of this recommendation .

We did not independently verify each step that
BOP took to implement this recommendation .
We verified that BOP revised the relevant policy
and relied on testimonial information BOP
officials reported to us about implementing this
policy.

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Report
10. 2014 Contracted
Assessment

I Recommendation

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Establish a separate program
performance
review for USP Florence ADX that includes a
Reports’
Recommendations
comprehensive evaluation of policies and procedures that are unique to the ADX.

IdGAtO
. t·
e erm1na 10n

11. 2014 Contracted
Assessment

Ensure that when [inca rcerated individuals] complete psychology self-help programs [for example
on anger management, coping, or drug and alcohol abuse] completion is documented so that case
managers and counselors are aware of it during reentry planning.

12. 2014 Contracted
Assessment

Given the level of disagreement in the (mental health] assessments and treatment plan formulation ,
the Bureau should conduct an inter-reliability test for its mental health staff to better determine the
accuracy of the diagnosis and treatment plan process.

13. 2014 Contracted
Assessment

Expand housing alternatives for [incarcerated individua ls] in verified protective custody status to
provide levels of programs and privileges equivalent to those provided for the general population.

14. 2014 Contracted
Assessment

Establish and maintain a culture among all BOP staff, employees, and contractors that recognizes
the need for meaningful reentry programs for all [incarcerated individuals] in the Bureau of Prisons,
including those in restrictive housing, beginning at new officer and staff training and continuing in
every annual in-service training.

15. 2014 Contracted
Assessment

On a monthly basis, track and monitor the numbers of [incarcerated individuals] who are scheduled
to be released within 180 days and are being released [directly to the community] from restrictive
housing at each facility.

16. 2014 Contracted
Assessment

A complete reevaluation of the mental health record should be performed by psychology and
psychiatry staff every 30 days. Included in this review should be a face-to-face interview by a
member of the mental health team in a private setting , and the res ults of this interview should be
included in the reevaluation record.

17. 2016 DOJ Report

All correctional staff should receive training on young adult brain development, and appropriate deescalation tactics. Training should incorporate reliable , evidence-based science.

18. 2016 DOJ Report

When transferring an [incarcerated individual] to another [facility] for protective custody reasons ,
correctional officials should give consideration to an individual's release residence , including a
desire to be housed close to family.

19. 2016 DOJ Report

Correctional systems should work with prosecutors and other law enforcement officials to ensure
that [incarcerated individuals] who engage in serious criminal activity while incarcerated-especially
those who assault or ki ll correctional staff-face criminal prosecution when appropriate.

20. 2016 DOJ Report

Except in emergency situations, an [incarcerated individual] should not be initially placed in
investigative segregation without prior approval by a supervisory official. This supervisor should
carefully scrutinize the proposed placement to determine whether segregation is necessary at this
stage.

21. 2016 DOJ Report

An [incarcerated individual's] initial placement in investigative segregation should be reviewed
within 24 hours by an appropriate, high-level authority who was not involved in the initial placement
decision.

22. 2016 DOJ Report

An incarcerated individual should be sentenced to a term of disciplinary segregation only after
officials conduct a disciplinary hearing and the incarcerated individual is adjudicated guilty of the
alleged violation. The hearing should be conducted by a correctional official outside the regular
chain of command at the institution where the incarcerated individual is housed .

(ff)

(ff)

Legend

(ff)

BOP took all recommended
steps to implement this
recommendation .

BOP did not agree with all the recommended steps, but
it updated relevant policies and reported to us about the
steps it took to satisfy the intent of this recommendation .

Page 55

Page 55

We did not independently verify each step that
BOP took to implement this recommendation.
We verified that BOP revised the relevant policy
and relied on testimon ial information BOP
officials reported to us about implementing this
policy.

GAO-24-1 05737 BOP Restrictive Housing

GAO-24-105737 BOP Restrictive Housing

Report
23. 2016 DOJ Report

I Recommendation

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’
Recommendations
Women who are pregnant,
who are
post-partum , who recently had a miscarriage, or who recently
had a terminated pregnancy should not be placed in restrictive housing.

IdGAtO
. t·
e ermma 10n

24. 2016 DOJ Report

In very rare situations, a woman who is pregnant, is postpartum , recently had a miscarriage, or
recently had a terminated pregnancy may be placed in restrictive housing as a temporary response
to behavior that poses a serious and immediate risk of physical harm. Even in such cases, this
decision must be approved by the agency's senior official overseeing women 's programs and
services, in consultation with senior officials in health services, and must be reviewed every 24
hours.

25. 2016 DOJ Report

[Incarcerated Individuals] who are [LGBTQ+] or whose appearance or manner does not conform
to traditional gender expectations should not be placed in restrictive housing solely on the basis of
such identification or status.

26. 2016 DOJ Report

Correctional officials can sometimes avoid the unnecessary use of restrictive housing for
protective custody reasons by making different classification assignments. In deciding whether
to assign a transgender or intersex [incarcerated individual] to a facility or program for male or
female [incarcerated individual] , correctional officers must consider on a case-by-case basis
whether a placement would ensure the [incarcerated individual's] health and safety, giving serious
consideration to the individual's own views.

27. 2016 DOJ Report

Juveniles should not be placed in restrictive housing.

({J

28. 2016 DOJ Report

In very rare situations, a juvenile may be separated from others as a temporary response to
behavior that poses a serious and immediate risk of physical harm to any person. Even in
such cases, the placement should be brief, designed as a "cool down" period , and done only in
consultation with a mental health professional.

({J

29. 2016 DOJ Report

When a disciplinary hearing officer is confronted with an [incarcerated individual] who demonstrates
symptoms of a mental illness, the officer should refer the [incarcerated individual] to a qualified
mental health professional to provide input as to the [incarcerated individual's] competence to
participate in the disciplinary hearing , any impact the [incarcerated individual's] mental illness
may have had on his or her responsibility for the charged behavior, and information about any
known mitigating factors in regard to the behavior. The disciplinary hearing officer should also
consult a mental health professional , preferably the treating clinician , as to whether certain types
of sanctions, (e.g ., placement in disciplinary segregation , loss of visits, or loss of phone calls) may
be inappropriate because they would interfere with supports that are a part of the [incarcerated
individual's] treatment or recovery plan. Disciplinary hearing officers should take the psychologist's
findings into account when deciding what if any sanctions to impose.

({J

30. 2016 DOJ Report

Correctional systems should incorporate developmentally responsive policies and practices for
young adults , and as resources allow, implement modified therapeutic housing communities with
wrap-around programming in order to reduce the number of incidents that result in placement in
restrictive housing .

({J

BOP took all recommended
steps to implement this
recommendation .

BOP did not agree with all the recommended steps , but
it updated relevant policies and reported to us about the
steps it took to satisfy the intent of this recommendation .

~

We did not independently verify each step that
BOP took to implement this recommendation .
We verified that BOP revised the relevant policy
and relied on testimonial information BOP
officials reported to us about implementing this
policy.

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Report
31. 2016 DOJ Report

I Recommendation

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
[Incarcerated individuals]
in restrictive
housing should be screened for signs of a serious mental
Reports’
Recommendations
illness. Correctional systems should implement policies, procedures, and practices to ensure that:

IdGAtO
. t·
e ermma 10n

a. Prior to an [incarcerated individua l]'s placement in restrictive housing (or when that is
infeasible, as soon as possible and no later than within 24 hours of placement), staff can
promptly determine whether the [incarcerated individual] has been previously designated
as having a serious mental illness or is at risk of developing a serious mental illness;
b. Multiple times per day, correctional officers, trained in identifying signs of mental health
decompensation , conduct rounds of the restrictive housing unit;
c. At least once per day, medical staff conduct medical rounds of the restrictive housing unit;
d. After 30 days in restrictive housing , and every 30 days thereafter, all [incarcerated
individual]s in restrictive housing receive a face-to-face psychological review by mental
health staff; and
e. If at any point an [incarcerated individual] shows signs of psychological deterioration while
in restrictive housing , the [incarcerated individual] should be immediately evaluated by
mental health staff. At the conclusion of this review, mental health staff should recommend
whether the [incarcerated individual] requires immediate transfer to a medical facility or
other treatment center, as well as whether the [incarcerated individual] should receive
enhanced mental health services and/or should be referred to a clinically appropriate
alternative form of housing .
A correctional system could make this determination by, for example, creating an index, or
"hot list," of [incarcerated individuals] with a previous diagnosis of a serious mental illness .
When a correctional system lacks this capacity, staff should conduct a psychological
review of the [incarcerated individual] at the time of placement to make this determination .
32. 2016 DOJ Report

Correctional systems should develop clear, specific policies for determining under what conditions
an [incarcerated individual] can be placed in segregation in response to an alleged disciplinary
violation-both during the investigative stage and after an adjudication of guilt.

33. 2016 DOJ Report

The denial of basic human needs-such as food and water-should not be used as punishment,
whether alone or in conjunction with the use of restrictive housing .

({;

Legend

({;

BOP took all recommended
steps to implement this
recommendation .

BOP did not agree with all the recommended steps, but
it updated relevant policies and reported to us about the
steps it took to satisfy the intent of th is recommendation .

Page 57

Page 57

We did not independently verify each step that
BOP took to implement this recommendation .
We verified that BOP revised the relevant policy
and relied on testimonial information BOP
officials reported to us about implementing this
policy.

GAO-24-105737 BOP Restrictive Housing

GAO-24-105737 BOP Restrictive Housing

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’ Recommendations

BOP has partially implemented the following 42 recommendations. Of
these 42 recommendations , BOP partially implemented 12 of the 34
recommendations from the 2014 contracted assessment and 30 of the 53
recommendations from the 2016 DOJ report.

Source: GAO analysis of Bureau of Prisons' data and information.

Report

I

GAO-24-105737

I Recommendation

I GAO determination

1.

2014 Contracted
Assessment

Reexamine the SMU levels as they currently operate , their
corresponding conditions of confinement, the length of time
at each level, and their compliance with the SMU program
statement. The program should be consol idated from four levels
to three and the minimum length of time to complete the program
adjusted accordingly.

BOP revised its relevant policy but did not implement
this policy in practice. We provide more information on
BOP's compliance with the SMU program statement
earlier in this report.

2.

2014 Contracted
Assessment

All [incarcerated individuals] should be seen in a private setting
for a comprehensive mental health evaluation prior to placement
in any [restrictive housing] setting .

BOP implemented th is recommendation for two of
the three types of restrictive housing units but did not
agree with and did not implement this recommendation
for the SHU .

3.

2014 Contracted
Assessment

A program of regular out-of-cell mental health treatment needs to
be implemented .

BOP did not agree with all the recommended steps ,
but agreed with the intent of this recommendation ,
and reported taking some steps to implement it. We
verified that BOP implemented the relevant policy, but
BOP did not provide sufficient information to verity the
steps it took to implement that policy.

4.

2014 Contracted
Assessment

Any [incarcerated individuals] who are found to be
decompensating from the effects of restrictive housing should be
transferred to a mental health unit for treatment and observation .

As of September 2023 , BOP had ongoing work or
plans to complete steps toward implementing th is
recommendation .

5.

2014 Contracted
Assessment

[Incarcerated individuals] with a serious mental illness who are
not excluded from restrictive housing should start participating in
a treatment program.

We verified that BOP policies address this
recommendation . However, we recently reported
on BOP's challenges related to ensuring program
access.'

6.

2014 Contracted
Assessment

[Incarcerated individuals] should not be housed in a SHU for
protective custody but rather should be in sheltered general
population housing .

BOP completed some , but not all recommended
steps needed for implementation . We provide
more information on BOP's efforts to address this
recommendation earlier in this report.

7.

2014 Contracted
Assessment

Reassess the performance review rating system.

As of September 2023 , BOP had ongoing work or
plans to complete steps toward implementing this
recommendation .

' GAO, Federal Prisons : Bureau of Prisons Should Improve Efforts to Implement its Risk and Needs Assessment System , GAO-23-105139 (Washington ,
D.C.: March 20 , 2023).
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Report
8.

2014 Contracted
Assessment

9.

2014 Contracted
Assessment

I Recommendation

I GAO determination

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
BOP revised some, but not all , relevant policies to
Establish a policy whereby
only under
extraordinary
Reports’
Recommendations
address this recommendation .
circumstances would an [incarcerated individual] be discharged
directly from a SHU , SMU , or ADX.

Develop and provide coordinated , comprehensive, targeted ,
specialized cognitive reentry programming specifically designed
for [incarcerated individuals] in restrictive housing .

BOP did not agree with all the recommended steps,
but agreed with the intent of this recommendation ,
and reported taking some steps to implement it. We
provide more information on BOP's efforts to address
this recommendation earlier in this report.

10. 2014 Contracted
Assessment

Enhance the external oversight of the local operational reviews
that are being conducted on at least an annual basis.

BOP completed some, but not all, recommended
steps needed for implementation . We provide more
information on BOP's external oversight of these
reviews earlier in this report.

11. 2014 Contracted
Assessment

A vigorous quality improvement program should be established
for the provision of mental health.

BOP did not agree with all the recommended steps,
but agreed with the intent of this recommendation , and
reported taking some steps to implement ii. However,
BOP did not provide sufficient information to verify the
steps it took.

12. 2014 Contracted
Assessment

Develop a step-down program with increasing incentives,
more out-of-cell opportunities, and increasing opportunities for
congregate programming.

As of September 2023, BOP had ongoing work or
plans to complete these steps.

13. 2014 Contracted
Assessment

[Incarcerated individuals] should be housed in the least
restrictive setting necessary to ensure their own safety, as well
as the safety of staff, other [incarcerated individuals], and the
public.

BOP revised some, but not all , relevant policies to
address this recommendation .

14. 2016 DOJ Report

Disciplinary sanctions, regardless of whether they involve a
period of segregation , should be applied in a manner that is swift,
certain , and fair

BOP completed some, but not all, steps needed for
implementation .

15. 2016 DOJ Report

[BOP] should collect data about several aspects of [its] use of
restrictive housing :
a. System-wide data . This data should describe the
incidence and prevalence of restrictive housing ,
including the total number of [incarcerated individuals]
in each type of restrictive housing , restrictive housing
recidivism rates [multiple SHU placements], and the
average length of stay. This information should be
publicly available on corrections websites . It should
include demographic information for incarcerated
individuals, including race , national origin , religion ,
gender, gender identity, sexual orientation , disability
status, and age, to the extent that the collection and
publication of such information complies with all
applicable laws.
b. [Incarcerated individual]-level data. This data
should allow correctional systems to track individual
incarcerated individuals throughout their incarceration .
This will allow facilities to determine whether, how
often , and how long a particular incarcerated individual
has been placed in segregation , including as the
incarcerated individual changes status (i.e. , from
investigative segregation to disciplinary segregation).
This information should be available to correctional
officers, to the extent consistent with applicable law,
as a way to identify strategies to treat disruptive
incarcerated individuals and should not be released
publicly.

BOP completed some, but not all , recommended
steps needed for implementation . We provide
more information on BOP's efforts to address this
recommendation earlier in this report.

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Report
15. 2016 DOJ Report
(continued)

I Recommendation

I GAO determination

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
c. Officer data. Correctional
should consider
Reports’ systems
Recommendations
implementation of an early intervention system,
a management tool that promotes supervisory
awareness and helps officials identify trends, revise
policy as needed , and deploy additional training where
necessary. This information should not be released
publicly.

16. 2016 DOJ Report

Correctional systems should always be able to clearly articulate
the specific reason(s) for an [incarcerated individual)'s placement
and retention in restrictive housing . The reason(s) should be
supported by objective evidence. [Incarcerated individuals)
should remain in restrictive housing for no longer than necessary
to address the specific reason(s) for placement.

BOP revised some, but not all , relevant policies to
address this recommendation .

17. 2016 DOJ Report

Restrictive housing should always serve a specific penological
purpose. When drafting or implementing policy authorizing the
use of restrictive housing , correctional systems should clearly
articulate the purpose(s) for employing restrictive housing in the
authorized circumstances.

BOP revised some, but not all, relevant policies to
address this recommendation .

18. 2016 DOJ Report

An [incarcerated individual's] initial and ongoing placement in
restrictive housing should be regularly reviewed by a multidisciplinary staff committee, which should include not only the
leadership of the institution where the [incarcerated individual) is
housed , but also medical and mental health professionals.

BOP revised some, but not all, relevant policies to
address this recommendation.

19. 2016 DOJ Report

All correctional staff should be regularly trained on restrictive
housing policies. Correctional systems should ensure that
compliance with restrictive housing policies is reflected in
employee-evaluation systems.

BOP revised some, but not all , relevant policies to
address this recommendation .

20. 2016 DOJ Report

When an [incarcerated individual] who is [LGBTQ+] or a gender
nonconforming [individual) faces a legitimate threat from other
[incarcerated individuals], correctional officials should seek
alternative housing , with conditions comparable to those of
general population to the extent possible.

BOP revised some, but not all, relevant policies to
address this recommendation .

21 . 2016 DOJ Report

All [incarcerated individuals] in restrictive housing should have
access to appropriate medical care, including emergency
medical care.

BOP revised relevant policies and reported taking
some steps to address this policy but based on
our interviews with incarcerated individuals at four
out of five BOP facilities , it was unclear that BOP
implemented all recommended steps at these facilities.

22. 2016 DOJ Report

When a [BOP facility] lacks the capacity to provide appropriate
medical care to an [incarcerated individual) in restrictive
housing , that [incarcerated individual] should be transferred to
an appropriate facility where he or she can receive necessary
treatment.

BOP revised relevant policies and reported taking
some steps to address this policy but based on our
interviews with incarcerated individuals at five BOP
facilities, it was unclear that BOP implemented all
recommended steps at these facilities.

23. 2016 DOJ Report

Absent a compelling reason , [incarcerated individuals) should not
be released directly from restrictive housing to the community.

BOP revised some, but not all, relevant policies to
address this recommendation.

24. 2016 DOJ Report

During the final 180 days of an [incarcerated individual's] term
of incarceration , officials should avoid placing the [incarcerated
individual) in involuntary restrictive housing. If an [incarcerated
individual) is housed in involuntary segregation 180 days out
from the end of his or her sentence , officials should consider
releasing the [incarcerated individual) to a less restrictive
setting if this can be done without endangering the safety of the
[incarcerated individual], staff, other [incarcerated individuals], or

BOP revised some, but not all, relevant policies to
address this recommendation

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Report
24. 2016 DOJ Report
(continued)

I Recommendation

I GAO determination

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
the public. If segregation
becomes
necessary during this time,
Reports’
Recommendations
officials should provide targeted re-entry programming to prepare
the prisoner for his or her return to the community.

25. 2016 DOJ Report

Generally, [incarcerated individuals] who require protective
custody should not be placed in restrictive housing .

As of September 2023, BOP had ongoing work or
plans to complete steps toward implementing this
recommendation . We provide more information on
BOP's efforts to address this recommendation earlier
in this report.

26. 2016 DOJ Report

When an [incarcerated individual] faces a legitimate threat from
other [incarcerated individual]s, correctional officials should seek
alternative housing , by transferring the threatened [individual]
either to the general population of another institution or to a
special-purpose housing unit for [those] who face similar threats,
with conditions comparable to those of general population. There
are two exceptions to this general principle:
a. When the [incarcerated individual] poses such
extraordinary security risks that even a special-purpose
housing unit is insufficient to ensure the individual's
safety and the safety of staff, and others. In such cases,
the [incarcerated individual] may be housed in more
restrictive conditions. The [incarcerated individual]'s
placement should be regularly reviewed to monitor any
medical or mental health deterioration and to determine
whether the extraordinary security risks have subsided.

BOP completed some, but not all , recommended
steps needed for implementation . We provide more
information on alternative housing for this population
earlier in this report.

b. During a brief investigative period while correctional
staff attempt to verify the need for protective custody or
while the [incarcerated individual] is awaiting transfer to
another facility.

27. 2016 DOJ Report

Correctional systems should identify the most common reasons
that incarcerated individuals request protective custody (e.g .,
prior cooperation with law enforcement, conviction for sex
offense, gang affiliation , sex or gender identification) and develop
strategies for safely housing these incarcerated individuals
outside traditional restrictive housing units.

BOP completed some, but not all, recommended
steps needed for implementation. We provide more
information on BOP's efforts to develop alternative
housing for individuals in protective custody earlier in
this report.

28. 2016 DOJ Report

Generally, [incarcerated individuals] with a serious mental illness
should not be placed in restrictive housing .

BOP revised a relevant policy but did not implement
this policy in practice We provide more information on
BOP's efforts to address this recommendation earlier
in this report.

29. 2016 DOJ Report

Correctional systems should establish maximum penalties for
each level of offense. d These penalties should always include
alternatives to disciplinary segregation. The maximum penalties
should be graded based on the seriousness of the offense. If
used for punishment, restrictive housing should be reserved
for offenses involving violence , involving escape, or posing a
threat to institutional safety by encouraging others to engage in
such misconduct. Policy and training should be crafted carefully
to ensure that this principle is not interpreted overly broadly to
permit the imposition of restrictive housing for infrequent, lowerlevel misconduct.

BOP completed some, but not all , recommended steps
needed for implementation.

30. 2016 DOJ Report

Officials should regularly review those in preventative
segregation with the goal of transitioning [incarcerated
individuals] back to less restrictive housing as soon as it is safe
to do so.•

BOP reported taking some steps to address this
recommendation but based on our interviews with
BOP staff and incarcerated individuals at BOP
facilities , it was unclear that BOP implemented these
steps at those facilities.

dBOP categorizes prohibited acts based on severity ranging from low to greatest severity: (1) Greatest Severity Level ; (2) High Severity Level; (3)
Moderate Severity Level ; and (4) Low Severity Level.
•According to the 2016 DOJ report, BOP uses preventative segregation in the SHU [and ADX] to house individuals that are too dangerous to be housed
in the general population after completing disciplinary segregation .

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Report
31 . 2016 DOJ Report

I Recommendation

I GAO determination

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
in preventative
segregation should be
As of September 2023, BOP had ongoing work or
[Incarcerated individuals)
Reports’
Recommendations
plans to complete steps toward implementing this
given the opportunity to participate in incentive or step-down
programs that allow them to progress to less restrictive housing.
recommendation .

32. 2016 DOJ Report

Correctional systems should seek ways to increase the minimum
amount of time that [incarcerated individuals) in restrictive
housing spend outside their cells and to offer enhanced in-cell
opportunities. Out-of-cell time should include opportunities
for recreation , education , clinically appropriate treatment
therapies, skill-building , and social interaction with staff and other
[incarcerated individuals].

BOP revised its relevant policies to address some, but
not all aspects of this recommendation.

33. 2016 DOJ Report

Correctional systems should provide out-of-cell , confidential
psychological assessments, and visits for [incarcerated
individuals) whenever possible , to ensure patient privacy and to
eliminate barriers to treatment.

BOP reported taking some steps to address this
recommendation but based on our interviews with
incarcerated individuals at five BOP facilities , it was
unclear that BOP implemented these steps at those
facilities .

34. 2016 DOJ Report

Restrictive housing units should maintain adequate conditions for
environmental, health , and fire safety.

BOP revised some, but not all, relevant policies to
address this recommendation . In addition , based on
our interviews with incarcerated individuals at five BOP
facilities , it was unclear that BOP implemented these
steps at those facilities .

35. 2016 DOJ Report

If an [incarcerated individual) with a serious mental illness is
placed in restrictive housing:
a. Mental health staff should conduct a mental health
consultation at the time of the [incarcerated individual]'s
placement in restrictive housing ;

BOP completed some, but not all , recommended
steps needed for implementation. We provide
more information on BOP's efforts to address this
recommendation earlier in this report.

b. The [incarcerated individual) should receive intensive,
clinically appropriate mental health treatment for the
entirety of the [incarcerated individual)'s placement in
restrictive housing ;
c. The [incarcerated individual) should receive enhanced
opportunities for in-cell and out-of-cell therapeutic
activities and additional unstructured out-of-cell time,
to the extent such activities can be conducted while
ensuring the safety of the [incarcerated individual], staff,
other [incarcerated individual]s, and the public;
d. At least once per week, a multidisciplinary committee
of correctional officials should review the [incarcerated
individual]'s placement in restrictive housing ;
e. At least once per week, a qualified mental health
practitioner, assigned to supervise mental health
treatment in the restrictive housing unit, should conduct
face-to-face clinical contact with the [incarcerated
individual], to monitor the [incarcerated individual]'s
mental health status and identify signs of deterioration ;
and
f. After 30 days in restrictive housing , the [incarcerated
individual] should be removed from restrictive housing ,
unless the warden of the facility certifies that transferring
the [incarcerated individual] to an alternative housing
is clearly inappropriate. In making this determination ,
the warden should consult with mental health staff,
who should conduct a psychological evaluation of the
[incarcerated individual] beforehand.

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Report
35. 2016 DOJ Report
(continued)

I Recommendation

I GAO determination

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’ Recommendations
In determining the appropriateness
of the [incarcerated
individual]'s continuing placement, wardens should be
guided by the principles outlined above regarding the
placement of [incarcerated individuals] with serious
mental illness in restrictive housing .

36. 2016 DOJ Report

[Incarcerated individuals] with a serious mental illness who are
diverted from restrictive housing should be placed in a clinically
appropriate alternative form of housing , such as a secure mental
health unit or other residential psychology treatment program.

As of September 2023 , BOP had ongoing work or
plans to complete steps toward implementing this
recommendation . We provide more information on
BOP's efforts to address this recommendation earlier
in this report.

37. 2016 DOJ Report

An [incarcerated individual] with a serious mental illness should
not be placed in restrictive housing , unless:
a. The [incarcerated individual] presents such an immediate
and serious danger that there is no reasonable alternative

As of September 2023 , BOP had ongoing work or
plans to complete steps toward implementing this
recommendation . We provide more information on
BOP's efforts to address this recommendation earlier
in this report.

("Immediate and serious danger" might arise during an
emergency, such as a large-scale prison riot, but would
only last as long as emergency conditions are present.
"Immediate and serious danger" also includes the
"extraordinary security needs" described in Institution
Supplement FLM 5310.16A, Treatment and Care of
Inmates with Mental Illness, dated July 22, 2015. See
DOJ Report, at 51 n.25) ; or
b. A qualified mental health practitioner determines:
i. That such placement is not contraindicated (A

qualified mental health practitioner might conclude
that placement in restrictive housing is not
contradicted, when, for example, the practitioner
determines that the [incarcerated individual] is stable,
responding well to medication, unlikely to remain in
restrictive housing for more than a short period of
time, and likely to decompensate if transferred away
from the [incarcerated individual]'s current mental
health treatment team) ;
ii. That the [incarcerated individual] is not a suicide risk;
iii. That the [incarcerated individual] does not have
active psychotic symptoms ; and
iv. In disciplinary circumstances, that lack of
responsibility for the misconduct due to mental illness
or mitigating factors related to the mental illness do
not contraindicate disciplinary segregation
38. 2016 DOJ Report

To incentivize conduct that furthers institutional safety and
security, [incarcerated individuals] who demonstrate good
behavior during disciplinary segregation should be given
consideration for early release from segregation , where
appropriate.

BOP revised its relevant policy to address some, but
not all, aspects of this recommendation .

39. 2016 DOJ Report

Correctional officials should strive to limit the use of restrictive
housing whenever possible, and to the extent used , to limit the
length of [incarcerated individuals] stay and to identify servicesincluding group educational and therapeutic services-that they
can safely participate in while in restrictive housing .

BOP took some steps to address this recommendation
but has not achieved its intended goal to limit its use of
restrictive housing .

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Report
40. 2016 DOJ Report

I Recommendation

I GAO determination

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’
Recommendations
As of September 2023, BOP had ongoing work
Correctional systems should
establish
standing committees,
or plans to complete steps toward implementing
consisting of high-level correctional officials, to regularly evaluate
this recommendation but did not provide sufficient
existing restrictive housing policies and develop safe and
evidence to verify that its ongoing work will fully
effective alternatives to restrictive housing .
address this recommendation .

41. 2016 DOJ Report

For every [incarcerated individual] in restrictive housing ,
correctional staff should develop a clear plan for returning the
[individual] to less restrictive conditions as promptly as possible.
This plan should be shared with the individual , unless doing so
would jeopardize their safety or the safety of [others] .

As of September 2023 , BOP had ongoing work
or plans to complete steps toward implementing
this recommendation but did not provide sufficient
evidence to verify that its ongoing work will fully
address this recommendation .

42. 2016 DOJ Report

An [incarcerated individual] should not be placed in restrictive
housing pending investigation of a disciplinary offense unless
the [individual's] presence in general population would pose a
danger to [self or others]. In making this determination , officials
should consider the seriousness of the alleged offense, including
whether the offense involved violence, involved escape, or posed
a threat to institutional safety by encouraging others to engage in
such misconduct. Policy and training should be crafted carefully
to ensure that this principle is not interpreted overly broadly to
permit the imposition of restrictive housing for infrequent, lowerlevel misconduct.

BOP revised its relevant policies to address some,
but not all , aspects of this recommendation , and did
not complete all recommended steps needed for
implementation .

Source: GAO analysis of Bu reau of Prisons' data and information.

I

GAO-24-1057 37

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Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Reports’ Recommendations

BOP has not implemented the following 12 recommendations. Of these 12
recommendations , BOP has not implemented six of the 34 recommendations
from the 2014 contracted assessment and six of the 53 recommendations
from the 2016 DOJ report.

Source: GAO analysis of Bureau of Pri sons' data and information.

Report

I

GAO-24-105737

I Recommendation

IdGAtO
. t·
e ermma 10n

1.

2014 Contracted
Assessment

Establish a system for monitoring patterns and trends in the use of
disciplinary sanctions among Bureau facilities .

X

2.

2014 Contracted
Assessment

Establish by policy that a sanction of restrictive housing time should be
issued retroactive to the date of the original admission , providing credit for
time served.

X

3.

2014 Contracted
Assessment

Psychiatrists need to be more actively involved in diagnosis and treatment.

BOP did not take any recommended
steps to implement this recommendation .
According to BOP officials, it was not
feasible to implement this recommendation
due to bureau-wide staffing shortages .

4.

2014 Contracted
Assessment

Provide programming that identifies and addresses most significant areas
of need for high-risk [incarcerated individuals] in order to assist them in
successfully reintegrating into the community.

BOP did not take any recommended
steps to implement this recommendation .
We previously reported on needed
improvements in this area.'

5.

2014 Contracted
Assessment

Educate staff about the need for [incarcerated individuals] in restrictive
housing to receive formal reentry programming if being released [into the
community] from restrictive housing .

6.

2014 Contracted
Assessment

The Bureau should complete a clinical staffing needs analysis.

7.

2016 DOJ Report

An [incarcerated individual] who demonstrates good behavior during
investigative segregation should be considered for release to the general
population while awaiting his or her disciplinary hearing . Similarly, if an
[incarcerated individual] is ultimately adjudicated guilty, the [incarcerated
individual's] good behavior should be given consideration when determining
the appropriate penalty.

8.

2016 DOJ Report

Ordinarily, disciplinary sentences for offenses that arise out of the same
episode should be served concurrently.

X

X

Legend

X

BOP did not take any recommended steps to implement this recommendation .

'GAO-23-1051 39.

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Report
9.

2016 DOJ Report

I Recommendation

Appendix III: Bureau of Prisons’ (BOP) Actions
to Implement Prior Restrictive Housing
Recommendations
Incarcerated individualsReports’
who violate
disciplinary rules should be placed in
restrictive housing only as necessary, and only after officials have concluded
that other available sanctions are insufficient to serve the purposes of
punishment.

10. 2014 Contracted
Assessment

[Incarcerated individuals] should not be placed in long-term preventative
segregation unless correctional officials conclude, based on evidence, that
no other form of housing will ensure the [individual]'s safety and the safety of
staff, and others. This determination should be guided by clearly articulated
procedural protections, including the use of a multidisciplinary review team.

11 . 2014 Contracted
Assessment

Correctional staff should complete their disciplinary investigation as
expeditiously as possible. Any time that an [incarcerated individual] spends
in investigative segregation should be credited towards the term he or
she ultimately serves in disciplinary segregation for that offense. Absent
compelling circumstances, such as a pending criminal investigation , an
[incarcerated individual] should not remain in investigative segregation for
a longer period of time than the maximum term of disciplinary segregation
permitted for the most serious offense charged .

12. 2014 Contracted
Assessment

As correctional systems reduce the number of [incarcerated individuals]
in restrictive housing , they should devote resources towards improving
the conditions of those remaining in segregation . In particular, correctional
systems should take advantage of lower staff-to-[incarcerated individual]
ratios within restrictive housing units by providing the remaining
[incarcerated individuals] with increased out-of-cell time.

Source: GAO analysis of Bureau of Prisons' data and information.

I

IdGAtO
. t·
e ermma 10n
X
X

GAO-24-105737

Legend

X

BOP did not take any recommended steps to implement this recommendation .

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Appendix IV: Illustrative Examples from
Interviews with Incarcerated Individuals
Appendix IV: Illustrative Examples from
Interviews with Incarcerated Individuals

This appendix provides illustrative examples from our interviews with
incarcerated individuals at five Bureau of Prisons (BOP) facilities in
Butner, North Carolina; Dublin, California; Florence, Colorado; Terre
Haute, Indiana; and Thomson, Illinois. Each of these individuals had
experience in one or more of BOP’s three primary types of restrictive
housing units—Special Housing Units (SHU); the Special Management
Unit (SMU); and the Administrative Maximum Unit (ADX). While the
anecdotal information we learned during these interviews provided
valuable insights about the experiences of individuals who were placed in
restrictive housing units, these interviews are not representative of the
entire restrictive housing population or the total BOP population.
Table 5: Illustrative Examples from GAO Interviews with Incarcerated individuals in Special Housing Units (SHU) that May
Indicate Possible Patterns of Noncompliance with Policy, July–November 2022
Issue of concern

Interviewee responses

Relevant SHU policy provisions

Lack of access to
psychology services

Six individuals at three facilities described challenges accessing
or being denied access to psychological services a For example:
•
One individual who was referred to psychology
services by medical staff told us that the psychologist
just slid a packet under the cell door with information
about coping strategies for insomnia, such as
exercising and avoiding naps.
•
One individual had waited over 6 months without an
external appointment because the facility did not have
a psychiatrist.

After 30 calendar days of continuous
placement in administrative detention or
disciplinary segregation status, mental
health staff should conduct a psychiatric
or psychological assessment, including
a personal interview.

Insufficient
opportunities for
recreation provided

Ten individuals across all five facilities told us they were not
regularly provided opportunities for recreation each week b For
example:
•
Individuals at three different facilities said they missed
the call for recreation time if they were not standing by
their cell door when officers made the announcement
between 4:00 a.m. and 6:00 a.m.
•
Individuals at one facility said recreation time was
cancelled when officers were attending to other
matters or was only offered once or twice per week
due to staffing shortages.

Individuals are to receive the
opportunity to exercise outside their cell
at least 5 hours per week, ordinarily on
different days in 1-hour periods. The
facility Warden may restrict or deny
exercise periods if an individual’s
activities pose a threat to the safety,
security, and orderly operation of a
correctional facility.

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Appendix IV: Illustrative Examples from
Interviews with Incarcerated Individuals

Insufficient amount of
hygiene products
provided

Eighteen individuals across all five facilities described not
having enough toilet paper or other hygiene products. For
example:
•
Some individuals said they were only provided two
napkins or tissues each day for toilet tissue or were
provided a small amount of toilet tissue that was
insufficient to last until the next distribution.
•
Some individuals said that when they ran out of toilet
tissue, soap, or other hygiene items, they could
sometimes request additional items from a correctional
officer who was willing to provide them or had to go
without until the next distribution because some
officers refused to provide additional items.
•
Some individuals we interviewed in a women’s facility
said they were provided an insufficient amount of
feminine hygiene products, or it was difficult to obtain
them while in the SHU.

Insufficient amount or
lower quality food
provided in SHU

Twenty individuals across all five facilities described the amount Individuals are to receive nutritionally
of food provided as insufficient or the quality of food as poor.
adequate meals.
For example:
•
Some said they felt hungry because meal portions
were insufficient or were smaller than the meals
provided in general population.
•
Some said they felt hungry because dinner was
provided at 3:00 p.m. or 4:30 p.m. and they could not
purchase snacks to sustain them until breakfast the
next day.
•
Some said they could not eat certain foods due to
religious, dietary, or medical restrictions and were not
provided alternative food options, which they could
receive in general population.

Poor conditions of
clothing and bedding
provided to individuals
in SHU

Twenty-three individuals across all five facilities described
unsanitary conditions of SHU clothing and bedding or conditions
that were worse than general population. For example:
•
Some said the clothing and bedding they were issued
was worn, stained, and in generally worse condition
than their general population unit.
•
Some said they did not have a pillow.
•
One individual said that facility staff kept a toilet “full of
excrement” in one of the SHU cells to use as a
punishment and then directed an orderly to clean it
before a visit from the regional director.

Individuals are to receive personal
items necessary to maintain an
acceptable level of personal hygiene,
for example, toilet tissue, soap,
toothbrush, and cleanser. Individuals
will have an opportunity to shower and
shave at least three times per week.

Individuals are to receive a mattress,
blankets, a pillow, and linens for
sleeping as well as opportunities to
exchange linens.
Individuals are provided institution
clothing, including footwear, while
housed in the SHU and will be provided
necessary opportunities to exchange
clothing and/or have it washed.

Source: GAO analysis. | GAO-24-105737

aWe only included individuals who specifically said they wanted and did not receive mental health services.
bWe only included individuals who said they wanted and were not provided the opportunity to do so.

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Appendix V: Comments from the Department
of Justice
Appendix V: Comments from the Department
of Justice

U.S. Department of Justice

Federal Bureau of Prisons
Central Office

Office of the Director

Washin,:ton, DC 2053-1

Jrumruy 18, 2024

Ms. Gretta L. Goodwin
Director
Homelru1d Security ru1d Justice
Government Accountability Office
441 G Street, NW
Washington, DC 20548

Deru· Ms. Goodwin,
The Federal Bureau of Prisons (FBOP) appreciates the opportunity to review and comment on the
Government Accountability Office' s (GAO's) draft report entitled "BOP's Use of Restrictive
Housing" (GAO-23-105737).
The proper care of those in our custody and the safety and well-being of our employees ru·e key tenets
of the mission ofFBOP. Because FBOP recognizes that restrictive housing is not an effective
deterrent and can increase future recidivism, FBOP has worked towards implementing both a shortterm plru1 ru1d a long-term plan. In t!1e short tenn, a workgroup comprised of executive terun
members has conducted site visits to review best practices from other correctional systems around the
country ruid internationally. Several recommendations have also been presented to the executive terui1
and the approval and implementation of these are well under way. Moreover, the Notice of Proposed
Rulemaking (NPRM) for Inmate Discipline, which proposes reduced Disciplinary Segregation
sanctions, is ru1ticipated to be published for notice ru1d comment iJ1 the near future.
In the long tem1, we entered into a partnership with the National Institute of Justice (NU), as
rumounced on August 9, 2023. 1 This partnership has been fom1ed to conduct a comprehensive ruid
rigorous study of the use and impact of restrictive housing in federal correctional facilities. FBOP and
the Office of Justice Program's National Institute of Justice (NI.I) partnered to advance the science and
practice of coffections ruid to ensure data ru1d reseru-d1 infonn coffectional policies. l11e partnership
also responds to tlie recommendations of DOJ's Report and Recommendations Concerning the Use of
Restrictive Housing, which called for more research on the prevalence and effects of restrictive
housing ru1d the development of alternatives to its u e.
RTI International, selected as the research entity conducting the study, will examine the reasons,
duration ru1d outcomes of restrictive housing placements in FBOP institutions. It will also assess the
extent to which FBOP policies and practices align with evidence-based standards and best practices
for reducing tlie use of restrictive housing. The study will provide recommendations for reforms
designed to enhruice the safety, security and well-being of employees ruid incru·cerated individuals, as
1 BOP: FBOP Partners with NIJ on Restrictive Housing Study (available at
https://www.bop.gov/resources/news/20230829_restrictive_housing_ study .j sp ).

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Appendix V: Comments from the Department
of Justice

GAO's Official Draft Report - Bureau of Prisons Additional Actions Needed to Improve Restrictive
Housing Practices I 05737
Date: January 18, 2024
Page 2 of 4
well as promote the successful reentry of incarcerated people into society. FBOP is committed to
making the findings of this multi-year research study public and making improvements in policies and
accountability mechanisms as a result of the findings.
FBOP leadership has also developed and started implementation of a new strategic framework that
will transform the agency over the next several years. Ibis framework devotes a goal specifically to
the critical issue of restrictive housing and states that FBOP will, "appropriately care for and house
those in our custody such that recidivism and the use of restrictive housing is reduced."
FBOP offers the following comments regarding the recommendations.

Recommendation One: The Director of BOP should develop and execute an approach to fully
implement all of the 2014 and 2016 restrictive housing reports recommendations. For each
recommendation that has not yet been implemented, the approach should include assigning
implementation responsibility to appropriate officials, establishing a time frame for completion, and
monitoring progress. In instances where BOP does not concur with a 2014 recommendation or deems
it impractical, it should document its rationale and the alternative steps, if any, it plans to take.
FBOP Response: FBOP does not agree with GAO' s conclusion that there are 55 recommendations
that it only partially implemented or did not implement at all. To the extent that there are
recommendations from the 2014 and 2016 reports that FBOP can implement, it agrees to develop
and execute a plan to implement those recommendations. For those recommendations that FBOP
believes have already been implemented or disagrees with, FBOP will continue to document the
rationale for its position and any alternative steps. For each recommendation that has not yet been
implemented, FBOP's approach will include assigning implementation and responsibility to
appropriate officials, establishing a time frame for completion, and monitoring progress.
Additionally, and as described above, FBOP and NlJ are working with RTI International, to conduct a
study examining the reasons, duration and outcomes of restrictive housing placements in FBOP
institutions. RTI is assessing the extent to which FBOP policies and practices align with evidencebased standards and best practices for reducing the use of restrictive housing and will provide
recommendations for reforms designed to enhance the safety, security and well-being of employees
and incarcerated individuals, as well as promote the successful reentry of incarcerated people into
society.

Recommendation Two: The Director of BOP should enhance oversight by developing and
implementing a process to verify and document that facilities have implemented corrective actions
that fully address all deficiencies.
FBOP Response: FBOP concurs with this recommendation. FBOP will implement a process to
verify and document that facilities have implemented corrective actions to address deficiencies
identified during internal audits conducted by FBOP's Program Review Division. The internal audit
follow-up process will involve all levels (local, regional, and divisional leadership) of the FBOP to
establish internal controls that mitigate the recurrence of findings of deficiencies.
Recommendation Three: The Director of BOP should develop and implement a mechanism to
identify causes of common deficiencies that recur across multiple facilities and take steps to address
those causes.

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Appendix V: Comments from the Department
of Justice

GAO's Official Draft Report - Bureau of Prisons Additional Actions Needed to Improve Restrictive
Housing Practices I 05737
Date: January 18, 2024
Page 3 of 4

FBOP Response: FBOP concurs with this recommendation. The FBOP will implement an internal
audit process that will identify causes of common deficiencies that recur across multiple facilities and
an internal audit follow-up process involving all levels (local, regional, and divisional leadership) of
the Agency to establish internal controls that mitigate the recurrence of findings of deficiencies, as
noted in the response to Recommendation Two, above.
Recommendation Four: The Director of BOP should conduct an evaluation of previous [Special

Management Unit (SMU)] placements to determine and address the cause of disproportionate
representation of individuals in certain racial groups in the SMU population.
FBOP Response: FBOP concurs with this recommendation to evaluate past SMU placements to
determine the cause of disproportionate representation. FBOP has already contracted with NIJ to
evaluate its use ofrestrictive housing and this issue falls within the scope of that effort.
Recommendation Five: The Director of BOP should develop and implement a mechanism for
routinely monitoring the extent to which facilities are applying the SMU placement criteria
consistently and equitably across all BOP facilities should BOP reinstate the SMU program.
FBOP Response: While BOP concurs with this recommendation, BOP notes that it has already

suspended the SMU program. FBOP is working to identify an appropriate replacement in
conjunction with the ongoing NIJ study. FBOP believes its closure of the SMU at USP Thomson,
previously documented to GAO during the course of fieldwork, adequately addresses this
recommendation and FBOP respectfully requests closure based on the same.
Recommendation Six: The Director of BOP should develop and implement a mechanism for
routinely evaluating SMU review documentation to ensure that incarcerated individuals progress
through the SMU program levels in accordance with SMU policy should BOP reinstate the SMU
program.
FBOP Response: While BOP concurs with this recommendation, BOP notes that it has already

suspended the SMU program. FBOP is working to identify an appropriate replacement in
conjunction with the ongoing NIJ study. FBOP believes its closure of the SMU at USP Thomson,
previously documented to GAO during the course of fieldwork, adequately addresses this
recommendation and FBOP respectfully requests closure based on the same.
Recommendation Seven: The Director of BOP should develop and implement a process to routinely
analyze administrative remedy program data.
FBOP Response: FBOP concurs with this recommendation and will work towards developing and
implementing a process to routinely analyze administrative remedy program data. However, it should
be noted that administrative remedy program data should not solely be relied upon to identify patterns
of noncompliance and other areas of program weaknesses. The Administrative Remedy Program is
designed to individually assess and respond to grievances specific to individuals challenging the
conditions of their confinement Therefore, because the response issued within the scope of the
Administrative Remedy Program is specific to the individual, responding FBOP official(s) do not
make overarching detenninations regarding policy noncompliance. As a result, information gleaned
during the Administrative Remedy process may not accurately reflect broader policy concerns/issues

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Appendix V: Comments from the Department
of Justice

GA O' s Official Draft Report - Bureau of Prisons Additional Actions Needed to Improve Restrictive
Housing Practices 105737
Date: January 18, 2024
Page 4 of 4
and should instead be reviewed together with other available data. Therefore, FBOP will incorporate
review of Administrative Remedy data into broader analyses of policy concerns and issues.
Recommendation Eight: The Director of BOP should develop and implement a process to address
any identified patterns of noncompliance related to restrictive housing policies and other areas of
program weaknesses.
FBOP Response: FBOP concurs with lhis recommendation and will develop and implement a
process to address any identified patterns ofnoncompliance related to restrictive housing policies and
other potential areas of program weaknesses.
Thank you for the opportunity to comment on this report. We look forward to GAO closing the
recommendations that the FBOP has agreed to address.
Sincerely,

Colene S. Peters
Director

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GAO-24-105737 BOP Restrictive Housing

Appendix VI: GAO Contact and Staff
Acknowledgments
Appendix VI: GAO Contact and Staff
Acknowledgments

GAO Contact

Gretta L. Goodwin, (202) 512-8777 or goodwing@gao.gov

Staff
Acknowledgments

In addition to the individual named above, Joy A. Booth (Assistant
Director), Carissa Bryant (Analyst-In-Charge), Nasreen Badat, Billy
Commons, Benjamin Crossley, Karen Doran, Michele Fejfar, Adrienne
Fernandes-Alcantara, Taylore Fox, Kathryn Lenart, Cherish Mumme,
Sarah Prokop, and Tasha Straszewski made key contributions to this
report.

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