THE WORST OFFENDERS
REPORT: THE MOST PROBLEMATIC
LOCAL CORRECTIONAL FACILITIES
OF NEW YORK STATE

February 2018

Thomas A. Beilein
Chairman
Thomas J. Loughren
Commissioner
Allen Riley
Commissioner

80 South Swan Street, 12th Floor, Albany, New York 12210 │ 518-485-2346 – phone │ 518-485-2467 – fax │ www.scoc.ny.gov

CONTENTS

Executive Summary ……………………………..….…………………………………………………. 1
Rikers Island Facilities ………………….….………………………………………………….……… 3
Facilities Overview ……………………………………………………………………………... 4
Commission Evaluations of DOC Facilities ………………..….…………………………….. 6
2016 Individual Facility Evaluations ……….…………….…………………………… 6
DOC Response to 2016 SCOC Evaluations ………………………………………. 15
2017 Individual Facility Evaluations ………………….………….………………….. 15
Department-wide Compliance Issues ………………………...…….…...…………. 23
Commission-issued Directives ……………………………………………...….……………. 26
Reported Significant Facility Incidents ……………...……………..…………….………….. 29
Inmate Mortality Investigation Findings …………………………………….………………. 33
Sanitation and Physical Plant Conditions …………………………………..………………. 40
Greene County Jail …………………………….…………………………………………………….. 45
Facility Overview …………………………………………………………………………..….. 45
Physical Plant Conditions ………………………………………………………………….…. 45
Facility Staffing Deficiencies …………………………………………………………………. 46
Variances and Facility Construction ………………………………………………………… 46
2016 Facility Evaluation ………………………………………………………….…………… 47
2017 Facility Evaluation ………………………………………………………..………….…. 49
Commission-issued Directives and Enforcement ………………………………………….. 50
Reported Significant Facility Incidents ……………………………………………………… 53
Erie County Holding Center and Correctional Facility …………………………………..…….. 54
Facility Overview …………………………………………………………………………...…. 54
Facility Staffing Deficiencies …………………………………………………………………. 54
Commission Special Investigations …………………………………………………………. 54
Inmate Mortality Investigations ………………………………………………………………. 55
2016 Facility Evaluation ………………………………………………………………………. 57
2017 Facility Evaluation ………………………………………………………………………. 58
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Commission-issued Directives and Enforcement ……………………………………..…... 59
Reported Significant Facility Incidents ………………………………………………..…….. 60
Dutchess County Jail ………………………………………………….…………………….………. 61
Facility Overview …………………………………………………………………………...…. 61
Inmate Overcrowding Management ………………………………………………………… 61
Inmate Mortality Investigations ………………………………………………………………. 61
Attorney General Inquiry – Correctional Medical Care, Inc. ………………………………. 62
2016 Facility Evaluation ……………………………………………………………….……… 63
2017 Facility Evaluation ………………………………………………………………………. 63
Reported Significant Facility Incidents ……………………………………………………… 64
Onondaga County Justice Center and Penitentiary ……………………..…………………….. 65
Facility Overview ………………………………………………………………………...……. 65
Facility Staffing Deficiencies …………………………………………………………………. 66
Inmate Overcrowding Management ………………………………………………………… 66
2016 Facility Evaluation ………………………………………………………………………. 67
2017 Facility Evaluation ………………………………………………………………………. 67
Civil Rights Litigation ………………………………………………………………………….. 68
Commission-issued Directives and Enforcement …………………………………….……. 69
Reported Significant Facility Incidents ……………………………………………………… 70

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EXECUTIVE SUMMARY
The State of New York operates a criminal correctional system comprised of two main
components. At the local level, counties and the City of New York are charged with the duty to
maintain and administer jails under the regulation and supervision of the State. These jails are
operated by local governments and are primarily responsible for holding individuals pending
adjudication, or sentenced to imprisonment for one year or less. At the state level, New York
State operates a prison system, which is responsible for long-term institutionalization and
rehabilitation – for sentences in excess of one year – and is under the authority of the State
Department of Corrections and Community Supervision.
Pursuant to both the Eighth Amendment to the United States Constitution as well as
Article I, Section Five of the New York State Constitution, the imposition of cruel and unusual
punishment is strictly outlawed. While individuals housed within correctional facilities have
either been charged with, or convicted of, committing a crime, we as a State must ensure that
our actions do not violate the basic rights of these individuals. The State Commission of
Correction (the Commission), is legally charged to regulate, supervise, and inspect the
operation of local jails to ensure and enforce compliance with state law. The Commission was
established by Article 17, section 5 of the New York State Constitution, and its functions, powers
and duties are set forth in Article 3 of the New York State Correction Law. The general powers
of the Commission include establishing minimum standards for the safe and proper operation of
local jails and the inspection and enforcement of local facilities to ensure that facilities are
meeting all legal requirements.
The Commission regulates the construction and improvement of local facilities, the care,
custody, correction, treatment, supervision, discipline, health standards, staffing, staff behavior,
staffing discipline, and related matters of all local facilities. The Commission is legally
empowered to advise local facilities of any legal or regulatory violations and require remedial
actions to correct any such violations. The Commission is also empowered to close local
facilities deemed out of legal compliance. The Commission is empowered to do on-site
inspections and to interview any administrators, staff, or inmates in said facilities. Local facilities
must grant the Commission and its employees access, at any and all times, to any facility,
including to all books, records, inmate medical records, or data that the Commission deems
necessary.
The Commission is empowered to issue and enforce subpoenas and subpoenas duces
tecum, administer oaths, and examine persons under oath. A person examined under oath has
the right to be accompanied by counsel subject to reasonable limitations to prevent obstruction
of, or interference with, the orderly conduct of the examination. The Commission, by its
Correctional Medical Review Board, is also charged with examining the death of any inmate in
any local facility, and may interview any facility employee or inmate in connection with that
death, including members of the deceased inmate’s family.
Where non-compliance with a statute or regulation is discovered, the Commission is
legally empowered to direct a local facility to achieve compliance and, when necessary, may
thereafter seek a judicial order for compliance in the New York State Supreme Court. The
Commission may close any facility which is unsafe, unsanitary, or which is not compliant with
the rules and regulations promulgated by the Commission. The Commission is also empowered

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to make recommendations and reports to the Governor of the State of New York when it deems
appropriate.
Findings
The Commission has conducted extensive on-site inspections, interviews, and
investigations on a number of local facilities. Several facilities have been found out of
compliance more than once, thus endangering the health and safety of inmates and staff
members. The Commission has issued numerous corrective action directives and provided staff
to closely monitor and assist with the implementation of said corrective action plans. However,
despite the Commission’s best efforts, some facilities still fail to meet minimum legal
requirements for safe operation.
The Commission now issues this report on the five local jails that are deemed the “worst
offenders” for being in violation of state law. These facilities pose an ongoing risk to the health
and safety of staff and inmates and, in instances, impose cruel and inhumane treatment of
inmates in violation of their Constitutional rights. Included in this report are synopses of
evaluative determinations of non-compliance with state law and regulations, a description of
Commission enforcement efforts, a brief analysis of significant facility incidents reported by the
various facilities to the Commission, summaries of Commission investigative report findings
regarding inmate mortalities, and an account of the sanitation and physical plant conditions
afflicting the facilities.
The five local facilities determined as “worst offenders,” after years of review, are: the
New York City Rikers Island Facilities, the Greene County Jail, the Erie County Holding
Center/Correctional Facility, the Dutchess County Jail and the Onondaga County Justice
Center/Penitentiary.

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RIKERS ISLAND FACILITIES
Rikers Island continues to be plagued by managerial failures, significant structural
problems, regulatory compliance failures, identified deficiencies that remain unaddressed, and
unabated harm to both staff and inmates alike. The Commission has sought to assist Rikers
management in addressing these and many other deficiencies, and facilitate improvements, but
those efforts have not been successful, further highlighting the need for closure of all jail
facilities located on Rikers Island.
Following the August 2014 report of the United States Attorney’s Office for the Southern
District of New York into the treatment of adolescent male inmates on Rikers Island, the
Commission dedicated additional resources to its oversight of the DOC. Additional staff were
assigned to conduct comprehensive annual evaluations of DOC facility compliance with
Commission regulations, and also to assist with the investigation of every inmate mortality, as
conducted by the Commission’s Medical Review Board. In collaboration with the New York
State Office of Information Technology Services (ITS), the Commission developed a system for
the reporting of significant incidents in local correctional facilities, including DOC facilities, via
the eJusticeNY Integrated Justice Portal. Lastly, a team of Commission staff were deployed in
March 2017 to conduct a three-day intensive tour of all facilities on Rikers Island to evaluate
sanitation and physical plant deficiencies.
This comprehensive report’s irrefutable facts make clear what is aptly described as a
deeply disturbing and discouraging situation. First, the evaluations of Rikers Island reveal
extensive and systemic non-compliance with fundamental and compulsory regulations intended
to provide for a safe, stable and humane correctional system. Second, the DOC has
demonstrated both an unwillingness and inability to take necessary actions to remedy identified
violations, often concerning facility safety and security.
Despite having less than half of the inmate population confined in county jails throughout
the State, the number of reported significant incidents for Rikers Island is generally far greater,
markedly so with regard to violent incidents, such as assaults, sex offenses and facility
disturbances. Possibly most concerning is that the number of such reported incidents has, for
most significant categories, increased from 2016 to 2017; this despite the enormous amount of
attention that is focused upon the island facilities. A review of inmate mortality cases includes
numerous instances where a death was attributable to deficient medical care, substandard
mental health services, or inadequate custody and supervision by security staff. Comprehensive
physical plant evaluations of the Rikers Island facilities have exposed conditions that are
unsecure, unsanitary and dangerous, for staff and inmates alike. Rikers Island is, and has
been, violating essential constitutional protections and State laws. There is no Rikers Island
closure plan that is legally binding on future city administrations nor is there a proposed
timetable that is reasonable considering the length, seriousness and spiraling year to year
increase of violent incidents and degrading conditions facing both inmates and staff.
Consequently, given the City’s inaction and protracted 10-year proposal, it is now time
for the Commission to examine steps to expeditiously close Rikers and to ensure that the
constitutional rights of inmates and staff are protected. The New York City jail system must be
brought into compliance with the laws, guarantees, and protections provided by the Federal and
State constitutions.

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FACILITIES OVERVIEW
Anna M. Kross Center (AMKC)
Description: Opened in 1978, AMKC houses male detainees in 78 housing areas spread over
40 acres.
Cells: 984 cells
Dorms: 656 beds
Modular (combination cells and dorms): 936
Total capacity: 2,576
12/1/17 population: 1,991 (unsentenced males)
Eric M. Taylor Center (EMTC)
Description: Opened in 1964 and expanded in 1973, was previously designated the
Correctional Institution for Men.
Cells: 136 cells
Dorms: 1,468 beds
Total capacity: 1,604
12/1/17 population: 1,230 (males, predominantly sentenced)
George Motchan Detention Center (GMDC)
Description: Opened in 1971 as the Correctional Institution for Women with a capacity of 679,
GMDC later became a male detention center.
Cells: 912 cells
Dorms (Modular): 659 beds
Total capacity: 1,571
12/1/17 population: 634 (males, predominantly unsentenced)
George R. Vierno Center (GRVC)
Description: Opened in 1991 as an 850-bed facility for male detainees. A 500-bed addition
opened at GRVC in 1993.
Cells: 853 cells
Dorms: 376 beds
Total capacity: 1,229
12/1/17 population: 687 (unsentenced males)
North Infirmary Command (NIC)
Description: Opened in 1932, NIC consists of two infirmary buildings, one of them the original
Rikers Island Hospital. The main facility has 281 beds, 84 cells and 197 beds in dorms. The
Annex, converted to housing in mid-1980, has 5 cells and 153 dorm beds for housing infirmary
care inmates. A 39-bed dorm was closed by the Commission in December 2016 due to
inadequate living conditions.
Cells: 89 cells
Dorms: 350 beds
Total capacity:439
12/1/17 population: 244 (sentenced and unsentenced males)
Otis Bantum Correctional Center (OBCC)
Description: Opened in 1985, OBCC includes the Department's 400-bed Central Punitive
Segregation Unit.
Cells: 750 cells
Dorms: 950 beds
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Total capacity: 1,700
12/1/17 population: 955 (unsentenced males)
Rose M. Singer Center (RMSC)
Description: Opened in 1988 as an 800 bed facility for female detainees and sentenced
inmates. A 650 bed addition opened at RMSC in 1995 increased capacity to its present level.
Cells: 470 cells
Dorms: 978 beds
Total capacity: 1,448
12/1/17 population: 603 (all females, including minors)
Robert N. Davoren Center (RNDC)
Description: Opened in 1972, formerly Adolescent Reception and Detention Center, RNDC
houses adolescent male detainees (ages 16-17) and adult male detainees.
Cells: 1,184 cells
Dorms: 50 beds
Modular (dorms): 700
Total capacity: 1,934
12/1/17 population: 663 (minor males and unsentenced adult males)
West Facility (West)
Description: Opened in 1991, as a 940-bed facility constructed of 12 Sprung-rigid aluminum
framed structures covered by a heavy-duty plastic fabric. Part of the West Facility was
converted into the DOC's Contagious Disease Unit (CDU) center in which 140 air-controlled
housing units are reserved for male and female inmates with contagious diseases, such as
tuberculosis. Reduced to 98 operational cells inside the sprungs, the remaining sprungs were
converted to Central Intake in 2014, but closed a few months later.
Cells: 98 cells
Total capacity: 98
12/1/17 population: 47 (unsentenced males)

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COMMISSION EVALUATIONS OF DOC FACILITIES
Pursuant to its authority set forth in Article 3 of the New York State Correction Law, the
Commission has promulgated minimum standard regulations for the management of
correctional facilities throughout the state. Contained in Chapter I of Subtitle AA of Title 9 of the
New York Codes, Rules and Regulations (NYCRR), the regulations applicable to county jails
and the New York City Department of Correction consist of 34 separate Parts, each of which
provides regulations relevant to a particular subject matter (i.e. security and supervision, inmate
visitation, legal services, etc.).
Historically, the Commission has conducted annual, comprehensive evaluations of each
county jail. To ensure that every regulation is periodically examined at every local correctional
facility, the Commission utilizes a cycle evaluation schedule, whereby 10 or 11 regulation Parts
are evaluated at every facility in a given year. Thus, in a four (4) year span, every regulation is
evaluated at least once, with the most critical regulations being evaluated on a biennial basis.
Depending on the size of a facility, on-site assessment by Commission staff can typically last
from 3 to 10 days, including entrance and exit interviews with facility administration. Thereafter,
a written evaluation is prepared and issued by the Commission, setting forth all findings of
facility non-compliance with Commission regulations, actions required of a facility to achieve
compliance, and requiring a written response from the facility within 45 days. Following receipt
of a local correctional facility’s evaluation response, Commission staff will verify all remedial
actions taken by a facility during a subsequent on-site inspection, or during the next year’s
scheduled cycle evaluation.
As part of its decision to dedicate additional resources to its oversight of the DOC, the
Commission assigned staff necessary to conduct annual evaluations of DOC facilities, including
those on Rikers Island, pursuant to the four (4) year cycle evaluation schedule, beginning in
calendar year 2016. Listed below are brief summaries of the deficiencies more
comprehensively listed in the Commission’s written evaluation reports of DOC’s Rikers Island
facilities.

2016 INDIVIDUAL FACILITY EVALUATIONS

AMKC – Report issued 3/7/17
Part 7003 - Security and Supervision
• Active Supervision: The facility is not maintaining an active security post in units having
more than 20 prisoners.
• Supervision of Prisoners in Facility Housing Areas:
a. The facility not consistently using mechanical or electrical time recording devices as
required.
b. Constant supervision prisoners being supervised by officers of opposite gender.
• Supervision of Prisoners outside of Facility Housing Areas: Prisoners were observed
moving through hallways unsupervised.
• Prisoner Population Counts:
a. Census verification forms have inaccurate reporting of inmates.

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b. Population counts not immediately forwarded to the Chief Administrative Officer and
did not consistently document the time of review.
Firearms Control: There is a lack of documentation to substantiate the facility was
conducting required inspections of all personal firearms staff are authorized to use during
the performance of their official duties.
Key Control:
a. Sub-control room doors found to be left unsecured.
b. Issuance and return of facility keys not consistently documented in logbook. Food
service and exterior dock keys not logged out.

Part 7006 - Discipline
• Policy: The Department’s policy is inconsistent with the inmate rulebook, which is causing
confusion among staff and inmates.
• Disciplinary Sanction: Facility policies and procedures incorrectly state that exercise can
be taken as a disciplinary sanction.
Part 7008 - Visitation
• Visitation Security and Supervision: Facility was unable to demonstrate the completion of
required visitation room searches prior and subsequent to each visitation period.
Part 7009 - Food Service
• Policy: Food carts and food warmers had buildup of food items from previous meal.
Part 7015 - Sanitation
• General Facility Sanitation: The facility had numerous areas where leaks were discovered.
Due to the water leaks walls and ceilings were damaged. Peeling paint, walls with rust and
holes in walls and ceilings were discovered.
• General Facility Sanitation: Prisoners cells found in disarray. Prisoners are not required to
maintain their cells in a clean and sanitary manner.
Part 7063 - Chemical Agents
• Use of Chemical Agent: Facility could not demonstrate that health service staff are trained
in the treatment of persons exposed to chemical agents.
• Training in the use of Chemical Agent: Chemical agents were being issued to staff whose
training certification has expired.

EMTC – Report issued 12/14/16
Part 7003 - Security and Supervision
• Supervision of Prisoners in Facility Housing Areas: The facility has no functioning
mechanical or electrical time recording devices.
• Prisoner Population Counts: Population counts take over 1.5 hours to clear. Individual
prisoner counts phoned into control are not matching submitted count sheets.

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Firearms Control: There is a lack of documentation to substantiate the facility was
conducting required inspections of all personal firearms staff authorized to use during the
performance of their official duties.

Part 7006 - Discipline
• Misbehavior Report: The facility is not recording the time the report was written and they
are not documenting that the prisoner received a copy of the report
• Disciplinary Hearing: The facility could not demonstrate that prisoners are receiving a
copy of hearing dispositions.
Part 7007 – Good Behavior Allowances
• Policy: The Department was unable to demonstrate they were explaining good behavior
allowance to the prisoners.
Part 7015 - Sanitation
• General Facility Sanitation: Prisoners cells cluttered and in disarray. Prisoners are not
required to maintain cells in a sanitary condition.
Part 7063 - Chemical Agents
• Training in the use of Chemical Agent: Chemical agents issued to staff whose training
certification has expired.

GMDC – Report issued 10/6/16
Part 7003 - Security and Supervision
• Supervision of Prisoners in Facility Housing Areas: The facility still has housing areas
with no mechanical or electrical time recording devices.
• Constant Supervision: Appropriate documentation is not being maintained when constant
supervision is ordered. Constant supervision records are documented on individual sheets
with pre-established times which is inconsistent with NYS Minimum Standards.
• Supervision of Prisoners Outside Facility Housing Areas: Inmates were permitted to
move throughout the facility hallways unsupervised.
• Prisoner Population Counts: The facility approves the inmate final population count
without accounting for all housing area count slips. This is an improper accounting of the
inmate population and can lead to a delay in responding to an escape or emergency
situation.
• Firearms Control: There is a lack of documentation to substantiate the facility was
conducting required inspections of all facility firearms.
• Locks and Other Securing Devices: The facility is not conducting inspections of all locks
and securing devices at intervals outlined by NYS Minimum Standards to ensure they are
working properly. Housing areas temporarily closed are not being assessed to ensure that
all the locks and securing devices are in proper working order.
Part 7006 - Discipline

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Policy: The Department’s policy is inconsistent with the inmate rulebook and is causing
confusion among inmates and staff.

Part 7007 – Good Behavior Allowances
• Policy: The Department was unable to demonstrate they were explaining what good
behavior allowance was and appropriate inmate outdates.
Part 7009 – Food Service
• Sanitation: Kitchen staff and inmates were not wearing hair nets during meal preparation.
Part 7015 - Sanitation
• Housing Units: Individual inmate cells were found to be in disarray and in many cases, in
unsanitary conditions.
Part 7063 - Chemical Agents
• Training: The Department is issuing Chemical agents to officers whose training certification
has expired.

GRVC – Report issued 12/14/16
Part 7003 - Security and Supervision
• Supervision of Prisoners in Facility Housing Areas:
a. The facility is not using mechanical or electrical time recording devices as required.
b. Order for additional supervision is not recorded in housing unit logbooks. Significant
events are also not recorded in the logbooks.
• Prisoner Population Counts:
a. Population counts submitted are not signed by the staff completing the count.
b. Population counts are frequently conducted by line staff and not verified and/or
reviewed by the Chief Administrative Officer.
• Requirements of Staff: When staff are on a post for more than one-hour they are not
documenting required information in the housing area logbooks.
• Firearms Control: The facility was unable to demonstrate that they are conducting required
inspections of all firearms.
• Key Control: Facility keys are not consistently logged in and out of logbook.
• Locks and other Securing Devices: The facility is not completing lock inspections of all
areas of the facility.
Part 7006 - Discipline
• Policy: The Department’s policy is inconsistent with the inmate rulebook and is causing
confusion among inmates and staff.
• Administrative Segregation: The facility was unable to demonstrate that all prisoners are
receiving a copy of their pre-hearing detention. The facility could not demonstrate that the
Chief Administrative Officer is consistently reviewing the administrative segregation orders
within 24-hours of confinement.

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Disciplinary Sanction: Facility policies and procedures incorrectly state exercise can be
taken as a disciplinary sanction.

Part 7008 - Visitation
• Limitation of Visits: Visitors and inmates were not notified in writing when they were turned
away from a visit.
Part 7015 - Sanitation
• General Facility Sanitation: Prisoners cells found in disarray. Common areas such as the
hallways, elevators and sally ports were dirty and not consistently cleaned or maintained.
Part 7063 - Chemical Agents
• Training in the use of Chemical Agent: Chemical agents issued to staff whose training
certification has expired

NIC – Report issued 12/14/16
Part 7003 - Security and Supervision
• Supervision on prisoners in Facility Housing Areas:
a. There are no housing areas that have functioning mechanical or electrical time
recording devices.
b. The facility was not consistently documenting in area logbooks when prisoners enter
or exit the housing area.
c. Facility staff not logging when prisoners exit or return to housing units.
• Firearms Control:
a. Personal weapons used in the performance of staff’s official duties were not
inspected.
b. Chemical agents are being issued to officers whose chemical agent training
certification had expired.
Part 7006 - Discipline
• Misbehavior Report: Notice of Infraction did not contain a signature of the prisoner
acknowledging that they received a copy of the misbehavior report.
• Assistance to Inmates: DOC form states that prisoners will only receive assistance with
their hearing if the Adjudication Captain deems it necessary. Such practice is unacceptable.
• Disciplinary Hearing: Prisoners not signing that they received a copy of their hearing
disposition.
Part 7007 - Good Behavior Allowances
• Record Keeping & Regulations: The facility was unable to demonstrate that facility staff
fully explained the meaning of Good Behavior Allowances to prisoners and that prisoners
acknowledge in writing that the explanation was provided.
Part 7015 - Sanitation
• General Facility Sanitation:
a. Housing areas cluttered with prisoner property.
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b. Prisoners not required to maintain housing areas in a clean and sanitary condition.
c. Leaks in the ceiling of the visitation area.
d. Dorm 3 flooded with approximately six (6) inches of water. SCOC required the
relocation of all inmates in Dorm 3.
e. SCOC ordered the closure of Dorm 3.
f. The department has yet to request the reopening of Dorm 3
Part 7063 - Chemical Agents
• Training in The Use of Chemical Agents: Chemical agents were being issued to officers
whose chemical agent training certification had expired.

OBCC – Report issued 8/3/16
Part 7003 - Security and Supervision
• Active Supervision: The facility is not consistently a staff post in housing areas containing
more than 20 prisoners.
• Supervision of prisoners in facility housing areas: There are no housing areas that have
functioning mechanical or electrical time recording devices.
• Population Counts: Population count sheets are not signed by officers completing the
count. A count was observed that took over an hour to clear. Count slips called in did not
match the inmate totals on submitted count sheets.
• Firearms Control: Staff did not consistently record the date and time an issued firearm and
ammunition was returned. It was also found that personal weapons used in the performance
of staff’s official duties were not inspected. Chemical agents are being issued to officers
whose chemical agent training certification had expired.
• Key Control: An intake area key box was broken and unsecured. Keys were not
consistently logged in and out of logbook. Staff maintained keys that could provide inmates
a means of egress from the facility.
Part 7006 - Discipline
• Rules of Inmate Conduct: The rules of inmate conduct concerning disciplinary sanctions
differ from the facility’s directive. Different infractions are listed for the same violations.
• Administrative Segregation Pending a Hearing: The facility is not consistently providing
written notice to prisoners within 24 hours of their confinement. The facility Chief
Administrative Officer is not consistently reviewing administrative segregation orders within
24 hours.
• Disciplinary Hearing: Prisoner hearings were adjourned for several months with no further
documentation or follow-up.
• Appeal Procedures: Prisoners are not consistently being notified in writing of the results of
their appeals.
Part 7007 - Good Behavior Allowances
• Record Keeping & Regulations: The facility was unable to demonstrate that facility staff
fully explained the meaning of Good Behavior Allowances to prisoners and that prisoners
acknowledge in writing that the explanation was provided.
11

Part 7008 - Visitation
• Limitation of Visits: The facility has a blanket policy whereby prisoners are placed on all
non-contact visits due to potential visitors being found with contraband. Visitors being turned
away from a visit are not provided an explanation in writing as to why visit was denied.
Part 7015 - Sanitation
• General Facility Sanitation: Food service areas had dirt and rust spots on ceiling and
debris on floors.
Part 7063 - Chemical Agents
• Use of Chemical Agents: The facility was unable to demonstrate that all health service staff
are trained in the treatment of persons exposed to chemical agents.
• Training in The Use of Chemical Agents: Chemical agents were being issued to officers
whose chemical agent training certification had expired.

RMSC – Report issued 9/21/16
Part 7003 - Security and Supervision
• Active Supervision: The facility is not consistently maintaining an active officer post in
housing areas containing more than 20 prisoners.
• Supervision of prisoners in facility housing areas:
a. There are no housing areas that have functioning mechanical or electrical time
recording devices.
b. The facility was not consistently documenting in area logbooks when prisoners enter
or exit the housing area.
• Population Counts: A count was observed that took over two hours to clear. Count slips
called into control did not match the inmate totals on submitted count sheets.
• Firearm Control: Personal weapons used in the performance of staff’s official duties were
not inspected. Chemical agents are being issued to officers whose chemical agent training
certification had expired.
• Key Control: Facility not consistently documenting the date/time of returned keys in the key
log book.
Part 7006 - Discipline
• Misbehavior Report: Notice of Infraction did not contain a signature of the prisoner
acknowledging that they received a copy of the misbehavior report.
• Assistance to Inmates: DOC form states that prisoners will only receive assistance with
their hearing if the Adjudication Captain deems it necessary. Such practice is unacceptable.
Part 7007 - Good Behavior Allowances
• Record Keeping & Regulations: The facility was unable to substantiate that facility staff
fully explained the meaning of Good Behavior Allowances to prisoners and that prisoners
acknowledge in writing that the explanation was provided.
Part 7015 - Sanitation
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General Facility Sanitation: Prisoners cells found in disarray. Prisoners are not required to
maintain their cell in a clean and sanitary manner.

Part 7063 - Chemical Agents
• Training in The Use of Chemical Agents: Chemical agents were being issued to officers
whose chemical agent training certification had expired.
• Storage and Maintenance of Chemical Agents: The facility chemical agent inventory
sheet was outdated and did not reflect the equipment being stored within the facility.

RNDC – Report issued 3/7/17
Part 7003 - Security and Supervision
• Policy: Secured cell doors can be popped open by prisoners.
• Supervision of Prisoners in Facility Housing Areas: The facility is not consistently using
mechanical time recording devices and also has defective equipment in need of repair.
• Constant Supervision:
a. Prisoners on constant observation being supervised by officers of opposite gender.
b. Appropriate documentation is not being maintained when constant supervision is
ordered.
• Prisoner Population Counts: submitted prisoner population count sheets had an
inaccurate reporting of prisoners assigned to housing areas.
• Prisoner Population Counts: Population counts are not immediately verified and signed by
the Chief Administrative Officer.
• Firearms Control: There is a lack of documentation to substantiate the facility was
conducting required inspections of all personal firearms staff are authorized to use during
the performance of their official duties.
• Key Control: Keys not properly logged in and out in the key control logbook.
Part 7006 - Discipline
• Policy: The Department’s policy is inconsistent with the inmate rulebook and is causing
confusion among inmates and staff.
• Disciplinary Hearing: Policy allows the facility to limit exercise as a disciplinary sanction.
This is unacceptable.
Part 7007 – Good Behavior Allowances
• Policy: The Department was unable to demonstrate they were explaining good behavior
allowance to the prisoners.
Part 7008 - Visitation
• Visitation Security and Supervision: The department was unable to demonstrate the
completion of visit room searches prior and subsequent to each visitation period.
Part 7009 – Food Service
• Medical and Religious Diets: Facility policies do not ensure prisoners are provided with
medical and religious diets.
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Part 7015 - Sanitation
• General Facility Sanitation:
a. Leaks are occurring throughout the facility.
b. Walls and ceilings are rusting due to water leaks.
c. Prisoner cells are cluttered and in disarray.
d. Prisoners not required to maintain cells in a sanitary condition.
Part 7063 - Chemical Agents
• Use of Chemical Agents: Facility was unable to demonstrate that medical staff are properly
trained in treatment of those exposed to chemical agents.

WEST – Report issued 9/27/16
Part 7003 - Security and Supervision
• Supervision of Prisoners in Facility Housing Areas: The facility does not have
functioning mechanical or electrical time recording devices.
• Firearm Inspections: Firearm inspections did not include the inspection of personal
firearms allowed to be carried in the performance of officers’ official duties.
• Key Control: Key control cabinet contained keys no longer in use and keys in which staff
could not identify. Key log does not consistently document when keys are returned.
• Locks and other Securing Devices: The facility was unable to demonstrate the completion
of inspections conducted on all locks and securing devices.
Part 7006 - Discipline
• Misbehavior Report: The facility could not demonstrate that prisoners are signing for a
copy of their misbehavior report. Therefore, there is no evidence that they are receiving a
copy of the report.
• Assistance to Inmates: Facility Correction Form 6500a states that prisoners have a right to
assistance with a hearing only if the adjudication Captain deems is necessary. This
practice is unacceptable.
• Disciplinary Hearing: The facility hearing form contains no signature acknowledgement
from a prisoner that they have received a copy of the misbehavior report.
Part 7015 - Sanitation
• General Facility Sanitation: Water leaks were found in numerous areas. The roofs appear
to have been leaking for an extended period of time, resulting in damage to the walls and
floors. Commission staff also found cluttered areas which pose a fire hazard, especially
considering the facility’s fire alarm system is inoperable.
Part 7063 - Chemical Agents
• Chemical Agent Inspections: Unable to demonstrate the completion of required Chemical
Agent inspections.

14

DOC RESPONSE TO 2016 SCOC EVALUATIONS
Each of the Commission’s on-site evaluations of DOC’s Rikers Island facilities were
conducted during calendar year 2016, as were the issuance of the resulting evaluation report,
except for the reports for AMKC and RNDC, each of which were issued on March 7, 2017.
Although the Commission requested timely written responses to each evaluation report
(generally within 45-90 days from the date of the report), the majority of DOC’s written
responses were not received by the Commission until late June 2017. Thus, the majority of
DOC’s evaluation responses were not provided to the Commission until six (6) to eight (8)
months after the reports were issued.
Despite the prolonged delay in responding to the Commission’s evaluation reports, it
does not appear on their face that the DOC substantially commenced remedial action before
responding to the report. Using the George R. Vierno Detention Center (GRVC) as an example,
the Commission issued its written evaluation report on December 14, 2016, to which the DOC
responded by letter dated June 26, 2016. Notwithstanding this six (6) months available to
implement corrective action to noted deficiencies, the DOC’s report predominantly made
references to future plans of its administration to act, stating it “will follow up with relevant
officials,” “will conduct periodic audits,” etc. In fact, the DOC’s evaluation response states, in
eleven (11) separate instances, that DOC’s administration “will issue a memorandum” to staff as
a means of corrective action.
Despite the DOC’s extended delay in providing the Commission its evaluation report
responses, Commission staff have commenced assessing the same, and will provide the DOC
its written assessment finding in forthcoming correspondence.

2017 INDIVIDUAL FACILITY EVALUATIONS
As of December 14, 2017, every on-site Cycle 2 evaluation of DOC’s Rikers Island
facilities has been completed by Commission staff. Initially, the Commission had withheld
issuing written Cycle 2 evaluation reports to the DOC, attempting instead to first assess
compliance and conclude outstanding issues regarding the Cycle 1 evaluation report. However,
written evaluation reports have recently been issued for GMDC, GRVC, RNDC and EMTC, with
the remainder forthcoming. Nonetheless, listed below are brief summaries of the deficiencies
noted by Commission staff during Cycle 2 on-site evaluations of DOC’s Rikers Island facilities in
2017.

AMKC
Part 7002 - Admissions
• Medical Screening and Initial Screening and Risk Assessments: The facility is not
consistently completing a suicide prevention screening form on all prisoners. When forms
are completed and indicators exist, supervisors are not immediately notified.

15

•
•

•

•

Staff Training: Facility staff assigned to complete initial screening and risk assessments are
not all trained in classification, as required.
Supervision of Prisoners in Facility Housing Areas: When prisoners were determined to
be suicidal or highly self-injurious, they were not immediately placed on constant
supervision.
Supervision of Prisoners outside of Facility Housing Areas: Prisoners were observed
walking unescorted/unsupervised in facility corridors. One such prisoner was able to line up
to access a vehicle transporting inmates to court. Fortunately, the prisoner was identified
right before he was to access the bus. The prisoner was never identified as missing from his
assigned housing area.
Facility Rules and Information: The Department’s last updated inmate rulebook was
completed in 2007. Reviews and revision of information is required to occur on an annual
basis.

Part 7003 - Key Control
• Key Control: The facility intake officer maintained a key that would provide inmates a
means of egress from the facility intake area.
Part 7005 - Prisoner Personal Hygiene
• Laundry and Repair of Clothing: The facility was only providing laundry services for
facility-issued uniforms and linens. Inmates are required to wash their personal clothing in
buckets with soap and water in their cells and hang them to dry.
Part 7024 - Religion
• Congregate Religious Activities: The facility is not providing services for some religious
service programs. Religious schedules are not accurate and do not describe the actual day
and times services are provided.
Part 7028 – Exercise
• Exercise Yard: Exercise yards contained broken pieces of metal and glass. The area also
contained holes and divots that are tripping hazards and can be used for the concealment of
contraband. Some gates require reinforcement, while some gates, fences, and roof lines
require additional concertina wire.
Part 7031 - Legal Services
• Access to Legal Reference Material: The facility does not have written policy or guidelines
for use of all legal reference materials.

EMTC
Part 7002 - Admissions
• Facility Rules and Information: The Department’s last updated inmate rulebook was
completed in 2007. Reviews and necessary revisions are required on an annual basis.
Part 7005 - Prisoner Personal Hygiene
16

•

•

Laundry and Repair of Clothing: The facility was only providing laundry services for
facility-issued uniforms and linens. Inmates are required to wash personal clothing in
buckets with soap and water in their cells and required to hang to dry.
Bedding: The inmate population is not consistently issued pillows. Such failure causes
tension among inmates.

Part 7025 – Packages
• Inspection of Incoming Prisoner Packages: The facility is not providing written notices to
the inmates when their package is returned to sender or sensor items sent through the mail.
Part 7028 – Exercise
• Exercise Area Searches: Facility was unable to demonstrate the completion of exercise
yard searches prior and subsequent to each exercise period.
Part 7031 - Legal Services
• Inmates who do not have direct access to legal reference materials are not being provided a
list of available legal reference materials to be able to assist in a proper defense.

GMDC
Part 7002 - Admissions
• Medical Screening: The Suicide Prevention Screening Guidelines Form required by NYS
standard is not being completed on all inmates admitted to the facility.
• Facility Rules and Information: The Department’s last updated inmate rulebook was
completed in 2007. Reviews and necessary revisions are required on an annual basis.
Part 7003 - Security and Supervision
• Key Control: The facility Intake Officer maintained a key that would provide inmates a
means of egress out of the facility intake area. This lack of key control could allow inmates
access to the unsecured portion of the facility.
Part 7005 - Prisoner Personal Hygiene
• Inmate Clothing: Issuing of socks and undergarments is not consistently issued to newly
admitted inmates.
• Laundry and Repair of Clothing: The facility was only providing laundry services for
facility issued uniforms and linens. Inmates are required to wash their personal clothing in
buckets with soap and water in their cells and hang them to dry.
• Bedding: The inmate’s population is not consistently issued pillows. Such failure causes
tension among inmates.
Part 7013 – Classification
• Initial Screening and Risk Assessment: The Suicide Prevention Screening Guidelines
Form required by NYS Minimum Standards is not being completed on all inmates admitted
to the facility.

17

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Staff Training: Officers assigned to complete the initial screening and risk assessment are
not properly trained in classification as required.

Part 7025 – Packages
• Inspection of Incoming Prisoner Packages: The facility is not providing written notices to
the inmates when their packages are returned to sender or sensor items sent through the
mail.
Part 7028 – Exercise
• Exercise Periods: The facility did not maintain outdoor exercise area logbooks.
• Exercise Areas and Equipment: The facility does not provide appropriate outer garments
during cold weather for the inmate population attending outdoor exercise.
• Exercise Area Searches: The facility was unable to provide documentation that the
required searches were being conducted of the exercise areas.
• Main Recreation Yard: The facility should add concertina wire to the Main Yard gate, fence,
and facility edge roofline.
Part 7031 - Legal Services
• Inmates who do not have direct access to legal reference materials are not being provided a
list of available legal reference materials to be able to prepare a proper defense.

GRVC
Part 7002 - Admissions
• Property Confiscation: Property confiscated was not accurately inventoried. Property
Confiscation sheets are not consistently signed by the inmate.
• Facility Rules and Information:
a. The facility did not have a supply of inmate rulebooks to provide inmates upon
admission.
b. The rulebook has not been updated since 2007.
Part 7002 – Security and Supervision
• Key Control: The facility’s Clothes Box Officer and Sanitation Officer maintained keys that
could provide inmates a means of egress from the facility.
Part 7005 - Prisoner Personal Hygiene
• Clothing: The facility did not have a supply of socks to be issued to prisoners.
Part 7024 - Religion
• Congregate Religious Activities: The facility does not provide services for inmates housed
in Unit 11b (young adults ages 18-21).
Part 7025 – Packages
• Inspection of Incoming Prisoner Packages: The facility staff (not the Chief Administrative
Officer) was making a determination of whether a prisoner could place his confiscated
18

property in the property room. Facility staff was giving the prisoner the option to throw items
away, send property out or donate them.
Part 7028 – Exercise
• Exercise Period: Facility logbooks do not include documentation when prisoners return
from exercise.
• Exercise Searches: The facility is not consistently documenting the search of exercise
areas prior and subsequent to each exercise period.
Part 7031 - Legal Services
• Access to Legal Reference Material:
a. Prisoners do not have direct access to legal reference materials.
b. The facility is not providing a list to prisoners of all reference materials available.
c. Reference materials are not provided to prisoners within three business days of
request.
d. There are no written guidelines for the use of reference materials.

NIC
On-site evaluation of the facility occurred the week of December 11, 2017, and an issued
report is forthcoming.

OBCC
Part 7002 - Admissions
• Property Confiscation: Prisoner Inventory Sheets did not match the itemized inventory
sheet attached to the property bags. Prisoners are not consistently signing the inventory
sheets. Property bags were found to be unsecured. Prisoner property is being released
without the prisoner’s signature.
• Personal Hygiene and Clothing Issue: Most prisoners are not issued 3 sets of uniforms as
required by Command Level Orders. Prisoners were found with only 2 shirts and one pair of
pants and forced to wash uniforms on the housing unit due to a shortage of uniforms.
• Facility Rules and Regulations: The inmate rulebook and handbook are outdated and
include information that no longer applies to the facility.
Part 7005 – Prisoner Personal Hygiene
• Haircuts: There are inaccuracies in the inventory of barber tools.
• Personal Health Care Items: Linen exchange does not occur as scheduled.
• Laundry and Repair of Clothing: Laundry services are not taking place when scheduled.
Prisoners only provided one set of clothing.
• Bedding: Pillowcases and sheets are not being exchanged weekly.
Part 7024 - Religion

19

•

Congregate Religious Services: Religious services are cancelled due to insufficient
supervisory staff.

Part 7025 – Packages
• Inspection of Packages: Senders are not notified when packages are disposed of due to
the existence of contraband.
Part 7028 – Exercise
• Exercise Area Searches: The facility is not conducting exercise area searches prior and
subsequent to each exercise period.

RMSC
Part 7002 - Admissions
• Property Confiscation: Prisoner Inventory Sheets did not match the itemized inventory
sheet attached to the property bags. Prisoners are not consistently signing the inventory
sheets. Property bags were found to be unsecured. Prisoner property is being released
without the prisoner’s signature.
• Personal Hygiene and Clothing Issue: Most prisoners are not issued 3 sets of uniforms as
required by Command Level Orders. Prisoners were found with only 2 shirts and one pair of
pants and forced to wash uniforms on the housing unit due to a shortage of uniforms.
• Facility Rules and Regulations: The inmate rulebook and handbook are outdated and
include information that no longer applies to the facility.
Part 7005 – Prisoner Personal Hygiene
• Haircuts: There are inaccuracies in the inventory of tools used in the beauty parlor.
• Personal Health Care Items: Laundry exchange does not always take place as scheduled
and did not provide for weekly exchange of bath towels.
• Laundry and Repair of Clothing: Laundry services do not always take place as scheduled.
Laundry services not occurring two times per week. There is a shortage of uniforms
throughout the facility.
• Bedding: Prisoners not provided with a pillow and pillowcases and sheets not being
exchanged weekly.
Part 7024 - Religion
• Congregate Religious Services: Religious services are cancelled due to insufficient
supervisory staff.
Part 7025 – Packages
• Inspection of Packages: Senders are not notified when packages are disposed of due to
the existence of contraband.
Part 7028 – Exercise
• Exercise Area Searches: The facility is not conducting exercise area searches prior and
subsequent to each exercise period.
20

RNDC
Part 7002 - Admissions
• Facility Rules and Information:
a. The facility does not consistently hand out rulebooks to prisoners upon admission.
b. The Department’s last updated inmate rulebook was completed in 2007. Reviews
and necessary revisions are to occur on an annual basis.
Part 7005 - Prisoner Personal Hygiene
• Laundry and Repair of Clothing:
a. The facility was only providing laundry services for facility issued uniforms and
linens.
b. Inmates are required to wash their personal clothing in buckets with soap and water
in their cells and then hang them to dry.
• Bedding: The inmate’s population is not consistently issued pillows which causes tension in
the inmate housing areas.
Part 7005 - Sanitation
• General Facility Sanitation: Laundry was unclean, with lint, dirt and dust built-up on
washers, dryers, pipes and floors, creating a fire hazard.
Part 7025 – Packages
• Inspection of Incoming Prisoner Packages: The facility is not providing written notices to
the inmates when their packages are sent back to sender or sensors items sent through the
mail.
Part 7028 – Exercise
• Exercise Periods: Exercise is not consistently provided to all housing units daily.
Part 7031 - Legal Services
• Inmates who do not have direct access to legal reference materials are not being provided a
list of available legal reference materials to be able to prepare a proper defense.

WEST
Part 7002 - Admissions
• Property Confiscation: Prisoner Inventory Sheets did not match the itemized inventory
sheet attached to the property bags. Prisoners are not consistently signing the inventory
sheets. Property bags were found to be unsecured.
• Facility Rules and Regulations: The inmate rulebook and handbook are outdated and
include information that no longer applies to the facility.
Part 7005 - Prisoner Personal Hygiene
• Laundry and Repair of Clothing: Laundry services are not taking place when scheduled.
Prisoners only provided one set of clothing.
21

•

Bedding: Pillowcases and sheets are not being exchanged weekly.

Part 7024 - Religion
• Congregate Religious Activities: Prisoners not permitted to congregate for religious
services. Religious activities not conducted weekly.
Part 7025 – Packages
• Inspection of Incoming Packages: Senders are not notified when packages are disposed
of due to the existence of contraband.
Part 7028 – Exercise
• Limitation of Exercise: Prisoners are not notified in writing when their recreation is denied
or revoked.
Part 7031 - Legal Services
• Policy: Facility was unable to substantiate that prisoners have access to legal reference
materials.
• Mutual Prisoner Legal Assistance: Prisoners are not permitted to meet for the purpose of
discussing and preparing legal materials.

22

DEPARTMENT-WIDE COMPLIANCE ISSUES
As explained above, the majority of the Commission’s evaluative reports are the result of
individual facility audits, and detail findings specific to such facility. Nonetheless, certain
programs, services and duties required by Commission regulations are, in the DOC, run
centrally above the facility level. In these instances, the Commission has elected to evaluate
the DOC’s overall compliance in a single report. Listed below are summaries of the
Commission’s recent findings with regard to department-wide issues.

9 NYCRR Part 7016 - Inmate Commissary
Per Commission regulations, in the discretion of the Commissioner, a commissary may be
established and operated for the purpose of making available, for sale to prisoners, items
deemed proper and consistent with the health and welfare of the prisoners and the security of
the facility. The prices of the items offered for sale shall be fixed by the Commissioner so that
the commissary operation is self-supporting and provides a modest return above costs. The
profits resulting from the sale of commissary items must be deposited in a separate bank
account and utilized only for purposes of prisoner welfare and rehabilitation. Lastly,
Commission regulations require that commissary accounts be maintained in a manner which
fully substantiates all purchases, sales and expenditures, and that arrangements be made for
periodic audits of the commissary accounts by the appropriate municipal agency.
Upon review, Commission staff found that the DOC operates a commissary program that is
neither self-supporting nor provides a modest return above costs. Records reviewed from the
period of 2014 – March 2017 show the DOC’s commissary program operated at a loss of
$11,465,031.00, leaving no profits for prisoner welfare and rehabilitation. Furthermore, the
DOC was unable to provide an appropriate list of agency staff whose primary functions were the
operations of the commissary program. There is a lack of accountability for payment of these
positions from the commissary account, as DOC financial and budget staff “just estimate” the
personnel costs. This estimate in staffing commissary positions cost the inmate commissary
account $29,541,819.00 in a 3 year and 3-month review period.
Since 2004, DOC has not had an audit of its commissary operations performed by an
appropriate outside authority. As of March 2017, there was $3,538,419.60 waiting to be
transferred to the Police Property Payable Fund. As the Commission questions whether
transferring abandoned inmate funds to this account is permissible by state law, this finding will
be referred to the Office of the New York State Comptroller for appropriate review and action.
The above findings and referrals were set forth in a Commission report addressed to the
DOC on November 3, 2017. The Commission is reviewing DOC’s response to the report, which
was received on December 5, 2017.

9 NYCRR Part 7022 - Reportable Incidents
New York State Correction Law and Commission regulations require that local correctional
facilities report to SCOC significant and unusual events, such as prisoner deaths, escapes, facility
fires, service disruptions, inmate group actions, etc. In most cases, these reports must be
submitted to SCOC within 24 hours of occurrence. In case of an inmate death, the facility must
report the death within 6 hours of the pronouncement of death, and in several other instances
23

(major disturbance, hostage situation, firearm discharge, etc.) the report is required immediately.
Incident reports must be submitted to the Commission via the eJusticeNY Integrated Justice
Portal, in accordance with the requirements set forth in the Commission’s Reportable Incident
Guidelines.
Upon Commission staff review, it was found that DOC’s policies and procedures do not
comply with corresponding Commission regulations, in that DOC’s incident categories and
definitions do not align with Commission regulations or the Reportable Incident Guidelines.
Additionally, it was evident that DOC is not reporting certain categories of incidents, nor
transmitting required reports consistently within the time periods required, each as required by
Commission regulations and the Reportable Incident Guidelines.
The above findings were set forth in a Commission report addressed to the DOC on
November 15, 2017. The Commission is awaiting DOC’s response to the report, which was
requested by January 2, 2018.
9 NYCRR Part 7039 – Fire Prevention and Safety
To safeguard the lives and property of all occupants, and to minimize the possibility of fire
emergencies or other similar hazards, Commission regulations require local correctional
facilities to practice proper fire prevention and safety measures, to include the development and
implementation of written policies and procedures, the performance of annual fire and safety
inspections by the appropriate authority having code enforcement jurisdiction, the performance
of weekly fire hazard inspections by facility staff, and the provision of appropriate training to
facility staff.
Upon Commission staff review, EMTC and GMDC do not maintain operable fire alarm
systems, and are thus required by code to perform and document 30-minute fire watches.
Nevertheless, DOC could not provide documentation that such fire watches were being
performed. Commission staff noted fire extinguishers in many that were not inspected in a
timely manner, or replaced when expired, as well as pull stations and emergency exit signs that
were non-functioning. Further, Commission staff noted an absence of posted evacuation plans,
and required weekly fire inspections, conducted by department staff, did not account for the
entire facility. There are multiple penetrations in firewalls throughout all the buildings on Rikers
Island without appropriate fire stop material, a condition which is infrequently noted on fire
hazard inspections. Fire doors were observed propped open with wooden door stops.
Commission staff observed exposed electrical wires and multiple extension cords utilized
throughout Rikers Island facilities, though such violations are not documented on the fire safety
inspection reports.
Required annual inspections by the appropriate code enforcement authority have not been
conducted at Rikers Island facilities within the required time frames. Additionally, the Officer
assigned to the EMTC fire safety position has not received the appropriate training, required by
Commission regulations and the New York State Office of Fire Prevention.
The above deficiencies were observed by Commission staff during recent on-site
evaluations of Rikers Island facilities, occurring over four (4) separate dates in October 2017.
Corresponding findings and required actions will be contained in a forthcoming Commission
24

report to DOC, requesting a response which details the remediation taken to achieve
compliance.
9 NYCRR Part 7040 - Maximum Facility Capacity
To promote a safe, secure and healthy correctional environment, Commission regulations
place a limit on the total number of inmates confined at any given time within each local
correctional facility. To accomplish this, regulations require the Commission to formulate a
written maximum facility capacity that specifies all properly equipped individual occupancy
housing units (cells) and multiple occupancy housing units (double cells, dorms), and
determines the maximum number of inmates that can be housed within the facility.
Upon Commission staff review, it was discovered that, in multiple facilities, the DOC has
housed inmates in areas that have been identified as closed by the Commission’s written
maximum facility capacity report, thus violating the corresponding regulation. Although DOC’s
administration has been notified that an amended maximum facility capacity must be requested
and received from the Commission before opening a closed housing unit for inmate population,
DOC continues to fail in this regard.
The above deficiencies were observed by Commission staff during recent on-site
evaluations of some Rikers Island facilities, occurring in November 2017. On-site evaluations of
additional facilities are scheduled, after which corresponding findings and required actions will
be contained in a forthcoming Commission report to DOC, requesting a response which details
the remediation taken to achieve compliance.

25

COMMISSION-ISSUED DIRECTIVES
Pursuant to Correction Law section 46(4), in any case where a Commission regulation or
law relating to a correctional facility has been violated, the Commission “shall notify the person
in charge or control of the facility of such violation, recommend remedial action, and direct such
person to comply with the rule, regulation or law, as the case may be.” As set forth above,
regulation violations discovered and cited by Commission staff in local facility evaluations are, in
the majority of cases, immediately remedied, with the actions taken set forth in the facility’s
written response to the evaluation.
In the Commission’s experience, only rarely does a situation necessitate the further
notification of the violation and direction of compliance, commonly referred to as a “Directive.”
However, upon subsequent non-compliance by the facility following the issuance of a Directive,
Correction Law section 46(4) allows the Commission to apply to the Supreme Court for an order
directing compliance with the regulation or law. Upon the Supreme Court’s issuance of such an
order, further noncompliance would constitute contempt of court, and be punishable as such.
Over the past two (2) years, the Commission has issued the following Directives to the
DOC following sustained non-compliance with Commission regulations at Rikers Island
facilities:

Robert N. Davoren Complex (RNDC)
In September 2015, the Commission issued a Directive to New York City Department of
Correction at the Robert N. Davoren Complex for the violation of 9 NYCRR sections 7003.3(a),
7003.3(e), 7003.3(f), §7003.8(g) and 7063.5(c). The Directive cited the DOC for the failure to
maintain minimum levels of inmate supervision and the failure to regularly perform mandated
annual chemical agent training for officers. Specifically, in multiple housing units that contain
more than twenty inmates, required security posts routinely lacked the continuous occupation of
a correction officer. Also, inmate housing units lacked functioning mechanical or electrical time
recording devices, necessary to record the completion of required officer supervisory visits of
inmates secured in their individual housing unity while general supervision is performed. Absent
these functioning mechanical or electrical time recording devices, the required records from
these devices were not maintained by the DOC, nor were the records periodically reviewed by
the Chief Administrative Officer. Furthermore, officers routinely ordered, supervised, and
utilized chemical agents without having received the required annual training.
DOC was directed to maintain active supervision of inmates within a multiple occupancy
housing unit by assigning a correction officer to continuously occupy a security post within any
such unit in which more than twenty inmates are housed. DOC was also directed to install,
maintain and utilize functioning mechanical or electrical time recording devices to record the
completion of each required supervisory visit whenever all prisoners are secured in their
individual housing units and general supervision is performed and for the facility’s chief
administrative officer to retain and periodically review the printed records of the time recording
devices to verify that officers are properly completing their supervisory rounds. Lastly, DOC
was directed to ensure that all facility staff with the authority to order the use of chemical agents,
supervise such use, or use chemical agents, receive the required annual training and to ensure
that those who have not been trained in the use of chemical agents or who have not received
the required annual training do not order the use of chemical agents, supervise such use, or use
chemical agents.
26

On October 21, 2015, the DOC responded to the Directive by indicating that they would
assign an additional officer in the two identified housing units to the “C” post. The DOC also
indicated that they planned to restore the previously installed watch tour system to be
operational by the end of December 2015. In its response to the 2016 Directive for AMKC
(detailed below), the DOC indicated that these watch tour systems were in place and
operational. With regard to the issuance of chemical agents, the DOC indicated that the RNDC
had established and implemented new written procedures to enforce and maintain compliance
with the requirements. The DOC also indicated that they were working with the Correction
Academy to schedule training for all RNDC staff whose chemical training had expired.

Anna M. Kross Center (AMKC)
In March 2016, the Commission issued a Directive to New York City Department of
Correction at Anna M. Kross Center for the violation of 9 NYCRR sections 7003.3(a), 7003.3(e),
and 7003.3(f). The Directive cited the DOC for the failure to maintain minimum levels of inmate
supervision. Specifically, in multiple housing units that contain more than twenty inmates,
required security posts routinely lacked the continuous occupation of a correction officer. Also,
inmate housing units lacked functioning mechanical or electrical time recording devices,
necessary to record the completion of required officer supervisory visits of inmates secured in
their individual housing unity while general supervision is performed. Absent these functioning
mechanical or electrical time recording devices, the required records from these devices were
not maintained by the DOC, nor were the records periodically reviewed by the Chief
Administrative Officer. The DOC was directed to maintain active supervision of inmates within a
multiple occupancy housing unit by assigning a correction officer to continuously occupy a
security post within any such unit in which more than twenty inmates are housed. The DOC
was also directed to install, maintain and utilize functioning mechanical or electrical time
recording devices to record the completion of each required supervisory visit whenever all
prisoners are secured in their individual housing units and general supervision is performed and
for the facility’s chief administrative officer to retain and periodically review the printed records of
the time recording devices to verify that officers are properly completing their supervisory
rounds.
On May 26, 2016, the DOC responded to the Directive by indicating that the DOC
planned to install electrical time recording devices in cell housing areas in all of the DOC’s
correctional facilities. The DOC indicated that the watch tour system was already in place at
Robert N. Davoren Center and George M. Motchan Center. The DOC went on to indicate that
the watch tour system would be installed and implemented in George R. Vierno Center and
Anna M. Koss Center by the end of 2016. On September 15, 2016, the DOC responded to the
Directive by indicating that the DOC plans to request funding in the City’s January 2017
Financial Plan to fund a capital project for the installation of Control Stations for the six West
Modular Housing Units at Anna M. Kross Center that would be posted with officers who would
monitor the West Modular Housing Units using cameras and intercoms.

Anna M. Kross Center (AMKC) – Reportable Incidents
In August 2017, the Commission issued a Directive to New York City Department of
Correction at Anna M. Kross Center for the violation of 9 NYCRR §7022.3(a)(1). The Directive
cited the DOC for not making an immediate notification of a reportable incident as required by
27

regulation. Specifically, the DOC failed to properly notify the Commission of the escape of an
inmate until more than five hours after the escape occurred. The DOC was directed to review
and modify, if necessary, all operational documents that do not comport with the timelines for
reporting reportable incident and to ensure that all personnel at the DOC who are assigned or
may be assigned to report a reportable incident to the Commission follow the required reporting
timeframes.
By letter dated September 12, 2017, the DOC responded to the Directive, alleging that it
“has taken and is taking corrective actions and measures to comply with the requirements cited
by the [Commission].” Among the planned action described, the DOC stated that it “is revising”
a Departmental Directive regarding reporting significant facility incidents, and that it “will be
issuing new command level procedures” to delineate lines of responsibility for reporting
incidents. Verification of such action by Commission staff is forthcoming.

Anna M. Kross Center (AMKC) – Construction and Renovation
In September 2017, the Commission issued a Directive to New York City Department of
Correction at Anna M. Kross Center for the violation of 9 NYCRR §7001.1. The Directive cited
the DOC for failing to obtain prior approval by the Commission for construction and renovation
projects. Specifically, the DOC failed to properly seek and obtain prior Commission approval for
the installation of fence/support posts and concertina wire in the walk-way of the main outdoor
exercise yard. The DOC was directed to review and modify, if necessary, all operational
documents that do not comport with the requirement of prior approval for construction and
renovation projects.
On October 24, 2017, the DOC responded to the Directive by indicating that they are
drafting an Operations Order to establish policies and procedures for requesting
construction/renovation projects which will specifically stat that any plans and specifications for
the construction and/or renovation of detention facilities must be submitted to the Commission
for review and that approval from the Commission must be obtained prior to an advertisement
for bids. The DOC also stated that if there is no bidding procedure for a project, then the
Commission’s approval must be obtained before any construction or renovation is undertaken.

28

REPORTED SIGNIFICANT FACILITY INCIDENTS
New York State Correction Law and Commission regulations require that all local
correctional facilities report to the Commission significant and unusual events, such as prisoner
deaths, escapes, facility fires, service disruptions, inmate group actions, etc. In most cases,
these reports must be submitted to the Commission within 24 hours of occurrence. In the case
of an inmate death, the facility must report the death within 6 hours of the pronouncement of
death, and in several other instances (major disturbance, hostage situation, firearm discharge,
etc.) the report is required immediately. Historically, such reporting was accomplished by a
combination of telephone, facsimile, e-mail and other outdated electronic means, which
rendered the data incapable of effective review, tracking and analysis. Collaborating with the
New York State Office of Information and Technology Services (ITS), the Commission took
steps to facilitate all such incident reporting via the eJusticeNY Integrated Justice Portal.
Besides the obvious benefits to the Commission’s data collection and management, correctional
facilities will have the ability to search an individual inmate’s institutional incident history. Such
incident reporting has been operation and mandatory for both the DOC and county jails as of
January 1, 2016.
Listed below are the total number of reported significant facility incidents for Rikers
Island facilities, by incident category, together with the corresponding aggregate totals for all
county jails in New York State. When comparing incident totals between Rikers Island facilities
and county jails, it is important to note that the average daily inmate population for Rikers Island
facilities, since 2016, is approximately 7,249, while the average daily inmate population for
county jails in that same period is 15,462. Thus, the average aggregate daily population of
county jails is more than double that of the facilities on Rikers Island.
Despite this population disparity, the number of incidents reported in each significant
category are, in almost every instance, considerably higher for Rikers Island facilities than for
county jails. Specifically, the number of inmate group/gang assaults and inmate/inmate assaults
are more than double the corresponding totals of county jails, and the number of
inmate/personnel assaults on Rikers Island is ten (10) times more. The number of both
reported major and minor disturbances are more than double the amount reported in county
jails. With regard to reported sex offenses, each category reflects a considerably greater
amount of incidents in Rikers Island facilities than county jails.

COMPARISON OF SIGNIFICANT INCIDENTS REPORTED BY RIKERS ISLAND FACILITIES
AND COUNTY JAILS, BY INCIDENT CATEGORY
**For the period of January 1, 2016 to November 27, 2017, as of 9:30 a.m.
Incident Category
Declared State of Emergency
Abscondence
Arrest of Staff

Rikers Total
0
0
2

County Jails
1
2
3

Attempted Escape

3

19

Capture/Erroneous Release
Capture/Escape
Discharge of Firearm

3
4
1

8
6
4

29

Erroneous Release
Escape/Other Agency Supervision
Evacuation of Facility
Fire/Non-arson
Fire/Arson
Fire/Unknown Source
Group Contagious Illness
Hospital Admission of Inmate

5
1
0
3
9
0
0
129

16
8
1
7
0
1
2
2175

Individual Inmate Disturbance
Inmate Accidental Injury
Inmate Attempted Suicide
Inmate Contagious Illness
Inmate Group Action
Inmate Group/Gang Assault
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Inmate Sexual Offense
Inmate/Personnel Assault
Inmate/Personnel Sexual Offense
Inmate/Visitor Assault
Inmate-Introduced Contraband
Major Disturbance
Major Maintenance/Service Disruption

3989
51
12
4
38
214
20
2370
77
2723
10
5
746
63
5

2120
195
267
15
6
57
249
804
13
263
5
0
1247
20
37

Minor Disturbance

1472

699

0

1

0
7
6
0
509
192
11
5
468
7
2
357
13523

1
19
6
2
3
14
5
288
221
0
0
162
8972

Natural/Civil Emergency
Newborn/Infant Death
Personnel Accidental Injury
Personnel Death
Personnel Group Action
Personnel/Inmate Assault
Personnel/Inmate Sexual Offense
Personnel-Introduced Contraband
Release of Hospitalized Inmate
Unknown Source-Contraband
Visitor Assault
Visitor/Inmate Assault
Visitor-Introduced Contraband
TOTALS

30

Also relevant and revealing is a comparison of the number of significant facility incidents,
reported by Rikers Island facilities, by year from 2016 to 2017. Listed below are the total
number of reported significant facility incidents for Rikers Island facilities in 2016 and 2017, by
incident category, for the period of January 1st to November 25th.
Comparing 2017 to 2016, Rikers Island facilities experienced significant increases in the
number of inmate group/gang assaults and inmate/personnel assaults, while seeing the number
of reported individual inmate disturbances double and reported minor disturbances nearly triple.
Reported sexual offenses, in both the inmate/inmate and personnel/inmate categories, both
experienced significant increases from 2016 to 2017.

COMPARISON OF SIGNIFICANT INCIDENTS REPORTED BY RIKERS ISLAND FACILITIES
FROM 2016 TO 2017, BY INCIDENT CATEGORY
Incident Category
Arrest of Staff
Attempted Escape
Capture/Erroneous Release
Capture/Escape
Discharge of Firearm
Erroneous Release
Escape/Other Agency Supervision
Fire/Arson
Fire/Non-arson
Hospital Admission of Inmate
Individual Inmate Disturbance
Inmate Accidental Injury
Inmate Attempted Suicide
Inmate Contagious Illness
Inmate Group Action
Inmate Group/Gang Assault
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Inmate Sexual Offense
Inmate/Personnel Assault
Inmate/Personnel Sexual Offense
Inmate/Visitor Assault
Inmate-Introduced Contraband
Major Disturbance
Major Maintenance/Service
Disruption
Minor Disturbance
Personnel Accidental Injury
Personnel Death

1/1/16-11/25/16
2
2
0
2
1
0
0
2
1
5
1209
21
3
1
20
55
13
1204
29
1104
7
1
223
31

1/1/17-11/25/17
0
0
3
2
0
5
1
6
2
123
2547
26
9
3
17
143
6
1048
48
1479
3
4
491
31

% Change

3
355
7
4

2
1045
0
2

-33%
194%

31

0%

200%
100%
2300%
110%
23%
200%
200%
-15%
160%
-54%
-13%
66%
34%
-57%
300%
120%
0%

-50%

Personnel/Inmate Assault
Personnel/Inmate Sexual Offense
Personnel-Introduced Contraband
Release of Hospitalized Inmate
Unknown Source-Contraband
Visitor Assault
Visitor/Inmate Assault
Visitor-Introduced Contraband
TOTAL

205
90
5
0
203
5
0
144
4957

32

286
100
3
5
248
2
2
194
7886

40%
11%
-40%
22%
-60%
35%
59%

INMATE MORTALITY INVESTIGATION FINDINGS
The Commission’s Correctional Medical Review Board is statutorily required, pursuant to
Correction Law §47(1)(a), to “[i]nvestigate and review the cause and circumstances surrounding
the death of any inmate of a correctional facility,” and thereafter “submit its report to the
commission and, where appropriate, make recommendations to prevent the recurrence of such
deaths to the commission and the administrator of the appropriate correctional facility.”
Correction Law §43 provides that the Medical Review Board shall consist of consist of six (6)
uncompensated members, appointed by the Governor and confirmed by the New York State
Senate, and chaired by one of the members of the Commission of Correction.
In recent years, the Medical Review Board has investigated numerous Rikers Island
mortality cases wherein the inmate’s death was directly attributable to grossly negligent medical
and mental health treatment, the failure of DOC security staff to provide adequate levels of
inmate supervision and care, and the failure of both entities to follow established policy and
procedure. Examples of such cases are listed below, together with a synopsis of the Medical
Review Board’s findings contained in the Commission-issued report.

AMKC
Indidividual 1
DOD: 2013
COD: MEDICAL – OVERDOSE
MOD: ACCIDENT
ISSUES: MEDICAL CARE
•
•

•
•

A review of the referral to the KEEP (methadone) program for screening of appropriate level
of dependence was not done prior to Individual 1 being placed in the program.
Individual 1 was inappropriately placed in a methadone program without supporting
documentation of previous methadone programs, without any documented symptoms of
withdrawal, and without any MD assessment or chart review. Urine toxicology was negative
for methadone. Inmate denied being on methadone program in the community numerous
times.
Individual 1 was placed on a Librium protocol without any signs of withdrawal. All
assessments for withdrawal scored “0”.
Individual 1 was not seen and evaluated by the MD after completion of dual detox protocol
and beginning methadone. Failure of medical to comply with their own policy and procedure
for Opioid Treatment Program which requires patients to be monitored for signs of oversedation and respiratory depression which Individual 1 was noted by other inmates to have.

Individual 2
DOD: 2013
COD: COMPLICATIONS OF DIABETES
MOD: NATURAL
ISSUES: ADMISSIONS AND MEDICAL CARE
•

Individual 2 reported history of diabetes and was noted to be vomiting with falling and
unsteady gait during his admission processing. Individual 2 was not given proper medical
care.
33

•
•

•
•

Failure by DOC staff to follow Operations Order 22/91 Emergency Health Care Log which
states inmates will be afforded prompt medical attention when required.
Failure by NYC DOC staff to follow DOC Operation Order Processing and Monitoring New
Admission 16/89 (K) that states from time of admission to DOCS to the time housed in
Rikers Island Facility Timeframe for DOC/Medical processing (four hours), to housing
assignment (four hours). Individual 2 was not taken to the medical clinic for almost 12 hours
after his admission.
Failure of RN to perform an assessment when summoned for a sick inmate and failure to
properly document the encounter.
Failure of NYC DOC staff to maintain documentation of emergencies in the log book.

Individual 3
DOD: 2013
COD: DIABETIC KETOACIDOSIS AND SEPSIS
MOD: HOMICIDE
ISSUES: MULTIPLE MEDICAL CARE, SECURITY AND SUPERVISION, AND CIVIL RIGHTS
VIOLATION ISSUES
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Inadequate psychiatric care as a sub-therapeutic antipsychotic was ordered without clinical
indication.
Failure by medical staff to complete ordered lab work in a timely manner.
Medication order for insulin was discontinued without any physician order or review.
Failure to produce Individual 3 to five specialty clinic appointments for his diabetes
management.
Inadequate psychiatric care by failing to recognize changing behavior and acts of self-injury
subsequent to a medication change.
Inadequate medical care by failing to conduct a thorough chart review and missing that
Individual 3 had no current insulin order.
Failure of medical staff to enter proper medical data.
Failure to have Individual 3 produced for glucose readings 48 times in a 28-day period
between 8/7/13 and 9/5/13.
Inadequate medical care by a physician reviewing Individual 3’s chart who missed his
current medication regimen, and marking “no” for serious persistent mentally ill despite
Individual 3’s extensive psychiatric history.
Failure of DOC officers to document reasons why Individual 3 was keeplocked in his cell.
Additionally, no disciplinary or administrative segregation documentation was filed in
justification of the keeplock placement.
Failure of DOC officers to assure that meals were provided to Individual 3.
Inadequate medical care as Individual 3 was denied access to medication while keeplocked
in his cell from 9/4/13 to 9/10/13.
Failure of DOC officers to provide Individual 3 access to a shower.
Failure of DOC officers to provide Individual 3 access to exercise outside his cell.
Inadequate mental health care in violation of Correctional Health Services Policy that
requires a mental health clinician to see any patient daily in a mental health observation unit
7 days a week.
Failure to provide adequate medical care in violation of Correction Law sections 137(6) and
500-k that require medical staff to examine confined inmates every 24 hours.
Multiple failures by DOC officers to maintain a constant supervision post on another inmate
in the housing unit in violation of 9 NYCRR §7003.2(d).
34

•
•
•
•
•

DOC officers shutting off water to Individual 3’s cell denying him access to water for over 4
½ days without any documented order or return of water for drinking or sanitation purposes.
Violations by DOC officers to provide other keep locked inmates in the same housing area
access to showers and exercise in excess of 72 hours.
Deliberate falsification of official records by DOC officers and supervisors who made log
book entries of completing supervisory tours when recorded video footage shows no actual
visits were conducted.
Multiple failures of DOC supervisors to document and intervene with the grossly obvious
unsanitary conditions inside Individual 3’s cell.
Failure of DOC officer to notify the medical clinic that Individual 3 was critically ill. Individual
3 was found unresponsive in his cell, naked, and covered in feces.

Individual 4
DOD: 2013
COD: PERFORATED ULCER
MOD: NATURAL
ISSUES: MEDICAL CARE
•

Medical staff failed to properly diagnose and treat Individual 4’s perforated ulcer and fatally
misdiagnosed him with gastroenteritis.

Individual 5
DOD: 2013
COD: SUICIDE
MOD: SUICIDE
ISSUES: SECURITY ISSUES, FAILURE TO FOLLOW POLICY, MEDICAL AND MENTAL
HEALTH CARE
•
•

•
•
•
•
•

•

Individual 5 was documented on the DOC Arraignment and Classification Risk Form as
showing signs of mental illness however this was contraindicated on the completion of the
form by the Supervisor.
DOC staff failed to follow proper policy and procedure for suicide screening. The Suicide
Prevention Screen (Form 330 ADM) was scored as a “4” with the first five questions left
blank. Individual 5 did answer yes to wanting to hurt himself. The proper procedure was not
followed with that response. Constant supervision was not initiated per DOC Directive
Suicide Prevention #4521.
DOC does not provide any refresher training for suicide prevention
A use of force occurred following Individual 5’s self-harm attempt and there was insufficient
documentation on the Injury to Individual 5 report under DOC Directive 4516. DOC staff
failed to indicate that Individual 5 made an attempt to hurt himself.
DOC staff failed to provide mental health housing when ordered.
DOC staff failed to submit a mental health referral for an inmate in distress following a
PROBE team response for violent conduct.
DOC staff failed to document another attempt at self-harm, failed to generate a mental
health referral, and failed to report or document incident which is violation of DOC Directive
4521 Suicide Prevention and DOC Directive 4018 Referral of Inmates to Mental Health
Services.
DOC staff violated Operation Order 16/89, Processing and Monitoring New Admission which
allows a maximum 16-hour time frame, where Individual 5 was kept for approximately 19
hours in a holding pen.
35

•

Failure of DOC staff to complete maintenance work on the shower frame in AMKC Intake
Pen #8

Individual 6
DOD: 2014
COD: ACCIDENT – EXTREME HYPERTHERMIA
MOD: ACCIDENT
ISSUES: MECHANICAL FAILURE OF HEAT REGULATION IN CELL, LEAD TO TERMINAL
LIVING CONDITION, FAILURE OF DOC STAFF TO PROPERLY SUPERVISE
•
•
•
•
•

•

Individual 6 had a long history of mental health issues and was placed in mental health
observation housing in AMKC.
Due to a failure of a regulator on the heat system, the temperature inside Individual 6’s cell
remained in excess of 100 degrees, a temperature incapable to maintain stable health with
prolonged exposure.
The DOC officer assigned to supervise the housing area failed to conduct required
supervisory visits in violation of 9 NYCRR §7003.3(c).
The DOC officer assigned to supervise the housing area falsely documented the log book
that rounds were complete. The officer was terminated and criminally charged.
Individual 6 suffered a terminal seizure due to prolonged exposure to the excessive heat.
When Individual 6 was found he was in rigor mortis indicating death in excess of over two
hours. This indicates that supervisory rounds were not completed in comportment with 9
NYCRR §7003.2.
DOC staff failed to recognize and address a serious environmental condition that
affected the safety and health of the inmates. The area supervisors during tours failed to
recognize and take appropriate action of the excessive temperatures on the unit.

Individual 7
DOD: 2015
COD: CHRONIC SUBSTANCE ABUSE
MOD: NATURAL
ISSUES: FAILURE TO IDENTIFY FOR DRUG WITHDRAWAL, INADEQUATE FIRST AID AND
EMERGENCY RESPONSE
•
•
•
•

DOC staff failed to identify and institute precautionary measures for a new admission inmate
at high risk for experiencing drug withdrawal.
DOC staff failed to provide adequate first aid and cardiopulmonary resuscitation at the
terminal event.
DOC staff failed to provide proper security by allowing inmates to remain in the area of a lifethreatening emergency.
Several of the responding officers, including supervisors, were out of compliance with DOC
policy and SCOC regulations for First Aid/CPR/AED certification at the time of the incident.

GRVC
Individual 8
DOD: 2012
COD: INGESTION OF CAUSTIC CHEMICAL
36

MOD: HOMICIDE (NEGLECT OF MEDICAL CARE)
ISSUES: SANITATION (SEWAGE BACK UP), DELIBERATE REFUSAL OF DOC STAFF TO
OBTAIN MEDICAL ASSISTANCE, FAILURE TO PROPERLY SUPERVISE
•

•
•
•

A sewage backup occurred in the housing area due to a plumbing failure. Inmates were
issued “soap balls” to clean their individual cells. A “soap ball” was a packet of highly
concentrated detergent intended to be diluted in a mop bucket for cleaning. Individual 8
swallowed one in an attempt to have his housing assignment changed.
Individual 8 began having severe esophageal corrosion and burning due to the caustic
chemicals in the soap packet. Individual 8’s requests for medical help were deliberately
ignored by the officer and captain assigned to supervise the area.
The officer was terminated and the captain was convicted of violating Individual 8’s civil
rights and sentenced to five years in federal prison.
Individual 8 was found in full rigor mortis the following morning by medical staff on rounds.

NIC
Individual 9
DOD: 2012
COD: HOMICIDE – USE OF FORCE BY OFFICERS
MOD: HOMICIDE
ISSUES: USE OF FORCE. FALSIFIED DOCUMENTATION BY DOC OFFICERS
•
•
•

•

Individual 9 had multiple medical issues including chronic kidney failure and required
dialysis.
Individual 9 had been hospitalized 11 times during his incarceration.
Individual 9 reportedly got into a confrontation with officers in his housing area. Officers
reported that Individual 9 attempted to strike them with his cane, and force was used by
officers to control him. Physical findings at Individual 9’s autopsy contradicted the officers’
reports and showed that he had multiple injuries not consistent with the reported use of
force.
Investigation by the US Attorney’s office found that officers violated Individual 9’s civil rights
by assaulting him while he was restrained. Officers were found guilty of falsely documenting
the incident.

OBCC
Individual 10
DOD: 2013
COD: PERITONITIS DUE TO NECROSIS OF THE STOMACH FROM POSSIBLE INGESTION
OF CAUSTIC SUBSTANCE
MOD: NATURAL
ISSUES: FAILURE TO PRODUCE TO MEDICAL AND FOLLOW POLICY
•

Failure of DOC and medical to have Individual 10 produced to medical appointments.
Individual 10 missed eight medical encounters to evaluate his asthma. These were
documented as “no show” and a pattern of missed appointments for the medical contractor
37

•
•
•
•

was noted as a finding which led to poor medical care in past cases.
DOC failed to follow Operation Order Daily Sick Call in that Individual 10 requested to see
medical and witnesses attested that it was not afforded to him.
DOC failed to provide proper access to medical as Individual 10 was informed there was no
sick call due to a holiday. The Operation Order Daily Sick Call states sick call is offered
daily.
DOC failed to maintain proper documentation as sick call forms completed by inmates were
not accessible to Commission staff.
DOC failed to document refusal of attendance to meals or refusal of meals

Individual 11
DOD: 2013
COD: SUICIDE – HANGING
MOD: SUICIDE
ISSUES: SECURITY AND SUPERVISION, POLICY AND PROCEDURE, MENTAL HEALTH
CARE
•
•
•
•
•
•
•
•
•
•

DOC officers failed to follow Directive, Inmate Observation Aide, as the Suicide Prevention
Aide did not make rounds per the directive and the officers did not enforce the directive with
the assigned aides.
DOC failed to provide proper supervision as rounds were not completed for three
consecutive 30 minute intervals.
An inadequate emergency response by DOC staff in that the cell was not entered for three
minutes because the senior officer felt Individual 11 may have been “playing possum.”
An inadequate emergency response by DOC staff in that CPR was not initiated by
discovering officers for eight minutes.
Inadequate security inspection by DOC staff as emergency equipment on the punitive
segregation unit was missing.
Inadequate response by DOC staff related to Individual 11 making suicidal statement.
Failure by DOC staff to have Individual 11 produced for mental health encounters nine
times, with a lack of follow up by mental health care providers.
Inadequate mental health care as Individual 11 refused three times to attend mental health
encounters, and mental health clinicians failed to follow up.
Inadequate mental health care as there was an inadequate assessment of Individual 11
prior to his placement into punitive segregation
Inadequate mental health care as there was a lack of collaboration and adequate
assessment by a mental health physician’s assistant and her collaborating physician.

Individual 12
DOD: 2014
COD: SEIZURE
MOD: NATURAL
ISSUES: MEDICAL CARE AND SUPERVISION
•
•
•
•

DOC staff failed to provide proper supervision in accordance with 9 NYCRR §7003.2(a).
DOC failed to provide proper supervision in accordance with 9 NYCRR §7003.2(b).
Inadequate medical care as Individual 12 was not delivered his anti-seizure medication on a
regular basis while housed in punitive segregation.
Individual 12’s prescriptions were not properly transferred between facilities when moved
into punitive segregation.
38

•
•

Proper lab monitoring of Individual 12’s anti-seizure medication was not performed.
DOC staff failed to comply with Operations Order 22/91, Emergency Health Care Log, by
failing to refer Individual 12 to medical despite him making numerous requests.

RNDC
Individual 13
DOD: 2015
COD: SUICIDE HANGING
MOD: SUICIDE
ISSUES: SUPERVISION AND MENTAL HEALTH CARE
•
•
•
•
•
•

Inadequate mental health care as there was no follow up by the psychiatric nurse
practitioner when made aware of Individual 13 refusing transfer to C-71.
Failure of medical provider to recognize a pattern of self-injurious behavior as risk factor of
suicidal intent.
Failure to provide a psychiatric evaluation following referral by medical provider. Inmate was
evaluated by non-physician level clinician.
Failure of DOC staff to immediately place Individual 13 on a suicide watch as ordered,
resulting in Individual 13 being transferred back to general population and placed in his cell
with no precautions.
Failure by DOC staff to complete a Suicide Risk Screen on a new admission.
Failure of DOC staff to secure the area of a medical emergency, resulting in inmates having
access to an unconscious inmate without supervision.

39

SANITATION AND PHYSICAL PLANT CONDITIONS
For a three (3) day period of March 18, 2017 to March 20, 2017, six (6) Commission staff
performed comprehensive tours of each DOC correctional facility on Rikers Island, for the sole
purpose of noting and assessing facility sanitation and physical plant conditions. Besides
making notes of observed deficiencies, Commission staff took over 1,300 pictures documenting
the same. Commission staff were, at all times, accompanied by staff of DOC’s Office of Policy
and Compliance. Set forth below are synopses of conditions observed by Commission staff
during said tours, by facility:
AMKC
•
•
•
•
•
•
•
•
•
•

Facility not consistently issuing toilet paper, undergarments and pillows. Inmates take toilet
paper from a roll hanging in the sub-control room.
Intake area toilet and sink did not flush or work.
Housing units have sheets covering the cell door windows or such windows are covered
with magazine pictures.
Clotheslines allowed to be hung across the cell to which creates poor sightlines into the cell.
Officer leaving unsecured keys laying around in unsecured control room.
Fire doors, exterior doors rotted on bottom.
Facility providing laundry services only once a week (per inmates and facility staff), not the
required twice, and have inmates wash their own laundry in provided white wash buckets.
Facility is not consistently issuing pillows, nor is there a schedule to launder blankets (staff
and inmates advise that blankets can go months without being washed).
Inmate cell areas, common areas, shower areas, and bathroom areas are unsanitary.
Peeling paint, rust, water damage, and deteriorating walls, floors and ceilings throughout the
facility due to water leaks and water damage. Toilets and sinks leaking.

EMTC
•
•
•
•
•
•
•

•
•
•
•

Abandoned post - facility staff conducting cross tour supervision (unit 10 Lower was without
an Officer from 3:31PM until 4:20PM on 3/18/17).
Cracked dorm windows: EMTC 5 Upper.
Broken Dorm window repaired with a piece of Plexiglas cover: EMTC 5 Upper.
Lights out/not working causing poorly lit areas.
Intake Officer maintains keys that opens exterior door. 6 Lower (Unit Paws for Purpose)
housing officers maintain exterior fire door keys to let the dogs out to go to the bathroom.
12 Upper - no hot water. Last work order placed 12/3/16.
Inmate cell areas, common areas, shower areas, and bathroom areas are unsanitary.
Additionally, there is peeling paint, rust, water damage, and deteriorating walls, floors and
ceilings due to water leaks and water damage. Toilets and sinks leaking.
EMTC 5 Upper has plastic bags over windows to stop drafts from entering through the
windows.
12 Lower janitor’s closet appears to have mold on the ceiling.
Exit door lights out.
Multiple fire extinguishers are tagged as being expired; one with questionable charge level.

40

•
•

EMTC 10 Main shows fire alarm system reading a fire alert, but no acknowledgement.
Advised the fire alarm system is down so staff consider it a false alarm and ignore.
Facility fire safety system is reported to be only 75% complete.

•

Damaged and bent beds.

GMDC
•
•
•
•
•
•
•
•
•
•
•
•

•
•
•
•
•
•
•

Facility’s main control room closed for (non-approved) renovation. Area sealed and notices
of asbestos abatement posted on door.
Multiple housing areas were closed for construction and or renovation (GMDC 8 Main A; & 8
Main B).
GMDC 6 Main B, has hole cut out/missing blocks running up/down cell exterior wall.
6 Main B, heating radiator torn out of cell.
GMDC Dorm 6 has plywood over the floor for support.
GMDC 6 Upper B operates on the BAR, no key tumblers and electric locks do not
consistently work.
GMDC 6 Main B, has hole cut out/missing blocks running up/down cell exterior wall.
GMDC 2 Upper, Plexiglas replaced window is broken open, pen stuck through to show nonsecure window.
GMDC Main Corridor Hallway Lights have no security cover over the light bulbs.
2 Upper B Side, no hot water; last work order was 2/17/17.
9 Main A, water leak down the wall.
Inmate cell areas, common areas, shower areas, and bathroom areas are unsanitary.
Additionally, there is peeling paint, rust, water damage, and deteriorating walls, floors and
ceilings due to water leaks and water damage. Toilets and sinks leaking.
Rodent Infestation.
Insect infestation.
GMDC 2 Upper - water in plumbing chase.
GMDC Mod 4, weak floor, floor sinks when you step on it.
GMDC Dorm 6 - pails catching water dripping from the ceiling.
Exit door lights out.
GMDC 6 Main B, Fire Exit Door and stairway has water leaks, water damage, rusted and
corroded fire hatch that goes to the roof, falling pieces of ceiling.

GRVC
•
•
•
•
•

Looking glass window on cell doors in 2B Isolation provide poor visibility into an inmate’s cell
due to such windows being scratched.
Other units have sheets covering the cell door windows or such windows are covered with
magazine pictures.
Control room doors left ajar.
Officers allow clotheslines to be hung across the cell to which creates poor sightlines into
the cell.
Broken window in GRVC Segregation Intake.

41

•

•
•

•
•
•

Off-going staff leave post before properly relieved due to relief staff being used for searches.
Unit Bldg. 15 A last entry was at 7:30am, relieving staff did not get on unit until
approximately 9:30am.
Housing area 2B Isolation has drains that backup and cause sewage to overflow out of the
drains and onto the housing area floors (per Officer working the housing area).
Inmate cell areas, common areas, shower areas, and bathroom areas are unsanitary.
Additionally, there is peeling paint, rust, water damage, and deteriorating walls, floors and
ceilings due to water leaks and water damage. Toilets and sinks leaking.
Insect and rodent infestation is evident. Pictures taken of bugs and mice in the facility
housing areas and plumbing chaises.
GRVC Bldg. 15 control room has water leak that falls from ceiling and down onto
electronics.
GRVC 7B has exposed uncapped wires in plumbing chase.

NIC
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

NIC main building was completely closed. Unable to get someone to escort SCOC staff
through the building as no one on duty knew the keys to the areas.
Annex is open, but many areas cannot be accessed without going to the main facility to
obtain keys.
Water leaks evident throughout facility.
Numerous floor patches throughout facility.
Inmate property is scattered throughout the facility.
Security camera covered with paper.
Medical room not secured, allowing inmate access to medical equipment.
Metal floor covering not secured in place.
Vents are dirty.
Showers in need of repair and replacement.
Wheelchair-bound inmates in infirmary have no access to shower chairs.
Garbage bags stacked on loading dock. It was explained that the compactor is broken.
Residential-type “bug zapper” hung in the intake area due to insect infestation.
Exposed electrical wires.
Exposed hot water tank wires.
Several housing unit egress doors blocked.

OBCC
•
•
•
•
•
•
•
•

Many security windows repaired with non-secure plexiglass.
Evidence of water leakage throughout facility.
Inmate property is scattered throughout the facility.
Inmates allowed to cover their cell windows.
Ceilings throughout the facility have fallen.
Exterior doors are rusted.
CERT room not secured and accessible to inmates in Admission area.
Vents are dirty.
42

•
•
•
•
•
•
•
•
•
•
•
•
•

Showers are in need of repair and replacement.
Inmate water fountains are rusted.
Exposed electrical wires.
Cells are used for storage.
Showers peeling paint and dirty.
Major water leak on right side elevator.
elevator broken and not operational.
Shower drain not draining, flooding the shower area.
Shower not operational.
Captains office was barricaded with plywood and officer had no access.
A/C Units were in the wall and drained into hallways.
Main structure hallways have multiple leaks from the roof into the corridors. Ceiling tiles
falling down in many areas.
Many of the exterior doors are rusted to the point of unsafe.

RMSC
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Many security windows repaired with non-secure plexiglass.
Non-security grade lighting.
Evidence of water leaks throughout the facility.
Inmate property scattered throughout the facility.
Lock and doors have key numbers on them.
Porcelain toilets and sinks.
Many showers and toilets are in poor condition and not cleaned.
Clogged and non-operational toilets and showers.
Vents are not cleaned.
Rusted ceilings throughout the facility.
Traps are not replaced in a timely manner.
Water closets are extremely dirty and have exposed wires in them.
Infestation of fruit flies in several areas.
Several water leaks into electrical fixtures.
Exposed electrical wires.
Access to non-secured electrical panels.
Supplies stacked to the ceilings.
Flammable items stacked above and adjacent to dryer vents.
Closed cells are used for storage.

RNDC
•
•
•
•
•

Commission staff notified by Key Control Officer that many locks cannot be replaced as the
doors are filled with asbestos
Security windows repaired with non-secure plexiglass.
Non-security grade lighting.
Basement had a wide hole through the concreate floor, approximately 15–20 feet deep.
Numerous water leaks in basement.
43

•
•
•
•
•
•
•
•
•
•
•
•
•
•

Staff dining area has significant roof leak.
Lock and doors have key numbers on them.
Inmates can open newly installed slider doors on the housing units.
Porcelain toilets and sinks.
Many bunks are bent and need to be replaced.
Many showers and toilets are in poor condition and not cleaned.
Roof leaks throughout the building.
Vents are not cleaned.
Rusted ceilings throughout the facility.
Water leaks into electrical fixtures.
Exposed electrical wires in basement area.
Access to unsecured electrical panels.
Supplies stacked to the ceilings.
Flammable items stacked above and by dryer vents.

WEST
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Security windows repaired with non-secure plexiglass.
Construction project in kitchen area not secured from inmates.
Non-security grade lighting.
Inmate property is scattered throughout the facility.
Doors to main facility broken and not operational.
Water leaks in tent structure.
Substructure of floor rotted through.
Inmates hang sheets over their housing area, preventing officer supervision.
Exposed electrical wires.
Supplies stacked to the ceilings.
Closed cells are used for storage.
Snow is not removed from external doors, preventing emergency egress.
Floor tiles missing.
Leaks from roof rotted the floor in an unsecured pen.
Toilets in pens extremely filthy.
All exterior doors were not secured or locked. Inmates were able to let themselves out if
they desired.
All exterior doors were blocked by snow covering.
Front door not secured. Work order submitted on 3/15/2017.

44

GREENE COUNTY JAIL
The Greene County Jail, originally constructed in the early 1900s, has outlived its
usefulness and requires replacement. Disagreement between local officials had long delayed
the process of constructing a new jail, to which point the county is exploring the possibility of
housing its inmates at the Columbia County Jail as part of a “shared services” agreement.
Although recognizing that facility replacement is important, the Commission’s paramount
concern remains with the management and operation of the current facility which, in recent
years, has deteriorated to the detriment of inmate and staff safety. Absent demonstrated and
immediate improvement of present jail operations, it is foreseeable that the Commission will be
forced to institute further enforcement action, to possibly include closure.

FACILITY OVERVIEW
Description:

Opened in 1905, Greene County Jail houses male and female detainees
in 10 housing areas. The jail stands on less than one acre.
Cells:
46 cells (30 of which are authorized for occupancy)
Dorms:
10 beds
Authorized capacity:40
12/30/17 population: 21 inmates in-house and 11 inmates boarded out

PHYSICAL PLANT CONDITIONS
2010
SCOC evaluated the extent of the jail’s physical plant continued deterioration, noting that
the first floor is partially supported by horizontal steel beams and adjustable lally columns; that
other sections of the basement ceiling have deteriorated to the extent that steel reinforcement
bars are exposed; and that interior and exit doors require adjustment or replacement due to the
shifting and continued settling of the building.
As a result, the Commission ordered the closure of a six-bed cell block on the first floor
directly above the basement lally columns. The Commission also directed Greene County to
arrange for a study to be performed by a qualified engineering/architectural firm to assess the
structural integrity of the jail along with compliance with the Uniform Fire Prevention and
Building Code.
Greene County subsequently contracted with an engineering firm to assess the
structural integrity of the jail. The resulting report from the engineering firm set forth findings
that the basement ceiling spalling of concrete near the lally columns’ steel plate was evidence of
water seeping into this area of the basement; that basement wall cracking observed was
attributed to masonry expansion and contraction in the absence of an expansion joint; that leaks
in the first floor housing shower area are the likely source of water observed leaking in the
basement; and that Greene County maintenance staff had replaced interior and exterior doors
that were functioning properly. Consequently, the engineering firm found no observable
structural issues that precluded the use of the six cell block, provided that the county extend the
steel plate, beam and columns from the existing area it covers to the exterior wall that is
common to the shower above, installs and secures an additional two lally columns to support
the beam and plate; installs a non-porous/nonslip liner in the bottom of the shower that extends
45

over the existing wall liner; and removes all loose spalling concrete from the basement ceiling
until sound material is observed, remove scale from the exposed reinforcing steel, repair the
concrete with Vertipatch concrete repair mix, and apply an appropriate sealant.
2013
During a site visit, SCOC staff noted a paraplegic inmate housed in the facility, though
his wheelchair did not fit into his cell, nor into the shower in his assigned housing area. By
February 21, 2013 correspondence, SCOC prohibited the facility from housing any inmates who
rely on wheelchairs, crutches, canes, walkers and/or prosthetic limbs for daily use.
2016
During evaluation visits in March and April of 2016, SCOC staff noted that the windows
in three (3) second floor cells were either inoperable, stuck in the open position, or had broken
glass, exposing inmates to the elements. Nevertheless, the facility continued to house inmates
in these cells. The facility was also found to have regularly abandoned required housing posts,
reassigning such staff to inmate transports. As a result, the Commission ordered the closure of
the D-Block 2nd Floor Right housing area (8 beds) and the D-Block 2nd Floor Left housing area
(8 beds), for a total of 16 beds.

FACILITY STAFFING DEFICIENCIES
Historically, Greene County has struggled to hire and retain correction officers to work in
the Greene County Jail. Officers who are hired for the jail often leave to work for the New York
State Department of Corrections and Community Supervision (DOCCS) at either the Coxsackie
or Greene Correctional Facilities for significantly higher wages and benefits. Such departures
often occur after the county has paid for staff to attend basic corrections training (4 to 6 weeks)
and on-the-job training at the jail.
Shortages in total staffing levels have resulted in the reduction of allowable inmate
capacity, cited regulation violations, and a resulting Directive. As discussed with Greene
County officials, construction of a new county jail facility may attract more Correction Officer
candidates, a result experienced by other New York counties in similar situations.

VARIANCES AND FACILITY CONSTRUCTION
The Greene County Jail does not maintain an outdoor exercise area of sufficient size to
comply with compulsory regulation. To provide Green County the opportunity to develop a longterm plan (i.e., construct a new facility) that would satisfy this requirement, the Commission has
approved a temporary variance that permits the facility to operate with the undersized outdoor
exercise area. Conditions set forth as part of this variance includes the development of a longterm plan to address this issue.
Subsequent to the granting of this variance, Greene County contracted with the SMRT
architectural firm to design a new jail that will meet the county’s long-term capacity needs.
Throughout this process, Commission staff have met with jail and county officials, as well as
SMRT representatives to provide technical assistance in the design of a new jail. Nevertheless,
the Greene County Legislature recently voted to continue on parallel paths to address
overcrowding. The first permits the design phase of a new jail to continue, while the second
focuses on a possible shared-services agreement with Columbia County that would permit the
46

housing of Greene County inmates at the Columbia County Jail. The Commission continues to
provide both counties with technical assistance as such an arrangement continues to be
explored.

2016 FACILITY EVALUATION
In March and April 2016, SCOC staff completed comprehensive evaluations of the
Greene County Jail. A report of findings and required actions was forwarded to Sheriff Seeley
on May 27, 2016. Such findings included:
Policies and Procedures
• Several operational policies and procedures were found to be outdated, with the most recent
revisions dating back to 2006, completed by the previous administration.
• Many policies and procedures do not reflect actual jail operations.
Part 7003 - Security and Supervision
• Written Policy:
a. Last updated in 2006
b. Does not reflect all security-related facility operations.
c. Missing required Minimum Standard elements
• Policy: the facility implemented a blanket policy in which all inmates deemed to be a risk of
self-harm were required to wear suicide smocks. Such inmates must be placed on constant
supervision – in such instances, there is no need to deprive inmates of clothing required by
regulation.
• Documentation: Facility staff failed to document that the exterior windows of three cells
were broken
• Firearms Control: Facility could not demonstrate that firearms were inspected as required.
• Lock Inspections: numerous inspections completed by facility staff did not identify the
broken exterior windows in three cells.
Correction Law sections 137(6) and 500-k
The facility was found to have been locking inmates in their cells for a preponderance of the day
as a matter of routine practice. Such inmates did not pose a threat to the safety and security of
the facility, staff, or other inmates, and the facility could not justify such lock-ins. The facility has
taken corrective action to address this violation.
Part 7006 - Discipline
• Written Policy:
a. Policy and procedures did not reflect operational practice.
b. Improperly permitted staff to lock inmates in their cells for extended periods of time.
c. Improperly permitted staff to impose loss of inmate privileges.
d. Sanctions differed from those outlined in the inmate rulebook
The facility has revised the Discipline policy but it has yet to be implemented.
Part 7008 - Visitation
• Written Policy:
47

a.
b.
•
•

Last revised in 2011
Did not address all required Minimum Standard elements

Initial Visit: Facility practice improperly counted inmates’ initial visit towards the required
two hours of visits weekly. The facility has taken corrective action to address this violation.
Limitation of Visits: Facility improperly implemented a practice whereby visitors were
refused entry if they did not meet certain dress code guidelines.

Part 7009 - Food Service
• Written Policy:
a. Policy and procedures were last revised in 2005
b. Did not reflect current operational practice
• Nutritional Adequacy: Facility menus were not approved by a nutritionist or dietician
certified by the State Education Department. The facility has taken corrective action to
address this violation.
• Policy: On occasion, facility mental health staff were improperly ordering a finger-food diet
for inmates placed on constant supervision.
Part 7016 - Commissary
• Purchases: Facility improperly used commissary profits to pay for services rendered to
inmates.
Part 7030 - Non-Discriminatory Treatment
• Policy: Facility did not have a written policy as required
• Practice: Female inmates were not subject to extended cell lock-in time as were male
inmates. The facility has taken corrective action to address this violation.
Part 7032 - Grievance Program
• Written Policy:
a. Policy and procedures were last revised in 2009, and not annually as required.
b. Policy did not address several elements required by Minimum Standards.
• Practice:
a. Facility lacked a truly functioning inmate grievance program.
b. Grievances were not processed by the facility as required,
c. Staff assigned to the grievance program were not permitted sufficient time to process
grievances filed by inmates.
Correction Law §500-c (Physical Plant)
• Control Room: serves numerous functions in light of the insufficient space provided by the
physical plant. Shift supervisors work out of the control room.
• Programs: the program areas are insufficient
• Inmate Property: due to lack of sufficient space, inmate property is stored in the basement.
• Inmate Holding: the facility lacks an appropriate area to hold inmates pending transport or
completion of the admissions process. Inmates are placed on a bench, handcuffed to a bullring.
48

•
•

Law Library: is located within the indoor exercise area
Professional Visitors: there is insufficient space for professional visitors

Outdoor Exercise: the facility’s outdoor exercise area is not of sufficient size to meet the
requirements of Part 7028, Exercise. The Commission currently permits this arrangement
through a variance.
Part 7041 - Staffing
• Staffing Levels Total: The facility does not maintain a sufficient number of security staff to
meet the requirements of the Commission’s Position and Staffing Analysis for the Greene
County Jail.
• Daily Posts:
a. The facility was found to have been abandoning staff posts required by the
Commission’s Position and Staffing Analysis.
b. Staff were being reassigned from required posts to conduct inmate transports. The
facility has taken corrective action to address this violation.

2017 FACILITY EVALUATION
In December 2017, SCOC staff completed a comprehensive evaluation of the Greene County
Jail. While the evaluation report has not yet been issued, notable findings include:
Part 7002 – Admissions
• Rulebook: the inmate rulebook is not current
Part 7005 – Prisoner Personal Hygiene
• Clothing: Facility not consistently issuing socks, underwear, and t-shirts
• Soap/Toothpaste: facility is not replenishing soap or toothpaste unless the inmate is
indigent.
• Laundry/Repair of Clothing: schedule only allows for laundering of clothing only once per
week, not twice as required.
• Bedding: inmates are not consistently issued pillows
Part 7013 – Classification
• Policies/Procedures: the facility administration has neither review nor revised the
classification policy and procedures annually as required.
• Objective System: the facility does not utilize a formal and objective system for inmate
classification
• Categories: facility is commingling minimum, medium, and maximum security inmates in
the same housing areas
• Medical Screening: the facility does not screen new admissions for medical conditions
requiring immediate treatment
• Housing Assignment: after initial screening and risk assessment, inmates are consistently
placed in a housing area designated for classification purposes
• Training: staff have not completed required classification training

49

Part 7016 – Commissary
• Purchases: the facility has used commissary profits to make improper purchases (i.e., items
or services that the facility is required to provide by Minimum Standard regulations).

Part 7022 – Reportable Incidents
• Policies/Procedures: facility has no policy that reflects current practice or regulations.
• Reporting: the facility has failed to report all incidents that meet SCOC criteria
• Guidelines: the facility does not make available to all staff the reportable incident guidelines
information established by the Commission
Part 7028 – Exercise
• Periods: see Variance and Construction section above.
Part 7039 – Fire Prevention and Safety
• Policies/Procedures: the facility does not have current written policies and procedures that
address the elements of this Part
• Weekly Inspection: the facility does not consistently conduct weekly fire safety inspections
• Annual Inspection: The CAO has not made arrangements for an annual fire safety
inspection as required

COMMISSION-ISSUED DIRECTIVES AND ENFORCEMENT
The Commission’s May 27, 2016 evaluation report required a response from Sheriff
Seeley by June 27, 2016. Sheriff Seeley failed to respond to the evaluation. As a result, the
Commission forwarded to Sheriff Seeley two reminders (7/21/16 and 9/28/16) that such
response was due immediately. Sheriff Seeley failed to respond to either reminder or the
original evaluation report.
On November 15, 2016, the Commission issued a Directive to the Greene County Jail
for operating without required policies and procedures, or with required policies and procedures
that do not reflect actual facility operations, for continuing to confine male inmates in their cells
for a preponderance of each day without need, for continuing to operate an inmate food service
program with menus that have not been reviewed and approved by a nutritionist or dietician
certified by the State Education Department, for continuing to implement discriminatory
treatment against male inmates who are subject to cell confinement and lack a functioning
inmate grievance program. The Greene County Jail was directed to update all of the facility’s
written policies, particularly with regard to security and supervision, inmate discipline, good
behavior allowances, visitation, inmate classification, nondiscriminatory treatment and inmate
grievances; to discontinue the practice of confining inmates to their cells for a preponderance of
each day, without the need for order or discipline and absent any specific determination or order
of the facility’s chief administrative officer; to obtain review and approval of all inmate food
program menus by a nutritionist or dietician certified by the State Education Department; to
discontinue the discriminatory treatment of male inmates who are subject to routine cell
confinement; to establish, implement and maintain a formal inmate grievance program that
comports with all of the regulatory requirements set forth in Part 7032; to provide any inmate
incarcerated in Greene County Jail access to the facility’s grievance program; to make formal
50

grievance forms readily accessible so that an inmate may file a grievance; to ensure that, within
five business days of receipt of a grievance, the grievance coordinator shall issue a written
determination, a copy of such is to be provided to the inmate; to ensure that, within five
business days of receipt of a grievance appeal, the chief administrative officer shall issue an
written determination, a copy of such is to be provided to the inmate; to ensure that, within three
business days after receipt of the grievant’s notice of appeal, the grievance coordinator shall
submit the appeal, the accompanying investigation report and all other pertinent documents to
the Commission’s Citizens’ Policy and Complaint Review Council; to ensure that if a grievant is
released or transferred from the facility prior to the resolution of a grievance, the chief
administrative officer shall cause a determination to be made on such a grievance; to ensure
that if the chief administrative officer denies such grievance, he/she shall submit the grievance
to the Citizen’s Policy and Complaint Review Council; to ensure that for any grievance that was
initially submitted electronically to the Citizen’s Policy and Complaint Review Council and the
Council has issued its determination to the chief administrative officer and the grievance
coordinator in a similar manner, the grievance coordinator has printed and provided a copy of
the written determination to the grievant, if he/she is still incarcerated in the facility, within one
business day; to maintain a centralized record of each grievance that is filed; and to provide
facility staff an orientation with regard to the facility’s grievance program, which is to include any
newly implemented grievance policy.
On December 13, 2016, Greene County responded to the Commission’s Directive by
indicating that the jail continues to update any and all policies which may reasonably require
updating to bring them into conformity with the daily operations. It also insisted that the jail does
not confine male inmates in their cells for a preponderance of the day, without need, and denies
that it engages in discriminatory housing policy based upon gender. Greene County indicated
that all food service menus in use at the Greene County Jail are approved and supplied by the
New York State Department of Corrections and Community Supervision (DOCCS). If an inmate
requests a dietary substitution or a request due to religious observance or directed by health
care professionals and the substituted portion deviates from the caloric and/or nutritionally
approved statistic, the substituted portion is selected from a New York State Department of
Corrections approved menu. Greene County indicated that the Greene County Jail
implemented the Commission’s recommendations related to the exit interview of April 11, 2016
and that all grievance related matters are monitored on a bi-weekly basis. Greene County
responded by indicating that grievance forms are readily accessible to all inmates at all housing
units and through the law library programs. Greene County indicated that all grievances are
processed on a timely basis, a written determination from the grievance coordinator is given to
the inmate within five days of receipt, the chief administrative officer’s determinations are within
five business days of receipt and all notices of appeal are directed to the Commission within the
time frames of 9 NYCRR §7032.5. Lastly, it was alleged that the jail has instituted all policies
and procedures recommended by the Commission relating to inmate grievances, including
maintenance of individual file folders, maintenance of a grievance log book subject to bi-weekly
review to ensure complete compliance.
On January 4, 2017, the Commission forwarded to Greene County its assessment of the
county’s response to the directive, requesting justification as to why locking inmates in their cells
for certain time frames is necessary for maintenance or order of discipline. The Commission
also indicated that field staff were in the process of reviewing the submitted policies and
procedures and that these items would remain open pending the review. The Commission also
51

requested documentation from a dietician or nutritionist certified by the New York State
Department of Education, demonstrating that all food and beverage items served at the Greene
County Jail met the current recommended daily allowances of the Food and Nutrition Board of
the National Academy of Sciences, Nation Research Council. The Commission requested
Greene County Jail’s Classification policies and procedures as the County’s response did not
address this issue.
On January 18, 2017, Greene County responded to the Commission’s assessment of
their response. Greene County indicated that all inmates are not locked in their cells for the
entire 7:45 a.m. to 11:30 a.m. time frame, 12:15 p.m. to 4:15 p.m. time frame and 4:45p.m. to
6:45 p.m. time frame. Greene County indicated that inmates are taken out of their cells for
various activities, such as exercise or showers. Greene County indicated that they had
contracted a certified dietician to review the food menus and once the reviews have been
completed, they will be forwarded to the Commission. Greene County did send the
Classification policies and procedures at this time for the Commission’s review.
Pursuant to Correction Law §45(8)(a), on May 25, 2017, the Commission issued a
citation to the Greene County Sheriff, Greene County Attorney, and the Chairman of the Greene
County Legislature to appear before the Commission on July 12, 2017 due to the finding that
the Greene County Jail was unsafe, unsanitary, inadequate to provide for the separation and
classification of prisoners as required by law and has not adhere to or complied with the rules
and regulations promulgated by the Commission. This appearance was adjourned until July 25,
2017.
On June 24, 2017, Greene County Sheriff responded to the Citation. In that response,
Greene County indicated that no mandatory facility officer posts are being abandoned to
perform inmate transports, that all broken windows in the Greene County Jail have been
repaired and inspected by Commission staff, that the inmate food program menus have and will
continue to be reviewed and approved by a nutritionist. Greene County also indicated that all
required facility policies and procedures are or will be revised where applicable and bound in a
single volume together with all current jail policies, that their inmate grievance program will be
double checked regularly to ensure that investigative reports are attached and all appeal
documents have been timely filed. Greene County also indicated that they would release all
inmates from their cells from 7:30 am to 10:00 pm daily except for scheduled shift changes and
discipline. Greene County provided documentation that the sewer back-up issue was fixed and
was cleaned up. Greene County also requested assistance with regard to classification of
inmates at the Greene County Jail.
Based upon the representations of Sheriff Seeley in his response to the Citation, the
Correction Law §45(8) hearing was indefinitely adjourned on July 25, 2017. The Commission
continues to monitor the Greene County Jail to ensure all violations are satisfactorily addressed.

52

REPORTED SIGNIFICANT FACILITY INCIDENTS
Number of reported incidents per category, from 1/1/16-12/26/17
Hospital Admission of Inmate
Inmate Self-Inflicted Injury
Inmate/Personnel Assault
Inmate-Introduced Contraband
Unknown Source-Introduced Contraband
Visitor-Introduced Contraband

1
2
1
2
1
1

53

ERIE COUNTY HOLDING CENTER AND CORRECTIONAL FACILITY
Managerial shortcomings of the Erie County Sheriff’s Office have contributed to
numerous serious incidents at the Erie County Holding Center and Erie County Correctional
Facility, including inmate escapes, assaults, and deaths. Consequently, the Commission has
previously been required to commence enforcement action (i.e., issuance of Directives,
applications for Supreme Court order) against the Erie County Sheriff for the failure to correct
identified violations of law and compulsory state regulations. Although the Commission will
continue to work with the Sheriff’s Office to correct identified regulatory violations and maintain
compliance, further enforcement action will be instituted where warranted.

FACILITY OVERVIEW
Erie County Holding Center
Description:
Opened in 1938, the Erie County Holding Center is a 7-story high-rise
facility that houses pre-trial and sentenced inmates in 30 housing areas.
Cells:
528 cells
Dorms:
112 beds
Authorized capacity:640
12/30/17 population: 347 inmates in-house and 2 inmates boarded out
Erie County Correctional Facility
Description:
Opened in 1985, the Erie County Correctional Facility houses pre-trial
and sentenced inmates in 42 housing areas.
Cells:
406 cells
Dorms:
388 beds
Total authorized capacity: 794
12/30/17 population: 592 inmates
Note: Both facilities are under the charge of the Sheriff of Erie County.

FACILITY STAFFING DEFICIENCIES
In 2011 and 2012, Commission staff updated the Position and Staffing Analyses at the
Erie County Holding Center and Correctional Facility. An April 17, 2012 report outlined the daily
and total staffing requirements for both facilities. Unfortunately, Erie County had failed to
maintain required staffing levels of the Commission’s previous staffing analyses. As a result,
Erie County had to hire 72 new Correction Officers and implement a myriad of in-house
promotions to meet the required staffing levels. The Commission worked with Erie County on a
multi-year plan that allowed for the necessary hires and promotions to meet staffing
requirements.

COMMISSION SPECIAL INVESTIGATIONS
2010 - Escape from Custody
Inmate Brian Collins escaped from the confines of the Erie County Holding Center and gained
access to the rooftop of the facility. The escape resulted from the failure of facility management
and staff to observe established practices and Minimum Standard regulations. The ECSO
54

addressed identified deficiencies and took corrective action to include, but not limited to,
revision of administrative orders and policy and procedures, increase of supervisory staff tours
of housing areas, and staff remedial training. One deputy was terminated, and several others
were disciplined.
2015 - Escape from Custody
Inmate Thomas Walsh escaped from Buffalo City Court while in the custody of the Erie County
Sheriff’s Office (ECSO). The escape resulted from the failure of ECSO transport officers to
supervise Walsh in accordance with Minimum Standard regulations, staff assignment practices,
and limitations caused by on-going construction at the Buffalo City Court Building. Actions
taken by the ECSO to correct identified deficiencies included revision of policies and
procedures, reinforcement of staff expectations, amendment to staff assignment protocols, and
enhancement of the department’s Field Training Officer Program.
2016 – Inmate/Inmate Assault
In September 2016, inmate Carl Miller was assaulted by another inmate while being
incarcerated at the Erie County Correctional Facility. Miller had previously requested to be
placed in protective custody due to his concerns of being harmed by other inmates. The assault
resulted in serious injuries to Miller that required a lengthy hospitalization. The assault occurred
due, in part, to the failure of supervisory staff to ensure Miller remained locked in his cell until
other housing arrangements could be made, and line staff’s failure to observe administrative
and security protocols, as well as Minimum Standard regulations. Actions taken by the ECSO
to correct identified deficiencies included additional training for supervisory and line staff, review
of relevant policy and procedures with staff, revision to applicable policies and procedures
relating to security and supervision and other areas.

INMATE MORTALITY INVESTIGATIONS
ERIE COUNTY HOLDING CENTER
Individual 14
DOD: 2012
COD: SUICIDE - HANGING
MOD: SUICIDE
ISSUES: MEDICAL AND MENTAL HEALTH CARE
• Inadequate care by nursing staff who failed to adequately screen Individual 14 for mental
health issues and appropriately refer him to mental health as a priority case.
Individual 15
DOD: 2012
COD: HOMICIDE – TRAUMATIC ASPHYXIA
MOD: HOMICIDE
ISSUES: USE OF FORCE, SUPERVISION, MEDICAL AND MENTAL HEALTH CARE
• Inadequate management plan by Erie County deputies for inmates with mental illness in
an acute crisis state.
• Improper restraint technique used by deputies who placed a spit mask over Individual
15’s face and tied it tightly around his neck and then added a pillow case over his face
that seriously restricted his airway and breathing while placed prone on a gurney.
55

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•
•
•

Deputies also violated specific agency policy and procedures which prohibited such
actions.
Failure of the deputies to allow the responding EMS personnel to adequately assess
Individual 15 and assure he was breathing adequately.
Failure of supervisors to properly supervise a use of force by staff.
Inadequate mental health care by Erie County MH clinicians who failed to have a
management plan for inmates who are in acute crisis state.
Failure by the Erie County MH clinicians to recognize Individual 15’s acute psychosis
and immediately refer him to a psychiatric provider.

Individual 16
DOD: 2014
COD: NATURAL – PERFORATED ULCER
MOD: NATURAL
ISSUES: INADEQUATE MEDICAL CARE
• Erie County nursing staff failed to perform an adequate medical assessment on
Individual 16, utilized treatment protocols for suspected cardiac issues on a person with
no known cardiac history and then returned him to his housing area without any
physician notification or evaluation.
• Erie County jail physician failed to recognize the seriousness of Individual 16’s illness
and failed to order a hospital evaluation and treatment after the use of a cardiac
treatment protocol on a patient with no known cardiac history.
• Erie County medical providers failed to properly review and sign telephone orders.
• Erie County medical providers failed to assure Individual 16’s lab work was completed.
• Erie County medical providers failed to obtain releases for Individual 16’s community
medical records.
• Erie County medical providers failed to recognize that Individual 16 had continued
unresolved complaints of abdominal pain, for over an eight-hour period, with signs of
hypoperfusion and failed to immediately seek hospital treatment for him.
Individual 17
DOD: 2014
COD: UNKNOWN – AS LISTED
MOD: UNKNOWN
ISSUES: OPEN INVESTIGATION – MULTIPLE MEDICAL MENTAL HEALTH AND MINIMUM
STANDARD VIOLATION ISSUES
• Current in-progress investigation by SCOC/MRB. Issues identified to date show serious
lapses in both medical and mental health care. Individual 17 languished in a cell for over
10 days in an acute state of psychosis without any crisis psychiatric intervention or
attempts to emergently hospitalize. Individual 17 continued to deteriorate with an
inability to adequately feed, hydrate, or manage her activities of daily living. She was
brought to the hospital in a state of acute renal failure after a suffering a cardiac arrest at
the jail. She was resuscitated and brought to the hospital where her condition continued
to deteriorate over several days. She was released from custody prior to her death.

56

2016 FACILITY EVALUATION
In June, July, August and October of 2016, Commission staff completed the Minimum
Standard evaluation of the Erie County Holding Center and Erie County Correctional Facility.
The report was issued November 2, 2016. Below are the significant findings.
Part 7003 - Security and Supervision
• Supervision of prisoners within facility housing areas: The facility is not accurately
documenting active and general supervision. Facility policy did not articulate the
requirement of recording the level of supervision.
• Additional Orders of Supervision: The facility was not consistently documenting the name
of individuals making such determination for additional supervision and they were not
documenting the underlying reason for additional supervision.
• Documenting Significant Events/Activities: The facility was not documenting significant
events in the housing unit logbooks.
• Population Counts: Written results from prisoner population counts are not consistently
being forwarded to central control.
• Firearms Control: Inspections only being conducted yearly.
• Locks and Securing Devices: Inspection sheets did not identify or define all securing
devices. The sheet was revised when Commission staff was onsite and the matter was
closed.
Part 7006 - Discipline
• Misbehavior Reports: The facility is not recording the time on the disciplinary reports.
Part 7007 - Good Behavior Allowances
• The facility was not requiring inmates to acknowledge in writing that this part had been
explained to them.
Part 7008 - Visitation
• Availability of Visits: The facility was distributing visitation information sheets that differed
from facility policy.
• Visitor Identification and Registration: Facility staff requiring proof of address for
prospective visitors.
• Contact Visitation: Signage at the facility allows for physical contact at the end of the visit
only.
• Limitation of Visits: Visits being denied due to clothing worn by prospective visitors.
Decisions to deny or limit visits are not documented and given to all those affected.
Part 7009 - Food Services
• Nutritional Adequacy: Portion size is not consistent with published menu. Menus not
certified by dietician.
• Medical Diets: Medical substitution list not certified by a dietician.
• Religious Diets: Religious substitution list not certified by a dietician.
Part 7015 - Sanitation
• General Facility Sanitation: Facility staff did not have 24-hour access to sanitation
equipment and supplies. The facility addressed the matter and ordered a key to be kept in
the watch commanders office. This matter was closed.

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Kitchen Sanitation: During the first site visit the kitchen at the Holding Center was found to
be deficient in acceptable sanitation standards. The facility addressed the matter and on the
second site visit the kitchen had been cleaned and the matter was closed.

Part 7030 - Nondiscriminatory Treatment
• Policy: The facility did not have a policy on nondiscriminatory treatment and no information
was contained in the inmate handbook. The facility addressed this immediately and the
matter was closed.
Part 7032 - Grievance Program
• Policy: Grievance policy not reviewed/revised since 2010.
• Program Requirements: The informal grievance process was not completed within
24hours therefore denying inmates access to the formal grievance process.
• Grievance investigations not completed fully and do not detail all facts resulting from
relevant interviews. In some cases, there was no documentation at all.
• Grievance being returned as too vague, outside control of the CAO or as non-grievable.
After a review it was found that the majority of the grievances should have been processed.
A grievance workshop was provided to facility staff in September and October of 2016.
• Grievance timelines not being followed.
• Continuation and Termination of Grievances: When inmates were released the CAO was
not rendering decisions consistently. When a denial was issued the grievance was not
forwarded to the CPCRC for review and determination.
• Grievance Coordinator Responsibilities: Facility Grievance staff was not aware of how to
electronically submit grievances to the CPCRC.
Part 7063 - Chemical Agents
• Recording the use of Chemical Agents: Facility staff not documenting the approximate
length and time of exposure.

2017 FACILITY EVALUATION
In September and October 2017, Commission staff completed Minimum Standard
evaluations of the Erie County Holding Center and Erie County Correctional Facility. Although
the report is pending release, below are the significant findings.
Part 7002 - Admissions
• Inmate Property: At the Erie County Holding Center, some property was destroyed with no
justification or required documentation.
• Inmate Rulebook – At the Holding Center, newly admitted inmates were being issued
obsolete versions of the facility rulebook.
Part 7005 – Prisoner Personal Hygiene
• Laundry: At the Holding Center, laundry services were only provided once per week, not
twice as required. The facility took immediate corrective action by revising protocols to
ensure requirements are observed. Considered Closed.
Part 7013 – Classification

58

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•
•

Commingling: At the Holding Center, minimum security female inmates were improperly
housed with maximum security inmates.
Risk Assessment: At the Holding Center, the screening process did not take into account
all relevant data when determining housing or special needs.
Override Decisions: At the Holding Center, an improper blanket policy had been
implemented whereby some overrides were automatically determined based on instant
offense.

Part 7022 – Reportable Incidents
• Reporting: Correctional Facility submissions of reportable incidents to the Commission
lacked sufficient information and detail.
Part 7039 – Fire Prevention and Safety
• Inspections: Weekly fire and hazard safety inspections were not completed on a consistent
basis.

COMMISSION-ISSUED DIRECTIVES AND ENFORCEMENT
On May 16, 2017, the Commission issued a directive to the Erie County Correctional
Facility for failing to report significant facility incidents as required by the Commission’s
regulations, 9 NYCRR §7022.1, §7022.2(b), and §7022.3(a). Specifically, Erie County
Correctional Facility failed to report inmate attempted suicides on March 23, 2013, April 24,
2013, December 7, 2013 and September 2, 2015 and failed to properly report an incident
involving Carl Miller occurring on September 30, 2016. The Erie County Correctional Facility
was directed to ensure that all significant facility events and incidents are reported to the
Commission consistent with the Commission’s Reportable Incident Guidelines for County
Correctional Facilities and to submit to the Commission by June 6, 2017 documentation
substantiating compliance with the Directive.
On June 2, 2017, Erie County responded to the directive. Erie County indicated that
even though they maintain that they documented and reported the incidents in question
correctly, they were committed to be in full compliance with the Standards. Erie County
indicated that the Command Level Staff were fully briefed on the Commission’s interpretation of
the terms “life threatening injury” and “life threatening situation” and staff had been advised that
the intent of the inmate should not factor into how an incident was categorized. Erie County
also indicated that Command Level Staff will review all incidents electronically within 24 hours of
occurrence to ensure accurate information is relayed to the Commission and that Line-Up
training has been scheduled for facility Watch Commanders and additional training for First-Line
Supervisors will be scheduled to ensure accurate information is submitted. Erie County also
indicated that in instances where medical and/or mental health determinations determine the
categorization of an incident, sufficient information that justifies the decision will be provided to
the Commission.
On June 7, 2017, the Commission forwarded to Erie County its assessment of the
County’s response to the directive, indicating that the actions taken were acceptable and that
on-site verification by Commission staff would occur during future visits.

59

REPORTED SIGNIFICANT FACILITY INCIDENTS
Number of reported incidents per category, from 1/1/16-12/26/17
ERIE COUNTY HOLDING CENTER
Attempted Escape
Erroneous Releases
Hospital Admission of Inmate
Individual Inmate Disturbance
Inmate Accidental Injury
Inmate Attempted Suicide
Inmate Group Assault/Gang Assault
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Inmate Sexual Offense
Inmate/Personnel Assault
Inmate-Introduced Contraband
Major Maintenance/Service Disruption
Minor Disturbance
Personnel Accidental Injury
Personnel/Inmate Sexual Offense
Release of Hospitalized Inmate From Custody
Unknown Source-Introduced Contraband
Visitor-Introduced Contraband

2
1
423
41
22
10
14
11
97
4
20
51
2
1
6
2
101
15
1

ERIE COUNTY CORRECTIONAL FACILITY
Hospital Admission of Inmate
Individual Inmate Disturbance
Inmate Accidental Injury
Inmate Attempted Suicide
Inmate Group Assault/Gang Assault
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Personnel Assault
Inmate-Introduced Contraband
Personnel Accidental Injury
Personnel-Introduced Contraband
Release of Hospitalized Inmate from Custody
Unknown Source-Introduced Contraband
Visitor-Introduced Contraband

18
11
40
2
2
5
82
6
24
3
1
2
13
3

60

DUTCHESS COUNTY JAIL
For decades, Dutchess County failed to properly plan to provide sufficient capacity at its
county jail, resulting in annual expenditures of millions of dollars to board overflow inmates to
other county jails, some located more than two hours from Poughkeepsie. In 2015, the
Commission granted a variance for 200 temporary modular dorm beds placed on the current jail
property to alleviate the county’s financial burden of boarding inmates, contingent upon the
county actively moving forward with the construction of new jail space. The Commission
continues to work closely with Dutchess County in the planning and design of a new jail
expansion project, with an anticipated completion of 2023.

FACILITY OVERVIEW
Description:

The Dutchess County Jail houses pre-trial and sentenced inmates in 13
housing areas.
Cells:
292 cells
Dorms:
0 beds
Variance Beds:
200 beds (modular dorms)
Authorized Capacity:492 beds
12/30/17 population: 374 inmates in-house and 5 inmates boarded out

INMATE OVERCROWDING MANAGEMENT
For decades, the Dutchess County Jail experienced significant inmate overcrowding,
due primarily to the county’s failure to add needed capacity to the jail. For an extended period
of time, the jail routinely boarded out in excess 200 inmates to other county jails throughout the
state. Such boarding was estimated to cost approximately $6 million per year.
In 2014, the Commission provided Dutchess County valuable assistance by authorizing
200 variance beds through the use of four temporary modular housing units erected on the jail
property. Such variances were granted on the condition that the county accelerate its efforts to
design and construct a new jail expansion. The county set an original goal of 2017 for
construction completion and opening of the jail expansion. However, significant delays by the
county have pushed the proposed completion date to 2023.
The Commission continues working with jail and county officials as part of the design
phase of the project.

INMATE MORTALITY INVESTIGATIONS
Individual 18
DOD: 2011
COD: SUICIDE
MOD: SUICIDE - HANGING
ISSUES: MEDICAL AND MENTAL HEALTH CARE

61

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•
•
•

Inadequate medical care by medical providers from CMC, Inc. regarding withdrawal
management where a benzodiazepine was prescribed to Individual 18 still experiencing
signs of intoxication without a physician’s exam being completed.
Individual 18’s prior history of a suicide attempt and documented suicidal ideation by nursing
staff was not addressed during the psychiatric assessment for continuation of constant
supervision.
Social worker from CMC, Inc. failed to review Individual 18’s history of suicide attempt and
current suicidal ideation.
Social worker form CMC, Inc. failed to refer Individual 18 to psychiatry for a follow up when
his clinical presentation indicated such was needed.

Individual 19
DOD: 2014
COD: SUICIDE
MOD: SUICIDE (HANGING)
ISSUES: MEDICAL AND MENTAL HEALTH CARE
•
•
•
•

Jail staff did not immediately refer Individual 19 to mental health at admission despite his
reporting a mental health history and being documented as acting strangely.
Nursing staff from CMC, Inc. failed to recognize Individual 19’s symptoms of mental illness
at his admission assessment and take proper precautions.
Social work staff from CMC, Inc. failed to recognize Individual 19’s signs of mental illness
and take appropriate actions.
Jail staff failed to recognize signs of acute mental illness in Individual 19 and refer him to
mental health after an incident in a hallway where Individual 19 could not properly follow
staff commands.

ATTORNEY GENERAL INQUIRY – CORRECTIONAL MEDICAL CARE, INC.
The Commission and its Medical Review Board investigated six inmate deaths, occurring
between 2009 and 2012, at five different county jails contracting with Correctional Medical Care,
Inc. (CMC) for inmate health services. CMC is a for-profit business incorporated in
Pennsylvania, whose owner is not a licensed medical professional, that previously contracted
with thirteen (13) upstate counties. In each of the six inmate death investigation reports,
including Individual 18 at the Dutchess County Jail, the Commission and its Medical Review
Board revealed that there were egregious lapses in medical care on the part of CMC, to include
unlicensed and inexperienced staff, inadequate staffing, a lack of adequate medical oversight,
and a failure to adhere to medical and administrative protocols and procedures.
In addition to referring individual healthcare providers to the Office of Professional Discipline
and the Office of Professional Medical Conduct, the cases were referred to the New York State
Attorney General, requesting an investigation as to whether CMC was illegally engaging in the
practice of medicine. Following the referral, the Office of the Attorney General (OAG) caused
an inquiry to be made to certain business practices of CMC relating to its delivery of health care
services to county inmates. In September 2014, OAG entered into an Assurance of
Discontinuance with CMC, whereby CMC agreed to restructure its New York State business
operations and contracts, pay for the services of an independent contract monitor, and pay
stated amounts of restitution and penalties.
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2016 FACILITY EVALUATION
Part 7070 – Educational Services for Youth
• Policies and Procedures
• Educational Services:
a. the facility is not providing educational services to eligible youth, as required, in
particular, minors.
b. The facility has not made arrangements with the school district to provide such
required services

2017 FACILITY EVALUATION
Policies and Procedures:
The Commission found multiple policies and procedure violations during the 2017 evaluation.
Many of the policies were found to be outdated and not in compliance with NYS Minimum
Standards. The department's policies have not been reviewed by administrative staff as
mandated by standard and lack direction to subordinate staff or provide outdated and incorrect
information. The following is a list of policies identified that were not in compliance during the
evaluation period:
* Inmate rulebook
* Commissary
* Reportable Incidents
* Legal Services
* Maximum Facility Capacity

* Classification
* Correspondence
* Religion
* Fire Prevention and Safety
* Correction Law 611

Part 7002 - Admissions
• Property Confiscation: Confiscated prisoner personal property was not kept in a safe and
secure manner. It was found that the hallway door to the property room and the inner door
were both unsecured allowing unauthorized access.
Part 7005 - Prisoner Personal Hygiene
• Clothing: Female inmates were not being allowed to receive brassieres via packages, as
required.
Part 7008 - Visitation
• Availability of Visits: The visitation schedule outlined in the inmate rulebook conflicted with
actual practice.
• Contact Visits: The facility improperly implemented a blanket policy in inmates placed on
constant supervision were only permitted non-contact visits with their families.
Part 7013 – Classification
• Policy: the facility’s written policy and procedures on inmate classification do not reflect
current pratice, and in some instances, violates Minimum Standard regulations.
Part 7016 - Commissary
• Purchases: the facility improperly used commissary profits to purchase items/services that
did not benefit the welfare and rehabilitation of inmates, as required.

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Audit: the facility could not demonstrate that periodic audits of the commissary program had
been completed, as required.

Part 7028 - Exercise
• Exercise Periods: the facility was not providing lock-in inmates with the required amount of
outdoor exercise on a daily basis.
• Searches: the facility was not searching outdoor exercise areas as required.
Part 7031 - Legal Services
• Notary Public: the facility was improperly charging inmates for notary services and
providing limited notary access to indigent inmates.
Part 7039- Fire Prevention and Safety
• Fire and Safety Inspections: the facility has not requested from the appropriate authority
an annual fire inspection of the jail.
• Hazards: the facility was not addressing, in a timely manner, fire hazards identified during
fire safety inspections.

REPORTED SIGNIFICANT FACILITY INCIDENTS
Number of reported incidents per category, from 1/1/16-12/26/17
Fire/Non-arson
Hospital Admission of Inmate
Individual Inmate Disturbance
Inmate Accidental Injury
Inmate Attempted Suicide
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Personnel Assault
Inmate-Introduced Contraband
Major Disturbance
Major Maintenance/Service Disruption
Minor Disturbance
Personnel Accidental Injury
Personnel/Inmate Assault
Unknown Source-Introduced Contraband
Visitor-Introduced Contraband

1
100
14
9
9
6
7
7
9
1
5
5
1
1
2
8

64

ONONDAGA COUNTY JUSTICE CENTER AND PENITENTIARY 1
Effective January 1, 2018, the Onondaga County Department of Correction has merged
with the Onondaga County Sheriff’s Office, with the Sheriff assuming custody and control of the
Penitentiary in Jamesville. Historically, the Sheriff’s downtown Justice Center has experienced
overcrowding, often necessitating the boarding of 90 inmates to the Penitentiary. While obvious
benefits will result from the merger, inmate overcrowding at the Justice Center may still
necessitate added capacity at either facility. The Commission has provided technical
assistance to both facilities by identifying existing areas that could be readily converted to
appropriate inmate housing, advice that recently led to the identification and realization of 26
added beds to the Penitentiary. Operationally, the Commission has cited the Justice Center
after discovering that mandated officer posts have been routinely abandoned, apparently
caused by the administration’s inability to mandate overtime based on unfavorable provisions of
the collective bargaining agreement. The Commission will continue working with the Onondaga
County Sheriff to remediate this issue and ensure that both facilities maintain the necessary
complement of security staff.

FACILITY OVERVIEW
Onondaga County Justice Center
Description: Opened in 1995, the Onondaga County Jail houses pre-arraigned arrestees and
pre-trial and sentenced inmates in 30 housing areas.
Cells: 593 cells
Dorms: 78 beds
Total authorized capacity: 671 beds
12/30/17 population: 537 inmates in-house and 54 inmates boarded out to the Onondaga
County Penitentiary.
Onondaga County Penitentiary
Description: Opened in 1983, the Onondaga Penitentiary previously housed only Onondaga
County sentenced inmates. In recent years, the facility has also housed unsentenced inmates
boarded from the Onondaga County Justice Center. The facility houses inmates in 30 housing
areas.
Cells: 190 cells
Dorms: 348 beds
Total authorized capacity: 538 beds
12/30/17 population:

1

On November 7, 2017, Onondaga County voters approved a proposal that would merge the Onondaga County Department of
Correction (DOC) with the Onondaga County Sheriff’s Office and the Onondaga County Jail (Justice Center), effective January 1,
2018.

65

FACILITY STAFFING DEFICIENCIES
In 2017, Commission staff identified numerous instances at the Justice Center in which
daily posts required by the Commission’s Position and Staffing Analysis were not filled. These
instances were attributed, by the Sheriff’s Office, to a provision in the current Collective
Bargaining Agreement which allows officers to obtain a physician’s certification report restricting
work of overtime entirely or limiting overtime on a voluntary basis. The Commission continues
to work with the Onondaga County Sheriff’s Office in addressing this matter.

INMATE OVERCROWDING MANAGEMENT
For the past several years, the Onondaga County Justice Center has experienced
significant inmate overcrowding. To assist the county, the Commission has routinely approved
Substitute Jail Orders, in accordance with Correction Law §504, that permit the Justice Center
to board overflow inmates to the Penitentiary. The Commission also assisted by authorizing
temporary capacity variances at both facilities. With the January 1, 2018 merger of both
departments, the Onondaga County Sheriff will assume custody of both facilities, rendering
reliance on Substitute Jail Orders moot. However, lack of sufficient housing at the Justice
Center still requires the county’s attention.
In 2016, Commission staff visited the Justice Center for the purpose of identifying
potential areas that could be converted to housing space. Commission staff identified two areas
that could be converted to housing, thus, adding approximately 40-beds to the facility’s capacity.
These areas would require certain upgrades (i.e., adding of toilets, sinks, and showers, etc.) in
order to house inmates.
In 2016, Commission staff visited the Penitentiary also for the purpose of identifying
potential areas that could be converted to housing space. Commission staff identified two
current housing areas, the capacities of which could be increased with minimal upgrades
(toilets, sinks, etc.). The Penitentiary requested and received authorization from the
Commission to increase the capacity in these two housing areas, realizing an increase of 26beds.
In recent years, Onondaga County has commenced discussions on long-term planning
to address overcrowding, including the construction of another tower (housing areas). The
county will likely take a wait-and-see approach as to the impact the merger will have on overall
operations and available housing.
The Commission remains available to provide technical assistance to the county in this
endeavor.

2016 FACILITY EVALUATION
Commission staff completed Minimum Standard evaluations of the Onondaga County Justice
Center during multiple site visits. Violations are noted below.
Part 7003 – Security and Supervision
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Key Control: Justice Center staff were observed leaving computer touchscreens
unattended and unsecured, thus creating a potential security breach.

Part 7006 – Discipline
• Discipline: Justice Center housing deputies were permitted to arrange for plea bargaining
with inmates as part of informal discipline. Such a practice is not authorized by Commission
regulations.
Part 7032 – Grievance Program
• Inmate Access: Serious concerns have arisen as to whether inmates are provided access
to grievance forms at the Justice Center.
• Grievable Issues: A review of inmate grievances filed at the Justice Center revealed
instances in which the facility improperly denied grievances as being timely.
• Documentation: A review of inmate grievances filed at the Justice Center revealed
instances in which the grievance coordinator closed the grievance but failed to provide
supporting documentation as to why.

2017 FACILITY EVALUATION
Commission staff completed Minimum Standard evaluations of the Onondaga County Justice
Center and Penitentiary during multiple site visits. Violations are noted below.
Part 7002 – Admissions
• Inmate Handbook: The Justice Center and Penitentiary inmate handbooks included rules
and policies that violate several Commission regulations.
• Property Destruction: The Penitentiary was found to have been destroying certain types of
inmate personal property (lighters, etc.) confiscated during the admissions process. The
facility addressed this matter.
Part 7005 – Prisoner Personal Hygiene
• Clothing: At the Justice Center, several instances were noted in which inmates placed on
constant supervision were not provided required clothing or bedding.
• Shaving: The Penitentiary was found to have been improperly limiting the opportunity of
certain inmates’ ability to shave on a daily basis.
Part 7013 – Classification
• Initial Screening: Neither the Justice Center nor the Penitentiary captures an inmate’s
entire history of detention nor does its classification instrument address all necessary
elements as required as required by this section.
• Review: The Justice Center’s review of inmate classifications does not take into account all
relevant information.
• Commingling: The Justice Center was found to have been commingling inmates of
different custody levels and housing males and females together in the medical unit.
Part 7016 – Commissary
• Purchases: The Justice Center and Penitentiary were found to have made improper
purchases, using commissary profits, that do not benefit inmate welfare and rehabilitation.
Part 7024 – Religion
67

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Services: The Penitentiary was found to have been restricting inmates of certain
classifications from participating in congregate bible study and Quran study programs. The
facility addressed this issue.

Part 7028 – Exercise
• Exercise: Determinations as to whether or not the exercise yards’ louver doors (which open
to allow a view to the outside) are made by deputies instead of the watch commander.
Correction Law §611 (Restraint of Pregnant Inmates)
• Policy and Practice: The Justice Center’s policy and procedures do not address all
requirements and, in some instances, violate the requirements of this law.

CIVIL RIGHTS LITIGATION
In September 2016, a class action complaint was filed against the Onondaga County
Sheriff, various jail officials, and the Syracuse City School District in United States District Court
for the Northern District of New York. The complaint alleged that 16 and 17-year-old inmates at
the Onondaga County Justice Center were routinely subjected to the imposition of solitary
confinement in violation of the Eighth and Fourteenth Amendments, and were thereafter denied
minimal education instruction and special education guaranteed by state law.
The action was settled in June of 2017 when the Onondaga County Sheriff stipulated
that such inmates would only be confined to a cell upon a determination that there exists an
imminent safety threat that “less restrictive measures cannot adequately resolve,” with such
confinement lasting for only the minimum period necessary to resolve such safety threat.
Additionally, the Syracuse School District agreed to provide such inmates access to education,
special education services, and an incentive program to encourage better behavior among teen
inmates.
It should be noted that this action, and similar litigation against the Broome County Jail,
was the impetus for the creation of new Commission regulations. Proposed in late 2017 and
scheduled for adoption in early 2018, the Commission’s new regulations will create a
presumption that every inmate in administrative or punitive segregation will be allowed out of his
cell for a minimum of four hours a day, which may only be denied upon a written determination
of the facility’s chief administrative officer that doing so would jeopardize facility safety, security
or good order. Furthermore, the regulations will require enhanced reporting, by a facility to the
Commission, of designated instances of cell confinement, and the denial of certain essential
services, such as educational programs. Once effective, the Commission will have a greater
capacity to sufficiently identify, monitor and investigate problematic inmate deprivations similar
to that alleged in Onondaga and Broome counties.

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COMMISSION-ISSUED DIRECTIVES AND ENFORCEMENT
In November 2012, it was brought to the Commission’s attention that inmates, whose
custody was legally transferred from the Justice Center to the Penitentiary, nevertheless
remained under the supervision of deputies employed by the Onondaga County Sheriff. The
Commission sent a Notice of Violation to both the Onondaga County Sheriff and the Onondaga
County Department of Correction’s Commissioner informing them of the violation of Correction
Law §504 and §500-a. On November 20, 2012, the Commission issued a directive to the
Onondaga County Penitentiary for allowing the detention and confinement of inmates,
committed to the custody of the Onondaga County Sheriff, within the Onondaga County
Penitentiary. Specifically, the Onondaga County Penitentiary was in violation of Correction Law
§500-a(1), in that the Onondaga County Penitentiary was allowing the detention and
confinement of inmates, committed to the custody of the Onondaga County Sheriff, within the
Onondaga County Penitentiary and supervised by the deputies of the Sheriff. The
Commissioner of the Onondaga County Penitentiary was directed to refrain from detaining and
confining inmates committed to the Onondaga County Sheriff within the Onondaga County
Penitentiary.
On December 27, 2012, the Commissioner of the Onondaga County Penitentiary agreed
that inmates who were transferred from the Onondaga County Justice Center to the Onondaga
County Penitentiary by a Substitute Jail Order would be supervised by Correction Officers from
the Onondaga County Department of Correction.
In 2014, the Onondaga Deputy Sheriff’s Benevolent Associate sued Onondaga County
and Sheriff Kevin Walsh in order to have the Deputy Sheriffs supervise the inmates who were
being housed from the Onondaga County Justice Center in the Onondaga County Penitentiary.
On February 11, 2016, the judge hearing the case, granted the Defendant’s motion for summary
judgement.

REPORTED SIGNIFICANT FACILITY INCIDENTS
Number of reported incidents per category, from 1/1/16-12/26/17
ONONDAGA COUNTY JUSTICE CENTER
Capture/Erroneous Release
Discharge of Firearm
Erroneous Releases
Individual Inmate Disturbance
Inmate Attempted Suicide
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Inmate Sexual Offense
Inmate/Personnel Assault
Inmate-Introduced Contraband

1
2
3
88
11
6
13
1
5
32
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Minor Disturbance
Release of Hospitalized Inmate from Custody
Unknown Source-Introduced Contraband
Visitor-Introduced Contraband

35
1
1
1

ONONDAGA COUNTY PENITENTIARY
Capture/Erroneous Release
Erroneous Releases
Evacuation of Facility
Hospital Admission of Inmate
Individual Inmate Disturbance
Inmate Attempted Suicide
Inmate Group Assault/Gang Assault
Inmate Self-Inflicted Injury
Inmate/Inmate Assault
Inmate/Personnel Assault
Inmate-Introduced Contraband
Minor Disturbance
Personnel Death
Unknown Source-Introduced Contraband
Visitor-Introduced Contraband

1
1
1
52
49
9
3
9
27
4
21
16
1
4
2

70