770 West Broad Street
Columbus, OH 43222
John R. Kasich, Governor

www.drc.state.oh.us

TO:

Barry Goodrich, Warden
Lake Erie Correctional Institution

FROM:

Michelle Burrows, Audit Administrator
Bureau of Internal Audits and Standards Compliance

SUBJECT:

LaECI Audit Reinspection

DATE:

November 15, 2012

Gary C. Mohr, Director

I am enclosing a copy of the Reinspection Audit Report for the Lake Erie Correctional Institution following the
inspection conducted November 7-8, 2012.
The following staff assisted with conducting the reinspection:
Michelle Burrows—Audit Administrator—Chairperson
Kathy Cole—Warden’s Assistant—Belmont CI (Food Service/Unit Management/Quartermaster)
Laura Solnick—Unit Management Chief—Lorain CI (Unit Management)
Christopher Harris—Captain—Ohio State Penitentiary (Security)
Joseph Dina—Lieutenant—Ohio State Penitentiary (Security)
Bryan Smith—Health & Safety Coordinator—Ross CI (Safety/Sanitation)
Steve Olds—Health & Safety Coordinator—Correctional Reception Center (Safety/Sanitation)
Patricia Champney—Regional Nurse Administrator—NE Region (Medical)
Michelle (Shelly) Viets—Regional Nurse Administrator—NW Region (Medical)
Congratulations on the many accomplishments achieved in such a short amount of time. It is evident that the
staff has taken the issues raised very seriously and have been very proactive during this process. I appreciate
the support and cooperation of you and your staff during the reinspection. If you have any questions regarding
the report, please feel free to contact this office.
Cc:

Gary Mohr, Director
Stephen Huffman, Assistant Director
Linda Janes, Chief of Staff
Todd Ishee, Regional Director
Andrew Albright, Chief, Bureau of Internal Audits and Standards Compliance
Jayne Haverfield, Audit Administrator
Daren Swenson, CCA, Vice President, Facility Operations, Business Unit 2
Melody Turner, CCA, Managing Director, Facility Operations

Audit Reinspection Report
Facility:

Lake Erie Correctional Institution

Original Audit Date:

September 18-20, 2012

Date of Re-inspection:

November 7-8, 2012

A. Reinspection Findings
During the internal management audit, there were a total of forty-seven (47) standards found in noncompliance. These included: three (3) Mandatory Standards, twenty-four (24) ACA Non-Mandatory
Standards, and twenty (20) Ohio Standards.
Upon completion of the audit reinspection, it was found that a total of thirty-eight (38) standards were
corrected. A total of one (1) standard remained in non-compliance and is beyond the control of the
facility. There is also an additional three (3) non-mandatory physical plant standards, beyond the
facility’s control, that have been identified as non-compliant. LaECI will be preparing waivers for their
upcoming ACA accreditation audit that effectively illustrates mitigation of the non-compliant conditions
beyond their control. A total of eight (8) standards were found in pending compliance upon completion
of corrective action. There were no standards that were classified as non-compliant that were within the
facility’s control.
Included within this report is a section that summarizes any significant observations that extend beyond
the noncompliant standards and an overview of any recommendations follows.
B. Examination of Records
1.

Accreditation File Preparation
During the initial IMA, food service file documentation was below standard. The files were
reviewed and all documentation met the requirements and has been corrected.

2.

Significant Incidents/Outcome Measures
The Outcome Measure/Significant Incident Summary information was reviewed and statistical
information appeared to be consistent with the security level and mission of LaECI.

3.

Safety/Sanitation Reinspection
A reinspection was conducted regarding the issues found during the Internal Management Audit.
All issues were found to be corrected and the actual inspection report is attached.

Facility: Lake Erie Correctional Institution

Re-Inspection Date: November 7-8, 2012

C. REINSPECTION OF RECOMMENDATIONS/OBSERVATIONS
1. The reinspection team observed much improved, high sanitation levels within the entire facility. It
was evident that staff and inmates have worked very hard to clean the areas. Showers were free of
any discolor/mildew and the housing units were exceptional.
2. During the initial internal audit, it was stated that staff felt unsafe. During this re-inspection, staff
stated they felt they had improved direction and it appeared their feelings of “frantic/panic” have
been replaced with confidence as all staff encountered was very proud of their efforts.
3. During the re-inspection of the Lake Erie Correctional Institution chemical control throughout the
institution was found in compliance. Below are observations of chemical compliance.
a. Gas cylinders in the maintenance area were properly separated and inventoried.
b. HMIS stickers were removed from non-hazardous chemicals in the maintenance area. Inaccurate
inventory numbers were removed from containers and replaced with new.
c. DRC Chemical list 1895 was placed in medical exam rooms as required. This replaces the use of
DRC1886 Chemical Inventory Log.
d. In the main chemical storage area of medical oxygen tanks are now being inventoried by size,
HMIS stickers have been placed on all hazardous chemicals.
e. MSDS sheets were readily available in all areas that contain chemicals.
f. In the control of housing unit chemicals it was discovered that 5 gallon containers of nonhazardous chemicals were still being issued in chemical boxes. Additionally, a log was being
used to sign chemicals in and out as well as staff were taking inmate ID’s who were issued
chemicals. These methods meet and exceed the DRC chemical control policy. However, the
audit reinspection team worked with facility staff to simplify these additional chemical
accountability processes. Simplification of these processes should ensure inconsistencies
between units are minimized.
g. All areas of the institution that store chemicals need to also have a chemical index and a list of
hazardous chemical that are used in their areas. These lists need to be provided to the safety
officer when this position is filled. Chemical approval forms DRC 1885 and MSDS were found
to be available in all required areas.
4. The food service area was completely different from the IMA report observations. The pots/pans
area has been relocated to alleviate the clutter in the kitchen area. The dry storage room has also
been neatly re-organized and the spices room has been relocated and organized. Sanitation levels in
this area were excellent.

Facility: Lake Erie Correctional Institution

Re-Inspection Date: November 7-8, 2012

5. The process for serving the inmates has become more streamlined and the time to feed the
population has decreased to almost half of what it was a month ago.
6. All doors and hallways were clear of debris in food service and the inmates were constantly cleaning
to ensure high sanitation levels.
7. Containers were added in a couple of locations in the food service area for hair nets and beard
guards.
8. A Health Inspection was conducted during this re-inspection by the Health Department and it was
found that the dish washer gauge covers were cracked and need to be replaced. This has to be
corrected and clear documentation has to be provided prior to the ACA audit in December.
9. Area post orders have been revised and placed on the DRC format. All areas were reviewed and
found to be accurate.
10. All emergency evacuation and preparedness issues are now corrected.
a. Physical barriers that were not part of the original approved building plans were removed,
creating an uninterrupted path of egress in the event of an emergency.
b. Repairs have been made to the fire alarm system, assuring early warning of fire or smoke
conditions
c. Hydraulic door closers have been replaced and doors are not propped open by mechanical
means, thus restoring the original integrity of fire and smoke compartments.
d. Employees now have a concrete written procedure for emergency release, and are very
knowledgeable of every aspect of the plan.
e. An obvious education program is now in place to promote fire safety to all employees.
f. All employees now appear to be familiar with alarm system keys.
11. New water fountains were installed to replace the non-working ones throughout the facility. The
broken ones are in the process of or have been removed.
12. During review of the DOTS portal for LC hearing information, it was observed that the program was
auto populating dates. It was recommended that Chief of Security Webb contact the appropriate
department at OSC to determine if there is a way of correcting this.
13. In the medical area, the staffing levels are not where they should be and it was recommended the
vacancies be filled as soon as possible to ensure staff has the resources needed to complete the
required tasks.

Facility: Lake Erie Correctional Institution

Re-Inspection Date: November 7-8, 2012

14. The medical area did appear to be calm and was better organized and staff was knowledgeable of
DRC policies as well.
15. The property room in segregation has been reorganized and there is much improved accountability
of the inmate property.
16. There were no complaints received from inmates. The inmates were complimenting the change in
atmosphere and they felt better about how the process was going. There were many compliments on
the food and how much it had improved.
17. Staff needs to continue to improve in the tracking of conduct reports. There has been a significant
improvement and they need to ensure they continue with completing the hearings within the required
seven day timeframes.
18. The conditions of confinement within the segregation area were vastly improved and documentation
of afforded privileges on the required DRC forms was compliant with applicable DRC policy. The
number of triple bunked cells has also been significantly reduced to seven (7) cells at the time of the
reinspection. It is anticipated this noncompliant condition will be eliminated in the very near future
as collaborative transfer efforts between LaECI staff and the DRC Bureau of Classification staff
action continues until completed.
D.

EXIT DISCUSSION
The final exit interview was held at 1:45 p.m. on November 8, 2012 in the Warden’s Conference Room
with Warden Goodrich, Daren Swenson, Melody Turner and approximately 20 staff in attendance. The
audit chairperson reviewed the reinspection information with staff in attendance.

Corrected Standards found in Compliance
4-4215

(MANDATORY) Written policy, procedure, and practice govern the control and use
of all flammable, toxic, and caustic materials.

Documentation was provided to show that each area has a complete list of hazardous chemicals, MSDS sheets
were present during the inspection in all areas, hazard numbers were placed on the HMIS stickers, and
accountability of non-hazardous cleaning chemicals was done.
4-4222

(MANDATORY) Written policy, procedure, and practice specify the means for the
immediate release of inmates from locked areas in case of emergency and provide for
a backup system.

The local fire plan was rewritten and approved by the local fire chief. The plan covered the release of inmates
from locked areas in case of an emergency and staff was properly trained and knowledgeable of the local fire
plan, evacuation routes, egress keys, etc.

Facility: Lake Erie Correctional Institution

4-4183

Re-Inspection Date: November 7-8, 2012

Written policy, procedure, and practice require that correctional staff maintain a
permanent log and prepare shift reports that record routine information, emergency
situations, and unusual incidents.

Post log books were reviewed to show that Officers are documenting the required information upon arrival and
being relieved from post to include emergencies, routine information, chemicals, etc.

4-4184

Written policy, procedure, and practice provide that supervisory staff conduct a
daily patrol, including holidays and weekends, of all areas occupied by inmates and
submit a daily written report to their supervisor. Unoccupied areas are to be
inspected weekly.

Training has been conducted and staff is completing rounds in the unoccupied areas and documenting the
information on the required forms.
4-4185

Written
policy,
procedure,
and
practice
require
that
the
warden/superintendent
or designee, assistant
warden/superintendent(s), and
designated department heads visit the institution's living and activity areas at least
weekly to encourage informal contact with staff and inmates and to informally
observe living and working conditions.

A review of the log books in all the areas showed that shift supervisors and administrative staff are conducting
rounds as required per DRC Policy 50-PAM-02, Inmate Communication/Weekly Rounds.
4-4192

Revised August 200 9.
Written policy, procedure, and p r a c t i c e provide for
searches of facilities and inmates to control contraband and provide for its disposition.
These policies are made available to staff and inmates.

Post logs were reviewed and documentation was provided to show that cell/bunk and area searches are being
completed as required.
4-4200

Revised January 2008. Written policy, procedure and practice govern the inventory, issuance
and accountability of routine and emergency distributions of security equipment.

Documentation was provided and the practice was observed to show that OC was being issued and inventoried
as required. The pepper ball system has been corrected and is now in compliance with DRC policy.

Facility: Lake Erie Correctional Institution

4-4207

Re-Inspection Date: November 7-8, 2012

Written policy, procedure, and practice provide for the preservation, control, and
disposition of all physical evidence obtained in connection with a violation of law
and/or institutional regulation. At a minimum, the procedures shall address the
following:
* chain of custody
* evidence handling
* location and storage requirements

Documentation was provided to show that contraband is being maintained as required per DRC
policy. Organization of the contraband vault was very high as well as the documentation by the staff.
4-4230

There are written guidelines for resolving minor inmate infractions, which include
a written statement of the rule violated and a hearing and decision within seven
days, excluding weekends and holidays, by a person not involved in the rule violation; the
inmate may waive their appearance at the hearing.

Documentation was provided to show that all conduct reports have been heard within the required seven days.
LaECI staff must continue to monitor the tracking of all conduct reports when sent to the units for hearings to
ensure compliance is maintained.
4-4234

Written policy, procedure, and practice specify that, when an alleged rule violation is
reported, an appropriate investigation is begun within 24 hours of the time the
violation is reported and is completed without reasonable delay, unless there are
exceptional circumstances for delaying the investigation.

Documentation was provided to show that extensions of security control are being completed as required.
4-4238

Revised J a nua r y 2008. Written policy, procedure, and practice provide that
inmates charged with rule violations are scheduled for a hearing as soon as practicable
but no later than seven days, excluding weekends and holidays, after being charged
with a violation. Inmates are notified of the time and place of the hearing at least 24
hours in advance of the hearing.

Staff at LaECI has put a process in place to get caught up with all conduct reports. At the time of the reinspection, all conduct reports have been heard.
4-4253

Written policy, procedure, and practice provide that whenever an inmate in segregation is
deprived of any usually authorized item or activity a report of the action is filed in the
inmate's case record and forwarded to the chief security officer.

Documentation was provided and the DRC4118 forms were reviewed to ensure Unit Management staff are
reviewing all inmates who are in segregation for any extended period of time.

Facility: Lake Erie Correctional Institution

4-4255

Re-Inspection Date: November 7-8, 2012

Revised August 2008. There is a sanctioning schedule for institutional rule violations.
Continuous confinement for more than 30 days requires the review and approval of the
warden/superintendent or designee.
Inmates held in disciplinary detention for periods
exceeding 60 days are provided the same program services and privileges as inmates in
administrative segregation and protective custody.

The Chief of Unit Management is working from a database and all LC hearings are being conducted in a timely
manner and is in compliance with policy.
4-4257

Revised August 2011. Written policy, procedure, and practice require that all special
management inmates are personally observed by a correctional officer twice per hour, but no
more than 40 minutes apart, on an irregular schedule. Inmates who are violent or mentally
disordered or who demonstrate unusual or bizarre behavior receive more frequent
observation; suicidal inmates are under continuous observation.

Documentation was reviewed and the practice was observed to show that rounds/activities are being completed
within the required timeframes and the suicide observation logs are being maintained as required.
4-4258

Written policy, procedure, and practice provide that inmates in segregation receive
daily visits from the senior correctional supervisor in charge, daily visits from a
qualified health care official (unless medical attention is needed more frequently), and
visits from members of the program staff upon request.

Documentation was reviewed to show that medical staff and the senior correctional supervisor are making daily
visits to segregation.
4-4263

Written policy, procedure, and practice provide that inmates in segregation receive
laundry, barbering, and hair care services and are issued and exchange clothing,
bedding, and linen on the same basis as inmates in the general population. Exceptions
are permitted only when found necessary by the senior officer on duty; any exception
is recorded in the unit log an justified in writing.

Documentation was reviewed to ensure that laundry and barber services are being provided. Procedure and
practice was observed and LaECI is now in compliance.
4-4270

Written policy, procedure, and practice provide that inmates in segregation receive a
minimum of one hour of exercise per day outside their cells, five days per week, unless security
or safety considerations dictate otherwise.

Documentation was reviewed to ensure the recreation times were being documented and if the inmate refuses,
then the time of the refusal was documented.

Facility: Lake Erie Correctional Institution

4-4318

Re-Inspection Date: November 7-8, 2012

Revised August 2004. Therapeutic diets are provided as prescribed by appropriate clinicians. A
therapeutic diet manual is available in health services and food services for reference and
information. Prescriptions for therapeutic diets should be specific and complete, furnished in
writing to the food service manager, and rewritten annually, or more often as clinically
indicated.

Documentation was reviewed to ensure the prescriptions for therapeutic diets are specific and completed as
required.
4-4320

Written policy precludes the use of food as a disciplinary measure.

Documentation was reviewed to ensure that the alternative meal service is being utilized properly and it was
found that LaECI is following DRC policy.
4-4325

Written policy, procedure, and practice provide that
stored shelf goods are
maintained at 45 degrees to 80 degrees Fahrenheit; refrigerated foods at 35
degrees to 40 degrees Fahrenheit, and frozen foods at 0 degrees Fahrenheit or
below, unless national or state health codes specify otherwise.

Review of temperatures during the reinspection showed the freezers and coolers were in compliance with
policy and state codes.
4-4328

Written policy, procedure, and practice require that at least three meals (including two
hot meals) are provided at regular meal times during each 24-hour period, with no
more than 14 hours between the evening meal and breakfast. Variations may be
allowed based on weekend and holiday food service demands provided basic nutritional
goals are met.

Documentation was reviewed to ensure the time between dinner and breakfast did not exceed 14 hours and
there were no discrepancies found.
4-4354-1

Added August 2006. The management of offenders with Methicillin Resistant
Staphylococcus Aureus (MRSA) infection includes requirements identified in the
communicable disease and infection control program. In addition, the program for
MRSA management shall include procedures for:
•
evaluating and treating infected inmates in accordance with an approved
practice guideline
•
medical isolation, when indicated
•
follow-up care, including arrangements with appropriate health
care
authorities for continuity of care if offenders are relocated prior to the
completion of therapy.

A process has been put in place to monitor transfers of inmates with MRSA. The staff at Lake Erie is
continuing to monitor this standard to ensure they remain compliant.

Facility: Lake Erie Correctional Institution

4-4425

Re-Inspection Date: November 7-8, 2012

Revised January 2006. Authorities having jurisdiction are promptly notified of an offender's
death. Procedures specify and govern the actions to be taken in the event of the death of an
offender.

Documentation was provided to show that security supervisors have been trained on the procedure for proper
notification of individuals in the event of an inmate death that may occur while housed outside the facility.

Ohio Standards
OH 04-01 All inmates who are placed in segregation from general population, or who are released
from segregation to general population housing shall have their personal property
accurately inventoried. This inventory shall be documented and a copy shall be retained in
the inmate property file.
Property inventories were reviewed and inmates who are placed in segregation or released back to general
population have their property inventoried and sign the required form.
OH 04-02 The Quartermaster shall update and maintain all Inmate Property Files in a secure manner
without the use of inmate workers and shall also maintain a written monthly inventory of all
clothing items and equipment in storage. The institution Quartermaster will document all
state property issuances to inmates on the Inmate Clothing Form (DRC4077Male/DRC4055-Female).
A monthly inventory was provided to show compliance. The staff has worked very diligently to come into
compliance and the organization of the area has improved tremendously.
OH 05-01

ODRC requires the Managing Officer, Deputy Wardens, and designated department
heads to visit the institution’s living and activity areas at least weekly to
encourage informal contact with staff and inmates and to informally observe living
and working conditions. In addition, e a c h institution s h a l l maintain a system of
two-way communication between all levels of staff and inmates.

Sign in logs and post logs were reviewed to ensure the Executive staff is visiting the institution’s living and
activity areas to ensure communication.

Facility: Lake Erie Correctional Institution

OH 05-02

Re-Inspection Date: November 7-8, 2012

If areas that house inmates on psychotropic medications exceed 90 degrees Fahrenheit,
temperatures must be monitored regularly by the correctional officer and logged on a Cell
Temperature Log (DRC5292). The following measures will be taken:
a. Increased ventilation to the area through utilization of fans to improve airflow and reduce
room temperature to less than 90 degrees.
b. Provision of increased fluids and ice.
c. Allowance of additional showers to provide cooling.

Staff was questioned as to the process when the temperature exceeds 90 degrees and the responses were in line with
DRC policy. A plan is in place to ensure compliance with this directive.

OH 06-09

The facility has a written confined space program that was developed by the Health and
Safety Coordinator and is made readily available to all staff. The program includes the
following elements:







The facility maintenance supervisor evaluates the workplace to determine the locations
of all confined spaces. In the event confined spaces are identified, the maintenance
supervisor is responsible for making the determination if a space is permit or nonpermit required.
Where a permit is required, the permit will be initiated by the maintenance supervisor
and authorized by the Health and Safety Coordinator.
The Confined Space Entry Permit, DRC Form 1682 is used to document the procedure
All permit required confined spaces shall be marked as required by OSHA 1910.146.
A list of confined spaces and permit required spaces is maintained and updated as each
additional space is located.

Procedures are developed for rescue operations in the event of an emergency rescue as
required in OSHA 29 CFR 1910.146.
Training is provided to all employees and inmates affected by the confined space program.
Training records are maintained by the maintenance supervisor and training officer.
Equipment for confined space entry is provided at no cost to the employee. The supervisor
for each employee entering confined spaces shall maintain the equipment properly and
ensure it is used properly.
The facility provided the auditors with an updated confined space program to ensure compliance with DRC
policy.

Facility: Lake Erie Correctional Institution

OH 06-10

Re-Inspection Date: November 7-8, 2012

The written local Fire Prevention and Safety Plan shall be reviewed annually and updated
as needed.
The plan shall also be reviewed by an independent outside inspector trained in the
application of national fire safety codes and be reissued to the local fire jurisdiction upon
each revision.
Facilities shall also develop and post written evacuation plans for each building/area of the
facility. Evacuation plans shall include building/room floor plans and the use of exit signs
and/or directional arrows for traffic flow.
The local Fire Prevention and Safety Plan and facility evacuation plans shall be publicly
posted for all interested parties.

The local fire plan was rewritten and approved by the local fire chief. The plan covered the release of inmates
from locked areas in case of an emergency and staff was properly trained and knowledgeable of the local fire
plan, evacuation routes, egress keys, etc.
OH 07-02

Where the spider alert system is not in place, telephone systems are established with an
off hook alarm system to respond to staff emergencies. Where the spider alert system
is in place, all staff have in their possession the required spider alert mechanism. For
both types of alarms, staff must respond to the alarm and have it visually cleared by a
supervisor.

A test of the off hook alarm system was conducted and it is now in compliance. The alarm alerts the Control
Center within 30 seconds of the phone being taken off the hook.
OH 11-03

The purpose of this protocol is to define the mechanism by which nursing competency is
evaluated for DRC medical nursing staff. All medical nursing staff in DRC shall
participate in the nursing competency training and assessment program.

All nurses have state email and/or the System Access Request has been submitted. All nursing staff has been
entered into the Lippincott System and has been assigned the required tests. The QIC/HCA has a system in
place to monitor completion of tests.
OH 11-04

Each medical CQI program shall develop a system that addresses real or potential
problems identified through investigation of complaints and grievances.
Each medical operation shall review the number and types of informal complaints and
grievances related to health care to assess for trends and commonalities in conjunction with
the Institutional Inspector.

The Ad Hoc groups have been held and all required parties were present.

Facility: Lake Erie Correctional Institution

OH 12-02

Re-Inspection Date: November 7-8, 2012

OCSS staff properly identifies inmates with special needs and suspected special
needs through the referral and red-flagging process, in compliance with
Departmental Policy 57- EDU-01, Inmate Assessment and Placement in Educational
Programs. The Intervention Assistance Team (IAT) interviews referred and redflagged inmates.

Documentation was reviewed to ensure the inmates with special needs are being identified through the referral
and red-flagging process.
OH 12-03

OCSS staff properly serves inmates with special needs and suspected special needs
through the Evaluation Team Report (ETR) and Individual Education (IEP) Team
procedures, in compliance
with Departmental Policy 57-EDU-11, Special
Proper documentation of the process is appropriately recorded.
Education.

Documentation was provided to ensure the inmates with special needs are being properly served through the
ETR and IEP team procedures. The documentation was properly recorded.
OH 14-10

Bank statements for all internal funds shall be accurately reconciled to the
appropriate checkbook at the end of each month. All internal funds should be
reconciled in the Cashless Commissary and Trust fund Accounting System (CACTAS)
bank reconciliation module monthly. At the end of each month, within 10 (ten) days
of receiving your bank statement, c o m p l e t e the on-line Monthly report of Cash Book
Balances a n d B a n k R e c o n c i l i a t i o n s . Any bank o r savings and l o a n association
h o l d i n g deposits shall be insured by federal insurance agencies.

Staff in the business office has been given access to CACTAS and are reconciling the monthly bank statements
in CACTAS with the Trust fund as required.
OH 15-01

It is mandatory that each institution offer reentry approved programs that clearly address
a criminogenic need in one or more of the eight dynamic domains/needs area and offer a
variety of non reentry approved programs, groups and activities.

Documentation was reviewed to ensure that reentry approved programs were offered. Inside/Out Dads began
on November 3 with a class of 14 inmates. The class includes intensive inmates and inmates with outdates.
Victim Awareness training has been scheduled and two staff are scheduled to attend. The plan is being
followed as required.
OH 17-01

Unit Management Staff will prepare a packet of information regarding release plans for
offenders who are incarcerated in order to ensure that all offenders released (parole, PRC)
are released on their POA, PRC date or as soon as possible.

A database has been created to monitor inmate release dates up to 180 days out. The database is updated
monthly and sent to the appropriate case manager for action. All packets are up to date except those inmates
who are out to court.

Facility: Lake Erie Correctional Institution

OH 17-04

Re-Inspection Date: November 7-8, 2012

The Deputy Warden will ensure that Unit Managers and Shift Captains meet weekly. The
Unit Management Administrator (UMA) will also ensure that Shift Commanders are
included in unit manager staff meetings as often as possible.

Documentation was provided to show that weekly meetings are being conducted. Email, sign in sheets,
agendas, and meeting minutes were provided.

Standards Found to be Pending Compliance
4-4400

(Mandatory) Revised August 2008. When an offender is transferred to segregation, health
care staff will be informed immediately and will provide a screening and review as
indicated by the protocols established by the health authority. Unless medical attention is
needed more frequently, each offender in segregation receives a daily visit from a qualified
health care professional. The visit ensures that offenders have access to the health care
system. The presence of a health care provider in segregation is announced and recorded.
The frequency of physician visits to segregation units is determined by the health
authority.

Even though the documentation provided demonstrated that medical staff are making rounds in segregation,
continual monitoring is needed to ensure the corrective action remains in full compliance.
4-4134

Each inmate confined to a cell/room for 10 or more hours daily is provided a sleeping area
with the following:





a sleeping surface and mattress at least 12 inches off of the floor
a writing surface and proximate area to sit
storage for personal items
adequate storage space for clothes and personal belongings

Each inmate confined to a cell/room for less than 10 hours daily is provided a sleeping area
with the following:




a sleeping surface and mattress at least 12 inches off of the floor
storage for personal items
adequate storage space for clothes and personal belongings

Tremendous effort was taken in transferring inmates to alleviate the triple bunking in segregation. There were
seven (7) cells that were being triple-bunked during the re-inspection. Arrangements have been made to
transfer these inmates to other facilities as soon as possible which will bring them into full compliance.
4-4141

All cells/rooms in segregation provide a minimum of 80 square feet, of which 35
square feet is unencumbered space.

There were seven (7) cells that were being triple-bunked during the re-inspection. Arrangements have been
made to transfer these inmates to other facilities as soon as possible. As soon as this is completed, the inmates
in segregation will have the required 35 square feet of unencumbered space and this standard will be compliant.

Facility: Lake Erie Correctional Institution

OH 11-01

Re-Inspection Date: November 7-8, 2012

Treatment for offenders with chronic illnesses should be provided in a standardized
manner that is consistent with nationally recognized disease treatment guidelines and has
the goal of improving patient outcomes while reducing morbidity and mortality.
Inmates diagnosed with a chronic illness that is not addressed through one of the other
established chronic care protocols shall still be enrolled into Chronic Care Clinic. Such
conditions may include, but are not limited to: Cancer, Multiple Sclerosis, Parkinson’s
Disease, Sickle Cell Anemia, Crohn’s Disease, and thyroid disorders.

The plan of action is being followed and additional monitoring is needed to ensure the Chronic Care Clinic
inmates are being seen throughout the CCC processes as required.
OH 11-02

The purpose of this protocol is to establish guidelines for complete, appropriate and
timely completion of specialty clinic referrals to FMC, OSUMC, and other specialty
clinics; and to facilitate and standardize the continuity of care received by
inmates returning from specialty consultation appointments.

The plan of action is being followed and additional time is needed to ensure the consult appointments are being
handled appropriately.
OH 15-02

The Reentry Coordinator will work to ensure that program providers prioritize admission
based upon the static risk assessment, dynamic needs assessment, length of sentence,
statutory requirements, and the ability to complete the program before release.

Fourteen LaECI staff attended ORAS training on Oct. 22. The LaECI Chief of Unit Management has obtained
a list of intensive/release date/needs waiting lists for program placement. Some of the staff is still waiting for
access to the ORAS system but they are on track to meet the November 30 deadline for completion of
RAPS/ORAS case plans.
OH 15-04

The Unit Management Administrator or the responsible Deputy Warden are responsible
for monitoring the quality of the Prison Intake Tool (PIT) interview, documentation and
management of the Case Plan and Reentry Accountability Plan (RAP) and ensuring all
program providers are communicating through the inmate’s case plan and RAP screens.

Lake Erie has implemented a housing unit for orientation of incoming inmates and a database to ensure 90 day
time period is met for the completion of the Prison Intake Tools (PIT). A large amount of the back log on the
PITs has been completed and this effort must continue to attain full compliance.
OH 15-05

The parent facility Unit Management Staff will complete a Prison Intake Tool (PIT)
within 90 days of arrival at the prison on inmates r a t e d as Moderate, High risk
on the Prison Screening Tool (PST) and have one year or more of prison time to serve.

Unit staff has been trained in ORAS and have completed a large amount of the back log of PIT’s. They are on
target to meet their approved response to non-compliance deadline in November.

Facility: Lake Erie Correctional Institution

Re-Inspection Date: November 7-8, 2012

Standards remaining in Noncompliance that are outside of the facility’s control
4-4132

Revised January 2012. Cells/rooms used for housing inmates shall provide at a
minimum, 25 square feet of unencumbered space per occupant. Unencumbered space
is usable space that is n o t e n c u m b e r e d b y f u r n i s h i n g s o r fixtures. At l e a s t
o n e d i m e n s i o n of t h e unencumbered space is no less than seven feet. In
determining unencumbered space in the cell or room, the total square footage is
obtained a n d the square footage of fixtures and equipment is subtracted. All fixtures
and equipment must be in operational position.

All housing units provide less than the requirement of 25 square feet of unencumbered space per
occupant. These ranged from 21.8 to 23.1 square feet of unencumbered space per occupant.